Forest Hill Health & Rehabilitation

Based on resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to allow resident to manage financial affairs for 1 of 38 residents (Resident #135), in the survey sample. The findings included: Resident #135 was originally admitted to the facility 9/10/24. The current diagnoses included Non-ST-elevation Myocardial Infarction, muscle weakness, type 2 diabetes mellitus with hyperglycemia, and essential hypertension. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/17/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #135's cognitive abilities for daily decision making were intact. An interview was conducted on 5/21/25 at 1:45 PM with Resident #135. Resident #135 stated, the facility is trying to kick me out because I owe them money. Resident #135 also stated, a payment plan has been set up with the Business Office Manager but they are still trying to make me leave the facility. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure two (2) of 63 residents (Resident #39 and Resident #46) in the survey sample were given the opportunity to formulate an advance directive. The findings included; 1. The facility staff failed to ensure Resident #39 had an opportunity to develop an advanced directive. Resident #39 was originally admitted to the facility 11/09/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Depression, Unspecified. The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #39 cognitive abilities for daily decision making were moderately impaired. In sectionGG(Functional Abilities Goals) the resident was coded as requiring partial/moderate assistance with eating, oral hygiene. Resident coded as…

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

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to complete an Advanced Beneficiary Notice (ABN) for two (2) Residents, (Residents #192 and #37) in the four (4) sampled residents. The findings included: Residents #192, and #37 were chosen from a list of residents discharged in the previous 6 months. On 2-3-25 at 9:00 AM, the Business Office Manager was asked for a copy of the Advance Beneficiary Notice for 4 Residents. The Director of Nursing (DON) presented 4 forms that she stated were the ABNs. The forms revealed two (2) of the four (4) sampled Residents received Form CMS-10123 NOMNC (Notice of Medicare Non-Coverage) which were signed by the resident or the authorized representative, and included the estimated date of non-coverage, and appeal information. The other two (2) of the four (4) sampled Residents (Resident #192, and #37) received form CMS-R-131 forms which revealed no date when insurance coverage would end, did not specify a cost for the Resident should they elect to pay for continued services, and did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure personal privacy was afforded to three (3) residents (Residents # 123, #2, and # 46) in a survey sample of 63 residents. 1. For Resident # 123, the facility staff failed to provide a curtain to pull around the bed while providing ADL (Activities of Daily Living) Care. Resident # 123 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: Dementia with Agitation, Diabetes, Hypertension, and Legal blindness. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/7/2025. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 13 out of 15, indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. On 1/29/2025 at approximate 10:40 a.m., a Certified Nursing Assistant was observed providing care to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff discouraged one Resident from communication with external local entities/police during an abuse allegation, and did not allow evidence from a police report of the abuse situation for 2 Residents (Residents #131, and #130) in a survey sample size of 63 residents. The findings included: The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130, without police protection. Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey. Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to protect one Resident from abuse by a room mate with known illicit drug and alcohol abuse in their shared room for 1 Resident (Residents #131) in a survey sample size of 63 residents. The findings included: Resident #131 was exposed to, and not protected from alleged sexual harassment and abuse, and facility known illicit drug and alcohol abuse in their shared room by his room mate (Resident #130). Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey. Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as 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 interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to implement their abuse policies to protect Residents, report abuse timely, investigate fully, and allow a police report of the abuse for 4 Residents (Residents #130, #131, #7, and #39) in a survey sample size of 63 residents. The findings included: 1. The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130. Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey. Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to report an allegation of abuse to the state agency, police, and other stake holders timely for 4 Residents (Residents #131, #130, #7, and #39) in a survey sample size of 63 residents. The findings included: 1. The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130. Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey. Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to investigate an allegation of abuse fully for 2 Residents (Residents #131, and #130) in a survey sample size of 63 residents. The findings included: 1. The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130. Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey. Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident record review, staff interviews and a review of facility documents, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 1 of 63 residents (Resident #50), in the survey sample. The findings included: Resident #50 was originally admitted to the facility 10/27/2016 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included a stroke with right hemiparesis and expressive aphasia. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/22/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were moderately impaired. A nurses' note dated 11/10/24 at 3:36 AM stated the resident was observed with a large amount of dark bloody liquid coming from his rectum and the resident complained of lower abdominal pain that radiated to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 63 residents in the survey sample (Resident # 139), a closed record resident. The findings include: Resident #139 was originally admitted to the facility 11/27/24 after an acute care hospital stay. The resident had an unplanned discharged from the facility on 12/01/24. The current diagnoses included; Chronic Pain Syndrome and Unspecified Fracture of the Lower end of Left Radius, Subsequent Encounter for Closed Fracture with Routine Healing. The 5-day, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/01/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #139 cognitive abilities for daily decision making were intact. Resident # 139's MDS dated [DATE] coded the resident as being admitted to the hospital instead of coding that resident was discharged to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 4 Residents (Residents #3, #32, #59, and #132) in a sample of 63 residents. The Findings included: 1. Resident #3 was admitted on [DATE] with diagnoses including: Bipolar Disorder, Anxiety, and Dementia. Physicians orders for medications were reviewed and revealed psychotropic medications actively being administered for those diagnoses. On 1-30-25, an observation was conducted of Resident #3. The Resident was sitting in her room in a wheel chair and talked with the surveyor who had entered the room and addressed her in a greeting, while attempting conversation and interview. The Resident was also talking to herself with questions and answers to an apparent inner monolog with herself. On 1-30-25 a review of Resident #3's clinical record was conducted. No previous to Long Term Care Skilled Nursing (after acute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to follow the professional standards of quality regarding treatments for one (1) resident (Resident # 24) in survey sample of 63 residents. The findings included: The facility staff failed to implement medication policy to ensure that Resident #24 had all of his medications on hand as ordered by the physician, and further failed to administer the medications and treatments as ordered by the physician. Resident #24 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paranoid schizophrenia, diabetes, chronic kidney disease, mild intellectual disabilities, hypertension, hypothyroidism, bipolar disorder, major depressive disorder, severe with psychotic features, and anxiety. A review of the clinical record revealed that Resident #24 had orders that included: [NAME] Moisture Barrier Cream (Skin Protectants, Misc.) Apply to Sacrum, buttocks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review and clinical record review, the facility staff failed to ensure proper Activities of Daily Living services were provided for three (3) residents (Residents #123, #83 and #24) in a survey sample of 63 residents. The findings included: 1. For Resident # 123, the facility staff failed to provide lotion after bathing. Resident #123 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: Dementia with Agitation, Diabetes, Hypertension, and Legal blindness. The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 9/10/2024. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. Resident #123 complained about not getting lotion on her body. She stated some facility staff members told her it 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 observation, interview clinical record review and facility documentation the facility staff failed to ensure Residents receive treatment and assistive devices to maintain vision for 1 Resident in a survey sample of 38 Residents. The findings included: For Resident #125 the facility staff failed to ensure the Resident received vision services for a resident with a diagnosis of glaucoma. Resident #125 was admitted to the facility on [DATE] with diagnoses that included but we're not limited to UTI, kidney stones, protein calorie malnutrition, asthma, epilepsy, repeated falls, COPD, chronic renal failure, colostomy, major depressive disorder, DVT, muscle weakness, traumatic brain injury, acute angle - closure, glaucoma, dysphasia, and hypertension. Resident #125 is wheelchair, bound and requires assistance with all aspects of care except for eating. His most recent BIMS (Brief Interview of Mental Status) scored the resident at 15 out of 15 indicating no cognitive impairment. On 5/21/25 at 11:00 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review and clinical record review, the facility failed to prevent, assess, identify and treat an avoidable pressure ulcer for one Resident (Resident #63) in a survey sample of 63 Residents. The findings included: Resident #63 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to Alzheimer's, muscle weakness, difficulty walking, vitamin deficiency, cognitive communication deficit, chronic kidney disease, anxiety, and repeated falls. Resident #63's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 12/7/2024 was a quarterly assessment. The MDS coded Resident #63 with a BIMS (Brief Interview for Mental Status) score of 00 out of 15 possible points, indicating severe cognitive impairment. The MDS coded Resident #63 as dependent with Activities of Daily Living (ADL's), dependent or 2 persons assist for all function abilities and frequently incontinent for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review and facility documentation review, the facility staff failed to ensure proper foot care was provided to one (1) resident (Resident # 83) in a survey sample of 63 residents. For Resident # 83, the facility staff failed to ensure proper nail care was provided. Resident # 83 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease, Diabetes, Acute Respiratory Failure and Congestive Heart Failure. The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 11/3/2024. Resident # 83's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident # 83 required assistance with Activities of Daily Living. During the initial tour of the facility on 1/28/2025 at 1:30 p.m., Resident # 83 was observed lying in bed. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and resident record review, the facility staff failed to provide incontinence care for one (1) of 63 residents (Resident #21), in the survey sample. The findings included: Resident #21 was originally admitted to the facility 05/27/2022 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included high blood pressure and bilateral lower extremity swelling. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/31/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section H0300 the resident was coded as occasionally incontinent of urine. On 1/28/25 at approximately 4:07 PM, Resident #21 was observed in his room with a puddle of urine beneath his wheel chair and his pants were saturated. The resident propelled the wheel chair out in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents did not sustain significant unplanned weight loss for one (1) Resident (# 109) in a survey sample of 63 residents. The findings included: For Resident #109 the facility staff failed to ensure the Resident's food preferences were addressed and failed to act on a significant unplanned weight loss of 13.25% in 6 mos. On 1/28/25 at approximately 12:45 p.m., an interview was conducted with Resident #109 who stated the food was not good at the facility. When asked to elaborate the Resident complained that a lot of times the food was burnt or overcooked. The Resident stated that they did not have any seasoning in the food and it was bland. He stated that he has lost weight since being at the facility and it was not intential weight loss. When asked if he had seen the Registered Dietician, he stated that he had not. When asked if anyone had contacted him 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 documentation review, the facility staff failed to provide routine medications to two (2) Residents (Residents #24, and #2) in a survey sample of 63 Residents. The findings included: 1. For Resident #24 the facility staff failed to ensure that the resident received the medications and treatments as ordered by the physician. Resident #24 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paranoid schizophrenia, diabetes, chronic kidney disease, mild intellectual disabilities, hypertension, hypothyroidism, bipolar disorder, major depressive disorder, severe with psychotic features, and anxiety. A review of the clinical record revealed that Resident #24 had orders that included: [NAME] Moisture Barrier Cream (Skin Protectants, Misc.) Apply to Sacrum, buttocks topically every day and evening shift for protection/prevention -Start Date- 09/29/2020 0700 -Hold Date from 01/27/2025 to 01/30/2025 Cerave…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure Residents were free from significant medication errors for two (2) Residents (Residents #24, and #139) in a survey sample of 63 Residents. The findings included: 1. For Resident #24 the facility staff failed to ensure that the Resident received the medications and treatments as ordered by the physician. Resident #24 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paranoid schizophrenia, diabetes, chronic kidney disease, mild intellectual disabilities, hypertension, hypothyroidism, bipolar disorder, major depressive disorder, severe with psychotic features, and anxiety. A review of the clinical record revealed that Resident #24 had orders that included: Lisinopril Oral Tablet 20 MG - Give 1 tablet by mouth at bedtime related to essential (primary) hypertension -Start Date- 12/30/2024 Levothyroxine 25 mcg give 1 tablet by mouth in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to reflect resident's cultural and ethnic needs of the resident by not providing meal preferences for one (1) of 63 residents (Resident #36), in the survey sample. The findings included: Resident #36 was originally admitted to the facility on [DATE]. The resident has never been discharged from the facility. The current diagnoses included; Magnesium and Vitamin D Deficiency. The Annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/21/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated Resident #36 cognitive abilities for daily decision making were moderately impaired. On 1/30/25 at approximately 12:00 PM., an interview was conducted with Resident #36. Resident #36 was asked if she had concerns with the food. The resident mentioned that she was from Ghana 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, clinical record review, and review of facility documents, the facility's staff failed to ensure that a resident's lunch was palatable and attractive for one (1) of 63 residents (Resident #129), in the survey sample. The findings included: Resident #129 was originally admitted to the facility 8/20/24. The resident has never been discharged from the facility. The current diagnoses included; Unspecified Protein Calorie Malnutrition. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/23/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #129 cognitive abilities for daily decision making were intact. The care plan dated on 1/16/25 read that Resident #129 was at risk for weight loss, malnutrition or poor hydration status related to chronic disease. The goal for Resident #129 was for the resident to have optimal nutrition and hydration status. The intervention for Resident #129 was to record the…

