Ghent Health and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility document review, and clinical record review, it was determined that the facility staff failed to maintain a safe, functional, and comfortable environment in the facility's shower rooms.The findings include: 1.The facility staff failed to provide a safe, functional, sanitary, and comfortable environment for the residents to shower On 2/05/2026 an observation of the shower room on unit 1A was conducted at 3:26 pm, with the unit manager, Licensed Practical Nurse (LPN) #6. The observation revealed a small to moderate brown substance on the commode seat. LPN #6 said that she will make sure the area is cleaned. LPN #6 was asked who's responsible for cleaning the commode. LPN #6 said that once the nursing staff clean off the toilet seat, they will contact housekeeping to get the commode sanitized. On 2/09/26 at 4:40 pm., End of day meeting with the administrator, the Director of Nursing and Regional Director. 2. The facility staff failed to provide a safe, functional, sanitary, 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 resident/staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain an effective pest control program so that the facility is free of pests and rodents.The findings include: 1.Observations during the survey period of 2/3/26-2/6/26 and 2/9/26-2/11/26 revealed, observations of roaches and mice. On 2/4/2026 at 10:33 AM, an observation was made of Resident #129 in their room. A large brown roach was observed climbing up to the top of the nightstand and then proceeding to the back side of the nightstand. The roach was observed by two surveyors. On 2/4/26 no observations of pests and rodents in the kitchen. On 2/5/2026 at 6:45 AM, this surveyor observed a mouse running across hallway from the biohazard room on first floor to underneath the door of a locked room. A review of the pest control invoices revealed this number of invoices per month: 7/25-1, 9/25-6, 10/25-5, 11/25-6, 12/25-14 and 1/26-10. A review of the pest control logs for…

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

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide a call bell accessible from the floor in the bathroom for one of 80 residents in the survey sample, Resident #6. The findings include:For Resident #6 (R6), the facility staff failed to ensure the bathroom call bell was accessible to the resident from the floor. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 1/6/2026, the resident scored 14 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. The assessment further documented R6 not having any upper or lower extremity functional limitations in range of motion, using a wheelchair and requiring setup or clean-up assistance for toilet transfers and toileting hygiene. R6 was assessed as being occasionally incontinent of urine and frequently incontinent of bowel. On 2/5/2026 at 9:08 AM, R6 was not in their room, 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, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide reasonable access to private use of the telephone to one of 80 residents in the survey sample, Resident #84.The findings include:For Resident #84 (R84), the facility staff failed to provide private access to a telephone for resident use.On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date of 1/15/2026, the resident scored 13 out of 15 on the brief interview for mental status (BIMS), indicating they were cognitively intact for making daily decisions. On 2/3/2026 at 12:50 PM, an interview was conducted with R84 who stated that they did not have access to a telephone to speak to anyone privately. R84 stated that they had to go to the nurses station and beg to use the phone. On 2/5/2026 at 12:13 PM, an observation was made of R84 using the telephone at the nurses station. Two staff members were seated behind the nurses station, and one staff member was at the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, the facility's staff failed to ensure the resident was allowed privacy while talking on the facility telephone located at the nurses' station for one (1) of 80 residents (Resident #82), in the survey sample.The finding include: Resident #82 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The current diagnoses included: aphasia following cerebral infarction and contracture of the muscles of the right hand.The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/15/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated that Resident #82's cognitive abilities for daily decision making were moderately impaired.The care plan dated 12/30/25 read resident is independent in meeting emotional, intellectual, physical, and social needs r/t ambulation. The Goal is that 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.

Based on staff interview, clinical record review, facility document review, the facility staff failed to resolve grievances for one of 80 residents in the survey sample, Resident #125 (R125). The findings include:For Resident #125 (R125), facility staff failed to provide resolutions to grievances filed on 06/09/2025, 07/17/2025, 07/30/2025, and 07/31/2025. On 2/5/2026 at 10:28 AM, an interview was conducted with R125, who stated that they had filed multiple grievances with the facility, and they never received any follow-up regarding the outcomes. On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date of 1/29/2026, Resident #125 (R125) scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. The facility's grievances filed by R125 dated 06/09/2025, 07/17/2025, 07/30/2025, and 07/31/2025 failed to document resolutions. On 02/10/2026 at approximately 10:30 a.m. an interview was conducted with the Social Worker regarding the process of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, a review of the clinical record, and facility documents, the facility staff failed to protect the residents' right to be free from verbal and physical abuse for 1 of 80 residents (Resident #3) in the survey sample. The findings included: Resident #3 was initially admitted to the facility on [DATE] from a community home. The residents' diagnoses included dementia, a psychotic disorder, and an anxiety disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/9/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 12 out of 15. This indicated Resident #3's cognitive abilities for daily decision making were intact. In section GG0130. (Self-Care), The resident was coded as requiring setup or clean-up assistance with eating, partial/moderate assistance with upper and lower body dressing, and putting on footwear, dependent on toileting, oral hygiene, and showers/baths.A review of facility…

