Canterbury Rehabilitation And Healthcare Center

Based on staff interview, and facility document review, the facility staff failed to ensure communication training was completed for one of seven employee reviews.The findings include:For CNA #9, the facility staff failed to ensure communication training was completed.CNA #9 was hired on 7/6/2022. The facility staff failed to provide evidence that CNA #9 had completed communication training. On 4/9/2026 at 9:57 AM, an interview was conducted with the staff development coordinator who stated that since she had begun working at the facility in December 2025 and there was an annual competency calendar for staff which assigned education to staff throughout the year for them to complete and they had until December 31st each year to complete the assignments. She stated that she had an on-going performance improvement plan to catch up on missed education in progress, but it was not completed at that time. A request was made to the staff development coordinator for any evidence of CNA #9 completing communication training however none was provided.The facility assessment reviewed 2/26/2026…

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

Based on staff interview, and facility document review, the facility staff failed to ensure QAPI (quality assurance and performance improvement) training was completed for three of seven employee reviews.The findings include:1. For certified nursing assistant (CNA) #9, the facility staff failed to ensure QAPI training was completed.2. For other staff member (OSM) #8, dietary staff member, the facility staff failed to ensure QAPI training was completed.3. For OSM #9, housekeeping staff member, the facility staff failed to ensure QAPI training was completed.On 4/9/2026 at 9:57 AM, an interview was conducted with the staff development coordinator (SDC) who stated that since she had begun working at the facility in December 2025 and there was an annual competency calendar for staff which assigned education to staff throughout the year for them to complete and they had until December 31st each year to complete the assignments. She stated that she had an on-going performance improvement plan to catch up on missed education in progress, but it was not completed at that time. The SDC 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 staff interview, and facility document review, the facility staff failed to ensure compliance and ethics training was completed for two of eight employee reviews.The findings include:1. For certified nursing assistant (CNA) #9, the facility staff failed to ensure compliance and ethics training was completed.2. For CNA #10, the facility staff failed to ensure compliance and ethics training was completed.On 4/9/2026 at 9:57 AM, an interview was conducted with the staff development coordinator who stated that since she had begun working at the facility in December 2025 and there was an annual competency calendar for staff which assigned education to staff throughout the year for them to complete and they had until December 31st each year to complete the assignments. She stated that she had an on-going performance improvement plan to catch up on missed education in progress, but it was not completed at that time. A request was made to the staff development coordinator for any evidence of CNA #9 and CNA #10 completing compliance and ethics training however none was provided.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 document review, the facility staff failed to ensure behavioral health training was completed for two of eight employee reviews.The findings include:1. For certified nursing assistant (CNA) #9, the facility staff failed to ensure behavioral health training was completed.2. For other staff member (OSM) #8, dietary staff member, the facility staff failed to ensure behavioral health training was completed.On 4/9/2026 at 9:57 AM, an interview was conducted with the staff development coordinator (SDC) who stated that since she had begun working at the facility in December 2025 and there was an annual competency calendar for staff which assigned education to staff throughout the year for them to complete and they had until December 31st each year to complete the assignments. She stated that she had an on-going performance improvement plan to catch up on missed education in progress, but it was not completed at that time. The SDC stated that she was working to obtain education for the contracted staff members including therapy staff and dietary staff.…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to implement the comprehensive care plan for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5, the facility staff failed to implement the comprehensive care plan for the administration of the medication, Midodrine (used to treat orthostatic hypotension, a sudden fall in blood pressure that occurs when a person assumes a standing position) (1) per the physician orders. The comprehensive care plan dated 11/3/2025 documented in part, Focus: I have hypotension related to ESRD (end stage renal disease). Interventions: Give medications as ordered. Monitor vital signs as ordered and as clinically indicated.An interview was conducted with LPN (licensed practical nurse) #4 on 1/29/2026 at 7:45 a.m. LPN #4 stated the care plan is a guide for the staff on how to care for the residents and their individual needs. The facility policy, Care Plans; Comprehensive Person-Centered documented in part, A comprehensive, person-centered care plan 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to clarify physician orders for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to clarify the physician orders for Midodrine (used to treat orthostatic hypotension, a sudden fall in blood pressure that occurs when a person assumes a standing position) (1) and Clonidine (used to treat high blood pressure) (2). The physician order dated, 1/14/2026 documented, Midodrine HCL (hydrochloride) Oral Tablet 10 MG (milligrams); Give 10 MG via Peg - tube (a feeding tube inserted in the stomach) (3) every 8 hours as needed for orthostatic hypotension. Give for SBP (systolic blood pressure) under 100 mmHg (millimeters of mercury). A second physician order dated 1/14/2026 documented, Clonidine HCL Oral Tablet; Give 1 tablet by mouth every 8 hours as needed for HTN (hypertension) for 30 days; Give for SBP over 170 mmHg. Review of the clinical record failed to evidence that the resident's blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to administer medications per the physician orders for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5, the facility staff failed to administer Midodrine (used to treat orthostatic hypotension, a sudden fall in blood pressure that occurs when a person assumes a standing position) (1) per the physician orders. The physician order dated, 11/4/2025 documented, Midodrine HCL (hydrochloride) [NAME] tablet 10 MG (milligrams); Give 10 MG via PEG-Tube (feeding tube) every 8 hours related to dependence on dialysis. Give for SBP (systolic blood pressure) under 100 mmHG (millimeters of mercury). The medication administration record (MAR) for January 2026 documented the above order. On 1/1/2026 at 8:00 a.m. the resident's blood pressures were documented on the following dates and times and the Midodrine was documented as administered:1/1/2026 at 8:00 a.m. - 126/801/2/2026 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services to promote a resident's highest level of wellbeing for three of six residents, Resident #1, #2 and #6. The findings include: 1. The facility failed to monitor blood sugar as ordered for Resident #1 (R1). R1 was admitted to the facility on [DATE] with diagnosis that included diabetes, acute/chronic respiratory failure and trach(tracheostomy).The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 11/18/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers, dressing, hygiene toileting and set up for eating. A review of the baseline care plan dated 11/13/25 revealed, FOCUS:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility document review and clinical record review, it was determined the facility staff failed to develop a baseline care plan for one of six residents in the survey sample, Resident #1 (R1). The findings include: The facility failed to develop a baseline care plan to include diabetes and monitoring of blood sugars for R1. R1 was admitted to the facility on [DATE] with diagnosis that included diabetes, acute/chronic respiratory failure and trach (tracheostomy).The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 11/18/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers, dressing, hygiene toileting and set up for eating. A review of the baseline care plan dated 11/13/25…

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

5. The facility staff failed to maintain a homelike environment for A) two of three nursing units and B) one of three common hallways. A) On 4/29/25 at 10:48 a.m., an observation of the Westham nursing station area and the three hallways of the Westham unit revealed a strong urine odor present. Housekeeping staff were observed on the unit cleaning resident rooms. On 4/29/25 at 11:12 a.m., an observation of the Grove unit revealed a strong urine odor immediately upon exiting the elevator in the common resident area, nurses station area and three hallways on the unit. Housekeeping staff were observed mopping the floors at that time. Additional observations of the Westham unit and Grove unit were made on 4/29/25 at approximately 3:39 p.m., 4/30/25 at approximately 8:19 a.m., 4/30/25 at approximately 2:12 p.m. and 5/1/25 at approximately 8:22 a.m. The observations all revealed housekeeping staff on the unit cleaning, however the urine odors remained. B) On 4/29/25 at 10:30 a.m., upon entrance to the facility a strong urine odor was noted in the hallway from the Westham dining room 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 3. For Resident #12 (R12), the facility staff failed to implement the abuse policy for reporting an injury of unknown origin (IUO) in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/22/25, the resident was assessed as being severely impaired for making daily decisions. The progress notes for R12 documented in part, - 04/18/2025 14:46 (2:46 p.m.) Note Text: Resident has been in the dining room all morning outside of therapy. She was found with a large bruise on her left hand in the dining room by activities. Resident does not have any pain or discomfort. MD (medical doctor) notified. RP (responsible party) was called and a message was left. - 04/18/2025 08:51 (8:51 a.m.) Nurse Practitioner Note: LATE ENTRY Note Text : X-ray ordered to rule out acute pathology. - 04/18/2025 08:48 (8:48 a.m.) Nurse Practitioner Note: LATE ENTRY .Hematoma noted to left hand Patient had ben [sic] in dining room in wheelchair, possibly hit against table .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #22 (R22), the facility staff failed to implement the comprehensive care plan to provide treatment as recommended by the wound nurse practitioner for A) the right heel and B) the right anterior lower leg pressure injury (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/20/25, the resident was assessed as severely impaired for making daily decisions. R22 was assessed as being non-verbal, totally dependent for personal hygiene, bed mobility, toileting and bathing. It further documented R22 always incontinent of bowel and bladder and at risk for pressure injuries but not having any unhealed pressure injuries at the time of the assessment. The comprehensive care plan for R22 documented in part, The resident has a pressure ulcer or has the potential for pressure ulcer development r/t immobility, diabetes. Right anterior Lower Leg Pressure. Date Initiated: 03/18/2024. Under Interventions/Tasks it documented in part, Administer treatments as ordered and monitor for effectiveness. Date Initiated: 03/18/2024 .…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for two of 25 residents in the survey sample, Residents #1 and #9. The findings include: 1. For Resident #1 (R1), the facility staff failed to provide tracheostomy care on multiple days in January 2025 and February 2025. A review of R1's clinical record revealed a physician's order dated 1/6/25 for tracheostomy care every shift and as needed. Further review of R1's clinical record failed to reveal tracheostomy care was provided on the following days during the night shift (as evidenced by blank spaces on the respiratory administration record): 1/9/25, 1/11/25, 1/13/25, 1/23/25, and 2/1/25. On 4/30/25 at 4:41 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated tracheostomy care consists of cleaning around the tracheostomy stoma, changing the gauze around the stoma, and changing the inner cannula. LPN #3 stated nurses evidence tracheostomy care was provided by signing off on the respiratory administration…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide complete dialysis services for one of 25 residents, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to evidence complete dialysis communication on multiple dates in November, December 2024 and January 2025. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/9/24, the resident was assessed as receiving dialysis while a resident at the facility. The physician orders for R5 documented in part, - Complete Dialysis Communication form prior to transporting residents to Dialysis. Vital signs prior to transport. every day shift every Mon, Wed, Fri. Order Date: 11/04/2024. Start Date: 11/04/2024. Review of the Hemodialysis Communication Records for R5 from 11/3/24-1/19/25 documented the following: - 11/15/24 No pre-dialysis communication completed. - 11/18/24 No dialysis communication completed. - 11/20/24 No pre-dialysis communication completed. - 11/22/24 No…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent significant medication errors for one of 25 residents, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to administer Midodrine (1) as ordered prior to dialysis when the blood pressure was in the parameters set for administration. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/9/24, the resident was assessed as receiving dialysis while a resident at the facility. The physician orders for R5 documented in part, - Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 1 tablet by mouth as needed for hypotension before dialysis 3 days a week Hold for systolic of 140 or more. Order Date: 11/04/2024. Start Date: 11/04/2024. End Date: 01/21/2025. Review of the Hemodialysis Communication Records for R5 from 11/3/24-1/19/25 documented the following dates and pre-dialysis blood pressures. - 11/4/24 blood pressure 135/72, no medication documented as…