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

Based on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the facility maintained a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases and infections for the facility in general, and for two (2) residents (Residents #3, and #130) in a survey sample of 63 residents The findings included: 1. On 1-28-25 during resident room observations, the room of Resident #3 was noted to have a sticky, tape style insect trap, hanging from the ceiling in the bathroom. The 2 inch wide by 24 inch long tape was so covered in insects that it had the appearance of fur covering it. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. Resident #3 stated yes, they have pest control bug people come and spray, however, she stated they only spray the halls, not the rooms, because they don't want to move things around in the room. During the entire survey there were fruit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility staff failed to ensure rooms had visual privacy for five (5) Residents (Residents # 123, # 2, # 128, # 132 and #46 ) in a survey sample of 63 residents. Findings included: 1. For Resident # 123, the facility staff failed to ensure the room was equipped with curtains that would extend around the bed. Resident # 123 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: Dementia with Agitation, Diabetes, Hypertension, and Legal blindness. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/7/2025. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 13 out of 15, indicating no cognitive impairment. Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025. On 1/29/2025 at 10:20 a.m., the surveyor observed a Certified Nursing Assistant providing ADL (Activities of Daily Living) care to Resident # 123. There…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review and clinical record review, the facility staff failed to follow standards of practice affecting one resident (Resident #1) in a survey sample of 16 residents. The findings included: For Resident # 1, the facility staff refused to provide education and resources to the resident who was discharging against medical advice. They failed to serve as an advocate for the resident. They failed to show practice the tenets of nursing . Resident # 1 was admitted to the facility on with diagnoses that included but were not limited to: Chronic Embolism and Thrombosis of the left femoral vein, , Acute Kidney Failure, Pressure Ulcer, Nontraumatic hematoma of soft tissue, Acute Embolism and Thrombosis of deep veins of lower extremity,Bipolar Disorder, History of falling, Acute Posthemorrhagic Anemia,Schizoaffective Disorder, Contracture of Muscle, Unspecified site. The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation the facility failed to ensure the Resident's right to right to choose a roommate when practicable, and the right to receive written notice, including the reason for the change, before the resident's room or roommate is changed, for 1 Residents (# 5) in a survey sample of 16 Residents. The findings included: 1. For Resident #5 the facility staff failed to notify the Resident prior to changing rooms. On 3/27/24 a review of the clinical record revealed that Resident #5 was admitted into room [ROOM NUMBER] and subsequently moved to room [ROOM NUMBER] however no documentation was found to support Resident or RP notification of room change. On 3/28/24 at approximately 9:00 AM an interview was conducted with the Social Worker who was asked about the process for changing a Resident's room. The Social Worker explained that if a Resident requested a room change or get a different room mate the Social Worker would intervene to ensure that there are 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 staff interview and facility documentation review, the facility staff failed to allow visitation for one resident (Resident # 1) in survey sample of 16 residents. Findings included: For Resident # 1, the facility staff failed to allow visitation during a COVID outbreak in August 2023. Resident # 1 was admitted to the facility on with diagnoses that included but were not limited to: Chronic Embolism and Thrombosis of the left femoral vein, , Acute Kidney Failure, Pressure Ulcer, Nontraumatic hematoma of soft tissue, Acute Embolism and Thrombosis of deep veins of lower extremity,Bipolar Disorder, History of falling, Acute Posthemorrhagic Anemia,Schizoaffective Disorder, Contracture of Muscle, Unspecified site. The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 7/1/2023. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) score of 4 (of a possible 15 points) which indicated severe cognitive impairment. Resident # 1 required assistance with ADLs (activities of daily living.) During 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 interview, clinical record review and facility documentation the facility staff failed to allow the Resident Representative access to the clinical record in a timely manner for two Residents ( Resident #7 & #1) in a survey sample of 16 Residents. The findings included: 1. For Resident #7 the facility staff failed to provide Medical Records to the POA (Power of Attorney) in a timely manner. On 3/28/24 at approximately 2PM an interview was conducted with the Administrator who was asked about Resident #7's family requesting medical records. She indicated she would look into the matter and get back with the survey team. On 3/28/24 at approximately 5 PM the Administrator admitted there was a delay in getting the medical records to the Resident #7's family. The Administrator stated that the person requesting the records (Resident #7's mother) was not the power of attorney. The Administrator stated that the girlfriend / significant other was the power of attorney on record. When surveyor mentioned the name of the Resident's power of attorney the Administrator stated, That is not…

