Harrisonburg Hlth & Rehab Cntr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain a performance improvement program that corrected previously identified concern regarding a clean, comfortable, homelike environment and ensure the availability of linen sufficient to provide daily care of residents. The facility's quality assurance and performance improvement program failed to ensure thd implementation of actions to improve and sustain regulatory compliance, which affected residents on three of three units. The findings included:On 4/13/26, upon surveyor entry to the facility, observations were conducted on each of the three resident units. The facility was found to be unclean, floors severely soiled, rooms overcrowded, and there was a lack of adequate linen. On 4/13/26, observations of Residents #101, #103, #107, and #114's rooms on 3 different units were noted to be hoarded with boxes, food items, personal items, and plastic storage containers in front of, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews, and staff interviews, the facility failed to ensure a heater was functioning for one of forty-three residents and failed to maintain essential equipment for one of four washers and one of four dryers in the laundry area. The findings included: 1. Resident #80 (R80) did not have a proper standard functioning heating system and relied on a portable heater. On 2/10/2026 at 2:41 p.m. an interview was conducted with R80. During the interview it was noted that R80 was using a portable electric heater to heat the room. R80 verbalized the permanent heating system had not been working for months. On 2/11/2026 at 4:37 p.m. the maintenance director was interviewed regarding the heating system in room [ROOM NUMBER] where R80 resided. The maintenance director explained that the facilities heating comes from a boiler system and a coil had busted in R80's room which resulted in water escaping. The heating unit had to be taken off-line and R80 refused to move out of the room, so 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 observation, and staff interview, the facility staff failed to maintain a clean and sanitary environment for nine of 89 resident rooms (rooms #86, #26, #19, #12, #6, #5, #3, #41, and #34), six of 89 resident room bathrooms (resident room bathrooms #84, #27, #8, #5, and #35, and #34), and two of three units (the South unit and East unit). The findings include:On 7/15/26 at 8:55 a.m., an observation of the facility was conducted. Layers of sticky dirt and dust were observed in the vents of the heating/air conditioning units in rooms #86, #26, #19, #12, #6, #5, #3, #41, and #34, in the ceiling air vents in the resident room bathrooms #84, #27, #8, #5, and #35, and #34, and in the ceiling air vents at the South unit nurse's station, and on the East unit short hall and the East unit long hall.On 7/15/26 at approximately 3:35 p.m., an interview was conducted with the Director of Maintenance. The Director of Maintenance stated the maintenance staff typically clean the vents of the heating/air conditioning units in the resident rooms and the ceiling air vents in the resident…

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, facility document review and clinical record review, the facility staff failed to assess one of forty-three residents for safe self-administration of medication (Resident #44).The findings include:Resident #44, with a self-managed insulin pump, had no assessment for self-administration of medication.Resident #44 (R44) was admitted to the facility with diagnoses that included hip fracture, diabetes, anemia, osteoporosis, hypothyroidism, cerebral infarction, major depressive disorder and asthma. The minimum data set (MDS) dated [DATE] assessed R44 as cognitively intact.On 2/10/26 at 1:49 p.m., R44 was interviewed about medication administration, including insulin. R44 stated she had an insulin pump for management of diabetes that provided insulin and monitoring of blood sugar levels. R44 stated she had the insulin pump prior to admission to the facility, had managed the pump/insulin without difficulty for years and that her family member provided supplies as needed.…

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, facility document review and clinical record review, the facility staff failed to protect the resident's right to be free from verbal abuse by a staff member for one of forty-three residents in the survey sample (Resident #44).The findings include:In response to a request for assistance with the bedpan, a certified nurse's aide (CNA #8) yelled at Resident #44, told R44 to change her own brief and provided rushed assistance with bedpan placement. Resident #44 (R44) was admitted to the facility with diagnoses that included hip fracture, diabetes, anemia, osteoporosis, hypothyroidism, cerebral infarction, major depressive disorder and asthma. The minimum data set (MDS) dated [DATE] assessed R44 as cognitively intact.On 2/10/26 at 1:36 p.m., R44 was interviewed about quality of life/care in the facility. When asked about any concerns with abuse, R44 stated she recently reported an issue with a CNA and that the facility had addressed the incident. R44 stated late one…

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, resident/staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for one of 37 residents in the survey sample, Resident #233.The findings include: The facility staff failed to complete an accurate MDS (minimum data set), an annual assessment for Resident #233. Resident #233 (R233) was admitted to the facility on [DATE] with diagnosis that included but were not limited to idiopathic neuropathy, left toe amputation and depression. The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/11/26, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is oriented to person, place and time and has unimpaired immediate recall. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision 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 resident interview, staff interview, facility document review and clinical record review, the facility staff to develop a comprehensive care plan for two of forty-three residents in the survey sample (Residents #44 and #198). The findings include:1. Resident #44 had no plan of care developed regarding self-administration of insulin and self-management of an insulin pump. Resident #44 (R44) was admitted to the facility with diagnoses that included hip fracture, diabetes, anemia, osteoporosis, hypothyroidism, cerebral infarction, major depressive disorder and asthma. The minimum data set (MDS) dated [DATE] assessed R44 as cognitively intact. On 2/10/26 at 1:49 p.m., R44 was interviewed about medication administration, including insulin. R44 stated she had an insulin pump for management of diabetes that provided insulin and monitoring of blood sugar levels. R44 stated she had the insulin pump prior to admission to the facility, had managed the pump/insulin without difficulty for years and that a family…

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, staff interview, and facility document review, it was determined that the facility staff failed to revise the comprehensive care plan for one of 37 residents in the survey sample, Resident #215. The findings include:For Resident #215 (R215), the facility staff failed to revise the comprehensive care plan regarding smoking status. On the most recent annual minimum data set (MDS) with an assessment reference date (ARD) of 2/2/2026, the resident was assessed as being a current tobacco user. The comprehensive care plan for R215 documented in part, The resident prefers to smoke cigarettes. Created on: 07/12/2024. Revision on: 12/28/2025. Under Interventions it documented in part, .May smoke independently. Created on: 08/14/2024 . Supervise with smoking. Created on: 03/12/2026. On the most recent smoking safety screen dated 3/13/2026, R215 was assessed as scoring a five indicating they required supervison with smoking. The section of the assessment titled Care Plan documented in part, Intervention: May smoke independently .Intervention: supervise 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to meet professional standards for two of 37, Resident #205 and Resident #216.The findings include: 1.The facility staff failed to meet professional standards by entering an order May go out on LOA (leave of absence) independently for Resident #205. Resident #205 (R205) was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident), COPD (chronic obstructive pulmonary disease) and DM (diabetes mellitus). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/16/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is oriented to person, place and time and has unimpaired immediate recall. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximum assist…

