Wonder City Rehabilitation And Nursing Center

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 follow physician orders for administration of insulin with specific parameters for (1) one of (13) thirteen residents in the survey sample (Resident #8).Findings included:Resident #8 was originally admitted to the facility 11/25/25 and re-admitted after a hospitalization from 4/26/26 to 5/1/26 for a GI bleed (gastro-intestinal, bleeding in the stomach). Other diagnoses included but are not limited to diabetes mellitus type 2, (GERD) gastroesophageal reflux disease, anemia, atrial fibrillation (irregular heart rate), hypertension, asthma, hemiparesis and hemiplegia following a cerebral infarction (reduced strength in extremities following a stroke), and memory deficit following stroke.Resident #8's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 3/3/26 coded the resident as completing the BIMS (Brief Interview for Mental Status) 15 out of 15. This indicates 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 observation, interview and record review, the facility staff failed to have credible evidence of a hospice plan of care, services provided by hospice and documentation of hospice provider visits for (1) one resident in a survey sample of (13) thirteen residents receiving hospice care (Resident #5).Findings included: Resident #5 was admitted to the facility on [DATE] with diagnosis including but not limited congestive heart failure, pulmonary embolism (blood clot), hypertension, chronic obstructive pulmonary disease, anxiety, and myocardial infarction (heart attack). Resident #5 was admitted to hospice services on 12/18/25. Resident #5's most recent MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 3/24/26 coded the resident in C0500 BIMS (Brief Interview of Mental Status) Summary as a 15 out of 15 indicating resident was cognitively intact and Section K1. the resident was coded as Yes for receiving hospice services.On 5/7/26 during clinical record review for Resident #5, an…

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

Based on observation, resident interview, and clinical record review, the facility failed to ensure a resident was treated with respect and dignity for one (1) of seventeen (17) residents, Resident #3.The findings include:For Resident #3 the facility staff failed to maintain the resident's dignity during a meal as evidenced by standing over the resident to feed the resident and failed to remove facial hair that the female resident indicated she did not wantResident #3 was originally admitted to the facility 02/10/2026. Diagnoses include but are not limited to anxiety disorder, adult failure to thrive, hypotension, fracture of unspecified part of neck of right femur, moderate protein calorie malnutrition, essential hypertension, acute respiratory failure with hypoxia, and insomnia.Resident #3's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 03/31/2026 coded the resident as completing the BIMS (Brief Interview for Mental Status) 14 out of 15. Indicating the resident was cognitively intact for daily decision making.Review of Resident #3's Physician…

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

Based on staff interview, facility document review, and clinical record review, the facility failed to notify a provider of two falls for one (1) of seventeen (17) residents, Resident #2.The findings include:Resident #2 was originally admitted to the facility 01/20/2026 with diagnoses to include but are not limited to diabetes mellitus type 2, muscle wasting and atrophy, muscle weakness, moderate protein calorie malnutrition, difficulty in walking, myocardial infarction type 2, history of falling, essential hypertension, benign prostatic hyperplasia, anemia, urinary tract infection, and Parkinson's Disease without dyskinesia.Resident #2's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 01/26/2026 coded the resident as completing the BIMS (Brief Interview for Mental Status) 08 out of 15. This indicates the resident is moderately cognitively impaired for daily decision making.On 05/06/2026 during a review of Resident #2's clinical record, there was no evidence that the facility notified the doctor/provider of falls that occurred on 01/21/2026 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 interview, record review, and policy review, the facility failed to implement its abuse prevention policies by ensuring staff identified in an allegation of sexual abuse were prohibited from resident contact pending completion of the investigation for 1 of 3 sampled residents reviewed for abuse allegations (Resident #9).The findings include: Review of the facility policy titled Responding to Abuse/Neglect/Misappropriation/Crime, dated 1/29/24, revealed the facility would immediately protect residents from further potential abuse, including removal of alleged perpetrators pending the outcome of the investigation.Review of an incident summary dated 12/16/25 revealed Resident #9 alleged on 12/16/25 that two identified housekeeping employees attempted revealed themselves and made sexual comments towards her . Documentation showed the allegation was reported to facility administration on 12/16/25. Review of statements from resident and staff all have time of incident redacted or blank.Further review of staffing schedules, payroll records, and assignment sheets revealed…

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

Based on interview, record review, and policy review, the facility failed to thoroughly investigate and prevent further potential abuse by ensuring protective measures were implemented after an allegation of sexual abuse was reported for 1 of 3 sampled residents reviewed for abuse investigations (Resident # 9).The findings include: Review of the facility policy titled Abuse Prevention and Investigation, dated 1/29/24, revealed the facility would immediately implement interventions to protect residents from further potential abuse during investigations, including removal of alleged perpetrators from resident contact pending investigative findings.Review of the facility investigation revealed Resident #9 alleged on 12/16/25 that two identified housekeeping employees attempted revealed themselves and made sexual comments towards her. Documentation showed the allegation was reported to administration on 12/16/25. Review of statements from resident and staff all have time of incident redacted or blank.The facility failed to implement interim protective measures after the alleged incident…

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 interview, record review, and policy review, the facility failed to implement its abuse prevention policies by ensuring staff identified in an allegation of sexual abuse were prohibited from resident contact pending completion of the investigation for 1 of 3 sampled residents reviewed for abuse allegations (Resident #9).The findings include:Review of the facility policy titled Abuse Prevention and Investigation, dated 1/29/24, revealed the facility would immediately implement interventions to protect residents from further potential abuse during investigations, including removal of alleged perpetrators from resident contact pending investigative findings.Review of the facility investigation revealed Resident #9 alleged on 12/16/25 that two identified housekeeping employees attempted revealed themselves and made sexual comments towards her. Documentation showed the allegation was reported to administration on 12/16/25. Review of statements from resident and staff all have time of incident redacted or blank.The facility failed to implement interim protective measures after…

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, clinical record review and facility document review, the facility staff failed to deliver the prescribed oxygen flow rate according to the physician's order for (1) one of (13) thirteen residents in the survey sample (Resident #6)Findings include:Resident #6 was admitted to the facility 4/1/25 with diagnoses to include but not limited to chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, diabetes mellitus type 2, chronic kidney disease stage 3, convulsions, hypertensive heart disease, and heart failure. Resident #6's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) 3/30/26 coded the resident in Section C. Cognitive Patterns for a BIMS (Brief Interview Mental Status) of 09 out of 15 indicating resident has moderate cognitive impairments with memory, attention and orientation. Section 0. Special Treatments C1 was coded yes for use of oxygen.On 5/4/26 at 12:20 PM, during initial rounds Resident #6 was observed in her bed with the head of the bed elevated and the oxygen…