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

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure the Residents right to a safe clean comfortable and homelike environment for residents on three of four units inhabited by facility residents. The findings included: 1. For Resident # 6 the facility staff has failed to maintain the Resident room in a clean and sanitary manner. Observations: On 3/26/24 during the initial tour of the building offensive odors were noticed on Unit 1 patient care area as well as in the hallways. The Resident rooms were cluttered and unkempt, there were visible stains on the tile floor in Resident rooms and common areas as well. Several rooms had fruit flies in them, Residents had open food and snacks at their bedside. On 3/27/24 at approximately 2PM observations were made of Resident #6's room and the room was cluttered there were visible stains on the floor there was debris (dust and dirt) in the corners of the room, there were fruit flies noted on the privacy curtain. The room smelled of urine. On 3/27/24 at approximately 11:45 AM an…

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

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure a safe and orderly discharge for one resident (Resident # 1) in a survey sample of 16 residents. Findings included: For Resident # 1. the facility staff failed to provide any assistance with discharge instructions when the resident was discharged (AMA) against medical advice. Resident # 1 was admitted to the facility on with diagnoses that included but were not limited to: Chronic Embolism and Thrombosis of the left femoral vein, , Acute Kidney Failure, Pressure Ulcer, Nontraumatic hematoma of soft tissue, Acute Embolism and Thrombosis of deep veins of lower extremity,Bipolar Disorder, History of falling, Acute Posthemorrhagic Anemia,Schizoaffective Disorder, Contracture of Muscle, Unspecified site. The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 7/1/2023. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) score of 4 (of a possible 15 points) which indicated severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement a comprehensive care plan for pressure ulcers for three Residents (Residents #10, #12 & #1) in a survey sample of 16 Residents. The findings included: 1. For Resident #10, the facility staff failed to implement a care plan for a sacral pressure wound. Resident #10 was admitted to the facility on [DATE] with diagnoses including; Diabetes, pulmonary embolism, stroke, aphasia, hypertension, contractures, syphilis, congestive obstructive pulmonary disorder (COPD), encephalopathy, carbon monoxide poisoning, and viral hepatitis C. Resident #10's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 11-27-23 was a quarterly assessment. The MDS coded Resident #10 as needing extensive to total staff assistance with toileting, hygiene, and bathing. The Resident was also coded as unable to complete a brief interview for mental status (BIMS), indicating significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation the facility staff failed to review and revise the care plan for 1 Resident (#5) in a survey sample of 16 Residents. The findings included: For Resident #5, the facility staff failed to review and revise the care plan and add interventions after each fall the Resident had. On 3/27/24 a review of the clinical record revealed that Resident #5 had 10 falls from the time of admission on [DATE] until her discharge on [DATE]. The dates of the falls are as follows: 7/21/22, 12/18/22, 1/7/23 (this fall happened while at the dialysis center), 1/16/23, 2/14/23, 4/16/23, 5/5/23, 5/10/23, 6/25/23, and 7/1/23. A review of the care plan read as follows: FOCUS - The Resident is at risk for falls r/t [related to] PVD [peripheral vascular disease], age related osteoporosis, cerebral infarction, - date initiated - 8/5/22. GOAL - Minimize the risk of falls through the next review date - date initiated 8/5/22. INTERVENTIONS: Anticipate and meet the resident'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 documentation review and clinical record review, the facility staff failed to implement an effective discharge plan for one resident in a survey sample of 16 residents. The findings include: For Resident # 1, the facility staff failed to ensure the discharge needs were identified and implemented. Resident # 1 was admitted to the facility on with diagnoses that included but were not limited to: Chronic Embolism and Thrombosis of the left femoral vein, , Acute Kidney Failure, Pressure Ulcer, Nontraumatic hematoma of soft tissue, Acute Embolism and Thrombosis of deep veins of lower extremity,Bipolar Disorder, History of falling, Acute Posthemorrhagic Anemia,Schizoaffective Disorder, Contracture of Muscle, Unspecified site. The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 7/1/2023. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) score of 4 (of a possible 15 points) which indicated severe cognitive impairment. Resident # 1 required assistance with ADLs…