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

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide dignity for two of 25 residents in the survey sample, Residents #18 and #20. The findings include: 1. For Resident #18 (R18), the facility staff failed to answer the resident's call bell in a timely manner. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/11/25, R18 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 4/30/25 at 8:54 a.m., Resident #18's call bell was observed ringing. Staff did not answer the resident's call bell until 9:07 a.m. (13 minutes). During this observation, seven staff members were observed in R18's hall. On 4/30/25 at 11:24 a.m., an interview was conducted with R18. The resident stated call bell response times vary but she has waited an hour for someone to answer the call bell. On 5/1/25 at 9:36 a.m., an interview was conducted with CNA (certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the resident of a change in treatment for one of 25 residents in the survey sample, Resident #2 (R2). For R2, the facility staff failed to inform them in advance of the physician's order for the use of Percocet (1) and Xanax (2) and the risks, benefits and alternatives. The findings include: R2 was admitted to the facility with diagnoses that included but were not limited to cancer of the larynx (voice box) (3) and anxiety (4). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/06/2025, R2 scored a 14 out of 15 on the BIMS (brief interview for mental status), indicating R2 was cognitively intact for making daily decisions. The physician's order for R2 documented, Alprazolam (Xanax) Tablet 0.5 MG (milligrams) *Controlled Drug* Give 1 (one) tablet via (by) PEG-Tube (percutaneous endoscopic gastrostomy) (5) every 8 (eight) hours as needed for Anxiety for 14 Days. Order Date: 2/5/2025 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, staff interview and facility document review, it was determined that facility staff failed to respect a resident's personal possessions for one of 25 residents in the survey sample, Resident #17. For R17, the facility staff failed to assure all clothing was within their possession and accessible. The findings include: On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 04/14/2025, R17 scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R17 was moderately impaired of cognition for making daily decisions. On 04/29/2025 at approximately 2:00 p.m. an observation of a room on the facility's Grove Unit revealed no resident names posted outside the door. Observations of the inside of the room revealed two dressers, one on the A-side and one on the B-side of the room. At approximately 2:10 p.m., an interview and observation of the room was conducted with LPN (licensed practical nurse) #3, unit manager. When asked if the room was vacant, she stated yes and that R17 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, staff interview, and facility document review, the facility staff failed to provide privacy for two of 25 residents in the survey sample, Residents #19 and #20. The findings include: 1. For Resident #19 (R19), ASM (administrative staff member) #5 (the nurse practitioner) failed to assess the resident in a private setting. On 4/30/25 at 11:17 a.m., ASM #5 was observed listening to R19's chest, back, and abdomen with a stethoscope in the dining room while other residents were present in the room. On 4/30/25 at 4:41 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated she assesses residents in private settings and would not assess residents in the dining room unless there was an emergency. On 5/1/25 at 1:12 p.m., an interview was conducted with ASM #5. ASM #5 stated she typically assesses residents in their rooms but sometimes for timing purposes, she assesses residents in therapy, in the dining room, and at the nurses' station. On 5/1/25 at 4:36 p.m., ASM #1 (the regional consultant) and ASM #2 (the director of nursing) were made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assure a resident was free of a chemical restraint for one of 25 residents in the survey sample, Resident #2 (R2). For R2, the facility staff failed to evidence attempts of alternate interventions prior to the administration of Xanax (1). The findings include: R2 was admitted to the facility with diagnoses that included but were not limited to anxiety (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/06/2025, R2 scored a 14 out of 15 on the BIMS (brief interview for mental status), indicating R2 was cognitively intact for making daily decisions. The physician's order for R2 documented, Alprazolam (Xanax) Tablet 0.5 MG (milligrams) *Controlled Drug* Give 1 (one) tablet via (by) PEG-Tube (percutaneous endoscopic gastrostomy) (5) every 8 (eight) hours as needed for Anxiety for 14 Days. Order Date: 2/5/2025 The eMAR (electronic medication administration record) for R2 dated February 2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 #12 (R12), the facility staff failed to report an injury of unknown origin (IUO) in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/22/25, the resident was assessed as being severely impaired for making daily decisions. The progress notes for R12 documented in part, - 04/18/2025 14:46 (2:46 p.m.) Note Text: Resident has been in the dining room all morning outside of therapy. She was found with a large bruise on her left hand in the dining room by activities. Resident does not have any pain or discomfort. MD (medical doctor) notified. RP (responsible party) was called and a message was left. - 04/18/2025 08:51 (8:51 a.m.) Nurse Practitioner Note: LATE ENTRY Note Text : X-ray ordered to rule out acute pathology. - 04/18/2025 08:48 (8:48 a.m.) Nurse Practitioner Note: LATE ENTRY .Hematoma noted to left hand Patient had ben [sic] in dining room in wheelchair, possibly hit against table . A skin assessment for R12 dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was determined that the facility staff failed to submit the follow-up report of an investigation for two of 25 residents in the survey sample, Resident #2 (R2) and R11. The findings include: 1. For R2, facility staff failed to submit a follow-up report to the state agency regarding an allegation of neglect. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/06/2025, R2 scored a 14 out of 15 on the BIMS (brief interview for mental status), indicating R2 was cognitively intact for making daily decisions. The facility's incident report for R2 documented, Incident Date: 02/18/2025. Incident type: Allegation of neglect. Describe the incident, including location and action taken: facility received a report of neglect on (Name of R2). Review of the facility's fax confirmation sheets and incident file failed to evidence documentation of the facility's final investigative report was sent to state agency. On 05/01/2025 at approximately 10:30 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.

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 follow professional standards of practice for one of 25 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to follow professional standards of practice for monitoring a resident after an unwitnessed fall on 2/13/25. Facility staff failed to evidence neuro checks (1) completed after the unwitnessed fall. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/6/25, the resident was assessed as taking anticoagulant medication and having no falls since readmission. The progress notes for R2 documented in part, - 2/12/2025 03:37 (3:37 a.m.) Note Text: During walking rounds the writer found the resident on the floor in his room. The resident was found on the left side of his bed, lying on his left side with his back against the bed. The writer had another staff member to…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to position an indwelling urinary catheter collection bag in a sanitary manner for one of 25 residents in the survey sample, Resident #13. The findings include: For Resident #13 (R13), the facility staff failed to position his indwelling urinary catheter collection bag off the floor on 4/29/25 and 4/30/25. A review of R13's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/4/25, R13 was coded as being totally dependent on facility staff for turning and positioning. He was admitted with a diagnosis of paraplegia. He was coded as being cognitively intact for making daily decisions. On the following dates and times, R13 was observed sitting up in bed. At each observation an indwelling urinary catheter collection bag was lying completely on the floor: 4/9/25 at 1:43 p.m. and 4:55 p.m.; 4/30/25 at 7:50 a.m. A review of R13's physician's orders revealed the following order, dated 8/16/24: Urinary Catheter .maintain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, it was determined that the facility staff failed to implement a complete pain management program for one of 25 residents in the survey sample, Resident #2 (R2). The findings include: 1. For R2, the facility staff failed to attempt non-pharmacological interventions prior to the administration of the prn (as needed) pain medication of Percocet (1) 10-325MG (milligrams). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/06/2025, R2 scored a 14 out of 15 on the BIMS (brief interview for mental status), indicating R2 was cognitively intact for making daily decisions. The physician's order for R2 documented, Oxycodone-Acetaminophen (Percocet)Tablet 10-325 MG *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for Pain. Order Date: 2/5/2025. The eMAR (electronic medication administration record) for R2 dated February 2025 documented the physician order for Percocet as stated above. Review of the eMAR revealed R2 received Percocet 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 resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide physician services for one of 25 residents in the survey sample, Resident #7. The findings include: For Resident #7 (R7), ASM (administrative staff member) #10 (the resident's physician) failed to address the resident's refusal of medications prior to dialysis. A review of R7's clinical record revealed the following physician's orders: 2/19/25-Amiodarone 200mg (milligrams)- one tablet once a day for antiarrhythmic (an irregular heartbeat) 2/19/25-Clopidogrel Bisulfate 75mg- one tablet once a day for anticoagulant (to prevent blood clots, heart attacks, and strokes) 2/19/25-Cymbalta 30mg- one capsule once a day for depression 2/19/25-Esomeprazole Magnesium 40mg- one capsule once a day gastroesophageal reflux disease 2/24/25-Eliquis 2.5mg- one tablet every 12 hours for atrial fibrillation (a heart condition) 2/25/25-Gabapentin 100mg- one capsule every 12 hours for neuropathy (nerve pain) 3/17/25-Bumetanide 2mg- one tablet twice a day for fluid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 evidence monitoring of anticoagulant medication use for one of 25 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to evidence anticoagulant medication monitoring from 2/1/25-2/11/25. R2 was readmitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/6/25, the resident was assessed as taking anticoagulant medication. The physician orders for R2 documented in part, - Apixaban Oral Tablet 5 MG (Apixaban) (1) Give 5 mg via PEG (percutaneous endoscopic gastrostomy)-Tube two times a day for blood thinner. Order Date: 01/31/2025. The eMAR for R2 dated 2/1/25-2/28/25 documented the Apixaban administered on 2/1/25-2/14/25. The eMAR documented anti-coagulant monitoring beginning on night shift 2/12/25. It failed to evidence monitoring 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 review and facility document review, it was determined that the facility staff failed to follow infection control practices for three of 25 residents in the survey sample, Residents #10, #7 and #13. The findings include: 1. For Resident #10 (R10), the facility staff failed to follow infection control practices during tracheostomy care observed on 5/1/25. The MDS (minimum data set) assessment was not due at the time of the survey. On the admission assessment dated [DATE], R10 was assessed as having a tracheostomy and being alert and oriented to person, place, time and situation. The baseline care plan for R10 documented in part, I have a tracheostomy r/t Dependence on mechanical ventilator, Impaired breathing mechanics, Respiratory Failure. Date Initiated: 04/24/2025. On 5/1/25 at 8:33 a.m., an observation was made of OSM (other staff member) #10, respiratory therapist performing tracheostomy care for R10. OSM #10 was observed to don a gown and clean gloves…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for four of six residents, R2, R3, R4 and R5. The findings include: 1. The facility staff failed to provide ADL (activities of daily living) specifically turning and positioning for a dependent resident, R2. R2 was admitted to the facility on [DATE] with diagnosis that included but were not limited to POA (present on admission) pressure wound sacral area, left and right heel, osteoarthritis, Adult FTT (failure to thrive) and osteomyelitis. The most recent MDS (minimum data set) assessment, an admission 5-day assessment, with an ARD (assessment reference date) of 2/3/25, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for three of 11 residents in the survey sample, Residents #7, #4, and #3. The findings include: 1. For Resident #7, the facility staff failed to implement the comprehensive care plan to give treatments as ordered. The comprehensive care plan dated, 12/26/24, documented in part, Focus: I have impaired skin integrity. The Interventions documented in part, Administer treatments as ordered and monitor for effectiveness. The physician order dated, 12/27/24, documented, [NAME] Prep (3) L (left) heel DTI every shift. [NAME] Prep R (right) heel DTI every shift. The January 2025 TAR (treatment administration record) documented the above orders. For both the left and right heel, there were blanks on the TAR on the following dates for the evening shift: 1/3/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, 1/16/25. The physician order…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer medications and/or treatments per the physician order for two of 11 residents in the survey sample, Residents #3 and #4. The findings include: 1.a. For Resident #3(R3), the facility staff failed to administer physician ordered treatments to an abdominal surgical wound, a right great toe callus, and right lateral foot callus. The physician orders dated, 1/8/25, documented, Cleanse abdominal surgical wound with wound wash; apply skin prep (1) daily one time a day for wound care. Apply skin prep to right great toe q (every) shift, every shift for wound care. Apply skin prep to the right lateral foot every shift for wound care. The TAR (treatment administration record) documented the above orders. On 1/20/25 for the day shift, there was no documentation that the treatement was adminstered. On 1/22/25 at 11:32 a.m., an interview was conducted with LPN (licensed practical nurse) #1, When asked how do nurses' evidence that they've completed a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide care and services for the treatment of pressure injuries (1) for three of 11 residents in the survey sample, Residents #7, #9, and #3. The findings include: 1. For Resident #7 (R7), the facility staff failed to apply physician prescribed Betadine and [NAME] Prep to treat DTI (deep tissue injury) (2) on both heels. The physician order dated, 12/27/24, documented, [NAME] Prep (3) L (left) heel DTI every shift. [NAME] Prep R (right) heel DTI every shift. The January 2025 TAR (treatment administration record) documented the above orders. For both the left and right heel, there was no documentation on the TAR for the following dates for the evening shift: 1/3/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, 1/16/25. The physician order dated, 1/16/25, documented, Betadine L heel DTI every shift. Betadine R heel DTI every shift. The January 2025 TAR…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to notify the physician and/or responsible party when medications were not administered for one of 11 residents in the survey sample, Resident #4. The findings include: For Resident #4,(R4), the facility staff failed to notify the physician when medications were not administered per the physician orders. The nurse's note dated, 1/4/25 at 2:00 a.m. documented, Patient is readmitted . R4's physician orders dated 1/4/25, documented, Sucralfate Oral Tablet; Give 2 gram via PEG - tube two times a day for ulcer. Vancomycin HCL (hydrochloride) 250 MG (milligrams); Give 125 mg via PEG-tube two times a day for infection. The above physicians' orders for R4 were documented on the January 2025 MAR (medication administration record), that indicates both medications and doses scheduled for 9:00 a.m. and 5:00 p.m., A 22 was documented. A 22 indicates, Drug/Treatment Not Administered. The nurse's note dated 1/4/25 at 12:34 p.m. documented, Ordered from pharmacy. The nurse's…

