Lynn Care Center

Based on staff interview and facility document review, the facility staff failed to evidence agreements for contractual services for one of one facility. The findings include:The facility staff failed to maintain agreements for services with the contracted wound care company. On 01/09/2026 at approximately 11:00 a.m., a request was made for the facility's contracts for hospice, dialysis, mobile X-ray, mobile laboratory, dental, podiatry, ophthalmology/optometry wound care and psych (psychiatric/psychological) service. On 01/12/2026 at approximately 1:00 p.m. a review of the facility contracts failed to reveal agreements for services with the contracted wound care company. On 01/12/2026 at approximately 4:28 p.m. an interview was conducted with ASM # 4, regional director of operations. ASM #4 stated that when services are initiated with an outside company, the facility has the company sign an agreement and it is kept at the facility. He stated that he was unable to locate the contract for wound care. The facility's policy Consultants documented in part, SPECIFIC PROCEDURES /…

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 follow infection control procedures for one of 52 residents in the survey sample, Resident #8.The findings include:For Resident #8 (R8), the facility staff failed to implement enhanced barrier precautions (1) and follow standard precautions (2) when providing tracheostomy (3) care on 1/6/26.On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/12/25, R8 was coded as being in a persistent vegetative state. She was also coded as requiring an invasive mechanical ventilator for breathing and requiring tracheostomy care.On 1/6/25 at 1:10 p.m., OSM (other staff member) #13, a respiratory therapist, was observed providing tracheostomy care to R8. OSM #13 put on gloves before he entered R8's room and began the tracheostomy care; he did not put on a gown or mask. He used gloved hands to remove the soiled gauze around the resident's tracheostomy, and he did not remove those gloves or sanitize his hands before…

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 employee record review and staff interview, the facility staff failed to provide required training on resident rights for one of five staff records reviewed, OSM (other staff member) #8, a member of the dietary staff. The findings include:For OSM #8, the facility staff failed to provide required resident rights training. On 01/09/2026 at approximately 11:00 a.m., OSM #8's education records were requested. On 01/12/2026 at approximately 10:00 a.m., a review of OSM #8's education record was conducted by the surveyor. The record failed to evidence the required training regarding resident rights. On 01/12/2026 at approximately 11:13 a.m. an interview was conducted with OSM #11, human resources, and OSM #7, regional director of human resources by telephone regarding OSM (other staff member) #8's annual training for resident rights. OSM #11 stated that OSM #8 was a contract employee and only received abuse training. OSM #7 stated that all contract employees receive an orientation packet from the facility's human resource (HR) department that contains the required trainings, 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 employee record review and staff interview, the facility staff failed to provide required training on QAPI (quality assurance and performance improvement)for one of five staff records reviewed, OSM (other staff member) #8, a member of the dietary staff. The findings include:For OSM #8, the facility staff failed to provide required training on QAPI elements. On 01/09/2026 at approximately 11:00 a.m., OSM #8's education records were requested. On 01/12/2026 at approximately 10:00 a.m., a review of OSM #8's education record was conducted by the surveyor. The record failed to evidence the required training regarding QAPI elements. On 01/12/2026 at approximately 11:13 a.m. an interview was conducted with OSM #11, human resources, and OSM #7, regional director of human resources by telephone regarding OSM (other staff member) #8's, annual training for resident rights. OSM #11 stated that OSM #8 was a contract employee and only received abuse training. OSM #7 stated that all contract employees receive an orientation packet from the facility's human resource (HR) department that…

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 employee record review and staff interview, the facility staff failed to provide required infection control training for one of five staff records reviewed, OSM (other staff member) #8, a member of the dietary staff. The findings include:For OSM #8, the facility staff failed to provide required infection control training. On 01/09/2026 at approximately 11:00 a.m., OSM #8's education records were requested. On 01/12/2026 at approximately 10:00 a.m., a review of OSM #8's education record was conducted by the surveyor. The record failed to evidence the required infection control training. On 01/12/2026 at approximately 11:13 a.m. an interview was conducted with OSM #11, human resources, and OSM #7, regional director of human resources by telephone regarding OSM (other staff member) #8's, annual training for resident rights. OSM #11 stated that OSM #8 was a contract employee and only received abuse training. OSM #7 stated that all contract employees receive an orientation packet from the facility's human resource (HR) department that contains the required trainings, and the…

