Westport Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the care plan for two of 17 residents in the survey sample, Residents #5 and #1.The findings include:1. For Resident #5 (R5), the facility staff failed to review and revise the care plan after a fall. On the following dates and times, R5 was observed lying on his back in bed; there were no fall mats to either side of the bed: 10/20/25 at 2:26 p.m. and 3:48 p.m.; 10/21/25 at 9:26 a.m. A review of R5's care plan dated 4/26/25 and most recently revised on 8/22/25 revealed no information regarding the implementation of fall mats to prevent injury to R5 in case of a fall. A review of R5's clinical record revealed the following progress note dated 3/30/2025: 03:38 (3:38 a.m.) Fall Note Description of the fall.Writer was called to Resident's room because CNA (certified nursing assistant) found the resident on the floor. Resident was laying (sic) on the floor on the right side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice to promote residents highest level of well-being for two of 17 residents in the survey sample, Resident #10 and Resident #4.The findings include: 1. For Resident #10 (R10), the facility staff failed to follow professional standards of practice during medication administration.On 10/20/2025 at 10:19 AM, an observation was made of licensed practical nurse (LPN) #5 preparing medication for R10. LPN #5 was observed removing one tablet of Folic Acid from a house stock bottle that was labeled Folic Acid 400mcg (microgram) and placing it in a medication cup and administered it to R10.Review of the physician orders for R10 documented in part, Folic Acid Oral Tablet 1 MG (milligram) (Folic Acid) Give 1 tablet by mouth one time a day for supplement. Order Date: 04/03/2025. Start Date: 04/04/2025.On 10/20/2025 at 2:15 PM, an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for one of twelve residents, Resident #104 (R104).The findings include: The facility staff failed to provide ADL (activities of daily living) specifically turning/repositioning, incontinence care and feeding R104.R104 was admitted to the facility on [DATE] with diagnosis that included but were not limited to quadriplegia, spinal stenosis and TIA (transient ischemic attack).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/9/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as dependent for bathing/transfer/dressing/toileting and eating; Section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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/resident interview, facility document review and clinical record review, it was determined that the facility staff failed to provide treatment and services for an indwelling catheter for one of twelve residents in the survey sample, Resident #104 (R104).The findings include: The facility failed to evidence treatment and services for Resident 104's (R105's) indwelling catheter.R104 was admitted to the facility on [DATE] with diagnosis that included but were not limited to quadriplegia, spinal stenosis and TIA (transient ischemic attack).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/9/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as dependent for bathing/transfer/dressing/toileting and eating; Section H-Bladder and Bowel coded 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 clinical record review, it was determined that the facility staff failed to provide food at a palatable temperature for one of twelve residents, Resident #104 (R104).The findings include: The facility staff failed to provide food at a palatable temperature for R104 during lunch on 12/15/25. R104 was admitted to the facility on [DATE] with diagnosis that included but were not limited to quadriplegia, spinal stenosis and TIA (transient ischemic attack).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/9/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as dependent for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan dated 8/1/24 revealed, FOCUS: LONG TERM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to maintain an accurate clinical record for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to maintain an accurate clinical record documenting transfer to the emergency room. The progress notes for R1 documented in part, - Effective Date: 04/13/2025 08:31 (8:31 a.m.) Type: eINTERACT SBAR (situation, background, assessment, recommendations) Summary for Providers. Late Entry. Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Shortness of breath . Nursing observations, evaluation, and recommendations are: Resident observed has SOB (shortness of breath), distress. Full Head to Toe assessment was performed. VS (vital signs) 137/76 (blood pressure)-20 (respirations)-97.6 (temperature)-72% (oxygen saturation). Both lungs coarse upon Auscultation, 2 L (liters) of oxygen administered, MD…

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

Based on observation, staff interview, and facility document review, the facility staff failed to prepare and serve food in a sanitary manner in one of one facility kitchen. The findings include: The facility staff failed to prepare and serve food in a sanitary manner for the lunch meal on 3/10/25. On 3/10/25 at 11:35 a.m., observation was made of the facility kitchen. OSM (other staff member) #4, a dietary aide, was observed obtaining holding temperatures of food on the steam table, ready for serving to residents. As OSM #4 took temperatures, she failed to sanitize the thermometer between foods. Instead of using an alcohol wipe, she used the same paper towel repeatedly. OSM #5, a dietary aide, was observed pushing a cart of clean silverware from the dish room. The silverware was visibly wet, and most utensils had water dripping from them. OSM #5, wearing gloves, touched the eating end of every utensil and put the still-dripping utensils upside down in a silverware container. OSM #5 began loading meal trays on to the serving line. Wearing the same gloves, he placed the same…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to implement the care plan for one of 16 residents in the survey sample, R208. The findings include: The facility staff failed to implement the comprehensive care plan for CPAP for R208. Observed R208's CPAP machine in his room at approximately 12:00 PM on 3/10/25. R208 was admitted to the facility on [DATE] with diagnosis that included but were not limited to chronic respiratory failure, COPD (chronic obstructive respiratory disease) and Parkinson's Disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance 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 observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for one of 16 residents, R208. The findings include: The facility staff failed to provide evidence of respiratory care services for R208. Observed R208's CPAP machine in his room at approximately 12:00 PM on 3/10/25. R208 was admitted to the facility on [DATE] with diagnosis that included but were not limited to chronic respiratory failure, COPD (chronic obstructive respiratory disease) and Parkinson's Disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance 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 resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to prevent an unevaluated CNA (certified nursing assistant) from operating a mechanical lift for one of three CNA (certified nursing assistant) records reviewed, CNA #1. The findings include: CNA #1 was allowed to operate a Hoyer lift while caring for Resident #1 (R1) prior to having her competency to do so reviewed by facility staff. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/14/24, R1 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as being completely dependent on facility staff for transfers from bed to chair. A review of R1's clinical record revealed the following Fall Note dated 11/29/24: Description of the fall .Resident was found on floor next to bed. CNA's (certified nursing assistants) present. Per Unit Manager writer was told to go call 911. Writer did as instructed 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, and facility document review, it was determined the facility staff failed to serve meals in a dignified manner on one of four units, unit two. The findings include: On 11/13/24 at 1:24p.m., an observation was made of the kitchen staff plating and preparing the food carts for delivery. When the kitchen staff got to the last one and a half carts, they started using plastic silverware and styrofoam take out containers to put the food in and placed them on the trays and into the meal carts. When asked why they were using plastic silverware and styrofoam take out containers to serve the food to the residents, the kitchen staff stated they don't have any more pellets (that keep the food warm) or covers to serve the residents to complete the tray line. OSM (other staff member) #15, the director of dietary services, stated she had just come to the facility on [DATE] and was in the process of finding out the needs of the kitchen in order to serve the residents better. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to accommodate resident needs for four of 69 residents in the survey sample, Resident (R) #36, R46, R125 and R179. The findings include: 1. For Resident #36, the facility staff failed to accommodate the resident preferences to have access to the outside. R36's room is on Unit 1. The end of Unit 1, there is a door to a covered patio with a ramp, the door is not automatic and requires you to turn handle to open the door. This door is unlocked from 8:00 AM -8:00 PM. The main lobby has 2 sets of double doors all with handles/bars to open them. The outside set of doors when opened put you in between 2 glass doors that then open into the lobby. The end of Unit 2 there is an automatic sliding door with a ramp that requires a code to open the door. R36 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Hepatic Encephalopathy, DM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of facility's documentation and staff interview, it was determined that the facility failed to evidence resolution of resident council concerns. The findings included: During the review of the Resident Council Minutes from 12/2022-10/2024, there was no evidence of resolution of resident concerns, regarding food/menus/alternate meals and missing belongings. On 11/21/24 at 9:15 AM an interview was conducted With ASM #2, the director of nursing. When asked where the resolution of concerns from Resident Council were documented and shared with the residents, ASM #2 stated, we do not have evidence of that. On 11/21/24 at approximately 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and RN (registered nurse) #3, the assistant director of nursing, were made aware of the findings. A review of the facility's Resident Council policy reveals, The Administrator is responsible for reviewing and signing the company Resident Council Meeting Minutes and responding in writing to concerns presented by the council on the Administrative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain confidentiality of resident information for three of 69 residents in the survey sample, Residents #249, #250 and #182. The findings include: 1. For Resident #249 (R249), the facility staff failed to maintain confidentiality of the resident information, A copy of text messages sent to the state agency were reviewed. The text messages documented in part, (R249) I admitted her to room (#) and (name of former administrator) ended up putting up somewhere else where a room was not ready because of housekeeping and so her arrival was very unwelcoming and not good. So, I went to put together a care package for her and her daughter and gave that to both of them that put a smile on her face. I set with them for 20 mins (minutes) answered all the question both of them had. They met with the unit manager and kitchen manager. Still, nobody checked on this lady since her arrival. An interview…