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

Based on interview, clinical record review and facility documentation the facility staff failed to ensure that each resident receives care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 resident in a survey sample of 16 Residents. The findings included: For Resident #6, the facility staff failed to speak with the Resident in a manner that preserved dignity and respect. On 3/27/24 at approximately 3PM an interview was conducted with Resident #6 who stated that she felt that staff were uncaring. She stated that she felt that some staff were rude to Residents without provocation. When asked if she knew of any specific staff members, she declined to give names. She stated, You know I ' m not the only one who has seen this. It has been brought up at Resident Council and the supervisors are aware of it. I am trying to get transferred out of here to [facility name redacted]. A review of the Resident council minutes for the preceding 6 months revealed the following: 12/27/23 - Nursing - DON present - Resident Concern /…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure incontinence hygiene care was provided timely for 2 residents (Resident #10 & # 3) of 16 residents in the survey sample. The findings included: 1. For Resident #10 the facility staff did not provide incontinence hygiene care timely. Resident #10 was admitted to the facility on [DATE] with diagnoses including; Diabetes, pulmonary embolism, stroke, aphasia, hypertension, contractures, syphilis, congestive obstructive pulmonary disorder (COPD), encephalopathy, carbon monoxide poisoning, and viral hepatitis C. Resident #10's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 11-27-23 was a quarterly assessment. The MDS coded Resident #10 as needing extensive to total staff assistance with toileting, hygiene, and bathing. The Resident was also coded as unable to complete a brief interview for mental status (BIMS), indicating significant cognitive impairment. 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 family interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide treatment and services for pressure sores for three Residents (Residents #10, 12, & #8) in a survey sample of 16 Residents. The findings included: 1. For Resident #10, the facility staff failed to give incontinence hygiene care timely, failed to assess, describe and document a sacral pressure wound, and further failed to provide a care plan for the sacral pressure wound. Resident #10 was admitted to the facility on [DATE] with diagnoses including; Diabetes, pulmonary embolism, stroke, aphasia, hypertension, contractures, syphilis, congestive obstructive pulmonary disorder (COPD), encephalopathy, carbon monoxide poisoning, and viral hepatitis C. Resident #10's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 11-27-23 was a quarterly assessment. The MDS coded Resident #10 as needing extensive to total staff assistance with toileting, hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Ombudsman interview, clinical record review, and facility documentation review, the facility staff failed to provide necessary dialysis services and transportation for 1 Resident (Resident's #12) in a survey sample of 16 residents. The findings included: For Resident #12, the facility staff failed to provide timely transportation to receive dialysis treatment from 5-18-23 until 5-23-23 (5 days). Resident #12 was initially admitted to the facility on [DATE]. The most recent readmission was on 2-14-22 after a hospital stay. Diagnoses included; Diabetes, hypertension, stroke, end stage renal disease with dialysis, seizure, atrial fibrillation, anemia, sarcopenia, peripheral vascular disease, and obstructive sleep apnea with refusal to wear C-pap. The Resident's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4-3-23 was coded as a quarterly assessment. Resident #12 was coded as cognitively intact with a Brief Interview for Mental Status (BIMS) score…

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

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure that food is palatable and served at an appetizing temperature for all Residents receiving meals from the kitchen. The findings included: 1. For all Residents receiving meals from the kitchen, the dietary staff failed to ensure food was consistently served in a manner that maintained appropriate temp for that food item (hot items served hot and cold items served cold). On 3/27/24 at approximately 12:20 PM an interview was conducted with Resident #6 who stated that she complained many times about the food since her admission. She stated, It's getting better now that the elevator is fixed. When asked what the elevator has to do with the food being cold, she said, Well the kitchen is in the basement, and they have to bring the trays up to the 2 floors. The elevator was broken for months and now its fixed but sometimes we still have a problem if they don't use the hot plates in the trays. Although a test tray was done during the survey and this issue was not found…

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

Based on interview, clinical record review and facility documentation the facility staff failed to maintain clinical records that were accurate for 1 Resident (#7) in a survey sample of 16 Residents. The findings included: For Resident #7 the facility staff failed to ensure that code status, and Power of Attorney information was consistently and accurately maintained in the clinical record. On 3/26/24 a review of the clinical record revealed that Resident #7 had orders for Full Code, dated since admission. Further review of records revealed that in Physician Progress Notes, Resident #7 was referred to as DNR (Do Not Resuscitate). 12/17/23 - 7:09 PM Resident declined additional episodes of hemodialysis. Advanced directive was discussed, and resident is a full code. The clinical record contained an order for Resident #7 that stated, FULL CODE, however, the physician's notes dated 12/13, 12/14, 12/18, 12/20 & 12/23 refer to the Resident as being DNR On 3/28/24 an interview was conducted with the DON and Administrator who were asked if they were aware of the conflicting documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and facility documentation the facility staff failed to ensure a safe and functional environment for all residents who reside in room [ROOM NUMBER], reside on Wing 2, utilize the Sunroom, or receive meals from the dietary staff. The findings included: On 3/26/24 a review of the maintenance logs was conducted. The following are excerpts from the maintenance logs. Created 1/2/24 at 9:19 AM - NO HEAT - Resident Room wing 2 Updated 1/3/24 10:40 AM Completed. Created 1/4/24 at 12:49 PM - Power is out in [NAME] River Sunroom - Updated 1/4/24 1:30 PM - Completed. Created 1/5/24 a -t 2:48 PM - Power is Out in [NAME] River Sunroom. Updated 1/11/24 at 10:27 AM Completed (Please note no power for 6 days) Radiator Heat Common Area 300 - 2/6/24- Created 1:15 PM Updated 3:03 PM - Messed with valves at the end of the hall to give more air to memory care unit, messing with the one 1/3 to give more heat as well. Created 2/19/24 at 8:05 AM- room [ROOM NUMBER] C Heating unit - Residents…

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

Based on observation, resident interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation the facility was not administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This has the potential to affect all residents. The Directors and Officers of the facility's parent company knew of the absence of leadership in the facility, as the Regional Administrator had been tasked with assisting in the capacity of Administrator for 2 buildings and they did not act to allocate effective full time leadership to the facility. The findings included; On 7-5-22 Staffing schedules were requested for the week, and were reviewed each day. A tour of the entire building to ascertain all staff currently providing care to the Residents and working during the shift was conducted on 7-5-22. The census on this day was 143 Residents. There was no Administrator, no Infection Preventionist (IP), nor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in the course of a complaint investigation, the facility failed to ensure employment of a qualified Social worker on a full time basis. This has the potential to affect all residents. This is Substandard Quality of Care. The Facility failed to provide a full time Social worker for the second week of survey, and planned to use another facility's Social worker to help out 2-3 days per week. The Findings included: The Social Worker was interviewed on 7-5-22, and stated it was her last week to work, as she was working out her notice, and that she had resigned her position with the facility. On 7-7-22 an interview was requested with the Social Worker. Employee Q stated that the Social worker was as of yesterday no longer employed by the facility. When surveyors asked why the termination and early departure as the Social Worker had self scheduled for 2 more days, no answer was given. On 7-12-22 The social worker (Employee T) from a sister facility, which had greater than 120 beds, was present during survey, and upon…

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

Based on observation, staff interviews, facility documentation review, and clinical record review, the facility staff failed to maintain an infection prevention and control program for the prevention, identifying, reporting, and investigating infections. The findings included: 1. The facility staff failed to maintain an infection prevention and control program to include infection surveillance, infection investigation and system to prevent the development and transmission of communicable diseases within the facility. On 7/12/22 at 8:09 AM, the facility administration was asked to provide the survey team with evidence of infection surveillance logs/line listing (for COVID and non-COVID infections) Jan-July 2022. On 7/12/22 at approximately 11 AM, a video call was conducted with the facility interim Infection Preventionist (IP)/Employee N, who was also the Corporate Clinical Consultant. During this video call the IP was asked to show evidence of the infection line listing and she said, I'm having difficulty finding it. When asked about their COVID infections and recent outbreaks,…