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 interviews, and clinical record review, the facility staff failed to ensure enteral nutritional feeding was administered according to physician's order for one of forty-three residents in survey sample (Resident #2).Findings include:Resident #2 was admitted to the facility on [DATE] with diagnoses to include but not limited to pulmonary embolism, tracheostomy, cerebral palsy, generalized epilepsy, neuromuscular dysfunction of the bladder, chronic respiratory failure, severe intellectual disabilities, bipolar depression, and dysphagia. Resident #2's most recent MDS (Minimum Data Set Assessment with ARD (Assessment Reference Date) of 11/20/25 coded her Section C. Cognitive Status as 99 unable to complete interview and Section K. Nutritional Approaches coded Yes for tube feeding.On 2/11/26 at 11:00AM, Resident #2's enteral pump was observed with Osmolite 1.5 (a specialized, high-protein, and low-residue enteral nutrition formula designed for tube feedings, a feeding through an opening 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 observations and staff interview, it was determined that the facility staff failed to dispose of refuse properly. The facility staff failed to maintain a clean dumpster area during the facility task- kitchen observation on 2/10/26 at 11:40AM.Findings include:On 2/10/26 at 11:50AM, an observation was conducted in the dumpster area outside of the kitchen, with the Dietary Manager. One dumpster was observed with top flaps pushed all the way back resting on the edge of the loading dock overflowing with bags of trash. The other dumpster was positioned in front of the open overflowing dumpster with the side door open. On the ground, on both sides of the dumpsters, the snow-covered area was littered with gloves, paper towels, candy wrappers, straws, and plastic cup lids., forks and spoons The loading dock was observed with pieces of trash, two wheelchairs and two mattresses. An interview was conducted with the Dietary Manager on 2/10/26 at the time the dumpster area was inspected. When asked about the findings, the Dietary Manager stated, the waste disposal company comes twice 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 and employee record review, the facility staff failed to provide required training in communication for one of ten employee records reviewed, RN (Registered nurse) #1. The findings include:On 2/11/2026 at approximately 12:20 p.m., a request was made for the employee training records for RN #1. The review of the employee training records revealed that RN #1 did not have the required training in communication. On 2/12/2026 12:36 PM, the Regional Director of Clinical Services, stated that the RN did not have the training in communication, QAPI and Ethics and compliance. For some reason, it wasn't triggered in their electronic education program for her to take these. The facility policy, Continuing training documented in part, All nursing staff will participate at a minimum in the following mandatory, annual in-services .bb. Effective Communication. The Administrator and [NAME] President of Operations were made aware of the above findings on 2/12/2026 at 12:45 p.m.

Based on staff interview, facility document review and employee record review, the facility staff failed to provide required training in quality assurance performance improvement (QAPI) for one of ten employee records reviewed, RN (Registered nurse) #1. The findings include: On 2/11/2026 at approximately 12:20 p.m., a request was made for the employee training records for RN #1. The review of the employee training records revealed that RN #1 did not have the required training in quality assurance performance improvement. On 2/12/2026 12:36 PM, the Regional Director of Clinical Services, stated that the RN did not have the training in communication, QAPI and Ethics and compliance. For some reason, it wasn't triggered in their electronic education program for her to take these. The facility policy, Continuing training documented in part, All nursing staff will participate at a minimum in the following mandatory, annual in-services .y. Quality Assurance Performance Improvement. The Administrator and [NAME] President of Operations were made aware of the above findings on 2/12/2026 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 employee record review, the facility staff failed to provide required training in ethics and corporate compliance for one of ten employee records reviewed, RN (Registered nurse) #1. the findings include: On 2/11/2026 at approximately 12:20 p.m., a request was made for the employee training records for RN #1. The review of the employee training records revealed that RN #1 did not have the required training in communication. On 2/12/2026 12:36 PM, the Regional Director of Clinical Services, stated that the RN did not have the training in communication, QAPI and Ethics and compliance. For some reason, it wasn't triggered in their electronic education program for her to take these. The facility policy, Continuing training documented in part, All nursing staff will participate at a minimum in the following mandatory, annual in-services .bb. Effective Communication. The Administrator and [NAME] President of Operations were made aware of the above findings on 2/12/2026 at 12:45 p.m.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to follow physician orders for two of eleven residents in the survey sample (Residents #1 and #7).The findings include:1. Facility staff failed to order and administer an eye medication for over 30 days, as recommended by an eye physician for treatment of Resident #1's glaucoma. Resident #1 (R1) was admitted to the facility with diagnoses that included glaucoma, diverticulosis, bipolar disorder, autism, diabetes, obesity, anxiety, personality disorder, sleep apnea, chronic respiratory failure, Crohn's disease and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. On 9/22/25 at 12:45 p.m., R1 was interviewed about quality of life/care in the facility. R1 stated during this interview that he was evaluated by an eye doctor in the facility about a month ago and had not received a new eye drop recommended by the provider for treatment of…

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 interviews and clinical record review, the facility staff failed to develop a care plan for one of eleven residents in a survey sample.Resident #4 (R4) did not have a care plan for bowel incontinence.The findings included: Resident #4 (R4) diagnoses include diabetes, congestive heart failure, respiratory failure, and peripheral vascular disease. The most recent MDS was a quarterly assessment dated [DATE]. R4 was assessed with a cognitive score of 15 indicating cognitively intact. Section H of R4's MDS indicated R4 is incontinent of bowel.On 9/22/25 at 2:30 p.m. R4 was interviewed. R4 verbalized being incontinent of bowel explaining numbness from the waist down and could not tell if a bowel movement had occurred and needed to be checked on frequently. Review of R4's care plan did not indicate that R4 had a care plan in place for bowel incontinence. On 9/22/25 3:15 p.m. certified nursing assistant CNA #1 was interviewed. CNA #1 verbalized taking care of R4 on a regular basis and will check R4 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 resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide timely incontinence care for two of eleven residents in the survey sample (Residents #2 and #5).The findings include:1. Resident #2 did not have timely incontinence care during the early morning on 6/7/25.Resident #2 (R2) was admitted to the facility with diagnoses that included quadriplegia, spinal cord compression, insomnia, gastroesophageal reflux disease and hypertension. The minimum data set (MDS) dated [DATE] assessed R2 as cognitively intact and frequently incontinent of bowel/bladder.On 9/23/25 at 8:30 a.m., Resident #2 was interviewed about a report by staff on 6/7/25 that the resident did not get timely incontinence care. R2 stated he remembered that night and that the CNA (certified nurse's aide) caring for him that early morning was new. R2 stated he slept most of the night, recalled the CNA bringing in water but did not recall when or if incontinence care was…

