Kings Daughters Community Health & Rehab

Based on staff interviews, resident interviews, clinical record reviews, and facility documentation review the facility staff failed to ensure residents were provided pharmaceutical services that included administration of medications to meet the needs of each resident. The findings included:The facility staff failed to have a licensed nurse on the medication cart to administer medications for approximately 12 hours on 1/31/26.On 5/12/26 at 4:30 pm, an interview was conducted with a licensed practical nurse, LPN3. During the interview, LPN3 stated that LPN2 apparently passed the medications on the west wing unit A hall but didn't pass any medication on the b hall. She stated that some of the residents on the b hall were complaining and went to the east wing unit to see if the nurse on that unit could give them medications and she told them she didn't have keys to their medication cart and she gave the residents grievance forms to fill out with their concerns. LPN3 also stated that LPN 2 was suppose to call her and let her know who received medications and who did not get their…

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

Based on observation, resident interviews, staff interviews, and facility documentation the facility staff failed to ensure resident furnishings and equipment were maintained in good repair and safe condition for one resident, Resident #7 (R7) out of a survey sample of nine residents. The findings included:The facility staff failed to ensure that the resident's furniture was safe and functional.On 5/13/26 at 11:15 am, an observation was made of R7 in her room holding the facing of a dresser drawer after the drawer had fallen apart. The resident's belongings were observed lying on the floor. While the surveyor was present in the room the maintenance assistant entered to repair the wrong piece of furniture and had to be redirected to the broken dresser drawer. The maintenance assistant picked up the broken wood, stated someone would be in to sweep the floor, and reported the drawer would be fixed. R7 reported that the dresser drawer facing had struck her knee when the drawer fell apart, and the concern was reported to nursing staff.On 5/13/26 at 11:15 am, an interview was conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview and facility document review, the facility staff failed to provide services of a registered nurse (RN) for at least 8 consecutive hours per day on three of seventeen days in December 2025 (12/7/25, 12/13/25 and 12/14/25).The findings include:On 12/17/25 at 10:25 a.m., the facility's as-worked nursing schedule for December 2025 was reviewed. The as-worked schedule documented no RN work hours on 12/7/25, 12/13/25 or 12/14/25.On 12/17/25 at 10:30 a.m., the scheduler (other staff #6) was interviewed about the days listed in December 2025 without RN coverage. The scheduler stated that no RNs worked on 12/7/25, 12/13/25 or 12/14/25 as she had no RN available to work. The scheduler stated the DON was on-call but that no RN actually worked on those dates.On 12/17/25 at 10:50 a.m., the director of nursing (DON) was interviewed about no RN coverage on the dates listed above. The DON stated the RN that typically worked weekends was out of medical leave on those dates and not available to work. The DON stated she had an abundance of licensed practical nurses but that she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to follow physician orders for medication administration for four of eleven residents in the survey sample (Residents #1, #4, #7 and #8).The findings include: 1. Registered nurse (RN) #1 administered the medication methadone 5 mg (milligrams) to Resident #4 when the physician's order required a 2.5 mg dose.Resident #4 was admitted to the facility with diagnoses that included osteoarthritis, hypertension, chronic kidney disease, liver cirrhosis, mood disorder, atrial fibrillation, chronic pain and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed Resident #4 with moderately impaired cognitive skills.Review of Resident #5's clinical record revealed a physician's order dated 6/28/24 for methadone 5 mg (milligrams) at each bedtime for treatment of chronic pain. This order was discontinued on 5/9/25 with a physician's order entered for methadone 5.0 mg, with instructions to give 1/2 tab (2.5 mg) at each bedtime for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to follow professional standards of care during medication administration for one of eleven residents (Resident #11).The findings include:A medication pass observation was conducted on 12/16/25 at 8:25 a.m. with licensed practical nurse (LPN #2) administering medications to Resident #11. Among medications administered to Resident #11 was one inhalation of Breo Ellipta (fluticasone furoate-vilanterol) aerosol powder 100-125 micrograms/actuation (mcg/act). After Resident #11 inhaled the medication from the device, LPN #2 administered the other prescribed oral medications. LPN #2 provided prompt or request for Resident #11 to rinse the mouth after inhaling the Breo Ellipta medication.Resident #11's clinical record documented a physician's order dated 7/10/25 for Breo Ellipta inhalation aerosol powder with breath activated device, 100-25 mcg/act with instructions to inhale one puff daily for treatment of COPD (chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of eleven residents in the survey sample (Resident #5).The findings include:Resident #5 was admitted to the facility with diagnoses that included schizoaffective disorder, hypertension, insomnia, protein-calorie nutrition and dysphagia. The minimum data set (MDS) dated [DATE] assessed Resident #5 as cognitively intact.Resident #5's clinical record documented physician orders for treatment of head lice starting on 8/17/25 that included RID Super Max 5-in-1 kit, nit combing each day and contact precautions. The lice treatment was initiated on 8/17/25 with treatment/precautions discontinued on 8/25/25.Resident #5's clinical record included no notes regarding the assessment of head lice, any associated symptoms or notification to the provider.On 12/17/25 at 9:45 a.m., the licensed practical nurse infection preventionist (LPN #1) was interviewed about documentation in Resident #5's…

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

Based on observation, staff interview and facility document review, the facility staff failed to follow infection control practices during a medication pass on one of two units (East unit).The findings include: A medication pass observation was conducted on 12/16/25 at 8:45 a.m. with licensed practical nurse (LPN #3) administering medications to an East unit resident (Resident #11). LPN #3 used hand sanitizer prior to the start of the medication pass. LPN #3 removed oral medications for the resident that included aspirin, simethicone, omeprazole, and vitamin D from supply bottles, touching/handling the tablets/pills with her bare fingers/hands prior to placement in the medicine cup. LPN #3 then administered the oral medications to Resident #11.On 12/16/25 at 8:50 a.m., LPN #3 was interviewed about touching the medications with bare fingers/hands. LPN #3 stated that directly touching the tablets/pills was probably not a good habit.On 12/16/25 at 10:35 a.m., the East unit manager (LPN #6) was interviewed about LPN #3 directly touching pills/tablets during the medication pass…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure medication was available for administration for one of 26 residents, Resident #124, during the medication pass and pour observation. The findings include: During a medication pass and pour observation, conducted on 7/24/24 at 8:00 AM, Resident #124 (R124) was scheduled to receive the medication telmisartan 40 MG. License practical nurse (LPN #3) looked into the medication cart and verbalized that the telmisartan was not available to give. LPN #3 then looked for the medication in the medication room, indicated that the medication was not on hand, called the pharmacy to reorder the medication, and then verbalized that the telmisartan would be sent later in the day. On 7/24/24 at 9:15 AM, the director of nursing (DON) verbalized that the physician had been notified and an order was received to hold the telmisartan and give when the medication arrived from the pharmacy. The physician's order for R124's telmisartan was reviewed and documented: Telmisartan 40 MG Tablet one time a day for…

