Elderwood at Burlington

Based on observation, interview, and record review the facility failed to implement appropriate infection control practices during medication administration via tube feed for one sampled resident (Resident #14). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys dated 4/2/25 and 1/11/24. Findings include:1. Medication administration via a tube feed was observed on 3/25/26 at approximately 8:45 AM for Resident #14 by LPN#2. Per observation, Resident #14 had an Enhanced Barrier Precautions sign outside of their room. Per record review, Resident #14 has an order stating Precautions: Maintain barrier precautions r/t [related to] hx [history] of MRSA [Methicillin-resistant Staphylococcus aureaus, a bacterium that is resistant to many antibiotics], PEG [Percutaneous Endoscopic Gastrostomy] tube use.Per observation, LPN#2 did not don PPE [Personal Protective Equipment] prior to going into the room.Per review of the facility's Transmission Based Precaution Levels (Type of Infectious Condition, Techniques and Documentation)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and interviews, the facility failed to document for 1 of 6 residents (Resident #124) whether the resident was offered, educated, and received or declined the influenza and pneumococcal vaccinations. Findings include:Per record review on 03/25/2026, Resident #124 was admitted on [DATE], and no documentation was located in the electronic medical record (EMR) to indicate the resident, or their representative had been educated, offered, and received or declined vaccinations. The Immunizations Report generated from the EMR indicates Resident #124's influenza status is historical, but lacks documentation of the immunization. The report doesn't indicate whether the resident received the pneumococcal vaccination. Per interview on 3/25/2026 at approximately 11:39 AM, the Infection Preventionist was asked to provide the Vaccination Review: Consent/Declination SNF Resident Form for Resident #124. Per interview on 3/25/2026 at approximately 4:05 PM, the Infection Preventionist confirmed documentation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 include documentation in the electronic medical record (EMR) for 1 of 6 residents (Resident #124) whether the resident was offered, educated, received, or declined the COVID-19 vaccinations.Findings include: Per record review on 03/25/2026, Resident #124 was admitted on [DATE], and no documentation was located in the EMR to indicate the resident or their representative had been educated, offered, received, or declined the COVID-19 vaccinations. The Immunizations Report generated from the EMR indicates Resident #124's COVID-19 status is historical with a date of receiving it on 12/5/24, however it lacks documentation of the immunizations. Per interview on 03/25/2026 at approximately 11:39 AM, The Infection Preventionist was asked to produce the Vaccination Review: Consent/Declination SNF Resident Form for Resident #124. Per interview on 3/25/2026 at approximately 4:05 PM, the Infection Preventionist confirmed documentation of offering, educating, 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 staff interviews and record reviews, the facility failed to ensure that 10 of 10 residents sampled (#1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) were free from misappropriation of 6 different types of controlled medications identified by the facility audit. Findings include:Per review of the facility's reported investigation, a concern was raised on 12/15/25 regarding documentation of resident #1 receiving an as-needed (prn) medication. The assigned medication nurse reported that resident #1 hadn't received the medication for 3 months, which they confirmed with the resident. The facility conducted audits of all Control Medication logbooks (record-keeping systems used by facilities to track the inventory, administration, and disposal of controlled substances) and the medication administration records of residents who were to receive these medications. It was found that on 2 separate occasions, for ten different residents (#1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) in the facility and on two units, a Licensed Practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that 1 of 5 nursing staff had an active [NAME] license to practice. Findings include:A review of credentials for a Licensed Practical Nurse (LPN) investigation for misappropriation of medications (see citation F602 for additional information) revealed that the LPN lacked an active [NAME] license to practice. The nurse's multistate compact license (a license with the authority to practice in multiple member states), which permitted practice in [NAME], had expired on [DATE]. A request for an updated license was made to the Administrator on [DATE] at 12:00 PM, and nursys.com (the national nurse licensure and disciplinary database) was used to search for it. The search confirmed the LPN's license was only active in North Carolina, a single-state license, and was no longer valid for [NAME]. The Administrator stated, I asked her to fix this. She was asked who she was referring to, and she stated she had spoken to the LPN by phone regarding the LPN's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to implement a system to ensure nursing staff members administering medications maintain ongoing qualifications for 1 of 5 nursing staff sampled. Findings include:Per the facility's reported investigation, a concern was raised on [DATE] when the oncoming shift medication nurse reported that a resident hadn't received an as-needed (prn) medication for 3 months, a claim the nurse confirmed with the resident. The facility conducted audits of all Control Medication logbooks (record-keeping systems used by facilities to track the inventory, administration, and disposal of controlled substances) and the medication administration records of residents who were to receive these medications. It was found that on 2 separate occasions, for ten different residents in the facility and on two units, a Licensed Practical Nurse (LPN) had not followed the procedure for administrating medications as evidence identified by the facility as irregularities 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.

