Barre Gardens Nursing and Rehab, LLC

Based on record review and interview it was determined that the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of her/his quality of life, recognizing each resident's individuality for 1 resident in a sample of 9 residents. (Resident #4).Findings include:Per record review, Resident #4 has diagnoses that include Alzheimer's disease, dementia, bipolar disease, schizophrenia, and need for assistance with personal care. Per Resident #4's care plan, revised 11/4/25, EATING: [She/he] requires extensive assist from staff participation to eat. Staff please encourage resident to open hand to engage in self-feeding and holding cup during meals. On 11/4/25 at 12:55 PM, an observation was conducted of Resident #4 during lunch. An LNA (licensed nursing assistant) was observed assisting the resident with eating. She/he was standing next to resident and leaning over to place the food in the resident's mouth. The LNA repeated the process of standing next to the resident 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, and record review the facility failed to ensure that 1 resident in the applicable sample (Resident #6) received proper foot care.Findings include:Per observation on 11/13/25 at 10:21 AM, Resident #6 was sitting barefoot at the edge of the bed with his/her feet on the floor. Resident #6's feet appeared to be dry and had long discolored toenails that were thick.Per interview with Resident #6 on 11/13/25 at 10:21 AM, they reported that their toenails are very long and that it is an issue, they haven't had their nails trimmed in a long time or seen a podiatrist.Per record review of Resident #6's care plan dated 9/19/25, s/he is care planned for skin breakdown due to impaired mobility, DM (Diabetes Mellitus), and peripheral vascular disease. Interventions include Podiatry consult as needed with a date of 3/8/23. The care plan also identifies that the resident has an ADL (activities of daily living) self-care performance deficient and requires assistance with personal hygiene, dated 3/8/23.Per review of the facilities policy titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions to address the residents' dementia care needs for 1 of 1 residents (Resident #10).Findings include:Per an observation on [DATE] at 6:43 PM at a nurse's station, Resident #10 was asking to call his/her family member. A Licensed Practical Nurse (LPN) was observed telling Resident #10 that she couldn't call his/her family member because they had died. Upon hearing this, Resident #10 got visibly upset and again asked for the LPN to call Resident #10 's family member and called the LPN a liar. The phone started ringing and Resident #10 was asking for them to pick it up saying it might be their family member, and the nurse was dismissive towards the Resident saying that it couldn't be. At 6:45 PM, the Resident #10 again asked to call the family member to which the LPN again stated that they had passed and that we told you this months ago, but you keep on forgetting. Resident #10 then stated that they were going to try…

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

Based on observation and interview, the facility failed to ensure only authorized personnel had access to the medication storage rooms. This is a repeat deficiency for this facility, with the violation cited during the previous recertification surveys, dated 6/25/25. Findings include:Per observation on 11/4/25 at 12:45 PM, a pharmacy delivery was accepted by an LPN (Licensed Practical Nurse). The delivery person and LPN went into the medication room together. The LPN emerged without the delivery person who remained alone in the medication room for approximately 5 minutes before exiting.Per interview on 11/4/25 at 1:00 PM, the LPN confirmed that the delivery person should not go into the medication room alone. The LPN confirmed that he/she was left alone in the medication room. Per interview with the Administrator on 11/4/25 at 2:45 PM, they confirmed the delivery person should not have been in the medication room alone.

Based on review of employee training records and interview, the facility failed to provide evidence of the minimum 12 hours of nurse aide training per year required to ensure the continuing competence of the LNAs (Licensed Nursing Assistants) for 1 (LNA #1) of 3 LNAs sampled. Findings include:Per review of the training records, three LNAs sampled were noted to have start dates before the 2025 calendar year. LNA #1's education file lacked documentation of evidence of the 12 hours of training per year required to meet identified staff or resident needs.Per interview on 11/13/25 at 5:18 PM, the Director of Nursing (DON) was unable to provide evidence that the LNA #1 had completed their required 12-hour annual training.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review, the facility failed to ensure a qualified dietitian or other clinically qualified nutrition professional is employed full-time, or designate a person to serve as the director of food and nutrition services who meets the minimum qualifications. Findings include: Per interview with the Administrator on 6/25/25 at 10:28 AM, the Administrator stated they did not have a dietary manager and were currently in the process of hiring one. The administrator was unable to provide any evidence that the facility had a dietary manager. The Administrator confirmed that the dietician for the facility was part-time and works 2 to 3 days a week. Per interview with the kitchen staff member on 6/25/24 at 10:38 AM, the kitchen staff member stated that the facility did not have a dietary manager For about six months .I do pretty much everything here. An interview was conducted with the registered dietician on 6/25/25 at 12:06 PM. The dietician confirmed that she only works Two days a week for 8…