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

Based on observation and staff interviews, the facility staff failed to post in a readily accessible place, inspection reports with a plan of corrections in effect, with respect to any surveys conducted during the past 3 years. The facility's non-compliance has the potential to impact all 112 Residents and their family's ability to make informed decisions with knowledge of the facility's regulatory compliance history. The findings included: The facility staff failed to have readily accessible to Residents and family members, the survey results with any plan of correction in effect for the surveys conducted for the past 3 preceding years. On 3/20/24 at approximately 11 a.m., the survey team observed the facility's survey results which were in the lobby. There was a typed document that read, Required to be retained for 18 months (includes full survey cycle). Observation of the posted survey results revealed that it contained the survey report from a standard survey conducted 1/31/23-2/2/23. The survey team reviewed the state survey agency website and determined that the facility had…

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

Based on resident interview, staff interview and facility documentation review, the facility staff failed to respond to resident council grievances, which had the potential to affect many residents on 3 of 3 nursing units. The findings included: 1. The resident council made a request for a monthly resident choice meal that was not responded to for a year. On 3/19/24-3/20/24, the resident council minutes for the past year were reviewed. It was noted that each month from January 2023-December 2023, the residents continued to verbalize that the resident choice meal they had selected had not been honored. The January 2023, minutes read, still wants what they didn't get. This notation went on until May 2023, when it was noted, this concern was resolved. However, in July, it was again noted that the residents didn't receive their resident choice meal. In October it was noted that the residents selected a meal which included fried chicken, potato salad, macaroni and cheese and lemon meringue pie. On 3/19/24-3/20/24, interviews were conducted with multiple residents, which included the…

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

Based on staff interview and facility documentation review, the facility staff failed to report allegations of abuse, neglect, and mistreatment to the required regulatory agencies, which involved 26 resident allegations of abuse and/or mistreatment, in a sample of 33 allegations reviewed. The findings included: In response to concerns that allegations of abuse/neglect/mistreatment were not being thoroughly investigated and the apparent lack of resident protection during the investigation of the allegations, the facility was notified that immediate jeopardy had been identified. While implementing the removal plan, the facility conducted resident interviews, which resulted in 26 additional investigations being initiated, which required reporting to the state survey agency and adult protective services. The facility documentation revealed that the residents who reported allegations of abuse, neglect and/or mistreatment included Resident #9, 10, 11, 14, 15, 16, 24, 27, 31, 39, 41, 44, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, and 60. On 4/2/24, during a review of the…

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

Based on observation, resident interview, staff interview, facility document review and clinical record review the facility staff failed to ensure residents receive treatment and care in accordance with professional standards of practice for numerous residents residing on 2 of 3 nursing units. The findings included: The facility staff failed to respond to call bells in a timely manner for residents requesting assistance on 2 of 3 nursing units. On 3/19/24 at 3:38 PM, resident #7 (R7) was interviewed regarding staff response to call bells. R7 recalled waiting for assistance in the bathroom so long her leg went numb. On 3/19/24 at 3:56 PM, resident #9 (R9) was interviewed and stated that response time isn't good, sometimes I have to wait 40-45 minutes more than I should. R9 also stated the day prior she sat on the toilet for an hour waiting for a roll of toilet paper. On 3/20/24 at 10:30 AM, surveyor entered residents room finding the call bell lying on the floor under the bed, the resident's roommate pushed the bell for assistance. Licensed practical nurse #4 (LPN #4), who was the…

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

Based on observations, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure 3 Residents (Resident #36, #35, and #31) who received dialysis services received care and treatment consistent with professional standards of practice, in a survey sample of 3 residents reviewed for dialysis services. The findings included: 1. For Resident #36, the facility staff failed to monitor the resident's vital signs before and after dialysis treatments and observe the dialysis access site for complications. On 3/26/24, R36's clinical record was reviewed. This review revealed an order that indicated R36 was to go to dialysis at an off-site location on Monday, Wednesday, and Friday of each week. The progress notes revealed no documentation of any concerns or issues with regards to the dialysis, resident's condition, access site, etc. On 3/26/24 at approximately 10:45 a.m., R36 was visited in their room. R36 reported that the facility sends a book back and forth to dialysis as a means for the two facilities to communicate 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.

Based on observation, resident interviews, staff interviews and facility documentation review the facility staff failed to prepare and serve meals in accordance with the menu, which had the potential to affect residents on 3 of 3 nursing units. The findings included: The facility staff failed to prepare foods in accordance with the menu and failed to post the correct menus for residents to view. On 3/19/24 at 11:57 a.m. an observation was conducted in the kitchen. The serving tray line in the kitchen did not have the alternate meal prepared that was posted on the menu board and listed on the menu. The alternate meal, according to the menu was supposed to be breaded fish on a bun, seasoned rice, and sliced carrots, which was not cooked and not available for residents. On 3/19/24 at 12:00- 1:20 p.m., observations of the resident's meals served was observed on 2 of the 3 nursing units and in the main dining room. It was noted that residents were served a plain cheeseburger with tater tots. According to the menu there was supposed to be lettuce and tomato for the burgers and a pickle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, resident interviews, and facility documentation review it was determined that staff failed to provide meals based on resident preferences, failed to provide nutritionally equivalent substitutions, and failed to serve foods that accommodate resident allergies, affecting multiple residents residing on 3 of 3 nursing units. The findings included: The facility staff failed to offer alternate foods, honor food preferences and were serving foods that residents had allergies to. On 3/19/24 at 11:57 a.m. an observation was conducted in the kitchen. The serving tray line in the kitchen was observed and it was noted that the alternate meal was not cooked and available for residents. On 3/19/24, the lunch meal service was observed in the dining room. Resident #14 (R14) was observed to not eat any of her meal and said she didn't like what was served. The facility staff did not offer any alternate options and R14 left the dining room having ate nothing. On 3/19/24/at 12:15 p.m. an observation of the lunch meal was conducted. The trays were served to the…