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 review of nursing schedules, the facility failed to ensure the services of a registered nurse were provided for at least 8 consecutive hours a day, 7 days a week, as required by S483.35(b), for a facility census of 123 residents.This deficient practice had the potential to affect all residents residing in the facility requiring ongoing nursing assessment, clinical oversight, care planning, change in condition evaluation, medication management, and supervision of licensed nursing staff.The findings included: Review of the facility nursing schedules, staffing records, and daily assignment sheets revealed the facility failed to schedule or provide coverage by a registered nurse (RN) for at least 8 consecutive hours on the following dates:4/4/26 and 4/5/26: No RN scheduled or documented as working during the required 8 consecutive-hour period and posted staffing records lacked evidence of RN presence for the required duration.Further review of payroll records and staffing documentation failed to demonstrate an RN was present 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 observation, resident interview, clinical record review and facility document review, the facility staff failed to honor resident's food preferences for (1) one of (13) thirteen residents in the survey sample (Resident #8).Findings included:Resident #8 was originally admitted to the facility 11/25/25 and re-admitted after a hospitalization from 4/26/26 to 5/1/26 for a GI bleed (gastro-intestinal, bleeding in the stomach). Other diagnoses included but are not limited to diabetes mellitus type 2, (GERD) gastroesophageal reflux disease, anemia, atrial fibrillation (irregular heart rate), hypertension, asthma, hemiparesis and hemiplegia following a cerebral infarction (reduced strength in extremities following a stroke), and memory deficit following stroke.Resident #8's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 3/3/26 coded the resident as completing the BIMS (Brief Interview for Mental Status) 15 out of 15. This indicates the resident is cognitively intact for daily decision making.On 5/5/26 at 9:00 AM, Resident #8 was visited as she…

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

Based on observation, interviews, clinical record reviews and facility documentation reviews, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) program that monitored its performance and ensured that improvements were sustained, which had the ability to affect all Residents within the facility. The findings included: The facility staff and QAPI program failed to monitor its performance and correct identified deficiencies and sustain improvements within multiple areas, which had the potential to affect resident care and safety. The facility had a standard recertification survey conducted 7/9/23-7/14/23. During that survey, the facility was cited for not being in compliance in multiple areas, to include but not limited to: notice of discharge, pre-admission screening assessment and resident review (PASRR), failure to following professional standards of nursing practice, care and treatment of pressure ulcers, accident hazards and upholding Resident's food preferences. Immediate Jeopardy was identified in the area of Quality of Care. The facility had…

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 documentation review, the facility staff failed to issue a notice in writing, at the time of transfer indicating the reason of transfer and appeal rights, for two Residents (Resident #208 and 213) in a sample of 3 Residents reviewed. The findings included: On 10/30/23, a sample of 3 recent unplanned discharges were selected for review. The clinical record for each Resident was reviewed and revealed the following: 1. For Resident #208, the facility staff failed to issue a notice of transfer/discharge to the Resident and/or Resident Representative, at the time of the transfer. On 10/30/23, a clinical record review was conducted. This review revealed that Resident #208, who was transferred to the hospital on [DATE], the Notice of Transfer/Discharge was not provided to the Resident and/or Resident responsible party at the time of transfer. The form indicated that it was mailed to the responsible party on 10/23/23. The section E. Notice was hand delivered…

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, facility staff interview, clinical record review and facility documentation review, the facility staff failed to provide assistance with activities of daily living (ADL) for three Residents (Resident #205, #207, and #214) to maintain good personal hygiene, in a survey sample of 3 Residents reviewed for ADL care. The findings included: For Residents #205, #207, and #214, all who required staff's assistance with ADL's, the facility staff failed to provide baths and/or showers to maintain personal hygiene. On 10/30/23 and 10/31/23, clinical record reviews were conducted of Resident #205, #207 and #214's chart, with special attention to ADL care. The following was noted: 1. Resident #205 received 3 showers from October 9, 2023-October 31, 2023. Resident #205 was noted to be totally dependent upon facility staff for bathing. The occurrences of a shower occurred on 10/12/23, 10/16/23, and 10/23/23. There was no documentation of refusals of showers noted. 2. Resident #207, received 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain an effective pest control program in the kitchen and on one of two nursing units, which had the ability to affect many Residents. The findings included: 1. The facility staff failed to maintain the kitchen in a manner, and respond to the pest control company's recommendations, to control pests. On 10/30/23 at 1:04 PM, observations were made in the facility's kitchen. The dietary manager/Employee H accompanied Surveyor D in making observations. It was noted in the dish room that under the dish machine and sink there was broken floor files, an abundance of food on the floor and a copious amount of small gnat sized pests flying around. Employee H, the dietary manager confirmed the observations. On 10/30/23 at 1;15 PM, an interview was conducted with Employee J, a cook. When asked about the flying pests, Employee J said, We see them, but we spray each night to clean. On 10/30/23 at approximately 2 PM, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #208, the facility staff failed to notify the Resident's Representative, of the Resident's transfer to the hospital. On 10/30/23, a clinical record review was conducted of Resident #208's chart. This review revealed that Resident #208, was transferred to the hospital on [DATE]. Review of Resident #208's progress notes revealed an entry from the medical provider on 10/18/23 at 1 PM, that read, Resident is a (age/gender) who is seen today in follow-up for 2 episodes of black vomit. Per nursing resident had 2 episodes this morning of black coffee-ground emesis. Upon examination resident is in no acute distress but complains of nausea and epigastric discomfort . Resident to be sent to the emergency room for evaluation for hematemesis. There was no evidence in the clinical record that indicated the Resident's family member, who according to the Resident's face sheet was listed as Responsible Party, Emergency Contact #1, POA- [power of attorney] Financial, and POA-medical, was made aware of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to obtain and/or complete a Preadmission screening (PASRR) timely for one Resident, (Resident #204) in a survey sample of 3 Resident's reviewed. The findings included: For Resident #204, who was admitted to the facility on [DATE], the facility staff failed to obtain/or complete a Pre-admission Screening and Resident Review (PASRR), to determine if the Resident had a mental disorder or intellectual disability. On 10/30/23, a clinical record review was conducted. This review indicated that Resident #204 was admitted to the facility on [DATE]. Under the Documents tab of the record there was a PASRR, that had been completed on 10/16/23. Review of the PASRR form, revealed the following statement(s) on the top of the form. It read, This form, or the DMAS-95 for Medicaid members, must be completed for ALL individuals seeking a Nursing Facility admission. The form must be completed PRIOR to a Nursing 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 interview, clinical record review and facility documentation the facility staff failed to review and revise the care plan for two Residents, (#214 & #223) in a survey sample of 32 Residents. The findings included: 1. For Resident # 214 the facility staff failed to revise care plan to reflect the removal of PICC (Peripherally Inserted Central Catheter) line inserted in 7/4/23 and put a new entry for the PICC line inserted on 10/2/23, they also did not put interventions to measure the external portion of the PICC line or the circumference of the upper arm. On 10/31/23 at approximately 11:00 AM observation was made of Resident #214 with a PICC line in her upper right arm. During clinical record review on 11/1/23 it was noted that the Resident had the following entry for PICC line: FOCUS: the resident has a PICC Line venous access, left arm Created on: 07/05/2023 Revision on: 10/03/2023. GOAL: the resident will not have complications from their PICC line access site thru review period Created on: 07/05/2023 Revision on: 10/03/2023 Target Date: 10/07/2023. INTERVENTIONS: CXE to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation review, the facility staff failed to provide services that meet professional standards of care for one Resident (#214), in a survey sample of 32 Residents. The findings included: For Resident #214 the facility staff 1. failed to provide care and maintenance of a PICC (peripherally inserted central catheter) line according to professional standards; and 2. failed to provide wound care in accordance with standards of practice as evidenced by failure to date dressings and replace dressings as per physician orders. 1. On 10/30/23 during clinical record review it was found that Resident # 214 had a PICC line ordered to administer Meropenem (an intravenous-IV antibiotic) for an infected pressure wound to the right foot. Excerpts from the progress notes are as follows: 10/2/2023 4:04 PM Order Note Text: N.O for IV ABT, PICC line placement has been ordered and [name redacted] RN @ [phone number redacted] infusion service he states he will…

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, interview, clinical record review, and facility documentation, the facility staff failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one Resident (#214) in a survey sample of 32 Residents. The findings included: For Resident #214, the facility staff failed to provide weekly dressing changes to the PICC (Peripherally Inserted Central Catheter) as ordered by the physician and failed to document the external PICC line and arm circumference measurements and when removing the PICC line failed to document the measurement of the PICC line and inspection of the catheter tip when RN B pulled (removed) the PICC LINE per facility policy and standards of nursing practice. On 10/30/23 during clinical record review it was found that Resident # 214 had a PICC line ordered to administer Meropenem (an intravenous-IV antibiotic) for an infected pressure wound to the right foot. Excerpts from the progress notes are 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.