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 employee record review and staff interview, the facility staff failed to provide required training on compliance and ethics for one of five staff records reviewed, OSM (other staff member) #8, a member of the dietary staff. The findings include:For OSM #8, the facility staff failed to provide required training on compliance and ethics. On 01/09/2026 at approximately 11:00 a.m., OSM #8's education records were requested. On 01/12/2026 at approximately 10:00 a.m., a review of OSM #8's education record was conducted by the surveyor. The record failed to evidence the required training on compliance and ethics. On 01/12/2026 at approximately 11:13 a.m. an interview was conducted with OSM #11, human resources, and OSM #7, regional director of human resources by telephone regarding OSM (other staff member) #8's, annual training for resident rights. OSM #11 stated that OSM #8 was a contract employee and only received abuse training. OSM #7 stated that all contract employees receive an orientation packet from the facility's human resource (HR) department that contains the required…

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 employee record review and staff interview, the facility staff failed to provide required behavioral health training for one of five staff records reviewed, OSM (other staff member) #8, a member of the dietary staff. The findings include:For OSM #8, the facility staff failed to provide required behavioral health training. On 01/09/2026 at approximately 11:00 a.m., OSM #8's education records were requested. On 01/12/2026 at approximately 10:00 a.m., a review of OSM #8's education record was conducted by the surveyor. The record failed to evidence the required behavioral health training. On 01/12/2026 at approximately 11:13 a.m. an interview was conducted with OSM #11, human resources, and OSM #7, regional director of human resources by telephone regarding OSM (other staff member) #8's, annual training for resident rights. OSM #11 stated that OSM #8 was a contract employee and only received abuse training. OSM #7 stated that all contract employees receive an orientation packet from the facility's human resource (HR) department that contains the required trainings, and the…

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 ensure medications were available for administration for two of six residents in the survey sample, Residents #1 and #4. The findings include: 1. For Resident #1 (R1), the facility staff failed to ensure Pantoprazole (1), Amantadine (2), Diltiazem (3), Docusate (4), Levetiracetam (5), Oxybutynin (6), Vimpat (7), Tizanidine (8) and Propranolol (9) were available for the scheduled administration times. The nurse's note dated 10/22/24 at 3:45 p.m. documented in part, (R1) was admitted from nursing home via stretcher. The physician orders dated 10/22/24 documented: 1. Pantoprazole Sodium Oral Packet 40 MG (milligrams); Give 1 packet [NAME] G-Tube (gastrostomy) one time a day for gastrostomy status. 2. Amantadine HCL (hydrochloride) Oral Solution 50 MG/5ML (milligrams per 5 milliliters); Give 10 ml via G-tube two times a day for epileptic seizures. 3. Diltiazem HCL Oral Tablet 30 MG; Give 1…

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 notify the physician and/or responsible party when medications were not administered for three of six residents in the survey sample, Residents #1, #3, and #4. The findings include: 1. For Resident #1, the facility staff failed to notify the physican and the responsible party when medications were not available for administration. The physician orders dated 10/22/24 documented: 1. Pantoprazole Sodium Oral Packet 40 MG (milligrams); Give 1 packet [NAME] G-Tube (gastrostomy) one time a day for gastrostomy status. 2. Amantadine HCL (hydrochloride) Oral Solution 50 MG/5ML (milligrams per 5 milliliters); Give 10 ml via G-tube two times a day for epileptic seizures. 3. Diltiazem HCL Oral Tablet 30 MG; Give 1 tablet via G-tube two times a day for HTN (high blood pressure), hold for SBP (systolic blood pressure) < (less than) 100 or HR (heart rate) < 60. 4. Docusate Sodium Oral Liquid 50 MG/5ML;…