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

Based on observations, staff interviews, resident interviews, and facility documentation review, it was determined the staff failed to provide care and services for therapeutic diets for ten residents (Resident #2- R2, Resident #6- R6, Resident #7- R7, Resident #9-R9, Resident #12-R12, Resident #4-R4, Resident #14- R14, Resident #33- R33, Resident #40- R40 and Resident #36-R36), in a survey sample of 48 residents. The findings included: For R2, R6, R7, R9, R12, R4, R14, R33, R40, and R36, the facility staff failed to provide and serve therapeutic diets in accordance with physician orders. 3/19/24 at 12:15 an observation was conducted of the lunch meal in the dining area for the 300 and 400 unit. During this observation, several residents received the incorrect diets. CNA #5 (CNA5) was in the dining room serving the meal and was unfamiliar with the residents and the diets that were printed on the meal tickets. On 3/19/24 at 12:15 p.m. an observation of Resident #2's (R2) at the lunch meal in the dining area was conducted. Observed a meal ticket at R2's meal setting and printed on the…

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

Based on observation, staff interviews, and facility documentation review, the facility staff failed to ensure the facility staff provided meals daily at regular times having affected residents on 3 of 3 nursing units. The findings included: The facility staff failed to ensure that residents were served meals daily at regular times. On 3/19/24, during an entrance conference held with the facility administrator, the facility staff were asked to provide a listing of mealtimes. The facility submitted mealtimes as breakfast being at 8 a.m., lunch at 12 noon, and dinner at 5 p.m. On 3/19/24, during an observation of the meal service, it was noted that the second cart of meal trays for the east wing arrived at the unit at 12:38 p.m. The last resident on the west wing was served their lunch meal at 1:11 p.m. On 3/19/24 and 3/20/24, during observations of the kitchen tray line it was noted that the dietary staff maintained a log of when the meal trays were delivered to the units. On 3/20/24, the logs were reviewed and revealed the following: breakfast was served as early as 7:40 a.m., 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 observations, resident interviews, staff interviews and facility document it was determined that the staff failed to prepare and store food in a safe and sanitary manner with regards to food temperatures on the service line and to keep holding temperatures adequate for serving the food to residents, having the potential to affect many residents on 3 of 3 nursing units. The findings included: The facility staff failed to check the internal temperatures of the food prior to plating the food and failed to hold the food at a safe temperature when serving the food to residents. On 3/19/24 at 11:57 a.m. an observation was conducted in the kitchen. The temperature logs were observed blank for that meal and the dietary manager filled in the log while checking temperatures of the food upon request of the surveyor. The food was being plated on the service line prior to temperatures being obtained of the food to ensure adequate cooking and holding temperature to prevent the grown of food borne illnesses. On 3/19/24 at 1:12 p.m. a test tray observation was conducted. The 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 and resident interviews, clinical record reviews and facility documentation reviews, the facility staff failed to provide effective administration regarding resident's right to be free from abuse, neglect and exploitation and the protection of residents and insidious weight loss, resulting in the identification of two immediate jeopardy situations and substandard quality of care being identified, which had the potential to affect multiple residents on all 3 of the nursing units. The findings included: 1. The facility administrator, who was the abuse coordinator, failed to effectively administer the facility to ensure that through investigations were taken and measures implemented to ensure residents were free from abuse and/or retaliation during an investigation. On 3/19/24-3/20/24, a review was conducted of a sample of resident allegations of abuse/neglect and/or mistreatment. This review revealed that on 5 occasions, the facility staff member named as the alleged perpetrator was permitted to return to work prior to the conclusion of an investigation and…

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

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to maintain an effective quality assurance program with regards to maintain ongoing compliance with food and nutrition services, which resulted in immediate jeopardy being identified, which had the potential to affect many residents on three of three nursing units. The findings included: The facility staff failed to maintain an effective quality assurance program to maintain ongoing compliance and address concerns with regards to food and nutrition services within the facility, which had previously been identified and communicated as an on-going area of concern by residents. On 3/20/24, the survey team leader reviewed the survey results from the abbreviated survey conducted November 27, 2023- November 29, 2023. It was noted that during that survey the facility was identified to not be in compliance and deficient practice was cited at F800, for failure to ensure accurate meal tickets, F804 for failure to provide appetizing food with palatable temperatures, and…

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

Based on staff interview and facility documentation review, the facility staff failed to maintain a quality assessment and assurance committee consisting of the minimum members being present for 4 of 6 meetings reviewed for compliance. The findings included: For 4 of 6 quality assurance meetings held, the facility failed to ensure the administrator and infection preventionist were a part of the committee in attendance as required and the required number of additional staff were present. On 3/22/24, at approximately 9 a.m., the facility administration was notified that an extended survey was being conducted and the quality assurance program would be reviewed. The facility was asked to provide a copy of the sign-in sheets from the last 6 meetings held and a listing of topic discussed, since the actual quality assurance meeting minutes and documents are protected and unable to be reviewed by the survey team. On 3/22/24, the facility staff provided documents were reviewed and it noted the following: The meeting held on 6/2/23, did not include the facility's assigned infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure residents receive services with reasonable accommodation of resident needs and preferences affecting 9 residents (Resident #21, 3, 10, 24, 25, 26, 19, 28, and 38) on 2 of 3 nursing units. The findings included: For Resident #21, 3, 10, 24, 25, 26, 19, 28, and 38, the facility staff failed to ensure call bells were accessible and they would have a means to notify staff if they needed something. On 3/19/24 at 12:19 PM, during a tour of the facility multiple call bells were observed to be out of the residents reach. Resident #21 (R21) was observed to be sleeping in a wheelchair and the call light was lying on the bed out of reach of the resident. Resident #3 (R3) who had a pancake call bell was observed lying in the bed with the call bell behind the headboard, out of reach. Resident # 10 (R10) was observed sitting in bed with the call bell lying on the floor behind the headboard. Resident #24 (R24) was observed lying in bed with the call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 uphold resident rights for visitation for two residents (Resident #14, R14 and Resident #15, R15) of 48 residents. The findings included: The facility staff would not allow R14 and R15 to visit one another in private in R14's room. R14 was admitted to the facility on [DATE]. Diagnoses for R14 included but not limited to anxiety disorder, hypokalemia, spinal stenosis, lymphedema, and atrial fibrillation. R14 Quarterly Minimum Data Set (MDS, an assessment protocol) with an assessment reference date (ARD) of 3/6/24 coded R14 with a BIMS of 15 and has no cognitive impairment. R15 was admitted to the facility on [DATE]. Diagnoses for R15 included but not limited to Type 2 diabetes mellitus without complications, generalized muscle weakness, repeated falls and mild cognitive impairment of uncertain or unknown etiology. R15's Quarterly MDS with an ARD 1/28/24 coded R13 with a BIMS of 13 and has…