2. For Resident #214, the facility staff failed to utilize alternatives and failed to assess for the risk of entrapment, prior to installing bed side rails. On 10/31/23, Surveyors C and D visited Resident #214 in the room, facility staff (RN B and LPN B) were present. It was noted that Resident #214 was non-verbal, severely contracted, and unable to assist with her care, to include turning and repositioning. Facility staff were observed to provide total care of the Resident to turn and move her in bed, the Resident was able to offer no assistance. It was also noted that Resident #214's bed had bilateral 1/2 side rails. Review of Resident #214's clinical record revealed the following: a. Resident #214's care plan indicated, the Resident was at risk for falls/injuries due to sensory deficit r/t [related to] MS [multiple sclerosis], Bulbar Palsy, cognitive impairment, incontinence, OP [osteoporosis], polyneuropathy, quadriplegia. Interventions included but were not limited to: bilateral 1/4 rails to assist with turning and repositioning, which was dated 1/25/23 and transfer using hoyer…

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

Based on observation, staff interview, and facility documentation review, the facility staff failed to provide food and drinks in accordance with residents preferences for two residents, Residents #210 and #211, in a sample of 4 residents reviewed for food preferences. The findings included: On 10/30/23 at approximately 1:00 PM, observations of lunch tray distributions were conducted on the second floor nursing unit and revealed the following: 1. For Resident #210, the facility staff failed to honor the resident's documented food preferences. Resident #210's tray ticket indicated her food and beverage dislikes included but was not limited to Beverages (Tea), Meats (Meatballs), and Vegetables (Tomato). Resident #210's lunch tray included spaghetti with tomato sauce and meatballs and a cup of tea. 2. For Resident #211, the facility staff failed to honor the resident's documented food pretences. Resident #211's tray ticket indicated her food and beverage dislikes included but was not limited to Other (Spaghetti) and Pasta. Resident #211's lunch tray included spaghetti with tomato sauce…

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, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for one Resident (Resident #214) in a survey sample of 32 Residents. The findings included: For Resident #214, the facility staff failed to maintain a complete and accurate clinical record to include all documentation from outside providers being entered into the clinical record in a timely manner. On 10/30/23 and 10/31/23, a clinical record review was conducted of Resident #214's electronic health record. It was noted that the most recent documentation with regards to a wound evaluation by the facility's consulted provider, was dated 10/11/23. The wound evaluation identified that Resident #214 had the following 8 wounds: a stage III pressure ulcer to the left first metatarsal, a stage III pressure ulcer to the left medial heel, an unstageable pressure wound to the left lateral ankle, an unstageable pressure ulcer to the left ischium, unstageable wounds to the right toes, a stage IV pressure wound to the right first…

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, interview, and facility documentation review, the facility staff failed to maintain all patient care equipment in safe operating condition for one Resident (#214) in a survey sample of 32 Residents. The findings included: For Resident # 214 the facility staff failed to use the bed equipment as per the manufacturer's instructions and guidelines. On the morning of 10/30/23 Resident #223 was observed resting in bed with the mattress sliding off the side of the bed frame, the mattress was hanging over the edge about 3-4 inches. Upon closer inspection of the bed frame, it was discovered that there were no mattress retainers on the bed frame. The bed had no type of bed rails or other positioning device attached. On 10/31/23 at 1:00 PM Resident #223 was observed in bed resting with eyes closed with the bottom of mattress slightly hanging over the frame about 2-3 inches. On 10/31/23 at approximately 1:00 PM on an interview was conducted with RN C (registered nurse-C) who was asked about the overlap, and she stated that this does pose a problem if the Resident were to…

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

Based on observation, interview, review of the facility's meal schedule, and facility policy review, the facility failed to have sufficient dietary staff to assure food was prepared, served, and stored in a sanitary and safe manner. Kitchen food preparation, service equipment and floors were not kept cleaned and sanitized. Dietary staff failed to cover stored food, discard hot dog buns with mold growth and serve milk from the kitchen tray line at a temperature of 41 degrees Fahrenheit or below. Additionally, there were not sufficient dietary staff to ensure resident meals were served as scheduled. The lack of dietary staff had the potential to affect 115 residents who consumed meals that were prepared from the kitchen. Findings include: Review of the facility's undated policy titled, Resident Meal Times, revealed, the resident breakfast meal service for the first and second floor was scheduled to begin at 7:30 AM, the resident lunch meal service for the first and second floor was scheduled to begin at 12:30 PM, and the evening meal service for the first and second floor was to begin…

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, interview, tasting of food served on a requested test tray, record review, and facility policy review, the facility failed to serve food that was palatable and hot to 10 of 12 sampled residents (Resident (R)7, R42, R47, R82, R85, R95, R98, R102, R123 and R126) reviewed for food palatability. Findings include: Review of the facility's undated policy titled, Food Temperatures, revealed, Food should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures (i.e. hot/cold carts, pellet systems, insulated bases and domes, etc.). 1. Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/23, located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact. During an interview on 07/09/23 at 2:40 PM, R7 stated the food served at the facility was not hot and did not taste good to 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 observation, interview, and facility policy review, the facility failed to cover stored food, discard hot dog buns with mold growth, keep kitchen equipment and areas clean including the dry storage can rack, food preparation pans, and floors, and serve milk from the tray line at an internal temperature of 41 degrees Fahrenheit (F.) or below. This failure had the potential to affect all 115 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's undated policy titled, Sanitation, specified, The food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters shelves and equipment shall be kept clean and maintained in good repair . Review of the facility's undated policy titled, Food Temperatures, specified, All cold items must be stored and served at a temperature of 41 [degrees] F. or below. 1. Observation during the initial kitchen…

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

Based on staff interview and facility record review, the facility staff failed to maintain a written transfer agreement with a hospital, which has the potential to affect all 123 Residents residing in the facility. The findings included: On 7/13/23, during the extended survey, Surveyor C asked the facility staff to submit for review the hospital transfer agreement. On 7/13/23, the facility submitted a policy titled, Extended Power Outages. An excerpt from this policy was pointed out, which read, . 5. The center will maintain current transfer agreement(s) with local hospital(s) and transportation agencies and will implement transferring procedures to move the patient if the medication condition necessitate or the patient's safety and/or comfort cannot be maintained appropriately within the building . On 7/13/23, Surveyor C let the facility Administration know the survey team was looking for a written/executed transfer agreement with a hospital, not a policy. On 7/14/23, the facility staff submitted a contract with the Veterans Administration. It was discussed by the survey team that…