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

Based on staff interview, clinical record review, facility document review, the facility staff failed to investigate an allegation of abuse for one of 80 residents in the survey sample, Resident #170 (R170). The findings include:For Resident #170 (R170), facility staff failed to investigate an allegation of abuse. R170 was admitted to the facility with a diagnosis that included but not limited to paraplegia (1), and depression. On the most recent MDS (minimum data set), a discharge assessment with an ARD (assessment reference date) of 10/27/2023. Section C0700 Cognitive Skills for Daily Decision Making coded R170 as Independent - decisions consistent/reasonable. The facility's nursing progress note for R170 dated 10/27/2023 documented, 05:47 (5:47 a.m.) Note Text : can reported to this nurse that another resident stated that this resident (R170) pulled out a knife on him and that he was afraid for his life. DON (Director of Nursing) was called and made aware. Resident is to be 1:1 (one-to-one) and to stay in his room per DON. This nurse called 911. police arrived and spoke with both…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for two of 80 residents, Resident #173 and Resident #137. The findings include: 1. For Resident #173 (R173), the facility staff failed to implement the comprehensive care plan to provide pain medications per order. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 4/5/2024, the resident was assessed as having a surgical wound, receiving scheduled pain medication and having occasional pain. The comprehensive care plan for R173 documented in part, [R173] actual impaired skin to Lower back r/t (related to) Laminectomy. Date Initiated: 04/01/2024. Under Interventions it documented in part, Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Date Initiated: 04/01/2024 . It further documented, [R173] has pain r/t Wound (surgical). Date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a surgical wound for 1 of 80 residents, Resident #173. The findings include:For Resident #173 (R173), the facility staff failed to assess and treat a surgical wound until 4/1/2024 after admission to the facility on 3/29/2024. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 4/5/2024, the resident was assessed as having a surgical wound and receiving surgical wound care. The emergency room discharge notes dated 3/28/2024-3/29/2024 documented in part, . here for getting placed into a rehab facility . She is also status post lumbar laminectomy done at [Name of hospital] on March 20. She was discharged home on March 22 to go home to her daughter's house with home health. Patient states that the home health nurse came out yesterday for the first time and that her daughter really…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce trauma to the urethra and bladder, and other complications while utilizing an indwelling catheter for 1 of 80 residents (Resident #106), in the survey sample.The findings included:Resident #106 was originally admitted to the facility 5/12/25 after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included; Urinary Tract Infection. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #106 cognitive abilities for daily decision making were intact. The personal centered care plan dated 11/19/25 read the resident has an indwelling catheter (20Fr 10cc) r/t Urinary Retention. The Goal for the resident is he will be/remain free 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.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for a urostomy consistent with professional standards of practice for one of 80 residents in the survey sample, Resident #125.The findings include:For Resident #125 (R125), the facility staff failed to maintain a urinary collection bag in a sanitary manner. R125 was admitted to the facility with diagnoses that included but were not limited to urostomy (1) and malignant neoplasm of bladder (2).On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date of 1/29/2026, the resident scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. On 2/5/2026 at 10:28 AM, an interview was conducted with R125 in their room. R125 stated that they had a history of kidney stones and cancer and had surgery in the past with a urostomy placed. R125 stated that the urostomy…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services to implement a complete pain management program for 1 of 80 residents, Resident #173.The findings include:For Resident #173 (R173), the facility staff failed to provide Hydrocodone-Acetaminophen as ordered by the physician after admission to the facility. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 4/5/2024, the resident was assessed as having a surgical wound, receiving scheduled pain medication and having occasional pain.The emergency room discharge notes dated 3/28/2024-3/29/2024 documented in part, .Your current discharge medications are: . Hydrocodone-Acetaminophen (Norco 5) (1) 5-325mg po (by mouth) tabs take 1 tab by mouth every 4 hours for 5 days .The physician orders for R173 documented in part, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (milligram) (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours for pain until 04/03/2024 23:59…