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

Based on observation and interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety and failed to maintain a sanitary kitchen. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 5/9/24. Findings include: Per observation of the kitchen on 6/23/25 at 10:42 AM, the floor under the storage shelves had debris on the floor. Per observation of the walk-in refrigerator on 6/23/25 at approximately 10:45 AM there was a 5 pound container of low fat cottage cheese with macaroni and beef in it dated 6/14[2025]-6/18 [2025]. There was a container of meat sauce dated 6/14 [2025]-6/18 [2025]. There was a package of 8 hot dogs on the third shelf from the top. Per interview with the kitchen staff member on 6/23/25 at 10:53 AM, she confirmed that the items were past their expiration date, stating, I didn't see those [items]. I'll get rid of them. The kitchen staff member also confirmed that the floor under the shelves had debris on it. The kitchen staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Per observations made during the survey, Resident #23 was observed in her/his room in bed without a fitted sheet on 6/25/2025 at 9:25 AM and at 2:40 PM. Throughout the survey, Resident #23 was observed without sheets properly fitted to her/his bed. Per interview with Resident #23 on 06/25/2025 at 09:25 AM, Resident #23 reported that she/he never has the right size fitted sheet and that it happens all the time and that the nursing assistants can never find bariatric sized bed sheets for his/her bed. Per interview with a Licensed Nursing Assistant (LNA) on 6/25/2025 at 9:34 AM, she reported they run out of towels and clean laundry about twice a week and they don't have enough bariatric sheets. Per interview with another Licensed Nursing Assistant (LNA) on 6/25/2025 at 10:00 AM, she reported that they run out of clean linens and that it delays resident care. She also reported that they only have five bariatric bed sheets so they can't always find one for a bariatric resident's bed. Per interview with the…

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

Based on interview and record review, the facility failed to review and revise resident care plans for 2 residents related to falls (Residents #34 and #1) and for 2 residents related to pressure ulcers (Residents #39 and #9), of a sample of 23 residents. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 5/9/24. Findings include: 1) Per record review, Resident # 39 has diagnoses that include: hemiplegia and hemiparesis ( paralysis and weakness on one side of the body), chronic kidney disease stage 3 ( moderate kidney damage), and osteomyelitis (infection of the bone) of the pelvis. On 6/2/25, a Weekly Skin Review notes a blister on the right heel. Skin prep is applied, and the wound is covered with a foam dressing. On 6/9/25, a weekly skin check revealed a blister on the right heel with a 1 cm x 1 cm red area in the center. A progress note dated 6/15/2025 reveals a hospital transfer, where it was noted that resident #39 had a Deep Tissue Injury to the right heel, measuring 4 centimeters (cm) in length, 5 cm in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents remained as free from accidents as possible related to resident altercations and falls for 2 of the 9 sampled residents (Residents #1 and #34) by failing to provide adequate supervision and create and implement effective, timely interventions that would reduce the likelihood of future accidents related to supervision. As a result, Resident #1 suffered a fall that resulted in pain, a large hematoma above his/her left eye, and a fracture of the left hip, which required surgery. Findings include: 1. Per record review, Resident #1 has diagnoses that include a history of falls, osteoporosis, and failure to thrive. Resident #1 is alert and oriented, and per record review, an MDS dated [DATE] revealed Resident #1 was independent for ambulation with a walker prior to the incident on 6/7/25. Per hospital physician note dated 6/8/25, Resident #1 reported to the physician that s/he was struck several times by his/her roommate's [Resident #34]…