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

Based on observation, staff interview, and facility document review, the facility staff failed to maintain a clean, comfortable, homelike environment for one of 69 residents in the survey sample, Resident #121, and in one of one reception area outside of the kitchen. The findings include: 1. For Resident #121 (R121), the facility staff failed to maintain the resident's tube feeding pole and floor in a clean and homelike manner. On 11/18/24 at 11:26 a.m., 11/19/24 at 7:40 a.m., and 11/20/24 at 9:25 a.m., R121 was observed lying in bed. Puddles of a dried light brown substance were observed on the base of the resident's tube feeding pole and on the floor. On 11/20/24 at 10:15 a.m., an interview was conducted with OSM (other staff member) #4 (the director of housekeeping). OSM #4 stated residents' rooms are cleaned daily and substances on the base of the tube feeding poles and floors should be cleaned. OSM #4 stated if certified nursing assistants or nurses see substances on the base of tube feeding poles or the floor, they should clean up the substances or notify the housekeeping…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #130 (R130), the facility staff failed to evidence the comprehensive care plan was sent to the hospital upon transfer on 8/3/24. The nurse's note dated. 8/3/24 at 11:16 a.m. documented, Resident observed with an oxygen level of 94%. Resident c/o (complained of) sob (shortness of breath). Resident observed with using accessory muscles to breathe. Resident c/o chest pain and upper right and left abdominal pain. Resident rate pain 10/10. Resident was placed on non-breather oxygen improved to 99%. NP (nurse practitioner) notified of change of condition. New order to transfer to hospital. Resident is own rp (responsible party). Resident was made aware of the transfer. Resident was sent to (name of hospital) ED (emergency department) via ems (emergency medical services) with face sheet, med (medication) list and transfer form. The Acute Care Transfer Document Checklist dated 8/3/24 failed to evidence what documents were sent to the hospital upon transfer. On 11/20/24 at 10:52 a.m., an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #130 (R130) the facility staff failed to evidence the resident and/or responsible party was provided a written notice for the reason of the need for transfer to the hospital on 8/3/24 and failed to notify the ombudsman of the transfer in a timely manner. The nurse's note dated. 8/3/24 at 11:16 a.m. documented, Resident observed with an oxygen level of 94%. Resident c/o (complained of) sob (shortness of breath). Resident observed with using accessory muscles to breathe. Resident c/o chest pain and upper right and left abdominal pain. Resident rate pain 10/10. Resident was placed on non-breather oxygen improved to 99%. NP (nurse practitioner) notified of change of condition. New order to transfer to hospital. Resident is own rp (responsible party). Resident was made aware of the transfer. Resident was sent to (name of hospital) ED (emergency department) via ems (emergency medical services) with face sheet, med (medication) list and transfer form. Review of the clinical record failed to evidence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #130 (R130), the facility staff failed to provide evidence that a bed hold notice was provided upon transfer to the hospital on 8/3/24. The nurse's note dated. 8/3/24 at 11:16 a.m. documented, Resident observed with an oxygen level of 94%. Resident c/o (complained of) sob (shortness of breath). Resident observed with using accessory muscles to breathe. Resident c/o chest pain and upper right and left abdominal pain. Resident rate pain 10/10. Resident was placed on non-breather oxygen improved to 99%. NP (nurse practitioner) notified of change of condition. New order to transfer to hospital. Resident is own rp (responsible party). Resident was made aware of the transfer. Resident was sent to (name of hospital) ED (emergency department) via ems (emergency medical services) with face sheet, med (medication) list and transfer form. Further review of the clinical record failed to evidence documentation of a bed hold notice provided upon transfer on 8/3/24. On 11/20/24 at 10:52 a.m., an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for six of 69 residents in the survey sample, Residents #5, #248, #74, #179, #48 and #138. The findings include: 1. For Resident #5 (R5), the facility staff failed to develop a care plan to address activities. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 10/2/24, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The Activities assessment dated [DATE] documented in part, 2d. How important is it to you to keep up with the news? Somewhat important. (R5) enjoys watching TV shows, games shows and news .2f. How important is it to you to do your favorite activities? Very important. (R5) prefers 1:1 visits, watching TV, and good conversation .2g. How…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for two of 69 residents in the survey sample, Residents #179 and #449. The findings include: 1. For Resident #179 (R179), the facility staff failed to administer medications in the prescribed time frame. An interview was conducted with R179 on 11/18/24 at approximately 1:00 p.m. R179 stated she doesn't get her morning medications until sometimes after 11:00 a.m. Also, some of her other medications are being given late. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 9/13/24, the resident scored a 15 out of 15, indicating the resident was not cognitively impaired for making daily decisions. A review of the Medication Administration Audit Report documented the following: 11/1/24 - Sennosides Tablet 8.6 mg (milligrams) 2 tablets by mouth in the afternoon for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for three of 69 residents, R138, R448 and R55. The findings include: 1. The facility staff failed to provide ADL care for a dependent resident, R138. R138 was admitted to the facility on [DATE] with diagnosis that included but were not limited to cerebral infarction, hemiplegia, aphasia and muscle wasting. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/8/24, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and supervision for eating. A review of the comprehensive care plan dated 8/7/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to administer medications per physician's orders for five of 69 residents in the survey sample, Residents #55, #106, #130, #248, and #500. The findings include: 1. For Resident #55 (R55), the facility staff failed to administer the medication buspirone (used to treat anxiety) per physician's orders twice on 3/12/23. A review of R55's clinical record revealed a physician's order dated 2/7/23 for buspirone 10 mg (milligrams)- one tablet by mouth three times a day for anxiety. A review of R55's March 2023 MAR (medication administration record) revealed the same physician's order. On 3/12/23 at 8:00 a.m. and 2:00 p.m., the nurse documented buspirone was not administered as evidenced by the code, 5=Hold/See Progress Notes on the MAR. A review of progress notes for 3/12/23 failed to reveal why the buspirone was not administered. On 11/14/24 at 10:59 a.m., an interview was conducted with LPN (licensed practical…

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

Based on staff interview, and clinical record review, the facility staff failed to provide Foley catheter care and services for one of 69 residents in the survey sample, Resident #300. The findings include: For Resident #300 (R300), the facility staff failed to provide Foley catheter care per physician's orders on multiple dates in April 2023 and May 2023. A review of R300's clinical record revealed physician's orders dated 11/28/22 and 4/26/23 for a Foley catheter due to urinary retention every shift and to provide Foley catheter care. A review of R300's April 2023 and May 2023 TARs (treatment administration records) failed to reveal Foley catheter care was provided during the day shift on 4/5/23, 4/24/23, 4/30/23, and 5/9/23 (as evidenced by blank spaces on the TARs). On 11/14/24 at 10:59 a.m., an interview was conducted with LPN (licensed practical nurse) #9. LPN #9 stated nurses evidence Foley catheter care is provided per physician's orders by signing the care off on the TAR. On 11/20/24 at 4:01 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the…

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

Based on staff interview, and clinical record review, the facility staff failed to provide colostomy care and services for one of 69 residents in the survey sample, Resident #300. The findings include: For Resident #300 (R300), the facility staff failed to change the resident's colostomy pouch per physician's orders on multiple dates in April 2023 and May 2023. A review of R300's clinical record revealed a physician's order dated 11/19/22 to change the resident's colostomy pouch every two to three days and as needed. A review of R300's April 2023 and May 2023 TARs (treatment administration records) revealed the same physician's order and a schedule for the resident's colostomy pouch to be changed every three days. Further review of R300's April 2023 and May 2023 TARs failed to reveal the resident's colostomy was changed during both months (as evidenced by blank spaces on the TAR). On 11/14/24 at 10:59 a.m., an interview was conducted with LPN (licensed practical nurse) #9. LPN #9 stated nurses' evidence the changing of a colostomy pouch by signing it off on the TAR. On 11/20/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 69 residents in the survey sample, R155. The findings include: The facility failed to provide evidence of communication with dialysis facility and providing meal for R155. R155 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), COPD (chronic obstructive pulmonary disease) and left above the knee amputation. The most recent MDS (minimum data set) assessment, a 5-day assessment, with an ARD (assessment reference date) of 8/5/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for toileting, bathing and hygiene. A review of the comprehensive care plan dated 7/31/24, which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement bed rail requirements for four of 69 residents in the survey sample, Residents #147, #55, #182, and #106. The findings include: 1. For Resident #147 (R147), the facility staff failed to offer/attempt appropriate alternatives prior to the use of bed rails and failed to assess the resident for risk of entrapment. On 11/18/24 at 11:21 a.m., and 11/19/24 at 9:05 a.m., R147 was observed lying in bed with bilateral quarter bed rails in the upright position. A review of R147's clinical record failed to reveal documentation that the facility staff offered/attempted appropriate alternatives prior to the use of bed rails and failed to assess R147 for risk of entrapment. On 11/20/24 at 10:52 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated appropriate alternatives to bed rails, such as one bed rail, a grab bar, or wedges should be attempted prior to the use of bed rails and should be documented in progress notes. LPN #3 stated she was not aware of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow the menus and provide alternate menu selection for one of one kitchen and for one of 69 residents in the survey sample, Resident #46. The findings include: 1. The facility staff failed to follow the menus on 11/13/24, 11/18/24 and 11/19/24. Observation was made of the kitchen on 11/13/24 at 11:33 a.m. The cook was preparing baked fish, when asked why he was cooking fish, he stated hamburgers were supposed to be the alternate, but they didn't have any in stock. The cook was observed boiling a pot of water and adding dry pasta. He proceeded to drain the pasta then mix it with paprika. When asked why he did that, the cook stated it was for an alternate starch for the meal. The staff were cutting up a sheet cake and putting it in individual containers. When asked why there was no icing on the cake, OSM (other staff member) #15, the dietary manager,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility document review, it was determined the facility staff failed to served food at a palatable taste and temperature for one of one meals tasted. The findings include: On 11/18/24 at 11:40 a.m., an interview was conducted with Resident #301. The resident stated he does not like the taste of the facility food and the meals are on the cool side. On 11/18/24 at 12:43 p.m. an interview was conducted with Resident #247. The resident stated the food is nasty and is cold most of the time. Observation was made of the kitchen 11/13/24 at 11:33 a.m. The food temperatures were as followed: Zucchini - 200 degrees Green beans - 205 degrees Mixed vegetables - 194 degrees Veal patties - 205 degrees [NAME] fish - 174 degrees Rice - 177 degrees Puree chicken - 189 degrees Thickened gravy - 145 degrees Pureed mixed vegetables - 191 degrees Pasta mixed with paprika - 185 degrees Mechanical chicken - 172 degrees Baked chicken - 173 degrees Mashed potatoes - 165…

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

Based on observation, staff interview and facility document review it was determined the facility staff failed to store, prepare and serve food in a sanitary manner in one of one kitchens. The findings include: Observation was made of the kitchen on 11/13/24 at 7:51 a.m. accompanied by OSM (other staff member) #15, the dietary manager. The following was found: Freezer - two wrapped package with no label as to contents, no date when opened or no use by date. On the table by the food processor, there were tortillas, cake mix, box of corn flake crumbs, three bags of dry pasta and a box of lasagna noodles. When asked why these things were there, OSM #15 stated they should be in the pantry. On top of the table next to this were two clear plastic storage bins with parchment paper in the bottom. Both storage bins had food/powder in them, the one bin was cracked. An uncovered container of thickener was observed on this table. OSM #15 stated, it should be covered when not in use. Steamer - top steamer had food debris in the bottom of it. and there were splashes of food substances down the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to protect a resident's rights to confidentiality of his medical record for one of 69 residents in the survey sample, Resident #303; and failed to maintain a complete and accurate clinical record for four of 69 residents in the survey sample, Residents #247, #250, #55, and #167. The findings include: 1. For Resident #303 (R303), the facility staff released the deceased resident's medical record to an individual who had not provided legal evidence that he was the resident's next of kin. This constituted a violation of releasing a confidential medical record to the individual, or their resident representative where permitted by applicable law. A review of R303's face sheet revealed Individual #1 was listed as the resident's responsible party. Individual #1 was identified on the face sheet as the R303's brother. A review of R303's admission MDS (minimum data set) with an ARD (assessment reference date) 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.