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, it was determined the facility staff failed to administer medications/supplements per the physician order for two of six residents in the survey sample, Residents #3 and #4. The findings include: 1. For Resident #3, the facility staff failed to administer Banatrol (1) and Ferrous Sulfate (2) per the physician orders. The physician order dated 1/18/25, documented, Banatrol plus Oral Packet (banana flakes); Give 1 packet via G - tube (gastrostomy tube) one time a day for diarrhea. The physician order dated 1/4/25, documented, Ferrous Sulfate Oral Solution 300 Mg/5ML (milligrams per five milliliters); Give 5 ml via G-Tube one time a day every other day for anemia. The January 2025 and February 2025 MAR (medication administration record) documented the above orders. On 1/10/25, 1/12/25 and 1/14/25, a 9 was documented in the block for the documentation of administration of the Ferrous Sulfate at 9:00 a.m. A 9 indicates Other/See Progress Notes. On 1/19/25 at 3:00 p.m. the Banatrol was documented with a 9 in…

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, it was determined the facility staff failed to review and revise the comprehensive care plan for two of four residents in the survey sample, Resident #2 and #3. The findings include: 1. For Resident #2 (R2), the facility staff failed to review and revise the comprehensive care plan for when the resident was moved to a secured dementia unit. The nurse's note dated 6/11/24 at 5:14 p.m. documented, Resident moved from room (XXX-x) to room (XXX-x) in the Shenandoah Gardens (secured dementia unit) MD (medical doctor) and RP (responsible party) made aware. Tolerating well. Will continue to monitor. The comprehensive care plan dated, 8/24/22, documented in part, Focus: (R2) is an elopement risk/wanderer r/t (related to) impaired safety awareness. The Interventions documented, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Frequent rounding while up in wheelchair. Q (every) 15-minute checks times 1 week. Signage placed…

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 follow professional standards of practice for one of four residents in the survey sample, Resident #1. The findings include: For Resident # (R1), the facility staff failed to clarify a physician's order for the application of compression wraps. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/23/24, the resident scored a 15 out of 15on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The physician order dated, 7/5/23, documented, Bilateral lower legs - wrap with compression wrap once a week for 6 months one time a every Mon (Monday) for edema for 6 months. The nurse's note dated, 7/5/23 at 11:06 a.m. documented, Resident had appointment (Name) Foot and Ankle Center, came back with a new order for edema. Bilateral lower legs - Wrap with compression wrap once a week for 6 months. Resident and Family (son in law) made aware. 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, it was determined the facility staff failed to provide supervision to prevent elopement for three of four residents in the survey sample, Residents #2, #3, and #4. The findings include: 1. For Resident #2 (R2), the facility staff failed to provide supervision to prevent the resident was getting out the doors and falling on the pavement outside the building on 5/27/24. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 6/28/24, the resident scored a three out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section J - Health Conditions, the resident was coded as having had one fall with minor injuries since the last assessment. The resident's mode of mobility was coded as using a wheelchair. The MDS assessment, prior to the elopement, a quarterly assessment, with 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.

Based on observation, staff interview and facility document review, it was determined the facility staff failed to store and prepare food in a sanitary manner in one of one kitchens. The findings include: Observation was made of the kitchen on 1/3/2023 at 6:19 p.m. A ice cream freezer was located just inside the kitchen. Inside the freezer was a fast-food large plastic cup with a straw, with ice in it. An interview was conducted with OSM (other staff member) #14, the cook, on 1/3/2023 at approximately 6:24 p.m. When asked if the fast-food cup in the freezer was resident related, OSM #14 stated, no. Three hard boiled eggs were on the counter. When asked how long the eggs had been out of the refrigerator, OSM #14 stated he believed an hour. Observation was made of a sink, with no tap for water and had a covering over it to cover the drain. Inside this sink were pieces of plastic, small pieces of uncooked spaghetti noodles, plastic closures from bread bags and crumbs. The food sink was observed with stagnant water in the bottom, when asked about the sink, OSM #14 stated the disposal…