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

Based on interview and observation, the facility failed to safely store locked medications for 2 of 2 units. Findings include: During observations on Wing 1 on 6/23/2025 at 12:51 PM two medication treatment carts were noted to be unlocked. There were three residents in the nurse's station, three residents in the sunroom, and no staff observed in-sight of the medication treatment carts. On 6/23/2025 at 12:53 PM, the Unit Manager confirmed that both medication treatment carts were unlocked and should have been locked. Per record review of the facility's policy titled Medication Storage in the Facility, it states Medication rooms, carts, and medication supplies are locked or attended by person with authorized access. While exiting the building on 6/25/2025 at 5:06 PM a medication cart was noticed to be unlocked. The medication cart was unlocked outside of the resident's rooms past one of the nurse's stations. There was one resident in sight who was interacting with the phone at the nurse's station with no staff members in sight. A nurse came and locked the cart after being notified by…

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

Based on interview and record review, the facility failed to ensure that residents are free from unnecessary psychotropic medications for one of five sampled residents (Resident #17) as evidenced by administration of prn (as needed) psychotropic medications without a discontinued date. Findings include: Per record review, Resident #17 was prescribed Lorazepam (Ativan, a medication used for anxiety) 0.5 mg (milligram) tablet: Give one tablet by mouth every 6 hours as needed for agitation. This medication was prescribed on 6/7/25. Resident #17 was also prescribed Haloperidol Lactate Oral Concentrate 2 MG/ML [two milligrams per milliliter]: Give 0.5 mL [milliliters] every six hours as needed for agitation. This medication was prescribed on 6/8/25. Per record review of Resident #17's June 2025 MAR [Medication Administration Record] Resident #17 was administered the Lorazepam on 6/12/25, 6/14/25, 6/15/25, 6/16/25, 6/17/25, 6/21/25, 6/23/24, and 6/24/25. Resident #17 was never administered the Haloperidol. Per record review of the facility's Psychotropic Medication Use policy [last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive care plan by failing to notify the provider of specific symptoms for 1 of 23 Residents (Resident #23). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 5/9/24. Findings include: Per interview with Resident #23 on 6/23/2025 at 11:44 AM, she/he reported that they requested to be sent to the hospital when she/he wasn't feeling well, but the facility wouldn't send her/him when she/he asked. Resident #23 reports having spent time in the Intensive Care Unit (ICU) and that she/he had double pneumonia. Per record review, Resident #23 is care planned for altered cardiovascular status with the interventions of observing, documenting, and reporting symptoms to the Medical Doctor including, chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refill, colour…

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

Based on interview and employee files, the facility failed to ensure annual performance evaluations were completed for 3 of 3 Licensed Nursing Assistants (LNAs) in the applicable sample (LNA #1, #2, and #3). Findings include: Per review of employee files for LNAs that have worked at the facility for longer than a year, there were no nurse aide performance evaluations completed within the past year for LNA #1, hired on 2/17/24, LNA #2, hired on 4/13/2001, and LNA #3, hired on 4/6/21. Per interview on 6/25/25 at approximately 3:11 PM, the Administrator confirmed that the facility did not have annual performance evaluations for the above 3 LNAs.

Based on interview and record review, the facility failed to follow their processes for documenting high value personal property for one of three resident (Resident #1). Findings include: Per interview on 4/16/25 at 1:23 PM with Resident #1's Durable Power of Attorney (DPOA) s/he stated that s/he was not aware that Resident #1's hearing aids were missing until s/he went to the facility to pick up his/her belongings. S/He stated that the nurse on duty told him/her that Resident #1's hearing aids had been missing for about two weeks before s/he passed on 5/1/24. S/He stated that Resident #1's hearing aids cost $6,495.00. S/He stated that s/he was never notified that the hearing aids were lost and would have come in the help look for them if known. Per record review of nurse's notes dated 4/5/24 - 4/25/24, Resident #1's hearing aids were documented as missing. There is no documentation that the DPOA was notified of the missing hearing aids. Per interview on 4/16/25 at 11:17 AM, the Administrator stated that when a resident is admitted to the facility, a Licensed Nursing Assistant (LNA)…