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, facility document review, the facility staff failed to obtain an assessment and consent for the use of bed rails for one of 80 residents in the survey sample, Resident #125 (R125). The findings include:For Resident #125 (R125), facility staff failed to complete an assessment and obtain consent for the use of bed rails. R125 was admitted to the facility with a diagnosis that included but not limited to muscle weakness. On the most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/29/2026, R125 scored 2 15 out of 15 on the BIMS (brief interview for mental status), indicating R125 was cognitively intact for making daily decisions. On 02/03/2026 at approximately 3:33 p.m. an observation revealed R125 was in bed with bilateral (right and left) upper rails were raised. R125 stated he uses to move in bed. On 02/03/2026 at approximately 4:50 p.m. an observation revealed R125 was in bed with bilateral upper rails were raised. On 2/5/2026 at approximately 10:28 a.m. 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 and a review of facility menus, the facility staff failed to serve portions of food planned on the facility's menu for 1 of 80 residents (Resident #109) in the survey sample. The findings include: Resident #109 was originally admitted to the facility 05/23/25 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Need for assistance with personal care and unspecified urinary incontinence.Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #109 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities) the resident was coded as being dependent with eating, oral hygiene, toileting, shower/bathe self and personal hygiene. The person-centered care plan dated 5/27/25 has a nutritional problem or potential nutritional problem, aeb dx CVD, HTN, hypothyroidism; advanced age; underweight per BMI; mechanically altered diet texture. The Goal is that the resident will The resident will maintain adequate nutritional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident/staff interview, and facility document review, it was determined that the facility staff failed to provide snacks to residents who want to eat at non-traditional times for three of 80 residents, Resident #12 (R12), Resident #14 (R14) and Resident #137 (R137).The findings include: 1. During the survey period of 2/3/26-2/6/26 and 2/9/26-2/11/26 snacks were observed to be delivered at 10:00 AM, approximately 2:00 PM and 6:00 PM. Initial observation of snacks delivered and available on the four units included saltine crackers, graham crackers and on two of the units, some captain's crackers with peanut butter. Pitchers of juice were not observed in refrigerator on 2B till 2/5/26. A few puddings were available. 2/5/26 observed cart bringing boxes of oatmeal cookies, crackers and two pitchers of juice to unit 2B.R12 was admitted to the facility on [DATE] with diagnosis that included but were not limited to epilepsy, DM (diabetes mellitus) and CVA cerebrovascular accident.R12's most…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and a review of the clinical record, the facility staff failed to have a hospice-coordinated plan of care for 1 of 80 residents (Resident #155) in the survey sample. The findings included: Resident #155 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included dementia. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/14/25, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 2 out of a possible 15. This indicated that Resident #155's cognitive abilities for daily decision-making were severely impaired. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, supervision or touching assistance with oral care, and dependent with toileting, showers/bathe, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. On 2/4/26 at 10:45 AM, 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, facility document review, the facility staff failed to conduct bed and bed rails inspections for one of 80 residents in the survey sample, Resident #125 (R125). The findings include:For Resident #125 (R125), facility staff failed to conduct a bed and bed rail safety inspection. R125 was admitted to the facility with a diagnosis that included but not limited to muscle weakness. On the most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/29/2026, R125 scored 2 15 out of 15 on the BIMS (brief interview for mental status), indicating R125 was cognitively intact for making daily decisions. On 02/03/2026 at approximately 3:33 p.m. an observation revealed R125 was in bed with bilateral (right and left) upper rails were raised. R125 stated he uses to move in bed. On 02/03/2026 at approximately 4:50 p.m. an observation revealed R125 was in bed with bilateral upper rails were raised. On 2/5/2026 at approximately 10:28 a.m. an observation revealed R125 was in bed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews and staff interviews the facility staff failed to maintain a clean, comfortable, homelike environment for 2 of 6 residents (Resident #1 and Resident #2), in the survey sample. The findings included: 1. Resident #1 was originally admitted to the facility 1/26/2007. The current diagnoses included cerebral palsy, major depressive disorder, anxiety disorder, and schizoaffective disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/31/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. On 7/16/24 during an observation tour for room [ROOM NUMBER], it was observed that the air conditioning unit was not functioning. On 7/16/24 at 4:30 PM an interview was conducted with Resident #1. Resident #1 stated that the air conditioning unit has not been working for a while. Resident #1…

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

Based on observation and staff interviews the facility staff failed to maintain a comfortable environment for residents, staff, and the public. The findings included: On 7/16/24 during an observation tour of unit 1A and unit 1B, it was observed that the air conditioning was not functioning properly. During the observation tour on 7/16/24 at 4:00 PM the Maintenance Assistance recorded an ambient temperature of 84.6 degrees Fahrenheit (F) on unit 1A hallway and 85.2 degrees (F). on unit 1B hallway. The Maintenance Assistant stated that the nursing unit hallways are hot due to the temperature outside. On 7/16/24 at 4:05 PM an interview was conducted with the Administrator. The Administrator stated that there are four (4) portable air conditioning units in the building due to the air conditioning system not working properly. The Administrator also stated that the plan is for the heating and air conditioning vendor to repair the air conditioning once they acquire the parts for the repair. On 7/17/24 at approximately 4:40 p.m., a final interview was conducted with the Administrator, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a Do Not Resuscitate resident wishes were in place for 1 of 6 residents (Resident #6), in the survey sample. The findings included: Resident #6 was originally admitted to the facility [DATE] after an acute care hospital stay. The current diagnoses included; Thrombocytopenia Unspecified. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #6 cognitive abilities for daily decision making were intact. The person-centered care plan dated [DATE] read that Resident #6 has advance directive indicating Do Not Resuscitate (DNR). The Goal for the resident was to have the advance directive followed. The intervention was a physician order for DNR. In sectionGG(Functional Abilities Goals)…

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 review of policies, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the facility failed to ensure community spaces, shared shower rooms, and sinks were in good repair. These failures had the potential to affect all 195 residents residing in the facility. Findings include: During an observation of the 2A nursing station on 11/08/21 at 9:42 AM, four ceiling tiles above the residents' charts were stained. These concerns were unchanged during follow up observations conducted on 11/09/21 at 4:49 PM, 11/10/21 at 3:30 PM, and 11/11/21 at 1:21 PM. During an observation on 11/08/21 at 9:45 AM of the Unit 2A back shower room revealed a missing drain cover, missing tiles on floor, visibly soiled grout, and visibly soiled floors and walls. Multiple ceiling tiles along the back of the wall were stained. These concerns were unchanged during follow up observations conducted on 11/09/21 at 4:47 PM,…