The facility staff failed to evidence medical director participation in four of four 2023 QAPI (quality assurance process improvement) meetings. The findings include: During the facility QAPI task, a review of the QAPI committee rosters from 11/2022 to 10/2024 revealed the there was no evidence of medical director participation for four of four 2023 QAPI meetings, 3/21/23, 6/29/23, 8/28/23 and 11/28/23. 11/20/24 QAPI rosters were reviewed as well as the plan. on 11/21/24 at 8:49 AM, an interview was conducted with ASM (administrative staff member) #1, the administrator. When asked the meeting schedule for QAPI, ASM #1 stated, when this corporation acquired this facility, they decided we needed to focus on quality and meet monthly in order to enhance quality. Monthly we expect attendance from the administrator, director of nursing, safety, maintenance, nursing leaders, IP, clinical rehab and dietary. Quarterly we expect attendance from the medical director and pharmacy. When ASM #1 was asked to review the 2023 QAPI attendance rosters for medical director participation, ASM #1 stated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, it was determined the facility staff failed to provide beneficiary notification for one of three residents in the beneficiary notification facility task, Resident #25. The findings include: During the facility task of beneficiary notification review on 11/20/24. The list of discharges for the last six months was provided at 4:30 PM on 11/19/24. Resident #25 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: neoplasm of breast, dementia and unsteadiness on feet. Resident #25 was a current resident in the facility during the survey period. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/21/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the social services progress note dated 6/18/24 at 2:21 PM, revealed the following, Jumpstart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility document review, and staff interview, it was determined that the facility staff failed to resolve a grievance in a timely manner for 1 of 69 residents in the survey sample, Resident #397. The findings include: For Resident #397 (R397), the facility staff failed to resolve a grievance regarding missing personal belongings in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/8/24, the resident was assessed as being severely impaired for making daily decisions. On 11/12/24 at 11:17 a.m., an interview was conducted with R397's responsible party (brother) who stated that R397 had recently passed away at the facility. He stated that when R397 was hospitalized the facility had packed up all their belongings and moved them out of the room. He stated that no one contacted him to ask if he wanted to pick them up and when R397 came back to the facility there were no belongings in the room, and no one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to protect one of 69 residents from abuse and/or neglect, R447. The findings include: The facility failed to protect R447 from verbal abuse from another resident, R450 based on grievance form, 11/1/23. R447 was admitted to the facility on [DATE] with diagnosis that included but were not limited to arthropathy, muscle wasting, ankle effusion and arthrodesis. The most recent MDS (minimum data set) assessment, a five-day assessment, with an ARD (assessment reference date) of 11/6/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for bed mobility/transfers, dressing, hygiene/toileting; and set up for eating. A review of the comprehensive care plan dated 11/2/23 revealed, FOCUS:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to prevent misappropriation of resident's property for one of 69 residents, R451. The findings included: Observations during survey period of 11/6/24-11/21/24 revealed no missing narcotics. A review of the final report from the facility dated 11/14/24 revealed, Oxycodone 5 mg, 30 tablet card for R451 remains missing. Three nurses were suspended pending investigation, LPN (licensed practical nurse) #12 had a negative drug screen, LPN #21 had a negative drug screen and LPN #22 has a prescription for Oxycodone and will test positive. Narcotics were not counted per policy and standards of practice. R451 was credited for the 30 tablets of Oxycodone and the facility will be responsible for payment. Audit of all narcotics books, carts and narcotic returns did not locate the missing 30 tablet Oxycodone card. Police investigated on 11/12/24. Review of Resident Council Minutes 1/24-11/24: There were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement a policy for reporting abuse for two of 69 residents, R447 and R397. The findings include: 1. The facility failed to implement their abuse policy to report occurrences according to regulations. A review of the facility grievance form, dated 11/1/23, revealed Resident 450 overheard verbally abusing roommate R447. R447 was admitted to the facility on [DATE] with diagnosis that included but were not limited to arthropathy, muscle wasting, ankle effusion and arthrodesis. The most recent MDS (minimum data set) assessment, a five-day assessment, with an ARD (assessment reference date) of 11/6/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report allegations of abuse to the state agency in a timely manner for three of 69 residents in the survey sample, Residents #182, #447, and #397. The findings include: 1. For Resident #182 (R182), the facility staff failed to report an allegation of abuse within two hours. A facility synopsis of events submitted to the state agency on 9/25/24 documented, On 9/23/2024 Resident reported to the Director of Admissions that the 11-7 shift was mean, told him 'to shut up, as closing his door, just die.' He also stated that they did not feed him nor change him with feces for 5 [sic] and reported to Administrator. On 11/14/24 at 10:23 a.m., an interview was conducted with OSM (other staff member) #13 (the former director of admissions). OSM #13 stated that on 9/23/24 at approximately 10:00 a.m., he spoke with R182, and the resident reported he was left in feces for five hours, the night shift nurse told him 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 clinical record review, facility document review, and staff interview, it was determined that the facility staff failed to investigate an allegation of misappropriation of property for 1 of 69 residents in the survey sample, Resident #397. The findings include: For Resident #397 (R397), the facility staff failed to investigate an allegation of misappropriation of property. On 11/12/24 at 11:17 a.m., an interview was conducted with R397's responsible party (brother) who stated that R397 had recently passed away at the facility. He stated that while R397 was hospitalized the facility had packed up all their belongings and moved them out of the room. He stated that no one contacted him to ask if he wanted to pick them up and when R397 came back to the facility there were no belongings in the room, and no one could find them. He stated that he spoke to the floor supervisor, the housekeeping supervisor, the admissions director, the social worker, and the former administrator regarding the belongings being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for one of 69 residents in the survey sample, R34. The findings include: The facility staff failed to complete an accurate MDS (minimum data set), a quarterly assessment for Resident #34. Resident #34 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: traumatic brain injury (TBI), muscle wasting and depression. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/4/24, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for bed mobility, transfer, hygiene and supervision for eating. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence an accurate PASARR (preadmission screening and resident review) screening for one of 69 residents in the survey sample, R88. The findings include: The facility failed to ensure a PASARR was completed upon admission for R88. Resident #88 was admitted to the facility on [DATE]. Resident #88's diagnoses included but were not limited to: quadriplegia, neurogenic bowel/bladder and delusional disorders. Resident #88's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/3/24, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G- Functional Status: coded the resident as max assist in bed mobility, transfers, walking, locomotion, dressing, toilet use, personal hygiene/bathing; independent for eating. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop a complete baseline care plan for two of 22 residents in the survey sample, Resident #112 and #113. The findings include: 1. For Resident #112 (R112), the facility staff failed to develop a complete baseline care plan that included a continuous IV (intravenous) Milrinone (1) drip for CHF (congestive heart failure) (2). R112 was admitted to the facility on [DATE]. The MDS (minimum data set) assessment was not due at the time of the survey. The admission nursing assessment dated [DATE] documented the resident being alert and oriented to person, place, time and situation. It further documented R112 having a PICC (peripherally inserted central catheter) line intravenous access on admission in the right upper extremity. On 1/22/25 at 11:01 a.m., an observation was made of R112 in their room at the facility with an intravenous infusion pump at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for three of 69 residents in the survey sample, Residents #130, #147 and #182. The findings include: 1. For Resident #130, the facility staff failed to remove from the care plan, the infection and use of a PICC (1) line after it was discontinued. The comprehensive care plan dated, 8/25/24, documented in part, Focus: The resident has a PICC line venous access to the left arm. The care plan further documented, Focus: GENERAL INFECTION: (R130) was admitted to facility with MRSA (2) bacteremia, IV (intravenous) ABT(antibiotics) therapy in place. This entry was dated 8/21/24. The last documented dose of Daptomycin (3) was administered on 9/8/24. The physician order dated 9/10/24 documented, DC (discontinue) PICC line, one time only for IV abx (antibiotic therapy complete for 2 days. The MAR (medication administration record) documented…

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

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide services for a contracture for one of 69 residents in the survey sample, Resident #140. The findings include: For Resident #140 (R140), the facility staff failed to provide palm guard/splinting for a left-hand contracture. An interview was conducted with R140 on 11/18/24 at approximately 12:20 p.m. R140 was observed to have a contracture of her left hand and wrist. R140 stated she needed a brace as she can't move her hand, they were supposed to be working on it. She stated she had one before and it was red but has been missing for quite some time. Review of the physician orders failed to evidence any documentation related to a brace/splint. A request was made for any therapy note for the past six months. On 11/19/24 at 1:30 p.m. ASM (administrative staff member) #1, the administrator, stated the resident has not have any occupational therapy for over six months. An interview was conducted with OSM (other staff member) #20, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for a PICC line for one of 69 residents in the survey sample, Resident #130. The findings include: For Resident #130 (R130) the facility staff failed to measure the PICC (1) line for 13 days after admission on [DATE]. The physician order dated 8/20/24, documented, PICC line - measure external portion of PICC line catheter weekly with dressing changes every night shift every Mon (Monday). PICC line dressing changes on admission, then Q (every) week and PRN. The MAR (medication administration record) for August and September 2024 were reviewed. The MAR documented the above orders. For the dressing change on admission, the dressing was documented as completed on 8/21/24. The order for the measure external portion of the PICC line was dated on 8/20/24 and nothing was signed off until 9/2/24. An interview was conducted with RN (registered nurse)…