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

Based on interview and record review, the facility failed to assist a resident to schedule a follow-up appointment with a provider specializing in the treatment of hearing impairment for one of three residents in the sample (Resident #1). Findings include: Resident #1 was admitted to Barre Gardens with a pair of reprogrammable hearing aids on 3/6/24. Per record review, Resident #1's has a Care Plan intervention dated 3/7/24 that reads, Resident uses bilateral hearing aids. Prefers to keep at bedside. A 4/2/2024 nursing note reveals, Noted [s/he] did not have [his/her] right hearing aid.- social services made aware. Per record review, a nursing notes dated 4/6/24 reads, Unable to find hearing aids this shift. Social services message left regarding hearing aids. Per record review from 4/6/24 through 4/25/24, nursing documentation continues to show both of Resident #1's hearing aids are missing. There is not any documentation that indicates the Durable Power of Attorney (DPOA) was notified that Resident #1's hearing aids were lost. Per interview on 4/16/25 at 9:45 AM with the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents received funds and jurisdiction of those funds within thirty days for one resident (Resident #1) out of three sampled residents. Findings include: Per telephone interview on [DATE] at 11:57 AM, Resident #1's Family Representative, who is charge of Resident #1's estate, stated that s/he requested a reimbursement of funds after the resident passed away on [DATE]. S/he stated s/he did not receive a check from the facility of approximately $1400 until May or June [of 2024]. The Family Representative expressed frustration with the situation. Per record review, Resident #1 passed away on [DATE]. A review of the Summation Financial Services Check Request Form states that the date of request was [DATE] for $1464.60 to be delivered to the Family Representative. Per record review, there is a FedEx delivery tracking document that states that the check was delivered on [DATE] at 11:42 AM. This was received 85 days after Resident #1 passed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to protect and promote the rights of 1 of 3 sampled residents (Resident #1) by failing to treat the Resident with respect and dignity in a manner and in an environment that promotes the maintenance or enhancement of their quality of life. Findings include: Per record review, Resident #1 resided in the facility from [DATE] to 6/20/24 with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following a cerebral infarction (a pathologic process that results in an area of dead tissue in the brain) affecting his/her right side and a displaced fracture of his/her right humerus. Per review of the facility's initial report submitted to the State Agency on 8/29/2024 and written witness statements, a Licensed Nursing Assistant (LNA) behaved disrespectfully and undignified toward the resident. A witness statement dated 6/16/2024 from a Licensed Practical Nurse (LPN) and a witness statement…

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

Based on observation and interview, the facility failed to ensure each resident has a right to self-determination and access to persons and services outside of the facility, by locking all doors to the facility 24 hours a day, 7 days a week. By creating a locked facility, there is a failure to ensure the right of each resident to exercise their rights as a citizen (or resident) of the United States or make personal choices about going outside without interference. This has the potential to affect all residents of the facility and all visitors, including family, legal representatives and advocates. The facility also failed to ensure residents had the right to get up at the time they want for 1 of 24 sampled residents (Resident #47), failed to have resolution for missing clothing for 3 of 24 sampled residents (Residents #47, #18, and #15), failed to schedule Resident Council meetings at times determined by the residents, and failed to ensure that 2 of 7 residents being served and assisted with meals were treated with dignity and respect, by not providing meals and nutrition while all…