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, document review, and facility policy review, the facility failed to maintain an effective pest control program to ensure the building remained free of pests, specifically the facility failed to follow recommendations from the pest control company. This failure had the potential to affect all 195 residents living in the facility. Findings include: Review of facility pest control policy dated 11/30/14, revealed the facility will maintain a pest control program, which includes inspection, reporting, and prevention and treatment will be rendered as required to control insects and vermin. Review of the pest control summary sheets dated 07/29/21, 08/17/21, 08/19/21, 8/24/21, 09/02/21, 09/16/21, 09/23/21, 09/30/21, 10/05/21, 10/14/21, 10/22/21, 10/26/21, and 11/09/21 indicated additional steps the facility could take to assist in reducing pests, such as removing organic matter found in resident rooms and picking up resident belongings off the floors in resident rooms. The pest control summary sheets also revealed recommendations that the facility needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], [NAME] Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to provide ensure a homelike environment for three (Resident (R) 75, R188, and R196) residents and failed to provide housekeeping services to ensure shared resident bathrooms were clean and in good repair on two of four units. Findings include: 1. During an interview on 11/08/21 at 11:09 AM, R188 stated there were environmental concerns in his room. Observation at 11:10AM, revealed a missing ceiling tile by the resident's window and exposed pipes. Hanging under the pipes was a large yellow funnel. The yellow funnel had a hose attached to the bottom of it. The hose's end was hung outside the window in the resident's room. Also observed was a mechanical lift stored next to the window where a second bed should be. At 11:18 AM, R188 stated staff would take the mechanical lift from his room and then return it. At 11:25 PM, R188 directed…

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 record reviews, interviews, and facility policy review, the facility failed to ensure four residents out of 65 sampled residents (Resident (R) 147, R188, R254, and R253) had baseline care plans developed. This had the potential for staff not to be aware of the associated care needs of the residents who were newly admitted . Findings include: 1. Review of R147's undated admission Record, in the Electronic Medical Record (EMR) located under tab Profile, indicated R147 was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, essential hypertension, and adult failure to thrive. Review of R147's clinical EMR failed to indicate a baseline care plan was completed. Review of an undated document provided by the facility titled Base Line Care Plan and Summary, was blank. 2. Review of R188's undated admission Record, in the EMR located under tab Profile, indicated R188 was admitted to the facility on [DATE] with diagnoses including vascular dementia, type two diabetes mellitus, 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 record review, interview, and facility policy review, the facility failed to revise the comprehensive care plan related to restorative services for one resident of three (Resident (R)13) reviewed for rehabilitation and restorative services; and related to falls/safety for two residents of five (R34 and R197) reviewed for accidents/falls in a total sample of 65 residents. Finding include: 1. Review of the Profile tab in the Electronic Medical Record (EMR) revealed R34 was admitted on [DATE] with diagnoses including cervical spinal cord injury, early onset dementia, and schizoaffective disorder. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/21 revealed R34 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The assessment documented R34 required supervision to one assist with bed mobility, transfers, mobility on and off the unit. Review of a nursing note dated 08/19/2021 at 3:24 PM, located in R34's EMR…

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 record review and interview, the facility failed to ensure that two residents of three residents (Resident (R) 109 and R81) reviewed for limited range of motion (ROM), received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion; and that one resident of three residents (R85) reviewed for rehabilitation restorative care received services to maintain or improve mobility. The findings include: Review of the facility policy for Contracture Prevention, Document Name: N-904, Effective date: 11/30/2014, Revision Date: 08/22/201 revealed the policy was to prevent contracture of extremities for those residents who no longer have full use of their extremities. Each resident must be evaluated for need of contracture prevention procedures on admission, readmission, and as needed. 1. During an observation on 11/08/21 at 10:15 AM, R109 was resident in bed with noted bilateral lower extremity contractures (a condition of shortening and hardening 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 facility policy review, the facility failed to ensure staff maintained appropriate infection control measures for the safe handling, cleaning, and storage of respiratory equipment for four residents of five residents (Resident (R)13, R44, R90 and R189) reviewed for respiratory care in a total sample of 65 residents. Findings include: Review of the facility policy, Oxygen Therapy, dated 08/28/17 stated, .label tubing and humidifier with date and time . 1. Review of R189's Treatment Administration Record (TAR) and Medication Administration Record (MAR) for November 2021, located in electronic medical record (EMR) under the orders tab, revealed an oxygen tubing change order active to be changed every Wednesday. During an observation on 11/08/21 at 12:18 PM, R189's oxygen tubing was not dated or labeled to indicate the last change of tubing. 2. Review of R13's admission Record, located in the EMR under the Profile tab, revealed the facility admitted R13 on 12/16/20 with diagnoses that included chronic respiratory failure, diastolic…