Per interview and record review, the facility failed to ensure one of four residents (Resident #2) was free from chemical restraints by prescribing an as needed psychotropic medication with no stop date of 14 days. Findings include:Per review of Resident #2's medical record, Resident #2 has major diagnoses of vascular dementia [a form of dementia associated with impaired reasoning, planning, judgment, and memory caused by brain damage from impaired blood flow to your brain], Stage 2 chronic kidney disease, and COPD [Chronic Obstructive Pulmonary Disease]. Resident #2 had a BIMS [Brief Interview of Mental Status] score of 9 as of 7/17/25. A BIMS score of 9 indicates that Resident #2 is cognitively impaired. Per record review of a physician order dated 7/23/25 states, Lorazepam tablet 0.5 mg [milligram]: Give one tablet by mouth every 6 hours as needed for itching and anxiety. There was no documented stop date of 14 days on this order. Resident #2 was administered the Lorazepam 8 times from 7/23/25 to 8/11/25.An interview was conducted with the DON [Director of Nursing] on 8/11/25 at…

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

Per interview and record review the facility's failed to prevent significant medication errors for one of four residents [Resident #1] sampled. Findings include:Per review of Resident #1's medical record, s/he had major diagnoses of Type II Diabetes, Alzheimer's Disease with late onset, Schizoaffective Disorder [a mental illness where the person experiences symptoms of both schizophrenia and a mood disorder], and anxiety. Resident #1 has a BIMS [Brief Interview of Mental Status] score of 4 as of 6/27/25. A BIMS score of 4 indicates Resident #1 was cognitively impaired. Per record review of the Resident #1's July 2025 MAR [Medication Administration Record] a medication order on the MAR states, Lisinopril [a medication used to treat high blood pressure] tablet 40 mg [milligrams] Give one tablet buy mouth in the morning for hypertension. Hold for SBP [systolic blood pressure] <100 [under 100] mmHg [millimeters of mercury] and notify provider. The MAR shows that the medication was ordered on 6/27/25.Per record review of Resident #1's nurse progress note written on 7/20/25 at 7:00 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.

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident [Resident #1] of 3 sampled residents. Findings include: Per interview with the State Surveyor on 5/12/25 at 10:30 AM and per review of the State Surveyor's written report, Resident #1 reported to the Surveyor allegations of employee misconduct and possible abuse involving Resident #1's roommate and a Licensed Nursing Assistant on 2/18/25. The Surveyor reported the allegations of abuse and misconduct to both the facility's former Administrator [FADM] and Assistant Director of Nursing [ADON] on the same date, 2/18/25. Additionally, the Surveyor reported the allegations of abuse and misconduct to Adult Protective Services. An interview was conducted on 5/12/25 at 11:47 AM with the facility's current Administrator [ADM] and Director of Nursing [DON]. The ADM and DON confirmed that Adult Protective Services arrived at the facility 7 days after the incident on 2/26/25 to…