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

Based on observations, resident interviews, staff interviews, and record review, the facility failed to ensure that food served to Residents is palatable, attractive, and at an appetizing temperature. Findings include: Per observation on 5/6/24 at approximately 12:30 PM, Resident #77 was exerting much energy and struggling to cut a chicken patty served to them for lunch with a metal fork and knife. Resident #77's roommate, Resident #243, was eating the chicken patty uncut with their hands. When asked why they were eating the patty this way, Resident #243 stated that it was difficult to cut and hard as a rock. Resident #243 then proceeded to bang the side of the patty on their bedside table and it made a hard clunking sound. On 5/6/24 at approximately 12:45 PM, this surveyor requested a lunch tray from both the Wing 1 steam table and the dining room steam table. Both trays were prepared after all other resident meals were plated and placed on the last meal cart sent to the units. The test trays were then sampled after the last resident on the last meal cart for each steam table was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview and record review, the facility failed to ensure that residents were served a nourishing snack at bedtime when the time between dinner and breakfast the following morning is more than 14 hours. The facility also failed to ensure that the Resident Council agrees to this amount of time between dinner and breakfast the following morning. Findings include: 1. Per review of the facility meal schedules, Residents are served breakfast at 8:00 AM and Dinner at 5:00 PM. There are 15 hours that elapse between the dinner meal and the breakfast meal the following morning. Per interview on 5/7/24 at approximately 4:00 PM, the following Residents were interviewed regarding bedtime snacks: - Resident #187, admitted on [DATE] with a BIMS (Brief Interview of Mental Status Score) of 13 (cognitively intact), stated that they have never been offered a snack before bed by staff. - Resident #240, admitted on [DATE] with a BIMS of 15 (cognitively intact), stated that they have never been offered a snack…

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

Per observation, staff interview, and record review, the facility failed to ensure that it stores and prepares food in accordance with professional standards for food service safety. Findings include: 1. Per an initial tour of the facility kitchen on 5/6/24 at approximately 9:30 AM, the following conditions were observed: - The reach-in refrigerator had a large container of bulk iced tea with a use by date of 5/4/24. - A steam table had dried, crusted food drippings on the bottom shelf as well as an unlabeled bag of hamburger buns with copious amounts of condensation on the inside of the bag. - Two food prep tables used for the breakfast service were no longer in use and had spilled milk, dropped applesauce, and copious amounts of crumbs spread across them. - A small table on the far wall of the kitchen was covered with food particles, an opened container of peanut butter with the lid askew, a pan of melted margarine/butter with a spoon inside, an opened bag of sliced bread, as well as other kitchen implements and clean containers. - The floors of the kitchen were dirty with dried…

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

Based on interview and record review, the facility Governing Body failed to ensure that facility policies were accessible to all staff members operating the facility and providing care to the facility's residents. This has the potential to affect all residents in the facility. Findings include: Per facility policy titled Governing Body, [undated], states the Governing Body is responsible for establishing and implementing policies regarding management and operation of the facility. Per interview on 5/08/24 at 12:58 PM, the Administrator was unable to access all facility policies. When asked how facility staff access policies, the Administrator explained that they would get them through the cooperate leadership team. S/He explained that policies are on the desktop computers but staff do not have access to them. S/He explained that it has always been that way and his/her corporate is aware of this issue. Per interview on 5/9/23 at 11:51 AM, a Licensed Practical Nurse was asked to pull up facility policies. S/He explained that, while in theory s/he should be able to access all care…

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

Based on interview and review of the facility assessment the facility failed to ensure that the required individuals including a representative of the governing body and the medical director were involved in the development of the facility assessment. This has the potential to affect all residents. Findings include: Per review of the facility assessment last updated on 4/9/2024, persons involved in completing the assessment lists: Administrator [name omitted] LNHA (Licensed Nursing Home Administrator); Director of Nursing: [name omitted] RN (Registered Nurse); Governing body Representative: LNHA; Medical Director: MD. Per interview on 5/09/24 at 1:23 PM, the Medical Director stated that s/he has not been involved in developing, reviewing, or revising the facility assessment. Per interview with the Administrator on 5/9/24 at 4:33 PM, s/he explained that the governing body is not involved in developing the facility assessment. The Administrator stated that s/he does report when the facility assessment was last updated during compliance calls with the governing body. The Administrator…