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

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain respiratory equipment in a sanitary manner for one of 69 residents in the survey sample, Resident #130. The findings include: For Resident #130 (R130), the facility staff failed to store a CPAP (1) mask in a sanitary manner. Observation was made on 11/12/24 at 2:35 p.m. of R130 in her bed. The CPAP mask was on the nightstand, behind where resident could not reach, uncovered, sitting on the nightstand. A second observation was made on 11/19/24 at 3:45 p.m. of the CPAP mask sitting on the nightstand, behind the CPAP machine, not stored in a bag. A third observation was made of the CPAP mask sitting on the nightstand on 11/20/24 at 11:41 a.m. The physician dated, 10/31/24, documented, CPAP - specify setting: Rate: 16; Inspiratory: 14; Expiratory: 8; *Use sterile H2O only* every evening shift apply CPAP. On 11/20/24 at 11:41 a.m. LPN (licensed practical nurse) #17 was asked to observe the CPAP machine mask for R130. LPN #17 stated, it's 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 resident interview, staff interview and facility document review, it was determined the facility staff failed to follow up on a psychiatric consult for one of 69 residents in the survey sample, Resident #500. The findings include: For Resident #500 (R500), the facility staff failed to follow up on a psychiatric consult recommendation to increase the resident's antidepressant, Zoloft. An interview was conducted with R500 on 11/19/24 at 9:54 a.m. R500 stated that her antidepressant, Zoloft, was to be increased after she saw the psychiatric nurse practitioner, and it hadn't been increased. The psychiatric nurse practitioner note dated 11/4/24, documented in part, Recommendation: Pt (patient) admits to significant depression with passive death wishes in the setting of further decline in functioning and tension at home. She is also having difficulty adjusting to being here. She is amenable to dose increase of Zoloft. 1. Increase Zoloft to 100 mg (milligrams) po (by mouth) QD (every day) for moderate depression. The physician order dated, 11/1/24, documented, Sertraline HCl…

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

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure a medication error rate less than five percent for one of five residents observed during the medication administration observation, Resident #48. During the medication administration observation, two errors out of 25 opportunities occurred, resulting in an eight percent medication error rate. The findings include: For Resident #48 (R48), the facility staff failed to administer inhalers per physician's orders. LPN #13 failed to assist the resident with rinsing his mouth after Advair use and failed to wait five minutes between administering inhalers. A review of R48's clinical record revealed the following physician's orders: -5/20/24- Incruse Ellipta 62.5 micrograms, one inhalation by mouth one time a day for chronic obstructive pulmonary disease (lung disease). -10/18/24- Advair Diskus 250 micrograms, one inhalation by mouth every 12 hours for chronic obstructive pulmonary disease. Rinse mouth after use. Wait five minutes between different inhalers. R48'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 resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a meal tray for one of 69 residents in the survey sample, Resident #500. The findings include: For Resident #500 (R500), the facility staff failed to offer the resident a lunch tray on 11/19/24. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 11/8/24, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The physician order dated, 11/1/24, documented, Diabetic diet; regular texture, thin liquids consistency. An interview was conducted with R500 on 11/19/24 at 2:29 p.m. R248 stated she had never got a lunch tray today. An interview was conducted with CNA (certified nursing assistant) #8, who was assigned to R500, on 11/19/24 at approximately 2:32 p.m. When asked if she offered R500 a lunch tray today, CNA #8 stated the nursing students passed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and facility document review, it was determined the facility staff failed to provide a diet according to the resident's preferences for one of 69 residents in the survey sample, Resident #173. The findings include: For Resident #173 (R173), the facility staff failed to serve food according to his preferences. On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 10/25/24, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. An interview was conducted with R173 on 11/18/24 at approximately 12:15 p.m. R173 stated he can't eat bread, and the menu posted for the residents today has sandwiches for both lunch and dinner. R173 went and retrieved the menu that is posted. The menu posted documented chicken salad sandwiches for lunch and turkey deli sandwiches for dinner. A second interview…

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

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide meals at times comparable to normal mealtimes for two of 69 residents in the survey sample, Residents #301 and #247. The findings include: For Residents #301 (R301) and Resident #247 (R247), the facility staff failed to serve meals in a timely manner. On 11/12/24 at 1:47 p.m., staff were observed passing lunch trays to residents on the 300 unit. On 11/13/24 at 9:43 a.m., a meal cart was observed being delivered to the 200 unit. On 11/18/24 at 11:40 a.m., an interview was conducted with R301. The resident stated meals arrive late and he is hungry when they arrive. On 11/18/24 at 12:43 p.m., an interview was conducted with R247. The resident voiced concern regarding mealtimes. R247 stated breakfast can arrive as late as 10:00 a.m., and sometimes she does not receive dinner until 7:00 p.m. The facility mealtimes were documented as: Breakfast: Unit 1: 8:00 a.m. Unit 4 8:30 a.m. Unit 3 9:00 a.m. Unit 2 9:30 a.m. Lunch: Unit 1: 12:15 p.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.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the provider (physician and/or nurse practitioner) of missed doses of medication for one of 24 residents in the survey sample, Resident #24. The findings include: For Resident #24 (R24), the facility staff failed to notify the provider of multiple missed doses of Azithromycin (1) and Triumeq (2) in August and September 2024. A review of R24's clinical record revealed the following orders: 8/22/24 Azithromycin Oral Tablet 500 mg (milligrams) Give 1 tablet by mouth one time a day related to Disseminated Mycobacterium Avium-Intracellulare Complex (DMAC) (3). 8/22/24 Triumeq Oral Tablet (3) 600-50-300 mg .Give 1 tablet by mouth one time a day related to Human Immunodeficiency Virus (HIV) disease. A review of R24's September 2024 MAR (medication administration records) and pharmacy manifests revealed the Azithromycin was not available from the pharmacy between 9/1/24 and 9/5/24, and was not administered to R24 on those dates. Further review of R24's August and September…

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

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for two of 24 residents in the survey sample, Residents #24 and #20. The findings include: 1. For Resident #24 (R24), the facility staff failed to implement the comprehensive care plan to administer medications to treat advanced HIV (human immunodeficiency virus). A review of R24's comprehensive care plan updated 9/28/24 revealed, in part: The resident has an infection, HIV .medications as ordered. A review of R24's clinical record revealed the following orders: 8/22/24 Azithromycin Oral Tablet 500 mg (milligrams) (1) Give 1 tablet by mouth one time a day related to Disseminated Mycobacterium Avium-Intracellulare Complex (DMAC) (2). 8/22/24 Triumeq Oral Tablet (3) 600-50-300 mg .Give 1 tablet by mouth one time a day related to Human Immunodeficiency Virus (HIV) disease. A review of R24's September 2024 MAR (medication administration records) and pharmacy manifests revealed the Azithromycin was 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 staff interview, clinical record review, and facility document review, the facility staff failed to follow professional standards of practice for the administration of medications for one of 24 residents in the survey sample, Resident #24. The findings include: For Resident #24 (R24), the facility inaccurately documented a medication was given when it was not on hand to be administered. A review of R24's clinical record revealed the following orders: 8/22/24 Azithromycin Oral Tablet (1) 500 mg (milligrams) Give 1 tablet by mouth one time a day related to Disseminated Mycobacterium Avium-Intracellulare Complex (DMAC) (2). 8/22/24 Triumeq Oral Tablet (3) 600-50-300 mg .Give 1 tablet by mouth one time a day related to Human Immunodeficiency Virus (HIV) disease. A review of R24's September 2024 MAR (medication administration records) revealed the Azithromycin was not available from the pharmacy between 9/2/24 and 9/5/24. However, on 9/2/24 and 9/3/24, the facility staff documented on the MAR that the medication had been administered to R24. Further review of R24's August and…

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

Based on staff interview, facility document review, and clinical record review, the facility pharmacy failed to provide medication for administration to one of 24 residents in the survey sample, Resident #24. The findings include: For Resident #24 (R24), the facility pharmacy failed to provide Azithromycin (1) and Triumeq (2) for administration in August and September 2024. A review of R24's clinical record revealed the following orders: 8/22/24 Azithromycin Oral Tablet 500 mg (milligrams) Give 1 tablet by mouth one time a day related to Disseminated Mycobacterium Avium-Intracellulare Complex (DMAC) (3). 8/22/24 Triumeq Oral Tablet (3) 600-50-300 mg .Give 1 tablet by mouth one time a day related to Human Immunodeficiency Virus (HIV) disease. A review of R24's September 2024 MAR (medication administration records) and pharmacy manifests revealed the Azithromycin was not available from the pharmacy between 9/1/24 and 9/5/24. Further review of R24's August and September 2024 MARs and pharmacy manifests revealed the Triumeq was not available from the pharmacy from 8/23/24 through…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to administer medications as ordered, resulting in significant medication errors, to one of 24 residents in the survey sample, Resident #24. The findings include: For Resident #24 (R24), the facility pharmacy failed to administer Azithromycin (1) and Triumeq (2) on multiple dates in August and September 2024, resulting in multiple significant medication errors. A review of R24's clinical record revealed the following orders: 8/22/24 Azithromycin Oral Tablet 500 mg (milligrams) Give 1 tablet by mouth one time a day related to Disseminated Mycobacterium Avium-Intracellulare Complex (DMAC) (3). 8/22/24 Triumeq Oral Tablet (3) 600-50-300 mg .Give 1 tablet by mouth one time a day related to Human Immunodeficiency Virus (HIV) disease. A review of R24's September 2024 MAR (medication administration records) and pharmacy manifests revealed the Azithromycin was not available from the pharmacy between 9/1/24 and 9/5/24, and was not administered to R24 on those dates. Further review of…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to evidence the provision of medical records to a discharged resident for one of 24 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to provide the resident with requested medical records after the resident was discharged . A review of R6's clinical record revealed the resident was discharged from the facility on 8/6/24. On 9/27/24 at 10:32 a.m., OSM (other staff member) #5, the clinical liaison, was interviewed. She stated she was the former discharge planner, and was working in that capacity when R6 was at the facility. She stated she has heard from R6 many times since his discharge, and the resident is requesting a copy of all of his discharge documentation. She admitted she did not know exactly what information the resident was trying to obtain from the discharge paperwork, and that she does not have access in the EMR (electronic medical record) to a discharged resident's clinical information. She added: I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a resident with a written summary of the baseline care plan for one of 24 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), who was admitted on [DATE], the facility failed to provide evidence that the resident and RP (responsible party) received a written copy of the baseline care plan goals. A review of R1's clinical record revealed a care plan that was initiated at the time of R1's admission to the facility on 1/3/24. Further review of the clinical record failed to reveal evidence that a written summary of the baseline care plan was ever provided to the resident or his RP. On 9/27/24 at 10:32 a.m., OSM (other staff member) #5, the former admissions director and current clinical liaison, was interviewed. She stated she is aware that a baseline care plan is initiated on admission by nursing staff, but she was not aware or a part of any process to provide 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, facility document review, and clinical record review, the facility staff failed to serve food according to the menu for three of 24 residents in the survey sample, Residents #21, #22, and #23. The findings include: 1. For Resident #21 (R21), the facility staff failed to serve food according to the established menu at dinner on 9/26/24 and breakfast on 9/27/24. On 9/26/24 at 5:04 p.m., R21 was observed sitting in bed. CNA (certified nursing assistant) #2 was feeding the resident. The resident's meal tray contained chicken and carrots. The posted menu for dinner on 9/26/24 was honey mustard chicken, orzo, and California blend vegetables. No California blend vegetables or orzo were visible on the plate. On 9/27/24 at 8:33 a.m., R21 was observed sitting up in her bed. CNA #4 was preparing to feed R21 breakfast. The resident's plate contained mechanically chopped sausage, pancakes, and oatmeal. The posted menu for breakfast on 9/27/24 was Belgian waffle with topping and bacon strips. On 9/27/24 at 10:07 a.m., OSM (other staff member) #3, a dietary…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to serve palatable food for three of 24 residents in the survey sample, Residents #21, #22, and #23. The findings include: 1. For Resident #21 (R21), the facility staff failed to serve carrots at a palatable texture and temperature at dinner on 9/26/24, and failed to serve toast and oatmeal at a palatable texture and temperature at breakfast on 9/27/24. On 9/26/24 at 5:04 p.m., R21 was observed sitting in bed. CNA (certified nursing assistant) #2 was feeding the resident. The resident's meal tray contained chicken and carrots. CNA #2 was observed to attempt to cut the resident's carrots into smaller pieces before feeding them to her. CNA #2 was unable to cut the carrots with a fork or knife. CNA #2 said: These carrots are so hard I can't cut them. CNA #2 stated the carrots were cold to her touch. On 9/27/24 at 8:33 a.m., R21 was observed sitting up in her bed. CNA #4 was preparing to feed R21 breakfast. The resident's plate contained pancakes and oatmeal. CNA #4…