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

Based on resident interview, staff interviews, and facility documentation review, the facility staff failed to make prompt efforts to resolve grievances involving one resident (Resident #14- R14), in a survey sample of 48 residents. The findings included: For Resident #14 (R14) who filed a grievance about receiving food she had an allergy to, the facility didn't respond to the grievance timely and failed to resolve the concern. Review of the facility grievance log revealed that on 1/14/24, R14 reported a concern that the kitchen keep giving resident fish resident allergic to fish, diet ticket states no fish. The grievance noted that the facility would re-train any employee who needs it. This grievance was noted as being completed on 1/21/24 and noted as resolved. On 3/19/24, during an initial tour of the facility, R14 was heard complaining that she had received fish for supper last night, requested an alternate twice, which was never received, and she went to bed hungry. On the afternoon of 3/19/24, during another interview with R14, the resident reported this is a frequent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews and facility documentation review, the facility failed to implement their abuse policy for 2 employees (CNA #12 and CNA #1 ) in a survey sample of 25 staff records reviewed. The findings included: 1. For certified nursing assistant #12 (CNA #12) the facility staff failed to obtain a criminal background check. On 3/19/24 during a review of facility documents it was determined that no criminal background check was obtained for CNA #12 during their employment at the facility. On 3/19/24 at 4:48 PM, other staff #1 (OS#1) who was the human resource manager, was interviewed and confirmed that CNA #12 did not have a criminal background check and therefore was permitted to work providing direct care to residents while the criminal history was unknown. OS#1 stated CNA #12 was hired on 2/10/23 and termed on 7/14/23. Review of the facility policy for Abuse, Neglect, Exploitation and Misappropriation effective 11/30/14 stated in part, persons applying for employment with the center will be screened for a history of abuse, neglect,…

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

Based on observation, resident interviews, staff interviews and clinical record review, it was determined that the facility staff failed to accurately code an assessment for two residents (Resident #13- R13, and Resident #3- R3) in a survey sample of 48 residents. The findings included: 1. For Resident #13, who had experienced a significant weight loss, the MDS (minimum data set, an assessment) assessment was inaccurately coded with regards to significant weight loss. On 3/20/24-3/21/24, a clinical record review was conducted of R13's chart. This review included but was not limited to, weights, physician orders, MDS assessments and the care plan. The weight records noted that on 1/12/24, R13 had experienced a significant weight loss of 10%, a 25-pound loss since September 12, 2023. On 1/19/24, a quarterly MDS assessment was conducted, which in section K, question K0300. indicated 0. No or unknown for the question loss of 5% or more in the last month or loss of 10% or more in last 6 months? 2. For Resident #3 (R3), who had a significant weight loss, the MDS assessment with an ARD…

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

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to review and revise care plans of residents following each assessment for 2 Residents (Resident #4 & Resident #3) in a survey sample of 48 Residents. The findings included: 1. For Resident #4 (R4), the nutritional care plan was not reviewed and revised following an assessment, which identified significant weight loss. On 3/20/24-3/21/24, a clinical record review was conducted, which included R4's weights, MDS (minimum data set assessment) and care plan. It was noted that beginning in December 2023, R4 was noted with a significant weight loss of 5.1 % loss within the month. On 1/28/24, R4 was noted with a 6.6 % weight loss within 30 days. On 1/30/24, R4 had a quarterly MDS assessment conducted, which in section K identified that R4 had experienced a significant weight loss. R4's nutritional care plan had been initiated 11/30/21, with a revision of the goal on 8/24/23. All of the nutritional interventions had been initiated in 11/30/21, except one which was implemented…

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

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing practice with regards to carrying out physician orders for one resident (Resident #35) (R35) in a survey sample of 48 residents. The findings included: For R35, the facility staff failed to carry out a physician order for a change in medication dosage. On 3/26/24 at approximately 10:15 a.m., R35 was visited in their room. R35 confirmed that their dialysis days were Monday, Wednesday, and Fridays of each week. R35 also confirmed that a book is sent with them to dialysis as a means for the facility and the dialysis clinic to communicate with one another. On 3/26/24 at approximately 10:20 a.m., R35's dialysis book was reviewed. It was noted that on 3/6/24, R35 had labs drawn while at dialysis and noted on the 3/6/24, Dialysis Communication form, Document any pertinent or relevant observations: New order 2 Renvela [also known as Sevelamer] TID [three times a day] with meals per Dr [redacted physician's name]. A copy of the labs…