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

Based on interview and record review, the facility failed to immediately put measures in place to ensure that further potential abuse, neglect, exploitation, or mistreatment did not occur after allegations of abuse were reported to the facility for 1 resident [Resident #1] of 3 sampled residents. Findings include: Per interview with the State Surveyor on 5/12/25 at 10:30 AM, and per review of the State Surveyor's written report, Resident #1 reported to the Surveyor allegations of employee misconduct and possible abuse involving Resident #1's roommate and a Licensed Nurse's Aide on 2/18/25. The Surveyor reported the allegations of abuse and misconduct to both the facility's former Administrator [FADM] and Assistant Director of Nursing [ADON] on the same date, 2/18/25. Additionally, the Surveyor reported the allegations of abuse and misconduct to Adult Protective Services. An interview was conducted via phone with the Assistant Director of Nursing [ADON] on 5/12/25 at 12:40 PM. The ADON stated that an investigation into Resident #1's allegations was done by the former ADM who was no…

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

Based on staff interview and record review, the facility failed to ensure that the individual who has completed the specialized training in infection prevention and control oversees the facility's infection prevention and control program. Findings include: Per review of the Facility Assessment, dated 11/15/24, Education/Training Requirements are, Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; Is qualified by education, training, experience or certification; Works at least part-time at the facility; and has completed specialized training in infection prevention and control. Per review of the facility's infection control log, that included the facility line listings, policies and procedures, and training, it was revealed that all infection prevention and control documents were completed by the facility's DON (Director of Nursing). Per interview on 4/2/25 at approximately 4:59 PM, the DON stated that s/he is responsible for both the facility's infection prevention and control program and the DON position 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 observation and interview, the facility failed to ensure residents are given the opportunity to eat meals in the dining room during breakfast, dinner, and the weekend meal service for 7 randomly sampled residents (Residents #73, #4, #13, #10, #54, #6, #74). Findings include: Per observation throughout the recertification survey on 3/31/25 through 4/2/25, the dining room was observed to be closed for meal service during breakfast and dinner. Per interview on 4/2/25 at 8:12 AM, Resident #73 stated, I prefer to eat breakfast in my room and have lunch and dinner in the dining room. Per interview on 4/2/25 at 8:25 AM with Resident #4 stated, I would like to have all of my meals in the dining room. Per interview on 4/1/25 at 11:56 AM, Resident #13 stated s/he really likes the dining room and would like to be able to come more often. S/he would like a place to go. Per interview on 4/1/25 at 11:57 AM, Resident #10 prefers to eat in the dining room. She/he would like it if s/he could eat more of her/his meals in the dining room. She/he does not like eating in his/her room. 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.