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

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to protect one of 11 residents from sexual abuse, Resident #1. The findings include: a. For Resident #1(R1), the facility staff failed to protect her from sexual abuse from Resident #8. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/6/24, R1 scored a zero out of 15 on the BIMS (brief interview for mental status) score, indicating R1 was severely impaired for making daily decisions. In Section GG - Functional Status, the resident was coded as being able to walk independently at least 150 feet. R1 progress note dated, 1/10/25 at 7:45 p.m. documented, While standing in the common area passing medications, writer overheard CNA (certified nursing assistant) (CNA #2) holler down the hall and call for CNA (CNA #1) to come here. (CNA #2) stated to (CNA #1), 'You will be my witness, I caught (name of R8) eating (name of R1)'s vagina.' Writer immediately stopped passing medications and proceeded down…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 11 residents in the survey sample, Resident #4. The findings include: For Resident #4, the facility staff failed to document the notification of the nurse practitioner of when a medication was held. The physician order dated, 1/9/25, documented, Metoprolol Tartrate Tablet (1) 25 MG (milligrams); Give 1 tablet via PEG-tube two times a day related to essential hypertension. The January 2025 MAR documented the above order. On 1/21/25 at the scheduled 5:00 p.m. dose a 5 was documented. A 5 indicates, Hold. The nurse's notes dated 1/21/25 at 8:13 p.m. documented, Patient received Midodrine (2). BP (blood pressure) 115/67. HR (heart rate) 97. There was no notification to the doctor or responsible party as to why the medication was held. There were no documented parameters for this mediation order. On 1/22/25 at 11:32 a.m., An interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to comply with the accepted professional standards and principles that apply to professionals providing services for two of 8 residents, Resident #1 and Resident #3. The findings include: 1.The facility failed to provide evidence that they performed respiratory care services according to professional standards for Resident #1. A review of the facility's Multiple Incident QA Reports for Resident #1 revealed incident reports of [DATE] at 12:00 AM, [DATE] 1:50 AM and [DATE] 9:00 PM with 'behavior symptom exhibited' being documented as trach out or resident decannulated himself. A review of the as worked staffing sheets provided by the facility, reveals one RT scheduled for [DATE] 7PM-7AM shift. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to respiratory failure, trach, CVA (cerebrovascular accident), hemiplegia/hemiparesis and diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to report an allegation of neglect and death in a timely manner for Resident #3. The findings include: The facility failed to report an allegation of neglect and death a timely manner for Resident #3. An abbreviated complaint survey began on [DATE], staff working night shift were identified and surveyor arrived on [DATE] at 6:30 AM to interview the staff. During the interview conducted on [DATE] at 6:40 AM with OSM (other staff member) #3, respiratory therapy, she informed me of Resident #3's death during the night. No facility event synopsis was submitted on [DATE]. On [DATE] at approximately 10:00 AM requested if the event had been reported to our office? ASM (administrative staff member) #1 stated she would check. On [DATE] at 1:30 PM, the facility provided evidence of the facility event synopsis for Resident #3's unanticipated death faxed to office on [DATE] at 11:53 AM. 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 The facility staff failed to take actions aimed at performance improvement (including adverse resident events) and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained for Resident #1. The findings include: During a complaint survey 8/1/24-8/6/24 regarding Resident #1, the facility was asked to provide information regarding Resident #1's care issues resulting in transfer to the hospital on 6/7/24. On 8/1/24, Surveyor was provided with the facility's Four Point Action Plan dated 6/10/24. Objective: Management of residents with a tracheostomy to reduce the occurrence of self-decannulation. Problem/Concern: Residents with tracheostomies self-decannulate. Action Steps: #1: The DON/designee conducted an audit of the resident's medications and made changes per physician orders 6/4/24. The Resident was transferred to the hospital. The MD was made aware of findings 6/7/24. #2: DON/designee and RT will conduct an audit/assessment of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for four of 56 residents in the survey sample, R429, F128, F479, F84 The findings include: 1. The facility staff failed to implement the comprehensive care plan for a urinary catheter for Resident #429. Resident #4295 was admitted to the facility on [DATE] with diagnosis that included but were not limited to respiratory failure, trach and non-traumatic intracerebral hemorrhage. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 2/20/24, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and eating. A review 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.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain the resident's highest level of well-being for two of 56 residents in the survey sample, Resident #229 and #479. The findings include: 1. For Resident #229, the facility staff failed to obtain daily weights per the physician order. On the most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date of 6/5/24, the resident scored a five out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired for making daily decisions. The physician order dated, 5/15/24, documented, Daily weights, notify MD (medical doctor) of weight gain greater than 2 pounds in one day or 3-5 pounds in a week. The May 2024 MAR (medication administration record) documented the above order. On 5/25,24, 5/27/24 and 5/29/24, there were blanks where the weight was to be documented. The June 2024 MAR documented the above order. On 6/5/24, 6/6/24, 6/8/24, 6/9/24, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to provide care and services for a catheter for three of 56 residents in the survey sample, Residents #129, #429 and #479. The findings include: 1. For Resident #129 (R129), the facility staff failed to maintain the urinary catheter (1) drainage bag in a sanitary manner. Resident #129's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/4/2024 the resident scored eight out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section H documented R129 having an indwelling urinary catheter. On 7/22/24 at 1:47 p.m. an observation was made of R129 lying in bed in their room. A urinary catheter collection bag was observed attached to the bed frame on the left side of R129's bed. The bottom of the bag was observed to be touching the floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for 3 of 56 residents, Resident #128, #165 and #84. The findings include: 1. The facility staff failed to provide respiratory therapy per physician orders for Resident #128. Resident #128 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DM (diabetes mellitus), acute/chronic respiratory failure, trach, ESRD (end stage renal disease) and hemodialysis. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 6/6/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/dressing/toileting/bathing and set-up 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 observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain food preparation utensils in good repair and/or in a sanitary manner in one of one kitchen in the facility. The findings include: On 7/22/24 at 11:27 a.m., an observation was conducted of the kitchen in the facility with OSM (other staff member) #12, dietary manager. Observation of the kitchen revealed a metal shelving unit with a basin of serving utensil and food preparation utensils. OSM #12 stated that the utensils on the shelving unit were all cleaned and available for use. Further observation revealed a metal serving spoon with visible debris inside the spoon area, a metal slotted spoon with visible debris inside the spoon area, an ice cream scoop with visible debris inside the scoop, a plastic spatula with approximately one-quarter of the end of the plastic tip broken off and a brush which was yellow with charred blacked ends and oily. The bristles of the brush were observed to be stiffened and immobile. OSM #12 stated that the utensils should 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for three of 56 residents in the survey sample, Residents #229, #95 and #92. The findings include: 1. For Resident #229, the facility continued to document changing of a urinary drainage bag on shower days when the Foley catheter was discontinued on 7/1/24. The nurse's note dated, 7/1/24 at 2:40 p.m., documented in part, Resident was out of facility for Urologist appointment and report Foley was taken out and voiding trial was completed at Urologist office per paperwork. The July 2024 TAR (treatment administration record) documented, Change urinary drainage bag every week on shower day Monday, one time a day every Mon (Monday) for cleanliness infection control. The treatment was documented as having been completed on 7/8/24, 7/15/24 and 7/22/24. An interview was conducted with LPN (licensed practical nurse) #4, the unit manager, on 7/24/24…

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

Based on observation, staff interview, and clinical record review, the facility staff failed to provide dignity for one of 56 residents in the survey sample, Resident #282. The findings include: For Resident #282 (R282), the facility staff failed to administer medications via PEG (percutaneous endoscopic gastrostomy) tube (1) in a dignified manner. A review of R282's clinical record revealed the resident was admitted to the facility with a PEG tube and a physician's order dated 7/16/24 for nothing by mouth. On 7/23/24 at 8:43 a.m., R282 was observed lying in bed while LPN (licensed practical nurse) #1 raised R282's gown, exposed the resident's abdomen, and administered medications via PEG tube. During this medication administration, R282's room door was left open, and the privacy curtain was not pulled. R282 was visible from the hall. On 7/24/24 at 4:15 p.m., ASM (administrative staff member) #1 (the administrator), and ASM #2 (the director of nursing) were made aware of the above concern. On 7/25/24 at 9:45 a.m., an interview was conducted with LPN #4. LPN #4 stated nurses should…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to maintain confidentiality for three of 56 residents in the survey sample, Residents #21, #162, and #44. The findings include: For Residents #21 (R21), #162 (R162), and #44 (R44), LPN (licensed practical nurse) #2 left a sheet of paper with confidential information on top of the medication cart in the hall while the nurse walked to the medication room. A review of R21's clinical record revealed a diagnosis of legal blindness and a physician's order dated 7/9/24 for dialysis every Monday, Wednesday, and Friday. A review of R162's clinical record revealed a physician's order dated 6/25/24 for dialysis every Monday, Wednesday, and Friday. A review of R44's clinical record revealed a physician's order dated 6/14/24 for dialysis every Monday, Wednesday, and Friday. On 7/23/24 at 8:51 a.m., LPN (licensed practical nurse) #2 was observed preparing medications at the medication cart in the hall. On 7/23/24 at 9:00 a.m., LPN #2 walked away from the medication cart to a…