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, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to notify the responsible party of a change in condition for one of 44 residents in the survey sample, Resident #18 (R18). The findings include: For R18, the facility staff failed to notify the responsible party of a change in condition requiring a facility initiated transfer to the emergency room on [DATE]. On the most recent MDS (minimum data set) assessment, a five-day assessment with an ARD (assessment reference date) of 11/18/2022, the resident scored a six out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The progress notes for R18 documented in part, - 11/3/2022 19:32 (7:32 p.m.) Note Text : Resident is having loss of fluid to mouth when fed. Will continue to encourage oral fluid. on call NP (nurse practitioner) [Name of NP] notified. - 11/3/2022…

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 clinical record review and staff interview, it was determined that the facility staff failed to evidence that all required documentation was provided to the receiving facility upon a hospital transfer for one of 44 residents in the survey sample; Resident #25. The findings include: For Resident #25, the facility staff failed to evidence what documentation, if any, was sent to the hospital when the resident was transferred on 10/8/22. A review of the clinical record revealed the following: Nurse's note dated 10/8/22 had documented, called hospital to get an update patient has a fracture and is being admitted . Nurse's note dated 10/9/22 had documented, patient found on floor @7:20pm (at 7:20 PM), vital signs taken assessed, MD (medical doctor) and [family member] SENT TO HOSPITAL. There were no notes indicating what, if any, of the required documentation was provided to the hospital. A review of the facility's transfer packet was conducted. This packet consisted of a manila envelope with a Check List for E.R. (Emergency Room) Transfer form attached to the front for the…

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 and staff interview, it was determined that the facility staff failed to evidence that a written notice of a hospital transfer was provided to the resident's representative upon a hospital transfer for one of 44 residents in the survey sample; Resident #25. The findings include: For Resident #25, the facility staff failed to evidence that written notification of a hospital transfer was provided to the resident's representative when the resident was transferred to the hospital on [DATE]. The most recent MDS (Minimum Data Set) a quarterly assessment with an ARD (Assessment Reference Date) of 10/20/22 coded the resident as being severely cognitively impaired in ability to make daily life decisions. A review of the clinical record revealed the following: A nurse's note dated 10/9/22 that documented, patient found on floor @7:20pm (at 7:20 PM), vital signs taken assessed, MD (medical doctor) and [family member] SENT TO HOSPITAL. A physician progress note dated 10/18/22 that documented,…

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 complete a significant change Minimum Data Set (MDS) assessment for one of 44 residents in the survey sample; Resident #25. The findings include: For Resident #25 the facility staff failed to complete a significant change MDS after a hip fracture that resulted in significant decline in functioning. Resident #25 was most recently readmitted to the facility on [DATE] following a fall with a fracture that resulted in hospitalization. The most recent MDS (Minimum Data Set) a quarterly assessment with an ARD (Assessment Reference Date) of 10/20/22 coded the resident as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as not ambulating; as having lower limb limitations; as requiring the use of a wheelchair; as requiring extensive assistance for mobility, transfers, toileting; limited assistance for dressing, hygiene, and bathing;…

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, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to accurately code the MDS (minimum data set) for two of 44 residents in the survey sample, Residents #15 (R15) and #79 (R79). The findings include: 1. For (R15), the facility staff failed to code the quarterly MDS (minimum data set) for the use of oxygen. Resident #15 was admitted to the facility with diagnoses that included but were not limited to: respiratory failure (1). On the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 10/19/2022, the (R15) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs failed to code (R15) for Oxygen Therapy. On 01/04/2023 at approximately 8:44 a.m., (R15) was observed sitting in their room in a wheelchair receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between four 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, resident interview, staff interview, facility document review, and clinical record, the facility staff failed to complete a baseline care plan for two of 44 residents in the survey sample, Residents #337 and #237. The findings include: 1. For Resident #337 (R337), the facility staff failed to include the resident's non-weightbearing status on the baseline care plan. R337 was admitted [DATE] with diagnoses of bilateral foot infections and bilateral toe amputations. R337 did not have a complete MDS (minimum data set) at the time of the survey. A review of the admission assessment dated [DATE] revealed the resident had no cognitive deficits, and required assistance with activities of daily living. On 1/4/23 at 8:18 a.m., R337 was sitting up on the side of the bed. Both feet were wrapped completely in white gauze bandages. R337 stated they had been admitted to the facility after having surgery to amputate toes on both feet because of an infection in the bones of both feet. The resident stated…

