The Jefferson

Based on observation, staff interview, and facility document review, the facility staff failed to prepare and serve food in a sanitary manner in one of one facility kitchen.The findings include:The facility staff failed to follow procedures for washing dishes in an automatic dishwasher on 2/17/26; and failed to serve food in a sanitary manner at lunch on 2/18/26.On 2/17/26 at 5:43 p.m., OSM (other staff member) #6, a dietary aide, and OSM #7, a dietary aide, were observed running loaded dish racks through the automatic dishwasher in the facility kitchen. The gauge displaying the current water temperature during the wash cycle never registered any temperature at all. Approximately 10 racks were observed being placed into the dishwasher and coming out on the other side. At no time did the wash temperature gauge fluctuate or register any temperature at all. OSM #6 stated the dishwasher was broken, but he could not say how long this had been the case. OSM #7 stated the dishwasher had not displayed an actual temperature during the wash cycle for at least two days. Neither staff member…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews and facility document review, the facility staff failed to follow state regulations at the time of hire for four of five staff records reviewed, LPN (licensed practical nurse) #8, LPN #9, CNA (certified nursing assistant) #10, and CNA #11.The findings include: For LPNs #8 and #9, and for CNAs #10 and #11, the facility staff failed to follow state regulations to verify professional licensure at the time of hire.According to Virginia state regulation 12VAC5-371-210 Nurse staffing, Before allowing a nurse aide to perform resident care duties, the nursing facility shall verify that the individual is.A certified nurse aide in good standing.On 2/23/26 at 9:00 a.m., facility staff were requested to provide evidence that licensure was verified at the time of hire for LPN #8, LPN #9, CNA #10, and CNA #11. According to information provided by the Director of Human Resources (HR), LPN #8 was hired 3/18/25; LPN #9 was hired 3/24/25; CNA #10 was hired 5/13/25; and CNA #11 was hired 10/10/25. Despite multiple requests for license verification at the time of hire, no such…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, the facility staff failed to provide required training for five of ten staff records reviewed, CNA (certified nursing assistant) #5, RN (registered nurse) #1, OSM (other staff member) #3, a speech and language pathologist, OSM #4, a dietary aide, and OSM #5, a housekeeper.The findings include:The facility staff failed to provide evidence of required training in Quality Assurance/Performance Improvement (QAPI) for CNA #5, RN #1, OSM #3, OSM #4, and OSM #5.On 2/20/26, evidence of training in QAPI was requested for CNA #5, RN #1, OSM #3, OSM #4, and OSM #5.A review of facility records provided by the Director of Human Resources (HR) failed to reveal evidence that the training in QAPI for these staff members had been completed.On 2/23/26 at 5:02 p.m., the Administrator and Director of Nursing (DON) were informed of these concerns.On 2/24/26 at 12:19 p.m., the Director of Human Resources (HR) was interviewed. She stated that at the time of hire, new employees receive a list of required trainings through a third-party education…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews and facility document review, the facility staff failed to provide required training for five of five CNA (certified nursing assistant) records reviewed, CNAs #5, #6, #7, #8, and #9.The findings include:The facility staff failed to provide evidence that CNA (certified nursing assistant) regular trainings were based on the results of individual annual performance reviews for CNAs #5, #6, #7, #8, and #9.On 2/20/26, evidence of annual performance reviews and that subsequent regular trainings were based on the results of these performance reviews was requested for CNAs #5, #6, #7, #8, and #9.On 2/23/26 at 10:01 a.m., the Director of Human Resources (HR) told the survey team that she had presented all the requested information she could locate at the time. She stated she did not have the evidence requested for the trainings for the CNAs.On 2/24/26 at 11:30 a.m., the Director of Nursing (DON) was interviewed. She stated that she had not been with this company for very long, and that when she first started work, the assistant DON was in charge of all evaluations.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to promote dignity and respect for one of 36 residents, Resident #5. The findings include: The facility staff failed to promote dignity and respect for Resident #5 (R55). R5 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident) with hemiparesis, hemiplegia and fibromyalgia. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 1/8/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 12/19/23 revealed, FOCUS: Toilet use,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician and/or the responsible party when medications are not available for administration for one of 36 residents in the survey sample, Resident #24.The findings include:For Resident #24 (R24), the facility staff failed to notify the physician when medication were not administered.The physician order dated, 1/21/2026 documented, Metoprolol Succinate Oral Capsule ER (extended Release) (1) 24 hours Sprinkle 25 MG (milligrams); Give 1 tablet by mouth one time a day for Heart failure.The January 2026 MAR (medication administration record) documented the above order. On 1/21/2026, a 9 was documented for the 9:00 a.m. dose of Metoprolol. A 9 indicated, Other/See Progress Note. A review of the progress note dated, 1/21/2026 at 11:53 a.m. documented, Awaiting pharmacy supply.The physician order dated, 1/17/2026, documented, Bumetanide Oral Tablet 0.5 MG (milligrams); Give 0.5 MG by mouth one time a day for diuretic.The January 2026 Mediation Administration Record (MAR)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident interview, staff interview, and clinical record review, the facility failed to maintain an accurate MDS (Minimum Data Set) record for 1 of 36 residents in the survey sample, Resident #25.The findings include: For Resident 25 (R25), the facility staff failed to accurately code section N (medications) on the MDS admission Assessment with an ARD (assessment reference date) of 2/9/2026. According to The Centers for Medicare and Medicaid Services Resident Assessment Instrument (RAI), a facility should review MAR (medication administration records) for the 7-day look-back period to determine if the resident received insulin injections and count the number of days insulin injections were received. This number should be entered on section N-0350 of the MDS assessment.Section N-0350 of R25's admission MDS with an ARD of 2/9/2026 coded R25 as having received insulin one day of the past seven days. On the same admission MDS with an ARD of 2/9/2026, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the baseline care plan for one of 36 residents in the survey sample, Resident #34. The findings include:For Resident #34 (R34), the facility staff failed to implement the resident's baseline care plan for anticoagulant therapy. R34's baseline care plan dated 2/11/26 documented, The resident receiving anticoagulant therapy Lovenox (Enoxaparin Sodium-blood thinning medication) r/t (related to) ORIF (Open Reduction and Internal Fixation surgery) to left hip. Administer medications as ordered by physician. Monitor for side effects and effectiveness daily. Observe/document/report any adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, nausea, vomiting, diarrhea, bruising, sudden changes in mental status, significant or sudden changes in v/s (vital signs). A review of R34's clinical record revealed a physician's order dated 2/11/26 for Enoxaparin Sodium 40 mg (milligrams)/0.4 ml…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 36 residents in the survey sample, Resident #36. The findings include:For Resident #36 (R36), the facility staff failed to review and revise the resident's comprehensive care plan to include the resident's use of glasses. A review of R36's clinical record revealed a Service Evaluation and Health assessment dated [DATE] that documented R36 wore glasses. Section B 1200. of R36's admission MDS (minimum data set) assessment with an assessment reference date of 11/24/24 documented R36 wore corrective lenses. A review of R36's comprehensive care plan initiated on 11/19/24 failed to reveal documentation regarding R36's use of glasses. On 2/21/26 at 10:38 a.m., an interview was conducted with the MDS Coordinator. The MDS Coordinator stated R36 did not have a diagnosis related to vision impairment, such as glaucoma, and the resident's vision was not impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and clinical record review, the facility staff failed to follow professional standards of practice for one of 36 residents in the survey sample, Resident #42. The findings include:For Resident #42 (R42), the facility staff failed to obtain a physician's order to use a straight catheter method to obtain a urine sample. R42 was admitted to the facility with diagnosis that included but was not limited to benign prostatic hyperplasia (1). On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/20/2025, R42 scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating R42 was severely impaired of cognition for making daily decisions. Section H0300 Urinary Continence coded R42 as being Always incontinent. The physician's order for R42 dated 01/24/2025 documented, UA (urinalysis) (2) C (culture) & (and) S (sensitivity) (3) every shift for 3 (three) days. The facility's Health Status Note for R42 dated 01/28/2025 at 11:35 p.m. documented, Note Text: Guest have [sic] order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to provide care and services to promote ADL (Activities of Daily Living) abilities for one of 36 residents in the survey sample, Resident #36. The findings include:For Resident #36 (R36), the facility staff failed to provide R36 with the resident's hearing aids and glasses to promote the resident's highest level of communication functioning. A review of R36's clinical record revealed a Service Evaluation and Health assessment dated [DATE] that documented the resident wore glasses and hearing aids. A physician's order dated 11/19/24 documented, Hearing aids to be charged at night time and apply in the morning one time a day and remove per schedule. Further review of R36's clinical record revealed a nurse's note dated 12/8/24 that documented, Hearing aids to be charged at night time and apply in the morning one time a day and remove per schedule. Hearing aid not found per CNA (Certified Nursing Assistant). wife [sic] is aware. A speech…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for one of 36 residents, Resident #5.The findings include: The facility staff failed to provide ADL (activities of daily living) specifically incontinent care for a dependent resident, Resident #5 (R5).R5 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident) with hemiparesis, hemiplegia and fibromyalgia. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 1/8/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and supervision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility staff failed to provide care and services for the assessment of a pressure injury for one of 36 residents in the survey sample, Resident #36. The findings include:For Resident #36 (R36), the facility staff failed to complete a thorough assessment of the resident's stage two pressure injury (1) from R36's date of admission [DATE]) until 1/25/25. A review of R36's clinical record revealed a Service Evaluation and Health assessment dated [DATE] that documented R36 presented with a stage two pressure injury on the sacrum. A nurse's note dated 11/19/24 documented R36 presented with a stage two pressure injury on the sacrum. A physician's order dated 11/19/24 documented-Desitin External Paste 40%. Apply to sacrum every shift for stage two pressure ulcer (injury). Further review of R36's clinical record failed to reveal any further documentation regarding an assessment of the pressure injury until 1/25/25 when a weekly skin check note documented R36's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and clinical record review, facility staff failed to provide care and services for an indwelling catheter for one of 36 residents in the survey sample, Resident #9. The findings include:For Resident #9 (R9), the facility staff failed to keep the catheter tubing (1) from resting on the base of the over-the-bed table. R9 was admitted to the facility with diagnoses that included but were not limited to neuromuscular dysfunction of the bladder (2). On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/28/2026, R9 scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R9 was moderately impaired of cognition for making daily decisions. On 02/17/2016 at approximately 7:00 p.m. an observation of R9 revealed she was in bed, head-of-the-bed raised with the over-the-bed table in front of her. Further observations revealed a catheter collection bag hanging on the side of the bed. Observation of the catheter tubing revealed it was going from R9 to the catheter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for one of 36 residents, Resident #22.The findings include: The facility staff failed to provide respiratory care services for Resident #22 (R22). R22 was admitted to the facility on [DATE] with diagnosis that included but were not limited to intraspinal abscess, neuromuscular dysfunction of bladder and polyarthritis.The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/6/26, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being moderate assistance for mobility/transfers/dressing, dependence for bathing and supervision for eating. Observations of R22's incentive spirometer on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure required physician visits for one of 36 residents in the survey sample, Resident #7. The findings include:For Resident # (R7), the facility staff failed to ensure the resident was seen by a physician between 3/12/25 and 6/19/25 (a total of 99 days), and between 6/19/25 and 9/3/25 (a total of 76 days). A review of R7's clinical record revealed the resident was seen by a physician on 3/12/25. Further review of R7's clinical record revealed the resident was not seen by a physician (or physician extender) until 6/19/25 (a total of 99 days). After 6/19/25, R7 was not seen by a physician (or physician extender) until 9/3/25 (a total of 76 days). On 2/21/26 at 10:06 a.m., an interview was conducted with the Director of Nursing. The Director of Nursing stated that most residents at this facility do not stay long term, and the facility does not really track physician visits. On 2/21/26 at 3:05 p.m., the Administrator and Director of Nursing were made aware of the above concern.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, the facility staff failed to verify licensure at the time of hire for two of three CNA (certified nursing assistant) records reviewed: CNAs #10 and #11.The findings include:The facility staff failed to verify licenses at the time of hire for CNA #10 and CNA #11.On 2/23/26 at 9:00 a.m., facility staff were requested to provide evidence that licensure was verified at the time of hire CNA #10 and CNA #11. According to information provided by the Director of Human Resources (HR), CNA #10 was hired 5/13/25, and CNA #11 was hired 10/10/25. Despite multiple requests for license verification at the time of hire, no such evidence was provided by the facility staff. On 2/23/26 at 5:02 p.m., the Administrator and Director of Nursing (DON) were informed of these concerns. The DON stated license verification at the time of hire is important to make sure staff members are competent and to prevent resident abuse.On 2/24/26 at 12:19 p.m., the Director of HR was interviewed. She stated that she is responsible for overall license verification.