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 label and initial three multi-vial medications from two of the four medication storage rooms located on the first and second floor. Additionally, the facility failed to monitor refrigerator temperatures daily for two of the facility's five medication refrigerators on the first and second floor. This had the potential to affect any resident who may receive medication which has been stored in these medication refrigerators. Findings include: Review of the facility policy for Administering Medications, Med-Pass, Inc. with a revision date of April 2019, documented .The expiration/beyond use date on the medication label is checked prior to administering .When opening a multi-dose container, the date opened is recorded on the container . 1. Observation on 11/11/21 at 8:00 AM of the medication room and medication refrigerator on the 2A nursing unit, revealed one open multi-dose vial of tubersol mantoux (serum used to test for the presence of Tuberculosis) with a lot number of 28764, and expiration…

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, review of facility policies and review of Center for Disease Control (CDC) guidance, the facility failed to: ensure all staff don (put on) proper personal protective equipment (PPE) prior to providing care and encountering R253 who potentially was exposed to COVID-19 while in the hospital; store and label resident personal items in shared restrooms in a manner to prevent cross-contamination; maintain infection control practices in the laundry area of the facility; and failed ensure staff members wore face masks appropriately to prevent the spread of COVID-19. Findings include: 1. Review of a document provided by the facility titled MODERNA-SARS-CoV-2- M RNA, dated 09/02/21, indicated R253 received her first COVID-19 vaccine. Review of a document provided by the facility, titled H&P (History and Physical), dated 11/03/21, indicated R253 presented to the hospital on [DATE] with a head injury and change in her condition. Review of a document provided by the facility, dated 11/03/21,…

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 interview the facility failed to ensure equipment located in the laundry services areas were in safe operating condition, specifically washing machine filters were not cleaned daily as indicated on the manufacturer's instruction label, dryer number two was not in working order, and the laundry room sink was not in working order. This failure has the potential to affect 187 of 195 residents in the facility whose laundry was cleansed onsite. Findings include: During an observation of the laundry department on 11/11/21 at 8:14 AM, with Laundry Aide 37 revealed the following: The sink next to the eye wash station was soiled with a missing faucet handle, and was not in working condition; The filter on left side of washing machine number two was visibly caked with dust and debris, with a label that read, clean filter daily; Washing machine number three's filter on the left side was visibly caked with dust and debris, with a label that read, clean filter daily; and Dryer number two's inside drum was visibly rusty and not in working order. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and review of facility policies, the facility failed to ensure two residents (Resident (R) 194 and R22) were assessed for the self-administration of prescribed medications out of a survey sample of 65. Specifically, the nursing staff left medications at the bedside for R194 and R22. In addition, the facility failed to properly assess each resident and identify the decision-making process to show the capabilities of each resident to self-administer medications. Findings Include: Review of a facility policy and procedure titled Self-Administration of Medication at Bedside, dated 11/30/14, documented The resident may request to keep medications at bedside for self-administration. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. Procedure: Verify physician's order in the resident's chart for self-administration of specific medications. Complete…

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 notify the physician of a change in condition for one (Resident (R) 66) of three reviewed for change in condition in a total sample of 65 residents. Findings include: Review of the Face sheet under the Profile tab in the Electronic Medical Record (EMR) revealed R66 was admitted on [DATE] and readmitted [DATE] with diagnoses including blindness, psychosis (a severe mental disorder in which thoughts and emotions are so impaired that contact is lost with reality), anxiety, and depression. Review of the annual Minimum Data Set (MDS), with and an Assessment Reference Date (ARD) of 09/14/21 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Review of the EMR Progress Notes tab, revealed a progress note dated 10/28/21 at 6:18 PM which documented, Upon return from LOA [leave of absence], resident was observed by this staff member to be intoxicated. 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.

Based on interview, record review, and facility policy review, the facility failed to complete a thorough investigation for one of three resident-to-resident altercations reviewed. Specifically, Resident (R)1 and R89 were involved in a physical altercation and the investigation lacked witness interviews and times. Findings include: Review of the facility's policy, Abuse, Neglect, Exploitation, and Misappropriation, dated 11/28/17 under Investigation documented The Abuse Coordinator and /or Director of Nursing shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. Review of the five-day report summary portion of the facility's investigation for an incident on 07/02/21 revealed R1 engaged in a physical altercation with R89, resulting in R89 going to the hospital for the treatment of injuries, including bite marks. Staff intervened in the altercation and kept R1 away from other residents until he was sent out of the facility for a psychiatric evaluation. The facility's investigation included…

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, record review, interview, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II was completed for one resident of eight residents (Resident (R)196) reviewed for PASRR II in a total sample of 65 residents. Findings include: Review of facility policy Preadmission Screening and Resident Review (PASRR) dated 11/08/21 revealed, The center will assure that all Serious Mentally Ill (SMI) .The purpose is to ensure that the residents with SMI .receive the care and services they need in the most appropriate setting. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. Results of the screening evaluation will be placed in the appropriate section of the individual's medical records and any recommendations for services will be followed. Recommendations will be…

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, record review, and interview, the facility failed to provide Activities of Daily Living (ADLs) related to nail care for one resident of four (Resident (R)15) reviewed for ADLs in a total sample of 65 Residents. Findings include: Review of R15's Face Sheet, located in the Electronic Medical Record (EMR) under the Face Sheet tab, revealed that R15 was admitted to the facility on [DATE] with diagnoses including manic-depressive disorder (mood disorder that causes feelings of sadness and loss of interest that can interfere in daily living), hemiplegia, and history of cerebrovascular accident (stroke). Review of R15's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/04/21 revealed that R15 was totally dependent on staff to meet her daily needs and had a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating that she is cognitively intact. Review of R15's care plan located in the EMR under the Care Plan tab, revealed staff were directed to checked for…