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

Based on observation, interviews, clinical record reviews and facility documentation reviews, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) program that monitored its performance and ensured that improvements were sustained, which had the ability to affect all Residents within the facility. The findings included: The facility staff and QAPI program failed to monitor its performance and correct identified deficiencies and sustain improvements within multiple areas, which had the potential to affect resident care and safety. The facility had a standard recertification survey conducted 7/9/23-7/14/23. During that survey, the facility was cited for not being in compliance in multiple areas, to include but not limited to: notice of discharge, pre-admission screening assessment and resident review (PASRR), failure to following professional standards of nursing practice, care and treatment of pressure ulcers, accident hazards and upholding Resident's food preferences. Immediate Jeopardy was identified in the area of Quality of Care. The facility had…

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 interview, record review and facility policy review, the facility failed to ensure two of three sampled residents (Resident (R) 38, and R91) and/or their Resident Representative (RR), reviewed for a facility-initiated emergent hospital transfer, were provided with a written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the resident and their Resident Representative by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Notice of Transfer/Discharge, dated of 01/06/20, specified, When the Center initiates a notice of transfer/discharge to a patient and/or responsible party, Social Work and Discharge Planning staff will pursue timely and appropriate transfer/discharge notifications as well as discharge planning initiatives to ensure a safe and orderly discharge…

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, interview, clinical record review, and facility documentation, the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for 3 Residents (# 123, 63, & 65) in a survey sample of 61 Residents. The findings included: 1. For Resident #123 the facility staff failed to give the Resident choice about bed bath or showers and failed to give shower upon resident request after episode of diarrhea incontinence. On 7/9/23 at approximately 3:00 PM, an interview was conducted with Resident #123 who stated that she has been told by staff You cannot have a shower, it is not your shower day. Resident #123 stated she requested the shower on a day where she had a large diarrhea incontinent episode. She stated the CNA was cleaning her up, but she stated it was just making a bigger mess smearing it up her back. She requested the CNA just take her to the shower. Resident #123 stated the CNA refused telling her that it was not her shower day. Resident #123 stated that…

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

Based on observation, interview, and facility policy review, the facility failed to properly dispose of garbage and refuse. One of two outside facility trash dumpsters contained uncovered and mounded garbage that was above the top of the dumpster because it did not have a lid to cover and contain the garbage placed inside by staff. Findings include: Review of the facility's policy titled, Food Related Garbage and Rubbish Disposal, dated December 2008, specified, Food-related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters. 2. All garbage and rubbish containers shall be provided with tight fitting lids or cover and must be kept covered when stored or not in continuous use. 5. Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin. 7. Outside dumpsters provided by garbage pick up will be kept closed and free of surrounding litter. Observation on 07/09/23 at 6:30 PM of the facility's outside dumpster area, revealed two trash dumpsters. One of the dumpsters was uncovered and contained…

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, interview, review of Resident Council Meeting minutes, and facility policy review, the facility failed to maintain an effective pest control program so the facility was free of pests. This deficient practice had the potential for residents of the facility to be at risk for diseases caused by pest infestations. Findings include: Review of the policy titled, Pest Control, dated 05/01/22, revealed, The Center environment will be inspected monthly and treated for pests by a corporate-approved contractor. 1. Observe and document sightings of pests in the contractor/pest sighting logbook maintained at each nursing station. Review of the policy titled, Sanitation, dated October 2008, revealed, All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Review of the Resident Council Meeting minutes dated 06/26/23, revealed (Residents (R)42 and R9) voiced concerns about seeing insects in their rooms. Observation during the initial kitchen sanitation inspection on 07/09/23…

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, interview, clinical record review and facility documentation the facility staff failed to assess for appropriateness of self-administration of medications for 1 Resident (Resident #119) in a survey sample of 61 Residents. The findings included: For Resident #119 the facility allowed Resident #119 to have Chlorhexidine Gluconate, a prescription disinfecting mouthwash used to treat periodontal disease, in her room, at the sink, without first assessing the Resident's ability to self-medicate. On 7/12/23 at approximately 10:00 AM, Resident #119 was noted to have Chlorhexidine Gluconate mouthwash at the sink in the room, unsecured. On 7/12/23 at approximately 10:05 AM, an interview was conducted with Resident #119. The Resident reported she has been using the medication for several weeks and uses after every episode of brushing her teeth. The Resident further reported she has always kept it in her room. A clinical record review was conducted. This review revealed a physician order dated 6/8/23, that read, Chlorhexidine Gluconate Solution 0.12 %; Give 15 ml orally…

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 interview, clinical record review, and facility documentation the facility staff failed to immediately inform the resident representative(s) when there was a significant change in the Resident's condition for 2 Residents (#201, #208) in a survey sample of 32 Residents. The findings included: 1. For Resident #201 the facility staff failed to notify the Resident's Power of Attorney of the Resident being sent out to the emergency room (ER). On 10/30/23 a review of the clinical record was conducted, and it was found that on 8/26/23 Resident #201 was send to the ER with maggots in his infected venous stasis ulcer. A review of the clinical record revealed that on the face sheet the Resident's daughter was listed as his Power of Attorney (POA) for medical and financial matters. On 10/31/23 a review of the Clinical Record revealed that Resident #201 had an E-Interact Change in Condition form dated 8/26/23 that read as follows: Page 3 Section C- Resident Representative Notification Name of family/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.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to issue appropriate notices when skilled services were ending for 1 Resident (Resident #10) in a survey sample of 3 Residents, reviewed for such notices. The findings included: For Resident #10 the facility staff failed to issue an Advance Beneficiary Notice (ABN) when skilled services were ending. On 7/9/23, the facility Administrator was asked to provide a listing of Residents who were discharged from Medicare Part A services. From this listing a sample was selected which included Resident #10. The notices issued to these Residents were reviewed and revealed the following: For Resident #10, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. Only a Notice of Medicare Non-Coverage (NOMNC) was issued. Resident #10 was under skilled care with Medicare Part A as her primary payer from 1/3/23-1/13/23. Upon skilled care ending, Resident #10 remained a Resident of the facility and therefore should have been issued an SNF ABN in addition…

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

Based on resident interview, staff interview and facility documentation review, the facility staff failed to provide privacy during care for 1 of 61 residents (Resident #123). The findings include: For Resident # 123 the facility staff failed to use the privacy curtain and failed to close the door to provide privacy during incontinent care. On 7/11/23 at approximately 11:00 AM an interview was conducted with Resident # 123 who stated that she gets hot, so she sleeps in the nude with only a sheet on her at night. She stated that the CNA's on nightshift come in to change her and they don't close the door or the privacy curtain, the just pull the sheet down and change her. She stated that when she complained the CNA's will say, Isn't nobody coming down this hall at this time of night. The roommate of Resident #123 confirmed that they do not close the privacy curtain and they do not close the door on night shift they just change Residents in full view of anyone in the hall or in the room. When asked if there was a specific CNA who did this both Resident #123 and her roommate stated, All…

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 interview, record review, and facility policy review, the facility failed to promptly respond to resolve resident grievances about resident clothing being lost in the laundry and clothing not being returned from the laundry in a timely manner for seven of seven (Residents (R) R42, R59, R82, R85, R95, R98 and R119) sampled residents reviewed for grievances. Findings include: Review of the facility's policy titled. Grievances, dated 01/23/20, revealed, The patient has the right to voice/file grievances/complaints (orally, in writing or anonymously) without fear of discrimination or reprisal. The Administrator serves as the grievance official of the Center and is responsible for overseeing the grievance process and for receiving and tracking to their conclusion. Review of R82's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/01/23, located in the resident's electronic medical record (EMR) under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact. During an…