Per observation, interview, and facility policy review, the facility failed to establish an anonymous grievance reporting system that supports the resident's right to voice any grievance without discrimination, reprisal, or the fear of discrimination or reprisal for 2 of 5 sampled residents (Residents #72 and Resident #82). Findings include: A resident council meeting was held on 4/1/25 at 2:00 PM. Five residents attended the resident council meeting. During resident council Residents #72 and Resident #82 discussed their concerns with grievances stating, Sometimes we don't get a response at all. Resident #82 discussed feelings of retaliation if a grievance is filed. An interview was conducted with Resident #82 on 4/2/25 at 5:12 PM. Resident #82 discussed that s/he did not know how to file a grievance anonymously, stating, We have to give them to the nursing supervisor. I don't even know where they go. Resident #82 also stated s/he has never received a copy of his/her grievances. S/he stated s/he filed two grievances, both within the last year and never received a written copy back.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and record review the facility failed to provide trauma informed care by not identifying triggers that may cause re-traumatization for 5 of 9 sampled residents (Resident #31, #60, #464,#99,#110). Findings include: 1) Record review shows that Resident #31 suffers from PTSD (post-traumatic stress disorder). Review of the resident's care plan did not identify any triggers that may re-traumatize this resident. A note from Deer Oaks (an outside provider of mental health services), dated 12/17/21, states do not talk about war trauma per resident's requests. The note also goes on to identify concerns about family members health, and the recent death of Resident #31's fiancé as triggers that may re-traumatize the resident. A Facility policy titled Trauma informed Care, last updated on 3/4/24 reads, The facility will ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting 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, interview, and record review, the facility failed to ensure there was enough nursing staff to administer medications timely for 1 of 27 sampled (Resident #45) and meet resident preferences of where to dine for 7 randomly sampled residents (Residents #73, #4, #13, #10, #54, #6, #74). This has the potential to impact multiple residents. This is a repeat deficiency for this facility, with violations cited during a partial survey, dated 8/15/24, and the previous recertification survey, dated 1/11/24. Findings include: 1) Per record review, Resident #45 has diagnoses that include Parkinson's disease and hypothyroidism. S/he had the following medications orders, Levothyroxine 75 mcg, give 1 tablet by mouth in the morning for hypothyroidism. Give before breakfast, starting 12/15/24. Per the facility medication administration record (MAR) the medication is scheduled between 7:00 AM and 10:00 AM every day. Per review of the medication administration record Resident #45 received his/her thyroid medication after breakfast four times in the month of March. Per drug guide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Surveyor: [NAME], [NAME] Based on observation and interview, the facility failed to ensure that food served to residents is palatable, attractive, and served at an appetizing temperature for 12 randomly sampled residents, (Residents #44 , #74, #4, #14, #72, #50, #97, #74, #33, #25, #68, and #83). Findings include: 1) Per interview with Resident #25 on 3/31/25 at 11:29 AM, s/he stated, The food is too salty, there are a lot of gristles in the ground meat, and the food does not look appetizing. S/he stated, I don't like it that they give us fried baloney sandwiches for dinner at least once a month. Per interview on 3/31/25 at 11:41 AM with Resident # 33, s/he stated, The food is terrible and the presentation is terrible. S/he also stated, The Kitchen Manager is very nice but does not make changes to the taste of the food and how it is cooked. Per interview on 3/31/25 at 12:09 PM with Resident # 83, s/he stated, The food is so/so, it is too salty, and buns are usually wet from the vegetables. S/he also stated, It…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, observations, and record review, the facility failed to provide residents appealing menu items that meet the preferences and choices of the residents for 6 randomly sampled residents (Residents #5, #82, #50, #34, #80, and #18). Findings include: Per interview with Resident #5 on 3/31/25 at approximately 2:55 PM, s/he stated that the meals offered are a lot of sandwiches and the alternative option is often sandwiches. Resident #5 reported buying ramen to have a hot meal. On 4/2/25 at approximately 10:01 AM, Resident #5 reported that staff don't show the menu to her/him, ask her/him what they want for food, and they don't offer her/him choices for meals. Resident #5 reports not having seen a menu in a very long time. At 6:00 PM on 4/2/25, Resident #5 reported they didn't get to choose their meal, that dinner is gross, and they were not offered anything different. Per interview with Resident #82 on 4/2/25 at approximately 3:25 PM, s/he reported about how they will frequently mess up their food order and s/he will have to ask for something else. They report s/he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain infection control practices specific to medication administration for 1 resident (#464) in a standard survey sample of 27, and failed to ensure facility equipment used for mechanic lift transfers was cleaned and maintained sanitarily. This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 1/11/24 and 12/7/22. Findings include: 1) Per observation on 4/2/25 at approximately 3:15 PM of the facility's laundry processing area, it was revealed that mechanical lift pads (a fabric sling that is used in conjunction with a patient lifting device to support and transfer individuals who have mobility limitations) are washed and then hung to dry on a hook in the laundry room. It was noted that there were 4 hooks under an open window in the laundry room and on all 4 hooks there were numerous mechanical lift pads of various sizes. On the third hook from the left there were 3 lift pads at the front of the hook that were wet and resting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care for 2 of 27 residents in the sample (Resident #464 and Resident #34). This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 1/11/24 and 12/7/22. Findings include: 1. Per record review, Resident #464 was admitted to the facility on [DATE]. He/she has an admission document from the admitting hospital, Hospital Medicine admission History and Physical, dated 11/19/24, in his/her medical record. The document states Post traumatic stress disorder (PTSD): sexually assaulted, prefers female caregivers. Resident #464 has a care plan for Trauma with Anxiety, dated 11/25/24 and revised 4/1/25. It does not address a preference for female caregivers or a history of sexual assault. On 4/02/25, at 10:00 AM, the Social Worker stated, We don't…