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

Based on staff interviews and facility documentation review, the facility staff failed to have a designated individual to serve as the Infection Preventionist (IP) which has the potential to affect all 143 Residents residing in the facility. The findings included: On 7/5/2022, the Regional Administrator reported to the survey team that the Infection Preventionist for the facility had quit. He (the Regional Administrator) said they were going to get the Corporate Clinical Consultant (nurse consultant) to fill in, but she was on vacation that week. On 7/11/22, the facility's interim Administrator and Regional Administrator stated that Employee N/Corporate Clinical Consultant is serving as the facilities interim Infection Preventionist. On 7/12/22 at 10:10 AM, an interview was conducted with Employee N/the Corporate Clinical Consultant/interim Infection Preventionist. Employee N stated, This was not one of my assigned buildings, I just took it over the first of June. [Previous Infection Preventionist name redacted] was here then, she left about 3 weeks ago. The Assistant Director 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 facility documentation review, the facility staff failed to notify Residents and families when new cases of COVID-19 were identified in the facility, affecting all 143 Residents residing in the facility. The findings included: On 7/12/22 at 8:09 A.M., a request for Evidence of Resident and family notifications of COVID cases and the weekly communication for May, June and July was made. On 7/12/22 at 10:40 AM, the facility provided the survey team with evidence of automated calls being made to Resident's families on 6/10/22, for notification of a COVID case identified on 6/9/22. On 7/12/22 at approximately 11 AM, during a video call with the Corporate Clinical Consultant/Interim Infection Preventionist (IP). The IP identified that on 5/30, 6/6, 6/13, and 6/20 the facility was in outbreak. She also stated that on 7/4/22, a Resident tested positive for COVID-19, which placed the facility back into an outbreak status. On 7/13/22, the facility staff provided an infection surveillance log with the last entry being 5/20/22, where a staff member tested positive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, and staff interview, the facility staff failed to provide a clean, comfortable, and homelike environment for Residents on one unit (the 400 unit) out of 4 units. Specifically, observations of the 400 unit shower room and Resident rooms included the following: 1) The shower room had no hot water from 2 out of 3 shower heads 2) One shower head was detached from the hose and inoperable so the water temperature could not even be tested. 3) The shower room sink had a leaky faucet and there were rust stains in the sink basin. 4) There were rust spots on the floor in various places in the shower room and black spots on the floor in one of the shower stalls. 5) There was a dry, white, crusty substance covering the entire base plate of the shower handle in one of the three shower stalls. 6) For Resident #50, the paper towel dispenser in the bathroom was on the bathroom floor 7) For Resident #111 and in Resident room [ROOM NUMBER], the floors were sticky to walk upon, stained,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, and clinical record review, the facility staff failed to review and revise care plans for 6 Residents (Resident #127, 93, 4, 49, 75, and 34) in a survey sample of 48 Residents. The findings included: 1. For Resident #127 the facility staff failed to revise the care plan to include an unstageable wound (a wound where the wound bed is not able to be visualized and therefore the extent of the wound cannot be determined) that required debridement. On 7/11/22 and 7/12/22, a clinical record review was conducted. This review revealed that on 6/30/22, the nurse practitioner ordered for a wound consult and would culture. On 7/8/2022, Resident #127 was seen by a wound specialist and a surgical debridement procedure was performed at the bedside on the unstageable sacral wound. Review of the care plan for Resident #127 revealed that the sacral wound had not been addressed on the care plan. 2. For Resident #93, the facility staff failed to review and revise the nutritional care plan to capture an 82 lb. weight gain. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility documentation review and clinical record review, the facility staff failed to follow the nursing standards of practice, for two Residents (Resident #106 & #127) in a survey sample of 48 Residents. The findings included: 1. For Resident #106, the facility staff failed to follow physician orders and obtain weekly weights as ordered by the physician. On 7/11/22 and 7/12/22, a clinical record review was conducted of Resident #106's clinical chart. This review revealed an active physician orders which read, Weekly weights with an effective date of 2/16/2021. Review of Resident #106's weights revealed a weight had not been obtained since 4/29/22. On 7/13/22 at 11:04 AM, an interview was conducted with the Nurse Practitioner (NP)/Employee R. The NP was asked what her expectations are when she writes or gives an order regarding a Resident. The NP said, To execute it as soon as possible or as soon as available, at least within 24 hours. When asked what is the importance of monitoring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the resident's needs safely, timely, and in a manner that promotes each residents rights, physical, mental, and psychosocial well being. The Findings included: On 7-5-22 Staffing schedules were requested for the week, and were reviewed each day. A tour of the entire building to ascertain all staff currently providing care to the Residents and working during the shift was conducted on 7-5-22. The census on this day was 143 Residents. There was no Infection Preventionist (IP), nor Director of Nursing (DON), and no MDS (Minimum Data Set)/care plan Coordinator present. Nursing staff were interviewed during initial tour and asked who the Administrator, DON, IP, and MDS Coordinators were for the building. All answered that none of those positions were filled and that Employee Q was the only one they had seen, and that had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure a Registered Nurse (RN) Director of Nursing (DON) was present and overseeing resident care, and staff competencies on a full time basis. The Findings included: On 7-5-22 Staffing schedules were requested for the week, and were reviewed each day. A tour of the entire building to ascertain all staff currently providing care to the Residents and working during the shift was conducted on 7-5-22. The census on this day was 143 Residents. There was no Director of Nursing (DON) present. Nursing staff were interviewed during initial tour and asked who the Administrator, DON, IP, and MDS Coordinators were for the building. All answered that none of those positions were filled and that Employee Q was the only one they had seen, and that had been seldom as he only came a couple times per week because his facility and home were hours away from this facility. There was an Assistant Director of Nursing…

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

Based on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure competent nursing staff to provide nursing and related services to meet the resident's needs for 4 of five record reviews. The Facility failed to provide performance competency reviews to ensuring skilled and competently trained staff, able to provide for Resident care needs. The Findings included: On 7-5-22 Staffing schedules were requested for the week, and were reviewed each day. A tour of the entire building to ascertain all staff currently providing care to the Residents and working during the shift was conducted on 7-5-22. The census on this day was 143 Residents. There was no Administrator, no Infection Preventionist (IP), nor Director of Nursing (DON), and no MDS (Minimum Data Set)/care plan Coordinator present. Staff members (2 LPN's, and all 3 CNA's) were asked during initial tour if they had received training and had annual competencies evaluated. All responded they could not…

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

Based on observation, and interview the facility failed to properly store drugs on two medication carts in a sample of four medication carts. The findings included: On 7/13/22 at approximately 11:04 a.m. while conducting a review of medication cart(S) observed the following: 1. On Unit 1 the medication cart was reviewed with LPN F. The following medications routes were commingled in the up left corner pocket of drawer one: topical patches (catapres), transdermal (rivastigmine), suppositories (bisacodyl), oral medications (alendronate). LPN F acknowledged that medications of various route are to be stored with dividers separating each medication route. However, the aforementioned medications were not stored in such a manner. 2. On Unit 2 the medication cart was reviewed with RN D. The following medication route were commingled: injectable (single dose of medroxyprogesterone syringe with needle), multi-dose vial (medroxyprogesterone), and oral medications (aspirin, Motrin). RN D acknowledged that medications of various route are to be stored with dividers separating each medication…

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

Based on observation, interview, facility record review and in the course of a complaint investigation, the facility staff failed to employ sufficient staff to carry out the functions of the food and nutrition services for the facility as a whole. The findings included: For the facility, on 6/21/22 the facility staff failed to ensure the proper number of staff including a cook as well as dietary aids to prepare and serve dinner. On 7/5/22 at approximately 1:00 PM the Social Worker was interviewed and she stated that she was aware of the incident involving having to order pizza for Residents. She stated that she was present at the time. She stated that the Acting Administrator was called in and he called a sister facility to get a kitchen staff member to prepare the puree foods and he then ordered pizza for the Residents who could eat regular consistency. On 7/7/22 at approximately 9:00 AM an interview was conducted with Resident # 34 who stated Oh yeah last month we had pizza from a restaurant because they didn't have enough staff to cook. On 7/7/22 at approximately 9:15 AM an…