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 interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to implement the care plan for two of 44 residents in the survey sample, Resident #32 and Resident #15. The findings include: 1. For Resident #32, the facility staff failed to implement the comprehensive care plan for two-person transfer. Resident #32 was admitted to the facility on [DATE] with diagnosis that included but not limited to: osteoporosis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/26/22, coded the resident as scoring a 08 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance of two persons for transfers. A review of the comprehensive care plan dated 2/15/22 revealed, FOCUS: The resident has a…

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, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to review and revise the care plan for one of 44 residents in the survey sample, Resident #18 (R18). The findings include: For R18, the facility staff failed to review and revised the comprehensive care plan after a pressure injury developed on the right heel. On the most recent MDS (minimum data set) assessment, a five-day assessment with an ARD (assessment reference date) of 11/18/2022, the resident scored a six out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section M documented R18 at risk of developing pressure injuries and not having any pressure injuries at the time of the assessment. Review of the facility wounds at the time of the survey documented R18 having a Stage 1 pressure injury (1) to the right heel identified on 12/7/2022. The comprehensive care plan for R18 dated 4/27/2022 documented in part, [R18] has a…

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, resident interview, staff interview, facility document interview, and clinical record review, it was determined that the facility staff failed to obtain a physician's order for a newly-admitted resident's method of transfer from bed to chair for one of 44 residents in the survey sample, Resident #337. The findings include: For Resident #337 (R337), a new admission, the facility staff failed to obtain a physician's order for the resident's non-weightbearing status. R337 was admitted [DATE] with diagnoses of bilateral foot infections and bilateral toe amputations. R337 did not have a complete MDS (minimum data set) at the time of the survey. A review of the admission assessment dated [DATE] revealed the resident had no cognitive deficits, and required assistance with activities of daily living. On 1/4/23 at 8:18 a.m., R337 was sitting up on the side of the bed. Both feet were wrapped completely in white gauze bandages. R337 stated they had been admitted to the facility after having surgery to…

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 provide toenail care to one of 44 residents in the survey sample, Resident #17. The findings include: For Resident #17, the facility failed to provide toenail care which resulted in thick, curved, overgrown toenails. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12-22-22, Resident #17 (R17) was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). R17 was coded as being dependent on staff for bathing and personal hygiene. On 1/4/23 at 8:12 a.m., R17 was sitting up in bed with eyes closed. R17's feet were visible at the end of the bed. Toenails on both feet were yellow, with both great toenails thick, longer than the end of the toe, and cracked. The skin around the great toenails was dry and scaly. The right great toenail was long and curved over the top of the resident's toe. The toenails on the other toes…

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, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for one of 44 residents in the survey sample, Resident #15 (R15). The findings include: For (R15), the facility staff failed to maintain (R15's) oxygen flow rate at four liters per minute according to the physician's orders. Resident #15 was admitted to the facility with diagnoses that included but were not limited to: respiratory failure (1). On 01/04/2023 at approximately 8:44 a.m., (R15) was observed sitting in their room in a wheelchair receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between four and four-and-a-half liters per minute. On 01/04/2023 at approximately 10:19 a.m., (R15) was observed sitting in their room in a wheelchair receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between four and four-and-a-half liters per minute. On 01/04/2023 approximately 2:45 p.m., (R15)…