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

Based on interview and record review, the facility failed to ensure that one resident out of 65 (Resident (R)187) sampled residents was seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Findings include: Review of the Medical Diagnoses tab in the electronic medical record (EMR) revealed R187 was admitted by the facility on 07/16/21 with diagnoses including generalized weakness, major depressive disorder, and chronic diastolic congestive heart failure. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/21 revealed R187 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. During an interview on 11/08/21 at 2:21 PM, R187 reported he was upset regarding not seeing the doctor or nurse practitioner since admission to the facility. Review of physician visits provided by the facility, revealed the R187 was seen by the attending physician on 07/19/21, three days after admission and by the Nurse Practitioner (NP) on…

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

Based on facility document review, staff interviews, and policy review, the facility failed to ensure three Certified Nursing Assistants (CNAs) of five CNAs (CNA23, CNA8, and CNA16) reviewed were provided annual performance reviews. Additionally, the facility failed to ensure CNA 23 completed 12 hours of annual education which included dementia training, and other areas in which CNA 23 showed an area of weakness. The deficiency could result in a decreased quality of life or quality of care for the residents. Findings include: Review of CNA23's employee record indicated the staff member was hired on 05/23/17. Review of a document provided by the facility titled Performance Evaluation, undated and unsigned was in CNA23's employee file. There was no evidence CNA23 had an annual performance review since his date of hire per review of the employee's file. In addition, review of a document provided by the facility titled Training Hours, dated 11/11/21, indicated CNA23 completed three hours of annual training for the date range of 05/23/18 to 05/23/19 and completed two hours of annual…

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 record review, interviews, and facility policy review, the facility failed to ensure pharmacy services thoroughly reviewed the resident medication regimens to identify irregularities related to the use of an anti-psychotropic (Seroquel) medication for one of five residents (Residents (R) R 147) reviewed for unnecessary psychotropic medication use. Findings include: Review of a hospital document provided by the facility titled Discharge Summary, indicated R147 was treated for a urinary tract infection. The discharge summary indicated the resident had a diagnosis of dementia with behaviors and was started on Seroquel 25 milligrams (mg). Review of R147's undated admission Record, in the Electronic Medical Record (EMR) located under tab Profile, indicated the resident was admitted to the facility on [DATE], with a diagnosis of dementia with behaviors. Review of R147's EMR physician orders, located under tab Orders, dated 10/11/21 indicated staff were to administer Seroquel 25 mg at bedtime. Review of a…

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

Based on observation, interview, and policy review the facility failed to adequately provide call light assistance for two) of 65 sampled residents (Residents (R)110 and R159). Findings Include: During an interview on 11/09/21 at 8:58 AM, R159 stated the ring bell was on table before but has no idea where it is now. R159 then pushed the call light attached to the wall and no light came on to alert staff. R159 stated the call light did not work and has not worked for a while and maintenance was aware. R159 confirmed the use of a wheelchair for mobility and pointed to the wheelchair next to bed. Record review R159 minimum data set (MDS) with an Assessment Reference Date of 10/15/21 found in the electronic healthcare Record (EHR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. During an interview on 11/09/21 at 8:58 AM, R110 stated he had a ring bell but it was on the floor by the dresser because it gets knocked off the table sometimes. R110 stated he would just yell nurse, nurse if he…