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

1) Based observation, interview and record review, the facility failed to ensure that services provided meet professional standards as evidenced by failing to follow physicians' orders related to the timing of administration for 2 of 27 sampled residents (Residents #45 and #34). This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated 1/11/24. Findings include: Per record review, Resident #45 has diagnoses that include Parkinson's disease and hypothyroidism. Per interview with Resident #45 on 3/31/25 at 3:30 PM, s/he stated that his/her medications for his/her Parkinson's disease are often late. S/he stated that s/he experiences increased tremors and pain when his/her medications are late. S/he stated when my medications are late, I start to have more tremors which are really painful, then I have a bladder spasm causing me to urinate in the bed. [Resident #45] further stated s/he has tried to explain this to the staff but s/he does not feel that they understand or listen. Per record review, Resident #45 has 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice including prevention of skin breakdown for 1 of 27 sampled residents (Resident # 14). Findings include: Per record review, Resident #14 was admitted to the facility with diagnoses of hemiplegia and hemiparesis following a stroke, muscle weakness and a need for assistance with personal care. Resident #14 has a care plan focus stating I have an alteration in bladder/bowel elimination related to incontinence and CVA [cerebrovascular accident, a stroke] with an intervention, dated 6/10/19 incontinent care every 2 to 4 hours and as needed, and a care plan focus stating I am at risk for impaired skin integrity with interventions, dated 6/10/19, for, apply/administer barrier creams as ordered and provide timely toileting incontinence care. He/she has a care plan intervention, dated 3/24/25 to be turned and repositioned every two hours. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to store all drugs and biologicals in locked compartments/medication carts and only permit authorized personnel to have access to 1 of 6 medication carts. This is a repeat deficiency for this facility, with violations cited during the previous recertification survey, dated 1/11/24. Findings include: Per observation on 3/31/25 at approximately 11:15 AM on the [NAME] Unit, a licensed nurse was observed walking away from an unlocked medication cart that was abutting the [NAME] Unit nurses station. S/he walked down a hallway on the [NAME] Unit pushing a wheelchair while following a resident. S/he did not have direct view of the medication cart from 11:16 AM until 11:21 AM. There were numerous residents in the area of the unlocked medication cart. Upon her/his return to the medication cart and while greeting the surveyors the nurse locked the medication cart. Per interview on 3/31/25 at approximately 11:23 AM with the licensed nurse, s/he…

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

Based on observation, resident and staff interviews, and record review, the facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, or plan of care, potentially impacting all residents of the facility. Findings include: 1. Observations and interviews reveal that ADL care (activities of daily living) was not provided in a timely manner. a. Per record review, Resident #7's care plan states that s/he has an alteration in bladder/bowel elimination [related to] impaired mobility, initiated on 3/18/19 and that s/he has a deficit in ADL function/mobility related to cerebral palsy and schizoaffective disorder, revised on 4/28/24. Care plan interventions include total dependence for toileting hygiene, revised on 3/20/24, maximum assistance for transferring, revised on 5/23/24, and for staff to provide prompt incontinent care, initiated on 8/7/19. On 6/10/24, Resident #7 was assessed to…