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

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a clean and homelike environment for two of 56 residents in the survey sample, Resident #86 and Resident #4. The findings include: 1. For Resident #86 (R86), the facility staff failed to change a blanket with a large brown stain from 7/22/24 at 2:04 p.m. through 7/23/24 at 9:30 a.m. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 4/26/24, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. The assessment documented no behaviors or rejection of care. On 7/22/24 at 2:04 p.m., an observation was made of R86 in their room. R86 was observed lying in bed covered with a white blanket that was observed to have a brown stain approximately 12 inches long and four inches wide on the lower center of the blanket. A strong urine smell was present. R86 was not able to be interviewed due…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 evidence ombudsman notification of a facility initiated transfer for one of 56 residents in the survey sample, Resident #30. The findings include: For Resident #30 (R30), the facility staff failed to evidence ombudsman notification of a facility initiated transfer on 4/6/24. A review of R30's clinical record revealed the following progress note: 4/6/2024 07:39 (7:39 a.m.) Note Text: CNA (certified nursing assistant) notified writer that resident was choking on a peanut butter sandwich. Writer assessed resident and performed the Heimlich maneuver. Small amount of sandwich came out of resident's mouth. Resident noted still unable to breathe. All available staff including respiratory therapist was notified of emergency situation and came up to assist with patient care. EMS (emergency medical services) was called and patient was sent to [Name of hospital] for evaluation. [Name of physician] and RP (responsible party) [Name of RP] was notified of patient…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for dependent residents for two of 56 residents in the survey sample, Resident #10 and #433. The findings include: 1. For Resident #10 (R10), the facility staff failed to answer call lights in a timely manner for a dependent resident. On the most recent MDS (minimum data set). a quarterly assessment with an ARD (assessment reference date) of 6/18/24, R10 was admitted the facility 2/2/2. R10 was coded as being moderately impaired for making daily decisions, having scored 12 out 15 on the BIMS (brief interview for mental status). The resident was coded as being frequently incontinent and dependent for toilet hygiene. On 7/23/24 at 11:49 a.m., an observation was made of room [ROOM NUMBER] with a call light on. At 12:05 p.m., there were two staff at the nurse's station. At 12:15 p.m., three staff members were at the nurse's station. At 12:22 p.m., a staff member was seen going…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide colostomy care and services for one of 56 residents in the survey sample, Resident #479. The findings include: For Resident #479 (R479), the facility staff failed to provide physician ordered colostomy care on multiple dates in February 2024. A review of R479's clinical record revealed the following physician's orders: 1/26/24-Empty colostomy bag as needed and every shift. 1/26/24-Remove colostomy appliance/bag, provide skin care and reapply colostomy appliance/bag as needed and one time a day every three days. R479's February 2024 TAR (treatment administration record) documented the same physician's orders. Further review of R479's February TAR failed to reveal the resident's colostomy bag was emptied during the day shift on 2/1/24 and during the day shift on 2/9/24 (as evidenced by blank spaces on the TAR). The TAR also failed to reveal R479's colostomy appliance/bag was removed, skin care was provided, and the appliance/bag was reapplied from 2/12/24 until 2/17/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for two of 56 residents in the survey sample, Resident #46 and #128. The findings include: 1.Resident #46 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), hemodialysis, Rheumatoid arthritis and COPD. The most recent MDS (minimum data set) assessment, a Medicare 5-day change assessment, with an ARD (assessment reference date) of 7/6/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/dressing/toileting/bathing and set up for eating. A review of the comprehensive care plan dated 7/3/24 revealed, FOCUS: Resident has…

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

Based on observation, staff interview, and facility document review, the facility staff failed to store medications in a locked compartment for one of seven medications carts, a cart on the Tuckahoe unit. The findings include: For one medication cart on the Tuckahoe unit, LPN (licensed practical nurse) #1 failed to lock the cart while she was in a resident room and in a medication room. On 7/23/24 at 8:17 a.m., LPN #1 left the medication cart in the hall unlocked while obtaining a resident's blood pressure in a resident room. The medication cart was not in LPN #1's line of sight. On 7/23/24 at 8:34 a.m., LPN #1 left the medication cart unlocked while she exited the hall and went into a medication room. The medication cart was not in LPN #1's line of sight. On 7/23/24 at 8:40 a.m., LPN #1 left the medication cart unlocked while administering medications to a resident in a resident room. The medication cart was not in LPN #1's line of sight. On 7/24/24 at 12:38 p.m., an interview was conducted with LPN #2. LPN #2 stated nurses should lock their medication cart when they leave the cart…

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

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain a heating/air conditioning unit in a resident room in a safe condition, Resident #4. The findings include: For Resident #4(R4), the facility staff failed to maintain a heating/air conditioning unit in a safe manner. Observation was made of R4's room on 7/22/24 at 1:12 p.m. The heating/air conditioning unit was observed. The grill on the upper surface of the unit had one missing slat, leaving a space of approximately two inches open. There were four other slats that were broken but still attached. There were sharp edges where the slats were missing and where they were broken. Observation was made of R4's room with OSM (other staff member) #2, the director of maintenance, on 7/23/24 at 2:43 p.m. The above findings were found again. When asked if the unit was a safety hazard, OSM #2 stated, yes, that needs to be replaced. The facility policy, Maintenance Services documented in part, Maintenance service shall be provided to all areas of the building, grounds, and…

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

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for three of 17 residents in the survey sample, Residents #4, #6 and #3. The findings include: 1. For Resident #4 (R4), the facility staff failed to implement the comprehensive care plan to provide assistance with toileting. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/30/2023, the resident was assessed as requiring partial to moderate assistance with toileting, being frequently incontinent of bowel and bladder, and not being on a toileting program. The comprehensive care plan for R4 documented in part, I have bowel incontinence r/t (related to) impaired mobility. Date Initiated: 10/24/2023 . Under Interventions it documented in part, Provide incontinence care and apply moisture barrier as needed. Date Initiated: 10/24/2023 . The care plan further documented, I have urinary incontinence r/t BPH (benign prostatic hypertrophy). Date Initiated:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide evidence of ADL (activities of daily living) care for two of 17 residents in the survey sample, Residents #3 and #4. The findings include: 1. For Resident #3, the facility staff failed to provide evidence of ADL care, specifically incontinence care. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 1/8/24, coded Section GG-functional abilities and goals as the resident requiring moderate assist for dressing; and dependent for personal hygiene and bathing. A review of the comprehensive care plan dated 12/12/23 revealed, FOCUS: I have urinary incontinence related to dementia, bph (benign prostatic hypertrophy). INTERVENTIONS: Provide incontinence care and apply moisture barrier as needed. Check resident approximately every 2 hours and provide incontinence care as needed. A review of Resident #3's ADL (activities of daily living) for December 2023 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 staff interview and facility document review, it was determined the facility staff failed to utilize outside resources to obtain COVID vaccines. The findings include: The facility failed to utilize outside resources to obtain COVID (coronavirus disease) vaccines from October 2023-March 6, 2024. A request was made on 3/4/24 at approximately 10:30 AM for evidence of COVID vaccinations and COVID policies. An interview was conducted on 3/5/24 at 11:30 AM with RN (registered nurse) #2, the regional Infection Preventionist (IP). When asked to describe the resident COVID immunization process, RN #2 stated, when a new admission comes in, we look PCC (point click care) connect, which allows us to look at shared immunizations among local health care facilities, nursing homes/hospital and dialysis centers. This information is imported into the immunization tab of the resident's medical record. Then we look at the Virginia immunization system for Influenza, Pneumonia and COVID. If we cannot find that the resident has been vaccinated then we hold clinics quarterly. The quarterly clinic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to provide the COVID-19 (coronavirus disease) vaccine for five of 17 residents in the survey sample, Residents #6, #8, #13, #16 and #17. The findings include: 1. For Resident #6, the facility staff failed to provide COVID-19 vaccine. A request was made on 3/4/24 at approximately 10:30 AM for evidence of COVID vaccinations and COVID policies. A review of Resident #6's COVID-19 immunization record revealed, consent for the COVID-19 vaccine was obtained 3/4/24, however no COVID-19 vaccine was administered since admission on [DATE]. A review of the comprehensive care plan dated 9/12/23 revealed, FOCUS: I am at risk for infection due to potential/actual exposure to COVID-19. INTERVENTIONS: Resident teaching should include the importance of Covid immunization completion. I will be screened for changes in vital signs and respiratory symptoms. Notify physician of changes in resident vital signs or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews it was determined that the facility staff failed to revise the comprehensive care plan with person-centered interventions for one of 17 residents in the survey sample, Residents #4. The findings include: 1. For Resident #4 (R4), the facility staff failed to revise the trauma informed care plan to include person-centered care related to PTSD (post traumatic stress disorder) (1) triggers. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/30/2023, the resident was assessed as having a diagnosis of PTSD. The comprehensive care plan for R4 documented in part, I have a history of PTSD (post-traumatic stress disorder) r/t (related to) Date Initiated: 10/29/2023. Under Interventions it documented in part, Avoid situations that may cause flashbacks. Ask me about my triggers and incorporate them into my plan of care. Date Initiated: 10/29/2023. The care plan failed to evidence any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, it was determined that the facility staff failed to provide treatment to a pressure injury to promote healing, for one of 17 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to provide pressure injury treatment as ordered for dates in February 2024. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 1/21/2024, the resident was assessed as scoring 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment documented R6 having one unstageable pressure injury that was not present on admission. The physician orders for R6 documented in part, - Left Lateral Ankle: clean with n/s (normal saline) then apply Manuka HD Alginate, collagen particles, silver alginate and Bordered Foam one time a day . - Right Lateral Foot: clean with wound cleanser, manuka hd alginate, apply…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide a resident's representative with written notification of a room change for one of 11 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to provide the resident's representative with written notification of a room change when the resident was transferred to a different room on 11/12/23. A review of R1's clinical record revealed the resident was transferred to a different room on 11/12/23, however there was no documented reason for the room change. Further review of R1's clinical record failed to reveal evidence the resident's representative was provided written notice of the room change, including the reason for the change. A note dated 11/12/23 and signed by the former director of nursing only documented, Reached out to family (name) returning call. Did not answer, left voicemail message. On 1/4/24 at 9:16 a.m., an interview was conducted with OSM (other staff member) #5. OSM #5 stated that most 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.