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

Based on observations, staff interview, resident interview and facility documents it was determined that the facility staff failed to provide activity of daily living (ADL) care for three residents (Resident #4, R4, Resident #14, R14, Resident #15, R15) out of 48 residents in the survey sample. The findings included: The facility staff failed to adequately groom the residents and to shower the residents on their scheduled shower days. 1. For Resident #4, who was dependent upon facility staff for care needs, the facility staff failed to shave the resident. On 3/26/24 at 11:45 a.m. an observation was made of Resident #4 (R4). R4 was observed with thick facial hair on the chin and upper lip area. R4 was nonverbal but gave a thumbs up when asked if wanting the facial hair removed. On 3/26/24 at 11:50 a.m. an interview was conducted with CNA #13 (CNA13) (certified nursing assistant). CNA13 verbalized that residents are shaved on their shower days but can be shaved on other days if needed. CNA13 verbalized that all residents can be shaved with a razor unless on blood thinners then an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure a resident who had Alzheimer's dementia had a dementia care plan with interventions to ensure dementia appropriate treatment and services were provided for one resident (Resident #6- R6) in a survey sample of 48 residents. The findings included: 1. For Resident #6, who had Alzheimer's, the facility staff failed to develop a dementia care plan to include interventions address the resident's wandering and failed to provide adequate supervision of the resident which resulted in the resident wandering into another resident room and wrapping the call bell cord around their body and wheelchair. On 4/15/24 at 3:54 p.m., upon the surveyor's arrival on the east unit, it was noted that 6 call bells were engaged and going off, which included room [ROOM NUMBER]. It was noted that there was only one CNA (certified nursing assistant) was working the unit and one nurse was assigned to the unit to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure medication was available for administration for one of 26 residents, Resident #124, during the medication pass and pour observation. The findings include: During a medication pass and pour observation, conducted on 7/24/24 at 8:00 AM, Resident #124 (R124) was scheduled to receive the medication telmisartan 40 MG. License practical nurse (LPN #3) looked into the medication cart and verbalized that the telmisartan was not available to give. LPN #3 then looked for the medication in the medication room, indicated that the medication was not on hand, called the pharmacy to reorder the medication, and then verbalized that the telmisartan would be sent later in the day. On 7/24/24 at 9:15 AM, the director of nursing (DON) verbalized that the physician had been notified and an order was received to hold the telmisartan and give when the medication arrived from the pharmacy. The physician's order for R124's telmisartan was reviewed and documented: Telmisartan 40 MG Tablet one time a day 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, resident interviews, staff interviews and facility documentation review, it was determined that the facility staff failed to provide appetizing food with palatable temperatures and appearance to residents on one of three units (400 unit). The findings include: On 3/19/24 at 11:57 a.m. an observation was made of the tray line and of the steam table in the kitchen . The temperature log had not been completed prior to the lunch meal being plated. The dietary manager obtained the temperatures during the observation and the temperature for the meal is as follows: Cheeseburgers-162.6, Tater tots-165.7, mashed potatoes-203.3, pureed hamburger 148.6, carrots-169.8. On 3/19/24 at 12:00 p.m. an observation of the lunch time meal in the dining area was performed. The surveyor observed several trays with the cheeseburger bread was not able to be separated to add any condiments to the cheeseburger. The tater tots were lukewarm, and no condiments were provided on the resident's tray to add to the food.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews, staff interviews and clinical record review, it was determined that the facility staff failed to maintain an accurate and complete clinical record for four residents (Resident #14, R14, Resident #15, R15, Resident #17, R17, and Resident #39, R39) in a survey sample of 48 residents. The findings included: 1. The facility staff failed to accurately document R14's meal intake on the ADL (Activity of daily living) sheet in the meal intake percentage area. R14 was admitted to the facility on [DATE]. Diagnoses for R14 included but not limited to anxiety disorder, hypokalemia, spinal stenosis, lymphedema, and atrial fibrillation. R14's Quarterly Minimum Data Set (MDS, an assessment protocol) with an assessment reference date (ARD) of 03/06/24 coded R14 with a BIMS of 15, which indicated no cognitive impairment. On 3/19/24 at approximately 12:15 p.m. an observation was made of the lunch meal for the residents on the 300 and 400 units in the dining area. R14's tray was observed…

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

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to employ sufficient kitchen/dietary staff to ensure palatable food and timely meals. The findings include: On 11/27/23 at 3:00 p.m., accompanied by the kitchen manager (other staff #5), the kitchen and food storage areas were inspected. Foods were observed stored in the refrigerator without proper sealing and date labeling, expired food items stored/available for use, staff members and vendors in the kitchen without hair restraints, improper sanitizer concentration in the 3-compartment sink, dirty stove area, and the dishwasher running with low wash temperature. On 11/27/23 at 4:15 p.m., the resident council president (Resident #1) was interviewed about food/meals in the facility. The council president stated that residents had expressed concerns in the past about sloppy meals and unorganized meal service. The council president stated there had been reports of cold food, but she thought the food presentation was better now. Questioned further, the council president…

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

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to provide daily meals at regular times and according to posted schedules. The findings include: On 11/27/23 at 4:15 p.m., the resident council president (Resident #1) was interviewed about issues with meal delivery times. Resident #1 stated that the meal service had been unorganized in the past, with meals served late. Resident #1 stated late meal service had been discussed in the resident council meetings and been communicated to the administration. On 11/27/23 at 4:45 p.m., the licensed practical nurse (LPN #1) working on the 300-unit was interviewed about mealtimes. LPN #1 stated they had experienced inconsistent meal service for months. LPN #1 stated that one day breakfast was served at 7:45 a.m. and the next day it was served at 9:30 a.m. LPN #1 stated approximately two weeks ago staff served dinner trays on her unit at 6:45 p.m., which was near shift change time. LPN #1 stated that residents had complained to her about not knowing when meals would be served and…

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

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure accurate meal tickets for eleven of fourteen residents in the survey sample. The findings include: Meal tickets sampled on the 300-unit did not accurately list the food items served. On 11/27/23 starting at 6:10 p.m., a meal observation was conducted on the 300-unit. With residents' permission, meal tickets located on the assigned trays were compared to the meal/food items served. Meal tickets for Residents #1, #4, #6, #7, #8, #9, #10, #11, #12, #13 and #14 did not accurately reflect the food items served. Residents #1, #4, #6, #7, #8, #9, #10, #12 were served rotisserie chicken, okra/tomatoes, macaroni and cheese, and a dinner roll. Residents #11, #13 and #14 were served the alternate meal of pork roast, buttered noodles, broccoli, and a dinner roll. The meal tickets for these residents did not reflect the food items served with exception of the okra/tomato dish and roll. The meal tickets for the sampled residents inaccurately…

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

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to provide appetizing food with palatable temperatures on one of three units (300-unit). The findings include: On 11/27/23 at 4:15 p.m., the resident council president (Resident #1) was interviewed about food/meals in the facility. The council president stated that residents had expressed concerns in the past about sloppy meals and unorganized meal service. When questioned further, the council president stated there had been reports of cold food, but that she thought the food presentation was better now. The council president stated that she had witnessed a spaghetti meal served with pasta water on the plate making the food soggy. On 11/27/23 at 4:55 p.m., the certified nurses' aide (CNA #1) working on the 300-unit was interviewed about resident food. CNA #1 stated that she had seen oatmeal served in the past several months that was hard. CNA #1 stated milk had to be added to the oatmeal for the resident to get it out of the bowl. CNA #1 stated that the oatmeal had been…

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

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, and distribute food in a sanitary manner from the main kitchen. The findings include: On 11/27/23 at 3:00 p.m., accompanied by the kitchen manager (other staff #5), the food storage and main kitchen were inspected. Stored in the walk-in refrigerator was an unsealed box of raw bacon. The bacon was exposed to air and had no label indicating the use-by date or date opened. There was a box containing approximately thirty-five 1-ounce packets of sour cream with each having an expiration date of 10/8/23. There were two quarts of unopened Half & Half with a use-by date of 11/20/23. There was an opened carton of liquid egg product with no date opened. A 48-ounce block of cream cheese was stored in plastic wrap with no date opened or use-by date. A one-pound block of margarine was unsealed without any date labeling. The kitchen manager stated at the time of this observation that she had been at the facility for about two weeks and some of the items in question were here before 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.