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, resident interview, staff interview, and facility documentation the facility staff failed to serve a palatable meal to two residents, Resident #7 (R7) and Resident #10 (R10) out of a survey sample of eleven residents.The findings included:On 9/23/25 at 12:00 p.m., an observation was conducted during the lunchtime meal service in the main dining room. During this observation, it was noted that several residents was not eating their meal. One resident complained about the temperature of the food. She stated that the food was not served hot and that is how she likes her food.On 9/23/25 at 12:11 p.m., a test tray was conducted. The tray served included: baked ham, mixed vegetables, scalloped potatoes, a roll, and a brownie. Food temperatures were taken with the following results:Baked ham: 121.6 FScalloped potatoes: 138.4 FMixed vegetables: 129.7 FRoll and brownie: served at room temperatureFor comparison, temperatures obtained in the kitchen prior to service were:Baked ham: 180 FScalloped potatoes: 190 FMixed vegetables: 183 FThe test tray food items were noted as…

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, resident interview, staff interview and facility documentation the facility staff failed to provide the residents preference with the meals for three residents, Resident #9 (R9), Resident #10 (R10), and Resident #11 (R11) out of a survey sample of eleven residents. The findings included: On 9/23/25 at 12:00 p.m., an observation was conducted during the lunchtime meal service in the main dining room. During this observation, it was noted that three residents did not receive their stated meal preferences as listed on their meal tickets. Specifically, two residents, R10 and R11, had preferences for baked potato with meals and milk, and one resident, R9 preferred dessert and milk. These preferences were not honored during the lunch service. On 9-23-25 at 12:00 p.m., during the lunchtime meal service, resident interviews were conducted.R9 stated, she never receives her dessert without having to ask for it and reported that she does not receive her milk with meals.R10 stated, she does not receive her milk with meals and that condiments are not provided on her…

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 documentation review, the facility staff failed to have medications available for administration for one resident (resident #102-R102) in a survey sample of twenty-three residents. The findings included: For R102, the facility staff failed to have two medications, niacin and oxycodone available for administration as ordered by the medical provider. On 6/3/25 at 11:31 a.m., an interview was conducted with R102. During the interview, R102 expressed concerns regarding care but did not verbalize any concerns with medications. On 6/3/25-6/4/25, a clinical record review was conducted of R102's chart. This review revealed that R102 had an active order for oxycodone-acetaminophen tablet 7.5-325 mg to be given every 12 hours for shoulder pain and low back pain. R102 had another order for oxycodone-acetaminophen tablet 7.5-325 mg to be given every six hours as needed for pain. According to the medication administration records, the oxycodone-acetaminophen was not given on 5/24/25, for the evening dose.…

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, resident interview, staff interview, and facility documentation review, the facility staff failed to provide a safe, functional and comfortable environment for one resident (Resident #123- R123), in a survey sample of twenty-three residents. The findings included: On 6/3/25 at 4:15 p.m., an interview was conducted with R123 in his room. R123 verbalized concern that his air conditioning in his room has not been working for several weeks. R123 stated that it was supposed to start getting warm, into the mid-upper 80's this week, and was concerned that his room would be too warm, cause him to be uncomfortable and exacerbate his breathing issues. R123 reported he has told staff about the air not working several times, but nothing has been done. R123 also verbalized concern about his and his roommate's closet doors. He reported that the drawers hit the doors above them, and you can't open them. He said it has been like that for over a year, since a prior roommate broke them, and he has been complaining but nothing has been done. R123 also expressed concern about 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 observation, staff interviews and facility documents, the facility staff failed to maintain an effective pest control program that affected three of three units. The findings included: The facility staff did not maintain an effective pest control program for the center. On 4/2/25 at 3:00 p.m., a tour of the facility's nursing units was conducted, and no concerns were noted. On 4/3/25 at 9:26 a.m., an interview was conducted with a licensed practical nurse LPN#17. LPN#17 said, If we see an ant in the room, I will put gloves on and kill all I see, fill out form on PCC (point click care), and that goes to maintenance man. Then I report it to the administrator and director of nursing. On 4/4/25 at 11:45 a.m., an interview was conducted with the administrator. The administrator presented the invoices from the pest control company from October 2024, November 2024, December 2024 and March 2025. The administrator shrugged his shoulders when asked about no pest control being in the building for the months of January and February 2025. The administrator stated that pest control was…

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, resident and staff interview and facility documentation review, the facility staff failed to provide a comfortable environment with internal temperatures affecting two of three units. The findings included: For the east and west wings, the facility staff failed to maintain comfortable temperatures within resident areas when the boiler was not operating properly. On 4/2/25 at 3 p.m., upon the survey team arrival to the facility, it was noted that a portable boiler was set-up in the parking lot. On 4/3/25 at 1:30 p.m., resident #3-R3 was visited in her room and a family member was present visiting. R3 and her family member were interviewed about the temperature in the facility. The family member stated, They have boilers for the heat after all the complaints, it took two to three days to get them up and running. I talked to the police department and requested a welfare check. On 4/3/25 at 1:30 p.m., during the above interview, R3 reported that she recalled saying, My God it's cold in here. I had a couple of sheets on me and my feet was froze! On 4/3/25 at 2:10…