Based on observations, resident interview, staff interview, and facility document review, the facility staff failed to provide a clean and homelike environment for one of 11 residents in the survey sample, Resident #9. The findings include: For Resident #9 (R9), the facility staff failed to provide a clean bathroom for the resident. On the following dates and times, R9's bathroom floor was observed visibly soiled with a 5 cm (centimeter) smear of brown matter: 1/3/24 at 2:00 p.m. and 4:10 p.m.; and 1/4/24 at 9:05 a.m. On 1/4/24 at 10:38 a.m., LPN (licensed practical nurse) #3 was interviewed. She stated that there is rounding every two hours for incontinence care. She also stated that it is everybody's responsibility to make sure bathrooms are clean. On 1/4/24 at 11:00 a.m., OSM (other staff member) #2, the housekeeping director was interviewed. She stated that housekeeping tries to do six detail cleanings each day, but the staff members clean all the rooms every day. She says it is up to all staff to ensure that the bathroom is clean and homelike. On 1/4/24 at 11:18 a.m., LPN #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, staff interview and facility document review, the facility staff failed to maintain a comfortable environment for one of 11 residents in the survey sample, Resident #11. The findings include: For Resident #11 (R11), the facility staff failed to maintain the resident's wheelchair in good repair. The right armrest was missing. On 1/3/24 at 1:52 p.m. and 1/3/24 at 4:11 p.m., R11 was observed in a wheelchair in the hall. The right armrest was missing, and the resident's arm was resting on the frame. On 1/4/24 at 8:29 a.m., the right armrest on R11's wheelchair remained missing. On 1/4/24 at 9:44 a.m., an interview was conducted with OSM (other staff member) #1 (the director of maintenance). OSM #1 stated staff is supposed to notify the maintenance department of broken wheelchairs via a computer work order system, but a lot times, the staff stops the maintenance staff in the hall and tells them. OSM #1 stated he said something about R11's missing wheelchair armrest a while back and someone told him the armrest was missing because the resident has a table that slides…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility document review, and clinical record review, the facility staff failed to maintain resident dignity for four of 57 residents in the survey sample, Residents #74, #48, #5, and #86. The findings include: 1. For Resident #74 (R74), the facility staff failed to provide incontinence care in a dignified manner. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date of 6/23/23), R74 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). R74 was coded as requiring the extensive assistance of two staff members for toileting, and coded as being always incontinent of both bowel and bladder. On 8/7/23 at 3:38 p.m., the surveyor entered R74's room. CNA (certified nursing assistant) #10 opened the door from the bathroom (shared with the two residents in the adjacent room), and stated: I'm going to do this resident [pointing to a resident standing with her in the bathroom], then do him…

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

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to physician notification for seven of 57 residents in the survey sample, Residents #90, #63, #86, #115, #360, #95 and #358. The findings include: 1. For Resident #90, the facility staff failed to notify the physician, per the physician order, of elevated blood sugar levels. The physician orders dated 3/24/2023 included, Novolin R (regular) Flex Pen Solution Pen Injector 100 UNIT/ML (milliliters) (Insulin Regular Human) inject as per sliding scale: if 0 - 150 = 0; 151 - 199 = 1; 200 - 249 = 2; 251 - 299 = 3; 300 - 349 = 4; 350 - 399 = 5; 400 - 450 = 6; > (greater than) 450 give 8 units and inform attending, subcutaneously at bedtime for dm (diabetes) bedtime ssi (sliding scale insulin). The physician orders dated 3/24/2023 included, Novolin R (regular) Flex Pen Solution Pen Injector 100 UNIT/ML (milliliters) (Insulin Regular Human) inject as per sliding scale: if 0 - 150 = 0 units; 151 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide, to the receiving facility, the required documents for four of 57 residents in the survey sample, Resident #155, #508, #3 and #106. The findings include: 1. For Resident #155, the facility staff failed to send the comprehensive care plan with the resident upon transfer to the hospital on 5/14/2023. The nurse's note dated 5/14/2023 at 7:26 a.m. documented, At 0530 (5:30 a.m.) patient was noted unresponsive to verbal stimuli and sternum rub .EMS [emergency medical services] was called and transported out of facility via stretcher. Hospital location unknown at time of departure . The Acute Care Transfer Document Checklist dated 5/14/2023, failed to evidence any notation related to the care plan being sent to the hospital with the resident. An interview was conducted with LPN (licensed practical nurse) #4 on 8/9/2023 at 12:33 a.m. When asked what documents are sent with the resident upon transfer to the hospital, LPN #4 stated she sends 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for 19 of 57 residents in the survey sample, Resident #90, #144, #106, #358, #86, #74, #48, #37, #43, #409, 118, #5, #54, #149, #142, #133, #34, #63, and #127. The findings include: 1. For Resident #90, the facility staff failed to implement the comprehensive care plan for monitoring the resident for side effects for the use of anticoagulants, Resident #90 had diagnoses that included but were not limited to: atrial fibrillation, history of a stroke, diabetes, and status post left below the knee amputation. The comprehensive care plan dated, 3/13/2023, documented in part, Focus: I am on anticoagulant therapy. The Interventions documented in part, Monitor/record/report PRN (as needed) s/sx (signs and symptoms) of anticoagulant complications: blood tinges or frank blood in urine, black tarry stools, dark or bright red blood in stools,…

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

4. For Resident #510, the facility failed to revise the comprehensive care plan to include the use of a wound vac (1). Resident #510 was observed in with wound vac in place on 8/7/23 at 12:00 PM. A review of the comprehensive care plan dated 12/30/22 and revised 8/1/23, revealed, FOCUS: Resident has a pressure ulcer or has the potential for pressure ulcer development related to immobility. INTERVENTIONS: Administer treatments as ordered and monitor for effectiveness. Offload my heels when in bed as tolerated using: (pillows). Monitor wound dressing during care to ensure it is intact and adhering. Report loose dressing to nurse. Resident need reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Keep resident's skin clean and moisturized as needed. Do not massage over bony prominences and use mild cleansers for peri-care and bathing. A review of the physician orders dated 8/2/23, revealed, SACRUM- Cleanse with 0.25% Dakin's solution. Apply black foam vac dressing to wound vac dressing to wound vac at 123mm Hg (millimeters of mercury) 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, resident interview, family interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for seven of 57 residents in the survey sample, Residents #74, #48, #5, #118, #361, #358, and #127. The findings include: 1. For Resident #74 (R74), the facility staff failed to provide incontinence care in a timely manner on 8/7/23. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date of 6/23/23), R74 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring the extensive assistance of two staff members for toileting. He was coded as being always incontinent of both bowel and bladder. On 8/7/23 at 3:38 p.m., the surveyor entered R74's room. CNA (certified nursing assistant) #10 opened the door from the bathroom (shared with the two residents in the adjacent room), and stated: I'm going to do this resident [pointing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4. For Resident #360 (R360), the resident was admitted to the facility on [DATE] with pressure injuries. The facility staff failed to initiate treatment for the pressure injuries until 8/2/23 and 8/3/23. R360 was admitted to the facility on [DATE]. A review of R360's clinical record revealed a wound progress report dated 8/2/23 that documented the resident presented with a stage two pressure injury (1) on the right heel on 7/31/23. Further review of R360's clinical record revealed treatment was not initiated until 8/2/23. A physician's order dated 8/2/23 documented to cleanse the right heel with normal saline and apply a hydrocolloid dressing once a day. A wound progress report dated 8/2/23 documented R360 presented with a stage four pressure injury (1) on the sacrum on 7/31/23. Further review of R360's clinical record revealed treatment was not initiated until 8/3/23. A physician's order dated 8/3/23 documented to cleanse the sacral wound with normal saline, apply green foam to the wound bed, cover with plastic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide foot care for five of 57 residents in the survey sample, Residents #48, #34, #144, #63, and #121. The findings include: 1. For Resident #48 (R48), the facility staff failed to ensure the resident's toenails were cleaned and trimmed. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 6/9/23, R48 was coded as requiring the extensive assistance of staff for ADLs (activities of daily living), including bathing and personal hygiene. R48 was admitted to the facility with diagnoses of intellectual disability/autism and diabetes. On 8/7/23 at 3:38 p.m., R48 was observed sitting up in his wheelchair, and had no socks on his feet. All of R48's toenails extended beyond the length of the toes. Some of the nails had brownish yellow material underneath them. On 8/8/23 at 10:22 a.m., R48's toenails were observed. All nails were beyond the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to keep residents free of accidents and hazards for one of 57 residents, Resident #144, and one of three wings on Grove Unit, the west wing. The findings include: 1. For Resident #144, the facility staff failed to ensure fall mats were in use to prevent injury from falls. Observations of Resident #144 revealed: on 08/07/23 at 11:40 AM, no floor mats on either side of bed; 8/10/23 at 2:45 PM, no floor mats on either side of bed; 8/08/23 at 7:45 AM, no floor mats on either side of bed; on 8/8/23 at 11:30 AM, no floor mats on either side of bed; and 8/10/23 9:15 AM, no floor mats on either side of bed. Resident #144's most recent MDS (minimum data set) assessment, a quarterly annual assessment, with an assessment reference date of 7/4/23, coded the resident as scoring 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely…