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure medications were available for administration for one of 36 residents in the survey sample, Resident #24.The findings include:For Resident #24 (R24), the facility staff failed to ensure Bumetanide was available for administration.The physician order dated, 1/17/2026, documented, Bumetanide Oral Tablet (1) 0.5 MG (milligrams); Give 0.5 MG by mouth one time a day for diuretic.The January 2026 Mediation Administration Record (MAR) documented the above order. On 1/21/2026 for the 9:00 a.m. dose a 9 was documented. A 9 indicates Other/See Progress Notes.Review of the progress notes dated, 1/21/2026 at 11:53 a.m. documented, Awaiting pharmacy supply.The review of the contents of the backup pharmacy system, located in the medication room, failed to evidence the Bumetanide Oral Tablets were in the system.An interview was conducted with LPN (licensed practical nurse) #1, on 2/20/2026 at 12:05 p.m. LPN #1 stated if a medication is not in the medication cart, the nurse should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility staff failed to prevent administration of unnecessary medications for three of 36 residents in the survey sample, Residents #34, #24, and #14. The findings include:1. For Resident #34 (R34), the facility staff failed to monitor the resident for side effects from the anticoagulant (blood thinning) medication Enoxaparin Sodium. A review of R34's clinical record revealed a physician's order dated 2/11/26 for Enoxaparin Sodium 40 mg (milligrams)/0.4 ml (milliliters)-inject 0.4 ml one time a day for deep vein thrombosis (blood clot) prophylaxis. A review of R34's medication administration record for February 2026 revealed the resident was administered Enoxaparin Sodium every day 2/12/26 through 2/20/26. A physician's order dated 2/12/26 documented, ANTICOAGULANT MEDICATION-MONITOR FOR DISCOLORED URINE, BLACK TARRY STOOLS, SUDDEN SEVERE HEADACHE, N&V (nausea and vomiting), DIARRHEA, MUSCLE JOINT PAIN, LETHARGY, BRUISING, SUDDEN CHANGES IN MENTAL STATUS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to store medications in a safe manner for two of 36 residents in the survey sample, Residents #6, and #25. The findings include:1. For Resident #6 (R6), the facility staff failed to store heparin flushes (blood thinning medication used to prevent blood clots in intravenous catheters) in a locked compartment. The heparin flushes were observed on the dresser and over bed table in R6's room. A review of R6's clinical record revealed a physician's order dated 1/24/26 for heparin sodium lock flush intravenous solution- 10 cc (cubic centimeters) intravenous every shift for an intravenous flush. On 2/18/26 at 9:26 a.m., R6 was observed lying in bed. One heparin flush (50 USP [United States Pharmacopeia]/5 ml [milliliters]-10 USP units/ml) was observed on the resident's dresser and one heparin flush was observed on the resident's over bed table. On 2/18/26 at 3:59 a.m., R6 was observed lying in bed. Two heparin flushes were observed on the resident's dresser. On 2/19/26 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to obtain physician ordered laboratory tests for two of 36 residents in the survey sample, Residents #6 and #24. The findings include:1. For Resident #6 (R6), the facility staff failed to obtain a physician ordered Vancomycin trough level (a measurement of an antibiotic medication) on 2/16/26. A review of R6's clinical record revealed a physician's order dated 2/11/26 with a start date of 2/16/26 for a Vancomycin trough level every Monday. Further review of R6's clinical record failed to reveal the laboratory results for a Vancomycin trough level that was due to be obtained on Monday 2/16/26. On 2/20/26 at 2:33 p.m., the Director of Nursing stated she could not provide the laboratory results for a Vancomycin trough level from 2/16/26. On 2/21/26 at 11:04 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #4. LPN #4 stated lab orders are entered and scheduled in the computer system then written in a lab communication book. LPN #4 stated the night before a lab is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to maintain a complete and accurate clinical record for one of 11 residents in the survey sample, Resident #108.The findings include:For Resident #108 (R108), the facility staff failed to maintain a complete and accurate record regarding the resident's discharge on [DATE].A review of R108's facility census information revealed that R108 was discharged on 4/26/26. A review of R108's progress notes revealed the following activities note dated 4/27/26: Guest discharged from unit AMA (against medical advice) before assessment could be conducted. Further review of the clinical record revealed no additional information regarding R108's discharge.On 4/30/26 at 10:40 a.m., LPN (licensed practical nurse) #1 was interviewed. She stated she was on duty when R108 left the skilled nursing unit. She explained that the resident's son approached her at the nurses' station to tell her that his mother wanted to leave. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, the facility staff failed to provide required training for three of ten staff records reviewed, OSM (other staff member) #3 (a speech and language pathologist), CNA (certified nursing assistant) #6, and LPN (licensed practical nurse) #6.The findings include:The facility staff failed to provide evidence of required training in effective communication was for OSM #3, CNA #6, and LPN #6.On 2/20/26, evidence of training in effective communication for OSM #3, CNA #6, and LPN #6 was requested.A review of facility records provided by the Director of Human Resources (HR) failed to reveal evidence that the training in effective communication for OSM #3, CNA #6, and LPN #6 had been completed.On 2/23/26 at 5:02 p.m., the Administrator and Director of Nursing (DON) were informed of these concerns.On 2/24/26 at 12:19 p.m., the Director