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, clinical record review and facility documentation review, the facility staff failed to ensure medications were available for administration in accordance with physician orders for one resident (Resident #8-R8) in a survey sample of 26 residents. The findings included: For R8, the facility staff failed to have Latanoprost eye drops available for administration as ordered by the physician. On 4/3/25 at 5 p.m., an interview was conducted with R8. During the interview R8 expressed concerns that frequently he doesn't receive his eye drops for glaucoma. On 4/3/25 and 4/4/25, a clinical record review was conducted of R8's chart. According to the physician orders, R8 was to receive Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma. The order for the eye drops was originally written 2/14/24 and remained an active order at the time of survey. On 4/10/25 at 3:30 p.m., interviews were conducted with two of the licensed practical nurses (LPN #16 & LPN #18). When asked what they do when administering medications and 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 observation and staff interviews, the facility staff failed to follow infection control standards on three of three units. The findings included: The facility staff failed to handle soiled linen and disposing of incontinent briefs according to infection control standards. On 4/2/25 at 3:10 p.m., an observation was made during the initial tour of the facility. On the south wing an employee (other staff#11, OS11) was observed transporting dirty linen that was not in a bag, carrying it up against her body and without wearing gloves. On the [NAME] wing the shower room was observed with dirty linen laying on the floor and a soiled incontinent brief in the trash can without a liner. On 4/2/25 at 3:40 p.m., an interview was conducted with a certified nursing assistant CNA#1 (CNA1). CNA1 said, absolutely not should dirty linen be on the floor or that brief in that trash can like that. CNA1 stated that he was going to take care of this as soon as possible. He stated dirty linen should be bagged up and taken to soiled utility room. He also stated the brief was to be bagged and put 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, resident interview, staff interview and facility document the facility staff failed to maintain a sanitary environment for rooms on three of three units. The findings included: 1. The facility staff were not maintaining a sanitary environment in two rooms, one room on the south wing and one on the west wing. On 4/2/25 an observation was made in the room on the south wing. The bathroom commode had brownish colored stains on the commode seat and down on the sides of the commode. The floor on both sides of the commode had brownish colored stains. On 4/2/25 an observation was made in the room on the west wing. The bathroom had brownish colored stains on the wall behind the commode, brownish colored stains on the floor on both sides of the commode and in the front of the commode. The wall had tears and areas were peeling with white chalk like material exposed. On 4/2/25 an interview was conducted with Resident #26 (R26). R26 said, look in my bathroom, it's a mess. My roommate sits to far back on the seat and gets a mess on the seat and runs down the sides 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 interviews, staff record review and facility documentation review, the facility staff failed to provide behavioral health training to five of eight employees. The findings included: For other staff #9 (OS9), other staff #10 (OS10), certified nursing assistant, CNA#11 (CNA11), CNA#12 (CNA12) and CNA#13 (CNA13) the facility staff had no credible evidence of the employees having received behavioral health training. On 4/9/25, a sample of eight employees was selected for review of educational requirements as part of the extended survey review. The facility administrator was given the list of employees selected for review and was asked to provide evidence of their educational training to include behavioral health training. On 4/9/25, the facility provided the surveyor with the employee training records. This review revealed no evidence that OS9, OS10, CNA11, CNA12 or CNA13 received any behavioral health training. According to the facility assessment, which was last reviewed on 8/6/25, the facility provides for residents with mental health and behavioral needs. According 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 the facility documentation and staff interview the facility staff failed to implement abuse policy regarding reporting to the Department of Health Professionals (DHP) for two residents (Resident #17 and Resident #23) out of a survey sample of 26 residents. The findings included: The facility staff failed to report an allegation of abuse and neglect to DHP that involved license staff. On 4/3/25 at 11:00 a.m., the facility provided a synopsis report for R17 for review. In this report dated 3/24/25 it was reporting an allegation of abuse/neglect. During the review there were fax forms and confirmation to adult protective services (APS), the ombudsman, and the Virginia Department of Health (VDH). The allegation involved a certified nursing assistant, CNA#15. There was no evidence of the DHP being notified of the allegation against CNA#15. On 4/3/25 at 4:47 p.m., an interview with the administrator was conducted. The administrator said, I did send to DHP, here is what happened: I sent it and it had incomplete on it. I called DHP last Thursday and resent the form. I have…

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 the facility documentation and staff interviews, the facility staff failed to report an allegation of abuse and neglect timely for two residents (Resident #17 and Resident #23) out of a survey sample of 26 residents. The findings included: 1. The facility staff failed to report an allegation of abuse and neglect timely to the regulatory agencies for R17. On 4/3/25 at 5:30 p.m., an interview was conducted with CNA #9. CNA#9 said, [R17's name redacted] daughter came into the facility about 7:55 p.m., on 3/15/25, and he had the brief on she tagged at 12 o'clock. He was wet enough to be changed. CNA#9 stated his bottom was red, and cream was applied. CNA#9 stated she would be concerned with a brief being left on for eight hours. CNA#9 did report this to charge nurse LPN#5 but no evidence of reporting this to upper management. On 4/3/25 at 7:20 p.m., an interview was conducted with LPN#5. LPN#5 stated that he saw the brief that was changed around 8:00p.m., and it was marked with a number 12 on the brief. LPN#5 stated he understood why the daughter was upset if R17 was in 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 facility documents and staff interviews, the facility staff failed to complete a thorough investigation regarding abuse and neglect for two residents (Resident #17, R17 and Resident #12, R12) out of a survey sample of 26 residents. The findings included: 1. The facility staff failed to thoroughly investigate an allegation of neglect for R17. On 4/3/25 at 11:00 a.m., the facility provided a facility synopsis report on R17 for the surveyor to review. R17's daughter was reporting an allegation of neglect. The report was dated 3/17/25, and the allegation read, [R17's name redacted] daughter brought concerns to nursing leadership related to allegation of incontinent care not being provided timely for her father. On 4/3/25 at 11:15 a.m., a review of the witness statements collected by the administrator was completed. The findings of the witness statements were as follows: A certified nursing assistant CNA#9's witness statement dated 3/24/25 read in part, . [CNA#15's name redacted] gave me the verbal report…

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, clinical record review and facility documentation review, the facility staff failed to review and revise care plan with fall interventions for one resident (Resident #11, R11) out of a survey sample of 26 residents. The findings included: The facility staff failed to revise the care plan to include R11's fall interventions. On 4/4/25 at 10:10 a.m., an observation on the [NAME] wing was conducted. In the room that R11 was in when at the facility nonskid strips were observed on the floor by the bedside. On 4/4/25 at 10:15 a.m., an interview was conducted with a licensed practical nurse LPN#17. LPN#17 stated that R11 did not have nonskid strips by his bedside for a fall intervention. LPN#17 stated R11 was moved closer to the nurse's station and had a concave mattress for his fall interventions. LPN#17 stated that the resident in the room now was a fall risk, and the nonskid strips was for her. On 4/4/25 at 10:40 a.m., an interview was conducted with the certified nursing…

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 interviews, clinical reviews and facility documents, the facility staff failed to provide activity of daily living (ADL) care for one resident (Resident #17, R17) out of a survey sample of 26 residents. The findings included: The facility staff failed to provide grooming and shower for R17. R17 was admitted to the facility on [DATE]. Diagnoses for R17 included but are not limited to urinary tract infection, muscle weakness and underweight. R17's Reentry Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/3/25 coded R17 with severe cognitive impairment. R17 was dependent on the activity of daily living care. Because Resident #17 was no longer a resident at the facility, a closed record review was conducted. On 4/3/25 at 11:15 a.m., a review of the facility incident summary was conducted. A written statement by licensed practical nurse, LPN#4 (LPN4) read in part, . [R17 name redacted] was not wanting to get up, so I said he could sleep a little longer. It was around 7:30…