Based on observation and staff interview, the facility staff failed to maintain essential kitchen equipment in good working order. The findings include: The sanitizer pump for the 3-compartment sink was not functional. A knob for the front eye was missing/broken on the main kitchen stove. On 11/27/23 at 3:15 p.m., the 3-compartment sink was inspected. When asked to check the sanitizer concentration, the kitchen manager (other staff #5) stated the sanitizer pump was not working for the sanitizer section of the sink. The kitchen manager stated that she thought the unit was waiting for a new battery. On 11/27/23 at 3:45 p.m., the kitchen stove was inspected. The knob to the front eye of the stove was missing. The kitchen manager stated that it was broken and in her office. The kitchen manager stated that the knob had been broken for at least a week. These findings were reviewed with the administrator and director of nursing, during a meeting on 11/28/23 at 4:40 p.m.

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 include the medical record as part of a monthly medication regimen review for four of twenty-two residents in the survey sample (Residents #7, #13, #64 and #75). The findings include: Medication regimen reviews for Residents #7, #13, #64 and #75 in December 2022 did not include review of the residents' medical records. 1. Resident #7 was admitted to the facility with diagnoses that included bipolar disorder, insomnia, hemiplegia, diabetes, congestive heart failure, and osteoporosis. The minimum data set (MDS) dated [DATE] assessed Resident #7 with moderately impaired cognitive skills for daily decision making. Resident #7's clinical record documented a medication regimen review by the consultant pharmacist dated 12/25/22. The consultation report documented the clinical record was not included as part of the review. Documented in the comment section of this report was, In lieu of the resident record,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food in a sanitary manner in the main kitchen. The Findings Include: The kitchen staff were thawing 5 bags of chicken pieces using improper technique. On 1/31/23 at 11:15 AM, during an initial tour of the kitchen, 5 bags containing approximately 20 pieces of chicken per bag was submerged in water without water running over the chicken. At this time, the dietary manager (other staff, OS #2), who also observed the chicken in the sink, was interviewed. OS #2 verbalized that the sink had gotten clogged up so the water was cut off. OS #2 was asked how is the chicken supposed to be thawed. OS #2 verbalized that chicken and frozen meat can be thawed in submerged water with water running over the meat. On 1/31/23 at 11:40 AM, the kitchen was again observed and the chicken had been removed from the sink. On 1/31/23 at 2:00 PM, the director of nursing (DON) was made aware of the above findings and agreed that water should being continuously running over frozen meat. On 2/1/23 at 9:10 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interview, the facility staff failed for one of 22 residents in the survey sample (Resident # 10) to ensure an accurate Minimum Data Set. Resident #10 was inaccurately identified on a Significant Change Minimum Data Set (MDS) as not receiving hospice services. The findings were: Resident # 10 was admitted with diagnoses that included chronic systolic and diastolic heart failure, anemia, atrial fibrillation, coronary artery disease, hypertension, gastroesophageal reflux disease, renal insufficiency, neurogenic bladder, diabetes mellitus, hyperlipidemia, thyroid disorder, arthritis, osteoporosis, anxiety disorder, and respiratory failure. According to the most recent MDS, a Significant Change with an Assessment Reference Date of 1/15/2023, Resident #10 was assessed under Section C (Cognitive Patterns) as moderately cognitively impaired for daily decision making, with a Summary Score of 10 out of 15. Under Section O (Special Treatments, Procedures, and Programs), 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 clinical record review and staff interview, the facility staff failed to develop a baseline care plan for immediate care upon admission for one of 22 residents, Resident # 293. Findings were: Resident #292 was admitted to the facility with the following diagnoses including but not limited to Osteomyelitis, urinary tract infection, Alzheimer disease, diabetes mellitus, and congestive heart failure. Due to her recent admission, no MDS (minimum data set) information was available. Review of Resident #292's clinical record on 02/01/2023, at approximately 10:00 a.m, included orders for the treatment and care of a PICC line, administration of IV antibiotics, ileosotomy care, and treatment to a sacral pressure ulcer. No interventions for these areas was observed on the baseline care plan. The MDS nurse, LPN (licensed practical nurse) #5 was interviewed on 02/01/2023 at approximately 2:00 p.m. regarding baseline care plans. LPN #5 stated, The admission nurse does the baseline care plan on paper .we use that for 14 days, while comprehensive is completed. She was asked if the above…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure drugs and biological's were labeled appropriately on one of two nursing units medication room. Findings include: The facility failed to appropriately label a multi-dose vial of Tuberculin on the East unit. On 2/01/23 9:39 AM the East unit medication storage refrigerator was observed with license practical nurse (LPN #3). The refrigerator had one multi-dose vial of tuberculin medication in it's original box. The vial of Tuberculin had been opened and accessed with approximately 1 to 2 doses of the medication remaining in the vial. Neither the vial of Tuberculin or the original box had an open date, indicating when the medication had been opened/accessed. LPN #3 said, The vial of Tuberculin should have an open date on it and should be discarded after 28 days of being opened .since there is no open date it would be discarded. A policy titled, Administering Medications documented, When opening a multi-dose container, the date opened is recorded on the container. On 2/1/23 at 4:15 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide a therapeutic diet for one of twenty-two residents in the survey sample (Resident #193). The findings include: Resident #193 was not provided dysphagia mechanical soft food items as ordered by the physician. Resident #193 was admitted to the facility with diagnoses that included respiratory failure with hypoxia, COPD (chronic obstructive pulmonary disease), gastroesophageal reflux disease (GERD), chronic kidney disease, hypertension, and arthritis. The admission assessment dated [DATE] assessed Resident #193 as cognitively intact. On 1/31/23 at 11:46 a.m., Resident #193 was interviewed about the quality of care in the facility. Regarding food/meals, Resident #193 stated the she was supposed to get a modified diet, but she was receiving regular textured food items. Resident #193 stated that she experienced esophageal burning due to GERD and the softer textured food…