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

Based on observation, staff interview, and facility document review, the facility staff failed to serve food according to the residents' preferences for three of 24 residents in the survey sample, Residents #21, #22, and #23. The findings include: 1. For Resident #21 (R21), the facility staff failed to serve food according to the resident's preferences at dinner on 9/26/24 and at breakfast on 9/27/24. On 9/26/24 at 5:04 p.m., R21 was observed sitting in bed. CNA (certified nursing assistant) #2 was feeding the resident. R21's dinner meal ticket listed tea and apple juice as preferences. R21's dinner tray contained neither of these items. On 9/27/24 at 8:33 a.m., R21 was observed sitting up in her bed. CNA #4 was preparing to feed R21 breakfast. R21's breakfast meal ticket listed fresh fruit as a preference. The breakfast tray contained no fresh fruit. On 9/27/24 at 10:07 a.m., OSM (other staff member) #3, a dietary director at a sister facility, was interviewed. She stated: We have a menu in place, and I give the residents the menu for a whole day so they can choose. She stated the…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of seven residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to review and revise the resident's comprehensive care plan for a fall the resident sustained on 4/11/24. A review of R5's clinical record revealed a nurse's note dated 4/11/24 that documented the resident fell in the hallway. A review of R5's comprehensive care plan revised on 4/3/24 failed to reveal evidence that the care plan was reviewed and revised for the 4/11/24 fall (the care plan was not revised until after R5 sustained another fall on 4/16/24). On 4/23/24 at 1:20 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the purpose of the care plan is, so the staff really know each individual: what their goals are, why they are at the facility, what they are being treated for, and what the staff needs to do so everyone is on the same page as the resident's plan…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent accidents for one of seven residents in the survey sample, Resident #5. The findings include: Resident #5 (R5) fell on 4/11/24. The facility staff failed to address and/or implement interventions to prevent future falls and the resident fell again on 4/16/24. A review of R5's clinical record revealed a nurse's note dated 4/11/24 that documented the resident fell in the hallway. Further review of R5's clinical record (including the comprehensive care plan revised on 4/3/24 and nurses' notes dated 4/11/24 through 4/16/24) failed to reveal the facility staff addressed and/or implemented interventions to prevent future falls. A nurse's note dated 4/16/24 documented R5 was observed on the floor in the bathroom (the resident did not sustain an injury). On 4/23/24 at 1:20 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that if a resident falls, the nurses usually implement a new intervention depending on why…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for one of seven residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to ensure an Ambu bag (a tool that delivers air into the lungs during respiratory failure) was at the bedside per the physician's order. A review of R4's clinical record revealed the resident was admitted to the facility on [DATE] with a tracheostomy (1). A physician's order dated 11/14/23 documented to keep an Ambu-bag at the bedside. On 4/23/24 at 8:55 a.m., an interview was conducted with OSM (other staff member) #1 (a respiratory therapist). OSM #1 stated that a resident with a tracheostomy should have an Ambu bag kept at his or her bedside in case the resident goes into respiratory distress or codes. On 4/23/24 at 9:25 a.m., R4 was observed lying in bed and an observation of R4's room was conducted with OSM #1. OSM #1…

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

Based on observation, staff interviews, facility document review, and clinical record review, it was determined the facility staff failed to implement the care plan for one of eight residents in the survey sample, Resident #1. The findings include: For Resident #1, the facility staff failed to implement the comprehensive care plan for activities of daily living care; specifically incontinence care and turning/positioning. The most recent MDS (minimum data set) assessment, a discharge return not anticipated assessment, with an ARD (assessment reference date) of 1/20/24, coded the resident Section GG-functional abilities and goals as being moderate assist for personal hygiene and bathing. A review of the comprehensive care plan dated 12/21/23 revealed, FOCUS: SKIN: resident is at risk for pressure ulcers related to decline in mobility . risk for malnutrition and occasional incontinence. INTERVENTIONS: Assist the resident to turn and reposition often. Provide incontinence care as needed. A review of Resident #1's, ADL (activities of daily living) care for December 2023 revealed Bed…

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

Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide evidence of ADL (activities of daily living) care for one of eight residents in the survey sample, Resident #1. The findings include: For Resident #1, the facility staff failed to provide evidence of ADL care (specifically incontinence care and turning/positioning) on four occasions. The most recent MDS (minimum data set) assessment, a discharge return not anticipated assessment, with an ARD (assessment reference date) of 1/20/24, coded the resident Section GG-functional abilities and goals as being moderate assist for personal hygiene and bathing. A review of the comprehensive care plan dated 12/21/23 revealed, FOCUS: SKIN: resident is at risk for pressure ulcers related to decline in mobility . risk for malnutrition and occasional incontinence. INTERVENTIONS: Assist the resident to turn and reposition often. Provide incontinence care as needed. A review of Resident #1's, ADL (activities of daily living) care for December 2023…

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

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to honor a resident's right to make choices about their ADL (activities of daily living) care for two of 78 residents in the survey sample, Resident #195 and Resident #140. The findings include: 1. For Resident #195 (R195), the facility staff failed to provide showers as per their preference. On the most recent MDS (minimum data set), a 5-day admission assessment with an ARD (assessment reference date) of 9/30/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section G documented R195 being totally dependent on one staff member for bathing. On 10/12/2022 at 9:18 a.m., an interview was conducted with R195 in their room. R195 stated that they had only received bed baths since being admitted to the facility and had not been offered a shower. R195 stated that they would love to have a shower if the staff would offer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to notify the physician of a change in a resident's clinical condition for two of 78 residents in the survey sample, Residents #61 and #124. The findings include: 1. For Resident #61 (R61), the facility staff failed to notify the physician when the resident's systolic blood pressure (1) was greater than 160 (mm Hg-millimeters of mercury) eleven times during May 2022. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/12/22, R61 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). R61 was coded as receiving dialysis services during the look back period. A review of R61's current diagnoses revealed the resident has high blood pressure. A review of R61's clinical record revealed…

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

4. For Resident #304 (R304), the facility staff failed to implement the resident's comprehensive care plan for pressure injury treatments per the physician's orders. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/1/22, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R304's comprehensive care plan dated 3/28/22 documented, (R304) has actual skin breakdown present on admission: SACRUM- PRESSURE INJURY, LLE (left lower extremity) POSTERIOR .Administer treatment per physician order . A wound care nurse practitioner note dated 3/31/22 documented an unstageable pressure injury (1) on R304's left posterior lower leg (present on admission). A review of R304's clinical record revealed the following physician's orders regarding the resident's left posterior lower leg pressure injury: -A physician's order dated 3/28/22 to cleanse the left posterior lower leg with Dakin's (cleansing solution), skin prep the periwound,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #304 (R304) the facility staff failed to apply physician ordered Nystatin (1) powder to the resident's groin on 4/9/22 and complete physician ordered treatment to the resident's left medial lower leg arterial wound on 5/6/22 and 5/7/22. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/1/22, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R304's comprehensive care plan dated 3/28/22 documented, (R304) has actual skin breakdown present on admission. GROIN-IRRITATION/REDNESS .Administer treatment per physician order . A review of R304's clinical record revealed a physician's order dated 3/28/22 for Nystatin powder to be applied to the resident's groin every day and evening shift and a wound care nurse practitioner note dated 3/31/22 that documented erythema to R304's groin. Review of R304's April 2022 MAR (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, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide a safe environment for four of 78 residents in the survey sample, Residents #108, #60, #86, and #120. The findings include: 1. For Resident #108 (R108), the facility staff failed to provide smoking supervision per the safe smoking assessment, and failed to store the resident's cigarettes in a safe location. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 9/1/22, R108 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). The resident was coded as needing oversight for locomotion off the unit. On 10/12/22 at 10:54 a.m., R108 was observed sitting at a picnic table in an area between the facility and an adjacent building. The picnic table was surrounded by trees and bushes. The dirt path leading from the facility to the picnic table was cleared of debris, and contained 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 2. For Resident #64 (R64), the facility staff failed to store oxygen in a safe manner and failed to store respiratory equipment in a sanitary manner. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/12/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatment, Procedures and Programs, R64 was not coded as receiving oxygen. Observation was made of R64's room on 10/11/2022 at approximately 12:30 p.m. An unsecured oxygen tank was observed next to the resident's dresser, not in a stand. A second oxygen tank was observed under the window but was stored in a stand. This oxygen tank had oxygen tubing with a nasal cannula attached to the tank and not covered or stored in anything, just exposed to the air. A second observation was made on 10/11/2022 at 4:17 p.m. accompanied by LPN (licensed practical…