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, clinical record review, and facility documentation review, the facility staff failed to administer medications as ordered by the physician for one resident (Resident #8-R8) in a survey sample of 26 residents. The findings included: For R8, the facility staff failed to administer Latanoprost eye drops as ordered. On 4/3/25 at 5 p.m., an interview was conducted with R8. During the interview R8 expressed concerns that frequently he doesn't receive his eye drops for glaucoma. On 4/3/25 and 4/4/25, a clinical record review was conducted of R8's chart. According to the physician orders, R8 was to receive Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma. The order for the eye drops was originally written 2/14/24 and remained an active order at the time of survey. On 4/8/25 at 5:49 p.m., an interview was conducted with the facility's director of nursing (DON). When asked what a blank on the MAR indicated, she said, I would assume it was not administered and something should have been written. The DON acknowledged 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation, staff interviews and clinical record review, the facility staff failed to maintain an accurate clinical record for two residents Resident #17 (R17) and Resident #12 (R12) in a survey sample of 26 residents. The findings included: 1. The facility staff failed to accurately document a shower for R17. R17 was admitted to the facility on [DATE]. Diagnoses for R17 included but are not limited to urinary tract infection, muscle weakness and underweight. R17's Reentry Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/3/25 coded R17 with severe cognitive impairment. R17 was dependent for activities of daily living care. On 4/3/25 at 11:00 a.m., the facility provided a synopsis report to the surveyor for review. In this report dated 3/24/25 it read in part, first rounds [certified nursing assistant, CNA#15's (CNA15) name redacted] had to shower him because he was soiled and then laid him back down after. On 4/3/25 at 11:15 a.m., a review of the facility…

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 documentation the facility staff failed to ensure staff had abuse training for two certified nursing assistants, CNA#11 (CNA11) and CNA#12 (CNA12) out of eight employee records reviewed. The findings included: The facility staff failed to have credible evidence of abuse training for CNA11 and CNA12. On 4/9/25, a sample of eight employees was selected for a review of training requirements as part of the extended survey. The list of employees was given to the facility administrator, and they were asked to provide evidence of staff training to include the area of abuse. On 4/9/25, the employee records were reviewed. It was noted that CNA11 and CNA12 had no evidence of having received training for abuse. On 4/9/25 at approximately 5:23 p.m., the above findings were reviewed with the facility administrator, director of nursing and corporate staff. The facility administrator provided the survey team with the percentage of the overall Relias completion record. The [NAME] President of operations stated that the surveyor was correct, and he was unable…

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 documentation the facility staff failed to provide infection control training for two certified nursing assistants, CNA#11 (CNA11) and CNA#12 (CNA12) out of eight employee records reviewed. The findings included: The facility staff failed to have credible evidence of infection control training for CNA11 and CNA12. On 4/9/25, a sample of eight employees was selected for review of training requirements as part of the extended survey. The list of employees was given to the facility administrator, and they were asked to provide evidence of staff training to include the area of infection control. On 4/9/25, the employee records were reviewed. It was noted that CNA11 and CNA12 had no evidence of having received training for infection control. On 4/9/25 at approximately 5:23 p.m., the above findings were reviewed with the facility administrator, director of nursing and corporate staff. The facility administrator provided the survey team with the percentage of the overall Relias completion record. The [NAME] President of operations stated that 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 observations, staff interviews, resident interviews, and facility documents, the facility staff failed to ensure a sanitary, clean, and comfortable environment for 3 of 3 nursing units in the facility and in the dining room. The findings included: 1. The facility staff failed to maintain a clean. sanitary and comfortable environment for the residents in their rooms, shower rooms, halls, and common areas. On 7/1/24 at 11:30 a.m. a tour of the facility on all three units was conducted. Observations of the [NAME] unit spa noted feces on the floor in the shower room, the tiles in the shower stall had black mold-like coloring around the tiles, black marks were observed on the floor in the shower room, that appeared to be feces upon closer inspection, the orange shower stall mat appeared heavily soiled and stained gray, and rust colored stain was on the floors under the air conditioner unit. room [ROOM NUMBER] was observed to have tiles missing under the sink, bathroom walls had blackened areas marks on 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 observation, resident interviews, and staff interviews, the facility staff failed to provide appetizing food with palatable temperatures and appearance to residents on one of three units (West unit). The findings include: On 7/1/24 at 11:25 AM, Resident #4 (R4), who resides on the [NAME] unit, was briefly interviewed concerning meals at the facility. R4 said, We get only what is delivered and it's usually cold and tastes nasty. On 7/1/24 at 11:30 AM, an observation was made of the tray line and the steam table in the kitchen. Temperatures of the food on the steam table were taken at this time and were as follows: Chicken breast 163 degrees Farheinheit, broccoli 162, mashed potatoes 178, peas 174, buttered noodles 162, fish nuggets 152, puree chicken 159, puree peas 159. The meal cart was loaded and sent to the [NAME] unit at 11:33 AM and arrived at 11:35 AM. At 11:35 AM, observations of staff (4 to 5 staff members) conducted, as they began delivering the trays to the residents on [NAME] Unit, upon arrival. A staff member was observed delivering a tray to a resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility failed to develop a care plan for one of two residents. Resident #1 (R1) had an admitting diagnoses of PTSD (Post Traumatic Stress Disorder) and a care plan was not developed. The Findings Include: Diagnoses for R1 included: PTSD, anxiety, and depression. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 10/9/23, which assessed R1 with a cognitive score of 15 out of 15, indicating cognitively intact. R1 was admitted to the facility from a hospital to receive post surgical care and therapy. R1's hospital record documented R1 had a diagnoses of PTSD and did not include any other information regarding PTSD. A review of the Trauma Informed Screen assessment dated [DATE] revealed R1 had abused drugs and/or alcohol and did not reveal any other information related to PTSD. No other social service assessments or notes revealed information related to PTSD. A review of nurse practitioner…