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

Based on staff interview and facility documentation review, the facility staff failed to maintain an ongoing antibiotic stewardship program to monitor the use of antibiotics which had the ability to impact numerous Residents throughout the facility on all nursing units/resident care units. The findings included: On 7/12/22 at 8:09 AM, a request was made for the facility administration to provide the survey team with, the Antibiotic surveillance tracking from Jan-July, 2022. On 7/12/22 at approximately 11 AM, a video call was conducted with the facility interim Infection Preventionist (IP)/Employee N, who was also the Corporate Clinical Consultant. The IP stated, I have gone through the binders and can't find antibiotic surveillance, I will keep looking for it. The IP was asked to provide the infection line listing, which was noted in the facility policy. The IP again said, I'm having difficulty finding it. On 7/12/22 at 4:20 PM, another video call was held with the IP. She stated, I did locate the binder and they did not do antibiotic surveillance/infection investigations for June,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 3 Resident (Resident #121, 23, 140), in a sample of 5 Residents reviewed for immunizations. The findings included: On 7/11/22 and 7/12/22, clinical record reviews were conducted for the sampled Residents with regards to immunization for flu and pneumonia. This review revealed the following: 1. Resident #121 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) it read, No immunizations found. Review of the misc. (miscellaneous) tab, assessment tab, and progress notes revealed no evidence of vaccine administration or offering of such. There was a document scanned into the EHR on the misc. tab that was titled, COVID vaccines no record. This document was reviewed and contained immunization…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 4 Residents (Residents #46, #23, #92, and #83) in a sample of 5 Residents reviewed for testing and for 9 staff (Employee K, CNA J, RN C, LPN C, Employee C, Employee L, CNA K, LPN E, and Employee M) in a sample of 9 employees reviewed for COVID testing. The findings included: 1. For Residents #46, #23, and #92, the facility staff failed to conduct COVID-19 testing upon their admission to the facility. On 7/11/22 and 7/12/22, a clinical record review was conducted and revealed the following: 1a. Resident #46 was readmitted to the facility on [DATE]. Resident #46 was not tested for COVID until 5/9/22. 1b. Resident #23 had been readmitted to the facility on [DATE]. The first instance of COVID testing for Resident #23 following readmission was 7/4/2022. Resident #23 had been tested in the hospital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to offer COVID vaccination(s) to four Residents (Resident #121, 23, 140 and 92), in a sample of 5 Residents reviewed for immunizations. The findings included: 1. The facility staff failed to provide evidence that Resident #121 was offered, educated and provided/or declined COVID vaccination. Review of the facility submitted listing of Resident's COVID vaccination status revealed Resident #121 was not vaccinated for COVID-19. On 7/11/22 and 7/12/22, a clinical record review for Resident #121 was conducted. This review revealed the following: Resident #121 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) it read, No immunizations found. Review of the misc. (miscellaneous) tab, assessment tab, and progress notes revealed no evidence of vaccine administration or offering of such. There was a document…

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

Based on staff interview and facility documentation review, the facility staff failed to complete exemption documents for 10 of 10 exemptions requested by staff (Employee K, Employee Y, Employee G, CNA J, CNA F, CNA H, CNA G, LPN C, LPN J, and RN C) The findings included: On 7-6-22, the facility staff was requested to provide the survey team with a copy of the staff vaccination matrix and as worked schedule. The as worked schedule was used to check that all facility employees were included on the staff vaccination matrix. On 7-8-22 after several revisions to omissions of staff, between the schedule and the matrix, a final copy was received. The final copy included all exemption forms (10) that had been requested by the staff. None of the (10) exemption documents were complete, to include; Dates, signatures, approved or denied status for the requested exemptions, and mitigation strategies to be adhered to by unvaccinated staff. On 7-8-22 at 2:00 p.m., a conference call was placed with the onsite survey team and the Regional Administrator, who was the only leadership in the building.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure completion of staff abuse training for 3 of 5 sampled records The Findings included: On 7-5-22 Staffing schedules were requested for the week, and were reviewed each day. A tour of the entire building to ascertain all staff currently providing care to the Residents and working during the shift was conducted on 7-5-22. The census on this day was 143 Residents. There was no Administrator, no Infection Preventionist (IP), nor Director of Nursing (DON), and no MDS (Minimum Data Set)/care plan Coordinator present. Staff members (2 LPN's, and all 3 CNA's) were asked during initial tour if they had received training and had annual competencies evaluated. All responded they could not remember any training other than a recent first CNA licensing course, and long ago abuse training that they had ever received. They were asked who provided training and evaluations, and all responded I don't know, some are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, the facility staff failed to maintain dignity for one Resident (Resident #142) in a sample size of 48 Residents. Specifically, the facility staff did not assist Resident #142 to obtain clothes/get dressed for approximately 2 months. The findings included: On 07/11/2022 at 2:35 P.M., Resident #142 was observed lying in bed wearing a hospital gown. When asked if it was their preference to be in bed in a hospital gown at this time of day, Resident #142 stated they would like to be dressed but they do not have clothes to wear. Resident #142 indicated that out of respect for other Residents, they really want to wear pants. When asked if the facility staff have assisted with getting clothes, Resident #142 stated that some clothes were ordered but were too small so other clothes needed to be ordered. Resident #142 stated it has been a few months since then. Resident #142 stated they have not received any clothes yet. On 07/12/2022, Resident #142's clinical record was reviewed. Resident #142's most recent…

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

Based on observation, interview, facility documentation and clinical record review the facility staff failed to promote self determination through support of resident choice, for Resident # 84 in a survey sample of 48 Residents. The findings included: For Resident # 84 the facility staff told the Resident he must go to bed between 9:00 PM and 10:00 PM. On 7/11/22 at approximately 2:00 PM Resident # 84 was interviewed about his stay at the facility and he stated They told me I have to go to bed between 9:00 and 10:00 o'clock. I am not a child, I am a grown man I don't need a bedtime. On 7/12/22 at 4 PM an interview was conducted with CNA B, (a staff member working 3-11 shift ) who stated We try to get the Residents in bed by 10:00 PM so that the night shift doesn't have to get them to bed. We have more staff on 3-11 than nights so we try to make sure everyone is in bed, in a gown by 10:00. When asked what is done if a Resident refuses to go to bed, CNA B said, Well we try at 9:00 and then give them more time like until 9:30. Then at 9:30 we remind them we will be back at 10:00 to get…

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

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to allow a Resident to have visitors at the time of their choosing, for one Resident (#127) in a survey sample of 48 Residents. The findings included: For Resident #127, the facility staff had her daughter removed from the facility for visiting beyond visiting hours. On 7/12/22, during a clinical record review a nursing note was noted that read, Late Entry: Note Text: Daughter [name redacted] c/o [complained of] Nurse called security previous night and walked sister out of building for staying past visiting hours. Reassured daughter that family was welcomed to visit with patient, as long as they wished to without being loud and interfering with other residents care. Daughter very appreciative and patient is currently alone in room. No further complaints voiced at this time. Patient resting comfortably in bed with eyes closed. No distress noted at this time. This entry was made on 7/10/22, by Employee C, the Assistant Director of Nursing (ADON) and noted as a late entry for…

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

Based on interview, facility record review and clinical record review the facility staff failed to report allegations of abuse to the State Agency (VDH Office of Licensure and Certification) for 1 Resident (# 64) in a survey sample of 48 Residents. The findings included: For Resident #64 the facility staff failed to report allegation of sexual abuse by a CNA. On 7/11/22 during review of FRI's (Facility Reported Incidents) for this facility it was discovered that on 8/27/21 APS (Adult Protective Services) reported to the OLC an allegation of sexual abuse of Resident # 64 that they were investigating. The alleged abuse occurred on 8/21/21 by a CNA, employee O. The report from APS states that the local Police were notified, APS was notified and that the Resident was taken to the hospital for an examination. On 7/12/22 at approximately 1:00 PM the facility was asked to see any and all FRI's for 2021. Employee Q submitted the FRI Book for the surveyors to examine. The FRI Book did not contain any FRI's for alleged sexual abuse of Resident #64. The acting Administrator and the Regional…