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

Based on clinical record review, and staff interview, the facility staff failed for one of 22 residents in the survey sample (Resident # 38) to ensure a complete and accurate clinical record. The reason for a room change was not included in Resident # 38's clinical record. The findings were: Resident # 38 was admitted with diagnoses that included congestive heart failure, hypertension, Non-Alzheimer's dementia, depression, psychotic disorder, rheumatoid arthritis, polyneuropathy, immunodeficiency, altered mental status, and osteoporosis. According to the most recent Minimum Data Set (MDS), a Quarterly review with an Assessment Reference Date (ARD) of 12/14/2022, Resident #38 was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired in daily decision making, with a Summary Score of 12 out of 15. Review of the Progress Notes in Resident # 38's Electronic Health Record (EHR) revealed the following entry: 1/23/2023 - 10:49 a.m. - Nursing Progress Note - Resident agreeable to room change to 413A. Courtesy call to son as well. There was no explanation in…

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

Based on observation, staff interview and facility document review, the facility staff failed to perform hand hygiene during a medication pass on one of two units (East). The findings include: During a medication pass on the East unit, a nurse failed to perform hand hygiene after gloves changes and between contact with residents' personal items. A medication pass observation was conducted on 2/1/23 at 8:07 a.m. with licensed practical nurse (LPN) #3. Without performing hand hygiene, LPN #3 put on gloves and prepared medicines for the first resident in the medication pass observation (Resident #47). LPN #3 touched Resident #47's cup of water and then discarded the empty medicine cup after the resident was administered the oral medicines. LPN #3 then removed/discarded the gloves and without hand hygiene, put on a clean pair of gloves. LPN #3 then filled the roommate's cup of water, touching the cup, top, and straw. LPN #3 removed/discarded the gloves after handling the resident's cup and then left the resident's room. Without performing hand hygiene, LPN #3 put on clean gloves 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 clinical record review and staff interview, the facility staff failed to accurately complete an MDS assessment for one of 21residents, Resident #83. Resident #83's discharge status was incorrectly coded as acute hospitalization. Findings were: Resident #83 was admitted on [DATE] with diagnosis including: Type II diabetes mellitus, fibromyalgia, hypertension and mild depressive disorder. The initial MDS (minimum data set) with an ARD (assessment reference date) of 03/04/2021, coded Resident #83 as cognitively intact with a summary score of 14. Resident #83 closed record was identified as hospital discharge. Review of the progress note section revealed notes dated 03/08/2021 which documented: 3/8/2021 13:07 [1:37 p.m.] Social Services Progress Note: (Resident name) left against medical advice (AMA) today. Social services spoke with (resident name) and her son regarding her wanting to leave and explained what AMA meant. It was explained that home health and equipment could not be ordered and follow up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow professional standards of care for one of 21 residents in the survey sample. Resident #33 was administered the medication alendronate (Fosamax) without following manufacturer recommendations to maximize effectiveness and prevent side effects such as esophagus injury. The findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, gastroenteritis, colitis, hypertension, vitamin D deficiency, major depressive disorder, osteoporosis, anemia and bipolar disorder. The minimum data set (MDS) dated [DATE] assessed Resident #33 with moderately impaired cognitive skills. Resident #33's clinical record documented a physician's order dated 2/10/21 for alendronate sodium (Fosamax) 35 milligrams (mg) to be given by mouth every Wednesday for treatment of osteoporosis. The resident's medication administration record (MAR) scheduled the alendronate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility staff failed to provide nail care for one of 21 residents in the survey sample. Resident #33 was observed with long, thick, distorted toenails described by the resident as causing discomfort. The findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, gastroenteritis, colitis, hypertension, vitamin D deficiency, major depressive disorder, osteoporosis, anemia and bipolar disorder. The minimum data set (MDS) dated [DATE] assessed Resident #33 with moderately impaired cognitive skills and as requiring the extensive assistance of one person for personal hygiene. On 4/13/21 at 11:19 a.m., Resident #33 was observed in bed. The resident was sitting on top of the bed covers with her bare feet/lower legs visible. The toenails on both feet were long, thick and distorted. The great toes nails extended beyond the end of the toe and curved outward. The first toenails on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review the facility failed to accurately complete an admission and weekly skin assessment for one of 21 Residents, Resident #242. The findings include: Resident #242 was admitted to the facility on [DATE]. Diagnoses for Resident #242 included: Schizoaffective disorder, adjustment disorder, chronic pain, and pressure ulcer. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 4/7/21. Resident #242 was assessed with a cognitive score of 2 indicating severely cognitively impaired. Review of Resident #242's medical record included an admission Data Collection assessment dated [DATE]. This assessment documented Resident #242 was newly admitted with a stage 2 pressure ulcer to the sacrum and an unstageable pressure ulcer to the right heel. The baseline care plan for skin integrity was completed upon admission and dated 4/1/21. The goal for skin integrity was to Prevent any skin breakdown or injury.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication pass observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. There were five observed medication errors out of 35 opportunities resulting in 14.2% error rate. The findings include: 1. On 4/14/21 at 7:45 a.m., licensed practical nurse (LPN #5) was observed administering medications to Resident #33. LPN #5 prepared and administered the following medications to Resident #33: folic acid 2 milligrams (mg), vitamin D 50 micrograms (mcg), loperamide 4 mg, mesalamine 1.2 grams (2 tablets), fiber capsule 625 mg and fiber powder (Metamucil) 10 cc (cubic centimeters) mixed in a cup of water. Cholestyramine powder was not included in the administered medications. Resident #33's clinical record documented a physician's order dated 2/10/21 for cholestyramine powder 4 grams/dose with instructions to give 1 packet by mouth twice per day for the treatment of Crohn's disease. Resident #33's clinical record did not include a physician's order for the fiber powder (Metamucil). On 4/14/21 at 9:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not readily available for distribution on one of 3 units, the 400 unit. The findings include: On 04/14/2021 at 8:35 a.m., medication storage observations were conducted on the 400 unit with licensed practical nurse (LPN #4). Observed on the 400 - [NAME] A medication cart was the following opened bottle of medication: [NAME] Natural K, Vitamin K 100 mcg (micrograms), with an open date of 7/2/19 and expiration date of 2-21 (February 2021). On 04/14/2021 at 8:45 a.m., LPN #4 was interviewed regarding expired medication. LPN #4 stated, Normally the third shift nurse and/or the unit manager checks the carts for expired medication. However, all of the nurses are responsible for checking for expired medications. A review of the facility's policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes, and Needles, Revision Date 10/31/16 documented the following: 4. Facility…