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

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to report an injury of unknown origin involving one Resident (Resident #18) in a survey sample of 61 Residents. The findings included: Resident #18 had an x-ray of her foot that revealed a dislocation at the metatarsophalangeal joint (MTPJ) of the fifth toe and the facility staff failed to report the injury of unknown origin. On 7/13/23, during an electronic health record review, the following was noted: On 7/7/23, an x-ray was performed of Resident #18's foot. The x-ray report read, There is dislocation at the MTPJ of the fifth toe with the proximal phalanx positioned medially. Postsurgical change is seen involving the phalanges of the second and fourth toes and possibly the third although I do not see the distal portion of the proximal phalanx of the third toe adequately to exclude osteomyelitis. The tarsometatarsal articulations are unremarkable . On 7/13/23, Surveyor C reviewed all the abuse allegations, injuries or unknown origin and allegations of neglect…

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

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to conduct an investigation with regards to an injury of unknown origin involving one Resident (Resident #18) in a survey sample of 61 Residents. The findings included: Resident #18 had an x-ray of her foot, that revealed a dislocation at the metatarsophalangeal joint (MTPJ) of the fifth toe and the facility staff failed to conduct an investigation into an injury of unknown origin to determine the cause and/or if abuse/neglect had occurred. On 7/13/23, Resident #18 was visited in her room. Resident #18 was not interviewable, as she was in a persistent vegetative state, as noted in her clinical chart. On 7/13/23, during an electronic health record review, the following was noted: On 7/7/23, an x-ray was performed of Resident #18's foot. The x-ray report read, There is dislocation at the MTPJ of the fifth toe with the proximal phalanx positioned medially. Postsurgical change is seen involving the phalanges of the second and fourth toes and possibly the third…

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 interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for antipsychotic use for two of five sampled residents (Residents (R) 47 and R91) reviewed for unnecessary medications. These failures placed the residents at risk of having unmet care needs and services. Findings include: Review of the RAI Manual 3.0, dated 10/19, revealed, .If an MDS assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected . 1. Review of the admission Record found on the Profile tab of the electronic medical record (EMR) revealed R47 was admitted to the facility with a diagnosis of major depressive disorder. Review of R47's physician's orders found on the Orders tab of the EMR revealed an order for a 10-milligram tablet of Abilify (an antipsychotic medication) each day. This order was initiated on 07/05/22. Review of the resident's June 2023 monthly Medication Administration Record (MAR) revealed R47 received Abilify…

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 interview, record review, and policy review the facility failed to make a referral for a Level II Preadmission admission Screening and Resident Review (PASARR) evaluation after a resident experienced a significant change in mental health status which included being newly diagnosed with major depressive disorder, psychosis, and mood affect disorder, and experiencing hallucinations. The failure to ensure the required PASARR screening and review was completed affected one (Resident (R) 38) of three sampled residents reviewed for PASARR Level II evaluations. Findings include: Review of the facility's policy titled, Level I PASRR-Virginia, dated 01/06/20, revealed, The preadmission Level I PASARR remains valid for the duration of the patient's care in the center unless there is a significant change in a patient's status affecting his/her mental health or mental retardation needs. a. A significant change can be in the form of a discovery of mental illness, mental retardation or a related condition after the preadmission Level I was preformed by the transferring agent; an increase…

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, interview, clinical record review and facility documentation, the facility staff failed to ensure a PASARR (Pre-admission Screening and Resident Review) was completed for 1 Resident (#76) in a survey sample of 61 Residents. The findings included: For Resident # 76, the facility staff failed to ensure a PASARR was completed. Resident # 76 was admitted to the facility on [DATE] with diagnoses that included but were not limited to PTSD (Post Traumatic Stress Syndrome) and Depression. On 7/14/23 approximately 1:45 PM an interview was conducted with the DON who was asked who ensures the PASARR's are completed she indicated that the Social Worker handled that part of the admission. On 4/14/23 at approximately 2:00 PM an interview was conducted with the Social Worker who stated that she did not have a PASARR for Resident #76. On 7/14/23 during the end of day meeting the Administrator was made aware and no further information was provided

Based on interview, clinical record review and facility documentation the facility staff failed to review and revise the care plan for 2 Residents (#'s 13 & 123) in a survey sample of 61 Residents. The findings included: For Resident # 13 the facility staff failed to update the care plan to include interventions from the latest fall on 6/2/23. Resident # 13 had diagnoses that included but was not limited to difficulty in walking, dizziness, syncope and collapse, history of falling, orthostatic hypotension, and dementia with behavioral disturbance. Resident #13 had a BIMS (Brief Interview of Mental Status) score of 7 of 15 indicating severe cognitive impairment. On 7/13/23, a review of the clinical record revealed that Resident #13 sustained a fall on 5/30/23 at 4:00 PM. The staff filled out an Situation-Background-Assessment-Recommendation (SBAR) form to notify the physician and the staff notified the family, however there was no update to the care plan. Resident #13 was care planned for falls, but no updates were made to the care plan for new interventions for falls. On 7/13/23 at…

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

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for 1 resident, Resident #65, of 61 sampled residents. The findings included: For Resident #65, facility staff failed to administer medications as ordered by the physician. On 7/9/23 at approximately 2:30 PM, an interview was conducted with Resident #65. Resident #65 stated, I have a history of bowel problems, loose stools, and I have managed it with medication, the doctor told me that I could have it when I need it, I have requested the medication both yesterday and today but the nurses just tell me that they are all out of it, I had diarrhea all over my bed early this morning and I know it would not have happened if they had given me the medicine yesterday when I asked, I have to leave here early tomorrow morning for a follow-up doctor's appointment about my broken arm, I am worried that I will have an accident [bowel movement] because I can't get my medication.…

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 ensure pain management was provided to 1 Resident (Resident #21) in a survey sample of 61 Residents. The findings included: For Resident #21, who reported pain from a sacral pressure ulcer and a Foley catheter, the facility staff failed to respond to a physician order for an increase in pain medication and to pre-medicate prior to dressing changes and failed to notify the physician of the catheter pain. On 07/09/23 at 01:55 PM, during an interview with Resident #21, the Resident said the facility staff replaced her Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine) few days ago, but something is not right, it hurts, and urine comes from around it. Resident #21 reported that she has told the nurses on several occasions and They said they were going to come look at it but haven't come back yet. Resident #21 also reported having a sacral wound that hurts. On 7/9/23, in the afternoon, an interview 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, interview, clinical record review, and facility documentation review, the facility staff failed to review for risk and benefits and assess for entrapment, prior to installing bed rails for two Residents (#223, #214), in a survey sample of 32 Residents. The findings included: 1. For Resident #223 the facility installed bedrails without proper assessment in response to surveyor inquiry of an unsecured mattress. On the morning of 10/30/23 Resident #223 was observed resting in bed with the mattress sliding off the side of the bed frame, the mattress was hanging over the edge about 3-4 inches. Upon closer inspection of the bed frame, it was discovered that there were no mattress retainers on the bed frame. The bed had no type of bed rails or other positioning device attached. On 10/31/23 at 1:00 PM Resident #223 was observed in bed resting with eyes closed bottom of mattress slightly hanging over the frame about 2-3 inches. On 10/31/23 at approximately 1:00 PM, an interview was conducted with RN C (registered nurse-C) who was asked about the overlap, and she stated…