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

Based on observation, resident and resident representative interview, staff interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) without assistance receives the proper level of assistance for 8 of 11 sampled residents (Residents #1, #4, #5, #6, #7, #8, #9, and an anonymous resident). Findings include: 1. Per record review, Resident #7's care plan states that s/he has an alteration in bladder/bowel elimination [related to] impaired mobility, initiated on 3/18/19 and that s/he has a deficit in ADL function/mobility related to cerebral palsy and schizoaffective disorder, revised on 4/28/24. Care plan interventions include total dependence for toileting hygiene, revised on 3/20/24, maximum assistance for transferring, revised on 5/23/24, and for staff to provide prompt incontinent care, initiated on 8/7/19. On 6/10/24, Resident #7 was assessed to have a BIMS of 15 (brief interview for mental status; a cognitive assessment score indicating cognitive intactness). Per observation and interview on 8/13/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to monitor 3 out 3 residents sampled for the adverse side effects related to psychotropic medications (Resident's #5, #9, and #10). Findings include: (1.) Per record review Resident #9 was admitted with diagnoses that include Alzheimer's, dementia with behavioral disturbances. S/He has the following medication orders written by the Advance Registered Practice Nurse (APRN): Haloperidol oral tablet 2 milligrams (mg) give one tablet by mouth two times a day for agitation, (Antipsychotic used to treat schizophrenia) (Schizophrenia is a serious mental health condition that affects how people think, feel and behave. Mayo Clinic 2024), Lorazepam oral tablet 0.5 mg give 1 tablet by mouth at bedtime for anxiety, Zyprexa oral tablet 5 mg give one tablet by mouth in the morning for agitation and one tablet by mouth in the evening for behaviors. (Zyprexa is an antipsychotic used to treat schizophrenia). Per Manufacturers warning for Haloperidol,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physicians and other providers (as delegated to per regulation) review the residents' total program of care, including medications and treatment plan at each visit as required for 1 of 3 sampled residents (Resident's #9). Findings include: Physician note dated 6/4/2024 under section titled Assessment and Plans reads ALZHEIMER'S DISEASE, UNSPECIFIED - G30.9-With behaviors, [s/he] has episodes of screaming out, restlessness and agitation. [S/he] currently is on Seroquel Haldol and Ativan without behavior changes continue meds for now . Per record review Seroquel was discontinued 05/23/2024. Per review of Resident #9's physician orders starting on 4/3/2024 shows that Resident #9 was taking the following medication at the time of regulated visit: Haloperidol oral tablet 2 milligrams (mg) give one tablet by mouth two times a day for agitation, Lorazepam oral tablet 0.5 mg give 1 tablet by mouth at bedtime for anxiety, A Physician note dated 7/20/2024 Assessment and Plans ALZHEIMER'S DISEASE, UNSPECIFIED -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and policy review, the facility failed to ensure that allegations involving abuse are reported no later than 2 hours to the Administrator of the facility and the State Survey Agency for 1 of 3 sampled residents (Resident #1); the facility failed to provide the State Agency sufficient information to describe the alleged violation and indicate how residents are being protected in its initial report for 3 of 3 sampled resident to resident altercations; the facility failed to provide sufficient information to describe the results of an investigation, and indicate any corrective actions taken, if the allegation was verified in its final investigation 5 day summary report for 2 of 2 sampled resident to resident altercations; and the facility failed to develop policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Findings include: 1. Per review of a facility investigation report submitted to the State Agency on 12/12/2024, a staff member was made aware on 12/12/2024 of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to maintain medical records on each resident that are accurately documented related to skin for two of three sampled residents (Residents #3 and #4). Findings include: 1. Per record review, Resident #3 was admitted to the facility on [DATE] for rehabilitation services following hospitalization for a left humerus fracture and a left femur fracture. A 1/22/24 Physician note reveals that Resident #3 was transferred to the hospital on 1/22/23 due to a displaced catheter. Per a complaint submitted to the State Agency on 1/25/2024, Resident #3 had questionable bruising to his/her right arm on transfer from the facility to the hospital on 1/22/24. Per review of Resident #3's medical record, there was no documentation that Resident #3 had any bruising on his/her body while at the facility between 1/15/24 through 1/22/24. The following interviews and record reviews reveal that Resident #3's skin condition was not accurately documented in their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, and record review, the facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, or plan of care, impacting all residents of the facility. Findings include: 1. Staff schedules reveal that there is frequently not enough staff working to consistently meet the needs of the residents. Review of facility direct care staff schedules and PPD (direct care staff to resident ratios) for October, November, and December 2023 reveals that the facility failed to maintain required [NAME] minimum staffing levels to allow for 2.0 hours of direct care per resident per day (PPD) on a weekly average by Licensed Nursing Assistants (LNAs) for 7 of the 8 sampled weeks and failed to maintain required minimum staffing levels to allow for 3.0 hours of direct care per resident 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 interview, staff education record review, and the facility assessment, the facility failed to ensure that licensed nurses and licensed nursing assistants were assessed for competency and skill sets to provide care and respond to each resident's individualized needs. This has the potential to affect all residents. The facility's Facility Assessment (an assessment that determines what resources are necessary to care for the residents competently during both day-to-day operations and emergencies), last reviewed 10/2/2023, reveals under section 3 titled Facility Resources Needed to Provide Competent Resident Support and Care Daily and During Emergencies a chart that lists the required staff competencies required to provide the level and types of care needed for the resident population, both initially and annually. Per this chart, licensed nurses use the Nurse Competency Skills Evaluation which lists 9 pages of skills licensed nurses are required to demonstrate. This list includes skills such as handwashing, safe medication administration, Treatment Administration Record (TAR)…