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 failed initiate trauma informed care for one of two residents. Resident #1 (R1) had an admitting diagnoses of PTSD (Post Traumatic Stress Disorder) and the facility did not identify past history of trauma, and /or triggers which may cause re-traumatization. The Findings Include: Diagnoses for R1 included: PTSD, anxiety, and depression. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 10/9/23. R1 was assessed with a cognitive score of 15 indicating cognitively intact. A review of the Trauma Informed Screen assessment dated [DATE] revealed abuse to drugs and/or alcohol and did not reveal any other information related to PTSD. No other social service assessments or notes revealed information related to PTSD. A review of nurse practitioner psychology notes and assessments dated 10/16/23 through 1/8/24 (multiple entries) did not reveal any identified triggers, root cause, or history…

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, facility document review, and clinical record review, the facility staff failed to ensure medications were available for administration for two of thirteen residents in the survey sample (Residents #1 and #2) The findings include: 1. Resident #1 (R1) missed six doses of oxycodone and/or methadone during April and May 2023 because the medicines were not provided by the pharmacy in a timely manner. R1 was admitted to the facility with diagnoses that included inflammatory polyneuritis, anemia, bipolar disorder, chronic pain syndrome, insomnia, major depressive disorder, hypotension, respiratory failure, hypoxia, enterocolitis, clostridium difficile and pneumonia. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented a physician's order dated 10/10/22 for oxycodone 10 milligrams (mg) every 12 hours for management of chronic pain. The clinical record documented a physician's orders dated 6/20/22 for methadone 5 mg two…

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 promptly notify the provider of abnormal laboratory results for one of thirteen residents in the survey sample (Resident #13). The findings include: Resident #13's provider was not promptly notified of abnormal/critical lab results. Resident #13 (R13) was admitted to the facility with diagnoses that included respiratory failure, congestive heart failure (CHF), COPD (chronic obstructive pulmonary disease), asthma, pulmonary hypertension, valve insufficiency, abnormal serum enzymes, diabetes, and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #13 as cognitively intact. R13's clinical record documented a physician's order on 10/12/22 for a CBC (complete blood count), CMP (complete metabolic panel), troponin, and hemoglobin A1C. The clinical record documented R13's lab results dated 10/14/22 that included abnormal lab values for red blood count, hemoglobin, hematocrit, glucose, potassium,…

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 group interview, staff interview, and facility document review, the facility staff failed to ensure residents had unlimited access to petty cash funds during the week and on weekends for four of 38 residents in the survey sample, Resident # 107, # 71, #17, and # 106. Findings include: On 5/25/22 at 10:00 a.m. a resident group interview was conducted with four cognitive residents, Resident # 107, # 71, #17, and # 106. The residents were asked about personal funds. The residents all responded that a new rule had been implemented for several months that petty cash funds could only be accessed one time for week, and was a limited dollar amount (forthy dollars) that could be accessed at one time. Resident # 71, stated It's the dumbest thing I've ever seen. So if I let my allotted forty dollars sit, and wait until I have, say, one hundred twenty dollars, I can only get forty of that one time per week. Resident # 107 stated I went up there (to the front lobby) to get some money for this week, and I was told there was no money Monday or Tuesday, both times I went up. I try to go…

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, the facility staff failed to incorporate and follow Level II PASARR recommendations for one of 38 residents, Resident #38. Findings were: Resident #38 was admitted to the facility with the following diagnoses including but not limited to: Morbid obesity, genetic related intellectual disability (ID), hypertension, and adult failure to thrive. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/11/2022 assessed Resident #38 as severely impaired with a cognitive summary score of 04. The clinical record was reviewed at approximately 2:00 p.m. on 05/24/2022. A Level II PASARR dated 02/01/2022 contained the following information: DIAGNOSIS: .Intellectual Disability; Severity Unspecified .REHABILITATIVE SERVICES RECOMMENDATIONS: .Targeted Case Management .DETERMINATION SUMMARY: .I encourage the nursing facility to work with the local Community Services Board to assist in identifying supports and services that he could benefit from. A targeted resident review is scheduled for 90 days to evaluate…

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 complaint investigation, the facility staff failed to follow physician orders for four of 38 residents in the survey sample, Resident #158, #166, #322, and #110. Resident #158 did not have medications administered as ordered. Resident #166 did not have a physician ordered dressing applied. Resident #322 did not have insulin administered and fluid intake monitored as ordered. Resident #110 did not have ace wraps applied as ordered. The findings include: 1. Resident #158 was admitted to the facility with diagnoses that included atrial flutter, chronic pain syndrome, morbid obesity, hypertension, gastroesophageal reflux disease, history of pulmonary embolism, hypothyroidism, major depressive disorder, anxiety, chronic respiratory failure, restless leg syndrome and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed Resident #158 as cognitively intact. On 5/24/22 at 11:45 a.m., Resident #158 was interviewed about quality…

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, the facility staff failed to ensure behavioral health services were provided to maintain his highest practicable level of well being for one of 38 residents, Resident #38. Findings were: Resident #38 was admitted to the facility with the following diagnoses including but not limited to: Morbid obesity, genetic related intellectual disability (ID), hypertension, and adult failure to thrive. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/11/2022 assessed Resident #38 as severely impaired with a cognitive summary score of 04. Resident #38 was observed on 05/24/2022 at approximately 11:00 a.m. He was seated in a wheelchair, self propelling from his room to the front foyer of the facility, down the hallways, and back. At approximately 12:45 p.m., Resident #38 was observed sitting in the facility lobby, he was holding a match box car, he randomly would flex his muscles and make grunting noises. Resident #38's clinical record was reviewed on 05/24/2022 at approximately 2:00 p.m 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 resident interview, staff interview, clinical record review and complaint investigation, the facility staff failed to ensure medications were available for administration for three of 38 residents in the survey sample, Resident #158, #121, and #30. Resident #158 had multiple medications for treatment of nausea, heart failure, pain, vitamin/electrolyte supplement, muscle spasms and constipation not available for administration. Resident #121 did not have the medication pravastatin available for administration. Resident #30 did not have prescribed nasal spray available for administration. The findings include: 1. Resident #158 was admitted to the facility with diagnoses that included atrial flutter, chronic pain syndrome, morbid obesity, hypertension, gastroesophageal reflux disease, history of pulmonary embolism, hypothyroidism, major depressive disorder, anxiety, chronic respiratory failure, restless leg syndrome and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed Resident…