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

Based on interview, clinical record review and facility documentation, the facility staff failed to ensure Residents are free from unnecessary psychotropic medications for 1 Resident (#63) in a survey sample of 61 Residents. The Findings included: For Resident #63 the facility staff failed to ensure PRN anti-anxiety medications were not for more than 2 weeks without the proper physician's documentation. On 7/12/23, a review of the clinical record revealed that Resident #63 had orders that included Buspirone HCL 15 mg (milligrams) three times a day for anxiety as well as a PRN order for Ativan 0.5 mg (an anti-anxiety drug) that was written on 5/1/2023. On 7/12/23 at approximately 11:00 AM an interview was conducted with LPN E who stated that Buspirone HCL was given routinely for anxiety. When asked what Ativan was for, she sated it was also for anxiety and agitation. She further elaborated that some Residents become agitated when they are anxious, so they need something extra like a PRN Ativan to help control the agitation. On 7/12/23 at approximately 10:00 AM an interview 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, interview, clinical record review and facility documentation the facility staff failed to store medications in a secure location on 1 of 2 nursing units. The findings included: The facility staff failed to ensure medications were stored in a secure location so that only persons authorized had access to the medications. On 07/09/23 at 02:24 PM, Surveyor C observed a Symbicort inhaler at the bedside of Resident #46. On 7/9/23 at 2:25 PM, an interview was conducted with Resident #46. When asked about the inhaler, the Resident said, I use it every morning. During the end of day meeting held on 7/9/23, the facility staff were notified of the above observation. On 07/10/23 at 09:14 AM, it was noted that the facility staff had removed the Symbicort inhaler. Resident #46, reported, they took it out. On 7/12/23 at approximately 10:00 AM, Resident #119 was noted to have Chlorhexidine Gluconate mouthwash at the sink in the room, unsecured. On 7/12/23 at approximately 10:05 AM, an interview was conducted with Resident #119. The Resident reported she has been using 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, interview, and record review, the facility failed to honor the food preferences for three of six sampled residents (Resident (R) 42, R82, and R95) reviewed for choices. Findings include: Review of R82's electronic medical record (EMR) revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/01/23 located under the MDS tab. The assessment recorded a Brief Interview for Mental Status (BIMS) score of 15 of 15 for R82, which indicated the resident was cognitively intact. An observation on 07/10/23 at 8:53 AM, revealed R82 was eating breakfast in her room. Observation of the resident's breakfast meal revealed she was served grits, one hard-boiled egg, hash browns, half of a banana, orange juice and coffee on her tray. Review of the resident's tray slip, that was provided with this meal, revealed the resident's breakfast preferences included cold cereal, two hard boiled eggs and two eight-ounce waters that were not served on her meal tray. During an interview on 07/10/23 at 8:55 AM, R82 stated the kitchen does not honor her food…

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, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for one Resident (Resident #214) in a survey sample of 32 Residents. The findings included: For Resident #214, the facility staff failed to maintain a complete and accurate clinical record to include all documentation from outside providers being entered into the clinical record in a timely manner. On 10/30/23 and 10/31/23, a clinical record review was conducted of Resident #214's electronic health record. It was noted that the most recent documentation with regards to a wound evaluation by the facility's consulted provider, was dated 10/11/23. The wound evaluation identified that Resident #214 had the following 8 wounds: a stage III pressure ulcer to the left first metatarsal, a stage III pressure ulcer to the left medial heel, an unstageable pressure wound to the left lateral ankle, an unstageable pressure ulcer to the left ischium, unstageable wounds to the right toes, a stage IV pressure wound to the right first…

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 implement infection control standards to prevent the spread of infections within the facility on 1 of 2 nursing units. The findings included: On the first-floor nursing unit the facility staff failed to don (put on) an isolation gown, gloves, and mask prior to entering the room identified as being on droplet precautions. On 7/9/23 at 2:17 PM, Employee S was observed to enter the room to deliver personal laundry. Employee S failed to don (put on) any PPE (personal protective equipment/gloves, gown, and mask). Upon Employee S' exit from the room an interview was conducted. Employee S said, I didn't know when asked why she had failed to put on the gloves, gown, and mask. When the droplet precaution sign beside the room door was pointed out, Employee S said, I don't know nothing about that. The sign outside the room read, STOP: Droplet Precautions: Perform hand hygiene using soap and water and/or alcohol-based hand rub before entering and before exiting room. Wear mask when entering room, remove before exiting 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, and facility documentation review, the facility staff failed to 1) provide influenza vaccines for 2 residents, Residents #13 and #98, out of 5 residents reviewed for influenza immunization and facility staff failed to 2) provide a pneumococcal vaccine for 1 resident, Resident #12, out of 5 residents reviewed for pneumococcal immunization. The findings included: 1. The facility staff failed to provide influenza immunization, to include education of risks/benefits about influenza immunization, for Residents #13 and #98. On 7/11/23 at approximately 2:30 PM, clinical record reviews were performed and revealed the following: 1A. Resident #13, who was admitted to the facility on [DATE], had no documentation with regard to influenza immunization, to include the resident's current influenza vaccination status, offer to provide immunization against influenza infection, or documentation of resident refusal or medical contraindication. 1B. For Resident #98, the clinical…

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 documentation review, the facility staff failed to provide COVID-19 bivalent vaccines for 1 resident, Resident #98, out of 5 residents reviewed for COVID-19 bivalent immunization. The findings included: 1. The facility staff failed to provide COVID-19 bivalent immunization, to include education of risks/benefits about COVID-19 immunization, for Resident #98. On 7/11/23 at approximately 2:30 PM, a clinical record review was performed and revealed Resident #98, who was admitted to the facility on [DATE], had received a monovalent booster on 6/17/22, however there was no evidence that Resident #98 had been offered or received a COVID-19 bivalent booster dose. On 7/11/23 at approximately 2:45 PM, an interview was conducted with the Director of Nursing (DON) who accessed the clinical records for Resident #98 and verified the findings. The DON confirmed there was no additional information. A facility policy was requested and received. On 7/11/23 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 Resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure that Resident beds were maintained in a safe operating condition for 2 Residents (Resident #21 and #330) in a survey sample of 61 Residents. The findings included: 1. For Resident #21, the facility staff failed to ensure an air mattress was properly maintained to prevent the Resident from laying directly on the metal bed frame. On 07/09/23 at 01:58 PM, an interview was conducted with Resident #21. During this interview, Resident #21 reported that she had a sacral wound. It was observed that Resident #21 was not on an air mattress. When asked about this, Resident #21 reported that on several occasions she did have an air mattress and they would blow out leaving her laying directly on the metal bed frame, so she isn't interested in being on an air mattress anymore. Review of the clinical record of Resident #21, revealed notes that indicated the Resident refused an air mattress. On 7/11/23 at 10:10 AM, an interview was conducted with RN C, the…