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

Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility failed to maintain a complete dialysis program for two of 78 residents in the survey sample, Residents #11 and #61. The findings include: 1. For Resident #11 (R11), the facility staff failed to provide evidence of the assessment of the resident's hemodialysis access site in March 2022, and from 4/1/22 through 4/12/22; and failed to maintain communication with the dialysis center on multiple dates between 6/2/22 and 10/10/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/11/22, R11 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). R11 was coded as receiving dialysis services during the look back period. A review of R11's clinical record revealed the following order dated 5/7/21: Hemodialysis Diagnosis: ESRD (end stage renal disease) Dialysis Days…

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

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to administer medications in a manner free of significant errors for one of 78 residents in the survey sample, Resident #61. The findings include: For Resident #61 (R61), the facility staff failed to administer Clonidine (1) as ordered when the resident's systolic blood pressure (2) was greater than 160 mm Hg (millimeters of mercury) eleven times during May 2022. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/12/22, R61 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). R61 was coded as having high blood pressure. A review of R61's clinical record revealed the following orders: Clonidine HCl Tablet 0/1 MG. Give 1 tablet by mouth every 12 hours as needed for systolic B/P (blood pressure) greater than 160. This order was dated 4/22/22. A review of R61's MARs…

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

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain dignity for two of 78 residents in the survey sample, Residents #130 and #54. The findings include: 1. For Resident #130 (R130), the facility staff failed to cover the resident's exposed lower body on 10/11/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/14/22, R130 was coded as being moderately cognitively impaired for making daily decisions, having scored eight out of 15 on the BIMS (brief interview for mental status). R130 was coded as requiring the extensive assistance of two staff members for bed mobility. On 10/11/22 at 2:03 p.m., R130 was sitting up in bed. The door to the resident's room was open, and the resident could be clearly seen from the hallway. R130 had nothing covering their lower body, and was wearing an incontinence brief. R130 intermittently called out to staff members as they walked by the resident's door. Staff members passed by R130's door 22…

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

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain a homelike environment for two of 78 residents in the survey sample, Residents #58 and #197. The findings include: 1. For Resident #58 (R58), the facility staff failed to maintain the resident's floor in good repair. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/11/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 10/11/22 at approximately 12:00 p.m. and 10/12/22 at 3:52 p.m., an observation of R58's room was conducted. Three sections of vinyl composite were missing from the floor. One section measured approximately three inches in length by five inches in width. Two other sections measured approximately three feet in length by five inches in width. The missing sections were located between the bed and privacy curtain. On 10/17/22 at 3:23 p.m., an…

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

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to act upon a reported grievance for missing personal items for one of 78 residents in the survey sample, Resident #62. The findings include: For Resident #62 (R62), the facility staff failed to fully investigate a known grievance in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/11/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 10/13/2022 at 12:57 p.m., an interview was conducted with R62. R62 stated that they had ongoing concerns about missing personal belongings at the facility. R62 stated that they had recently had clothing that had not been returned from the laundry which had been replaced by the social worker. R62 stated that they had lost a gray and white quilt which had their name in all four corners a few months prior and had…

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

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence required documents were sent to the receiving facility at the time of transfer for one of 78 residents in the survey sample, Resident #96. The findings include: For Resident #96 (R96), the facility staff failed to provide evidence that required clinical documentation, pertaining to the continuity of care, was sent to the receiving hospital on 8/8/22 when R96 was transferred to the hospital. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 28/26/22, R96 was coded as being cognitively intact for making daily decisions, having scored 14 out of 15 on the BIMS (brief interview for mental status). A review of R96's clinical record revealed the following progress note: 8/8/2022 13:21 (1:21 p.m.) .Clinical Note Text: Resident has complaints of pain and 'just not feeling well. Res (Resident) also crying. Wound care in to do dressing change and informed this writer that 'there has been a 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.

Based on staff interview and clinical record review, the facility staff failed to comprehensively complete an MDS (minimum data set) assessment for one of 78 residents in the survey sample, Resident #29. The findings include: For Resident #29 (R29), the facility staff failed to complete the mood interview, section D, on the five day Medicare MDS assessment with an ARD (assessment reference date) of 8/24/22. On the most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 8/24/22, the resident scored 8 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. Section B coded R29 as understood. In Section D, the resident mood interview was coded with dashes, indicating the resident mood interview was not completed. On 10/17/22 at 11:27 a.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated the therapy staff completes residents' mood interview assessments then she pulls that information from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, clinical record review and in the course of complaint investigations, the facility staff failed to provide residents with a summary of the baseline care plan for three of 78 residents in the survey sample, Residents #304, #195 and #140. The findings include: 1. For Resident #304 (R304), the facility staff failed to provide the resident with a summary of the baseline care plan. Resident #304 was admitted to the facility on [DATE] and discharged on 5/15/22. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/1/22, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A review of R304's clinical record failed to reveal the facility staff provided R304 with a summary of the baseline care plan. On 10/18/22 at 9:21 a.m., an interview was conducted with LPN (licensed practical…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 78 residents in the survey sample, Resident #304. The findings include: For Resident #304 (R304), the facility staff failed to review and revise the resident's comprehensive care plan when the resident developed a new left medial leg arterial wound on 5/3/22 which required treatment. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/1/22, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A review of R304's clinical record revealed a wound care nurse practitioner note dated 5/3/22 that documented a new arterial wound on R304's left medial lower leg. Review of R304's clinical record revealed a physician's order dated 4/30/22 to paint a small area of eschar (dead skin) with betadine and leave the area open to air every day shift. Review of R304'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 resident interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to follow professional standards of nursing for medication administration documentation for one of 78 residents in the survey sample, Resident #124. The findings include: For Resident #124 (R124) the facility staff falsely documented the administration of Sarvella (1) five times in September 2022. The facility staff documented the medication was administered when it was not available from the pharmacy for administration. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/12/22, R124 was coded as being cognitively intact, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as having experienced pain frequently during the look back period. On 10/13/22 at 9:05 a.m., R124 was sitting up in bed. R124 stated they have almost constant pain due to fibromyalgia. The resident stated the facility has not always administered fibromyalgia medication the way…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide monitoring for strict intake and output (I & O) for one of 78 residents, Resident #171. The findings include: The facility failed to provide monitoring for strict I & O for Resident #171. Resident #171 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: ESRD (end stage renal disease). The most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an ARD (assessment reference date) of 9/28/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring supervision for eating. A review of the comprehensive care plan dated 9/23/22 documented in part, DIALYSIS: the resident is at increased risk for complications secondary to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure required physician visits were conducted for one of 78 residents in the survey sample, Resident #94. The findings include: For Resident #94 (R94), the facility staff failed to ensure the resident was seen by a physician as required, since 5/25/22. R94 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/29/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 10/11/22 at approximately 12:30 p.m., an interview was conducted with R94. R94 stated the resident does not see a doctor that often. A review of R94's clinical record revealed the resident was seen by a nurse practitioner on 7/28/22, 8/5/22, 8/12/22, 8/15/22, 8/19/22, 9/23/22 and 10/2/22, however the resident 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 resident interview, facility staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide a medication as ordered by the physician for one of 78 residents, Resident #124. The findings include: For Resident #124 (R124) the facility staff failed to provide Sarvella (1) for administration, as ordered by the physician, on multiple dates in September and October 2022. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/12/22, R124 was coded as being cognitively intact, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as having experienced pain frequently during the look back period. On 10/13/22 at 9:05 a.m., R124 was sitting up in bed. R124 stated they have almost constant pain due to fibromyalgia. The resident stated the facility has not always administered fibromyalgia medication the way the doctor ordered. A review of R124's clinical…

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

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to monitor a resident on psychoactive medication, in order to prevent unnecessary medication administration for one of 78 residents in the survey sample, Resident #96, The findings include: For Resident #96 (R96), the facility staff failed to monitor for the presence of targeted behaviors and adverse side effects while the resident was receiving a psychoactive medication. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/26/22, R96 was coded as being cognitively intact for making daily decisions, having scored 14 out of 15 on the BIMS (brief interview for mental status). R96 was coded as receiving psychoactive medications during the look back period. A review of R96's clinical record revealed the following orders: Buspirone HCl (1) Tablet 10 mg (milligrams) Give 1 tablet by mouth three times a day for anxiety. This order was dated 8/14/22. Citalopram Hydrobromide (2) Tablet 20 mg Give 1 tablet by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was determined the facility staff failed to maintain a medication error rate of less than five percent for one of four residents in the medication administration observation, Resident #87 (R87). There were two errors within 25 opportunities. The findings include: For R87, the facility staff failed to administer medications per the physician order and failed to check a blood sugar per physician order. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/24/2022, the resident scored a 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. Observation was made of LPN (licensed practical nurse) #2 administering medications to R87, on 10/12/2022 at 9:29 a.m. The resident was sitting in their room in a wheelchair with an empty breakfast tray in front of them. LPN #2 first checked the resident's blood pressure. She then proceeded to perform the blood sugar check…