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, clinical record review, and facility document review, it was determined that the facility staff failed to provide care and services for a complete dialysis (1) program for one of 44 residents in the survey sample, Resident #237 (R237). The findings include: For (R237) the facility staff failed to obtain a physician's order for dialysis care and treatment, and failed to provide a dialysis communication form for (R237's) dialysis visit on 01/02/2023. (R237) was admitted to the facility with diagnoses included but were not limited to: end stage renal failure (2). The facility's admission assessment for (R237) dated 12/27/2022 documented that (R237) was oriented to person, place, time and situation. On 01/04/2023 at approximately 10:00 a.m. a review of the physician's order sheet for (R237) failed to evidence an order for dialysis. On 01/04/2023 at approximately 10:05 a.m., an interview was conducted with LPN (licensed practical nurse) #3. When asked about a physician's order for (R237's) dialysis LPN #3 checked the physician's orders for…

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, resident interview, staff interview, facility document review, and clinical record, the facility staff failed to assess a resident for the safe use of side rails for one of 44 residents in the survey sample, Resident #337. The findings include: For Resident #337 (R337), the facility staff failed to assess the resident for the safe use of side rails when the resident was admitted . R337 was admitted on [DATE]. R337 did not have a complete MDS (minimum data set) at the time of the survey. A review of the admission assessment dated [DATE] revealed the resident had no cognitive deficits, and required assistance with activities of daily living. On 1/4/23 at 8:18 a.m. and 1/5/23 at 9:35 a.m., R337 was sitting up on the side of the bed. At both observations, quarter side rails were up on both sides at the head of the resident's bed. R337 stated they had been admitted to the facility after having surgery. The resident stated they could not transfer from bed to chair without a mechanical lift, 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 employee record review it was determined that the facility staff failed to ensure three of five CNAs (certified nursing assistants) received annual performance reviews, CNA #4, #5, and #6. The findings include: On 01/05/2023 an employee record review was conducted to include the annual performance reviews of five CNAs. This review revealed the following: 1. CNA # 4 hired 12/17/2018, revealed no evidence of performance review between 12/17/2021 and 12/17/2022. 2. CNA # 5 hired 10/22/2018, revealed no evidence of performance review between 10/22/2021 and 10/22/2022. 3. CNA # 6 hired 03/09/2020, revealed no evidence of performance review between 03/09/2021 and 03/09/2022. On 01/05/2023 at approximately 4:40 p.m., ASM (administrative staff member) #1, administrator ASM #2, director of nursing, ASM #5, regional nurse consultant and ASM #6, maintenance director, were made aware of the above findings. On 01/06/2023 at approximately 9:57 a.m. an interview was conducted with ASM (administrative staff member) #1, administrator. When asked for the…

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 in the course of a complaint investigation, it was determined the facility staff failed to prepare and serve food at an appetizing temperature in one of three nursing units, Shenandoah Farms. The findings include: Observation was made of the tray line and food delivery on 1/4/2023 at 11:04 a.m. The temperatures were as followed: Ham slices - 151 degrees Cauliflower - 161 degrees Sweet potatoes - 63 degrees - removed from tray line by staff; new pan 158 degrees. White rice - 165 degrees Chopped ham - 160 degrees Chopped cauliflower - 165 Pureed sweet potatoes - 129 degrees - removed from tray line by staff, new pan 158 degrees. Pureed ham - 167 - degrees Mashed potatoes - 158 - degrees Pureed cauliflower - 179 - degrees Gravy - 167 - degrees Observation was made that the hot pellets were not being used under the plates. The plates did come from a warmer. The cart with the food trays left the kitchen at 1:10 p.m. Observation was made of the staff on Shenandoah unit passing the trays and assisting resident to eat. On 1/4/2023 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 the facility staff failed to ensure a staff member was a trained feeding assistant prior to allowing staff member (OSM #17) to feed one of 44 residents in the survey sample, Resident #26 (R26). The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/21/2022, the resident scored a one out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired for making daily decisions. In Section G - Functional Status, R26 was coded as requiring supervision with one-person physical assistance for eating. The comprehensive care plan dated, 10/5/2022, documented in part, Focus: (R26) has an ADL (activities of daily living) self-care performance deficit AEB (as exhibited by) need for physical assist with ADL self-performance debility. The Interventions documented in part, Physical assist as needed with ADL self-care. Provide supervision and cuing as needed to promote…