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

Based on observation, resident and staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide care and services for urinary catheter care for two of 15 residents with urinary catheters; Resident #144 and #86. The findings include: 1. For Resident #144, the facility staff failed to ensure care for an indwelling urinary catheter was provided. Observations of Resident #144 during the survey revealed the resident with a Foley (1) catheter and privacy covering on bag. Urinary catheter care was not observed. A review of the physician order dated 6/27/23, revealed, Foley Output every shift for Foley Cath related to obstructive and reflux uropathy. A review of the July and August 2023 TAR (treatment administration record) revealed urine output documented each shift. There was no evidence of urinary catheter care documented for Resident #144 for July and August 2023. An interview was conducted on 8/9/23 at 2:25 PM, with RN (registered nurse) #1. When asked if a physician's order is required for urinary catheter care, RN #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services consistent with professional standards for four of 57 residents in the survey sample, Residents #360, #358, #106 and #54. The findings include: 1. For Resident #360 (R360), the facility staff failed to obtain a physician's order for the use of an incentive spirometer and failed to store the incentive spirometer in a sanitary manner. R360 was admitted to the facility on [DATE]. R360's admission minimum data set (MDS) assessment was in progress. An admission assessment dated [DATE] documented R360 was alert and oriented to person, place, time and situation. Further review of R360's clinical record failed to reveal a physician's order for an incentive spirometer. On 8/7/23 at 12:11 p.m., 8/7/23 at 3:54 p.m., and 8/8/23 at 9:53 a.m., R360 was observed lying in bed. An incentive spirometer was observed on the heating/air conditioning unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, it was determined that the facility staff failed to implement a complete pain management program for two of 57 residents in the survey sample, Residents #63 and #133. The findings include: 1. For Resident #63 (R63), the facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medications, Acetaminophen (1) and failed to document the location of the pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 05/21/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. The physician order for R63 documented in part, Acetaminophen Tablet. Give 325 mg (milligrams) by mouth every 6 (six) hours as needed for pain not to exceed 3000mg per day. Order Date: 05/06/2022. The eMAR (electronic medication administration record) for R63 dated July 2023 documented the physician's orders as 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 staff interview and clinical record review, it was determined that facility staff failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services, for one of seven residents receiving dialysis services; Resident #149. The findings include: For Resident #149, the facility staff failed to utilize and maintain consistent communication with the dialysis center by way of the dialysis communication book in June, July, and August of 2023 A review of the clinical record revealed a physician's order dated 6/16/23 for dialysis on Tuesdays, Thursdays and Saturdays. A review of the dialysis communication book was conducted. The following dates for which the resident was scheduled for dialysis were not represented in the communication book to evidence that any communication occurred between the facility and the dialysis center: June 17, 20, 24, 27, and 29 of 2023. July 6, 8, 11, 15, 18, 22, 25, 27, and 29 of 2023. August 1, 3, 5, and 10 of 2023. On 8/15/23 at 9:24 AM, an interview was conducted with LPN #1 (Licensed Practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for five of 57 residents in the survey sample, Residents #86, #115, #360, #95 and #358. The findings include: 1. For Resident #86 (R86), the facility staff failed to ensure the physician ordered medication levothyroxine sodium (1), was available and administered on 8/5/23 and 8/6/23. A review of 86's clinical record revealed a physician's order dated 4/1/23 for levothyroxine sodium 175 mcg (micrograms)- one tablet once a day for hypothyroidism. A review of R86's August 2023 MAR (medication administration record) revealed the same physician's order for levothyroxine sodium. On 8/5/23 and 8/6/23, the MAR documented the code, 5=Hold. Nurses' notes dated 8/5/23 and 8/6/23 documented, Med on order. Further review of nurses' notes and the August 2023 MAR failed to reveal documentation that levothyroxine sodium was administered to R86 on 8/5/23 and 8/6/23. A 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, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure five of 57 residents in the survey sample were free of unnecessary medications, Resident #90, #11, #160, #149 and #133. The findings include: 1. For Resident #90 (R90), the facility staff failed to monitor the resident for side effects (bleeding) from the anticoagulant medications, Eliquis (1). Resident #90 had diagnoses that included but were not limited to: atrial fibrillation, history of a stroke, diabetes and status post left below the knee amputation. The physician order dated, 3/3/2023, documented, Apixaban Oral tablet 5 mg (milligram); Give 1 tablet by mouth two times a day for blood thinner. The July and August 2023 MAR (medication administration record) documented the above order. The medication was documented as having been administered per the physician order. There was no documentation of monitoring of side effects for the use of an anticoagulant. The July and August 2023 TAR (treatment administration record) failed 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 resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain an accurate clinical record for four of 57 residents in the survey sample, Residents #86, #361, #144 and #63. The findings include: 1. For Resident #86 (R86), the facility staff failed to accurately document the resident's ADLs (activities of daily living). On 8/8/23 and 8/9/23, the facility staff documented R86 was assisted with transferring but the resident was not out of bed. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/17/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/8/23 at 7:27 a.m., 8/8/23 at 10:43 a.m., 8/8/23 at 3:42 p.m., 8/9/23 4:12 p.m., 8/10/23 at 7:51 a.m. and 8/10/23 at 2:02 p.m., R86 was observed lying in bed. On 8/10/23 at 2:02 p.m., an interview was conducted with R86. R86…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide a safe and homelike environment for one of 57 residents, Resident #129 and in one of six bathrooms on the Westham Unit. The findings include: 1. The facility staff failed to maintain a clean and homelike environment for Resident #129. During the initial resident screening on 8/7/23 at 2:59 PM, the resident's room revealed a wall mounted hand sanitizer dispenser partially torn off the wall above and to the left of the resident's sink, a section of damaged dry wall containing a hole approximately six inches below and to the left of the resident's sink, missing flooring in the doorway between the resident room and bathroom, approximately 12 inches of cove base torn off the wall with additional tearing of the dry wall between the head of the residents beds and an approximate 12 inch piece of cove base falling off the wall to the left side the HVAC unit at the far side 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, staff interview and clinical record review, the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 57 residents in the survey sample, Resident #86. The findings include: For Resident #86 (R86), the facility staff failed to accurately code the resident as having an external urinary catheter on the quarterly MDS with an ARD (assessment reference date) of 7/17/23. On 8/7/23 at 12:37 p.m., 8/8/23 at 7:27 a.m., 8/9/23 at 4:18 p.m., and 8/10/23 at 7:50 a.m., R86 was observed lying in bed with an external urinary catheter draining to a collection canister. A review of R86's clinical record failed to reveal a physician's order for an external urinary catheter. A review of section H100- bladder and bowel appliances of R86's quarterly MDS with an ARD of 7/17/23, revealed the resident was coded as having an indwelling urinary catheter and not coded as having an external urinary catheter. A review of section H100-bladder and bowel appliances of the modified quarterly MDS with an ARD of 7/17/23 revealed the resident was not 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to develop and/or implement the baseline care plan for one of 57 residents in the survey sample, Resident #160. The findings include: 1. For Resident #160 (R160), the facility staff failed to A) implement the care plan to provide non-pharmacological interventions prior to administration of as needed pain medications, B) implement the care plan to monitor for adverse effects of anticoagulant use and C) develop a care plan for diabetes and the use of insulin. R160 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Type 2 Diabetes Mellitus, major depressive disorder and pain, unspecified. On the admission assessment for R160 dated 7/27/2023 the resident was assessed as being alert and oriented to person, place and time. The assessment documented R160 being cognitively able to report pain, having pain less than weekly with preferred pain relief…

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

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for medication administration for two of 57 residents in the survey sample, Residents # 90 and #11. The findings include: 1. For Resident #90, the facility staff failed to administer insulin per the physician orders and failed to document what insulin was administered. The physician orders dated, 3/24/2023 documented, Novolin R (regular) Flex Pen Solution Pen Injector 100 UNIT/ML (milliliters) (Insulin Regular Human) inject as per sliding scale: if 0 - 150 = 0; 151 - 199 = 1; 200 - 249 = 2; 251 - 299 = 3; 300 - 349 = 4; 350 - 399 = 5; 400 - 450 = 6; > (greater than) 450 give 8 units and inform attending, subcutaneously at bedtime for dm (diabetes) bedtime ssi (sliding scale insulin). The physician orders dated 3/24/2023 documented, Novolin R (regular) Flex Pen Solution Pen Injector 100 UNIT/ML (milliliters) (Insulin Regular Human) inject as per sliding scale: if 0 - 150 = 0 units; 151 - 199 = 2 units; 200…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to meet the assessed activities needs of one of 57 residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to provide evidence of providing individual activities to the resident. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/22/23, R5 was coded as being moderately cognitively impaired for making daily decisions. She was coded as having impairment in range of motion for both left and right upper extremities. On the most recent annual MDS with an ARD of 3/9/23, R5 was coded as having expressed the following activities as very important: listening to music she likes, going outside when weather permits, and participating in religious services. On the following dates and times, R5 was observed in her bed, with no music playing: 8/7/23 at 12:24 p.m. and 4:14 p.m.; 8/8/23 at 7:55 a.m. and 10:20 a.m.; and 8/9/23 at 4:13 p.m. A review of R5's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to maintain the highest level of well-being for one of 57 residents in the survey sample, Residents #360. The findings include: For Resident #360 (R360), the resident was admitted to the facility on [DATE] with a diabetic ulcer and a surgical wound. The facility staff failed to initiate treatment for the diabetic ulcer until 8/2/23 and failed to initiate treatment for the surgical wound until 8/3/23. R360 was admitted to the facility on [DATE]. A review of R360's clinical record revealed a wound progress report dated 8/2/23 that documented the resident presented with a diabetic neuropathic ulcer on the right plantar heel on 7/31/23. Further review of R360's clinical record revealed treatment was not initiated until 8/2/23. A physician's order dated 8/2/23 documented to cleanse the right plantar heel with soap and water, pat dry and apply skin prep every shift. A wound progress…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide treatment for contractures (1) for two of 57 residents in the survey sample, Residents #5 and #48. The findings include: 1. For Resident #5 (R5), the facility staff failed to provide a left hand palm guard for the resident's contacted left hand. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/22/23, R5 was coded as being moderately cognitively impaired for making daily decisions. She was coded as having impairment in range of motion for both left and right upper extremities. A review of R5's care plan dated 12/8/22 revealed, in part: I require assistive/adaptive device .resident to wear Left palm protector at all times, as tolerated with removal for hand hygiene and skin checks. On the following dates and times, R5 was observed in her bed, with no palm guard/protector in her left hand: 8/7/23 at 12:24 p.m. and 4:14 p.m.; 8/8/23 at 7:55 a.m. and 10:20 a.m. On 8/9/23 at 4:13 p.m., R5 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide tube feeding per physician orders, for one of 16 residents; Resident #144. The findings include: For Resident #144, the facility staff failed to follow physician orders for tube feeding. On 8/7/23 at 2:30 PM, Resident #144 was observed with Glucerna 1.5 calorie, 700 ml (milliliters) still hanging at the bedside and not infusing. The feeding was labeled with a start date of 8/6/23 6:00 AM. The Glucerna container held 1500 milliliters. Resident #144 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: dysphagia. Resident #144's most recent MDS (minimum data set) assessment, a quarterly annual assessment, with an assessment reference date of 7/4/23, coded the resident as scoring 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. MDS…

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

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement bed rail requirements for three of 57 residents in the survey sample, Residents #359, #95 and #358. The findings include: 1. For Resident #359 (R359), the facility staff implemented bed rails without a documented recommended clinical need, failed to review the risks and benefits of bed rails, and failed to obtain informed consent for the use of bed rails. On 8/7/23 at 12:17 p.m. and 8/8/23 at 11:38 a.m., R359 was observed lying in bed with a left grab bar (bed rail) in the upright position. A review of R359's clinical record failed to reveal a physician's order for bed rails, failed to reveal evidence that the risks and benefits of bed rails were explained to the resident (or resident representative), and failed to reveal evidence that informed consent for the use of bed rails was obtained. The bed rail evaluation section of an admission/readmission evaluation packet form dated 8/4/23 documented, 1. Is the resident ambulatory? No. 3. Does 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, facility document review, and clinical record review, the facility staff failed to provide services related to trauma-informed care for one of 57 residents in the survey sample, Resident #37. The findings include: For Resident #37 (R37), who had a diagnosis of PTSD (post-traumatic stress disorder) (1), the facility staff failed to follow up on a recommendation for counseling services. On the most recent MDS (minimum data set). an annual assessment with an ARD (assessment reference date) of 5/21/23, R37 was coded as being moderately impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). He was scored a zero on the mood severity evaluation, indicating he had no symptoms of mood dysfunction during the look back period. He was coded as having demonstrated no behaviors during the look back period. R37 was admitted to the facility with diagnoses including depression, chronic PTSD, and visual hallucinations. A review of R37's clinical record revealed a progress note from a licensed clinical social worker…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for one of 57 residents in the survey sample, Resident #37. The findings include: For Resident #37 (R37), who had a diagnosis of PTSD (post-traumatic stress disorder) (1), the facility social worker failed to follow up on a recommendation for counseling services. On the most recent MDS (minimum data set). an annual assessment with an ARD (assessment reference date) of 5/21/23, R37 was coded as being moderately impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). He was scored a zero on the mood severity evaluation, indicating he had no symptoms of mood dysfunction during the look back period. He was coded as having demonstrated no behaviors during the look back period. R37 was admitted to the facility with diagnoses including depression, chronic PTSD, and visual hallucinations. A review of R37's clinical record revealed a progress note from a licensed clinical social worker…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to take action on a recommendation from the pharmacist for one of 57 residents in the survey sample, Resident #90. The findings include: For Resident #90, the facility staff failed to have the physician/nurse practitioner, respond timely to a pharmacy recommendation made on 5/25/2023. The Medication Regimen Review dated, 5/25/2023, documented, This resident continues to utilize sliding scale insulin to manager glucose control. CMS [Centers for Medicare & Medicaid Services] guidelines state that continued or long-term need for sliding scale insulin for non-emergency coverage may indicate inadequate blood sugar control. Also, high rates of finger sticks and insulin injections may add to patient discomfort and nursing time expenditures without significant long-term benefit in patient outcomes. Please consider modifications to this resident's medication therapy to minimize or eliminate the use of Sliding Scale Insulin Therapy. Review of the physician orders for…