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

Based on observation, staff interview, clinical record review, and facility document review it was determined that the facility staff failed to provide routine dental services for one of 78 residents in the survey sample, Resident #54 (R54). The findings include: For R54, the facility staff failed to offer routine dental services. R54's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/9/2022, the resident scored 8 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section K documented a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and R54 receiving a mechanically altered diet. Section L documented no mouth pain or dentures. On 10/12/2022 at 8:38 a.m., an observation was made of R54 in their room. An attempt was made to interview R54, however due to their cognitive status the interview was not completed. Observation of R54 revealed a single visible tooth protruding from the mouth. 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 resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain an accurate clinical record for one of 78 residents in the survey sample, Resident #124. The findings include: For Resident #124 (R124), the facility staff failed to maintain an accurate MAR (medication administration record) in September 2022 for the administration of the medication, Sarvella (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/12/22, R124 was coded as being cognitively intact, having scored 15 out of 15 on the BIMS (brief interview for mental status). On 10/13/22 at 9:05 a.m., R124 was sitting up in bed. R124 stated they have almost constant pain due to fibromyalgia. The resident stated the facility has not always administered fibromyalgia medication the way the doctor ordered. A review of R124's clinical record revealed the following order dated 8/21/22: Savella Tablet 25 mg (milligrams) (Milnacipran HCl) Give 1 tablet by mouth two times a day…

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

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow transmission based precautions for one of 78 residents in the survey sample, Resident #96. The findings include: For Resident #96 (R96), the facility staff failed to properly dispose of contaminated medical waste after providing wound care on 10/12/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 28/26/22, R96 was coded as being cognitively intact for making daily decisions, having scored 14 out of 15 on the BIMS (brief interview for mental status). On 10/12/22 at 8:39 a.m., RN (registered nurse) #6 provided wound care to R96. On R96's door was a sign stating that all who entered the room should follow contact precautions. RN #6 stated R96 had a wound infected with an extremely contagious strep bacteria. RN #6 donned an isolation gown and gloves before entering R96's room. After the old dressings were removed, the wounds cleansed, and the new dressings applied, RN #6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide written notice to the resident and or resident representative, including the reason for the change, before the resident's room or roommate in the facility is changed for eighteen of 84 residents in the survey sample, (Residents #510, #111, #29, #153, #30, #75, #26, #512, #66, #513, #139, #515, #13, #516, #517, #511, #514 and #383). The facility staff failed to evidence written notification for multiple room changes were provided to the resident represenative and or Residents #510, #111, #29, #153, #30, #75, #26, #512, #66, #513, #139, #515, #13, #516, #517, #511, #514 and #383. The findings include: 1. The facility staff failed to evidence written notice of the room change provided to the Resident #510/RR (resident representative) for room transfers on 6/2/21, 6/30/21, 7/19/21, and 8/5/21. Resident #510 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. The facility staff failed to implement Resident #145's comprehensive care plan for the administration of oxygen at the physician ordered rate. Resident #145 was admitted on [DATE] with the diagnoses of but not limited to COVID-19, respiratory failure, atrial fibrillation, and hypothyroidism. The most recent MDS (Minimum Data Set) was an admission assessment with an ARD (Assessment Reference Date) of 9/9/21. The resident was code as being cognitively impaired in ability to make daily life decisions. Resident #145 was coded as requiring extensive assistance for bathing, hygiene, toileting, dressing, and bed mobility; and limited assistance for transfers and eating. On 9/28/21 at 12:53 PM, an observation of Resident #145 and the resident's oxygen was conducted. The resident was observed receiving oxygen via a nasal cannula that was connected to an oxygen concentrator that was running. The oxygen concentrator flow rate was set at 1 liter per minute, as evidenced by the flow meter ball set on the 1 liter line with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to review and revise the comprehensive care plan for eight of 84 residents in the survey sample, Residents #502, #91, #111, #65, #21, #19, #155, and #47. 1. The facility staff failed to review and revise Resident #502's comprehensive care plan to address the resident being found physically restrained on 5/6/21, and the resident care needs post the incident. 2. The facility staff failed to review and revise Resident #91's comprehensive care plan following the resident's angry outburst, during which he fractured his hand by punching a hole in his wall on 6/21/21. 3. The facility staff failed to review and revise Resident #111's comprehensive care plan after the resident fell on 7/6/21 and 7/7/21. 4. The facility staff failed to review and revise Resident #65's comprehensive care plan after the resident fell on 6/17/21, 6/24/21 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure the weights were monitored per the comprehensive person-centered plan of care for two of 84 residents in the survey sample, (Resident #153 and Resident #82); and failed to ensure physician ordered wound treatments were provided as ordered for one of 84 residents in the survey sample, (Resident #433). 1. Resident #153 was identified as being at risk nutritionally with interventions to obtain weights, monitor for weight loss and report significant weight loss, and had not been weighed since 3/6/21. 2. Resident #82 was assessed and identified as being at risk nutritionally with interventions to obtain weights, monitor for weight loss and report significant weight loss and had not been weighed since 5/8/21. 3. The facility staff failed to provide the physician ordered treatments to Resident #433's left hip surgical wound on multiple dates during April and May 2021.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview, clinical record review, facility document review and in the course of a complaint investigation the facility staff failed to provide the necessary treatment and services, to promote healing of a pressure ulcer for five of 84 residents in the survey sample, Resident #433, Resident #142, Resident #22, Resident #153 and Resident #129. 1. The facility staff failed to provide the physician ordered treatments to Resident #433's sacral pressure injury on multiple dates during April and May 2021. 2. The facility staff failed to provide the physician ordered treatments to Resident #142's left lateral foot (stag), right elbow (stage), sacral (stage) and left lateral heel (what stage it is) pressure injuries on multiple dates during September 2021. 3. The facility staff failed to provide physician ordered treatments for Resident #22's pressure injuries on multiple dates in July 2021, August 2021 and September 2021. 4. The facility staff failed to provide treatments as ordered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of complaint investigation, it was determined that the facility staff failed to provide supervision, and interventions to prevent accidents for four of 84 residents in the survey sample, Residents #111, #65, #19, and #40. The facility staff failed to address and/or implement fall prevention interventions to prevent further falls, for Resident #111 after the resident fell on 7/6/21 and 7/7/21, for after Resident #65 after the resident [NAME] on 6/17/21, 6/24/21 and 6/25/21 and for Resident #19, after the resident fell on 1/5/21, 2/16/21 and 3/15/21; and failed to provide supervision to Resident #40 while he smoked on 9/28/21. Resident #40 was assessed as requiring supervision while smoking for his safety. The findings include: 1. The facility staff failed to address and/or implement fall prevention interventions to prevent further falls, after Resident #111 fell on 7/6/21 and 7/7/21.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide respiratory care and services in accordance with professional standards and the resident plan of care for four of 84 residents in the survey sample, Residents #501, #22, #145, and #165. The facility staff administered oxygen to Resident #501 without a physician's order, failed to store Resident #22's oxygen tubing in a clean and sanitary manner; failed to administer oxygen to Resident #145 at the physician ordered rate, and failed to ensure Resident #165's incentive spirometer was maintained in a sanitary manner. The findings include: 1. Resident #501 was admitted to the facility on [DATE] with diagnoses including pulmonary hypertension, bladder cancer, prostate cancer, and Parkinson's disease. The resident was not in the facility long enough to have a MDS (minimum data set) assessment completed. On…

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

Based on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to implement a complete pain management program for one of 84 residents in the survey sample, Resident #153. The facility staff failed to attempt /provide non-pharmacological interventions prior to administering as needed pain medication to Resident #153 on multiple dates in August 2021 and September 2021. The findings include: Resident #153 was admitted to the facility with diagnoses that included but were not limited to bipolar disease (1), pressure ulcer of sacral region, stage 4 (2) and quadriplegia (3). Resident #153's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/13/2021, coded Resident #153 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired for making daily decisions. Section J coded Resident #153 as receiving scheduled and as needed pain medications. Section J further coded Resident #153 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 and facility document review, it was determined the facility staff failed maintain food in a safe and sanitary manner. A gallon of whole milk unopened with an expiration date of 9/24/21 and one-half of a gallon of whole milk with an expiration date of 9/24/21 were found in the refrigerator. The findings include: On 9/28/21 at 10:55 AM, an observation was conducted in the main kitchen. In the refrigerator a gallon of whole milk unopened with an expiration date of 9/24/21 and one-half of a gallon of whole milk with an expiration date of 9/24/21 were found. An interview was conducted on 9/28/21 at 11:10 AM with OSM (other staff member) #1, the chef. When asked the expiration for milk, OSM #1 stated, Yes, the opened whole milk with best by date of 9/24/21 will get discarded on 9/30/21. If it were an unopened gallon with date of 9/24/21, I would discard it now. When OSM #1, was shown the gallon of whole milk unopened with date of 9/24/21. OSM #1 stated, I'll discard this now. An interview was conducted on 9/28/21 at 11:40 AM with OSM #2, the dietary manager. When…

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

Based on staff interview and facility document review, it was determined the facility staff failed to have a written dialysis agreement for the facility. The facility failed to have current written contracts with two dialysis companies being utilized for residents. The facility failed to ensure new contracts were obtained when undergoing a CHOW (change of ownership) in January 2020. The findings include: During the entrance conference to the facility on 9/28/21, a request was made for the dialysis contracts or agreements to be provided. On 9/29/21, a review of the dialysis contracts evidenced contracts dated 2009 and 2013 for the one dialysis company. On 10/4/21 at approximately 1:30 PM, ASM (administrative staff member) #1, the administrator, brought in requested documents including the facility policy End-Stage Renal Disease, Care of a Resident with no date on policy. There was an attached sticky note to the policy documenting Verbal agreement for dialysis. On 10/4/21 at 1:51 PM ASM #1, the administrator, brought papers to the survey team and stated, We have a verbal agreement…