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

Based on staff interview and facility documentation review, the facility staff failed to ensure that the required 12 hours annual in-service training was completed for 2 certified nursing aides (CNAs), CNA C and CNA D, in a survey sample of 3 CNAs. The findings included: The facility staff failed to ensure 12 hours of required annual training for CNA C and CNA D were completed. On 7/13/23 at approximately 11:00 AM, a request was made to the Facility Administrator to provide evidence that CNA C, hired on 4/29/2004, and CNA D, hired on 12/3/2020, had completed 12 hours of required annual in-service training and a facility policy regarding annual in-service training for CNAs. On 7/13/23 at approximately 7:00 PM, during the end of day debriefing with the Facility Administrator, Director of Nursing, and Regional Clinical Consultant, a second request was made to provide evidence of required annual in-service training for CNA C and CNA D, along with a facility policy that addressed annual in-service training for CNAs. The Facility Administrator stated, Okay. On 7/14/23 at approximately…

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, interview, record review and policy review, the facility failed to ensure the kitchen was maintained and operating in a sanitary manner. This created the potential for the transmission of food borne illness to 100 of 109 residents who received meals prepared in the kitchen, (9 residents received nutrition via feeding tubes). Findings include: 1.The initial kitchen tour was conducted on 05/03/21 from 9:37 AM 10:17 AM with the Interim Dietary Manager. The following concerns were noted: a. Garbage, including a soiled N95 mask was on the floor in the corner by the handwashing sink. b. Five cycles of the commercial dish washer were observed. A rinse additive was observed dripping onto the stainless-steel counter, of the clean side, where trays of clean dishes came out of the dish machine. The rinse additive, a green solution, dripped continuously and the container on the wall was positioned such that the solution had the potential to drip directly on clean dishware while it was being removed from the machine. In addition, there was a significant amount of pooled…

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, interview, record review and policy review, the facility failed to ensure eight of 40 sampled residents (Resident (R) 6, R12, R51, R53, R54, R63, R78, and R84) were treated in a dignified manner and care and services provided as needed. Specifically, R53's clothing and bedding were soiled with vomit; staff failed to change her clothing and bedding in a timely manner, R6, R51, R54, R63, and R78, who required assistance with meals, were identified by nursing staff as, feeders. Staff failed to apply R12's hand splint so she could feed herself using silverware resulting in the resident putting her head down and eating directly from the plate with her mouth. The resident was tearful when recounting this experience. The facility failed to provide R84 with the appropriate skin/scalp care to prevent the excessive shedding of skin to the resident's clothing. Findings include: Review of the paper Quality of Life - Dignity policy dated August 2009 revealed, Each resident shall be cared for in a manner…

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, interview with the Director of Maintenance (DOM), and review of facility policies and procedures, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly environment for four bedrooms on one of six units affecting four resident rooms (bedrooms 210, 200, 204, 208.) 2. The facility failed to ensure two of two residents reviewed for property in a sample of 40 residents R12 and R44 who reported missing clothing after sent to the laundry and provided no process in place to find their clothing or replace their clothing or put a system in place to ensure tracking of resident's personal property. Findings include: 1. Observations on 05/03/21 at 3:41 PM revealed the wall under the sink in bedroom [ROOM NUMBER] had a two foot section of corner base peeled away from the wall and chunks of drywall missing and on the floor. In addition, bed A wall near the door had a eight inch by eight inch dry wall mud patch near the electrical light switch 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, interview, record review and policy review, the facility failed to ensure menus were followed for four of 40 sampled residents (Resident (R)12, R44, R69, R105) for residents on pureed diets, for residents who were part of the resident council, and for a resident who wished to remain anonymous. Menu substitutions were made without documentation or Dietitian approval. A food group (bread) was consistently omitted for residents on pureed diets and small portions were served. Findings include: Review of the paper Menus policy dated October 2017 revealed, Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy . Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and are dated and posted in the kitchen at least (1) week in advance . The Dietitian reviews and approves all menus . Deviations from the posted menus (as served, including substitutions) are kept on file for at least 1 year . Menus provide a variety 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.

Based on observation, interview, record review and policy review, the facility failed to ensure the food was palatable for seven of 40 sampled residents (Resident (R)6, R12, R21, R44, R64, R69, R105) for residents who were part of the resident council, and for a resident who wished to remain anonymous. Specifically, food was not consistently served at the appropriate temperatures, was not appetizing, and/or was not appealing. Findings include: Review of the paper Food and Nutrition Services policy dated October 2018 revealed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits . that affect eating and nutritional intake and utilization . Reasonable efforts will be made to accommodate resident choices and preferences . Food and nutrition service staff will…

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, interview with facility staff and resident family members (F1), and review of facility policies, the facility failed to ensure that one resident (R34) of 27 sampled was free from misappropriation of property. Findings include: Interview with F1 on 05/03/21 at 4:47 PM revealed a chair was purchased for R34's use. The chair was placed in her bedroom and was now missing. The chair was purchased in 2020 and cost $144.00. In February 2021 when visitation had been suspended, R34 was moved from the first floor of the building to the second floor or R34's current bedroom. In March 2021, compassionate visitations were permitted allowing F1 to visit. During F1's first visit, she noticed the chair she had purchased was missing. She contacted the Administrator the next day requesting an explanation. The Administrator told F1 she would look for the chair. Interview with the Administrator on 05/06/21 at 1:00 PM verified the conversation and search for the chair. F1 explained the Administrator found the chair in the employee breakroom. The Administrator explained to F1, 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, staff interview and family member (F1) interview, and review of facility policy the facility failed to report misappropriation of property to the state survey agency related to one of four residents reviewed for property in a sample of 40 residents, (R34). Findings include: Interview with F1 on 05/03/21 at 4:47 PM revealed a chair that was purchased before visitations were suspended for her daughter or resident 34 (R34), was reported missing in March of 2021 after her daughter moved to another room on another floor of the building. F1 complained to the Administrator the day after compassionate visitations were resumed in March 2021 after she noticed the chair was missing. In a conversation described by F1 and confirmed by the Administrator on 05/06/21, the Administrator and staff searched for the chair and located the chair in the employee breakroom. F1 described the conversation confirmed by the Administrator on 05/06/21 at 1:00 PM that the chair purchased for her daughter was broken and thrown out. F1 indicated on 05/03/21 at 4:47 PM that the Administrator…

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 record review and interview, the facility failed to ensure that a pre-admission screening and resident review (PASARR) Level II was completed on a Resident (R), with a serious mental disorder, admitted to their facility for one of two sampled residents (R17) for PASSAR II compliance. This failure could negatively impact R17 due to R17 not receiving a comprehensive evaluation in order to determine if R17 needed or qualified for specialized services. Findings include: A review of R17's electronic medical record (EMR) under the face sheet tab revealed R17's admission date as 03/12/19. Continued review of the EMR, under the diagnosis tab, revealed the diagnosis of bipolar disorder. After a review of R17's EMR it was determined a completed PASARR Level II form could not be located. In an interview on 05/06/21 at 2:05 PM with the SSD she said she thinks that the PASARR II was in process for R17. SSD agreed to try and locate the PASARR II. In an interview on 05/06/21 at 4:30 PM with the SSD she stated, I honestly don't have it (PASARR II), she (R17) was here when I started working…

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, record review, and interview of one resident (Residents (R) 12) with a history of pressure ulcers in a sample of six residents reviewed for pressure ulcers from a sample of 40 residents showed the facility failed to replace a sagging mattress to provide support and comfort for the resident. Findings include: Observation on 05/03/21 at 12:34 PM identified the R12's mattress to be sagging to the extent R12 who was sitting sideways on the bed, appeared to be sitting in a hole. Review of resident 12's Minimum Data Set (MDS ) with an Assessment Reference Date (ARD) of 02/10/21 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. The assessment documented the resident required extensive of two-person physical assist for all ADL's and was non-ambulatory. R12's diagnosis included history of pressure ulcer, cerebral infarction and muscle weakness. Review of the RCP (resident care plan) dated 02/05/21 identified Actual skin breakdown related to sacral pressure ulcer. Review 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.