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

Based on interview and review of facility policies, the facility failed to ensure that the Medical Director fulfilled his/her responsibility to coordinate medical care with facility providers and assist the facility with the development and implementation of resident care policies. This deficient practice has the potential to affect all residents residing in the facility. Findings include: Facility policy titled Medical Director Responsibilities, dated 2023, states 4. The Medical Director's responsibilities include participation in: a. Administrative decisions including recommending, developing and approving facility policies related to resident care of physical, mental and psychosocial well -being; c. Organizing and coordinating physician services and services provided by other professionals as they relate to resident care; 8. Medical Director will assist in the development of systems to monitor the performance of the health care practitioners including . ensuring other licensed practitioners (e.g., nurse practitioners) who may perform physician delegated tasks act within the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections as evidenced by the improper use of PPE (personal protective equipment) for 1 resident on precautions (Resident #24) and the failure to implement infection prevention practices related to blood glucose monitoring. Findings include: 1. Per record review, Resident #24 has physician orders dated 5/7/24 that read: Contact and Droplet Precautions related to respiratory cold symptoms one time only for 7 days. [Contact precautions [are] Used for patients/residents that have an infection that can be spread by contact with the person's skin, mucous membranes, feces, vomit, urine, wound drainage, or other body fluids, or by contact with equipment or environmental surfaces that may be contaminated by the patient/resident or by his/her secretions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 upon observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment was maintained for the residents on 1 of 2 units (Unit 1). Findings include: 1. Observation on 5/6/24 at approximately 12:57 PM of Resident #47 and #50's room revealed a strip approximately 4-6 inches wide at chair rail level, that runs the full length of the right hand side of the residents room. The strip was falling off the wall and was laying on the foot of Resident #47's bed. Interview on 5/6/24 at approximately 1 PM with Resident #50, they confirmed that this chair rail strip keeps falling off and the maintenance man keeps re-gluing it and placing it back on the wall. Interview on 5/6/24 at approximately 1:15 PM with Resident #47, they confirmed that this chair rail strip keeps falling off and the maintenance man keeps re-gluing it and putting it back on the wall. Resident #47 stated that their spouse has complained to staff about this many times and this strip just keeps getting put back up on the wall. The resident said, if the maintenance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to revise the comprehensive care plan as the resident's plan of care changes for 2 of 27 sampled residents (Resident #23 and #62) related to catheter use and pain management for Resident #23 and activity preference for Resident #62. Findings include: 1. Per record review Resident #23 was admitted on [DATE] for rehabilitation following a hospital stay related to a urinary tract infection and sepsis. S/He has diagnoses that include uropathy (blockage in the urinary tract), bladder cancer, heart failure, chronic pulmonary embolism (a blood clot that forms a blockage in the artery of the lung), rheumatoid arthritis, peripheral neuropathy (nerve damage), and lung cancer. A 10/30/23 admission Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) reveals that Resident #23 was admitted without a catheter and has moderate pain for which s/he has received as need pain medication and is not on a scheduled pain medication regime. 1.a.…