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

Based on clinical record review, staff interview and facility document review and in the course of a complaint investigation it was determined that the facility staff failed to notify the responsible party of an fall and physician orders for diagnostic testing for one of 84 residents in the survey sample, Resident #383. The facility staff failed to evidence Resident #383's responsible party was notified on Resident #383's fall on 6/2/21 and the physician order for an x-ray of the resident's left knee. The findings include: Resident #383 was admitted to the facility with diagnoses that included but were not limited to fracture of left femur (1) and major depressive disorder (2). Resident #383's most recent MDS (minimum data set), a discharge assessment with an ARD (assessment reference date) of 6/5/2021, coded Resident #383 as scoring a 15 on the brief interview for mental status (BIMS) scale, 15- being cognitively intact for making daily decisions. Section J documented Resident #383 having one fall without injury since admission. The admission record for Resident #383 documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, it was determined the facility staff failed to issue an advanced beneficiary notification for the ending of skilled services for three of three residents in the survey sample, (Residents #132, #13 and #483). The facility staff failed to issue an advanced beneficiary notice upon discontinuing Medicare services for Resident #132 on 7/14/202, Resident #13 on 7/17/2021, and Resident #483 on 9/16/2021, thus not allowing the residents and/or their responsible party's to appeal the discharge from services decision. The findings include: 1. The facility staff failed to issue an advanced beneficiary notice to Resident #132 upon discontinuing Medicare services on 7/14/202, thus not allowing the resident and/or their responsible party to appeal the discharge from services decision. Resident #132 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: depression, dementia (a progressive state of mental decline, especially memory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a clean, comfortable, homelike environment for one of 84 residents in the survey sample, Resident #72. The facility staff failed to clean Resident #72's bed rail. On 9/28/21, 9/29/21 and 9/30/21, a brown substance was observed on the resident's left bed rail. The findings include: Resident #72 was admitted to the facility on [DATE]. Resident #72's diagnoses included but were not limited to diabetes, dementia and osteoarthritis. Resident #72's significant change in status minimum data set assessment with an assessment reference date of 8/5/21, coded the resident's cognitive skills for daily decision making as moderately impaired. On 9/28/21 at 12:17 p.m. and 9/29/21 at 10:41 a.m., Resident #72 was observed lying in bed. A brown substance (approximately one and a half inch in length by a half inch in width) was observed on the left bed rail. On 9/30/21 at 8:49…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to act upon and make prompt efforts to resolve a reported grievance for one of 84 residents in the survey sample, Resident #153. The facility staff failed to evidence Resident #153's verbal grievance regarding a missing clothing item was promptly acted upon and efforts made to resolve the resident's grievance. The findings include: Resident #153 was admitted to the facility with diagnoses including but not limited to bipolar disorder (1) and diabetes (2). Resident #153's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #153 as scoring a 12 on the brief interview for mental status (BIMS) assessment, 12- being moderately impaired for making daily decisions. On [DATE] at approximately 3:37 p.m., an interview was conducted with Resident #153. Resident #153 stated that they had attended 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide documented evidence of facility-initiated transfer requirements for two of 84 residents in the survey sample, Residents #111 and #72. 1.a. Resident #111 was transferred to the hospital on 8/30/21. The physician failed to document the basis for the transfer, the specific resident needs that could not be met, facility attempts to meet the resident needs and the service available at the receiving facility to meet the resident's needs. 1.b. The facility staff failed to provide evidence that all required information was provided to the hospital staff when Resident #111 was transferred to the hospital on 9/6/21. 2. The facility staff failed to provide evidence that all required information was provided to the hospital staff when Resident #72 was transferred to the hospital on 7/18/21. The findings include: 1.a. Resident #111 was admitted to the facility on [DATE]. Resident #111'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide written notice of transfer to a RR (resident representative) and/or the ombudsman for three of 84 residents in the survey sample, Residents #111, #72 and #19. 1. Resident #111 was transferred to the hospital on 8/30/21 and on 9/6/21. A. The facility staff failed to provide written notification of the transfer to the resident's representative and the ombudsman for the 8/30/21 transfer, and B. failed to provide written notification of the transfer to the resident's representative for the 9/6/21 transfer. 2. Resident #72 was transferred to the hospital on 7/18/21. The facility staff failed to provide written notification of the transfer to the resident's representative. 3. Resident #19 was transferred to the hospital on 7/31/21. The facility staff failed to provide written notification of the transfer to the ombudsman The findings include: 1. A. Resident #111 was admitted 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, clinical record review, and facility document review, it was determined that the facility staff failed to complete a significant change MDS (minimum data set) assessment for one of 84 residents in the survey sample, Resident #47. The facility staff failed to complete a significant change MDS assessment after dialysis services for the resident were discontinued due to improved laboratory values on 9/6/21. The findings include: Resident #47 was admitted to the facility on [DATE] with the diagnoses of but not limited to metabolic encephalopathy, chronic obstructive pulmonary disease, congestive heart failure, atrial fibrillation, somatoform disorder, angina, depression, insomnia, high blood pressure, end stage renal disease, and dysphagia. The most recent MDS (Minimum Data Set) was an admission/5-day assessment with an ARD (Assessment Reference Date) of 7/22/21. The resident was coded as being cognitively impaired in ability to make daily life decisions. Resident #47 was coded as requiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure a preadmission screening and resident review, (PASARR) was completed and or completed accurately for two of 84 residents in the survey sample, Resident #160 and Resident #22. 1. The facility failed to ensure a PASARR was completed upon admission for Resident #160. 2. The facility staff failed to thoroughly complete Resident #22's level I PASRR (Preadmission Screening and Resident Review) and failed to refer the resident for a level II PASRR as recommended. The findings include: 1. Resident #160 was admitted to the facility on [DATE]. Resident #160's diagnoses included but were not limited to: end stage renal disease (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (1) and schizophrenia (mental disorder characterized by gross distortions of reality, withdrawal from social contacts and disturbances of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to follow professional standards of practice for two of 84 residents in the survey sample, Resident #153, and #129. The facility staff failed to clarify a duplicate physician order for Alpralozem for Resident #153, and failed to transcribe a telephone order for treatment of Resident #129's pressure ulcer. (1) The findings include: 1. Resident #153 was admitted to the facility with diagnoses that included but were not limited to bipolar disease (1) and pressure ulcer of sacral region, stage 4 (2). Resident #153's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #153 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired for making daily decisions. The physician order summary dated [DATE] documented in part the following: - Alprazolam…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview, facility document review and clinical record review, it was determined the facility staff failed to evidence ongoing communication and collaboration with the dialysis facility for one of 84 residents, Resident #110. The facility staff failed to evidence ongoing communication and collaboration with Resident #110's dialysis center. Multiple dialysis progress notes were incomplete and or missing in June 2021, July 2021, August 2021 and September 2021. The findings include: Resident #110 was admitted to the facility on [DATE]. Resident #110's diagnoses included but were not limited to: diabetes mellitus (1), end stage renal disease (2) and schizophrenia. (3) Resident #110's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/27/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, it was determined the facility staff failed to assess the risks and benefits of side rails for two of 84 residents in the survey sample, Resident #127 and Resident #67. The facility staff failed to evidence that the risks / benefits for the use of side rails had been reviewed with Resident #127 and Resident #67 prior to use of side rails. The findings include 1. The facility staff failed to evidence the risks / benefits for the use of side rails had been reviewed with Resident #127 prior to use. Resident #127 was admitted to the facility on [DATE]. Resident #127's diagnoses included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), chronic obstructive pulmonary disease 'COPD' (chronic and non-reversible lung disease) (2) and congestive heart failure 'CHF' (circulatory congestion and retention of salt/water by the kidneys) (3). Resident #127's most recent MDS (minimum data set) assessment, an annual…

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

Based on staff interview and employee record review, it was determined the facility staff failed to document the annual training to include in dementia and abuse and neglect, for four of five CNA (certified nursing assistant), (CNA # 13, #14, #6 and #16). The findings include: The list of CNAs, employed greater than one year, was provided by ASM (administrative staff member) #1, the administrator, on 10/4/2021 at approximately 12:30 p.m. The list consisted of 38 CNA names and hire dates. Five CNA employee training records were reviewed, CNA #13, #14, #15, #6 and #16. A request was made for the annual performance reviews and documentation of the required educations for CNAs to include abuse and dementia. On 10/4/2021 at 4:17 p.m. RN (registered nurse) #3, the quality assurance and infection preventionist nurse, provided training documents from the following dates and the training that was performed: 4/29/2021 - dementia and Alzheimer's disease training 4/29/2021 - abuse and neglect training 6/10/2021 - abuse and neglect training 10/1/2021 - dementia training 10/2/2021 - abuse 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 and staff interview, it was determined the facility staff failed had expired medications and IV (intravenous) fluids that were available for use in one of two medication rooms and one of four medication carts, Wing Two medication room and Wing Two front hall medication cart. In the Wing two medication room, three bags of IV solution, Dextrose 5% with .9%Normal Saline were observed available for resident use. Two of the bags expired Sep (September) 2021 and one bag documented the expiration date of [DATE]. In the front hall medication cart for Wing two on 10/5/2021, a bottle of Aspirin 325 mg (milligrams) was opened on 2/4/2021 and available for resident use. The expiration date on the bottle documented, expired 7/2021. A bottle of One Daily Multivitamin was open, available for resident use and had an expiration date documented on the bottle that read, Best by: 11/20. The findings include: Observation was made of the mediation room on Wing two on 10/5/2021 at 8:15 a.m. There were three bags…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to provide timely laboratory services for one of 84 residents in the survey sample, Resident #13 and failed to ensure laboratory supplies past their expiration date were not available for use in one of two medication rooms observed, Wing two medication room. 1. The facility staff failed to ensure timely results of an ordered urinalysis for urinary tract infection symptoms for Resident #13. Resident #13 complained of concerns of a urinary tract infection with a urinalysis ordered on [DATE], collected on [DATE] and results still pending from laboratory on [DATE] when discussed with facility staff. 2. A box of Hemoccult slides (1), approximately half full, with an expiration date of [DATE], was found available for resident use in the Wing two medication room. The findings include: 1. Resident #13 was admitted to the facility with diagnoses that included but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete clinical record for two of 84 residents in the survey sample, Residents #111 and #158. The facility staff failed to maintain a physician's note in Resident #111's and Resident #158's clinical records. The findings include: 1. Resident #111 was admitted to the facility on [DATE]. Resident #111's diagnoses included but were not limited to diabetes, dementia and anxiety disorder. Resident #111's quarterly minimum data set assessment with an assessment reference date of 8/28/21, coded the resident's cognition as severely impaired. Review of Resident #111's clinical record revealed a nurse's note dated 9/6/21 that documented the resident was transferred to the hospital due to a fall. Further review of Resident #111's clinical record failed to reveal physician documentation regarding Resident #111's hospital transfer. On 9/30/21 at approximately 8:00 a.m., ASM…

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