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

Based on electronic health record (EHR) review the facility failed ensure the preadmission screening (PASARR) evaluation for an individual with a mental disorder was conducted for one resident (Resident #45) in a sample of 48. The findings include: On 07/13/22 at approximately 4:30 p.m., while conducting EHR review observed that Resident #45 did not have a PASARR on record. Administrator was made known that the PASARR for Resident #41 could not be located.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop a resident-centered baseline care plan that met professional standards of quality care for one resident (Resident #127) in a sample of 48 Residents. The findings included: For Resident #127, the facility staff failed to develop a baseline care plan to direct the Residents care upon admission. On 7/11/22 and 7/12/22, a clinical record review was conducted. This review revealed the following: 1. Resident #127, was admitted to the facility on [DATE]. 2. There was no evidence of a baseline care plan being developed. 3. The comprehensive care plan was not initiated until 6/30/22. On 7/12/22, the facility Administrator was asked to provide Resident #127's baseline care plan. On 7/12/22, the facility Administrator advised the survey team that a base line care plan for Resident #127 was not available. On 7/13/22, the facility's Corporate Clinical Consultant confirmed that a base line care plan 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, staff interview, and clinical record review, the facility staff failed to supervise one Resident during meal time to ensure safety (Resident #49) in a sample size of 48 Residents. Specifically, Resident #49 was observed eating her lunch in an unsafe position presenting a potential choking hazard on 07/11/2022. The findings included: On 07/11/2022 at 1:25 P.M., Resident #49 was observed in her bed eating lunch. The head of the bed was elevated approximately 45 degrees but Resident #49's upper back was in the fold of the bed where the head of the bed begins to rise. Resident #49's head was at the level of the tray table with the lunch tray on it. Resident #49 was not seated upright to safely consume food without the risk of choking. There was no staff in the room. At approximately 1:28 P.M., this surveyor and Certified Nurse Assistant H (CNA H) observed (from the hall) Resident #49 eating their lunch. When asked if any concerns were identified, CNA H stated that the room floor looked dirty. When asked if there were any concerns related to positioning, CNA H…

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

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to identify, monitor, and treat significant weight loss for one Resident (Resident #49) in a sample size of 48 Residents. Specifically, Resident #49 experienced an 18.91% weight loss over a 3 month time period (January 2022 through April 2022). The findings included: On 07/11/2022 at 1:25 P.M., Resident #49 was observed in her bed eating lunch. Resident #49 appeared small-framed and thin. On 07/12/2022, Resident #49's clinical record was reviewed. According to the weight flow chart, Resident #49 was weighed twice since 01/13/2022. Resident #49 weighed 110 pounds on 01/13/2022 and 89.2 pounds on 04/18/2022 which represented an 18.91% weight loss in 3 months. The nursing progress notes around 04/18/2022 were reviewed. There were no progress notes addressing the significant weight loss nor notification of provider or responsible party. The following excerpts of a provider progress note dated 04/19/2022 documented the following: .currently tolerating a regular…

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

Based on observation, interview, facility record review and clinical record review the facility staff failed to provide medically related social services to maintain highest practicable well-being for 1 Resident (#34) in a survey sample of 48 Residents. The findings included: For Resident #34 the facility staff failed to provide needed prescription eye glasses to enable Resident # 34 to pursue reading and other leisure activities that require adequate vision. On 7/6/22 at approximately 1:45 PM an interview was conducted with Resident #34 who explained that he needed eyeglasses and had not had his vision checked in some time. He stated he was not aware of the exact date he last had an eye exam but he knew it was more than a year ago. Resident #34 stated that he had his eyes examined and the doctor recommended a certain type of eyeglasses and the facility staff told him They are too expensive we won't buy them. On 7/12/22 at approximately 11:00 AM an interview was conducted with Employee T (a Social Worker) who stated that she was not from this building she had been called from a…

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

Based on observation, interview, facility documentation and during the course of a complaint investigation the facility staff failed to follow the menus for the facility in general and for Resident #34. The findings included: For the facility in general, it was reported in an anonymous complaint that the facility did not follow the menus and ordered pizza for Residents on 6/21/22, also during survey it was noted that Resident #34 received turkey sandwich instead of what was on his meal ticket and had some food items missing from his lunch tray. On 7/5/22 at approximately 1:00 PM the Social Worker was interviewed and she stated that she was aware of the incident involving having to order pizza for Residents. She stated that the allegation was true and that she was present at the time. She stated that the Acting Administrator was called in and he called a sister facility to get a kitchen staff member to prepare the puree foods and he then ordered pizza for the Residents who could eat regular consistency. On 7/7/22 at approximately 9:00 AM an interview was conducted with Resident # 34…

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

Based on observation, interview, clinical record review and facility documentation the facility staff failed to maintain accurate clinical records for 2 Residents (#'s 75) in a survey sample of 48 Residents. The findings included: For Resident # 75 the facility staff failed to maintain accurate and consistent information on catheter. On 7/6/22 at approximately 11:45 AM an interview was conducted with Resident #75 when asked if she has had her catheter since admission. The resident stated she had gotten the catheter at the hospital prior to admission. Observation was made of Resident with Foley Catheter in privacy bag attached to wheelchair. On 7/6/22 during clinical record review it was noted that Resident #75 has had an indwelling catheter since admission for a diagnosis of neurogenic bladder. Excerpts from skilled nurses notes are as follows: 5/24/22 at 402 AMCatheter is not noted 5/25/22 at 2:31 PM Catheter is in dwelling 5/25/22 at 7:05 PM Catheter not noted 5/25/22 at 9:30 PM Catheter not noted 5/26/22 at 3:30 AM Catheter not noted 5/26/22 at 10:36 AM Catheter is indwelling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in observation, interview, facility documentation and clinical record review the facility staff failed to maintain patient care equipment for 1 Resident #34 in a survey sample of 48 Residents. The findings included: For Resident #34 the facility staff failed to ensure the proper working order of his CPAP machine. On 7/13/22 at approximately 9:00 AM an interview was conducted with Resident #34 who stated I didn't sleep at all last night, this CPAP was worse than ever. It doesn't work right and I was up all night. When asked if the Resident had told the staff he stated We don't have a DON we don't have a Social Worker we don't have an Administrator. I told all of them a bunch of times before they quit and nothing was done. Now I have told the nurses but half of them don't care and the other half are agency staff, what are they going to do. After leaving the Resident's room this surveyor went to the ADON's office and reported the concerns of the Resident and how he stated that he has complained repeatedly about this issue. The ADON stated she would check on it. On the afternoon…