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 the facility staff failed to maintain kitchen equipment in operating condition in one of one kitchens. The three-compartment sink was not functional. The findings include: Observation was made of the kitchen on 1/3/2023 at 6:19 p.m. In the dish room the dishwasher was observed. On the opposite side of the room was the three-compartment sink. There were pans stacked in the middle sink in water. There was no water or chemicals in the two other sinks. An interview was conducted with OSM (other staff member) #15, the dietary manager, on 1/3/2023 at approximately 6:40 p.m. When asked what is wrong with the three-compartment sink, OSM #15 stated it's clogged up and it doesn't work and the grease trap is not working. A policy on the use and maintenance of the three-compartment sink was requested on 1/4/2023 at 3:31 p.m. from ASM #1. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 1/4/2023 at 3:58 p.m. When asked why the three-compartment sink is not…

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 employee record review it was determined that the facility staff failed to ensure CNAs (certified nursing assistants) received required training as part of the annual performance reviews for three of five CNA records reviewed, CNA #4, #5, and #6. The findings include: On 01/05/2023 an employee record review was conducted of the annual retraining transcripts of five CNAs. This review failed to evidence the following required training for the CNAs: 1. CNA # 4, hired 12/17/2018, revealed no evidence of dementia, abuse/neglect, infection control and emergency preparedness training between 12/17/2021 and 12/17/2022. 2. CNA # 5, hired 10/22/2018, revealed no evidence of dementia, abuse/neglect, infection control and emergency preparedness training between 10/22/2021 and 10/22/2022. 3. CNA # 6, hired 03/09/2020, revealed no evidence of dementia, abuse/neglect and infection control training between 03/09/2021 and 03/09/2022. On 01/05/2023 at approximately 4:40 p.m., ASM (administrative staff member) #1, administrator ASM #2, director of nursing, ASM #5, regional…

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 and staff interview, it was determined facility that the facility staff failed to store food in a sanitary manner. In the walk in freezer one nine pound half full box of crab cakes and one half full one pound box of frozen egg patties were observed open to the environment, and in the walk in refrigerator one 40 ounce package of provolone cheese was open to the environment. A mixer and blender on a food preparation table available for use were observed with food debris in the mixer bowl and the blender pitcher. The findings include: On 08/29/2021 at approximately 2:00 p.m., an observation of the facility's kitchen was conducted with OSM [other staff member] # 1, dietary clerk. Observation of the walk-in freezer in the facility's kitchen revealed the following: One - nine pound box of frozen crab cakes approximately half full, open to the environment. One - 11.25 pound box of frozen egg patties approximately half full, sitting on the middle shelf open to the environment available for use. Observation of the walk-in refrigerator in the facility's kitchen revealed…

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 the comprehensive care plan for two of 28 residents in the survey sample, Residents #6 and #73. The facility staff failed to implement weekly skin assessments per Resident #6's comprehensive care plan, and failed to implement Resident #73's comprehensive care plan for fall mats. The findings include: 1. Resident #6 was admitted to the facility on [DATE]. Resident #6's diagnoses included but were not limited to a fractured right leg, heart failure and muscle weakness. Resident #6's quarterly minimum data set with an assessment reference date of 5/31/21, coded the resident's cognition as moderately impaired. Review of Resident #6's clinical record revealed a nurse's note dated 12/9/20 that documented the resident returned from the emergency department on 12/9/20 with a right knee immobilizer due to a right leg fracture. A physician's order dated 12/9/20…