of Human Resources (HR) was interviewed. She stated that at the time of hire, new employees receive a list of required trainings through a third-party education provider. She explained that these trainings are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, the facility staff failed to provide required training for one of ten staff records reviewed, OSM (other staff member) #3, a speech and language pathologist.The findings include:The facility staff failed to provide evidence of required training in resident rights and facility responsibilities for OSM #3.On 2/20/26, evidence of training in resident rights and facility responsibilities was requested for OSM #3.A review of facility records provided by the Director of Human Resources (HR) failed to reveal evidence that the training in resident rights and facility responsibilities for OSM #3 had been completed.On 2/23/26 at 5:02 p.m., the Administrator and Director of Nursing (DON) were informed of these concerns.On 2/24/26 at 12:19 p.m., the Director of Human Resources (HR) was interviewed. She stated that at the time of hire, new employees receive a list of required trainings through a third-party education provider. She explained that these trainings are online, and once the new employees have completed the training, she transfers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, the facility staff failed to provide required training for one of ten staff records reviewed, OSM (other staff member) #3, a speech and language pathologist.The findings include:The facility staff failed to provide evidence of required training in abuse, neglect, and exploitation for OSM #3.On 2/20/26, evidence of training in abuse, neglect, and exploitation was requested for OSM #3.A review of facility records provided by the Director of Human Resources (HR) failed to reveal evidence that the training in abuse, neglect, and exploitation for OSM #3 had been completed.On 2/23/26 at 5:02 p.m., the Administrator and Director of Nursing (DON) were informed of these concerns.On 2/24/26 at 12:19 p.m., the Director of Human Resources (HR) was interviewed. She stated that at the time of hire, new employees receive a list of required trainings through a third-party education provider. She explained that these trainings are online, and once the new employees have completed the training, she transfers the record of completion to another…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, the facility staff failed to provide required training for one of ten staff records reviewed, OSM (other staff member) #3, a speech and language pathologist.The findings include:The facility staff failed to provide evidence of required training in infection control for OSM #3.On 2/20/26, evidence of training in infection control was requested for OSM #3.A review of facility records provided by the Director of Human Resources (HR) failed to reveal evidence that the training in infection control for OSM #3 had been completed.On 2/23/26 at 5:02 p.m., the Administrator and Director of Nursing (DON) were informed of these concerns.On 2/24/26 at 12:19 p.m., the Director of Human Resources (HR) was interviewed. She stated that at the time of hire, new employees receive a list of required trainings through a third-party education provider. She explained that these trainings are online, and once the new employees have completed the training, she transfers the record of completion to another third-party education provider's software. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, the facility staff failed to provide required training for one of ten staff records reviewed, OSM (other staff member) #3, a speech and language pathologist.The findings include:The facility staff failed to provide evidence of required training in compliance and ethics for OSM #3.On 2/20/26, evidence of training in compliance and ethics was requested for OSM #3.A review of facility records provided by the Director of Human Resources (HR) failed to reveal evidence that the training in compliance and ethics for OSM #3 had been completed.On 2/23/26 at 5:02 p.m., the Administrator and Director of Nursing (DON) were informed of these concerns.On 2/24/26 at 12:19 p.m., the Director of Human Resources (HR) was interviewed. She stated that at the time of hire, new employees receive a list of required trainings through a third-party education provider. She explained that these trainings are online, and once the new employees have completed the training, she transfers the record of completion to another third-party education provider's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, the facility staff failed to provide required training for one of ten staff records reviewed, OSM (other staff member) #3, a speech and language pathologist.The findings include:The facility staff failed to provide evidence of required training in behavioral health for OSM #3.On 2/20/26, evidence of training in behavioral health was requested for OSM #3.A review of facility records provided by the Director of Human Resources (HR) failed to reveal evidence that the training in behavioral health for OSM #3 had been completed.On 2/23/26 at 5:02 p.m., the Administrator and Director of Nursing (DON) were informed of these concerns.On 2/24/26 at 12:19 p.m., the Director of Human Resources (HR) was interviewed. She stated that at the time of hire, new employees receive a list of required trainings through a third-party education provider. She explained that these trainings are online, and once the new employees have completed the training, she transfers the record of completion to another third-party education provider's software. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to develop and/or provide residents and/or their responsible party, with a summary of the baseline care plan for five of 17 residents in the survey sample, Residents #176, #18, #177, #174 and #23. The findings include: 1. For Resident #176 (R176), the facility staff failed to provide the resident and/or the responsible party with a summary of the baseline care plan. R176 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/8/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 1/11/2023 at 9:42 a.m., an interview was conducted with R176 in their room. When asked about receiving a written summary of their baseline care plan, R176 stated that they did not recall receiving anything…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide a complete pain management program including implementation of non-pharmacological interventions prior to the administration of as-needed pain medications for two of 17 residents in the survey sample, Residents #177 and #19. The findings include: 1. For Resident #177 (R177), the facility staff failed to evidence implementation of non-pharmacological interventions prior to administration of as-needed pain medication. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/25/2022, the resident scored 1 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section J documented R177 receiving as needed pain medications and not receiving non-medication interventions for pain. The physician order's for R177 documented in part, -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, facility document review, and in the course of a complaint investigation, the facility staff failed to prepare, store, and serve food in a sanitary manner in one of one facility kitchen, and in one of one activity room refrigerator. The findings include: On 1/10/23 at 12:01 p.m., a food transportation cart was checked for cleanliness in the facility's main kitchen. The inside of the cart contained loose black debris on the bottom, and multiple patches of sticky material on the top and sides. Several shelves of prepared food, including vegetables and desserts, were inside the cart. OSM (other staff member) #3, the dietary manager looked inside the cart, and stated: It needs to be cleaned out, for sure. OSM #3 wore a hairnet that only partially covered her loose hair. Her bangs and loose hair stuck out from under the net, exposing it to food being prepared in the kitchen. In the walk-in refrigerator, a tray of bite size, roasted mixed vegetable had been left uncovered to cool. Also, a large block of cheese was opened and partially unwrapped, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and clinical record review, it was determined that the facility staff failed to provide a written notice to the Office of the State Long-Term Care Ombudsman of a hospital transfer for one of 17 residents in the survey sample; Resident #10. The findings include: The facility staff failed to provide a written notice to the ombudsman about a hospital transfer when Resident #10 was transferred to the hospital on 9/21/22. A review of the clinical record revealed a nurse's note dated 9/21/22 that documented, Guest left the facility at about 1430 (2:30 PM) on transfer to [name of hospital] emergency room via [name of company] transportation as ordered. A physician's progress note dated 9/21/22 documented, Pt (patient) is complaining of chest pains Pt is being sent to the ER (emergency room) for further eval (evaluation) Review of the clinical record failed to reveal any evidence of written notification to the ombudsman. On 1/12/23 at 8:35 AM, in an interview with ASM #1 (Administrative Staff Member), the Administrator, she stated that the facility does not send an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, it was determined that the facility staff failed to follow professional standards of practice for medication administration for one of six residents in the medication administration task; Resident #174. The findings include: For Resident #174, the facility staff failed to properly prepare a dose of the medication, Lactulose (1), for administration. A review of the physician's orders revealed one dated 1/9/23 for Lactulose 20 GM (grams) / 30 ML (milliliters), give 15 ml one time a day. On 1/11/23 at 9:21 AM, RN #2 (Registered Nurse) was observed to prepare and administer medications to Resident #174. For the administration of the Lactulose, which was supplied in a 30 ml cup, RN #1 did not measure out the 15 ml ordered dose. Instead, RN #2 encouraged the resident to consume the medication from the prefilled 30 ml cup and then estimated when the resident had consumed approximately half of the cup, then discarded the rest. On 1/11/23 at 5:18 PM an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide clinical services in a manner to promote a resident's highest level of well-being for two of 17 residents in the survey sample, Residents #23 and #7. The findings include: 1. For Resident #23 (R23), the facility staff failed to apply compression stockings per a physician's order. R23 was admitted to the facility on [DATE]. On the admission assessment dated [DATE], R23 was assessed to have both long term and short term memory problems. R 23 was admitted following recent surgery to repair a broken hip. On 1/11/23 at 9:35 a.m., 10:51 a.m., and 1:44 p.m., R23 was sitting up in bed. The resident was not wearing compression stockings at any of these times. A review of R23's physician's orders revealed the following order dated 1/6/23: Compression stockings Midgrade to the knee (BLE) in the morning and remove per schedule. A review of R23's baseline care plan failed to reveal any information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, facility document review, and clinical record review, the facility failed to follow and clarify an order for oxygen for one of 17 residents in the survey sample, Resident #17. The findings include: For Resident #7 (R7), the facility failed to clarify an order for oxygen, and to administer oxygen as ordered. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/9/22, R7 was coded as cognitively intact for making daily decisions, having scored 13 out of 15 on the BIMS (brief interview for mental status). The resident was coded as receiving oxygen prior to admission and during the look back period at the facility. On 1/10/23 at 1:18 p.m., 1/11/23 at 9:35 a.m. and 10:22 a.m., R7 was receiving oxygen via a nasal cannula from an oxygen concentrator. The concentrator was set at 1.5 lpm (liters per minute). A review of R7's clinical record revealed the following order dated 11/28/22: Oxygen 0.5L (liter) to 1L at bedtime. A review of R7's care plan dated 11/28/22 revealed nothing specifically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, it was determined that the facility staff failed to complete annual performance evaluations for two of five CNA (certified nursing assistant) employee records reviewed, CNAs #2 and #3. The findings include: For CNA #2, no performance review had been completed since her hire date of 7/21/22. For CNA #3, no performance review had been completed since 7/13/21. Five CNA employee records were reviewed to determine compliance with the requirement for annual performance reviews. When the facility provided the requested documents, CNA #2's record contained no evidence of any performance reviews since her hire date of 7/21/22. CNA #3's record contained no evidence of a performance review since 7/13/21. On 1/22/23 at 10:08 a.m., ASM (administrative staff member) #1, the administrator, stated she was currently responsible for completing staff performance evaluations. When asked about CNA #2, she stated, It is in progress. I have started on it. When asked about CNA #3, she stated, His is due. I have not gotten a chance to start on it. ASM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to ensure a medication was available for one of six residents in the medication administration task; Resident #174. The findings include: For Resident #174, the facility staff failed to ensure the physician ordered medication, Lidocaine gel (1), was available for use. A review of the physician's orders revealed one dated 1/9/23, to start on 1/10/23, for Lidocaine external gel 4%, apply to left buttock topically in the morning for pain, and remove per schedule. On 1/11/23 at 9:21 AM, RN #2 (Registered Nurse) was observed to prepare and administer medications to Resident #174. RN #2 was unable to locate the Lidocaine gel for Resident #174 in the medication cart. A review of the nurse's notes revealed one dated 1/11/23 that documented in relation to the lidocaine, Pharmacy contacted and reminded to deliver lidocaine patch. Second reminder pending. A nurse's note from the day before, 1/10/23, documented in relation to the lidocaine, new admission, medication pending, MD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to act upon pharmacy recommendations in a timely manner for one of 17 residents in the survey sample; Resident #19. The findings include: For Resident #19, a monthly pharmacy review was conducted on 12/23/22. The review documented in all capital letters at the top, *CLINICALLY URGENT RECOMMENDATION. PROMPT RESPONSE REQUESTED.* As of the survey, on 1/12/23, 2 of the 3 items identified on the review had not been addressed. On the most recent MDS (Minimum Data Set), an admission / 5-day assessment dated [DATE], Resident #19 was coded as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a pharmacy note dated 12/23/22 that documented, See report for any noted irregularities and/or recommendations. A review of the pharmacy's report, dated 12/23/22 documented at the top, *CLINICALLY URGENT RECOMMENDATION. PROMPT RESPONSE…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and resident interview, it was determined that the facility staff failed to comply with all the requirements of a binding arbitration agreement for two of 17 residents in the survey sample; Residents #1 and #19. The findings include: 1. For Resident #1, the facility staff failed to ensure the binding arbitration agreement the resident signed at the time of the most recent admission [DATE]) met all the requirements by law. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #1 was coded as being cognitively intact in ability to make daily life decisions. Resident #1 was coded as requiring supervision for eating and limited assistance for locomotion and hygiene; and extensive assistance to total care for all other areas of activities of daily living. A review of the resident's admission agreement was conducted and the following was revealed: VII. DISPUTE RESOLUTION A. Grievance Policy: The Nursing Facility's Resident Grievance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and resident interview, it was determined that the facility staff failed to ensure the binding arbitration agreements contained explicit language for the selection of an arbitrator and venue, for two of 17 residents in the survey sample; Residents #1 and #19. The findings include: 1. For Resident #1, the facility staff failed to ensure the binding arbitration agreement the resident signed at the time of the most recent admission [DATE]) met all the requirements by law. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #1 was coded as being cognitively intact in ability to make daily life decisions. During a review of the resident's admission agreement, the following document was reviewed: VII. DISPUTE RESOLUTION A. Grievance Policy: The Nursing Facility's Resident Grievance Policy is available upon request and includes components required by applicable law. Contacts for all pertinent State regulatory and informational…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement a complete immunization program for one of five residents immunization record reviews, Resident #10. The findings include: 1. For Resident #10 (R10), the facility staff failed to provide the pneumonia vaccination in a timely manner. R10 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/9/2022, the resident was assessed as being cognitively in making daily decisions. In Section O - Special Treatments, Programs and Procedures, the resident was coded as not being up to date on the pneumococcal vaccination and the vaccine not being offered. Review of R10's clinical record failed to evidence documentation of a pneumococcal vaccine being administered or offered. The admission Evaluation for R10, dated 9/1/2022, documented the date unknown for pneumococcal vaccine. On 1/11/2023 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to dispose of garbage in a sanitary manner. On 8/10/21, the facility staff failed to ensure trash in the garbage compactor was covered. Multiple flies were observed flying above the trash. The findings include: On 8/10/21 at 1:25 p.m., observation of the garbage compactor was conducted with OSM (other staff member) #1 (the director of dining services). The covered portion of the garbage compactor was full and multiple trash bags in the compactor were not covered. Multiple flies were observed flying above the exposed trash bags. OSM #1 stated the facility staff was not able to keep all trash covered when the compactor was full and the housekeeping department would have to call the trash compactor company to empty the compactor. On 8/11/21 at 12:47 p.m., an interview was conducted with OSM #2 (the housekeeping director). OSM #2 stated the housekeeping staff is supposed to compact the trash every time trash is placed into the compactor so the trash moves into the covered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for five of 17 residents in the survey sample, Residents #20, #22, #74, #13 and #8. The facility staff failed to obtain informed consent prior to the use of bed rails for Residents #20, #22, #74, #13 and #8. The findings include: 1. The facility staff failed to obtain informed consent for Resident #20's use of bed rails. Resident #20 was admitted to the facility on [DATE]. Resident #20's diagnoses included but were not limited to diabetes, chronic kidney disease and muscle weakness. Resident #20's admission minimum data set assessment with an assessment reference date of 7/28/21, coded the resident as being cognitively intact. Review of Resident #20's clinical record revealed a therapy communication form dated 7/22/21 that documented Resident #20 needed halo bars (bed rails) to help with bed mobility and transfers. Resident #20's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for six of 17 residents in the survey sample, Residents #18, #20, #22, #74, #13 and #8. The findings include: 1. The facility staff failed maintain wound care physician notes in Resident #18's clinical record. Resident #18 was admitted to the facility on [DATE]. Resident #18's diagnoses included but were not limited to diabetes, major depressive disorder and history of stroke with paralysis. Resident #18's significant change in status minimum data set assessment with an assessment reference date of 6/28/21, coded the resident's cognition as moderately impaired. Review of a facility pressure injury document revealed Resident #18 presented with a facility acquired left heel pressure injury on 6/21/21, a facility acquired right heel pressure injury on 6/21/21, a facility acquired right first toe pressure injury on 7/26/21 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store medications according to professional standards for one of one medication room. Two expired vials of Aplisol PPD (purified protein derivative) solution (1) was stored in the medication room refrigerator available for resident use. The findings include: On [DATE] at 3:59 p.m., observation of the medication room refrigerator was conducted with LPN (licensed practical nurse) #1. A plastic bottle containing one vial of opened PPD solution that was approximately one eighth full had a hand written date of [DATE] on in. Another plastic bottle containing one vial of opened PPD solution that was approximately half full had a hand written date of [DATE] on it. LPN #1 stated she would ask the director of nursing what the hand written date meant. LPN #1 stated PPD solution is good for 30 days after being opened. LPN #1 stated PPD vials that are open for more than 30 days should not be used and should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.