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 and staff interviews the facility staff failed to maintain a clean, comfortable, homelike environment. Multiple resident rooms were not clean and had wall damage. The activity room wall paper was not maintained. The findings included: During an environmental tour for room [ROOM NUMBER], it was observed that the heating/air condition unit covering was off. The window was observed to have a copious amount of dust. The Activity room on Unit 1-B was observed to have wall paper coming down. room [ROOM NUMBER] was observed with a hole in the wall. room [ROOM NUMBER] had a hole in the wall. room [ROOM NUMBER]-A had tube feed on bed rail and over-bed table. room [ROOM NUMBER] had dirt, lint and debris under heat/air condition unit. room [ROOM NUMBER] had dirt, lint and debris under air condition unit. room [ROOM NUMBER] had holes in the walls. room [ROOM NUMBER] had dirt, lint and debris under heat/air condition unit. room [ROOM NUMBER] had holes in the wall and dirt, lint and debris under the air…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews and clinical record review the facility staff failed to provide personal care to include showers for 1 of 62 residents (Resident #183) in the survey sample who was unable to independently carry out activities of daily living (ADL's). The facility staff failed to ensure Resident #183 was offered and received a scheduled twice-weekly showers to maintain good personal hygiene. The findings included: Resident #183 was originally admitted on [DATE] with a readmission date of 11/02/18. Diagnoses for Resident #183 included, but not limited to, Major Depressive Disorder. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 01/18/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated no cognitive impairment. In addition, the MDS coded Resident #183 total dependence of two with bathing and transfer, extensive assistance of two with bed mobility, dressing 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 information obtain during the Infection Control task, staff interview, and facility documentation review, the facility staff failed to ensure 1 of 62 residents was free from unnecessary drugs (Resident #68), in the survey sample. The facility staff administered 18 doses of Ciprofloxacin (an antibiotic) to Resident #68, for a bacteria resistant to the drug. The findings included: Resident #68 was originally admitted to the facility 9/27/13 and readmitted to the facility after an acute care hospital stay 9/27/16. The resident's current diagnoses included; dementia, schizophrenia, depression high blood pressure, and a seizure disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/5/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #68's cognitive abilities for daily decision making are moderately impaired. In section E (Behaviors) the resident was coded for rejecting care daily. In section G (Physical functioning) the resident was coded 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 information obtain during the Infection Control task, staff interview, and facility documentation review, the facility staff failed, for 1 of 62 residents (Resident #68) in the survey sample, to implement their antibiotic use protocol/policy. The facility staff administered a course of Ciprofloxacin (an antibiotic) to Resident #68 for a urinary tract infection however, the bacteria was resistant to the drug. The findings included: Resident #68 was originally admitted to the facility 9/27/13 and readmitted to the facility after an acute care hospital stay 9/27/16. The resident's current diagnoses included; dementia, schizophrenia, depression high blood pressure, and a seizure disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/5/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #68's cognitive abilities for daily decision making are moderately impaired. In section E (Behaviors) the resident was coded for rejecting care daily. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility staff failed to provide a safe, comfortable environment for residents and the public. Multiple resident room and general doors within the facility had chipped sharp edges. The findings included: During the Environmental Tour on 2/19/19 at 10:00 A.M. room [ROOM NUMBER] door was observed to have chipped, sharp edges. room [ROOM NUMBER] door was observed to have chipped sharp edges. room [ROOM NUMBER] door was observed to have chipped, sharp edges. room [ROOM NUMBER] room door was observed to have chipped sharp edges. The 2-A Activity Room door was observed to have chipped sharp edges. room [ROOM NUMBER] door was observed to have chipped sharp edges. room [ROOM NUMBER] door was observed to have chipped sharp edges. room [ROOM NUMBER] door was observed to have chipped sharp edges. room [ROOM NUMBER] door was observed to have chipped sharp edges. room [ROOM NUMBER] door was observed to have chipped sharp edges. room [ROOM NUMBER] door was observed to have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility record review, and staff interview, the facility staff failed to maintain an effective pest control program. Roaches and/or mice were seen in the resident rooms, the courtyard, dining room, supply closets, refrigerator, nursing desk drawer, hallways, and conference room. The findings included: During the Initial Tour on 2/12/19 at 11:22 A.M. a live roach was observed in room [ROOM NUMBER]. A live roach was observed in room [ROOM NUMBER] and 249. A review of the Pest Log for Unit 1-B indicated: On 2/11/19 at 9:00 A.M. a roach was seen in the hallway. On 2/11/19 at 12:10 P.M. a roach was seen in the upstairs dinning room. On 2/13/19 at 11:35 A.M. a roach was seen in the upstairs dinning room. A review of the Pest Log indicated: On 11/20/18 Roaches were seen in rooms 255, 257 and 266. Roaches were seen near the elevator on 11/26/18, 11/29/18, 12/04/18, 12/06/18, 12/15/18, 12/18/18, 12/21/18. On 12/27/18 three (3) house mice were seen in the smoking area of the courtyard. On 12/31/18…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and facility document review, the facility staff failed to provide privacy during a wound dressing change for 1 of 62 residents (Resident #183) in the survey sample. The facility staff failed to ensure Resident #183's door was closed during a left heel wound care observation, allowing public view from the hallway. The findings included: Resident #183 was originally admitted on [DATE] with a readmission date of 09/28/18. Diagnosis for Resident #183 included, but not limited to, Major Depressive Disorder. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 01/18/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #183 total dependence of two with bathing and transfer, extensive assistance of two with bed mobility, dressing and toilet use and extensive assistance of one with physical hygiene for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility policy review, the facility staff failed to provide care plan information to the receiving provider at the time of transfer to the hospital for 1 of 62 Residents in the survey sample, Resident #94 The facility staff failed to convey Resident #94's comprehensive care plan goals upon transfer to the acute care hospital on 1/24/18. The findings included: Resident #94 was originally admitted to the facility 8/19/14 and was readmitted to the facility 1/30/18, after an acute care hospital stay. The current diagnoses included; paraplegia secondary to a gunshot wound, chronic sacral pressure ulcer, neurogenic bladder with suprapubic catheter placement and recurrent urinary tract infections. The significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/7/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of 15. This indicated Resident #94's daily decision making abilities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, facility document review and the facility's policy, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 1 of 62 residents (Resident #94) in the survey sample. The facility staff failed to notify the Long-Term Care Ombudsman of Resident #94's discharge and admission to a local acute care hospital on 1/24/18. The findings included: Resident #94 was originally admitted to the facility 8/19/14 and was readmitted to the facility 1/30/18, after an acute care hospital stay. The current diagnoses included; paraplegia secondary to a gunshot wound, chronic sacral pressure ulcer, neurogenic bladder with suprapubic catheter placement and recurrent urinary tract infections. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/7/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of 15. This indicated 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 clinical record review, staff interview, facility document review and the facility's policy, the facility staff failed to provide written information to residents explaining how a resident's bed is held while the resident is absent from the facility due to hospitalization for 1 of 62 residents (Resident #94) in the survey sample. The facility staff failed to provide written information to the resident or resident representative which specifies the duration of the bed-hold policy upon transfer to the local acute care hospital on 1/24/18. The findings included: Resident #94 was originally admitted to the facility 8/19/14 and was readmitted to the facility 1/30/18, after an acute care hospital stay. The current diagnoses included; paraplegia secondary to a gunshot wound, chronic sacral pressure ulcer, neurogenic bladder with suprapubic catheter placement and recurrent urinary tract infections. The significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/7/19, coded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review and facility document review, the facility staff failed to provide the necessary care and services to prevent and treat a pressure ulcer and promote healing for 1 of 62 residents (Resident #183) in the survey sample. The facility staff failed to identity a left heel pressure ulcer prior to it being found at an advanced stage; the pressure ulcer was found as an unstageable with 100% eschar (hard black dead tissue). And, the facility staff failed to implement pressure relieving devices as ordered by the physician. The findings included: Resident #183 was originally admitted on [DATE] and readmitted on [DATE]. Diagnoses for Resident #183 included, but not limited, to Major Depressive Disorder. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 01/18/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated no cognitive impairment. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews the facility staff failed to implement interventions to reduce a potential accident hazard for 1 of 62 residents (Resident #183) in the survey sample. The facility staff used a pair of sharp tip scissors to cut off Resident #183's dressing to her left foot. This could have caused potential injury by cutting or poking the resident's skin. The findings included: Resident #183 was originally admitted on [DATE] with a readmission date of 11/02/18. Diagnosis for Resident #183 included but not limited to Major Depressive Disorder. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 01/18/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #183 total dependence of two with bathing and transfer, extensive assistance of two with bed mobility, dressing and toilet use and extensive assistance of one with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility documentation review the facility staff failed to ensure medications were stored in a secured location, accessible to designated staff only on 1 of 4 units (Unit 1-A). The facility staff failed to ensure the following medications (Vitamin B12 500 mcg, Multivitamin, Folic Acid 400 mcg, Claritin 10 mg, Magnesium Oxide 400 mg and Calcium + DS 600 mg) were stored in a secured location, accessible to designated staff only. The findings included: Resident #29 was originally admitted on [DATE] with a readmission date of 03/27/15. Diagnoses for Resident #29 included but not limited to, Schizophrenia. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 11/10/18 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. On 02/13/19 at approximately 8:21 a.m., during the medication pass and pour observation, Registered Nurse (RN #2), pulled…