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, clinical record review, and staff interview, the facility staff failed to ensure one of 38 residents in the survey sample was free from a significant medication error, Resident # 322. Resident # 322 did not receive her thyroid medication for eleven days. Findings include: Resident # 322 was admitted to the facility with diagnoses to include, but were not limited to: acute respiratory failure, diabetes, hypothyroidism s/p (status post) removal of thyroid gland, and peripheral vascular disease. The most recent MDS (minimum data set) was the admission assessment dated [DATE] and had the resident coded as cognitively intact with a score of 14 out of 15. On 5/25/22 at 8:20 a.m. Resident # 322 was interviewed about her life in the facility. She stated, I guess things are okay. I finally got my thyroid medicine for the first time since I got here. My daughter was here yesterday (5/24/22) and I had told her I was feeling bad, but didn't know why. She asked if I was getting my thyroid pill,…

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 group interview, the facility staff failed to provide condiments, menu items, and honor dietary preferences for two of 38 residents in the survey sample, Resident # 322 and # 158; and also in the main kitchen. Findings include: 1. Resident # 322 was admitted to the facility with diagnoses to include, but were not limited to: acute respiratory failure, diabetes, hypothyroidism s/p (status post) removal of thyroid gland, and peripheral vascular disease. The most recent MDS (minimum data set) was the admission assessment dated [DATE] and had the resident coded as cognitively intact with a score of 14 out of 15. On 5/24/22 at approximately 2:45 p.m. Resident # 322 was interviewed. When asked about the food in the facility she stated, Well, it's not bad, but it's not good .I get things I don't like, so I just don't eat them. But the other night for supper, we got cheese steak sandwiches .without the cheese .and potato wedges. Now, I'm not supposed to have a lot of carbs…

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 clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 38 residents in the survey sample, Resident #52 Resident #52's treatment administration record had incomplete documentation regarding gastrostomy care orders. The findings include: Resident #52 was admitted to the facility with diagnoses that included cerebral infarction, respiratory failure, dysphagia with gastrostomy, hypertension, vascular dementia, gastroesophageal reflux disease, history of Covid-19, anxiety, depression, anemia and hemiplegia/hemiparesis following cerebrovascular disease. The minimum data set (MDS) dated [DATE] assessed Resident #52 as cognitively intact. Resident #52's clinical record documented physician orders for care related to a gastrostomy as follows: 4/28/22 - Change split gauze dressing on PEG (percutaneous endoscopic gastrostomy) tube site once per day 1/5/21 - Complete gastrostomy tube site care each day shift 1/5/21 - Change…

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, the facility staff failed to ensure one of 38 residents had privacy while in his room, Resident #38. Resident #38 who resided in a private room on the east wing did not have a door separating his room from the hallway. Findings were: Resident #38 was admitted to the facility with the following diagnoses including but not limited to: Morbid obesity, genetic related intellectual disability (ID), hypertension, and adult failure to thrive. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/11/2022 assessed Resident #38 as severely impaired with a cognitive summary score of 04. Resident #38's clinical record was reviewed on 05/24/2022 at approximately 2:00 p.m. Observed in the progress notes was the following: 2/16/2022 14:01 (2:01 p.m.) Transfer to Hospital Summary Note Text: Observation of worsening behavior on this day (Resident #38) slammed bedroom door so hard that it finished cracking and literally door split from the top Resident #38's care plan included the intervention dates…

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 ensure an accurate assessment for two of 38 residents, Resident #90 and #53. Resident #90's current MDS section O was not triggered for dialysis; and Resident #53's current MDS sections C and D were not accurately completed for cognition and mood. The Findings Include: 1. Diagnosis for Resident #90 included: Parkinson's disease, End stage renal disease on dialysis, bipolar disease, and diabetes. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/13/22. Resident #90's cognitive score was 15 indicating cognitively intact. On 5/24/22 review of Resident #90's current MDS dated [DATE] section O did not trigger for dialysis. Review of Resident #90's physician orders included an order for dialysis weekly on Tuesday, Thursday, and Saturday. Resident #90 was interviewed on 05/24/22 at 11:34 AM and stated she had been on dialysis for at least three years. On 05/25/22 at 9:39 AM,…

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, the facility staff failed to ensure one of 38 residents were free from accidents, Resident #3. Resident #3 eloped through one of the facility's fire doors and fell. The findings include: Resident #3 was admitted to the facility with diagnoses that included diabetes, dementia with behavioral disturbance, hypertension, atherosclerotic heart disease, aortic stenosis, major depressive disorder, sleep disorder, osteoporosis, dysphagia and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed Resident #3 with moderately impaired cognitive skills. Resident #3's clinical record documented nursing notes as follows. 5/7/21 at 1:43 a.m. - .wandering the halls, wandergard (Wanderguard) in place to right wrist . 5/7/21 at 8:20 a.m. - .Resident was exit seeking this morning. dock door wander guard alarm was sounding. Resident was ambulating with walker at the Dock door. Writer redirected resident back down hallway . 5/7/21 at 11:42 a.m. - Reported…

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 respond to pharmacy recommendations for one of 38 residents in the survey sample, Resident #158. A provider failed to respond to two pharmacy recommendations for Resident #158 regarding risks with continued use of an antimicrobial agent and an anticholinergic medication. The findings include: Resident #158 was admitted to the facility with diagnoses that included atrial flutter, chronic pain syndrome, morbid obesity, hypertension, gastroesophageal reflux disease, history of pulmonary embolism, hypothyroidism, major depressive disorder, anxiety, chronic respiratory failure, restless leg syndrome and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed Resident #158 as cognitively intact. Resident #158's clinical record documented a physician's order dated 2/8/22 for Hydroxyzine 10 mg (milligrams) to be administered each morning and at bedtime for itching related to anxiety. The record…

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 medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate less than 5 percent. There were three errors out of 34 opportunities resulting in a medication error rate of 8.82 percent. The Findings Include: 1. On 05/25/22 at 7:44 AM, a medication pass and pour observation was conducted. Resident #121's Pravastatin Sodium 10 milligrams was ordered to be given at 8:00 AM. License practical nurse (LPN #4) could not find Resident #121's Pravastatin in the medication cart. LPN #4 then went to the medication storage room and did not find any Pravastatin. LPN #4 then called pharmacy and asked for the medication to be sent. LPN #4 stated that pharmacy was going to send the medication later in the day. On 5/25/22 at 9:00 AM, LPN #4 was asked about reordering medications. LPN #4 stated she tries to reorder medications when there are about 5 or 6 six doses left. LPN #4 then reviewed when Pravastatin was ordered for Resident #121 and stated it was last reordered on 4/23/22. 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 observation and staff interview, the facility staff failed to ensure expired medication was not available for administration on the east wing. Two opened vials of Aspart insulin dated [DATE] were available for administration. Findings were: The medication cart on the east wing of the facility was inspected on [DATE] at approximately 11:30 a.m. with LPN (licensed practical nurse) #5. Observed in the top drawer of the medication cart was a brown bottle from the pharmacy. The bottle was labeled with a resident's name. Inside of the bottle were two opened vials of aspart insulin. Neither of the vials were dated. The brown bottle had a handwritten date of [DATE]. LPN #5 stated, I doubt that date is correct, but it is the only one I see. She was asked how long after opening was the insulin safe to use. She stated, That one should be 28 days, but certainly no more than a month. She was asked if the vials should be dated. She stated, I date them, but since they aren't I would go by the date on the brown bottle…