Based on observation, interview with facility staff and review of the electronic medical record (EMR), the facility failed to ensure that one resident (R14) of eight residents reviewed for range of motion in a sample of 40 residents received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. Findings include: Observations of the R14 in her bed on 05/03/21 at 9:50 AM, 05/05/21 at 10:25 AM and 12:20 PM revealed the resident did not have a splint on her right arm/elbow. In addition, both observations on 05/05/21 at 10:25 AM and 12:20 PM revealed the towel roll in her right hand had unraveled completed extending down her arm with only a small portion of the towel in her right hand. The towel was not opening the right hand to prevent contractures as intended due to the unraveling. Review of the EMR for R14 revealed diagnosis that included persistent vegetative state, anoxic brain damage not elsewhere classified, contracture of right wrist, contracture of unspecified joint, contracture of muscle, multiple sites, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, electronic medical record (EMR) review, and interviews the facility failed to ensure that three of five residents in a sample of 40 residents reviewed for falls (Resident (R) 59, R14, and R103 were provided a safe environment to prevent and decrease residents risk for falls. The facility failed to ensure R59 remained free of accidents to prevent harm when the facility failed to secure a pressure reduction cushion properly to the wheelchair causing R59 to fall out of a chair resulting in a major injury. Findings include: 1. Review of the EMR revealed a diagnosis for R59 of periprosthetic fracture around internal prosthetic right knee joint, subsequent encounter, unspecified dementia without behavioral disturbance, repeated falls, and lack of coordination. The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/21 revealed that R59 required extensive assistance in bed mobility and extensive assistance with staff support and weight bearing assistance…

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 complete a Pre-admission Screening and Resident Review for five Residents (Residents #59, 5, 50, 23, and 60 ), in a survey sample of 33 Residents. 1. For Resident #59, the facility staff failed to complete a Pre-admission Screening and Resident Review (PASARR). 2. For Resident #5, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission. 3. For Resident #50, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission. 4. For Resident #23, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission. 5. For Resident #60, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission. The findings included: 1. Resident #59 was admitted on [DATE]. Diagnoses included: Parkinson's dementia, seizures,…

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 interviews, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure that a resident received necessary, safe, transfer assistance in a timely manner, for one resident (Resident #84) in a survey sample of 33 residents. For Resident #84, the facility staff allowed the resident (who was a quadriplegic) to remain suspended over the floor in a hoyer lift for approximately 30 minutes unattended. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses including; Quadriplegia from a traumatic fall, hypertension, and pressure ulcers. Resident #84's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 7-24-18. Resident #84 was coded with a Brief Interview of Mental Status score of 15, indicating no cognitive impairment. Resident #84 was completely dependant on staff assistance for activities of daily living…

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 interviews, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure that a Resident was free from Neglect, for one Resident (Resident #84) in a survey sample of 33 residents. For Resident #84, the facility staff allowed the resident (who was a quadriplegic) to remain suspended over the floor in a hoyer lift for approximately 30 minutes unattended. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses including; Quadriplegia from a traumatic fall, hypertension, and pressure ulcers. Resident #84's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 7-24-18. Resident #84 was coded with a Brief Interview of Mental Status score of 15, indicating no cognitive impairment. Resident #84 was completely dependant on staff assistance for activities of daily living care, such as transferring from bed into 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 Resident interviews, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to implement abuse and neglect policies and procedures for one Resident (Resident #84) in a survey sample of 33 residents. For Resident #84, the facility staff did not implement abuse and neglect policies and procedures after the allegation was made by a Resident. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses including; Quadriplegia from a traumatic fall, hypertension, and pressure ulcers. Resident #84's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 7-24-18. Resident #84 was coded with a Brief Interview of Mental Status score of 15, indicating no cognitive impairment. Resident #84 was completely dependant on staff assistance for activities of daily living care, such as transferring from bed into a wheel chair. On 8-7-18 at 1:00…

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 interviews, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to report to authorities an allegation of Abuse/Neglect per federal regulation, in a timely manner for one Resident (Resident #84) in a survey sample of 33 residents. For Resident #84, the facility staff did not report an allegation of abuse/neglect for 2 weeks after the allegation was made by a Resident. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses including; Quadriplegia from a traumatic fall, hypertension, and pressure ulcers. Resident #84's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 7-24-18. Resident #84 was coded with a Brief Interview of Mental Status score of 15, indicating no cognitive impairment. Resident #84 was completely dependant on staff assistance for activities of daily living care, such as transferring from…

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 and facility documentation review, the facility staff failed, for 1 resident (Resident #67) of the survey sample of 33 residents, to implement interventions to prevent pressure ulcers. 1. The facilty staff failed to provide services to prevent skin breakdown (heel/boot protectors) for one resident (Resident #67) to ensure prevention of pressure ulcers. Resident #67 was admitted on [DATE]. His most recent readmission after hospitalization occurred on 7/11/2018. readmission diagnoses included: Parkinson's disease, muscle weakness, chronic kidney disease (Stage 3, moderate), and Type II Diabetes Mellitus. His most recent MDS (Minimum Data Set) was a Quarterly assessment dated [DATE]. This MDS showed that the staff considered him to have moderately impaired cognitive skills, and that the resident was rarely/never understood when he attempted to communicate. This MDS also showed that Resident #67 required extensive assistance of 2 staff members for bed mobility,…

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, the facility staff failed to ensure a system of prompt identification of potential diversion of controlled medications and provide safekeeping of hard scripts for all controlled drugs for 1 resident (Resident # 85) in a survey sample of 23 residents. 1. For Resident # 85, the facility staff failed to ensure a method of disposition of written prescriptions for narcotics to prevent potential diversion of controlled drugs. The facility staff failed to send a hard copy script dated 7/16/2018 for the narcotic, Hydrocodone/APAP Lortab 5/325 MG (milligrams) to the Pharmacy. Findings included: 1. For Resident # 85, the facility staff failed to send a hard copy script dated 7/16/2018 for the narcotic, Hydrocodone/APAP Lortab 5/325 MG (milligrams) to the Pharmacy. Resident # 85 was an [AGE] year old female admitted to the facility on [DATE] with the diagnoses of, but not limited to, Left Pubic and Hip Fracture, History of meningioma, status post resection,…

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, interview and clinical record review the facility failed to ensure 1 Resident (Resident #54) was free from unnecessary psychotropic medication in a survey sample of 33 residents. For Resident #54 the facility failed to ensure that Resident #54 had an appropriate diagnosis for receiving Seroquel (an anti-psychotic medication). The findings include: Resident # 54 a [AGE] year old female was admitted into the facility on 5/11/2015 with diagnoses of but not limited to Hypertension, Congestive Heart Failure, Diabetes, Chronic Renal Failure, Atrial Fibrillation (irregular heart rhythm) and Dementia. The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 6/20/2018. The MDS coded Resident #54 with a BIMS (Brief Interview for Mental Status) of 7/15 indicating resident is severely cognitively impaired. On 8/9/2018 at 9:00 AM a review of the clinical record was conducted and according to the MAR (Medication Administration Record) Resident #54…

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.