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

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to evidence monitoring of antipsychotic medication for one of 57 residents in the survey sample, Resident #160. The findings include: For Resident #160 (R160), the facility staff failed to monitor behaviors and adverse effects of the antipsychotic medication Quetiapine Fumarate (1). R160 was admitted to the facility with diagnoses that included but were not limited to major depressive disorder and pain, unspecified. On the admission assessment for R160 dated 7/27/2023 the resident was assessed as being alert and oriented to person, place and time. The resident was assessed as having a psychiatric or cognitive condition, taking an antidepressant, and having a pertinent diagnosis of Dementia, OBS (organic brain syndrome), Alzheimer's, Delusions, Hallucinations, Anxiety disorder, Depression, Manic Depression or Schizophrenia. The physician orders for R160 documented in part, - Quetiapine Fumarate Tablet 50 MG (milligram) Give 1 tablet by mouth two times a day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, the facility staff failed to ensure medications were stored properly on one of four medication carts on the Tuckahoe unit. The findings include: Observation was made on 8/8/2023 at 12:23 p.m. of the Tuckahoe unit. RN (registered nurse) #2 had left her medication cart which was outside of room [ROOM NUMBER] and entered the room on the opposite side of the hallway. Her medication cart was not within her sight. On top of the medication cart was a plastic medication cup which contained a bright orange substance with a white plastic spoon sticking out of it. When RN #2 returned to her medication cart, she was asked what was in the plastic cup that was orange, RN #2 stated it was a resident's medication that she's been trying to get into her all morning. RN #2 stated the orange color is coming from the multivitamin that was mixed in it. When asked if medications are to be left on the top of a medication cart when she is not at her cart, RN #2 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 staff interview and clinical record review, the facility staff failed to provide laboratory services in a timely manner for one of 57 residents in the survey sample, Resident #360. The findings include: For Resident #360 (R360), the facility staff failed to obtain STAT (immediate) BMP (basic metabolic panel) (1) and CBC (complete blood count) (2) laboratory tests, per a physician's order, on 8/3/23. A review of R360's clinical record revealed a nurse practitioner's note dated 8/3/23 at 8:47 a.m. that documented, Assessment and Plan: 1. Nausea and vomiting without abdominal pain or diarrhea. Regular bowel movements. No chills or fever. Vital signs are stable, abdominal exam is benign. Ordered Zofran (medication used to treat nausea and vomiting) 4 milligrams POQ (by mouth every) 6 hours PRN (as needed) nausea vomiting x3d (times three days), ordered stat BMP to assess for dehydration given patients report of decreased fluid intake, we can do IV (intravenous) fluids if necessary, ordered clear liquid diet times 24 hours. Discussed with nurse. Further review of R360's 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 observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide food at a palatable temperature. The findings include: The facility staff failed to provide food at a palatable temperature during lunch on 8/8/2023. On Resident #48's (R48) most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 6/9/2023, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact. On 8/07/2023 at 3:38 p.m., R48 was interviewed. When asked about the food he was served, he stated, It is cold and inedible. On Resident #160's (R160) admission assessment dated [DATE], the resident was assessed as being alert and oriented to person, place and time. On 8/8/2023 at 10:14 a.m., R160 was sitting up in her bed eating breakfast. She stated the food was terrible. When asked if the food she was served was warm, 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 observations, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one kitchen, in one of three nourishment rooms in the facility and during meal service. The findings include: 1. On 8/7/2023 at 11:20 a.m., an observation was conducted of the kitchen with OSM (other staff member) #2, dietary manager. Observation of the dry goods storage area revealed a two pound bag of brown sugar approximately three-quarters full closed by plastic wrap. The package was observed to not have an opened date. OSM #2 stated that the staff should date the product when opened so that they knew when it needed to be discarded. She stated that she was going to discard it because she was unable to identify when the bag had been opened. Further observation of the dry goods storage area revealed an 18 quart plastic storage bin with approximately four quarts of a ground course yellow substance that OSM #2 identified as cornmeal. The plastic storage bin was observed to not be labeled or dated. OSM #2 stated that the…

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

Based on observation, staff interview and facility document review, it was determined the facility staff failed to maintain effective infection control practices in one of two dining rooms. The findings include: Observation was made of the staff serving the residents in the Tuckahoe dining room on 8/7/2023 at 11:32 a.m. OSM (other staff member) #10, the activity assistant, was helping getting resident's orders for their lunch and passing out drinks to the residents. OSM #10 had gloves on. OSM #10 was observed using hand sanitizer with the gloves on between serving residents. OSM #10 continued to pass plates to residents. At 11:53 a.m. OSM #10 was observed using hand sanitizer with his gloves on, again. He never changed gloves. An interview was conducted with OSM #10 on 8/7/2023 at 12:00 p.m. When asked why he used hand sanitizer with his gloves on, OSM #10 stated, To make sure my hands are disinfected well. An interview was conducted with RN (registered nurse) #4, the infection preventionist, on 8/8/2023 at 1:49 p.m. When asked if a staff member should use hand sanitizer on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a safe and functional environment for one of 12 resident rooms (for Resident #129). The findings include: The facility staff failed to provide a safe and functional environment for one of 12 resident rooms, for Resident #129. During the initial resident screening on 8/7/23 at 2:59 PM, resident room [ROOM NUMBER] revealed a wall mounted hand sanitizer dispenser partially torn off the wall above and to the left of the resident's sink, a section of damaged dry wall containing a hole approximately six inches below and to the left of the resident's sink, missing flooring in the doorway between the resident room and bathroom, approximately 12 inches of cove base torn off the wall with additional tearing of the dry wall between the head of the residents beds and an approximate 12 inch piece of cove base falling off the wall to the left side the heating/air conditioning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to perform regular bed inspections per the manufacturers'' instructions for 10 of 62 residents in the survey sample, Residents #105, #138, #326, #148, #146, #131, #22, #13, #15, and #168. The facility staff failed to perform regular bed inspections per the manufacturer's instructions for 2021 for Residents #105, #138, #326, #148, #146, #131, #22, #13, #15, and #168 beds. The failure to conduct regular inspections to identify possible entrapment hazards as part of the routine maintenance program had the potential to affect all 177 residents using beds in the facility. The findings include: 1. Resident #105 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including diabetes and liver disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/9/21,…

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 resident interview, staff interview, facility document review, and clinical record review it was determined that the facility staff failed to honor the preference for showers twice a week for one of 62 residents in the survey sample, Resident # 162. The facility staff failed to honor Resident #162 preference for a shower on multiple dates in September 2021, October 2021 and November 2021. The findings include: Resident #162 was admitted to the facility with diagnoses that included but were not limited to: hemiplegia [1], muscle weakness and high blood pressure Resident # 162's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/29/2021, coded Resident # 162 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 162 was coded as requiring extensive assistance of two staff members for activities of daily living and being totally dependent of one staff member for bathing. On 01/112022 at approximately 1:56 p.m., an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence a written notification was provided to the Resident Representative and/or Ombudsman for a hospital transfer for five of 62 residents in the survey sample; Residents #97, #149, #15, #13, and #177. The findings include: 1. The facility staff failed to evidence that a written notification was provided to the Resident Representative for Resident #97's hospital transfer on 11/17/21. Resident #97 was admitted to the facility on [DATE] and had the diagnoses of but not limited to fall with fractures of the tibia and ribs, dysphagia, depression, insomnia and dementia. The most recent MDS (Minimum Data Set) was an admission assessment with an ARD (Assessment Reference Date) of 11/29/21. The resident was coded as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive assistance 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 staff interview and clinical record review it was determined that the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for six of 62 residents in the survey sample, Residents #103, #32, #94, #146, #22 and #56. The findings include: 1. The facility staff failed to complete a PASRR in a timely manner for Resident #103 who was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #103's PASRR was not completed until 1/12/2022. Resident #103 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (1) and post-traumatic stress disorder (2). Resident #103's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/9/2021, coded Resident #103 as scoring a 7 on the brief interview for mental status (BIMS) of a score of 0 - 15, 7 - being severely impaired for making daily decisions. Review of Resident #103's clinical record failed to evidence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review it was determined that the facility staff failed to provide respiratory services consistent with the comprehensive person-centered plan of care for four of 62 residents in the survey sample, Resident #15, Resident #73, Resident #117 and Resident #328. The facility staff failed to administer oxygen to Resident #15 at the flow rate ordered by the physician, failed store Resident # 73's nebulizer mask in a sanitary manner when it was not in use, failed to administer oxygen to Resident #117 per physician's orders, and failed to obtain a physician's order for the administration of oxygen to Resident #328. The findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: chronic obstructive pulmonary disease [COPD] (chronic non-reversible lung disease) (1), asthma (recurrent episodes of difficulty in breathing) (2) and osteoarthritis (degenerative changes in the joints) (3). 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 resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet the needs for one of 62 residents in the survey sample, Resident # 162. The facility staff failed to provide Resident # 162 who is coded as dependant on one staff member for bathing, with a shower two times a week, Wednesdays and Saturdays, due to insufficient CNA (certified nursing assistant) staffing. The findings include: Resident #162 was admitted to the facility with diagnoses that included but were not limited to: hemiplegia [1], muscle weakness and high blood pressure Resident # 162's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/29/2021, coded Resident # 162 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 162 was coded as requiring extensive assistance of two staff members for activities of daily living and being totally dependent of one staff member 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 and staff interview, it was determined that the facility staff failed to provide food at a palatable temperature during the lunch meal service on the Tuckahoe unit. The facility staff failed to provide food at a palatable temperature during lunch service on 1/12/2022. A test tray sampled on the Tuckahoe unit found the food was not warm or palatable. The findings include: During the dates of the survey, group gatherings were limited due to an active COVID-19 (1) outbreak. A group interview was not conducted, however private interviews were conducted. Review of the resident council meeting minutes for 9/23/2021, 10/20/2021 and 12/16/2021 was conducted. The minutes dated 12/16/2021 documented complaints regarding the temperature of the food being cold when served at the facility. Resident #105 was admitted to the facility with diagnoses that included diabetes (2) and liver disease. Resident #105's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/9/2021, coded Resident #105 as being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and clinical record review, it was determined that the facility staff failed to provide dignity for two of 62 residents in the survey sample, Residents #327 and #171. 1. The facility staff failed to maintain Resident #327's urinary catheter in a dignified manner. Urine in the catheter bag was observed from the hall while Resident #327 was lying in bed. 2. CNA (certified nursing assistant) #2 failed to close the door to Resident #171's room and bathroom while toileting and providing Resident #171 personal care. Resident #171 was observed exposed to the open doorways unclothed from the wait up. The findings include: 1. Resident #327 was admitted to the facility on [DATE]. Resident #327's diagnoses included but were not limited to multiple sclerosis, paralysis and high blood pressure. Resident #327's admission minimum data set assessment with an assessment reference date of 1/5/22, coded the resident as being cognitively intact. Review of Resident #327's…