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 interviews, clinical record review and facility document review, the facility staff failed to ensure records of weekly hospice visits were provided to the facility as required in the hospice services agreement for 1 of 38 residents in the survey sample, Resident #148. The facility also failed to develop an hospice care plan and XXX for one of 38 residents in the survey sample, Resident #170. The findings include: Resident #148 was admitted to the facility with diagnoses that included palliative care, stage 2 pressure ulcers and unstageable pressure ulcers to left buttock and sacral region, mood disorder, GERD, COPD, respiratory with hypoxia, type 2 diabetes, malignant neoplasm of head of pancreas, neoplasm related pain, weight loss, congestive heart failure, and oxygen dependent. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #148 as moderately impaired for daily decision making with a score of 12 out of 15. Under Section O - Special…

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, resident council interview and staff interview, the facility staff failed to respond to call bells in a timely manner on one of three units. Residents on the East unit reported frequent call bell wait times from 30 minutes to one hour. The findings include: 1. Resident #92 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, diabetes, depression, cirrhosis and hyperlipidemia. The minimum data set (MDS) dated [DATE] assessed Resident #92 as cognitively intact. On 4/20/21 at 11:20 a.m., Resident #92, who resided on the East unit, stated she experienced extended wait times for call bell response especially on the evening shift. Resident #92 stated her bed was frequently not made and call bell response depended on which aides were working. Resident #92 stated when certain aides were working she heard staff telling stories and carrying on and call bell response was slow. 2. Resident #84 was admitted to the facility on [DATE] with diagnoses 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure one of 36 residents, Resident #400, was free from physical abuse. Findings were: Resident #400 was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to: COPD (chronic obstructive pulmonary disease) hypertension, Parkinson's, Epilepsy, bipolar disorder, and dementia with behaviors. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/04/2020, coded Resident #400 as severely impaired in her cognitive status with a summary score of 05. The clinical record was reviewed beginning at approximately 12:45 p.m., on 04/20/2021. The following notes were observed in the progress note section: 04/24/2020 01:26 [a.m.] Behavior note: @ 00:15 [12:15 a.m.] resident spitting, hitting, kicking staff. CNA [certified nursing assistant] reported earlier when in the room resident started hitting her and came out of room…

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, facility document review and in the course of a complaint investigation, the facility staff failed to report an allegation of abuse to the State Agency for one of 36 residents, Resident #400. Findings were: Resident #400 was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to: COPD (chronic obstructive pulmonary disease) hypertension, Parkinson's, Epilepsy, bipolar disorder, and dementia with behaviors. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/04/2020, coded Resident #400 as severely impaired in her cognitive status with a summary score of 05. The clinical record was reviewed beginning at approximately 12:45 p.m., on 04/20/2021. The following notes were observed in the progress note section: 04/25/2020 22:45 [10:45 p.m.] Large bruise noted to right forearm with large hematoma. Complained of pain in this arm and bilateral legs .Family called in stating they want to talk to administration .…

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 develop a baseline care plan for one of 36 residents in the survey sample. Resident #147's baseline care plan failed to include problems, goals and/or interventions for anticoagulant medication. The findings include: Resident #147 was admitted on [DATE] with diagnoses that included hypertension, gastronomy, dysphasia, generalized epilepsy, atrial fibrillation, and frontal lobe and executive function deficit. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #147 as cognitively impaired for daily decision making with a score of 2 out of 15. Resident #147's clinical record was reviewed on 04/21/2021. Observed on the physician's order summary was the following: .Eliquis Tablet 2.5 MG (milligrams) (Apixaban). Give 1 tablet via PEG-Tube every 12 hours for AFIB (atrial fibrillation). Start Date 03/31/2021 A review of the medication 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to review and revise a comprehensive care plan for 3 of 36 residents in the survey sample, Resident #132, Resident #74, and Resident #400. Resident #132's care plan was not revised for the discontinuation of psychotropic medications. Resident #74's care plan was not revised regarding a meatus/urethral tear from a chronic indwelling foley catheter. Resident #400's care plan was not revised to include behaviors. The findings include: 1. Resident #132 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes, urine retention, chronic ulcer of left and right foot, mild cognitive impairment, hypertension, history of pulmonary embolism, and history of COVID-19. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #132 as cognitively intact for daily decision making with 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 staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for two of 36 residents in the survey sample, Residents #46 and #84. License practical nurse (LPN #1) did not follow physician's orders when giving Ferocon (a hematopoietic agent given for anemia) to Resident #46. Facility staff failed to assess and monitor Resident #84 for correct inhalation technique and nebulizer operation to ensure proper dose administration of prescribed respiratory medications. The findings include: 1. On 04/21/21 at 7:51 AM, during an observation of a medication pass and pour, LPN #1 began pulling medications out for Resident #46. One of the medications scheduled to be given was Ferocon 110-0.5 MG (milligram). The label on the medication card read to give Ferocon prior to breakfast. LPN #1 then went into Resident #46's room and administered Ferocon along with other medications while Resident #46 was sitting at the bedside table eating…

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 clinical record review the facility staff failed to provide a complete and accurate clinical record for 1 of 36 residents in the survey sample, Resident #143. Resident #143's clinical record did not document weights per physician orders. The findings include: Resident #143 was admitted to the facility on [DATE] with diagnoses that included aftercare for surgical amputation of right toe, osteomyelitis (right ankle and foot), hyperlipidemia, type 2 diabetes, hypertension, and heart failure. The most recent minimum data set (MDS) dated [DATE] was the 5-day admission assessment and assessed Resident #143 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #143's clinical record was reviewed on 04/21/2021. Observed on the physician's order summary was the following orders: Daily Weight every day shift . Order Date: 03/26/2021 Start Date: 03/27/2021 Observed on Resident #143's care plans was the following: . The resident has potential 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.