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 review and revise the comprehensive care plan for one of 28 residents in the survey sample, Resident #6. The facility staff failed to review and revise Resident #6's comprehensive care plan when Resident #6 developed a DTI (deep tissue injury) pressure injury (1) on 12/21/20. The findings include: Resident #6 was admitted to the facility on [DATE]. Resident #6's diagnoses included but were not limited to a fractured right leg, heart failure and muscle weakness. Resident #6's quarterly minimum data set with an assessment reference date of 5/31/21, coded the resident's cognition as moderately impaired. A nurse's note dated 12/21/20 documented, Received new orders from NP (nurse practitioner) to apply 'blue boots' to resident's bilateral feet. Also Nursing noted DTI to distal RLL (right lower leg). Area is being rubbed by resident's brace. Applied mepilex border (a dressing used to…

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 provide adequate supervision and implement a fall intervention for two of 28 residents in the survey sample, Resident #41 and 73. 1. On 7/21/21, staff observed Resident #73 inappropriately touch Resident #41 on the thigh. The facility staff failed to provide adequate supervision to ensure Resident #41 was not inappropriately touched again by Resident #73. Within a half hour of the first incident, Resident #73 was observed by staff with his hand inside of Resident #41's shirt. 2. The facility staff failed to implement fall mats per the plan of care for Resident #73 who had a history of falls and who was assessed and as being high risk for falls. The findings include: 1. Resident #73 was admitted to the facility on [DATE]. Resident #73's diagnoses included but were not limited to dementia, chronic kidney disease and heart failure. Resident #73's annual minimum data set…

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, resident interview, facility document review and clinical record review, it was determined the facility staff failed to evidence of ongoing communication and collaboration with the dialysis facility for one of 28 resident in the survey sample, Resident #29. The dialysis communication records for Resident #29, from 7/28/21-8/25/21, evidenced a total of three missing communication forms for the dates of: 8/11, 8/16, and 8/27. The findings include: Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to: end stage renal disease 'ESRD' (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (1) and chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (2), dementia (progressive state of mental decline especially of memory function and judgement and often accompanies by disorientation and loss of ability to plan and organize) (3) and Parkinson'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 review of facility documentation it was determined the facility staff failed to ensure expired medications were not available for resident administration on two of six medication carts, (Blue Ridge Terrace Unit medication cart, and Sycamore Terrace Unit medication cart). Observation revealed four Prosource (1) 1.5 milliliter pouches, with an expiration date of 10/24/220 were available for administration on the Blue Ridge Terrace Unit medication cart and a bottle of polyethylene glycol (2) with an expiration date of 08/24/2021, was available for resident administration on the Sycamore Terrace Unit medication cart. The findings include: On 8/30/21 at 11:00 AM, an observation of the facility's Blue Ridge Terrace Unit medication cart was conducted with LPN (licensed practical nurse) #8. This medication cart was located in the red portion of the Blue Ridge Terrace Unit. In the bulk medication drawer, four -Prosource (1) 1.5 milliliter pouches were found with an expiration date of 10/24/220. On 08/30/2021 at approximately 2:30 PM, an observation…

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, and staff interview, it was determined that the facility staff failed to ensure expired laboratory medical supplies were not available for resident use in one of two facility medication storage rooms, Blue Ridge Terrace Unit medication storage room. The first floor medical supply cabinet was observed to contain multiple expired laboratory tube supplies that were available for resident use. The findings include: On [DATE] at 11:15 AM, an observation of the facility's Blue Ridge Terrace Unit medication storage room was conducted with LPN[licensed practical nurse] #8. This medication storage room was located in the yellow portion of the Blue Ridge Terrace Unit. Expired laboratory [lab] tubes available for use were observed and included the following: three pink top 6.0 milliliter tubes with expiration date of [DATE], four yellow top 5.0 milliliter tubes with expiration date of [DATE], seven yellow top 5.0 milliliter tubes with expiration date of [DATE] and 13 red top 6.0 milliliter tubes with…

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.