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

Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to maintain a clean and homelike environment for one of 62 residents in the survey sample, Resident #426. The facility staff failed to clean a spill off of the floor in Resident #426's room in a timely manner. The findings include: Resident #426 was admitted to the facility with diagnoses that included but were not limited to anoxic brain damage (1) and congestive heart failure (2). Resident #426's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/21/2021, coded the resident as being severely impaired for making daily decisions. Section G coded Resident #426 as requiring total assistance of two or more staff with bed mobility and total assistance of one staff member for personal hygiene, toileting, dressing and eating. On 1/11/2022 at approximately 12:30 p.m., an observation was made of Resident #426 in their room. Resident #426 was observed lying in bed receiving a tube feeding attached to a feeding pump. 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a bed hold notice was provided upon transfer for three of 62 residents in the survey sample, Resident #13, Resident #15 and Resident #177. The facility staff failed to provide a bed hold notice to Resident #13 upon transfer and admission to the hospital on [DATE], and failed to provide a bed hold notice to the resident or resident responsible party (RP), at the time of Resident #15's transfer to the hospital on [DATE], and at the time of Resident #177's transfer to the hospital on [DATE]. The findings include: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: chronic obstructive pulmonary disease [COPD] (chronic non-reversible lung disease) (1), diabetes mellitus (inability of insulin to function normally in the body) (2) and chronic kidney disease (decreased function of the kidneys frequently as a complication 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 staff interview and clinical record review it was determined that the facility staff failed to correctly code MDS (minimum data set) resident assessments for two of 62 residents in the survey sample, Resident #94 and #89. 1. The facility staff failed to code the quarterly MDS (minimum data set) for Resident #94 with the ARD (assessment reference date) of 12/3/2021 for falls sustained since the previous quarterly assessment on 9/14/2021. 2. The facility staff failed to code the quarterly MDS (minimum data set) for Resident #89 with the ARD (assessment reference date) of 11/27/2021 for restraint usage. The findings include: 1. Resident #94 was admitted to the facility with diagnoses that included but were not limited to dementia (1) and schizoaffective disorder (2). Resident #94's most recent MDS, a quarterly assessment with an ARD of 12/3/2021, coded Resident #94 as scoring a three (3) on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 - being severely impaired for making daily decisions. Section J documented no falls since the prior assessment. 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, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for two of 62 residents in the survey sample, Residents #326 and #328. The facility staff failed to develop a complete baseline care plan to address colostomy care for Resident #326 and failed to develop a baseline care plan to address and include Resident #328's oxygen use. The findings include: 1. Resident #326 was admitted to the facility on [DATE]. Resident #326's diagnoses included but were not limited to chronic kidney disease, history of breast cancer and an underactive thyroid. Resident #326's admission minimum data set assessment was not completed. An admission nursing evaluation dated 1/4/22 documented Resident #326 was alert and oriented to person, place and time. Review of Resident #326's clinical record revealed physician's orders dated 1/10/22 and 1/11/22 for the resident's colostomy care. Resident #326's baseline care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop/implement the comprehensive care plan for three of 62 residents in the survey sample, Resident #131, Resident #426 and Resident #117. The facility staff failed to implement Resident #131's comprehensive care plan for a left hand splint, failed to implement Resident #426's comprehensive care plan for preferred activities and failed to implement Resident #117's comprehensive care plan for the administration of oxygen. The findings include: 1. Resident #131 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: cerebral infarction [CVA] (hemorrhage or blockage of blood vessels of the brain leading to a lack of oxygen) (1) hemiplegia (paralysis affecting one side of the body) (2) and atherosclerotic cardiovascular disease (plaque consisting of lipids and cholesterol building up in arterial walls) (3). Resident #131's most recent MDS (minimum data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident family interview and facility document review, it was determined that facility staff failed to review or revise the comprehensive care plan for two of 62 residents in the survey sample, Resident #426 and Resident # 148. The facility staff failed to include the resident representative in reviewing and revising the comprehensive care plan for Resident #426 and failed to review and revise Resident #148's comprehensive care plan for the use of bed rails. The findings include: 1. The facility staff failed to include the resident representative in reviewing and revising the comprehensive care plan for Resident #426. Resident #426 was admitted to the facility with diagnoses that included but were not limited to anoxic brain damage (1) and congestive heart failure (2). Resident #426's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/21/2021, coded the resident as being severely impaired for making daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, family interview, staff interviews and facility document review it was determined that the facility staff failed to provide preferred activities to meet the needs of one of 62 residents in the survey sample, Resident #426. The findings include: Resident #426 was admitted to the facility with diagnoses that included but were not limited to anoxic brain damage (1) and congestive heart failure (2). Resident #426's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/21/2021, coded the resident as being severely impaired for making daily decisions. Section G coded Resident #426 as requiring total assistance of two or more staff with bed mobility and total assistance of one staff member for personal hygiene, toileting, dressing and eating. On 1/11/2022 at approximately 12:30 p.m., an observation was made of Resident #426 in their room. Resident #426 was observed lying in bed receiving a tube feeding attached to a feeding pump. Resident #426 was alert with their eyes open and non-verbal. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to administer medication per physician's order and comprehensive plan of care for one of 6 residents in the Medication Administration task, Resident #14. The facility staff administered a Lidocaine patch 5% to Resident #14 instead of Lidocaine cream 4% to neck, shoulder topically four times a day for pain as ordered by the physician, the incorrect type (patch vs cream) and dose 5% vs 4% and location knee vs neck/shoulder of this medication. The findings include: Resident #14 was admitted on [DATE] and had the diagnoses of but not limited to dementia, traumatic brain injury, depression, chronic migraine, overactive bladder, high blood pressure, and dysphagia. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 10/12/21. The resident was coded as being severely cognitively impaired in ability to make daily life…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review it was determined that the facility staff failed to provide treatment and services to maintain or improve mobility for one of 62 residents in the survey sample, Resident #131. Resident #131 was observed on separate occasions on 1/11/21 and 1/12/21 without the physician ordered neutral resting splint for the resident's left hand and wrist in place. The findings include: The facility staff failed to implement the splint for Resident #131. Resident #131 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: cerebral infarction [CVA] (hemorrhage or blockage of blood vessels of the brain leading to a lack of oxygen) (1) hemiplegia (paralysis affecting one side of the body) (2) and atherosclerotic cardiovascular disease (plaque consisting of lipids and cholesterol building up in arterial walls) (3). Resident #131's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for two of 62 residents in the survey sample, Residents #326 and #148. The facility staff implemented bed rails for Resident #326 without a documented clinical need and failed to obtain informed consent for the use of bed rails and the facility staff implemented bed rails for Resident #148 without a documented clinical need. The findings include: 1. Resident #326 was admitted to the facility on [DATE]. Resident #326's diagnoses included but were not limited to chronic kidney disease, history of breast cancer and an underactive thyroid. Resident #326's admission minimum data set assessment was not completed. An admission nursing evaluation dated 1/4/22 documented Resident #326 was alert and oriented to person, place and time. On 1/11/22 at 1:55 p.m., Resident #326 was observed lying in bed with bilateral grab bar bed rails in the upright…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to store medications in a safe and secure manner on one of three nursing units, the Grove unit. The facility staff failed to secure medications and lock the medication cart and left unsecured medications on top of the cart while the cart was out of the line of sight when administering medications to residents on the Grove unit. The findings include: Resident #164 was admitted on [DATE] and had the diagnoses of but not limited to stroke, dysphagia, aphasia, dementia, diabetes, viral hepatitis, high blood pressure and gastrostomy. The most recent MDS (Minimum Data Set) was an annual assessment with an ARD (Assessment Reference Date) of 12/24/21. The resident was coded as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for eating and toileting; total care for all other areas of activities of daily…

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

Based on observation, staff interview, and facility document review it was determined facility staff failed to maintain kitchen equipment in a sanitary manner and in accordance with professional standards for food service safety. The findings include: The facility failed to fully clean the deli slicer that was available for use in the facility kitchen. On 1/11/2022 at approximately 11:00 a.m., an observation of the facility's kitchen was conducted with OSM (other staff member) #11, the dietary manager. Observation of the kitchen revealed a deli slicer located on a stainless steel table in the kitchen. The deli slicer was observed to be covered with a clear plastic bag. When asked about the deli slicer, OSM #11 stated that it was used the day before and was cleaned and available for use. Upon inspection of the deli slicer, visible food debris was observed to be on the surface of the deli slicer and a grease-like film was observed on the deli slicer blade surface. OSM #11 observed the deli slicer and the blade and stated that it was not cleaned properly and would have to be taken…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow infection control practices for the administration of medication for one of 6 residents in the Medication Administration task; Resident #23. The findings include: Resident #23 was admitted on [DATE] and had the diagnosis of but not limited to dysphagia, stroke, dementia, chronic obstructive pulmonary disease, bilateral above knee amputations, depression, aphasia, and high blood pressure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 10/21/21. The resident was coded as being severely cognitively impaired in ability to make daily life decisions. On 1/12/22 at 8:59 AM, LPN #3 (Licensed Practical Nurse) was observed during the Medication Administration task for Resident #23. She was observed sanitizing her hands and putting clean gloves on. Then she proceeded to touch the medication cart on the top and…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to evidence mandatory CNA (certified nursing assistant) annual education in dementia training and abuse prevention training for three of five CNA records reviewed, CNA #4, CNA #5, and CNA #6. The findings include: During the sufficient and competent staffing facility task, CNA (certified nursing assistant) education for dementia and abuse prevention were not evidenced in the previous twelve months. Per CMS it is not waiving the requirements for 42CFR483.35[c], which requires facilities to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. CNA #4's employee record documented they were hired as a CNA with the facility on 10/1/20. CNA #4's education records failed to evidence either in-service training or on line training in dementia and abuse prevention. CNA #5's employee record documented they were hired as a CNA with the facility…

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