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

Based on observation and interview, the facility failed to ensure that food is stored in accordance with professional standards for food service safety. The facility also failed to ensure that dishwasher temperatures were monitored to ensure proper sanitation. Findings include: On 12/17/23 at 4:10 p.m. during the initial tour of the kitchen, the following observations were made: 1. In the walk-in cooler observed a milk crate with 8 containers of egg nogg being stored directly on the floor. The facility cook confirmed the egg nogg should not be on the floor it should be on a shelf. 2. In the walk-in cooler a box of celery was wilted, with soft and bendable stocks and the color of the celery was pale indicating that it is not suitable for eating. The facility cook confirmed the celery was spoiled and removed it from the walk-in cooler. 3. In the walk-in cooler a watermelon had mold and brown spots on the outer rind. The facility cook confirmed the watermelon was spoiled and removed it from the walk-in cooler. 4. In the walk-in cooler there were 6 half-gallon containers of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, it was determined that the facility failed to ensure the Medical Director (MD) duties per the Medical Director Agreement and Medical Director facility policy were implemented to ensure resident care policies and services were provided to all residents that were consistent with current professional standards of practice on 3 of 3 resident units. Findings include: A document titled Medical Director Agreement, signed by the facility on 5/31/23 [NAME] the following services will be provided by the MD: Minimum Qualification Standards and Performance Requirements of a medical Director 1.2.9.2 Review of the resident's overall condition and program of care at each visit, including medication and treatment 1.2.14 Process for accurate assessments, care planning, treatment implementation, and monitoring or care and services to meet resident needs. 1.3 Physician shall review and update resident care policies and procedures to reflect current standards of practice for resident care 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 and interview it was determined that the facility failed to maintain an effective pest control program that ensures the facility is free of pests. Findings include: 12/17/23 4:10 p.m. On the initial tour of the facility kitchen observed several fruit flies in all sections of the kitchen, including the food prep area, food storage areas, and dishwashing areas. Also during the initial tour observation of a blue light unit mounted on the wall in the kitchen had many trapped flies and fruit flies in the unit. An interview with the facility cook on duty during the initial tour confirms that the fruit flies come from the sink drains and that they need to contact the exterminator for control of these pests. On 12/17/23 at 6:26 p.m. observed during the supper meal tray pass, fruit flies came out of the tray cart that resident's meal trays were on waiting to be passed out. On 12/18/23 at 11:55 a.m. fruit flies were observed in the resident's dining room while the lunch meal was being served. Fruit flies are mainly attracted to extra ripe, fermenting fruits 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 and interviews, the facility failed to treat those residents reliant on wheelchairs with dignity by failing to clean the wheelchairs. The facility has 80 residents who utilize wheelchairs. Findings include: On December 19, 2023, at approximately 9:00 AM Resident #5 was sitting in his/her power wheelchair waiting to leave the facility for an outing. The base of the wheelchair housing the motorized mechanisms was noted to have a coating of sticky, dusty grime, this coating was noted along all flat surfaces of the chair. The posterior view of the backrest was noted to