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

Based on observation, interview, and record review, the facility failed to provide an ongoing activities program to support residents in their choice of group, individual, and independent activities to meet the interests of and support the well-being of each resident as evidenced by a lack of engaging activities both in and out of resident rooms for 4 of 24 sampled residents (Residents #82, #3, #73, and #23). Findings include: 1. During an interview on 5/6/2024 at 1:30 PM Resident #82 stated that s/he wished that there were more activities for the residents. S/he is able to socialize and participate in independent activities but many cannot. S/he said that the some days there is not much going on and it is starting to get to some of the residents. Per observation on 5/6/2024 at 11:10 AM there were 8 residents sitting in the sunroom with the television on. The Medical Records Specialist was in the room talking with the residents. Resident #3 was asking what crafts were happening and if there was going to be someone there who knew what they were doing with the crafts. The Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to ensure that physicians and other providers (as delegated to per regulation) review the Residents' total program of care, including medications and treatments, at each visit as required for 6 of 24 sampled residents (Residents #2, #78, #23, #19, #47, #53). Findings include: 1. Per record review, Resident #2 was admitted to the facility on [DATE]. Per review of physician/provider notes from June 2023 through the survey date, there are no provider visit notes during this timeframe that meet the definition of a total program of care review, including a review of all current medications, treatments, and all aspects of the resident's comprehensive plan of care. 2. Per record review, Resident #78 was admitted to the facility on [DATE]. Per review of physician/provider notes from June 2023 through the survey date, there are no provider visit notes during this timeframe that meet the definition of a total program of care review, including a review of all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure residents are seen by a physician personally, face-to-face, for regulatory visits for 1 of 24 sampled residents (Resident #23), and failed to ensure that regulatory visits were conducted every 30 days for the first 90 days after admission for 1 of 24 sampled residents (Resident #31). The facility also did not have a system in place to track required regulatory visits for any resident. Findings include: 1. Review of Resident #23's Attending Physician regulatory visit dated 12/20/2023 states Patient was not seen but was discussed with [the Nurse Practitioner]. The note explains that there were no vitals signs taken and no physical exam completed for this visit. Per interview 5/08/24 at 3:53 PM, the Director of Nursing confirmed that the above visit would not meet regulatory requirements because it was not in person. 2. The facility did not have a system in place to track regulatory visits as evidenced by the following interviews. Per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to ensure that the attending physician documents in the Resident medical record any rationale against, or actions taken as a result of, irregularities identified by the Pharmacist during the monthly medication regimen review for 4 of 5 sampled Residents (Residents #2, #71, #23, and #19). Findings include: 1. Per record review, a pharmacist medication regimen review note from December of 2023 recommends that the physician consider reducing or eliminating Resident #2's Ambien (a sleeping medication) dose due to resident #2's recent falls and the possibility that Ambien could increase fall risk. The physician checked the box disagree. There is no rationale that can be located in the medical record for Resident #2 explaining why the physician did not want to change the Ambien order. Per interview on 5/8/24 at approximately 11:30 AM, the Unit Manager confirmed that there is no evidence of a physician rationale for not wanting to change Resident #2's Ambien order in response to the pharmacist's recommendation. 2. Per 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 staff interview and record review, the facility failed to ensure that Residents taking psychotropic medications receive gradual dose reductions, unless contraindicated, for 3 of 5 sampled Residents (Residents #2, #25, #19). Findings include: 1. Per record review, Resident #2 is receiving Venlafaxine Extended Release Tablets 150 mg in the morning and 37.5 mg before bed every day. This dosing has been consistent for Resident #2 over the last year. Per review of pharmacist monthly MRRs (Medication Regimen Reviews) for the past year, there is no evidence that a GDR (gradual dose reduction) for Venlafaxine was ever discussed. There is also no documentation from Resident #2's Provider regarding any contraindications for attempting a GDR for Venlafaxine. Per interview on 5/8/24 at approximately 11:30 AM, the Unit Manager confirmed there is no evidence of any consideration of a GDR of Venlafaxine for Resident #2 in the last year, and stated that the facility doesn't generally consider doing GDRs for antidepressants. Per interview on 5/9/24 at approximately 12:15 PM, a pharmacist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that records are complete, accurately documented, readily accessible, and systematically organized related to physician notes for 2 of 27 sampled residents (Residents #23 and #31). Findings include: 1. Per review of Resident #23's medical record, the following provider visits were missing from the resident's medical record: -A 11/30/23 Hematology progress note revealing that Resident #23 is to continue his/her anticoagulant, Lovenox, daily. The physician order for the anticoagulant enoxaparin sodium (Lovenox) ended on 12/14/24 and a new order was never placed. A 2/2/24 nursing note reveals that hematology should be restarted on Lovenox. See F760 for more information. -A 12/21/2023 Emergency Department provider note, revealing that Resident #23 was being seen related to an accidental or unintentional opiate overdose that the facility just started to administer. This information is not addressed in any other facility nursing note or 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 and interview it was determined that the facility failed to provide reasonable accommodation of resident needs for 1 of 24 residents in a standard survey sample (Resident #53). Findings include: Interview on 5/6/24 at approximately 2:35 PM, Resident #53, who was laying in their bed was asked about call bell access and staff response time. S/he stated, That's laughable, staff never make sure I have my call bell. Do you see it anywhere? Observation on 5/6/24 at approximately 2:37 PM revealed Resident #53 with no access to the call bell system. Upon the residents bedside table was a white coiled call bell cord which was not within Resident #53's reach. At the same time as this observation, the LPN assigned to resident #53 had been assisting Resident #53's roommate and had heard the conversation between Resident #53 and the surveyor. The LPN located the residents call bell on their bedside table and attempted to provide it to the resident. S/he stated, I have clipped it [call bell] to your pillow case. The surveyor asked the resident if they could reach 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 interview and record review, the facility failed to develop a comprehensive care plan that addressed anticoagulant use for 1 of 4 sampled residents reviewed for anticoagulant use (Resident #23). Findings include: Per record review Resident #23 was admitted on [DATE] for rehabilitation following a hospital stay related to a urinary tract infection and sepsis. S/He has diagnoses that include heart failure, chronic pulmonary embolism (a blood clot that forms a blockage in the artery of the lung), and pacemaker. A 10/30/23 admission Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) reveals that Resident #23 was admitted taking an anticoagulant. admission orders reveal a physician order for enoxaparin [Lovenox; an anticoagulant, used to prevent and treat blood clots] 120 mg/0.8 mL injection, inject 120 mg into the skin for 90 days. Review of Resident #23's care plan reveals that Resident #23 did not a have a care plan that addressed the use of anticoagulants until 4/18/24. Per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to ensure that residents with Peripheral IVs receive treatment and care in accordance with professional standards of practice for the only resident in the facility with a Peripheral IV (Resident #2). Findings include: Per observation on 5/6/24 at approximately 4:00 PM, Resident #2 was observed with a peripheral IV in their left arm. A date of 5/3/24 was written on the IV dressing. Per record review, Resident #2 was ordered for Cefepime HCl (an antibiotic) Intravenous Solution 1 GM/50ML Use 1 gram intravenously two times a day for an infection on 5/2/24. There is also orders for Normal Saline Flush Intravenous Solution 0.9 % Use 10 ml intravenously two times a day for both pre and post-antibiotic administration, ordered on 5/3/24. There are no orders for peripheral IV monitoring or dressing changes. Per care plan review, there is also no care plan focus for Resident #2's peripheral IV Per review of the facility policy titled Peripheral IV Dressing Changes states under the General Guidelines section the…