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

Based on observation, staff interview and facility document review, the facility staff failed to follow infection control protocols for hand hygiene on one of three nursing units. A nurse on East wing failed to don gloves and perform hand hygiene between residents when obtaining fingerstick blood samples for glucometer testing. The findings include: On 4/13/21 at 11:30 a.m., licensed practical nurse (LPN) #6 was observed checking Resident #11's blood sugar using a glucometer. LPN #6, with a glove only on her right hand, used a lancet to stick one of Resident #11's fingertips and applied the blood sample onto a testing strip. After completing the fingerstick and obtaining a blood sugar reading, LPN #6 removed the glove on her right hand and exited the room. Without performing hand hygiene, LPN #6 went to the medication cart located near the nursing desk and recorded the blood sugar reading. LPN #6 then proceeded to Resident #66 with the glucometer. On 4/13/21 at 11:32 a.m., LPN #6 used a lancet to stick Resident #66's fingertip. LPN #6, with a glove only on her right hand, obtained a…

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

Based on survey findings and staff interviews, the facility administrator failed to ensure that resources regarding the use of side rails were used effectively and efficiently to maintain the highest practicable well-being of each resident. Information regarding the 2017 regulatory requirements for side rails was available to the facility administrator but not implemented. Findings were: An onsite survey was conducted from 06/18/2019 through 06/24/2019. During the survey deficient practice was identified in the area of quality of care at F700. The scope and severity was cited at a level IV, pattern. The facility failed to provide alternative measures to residents in lieu of side rails, failed to assess residents for the risk of entrapment prior to the implementation of side rails, failed to obtain informed consents prior to the use of side rails, and failed to provide ongoing assessment and monitoring of side rails in use. Immediate Jeopardy and Substandard quality of care were identified on 06/20/2019. While discussing and reviewing the facility's plan of removal, an assessment 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 an overview of the facility's Quality Assurance and Performance Improvement (QAPI) Program, staff interview, and the identification of Immediate Jeopardy and Substandard Quality of Care in the area of Quality of Care, specifically Federal Tag F-700 (Bedrails), the facility's QAPI Program failed to identify a systemic problem with the use of bedrails, and failed to develop a mitigation program to address the problem. The findings were: During the survey process, the survey team identified a systemic problem with the facility's use of 1/4 bedrails that resulted in the identification of Immediate Jeopardy and Substandard Quality of Care. The facility was using 1/4 bedrails for residents who were not individually assessed for the need of bedrails, who were not offered alternative measures before the use of bedrails, who did not have an order for bedrails, who did not have a care plan for bedrails, and for whom no consent had been obtained from the resident or the resident's Responsible Party for the use of bedrails. At approximately 3:30 p.m. on 6/24/19, the Administrator 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, staff interview, and clinical record review, the facility staff failed to perform a pressure ulcer dressing change per physician's order for one of 24 residents, Resident #67. LPN (licensed practical nurse) #2 was observed providing incorrect treatments to two pressure ulcer sites on Resident #67's hips. Findings were: Resident #67 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Osteoporosis, history of breast cancer, chronic obstructive pulmonary disease, schizoaffective disorder, atrial fibrillation, and diabetes mellitus. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/15/2019, assessed Resident #67 as moderately impaired in her cognitive status, with a summary score of 10. The clinical record was reviewed on 06/18/2019. Per the clinical record, Resident #67 had two unavoidable pressure ulcers. One was located on the right hip and was classified as a Stage II, the other was on the left hip and classified as a Stage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to provide supervision for one of 24 residents in the survey sample, Resident #89. Resident #89 was observed seated in a wheelchair with her toes pointing downward and her feet not flat on the floor. Resident #89 was attempting to self propel in her wheelchair but was unable to do so using only her toes. Resident #89 was then pulling at the door of another resident's room and in the living room of the unit, leaning forward and getting cups out of the trash cans; she was observed putting the cups to her lips and spitting into them. The findings include: Resident #89 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Alzheimer's Disease, weight loss, Chronic diastolic heart failure, anxiety, history of TIA (transient ischemic attacks), history of falls, and abnormal posture. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/29/2019, assessed Resident #89…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure two of 24 residents in the survey sample (Residents # 48 and 97) were free of unnecessary psychotropic medications. Residents # 48 and 97 both had an as needed (PRN) psychotropic medication ordered for more than 14 days without a stop date. The findings include: 1. Resident # 97 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included anxiety disorder, depression, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, generalized muscle weakness, history of falling, dysphagia, dyspnea, non-rheumatic mitral valve insufficiency, and adjustment disorder with mixed anxiety and depressive mood. According to a Medicare 14-Day Minimum Data Set with an Assessment Reference Date of 6/10/19, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 11 out of 15. Resident # 97 had the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure expired medications were not available for administration in two of two medication rooms, and also failed to ensure insulin was properly labeled on one of 6 medication carts. 1. The medication room refrigerators on the East hall and [NAME] hall contained three bottles each of Lorazepam (an antianxiety medication) which were expired and available for administration. 2. The medication cart on the 400 unit contained two vials of improperly labeled insulin. Findings include: 1. On 6/18/19 the medication room on the East hall was inspected with RN (registered nurse) # 1. The refrigerator contained three opened bottles of Lorazepam. The bottles were not dated. RN # 1 was asked about the medications, and if an opened date was needed on each one. RN # 1 stated Those aren't mine; we store the other residents on the other hall in this refrigerator as well. I do not have any residents on that medication right now; those must belong to the other nurse. If they were mine, they would have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 24 residents in the survey sample: Resident # 84. Findings include: Resident # 84 was admitted to the facility 9/1/18 with a readmission date of 3/12/19. Diagnoses for Resident # 84 included, but was not limited to: unspecified abdominal pain, Parkinson's disease, gout, high blood pressure, and dementia. The most recent MDS (minimum data set) was a significant change in status assessment dated [DATE]. Resident # 84 was coded with severe cognitive impairment with a total summary score of 00 out of 15. During review of Resident # 84's electric medical record (EMR) on 6/19/19 at 3:30 p.m. it was noted a hospital discharge summary for another resident was scanned into Resident # 84's record. The documentation was dated 5/15/19. On 6/20/19 at 8:30 a.m. the medical record staff, OS (other staff) # 1 was asked about the scanned documentation. OS # 1 stated This scanning into a…

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