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 a resident record review, staff interviews, facility document review and resident interview the facility staff failed to obtain dental services review for 1 of 62 residents in the survey sample, Resident #146. The facility staff failed to follow physician orders and obtain dental care for Resident #146. The findings included: Resident #146 was admitted to the facility 11/10/2017. Diagnoses included but were not limited to Psychosis, Non-Alzheimer's Dementia and Major Depressive Disorder. Resident #146's Minimum Data Set (an assessment protocol) Quarterly with an Assessment Reference Date of 01/17/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #146 as requiring extensive assistance of 2 with bed mobility, dressing, personal hygiene, supervision and set up help only for eating and total dependence of 2 with toilet use and bathing. On 02/13/2019 at 10:44 a.m., an interview was conducted with Resident #146 and he stated, I have a cavity. I've had a toothache…

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 review of the Hospice policy, the facility staff failed to ensure the Hospice Agency provided a written agreement describing the provision of services for 1 of 62 residents (Resident #175), in the survey sample. The facility staff failed to ensure the Hospice Agency provided the facility staff with the coordinated plan of care for Resident #175, to identify which services the Hospice Agency would provide, when the services would be provided, the communication process, and when or why the nursing facility staff should notify the Hospice Agency. The findings included: Resident #175 was originally admitted to the facility 12/17/18 and has never been discharged from the facility. The current diagnoses included; Atresia of Foramina of Magendie and Luschka/[NAME]-Walker syndrome (congenital abnormality of the central nervous system), strokes, a seizure disorder and dementia. The significant change Minimum Data Set (MDS) assessment with an assessment reference date…

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

Based on observations and staff interview the facility staff failed to maintain good infection control practices for 2 of 62 residents (Residents #145, #52), in the survey sample. 1. The facility staff contaminated the clean left buttock pressure ulcer dressing with the soiled dressings left on the chux pad below Resident #145's left buttock during wound care. 2. The facility staff failed to ensure soap was in a dispenser on 3 survey days in Resident #52's room. Therefore, increasing the chances of spreading infections, illnesses and diseases. The findings included: 1. Resident #145 was originally admitted to the facility 1/10/19 and has never been discharged from the facility. The resident's diagnoses included; quadriplegia related to a motor vehicle accident, tracheostomy, systemic inflammatory response syndrome, seizure disorder and pressure ulcers to bilateral buttocks and the sacrum. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/17/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out…

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.