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

Based on interview and record review, the facility failed to ensure that 1 of 24 applicable residents (Resident #23) remained free from unnecessary medications. Findings include: Per record review, Resident #23 has a physician order for Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.1 ml by mouth every 4 hours for pain, [shortness of breath]. This dosing and frequency has been consistent for Resident #23 since it was first ordered on 1/9/24 and Resident #23's Medication Administration Record reveals that the morphine has been administered as ordered since 1/9/24. Per record review, a pharmacist medication regimen review note for Resident #26 from May of 2024 recommends currently receiving Morphine 6 times daily. Please evaluate continued need, consider trial taper to 4 times daily, if appropriate. The provider checked the box disagree. There is no rationale that can be located in the medical record for Resident #26 explaining why the physician did not want to change the Morphine order. Review of Resident #23's vitals, Resident #23 has not reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 24 sampled resident (Resident #23) are free from significant medication errors. Findings include: Per record review Resident #23 was admitted on [DATE] for rehabilitation following a hospital stay related to a urinary tract infection and sepsis. S/He has diagnoses that include heart failure, pacemaker, chronic pulmonary embolism (a blood clot that forms a blockage in the artery of the lung), and lung cancer. Per interview on 5/07/24 at 9:26 AM, Resident #23's Representative explained that s/he was concerned that Resident #23 did not receive his/her anticoagulant for weeks, around the time when Resident #23 had a significant decline in his/her health. S/He explained that Resident #23 had been seeing a hematologist who had been treating his/her history of blood clots with anticoagulants for a long time. The Representative stated that no one had alerted him/her to the discontinuation of the anticoagulant and s/he became aware that Resident #23…

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