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

Based on observation, interview, and facility documentation the facility staff failed to ensure the bed frame and the mattress are compatible, for 1 Resident # 34 in a survey sample of 48 Residents. The findings included: For Resident #34 the facility staff failed to supply the appropriate sized mattress for the bariatric bed Resident #34 was using. On 7/11/22 at approximately 12:30 AM Resident #34 was interviewed and he stated that the bed he has is uncomfortable and that he had to order feather pillows from [name of company redacted] to put under his back and bottom because the mattress was not comfortable. In visualizing the mattress there was a 3 inch gap on either side of the mattress where it did not meet the edge of the bed frame or the top rails. When asked about this the Resident stated he has always had this problem with the mattress not being wide enough, and stated I have complained a number of times but nothing is done about it. On the afternoon of 7/11/22 during clinical record review it was discovered that Resident # 34 has resided at the facility since 7/23/15 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 documentation review, the facility staff failed to ensure a working call light for one Resident (Resident #91) in a sample size of 48 Residents. Resident #91's call light was not working for a number of days in June and July 2022. The findings included: On 07/11/2022 at approximately 12:05 P.M., Resident #91 was observed lying in her bed. When asked if there were any concerns about the care received at the facility, Resident #91 stated that the call light has not been working. Resident #91 indicated staff was notified about it. This surveyor observed Resident #91 press the button on the call light several times and the light and sound were not activated. On 07/11/2022 at approximately 12:15 P.M., the Regional Administrator was notified Resident #91's call light was not working. The Regional Administrator stated he would let maintenance staff know. On 07/12/2022 at 9:30 A.M., Resident #91 was interviewed. Resident #91 stated that the call light was now working. On 07/12/2022, a grievance for Resident #91 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 interviews and facility document review, it was determined that facility staff failed to ensure a clean comfortable and homelike environment on 3 of 4 units, unit's 200, 300 and 400. The findings include: 1. On 4/6/21 at 11:15 a.m. through 4/7/21 at 4:00 p.m., the following rooms represented the facility's failure to maintain a clean and comfortable homelike environment in the following rooms on the 300 and 400 unit: -In room [ROOM NUMBER] Heavy accumulations of dust, dirt, debris and unidentified food items were identified up against and behind the 5 chest, as well as under both beds. The base of the two over bed tables possessed spillage from liquids and food. -In room [ROOM NUMBER]-A A urinal with yellow substance inside was wedged against the wall and the wheel of the resident's bed. A prominent urine odor permeated the room. The resident had a urinal on his over bed table that he said he was currently using. This urinal was observed removed on 4/8/21 after brought to 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 documentation review, the facility staff failed to implement their abuse policy with regard to employee screening for 9 Employees (CNA C, CNA D, CNA E, CNA F, CNA G, LPN D, LPN E, LPN F, LPN G) in a survey sample of 25 employee records. The findings included: The facility staff failed to implement their abuse policy to screen employees prior to hire. On 4/8/21, a review was conducted of a sample of 25 employee records. This review was conducted with Employee J, the human resources coordinator. The review revealed the following: 1. The facility staff failed to check references prior to employment for 8 employees CNA C, CNA E, CNA F, CNA G, LPN D, LPN E, LPN F, LPN G. 2. The facility staff failed to verify employee license prior to hire for 4 employees CNA F, CNA G, LPN D, LPN E. 3. The facility staff failed to obtain a Criminal Background check with the within 30 days of hire for 8 employees CNA C, CNA D, CNA E, CNA F, CNA G, LPN E, LPN F, LPN G. On 4/8/21 at 8:55 AM, Surveyor A sat with Employee J, the Human Resources Coordinator.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation, the facility staff failed to maintain infection control practices in accordance with the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommendations to prevent the spread of COVID-19 for 2 Residents (Resident #555 and #102) and 2 of 5 areas of the facility. 1. The facility staff failed to implement transmission based precautions (TBP) for Resident #555, who was a new admission to the facility. 2. The facility staff failed to implement transmission based precautions (TBP) for Resident #102, who was a new admission to the facility. 3. The facility staff failed to provide proper screening for visitor/vendor entry into the facility. 4. The facility staff failed to ensure personal protective equipment was properly worn. The findings included: 1. The facility staff failed to implement transmission based precautions (TBP) for Resident #555, who was a new admission to the facility. Resident #555…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, staff interviews and review of facility documentation, the facility staff failed to ensure misappropriation of resident property to include the diversion of 2 of 40 resident's (#254 and #304) physician ordered controlled substances for staff use or personal gain. The findings include: 1. Resident #254 was admitted to the nursing facility on 3/16/21 with a primary diagnosis of Human Immunodeficiency Virus (HIV) and secondary diagnoses that included generalized muscle weakness, pressure ulcers, seizures and pain. The resident was discharged to the local hospital on 3/22/21 and did not return to the admitting facility. The Minimum Data Set (MDS) was an admission dated 3/22/21 and coded Resident #254 on the Brief Interview for Mental Status (BIMS) with a 3 out of a total score of 15 which indicated the resident was severely impaired in the cognitive skills for daily decision making. The resident was assessed to require extensive assistance from two staff for bed mobility, transfer,…

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

Based on facility documentation, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The findings included: A review of the facility as-worked staffing documentation during a 30-day look back indicated the following: 1.) On 03/14/21, Registered Nurse (RN-A) worked a total of 7.68 hours out of a scheduled 8 hour shift. 2.) On 04/03/21, (RN-B) worked a total of 7.31 hours out of a scheduled 8 hours shift. A pre-exit conference was conducted with the Administrator, Director of Nursing (DON) and Corporate Nurse on 04/07/21 at 6:30 p.m. During that time, the Administration team were made aware that the facility did not have 8 hours of RN coverage on 03/14/21 and 04/03/21. A phone interview was conducted with the (DON) on 04/08/2021 at approximately 8:27 a.m. When asked about the facility not having 8 hours of RN coverage on 03/14/21 and 04/03/21, the DON replied, My first time hearing about the nurses not working a full 8 hour shift was yesterday, 04/07/21. The DON stated, I expect for the RN providing coverage to work their…

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

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an accurate record of controlled medications and provide safekeeping of hard scripts for controlled drugs, for 3 Residents (Resident #28, #32, and #102) in a survey sample of 40 Residents. 1. For Resident #28, the facility staff failed to maintain an accurate inventory of controlled medications. 2. For Resident #32, the facility staff failed to maintain an accurate inventory of controlled medications. 3. For Resident #102, the facility staff failed to provide safekeeping of hard scripts for controlled drugs, to prevent drug diversion. The findings included: 1. For Resident #28, the facility staff failed to maintain an accurate inventory of controlled medications. On 4/7/21 at 1:35 PM, a review of the medication storage of the unit 2 back hall medication cart was performed by Surveyor A, who was accompanied by LPN A, the unit manager. This review revealed the following: The controlled drug count sheet was compared to the actual medication count 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 resident interview, staff interviews, clinical record review, and review of facility documents, the facility's staff failed to obtain routine dental services for 1 of 40 residents (Resident #52), in the survey sample. The findings included: Resident #52 was originally admitted to the facility 4/20/20 and had never been discharged from the facility. The current diagnoses included; high blood pressure, atrial-fibrillation and a seizure disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/1/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #52's cognitive abilities for daily decision making were intact. In section L (Dental) the resident was coded as having obvious or likely cavities or broken natural teeth. On 4/7/21 an interview was conducted with Resident #52. The resident stated he had been seen by the dentist last August and the plan was to have thirteen teeth extracted for they were not repairable and would eventually cause…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and facility document review, it was determined that facility staff failed to provide a safe environment in 1 bathroom on 1 of the facility's 4 units. The findings included: On 4/6/21 at 11:15 a.m., during the orientation tour through 4/8/21 at 3:15 p.m., the ceiling panels in the bathroom of room [ROOM NUMBER] were observed loose, bowed and unstable. The aforementioned finding was brought to the attention of the Administrator during an end of day debriefing on 4/7/21 at approximately 5:50 p.m. She stated she would have the maintenance inspect all bathrooms and ensure all necessary repairs were made. On 4/8/21 at approximately 3:15 p.m., Surveyor (D) took the Maintenance Director to room [ROOM NUMBER]. He stated he repaired a ceiling track of a bathroom on the 200 Unit and was never made aware by the Administrator or the maintenance team of the needed repairs in the 301 bathroom. He stated, the housekeeping staff push broom handles up into the ceiling tiles when they are…

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