have an approximately 2 inch streak of a dark colored smeared sticky substance on the top edge. A unit Licensed Nurses Aid in the area at the time confirmed the chair was unclean. Further observations of wheelchairs in resident rooms, in hallways, or being used by residents revealed similar dusty, dirty surfaces, one with what appeared to be hair or thread wound around 2 of the spokes on the left large back wheel. Per facility policy entitled Wheelchair, Geri-Chair Inventory, Maintenance, Cleaning,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 determine whether it is clinically appropriate for residents to self-administer medications for 2 of 35 residents (Resident #31 and #81). Findings include: Per facility policy titled Medication Administration Methods, last revised on 7/12/23, A medication must never be left at bedside or be out of sight of the nurse administering the medication. The nurse must watch each resident take the medication, and ensure the medication is swallowed, unless the resident has an order for self-administration of medications. 1. Per observation on 12/19/23 at 10:53 AM Resident #31 was lying in their bed in their room. On his/her bedside table was a respiratory inhaler labeled Trelegy Ellipta Aerosol Powder. Resident #31 explained that the nurse left it there this morning but s/he also has another inhaler that s/he keeps in the room all the time. Resident #31 then revealed a respiratory inhaler labeled Albuterol Sulfate from a cup on his/her bedside table. Record review reveals that Resident #31 has diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review the facility failed to use the data collected using the Resident Assessment Instrument (RAI) process, specifically the Minimum Data Set (MDS) assessment, as part of an ongoing process to develop a comprehensive care plan, to provide the appropriate care and services and to modify the care plan for 1 of 35 Resident's sampled (Resident # 28). Additionally, the facility failed to accurately code the MDS assessment, due to lack of accurate review of records and/or lack of actual assessment of the resident's wounds by the facility, for 3 of 35 Resident's sampled (Residents #47, #99, and #1). Findings include: 1. Resident #28 has a score of 14 out of 15 on the Brief Interview for Mental Status assessment indicating a high level of cognitive function. Section D regarding mood on the MDS assessment includes questions asking if the resident has been feeling down or depressed, have little interest or pleasure in things, or feeling badly about themselves. If so, how many days during the past two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to develop a Comprehensive person-centered care plan for 2 of 35 sampled residents (Resident #111 and #88). Findings include: 1. Per record review, Resident #111 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, muscle weakness, and abnormalities of gait and mobility. Per interview on 12/18/23 at 9:08 AM, Resident #111 expressed that s/he was sad. S/He got teary three times during the interview and cried twice. S/He talked about wanting to commit suicide prior to being admitted to the facility. When asked if anyone had hurt her at the facility, s/he replied no but became very upset; his/her voice became louder and s/he began to cry again, as if asking him/her about getting hurt was a trigger for him/her. Record review reveals that Resident #111 showed symptoms of depression prior to the creation of the comprehensive care plan. Resident #111's admission MDS (Minimum Data Set; a comprehensive assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plans for 4 residents of 35 sampled residents (Resident #24, Resident #28, Resident #69 Resident #47) and failed to develop or revise resident's care plans after each assessment and with the required team for 9 of 37 sampled residents (Residents #7, #31, #111, #99, #1, #43, #50, #107, and #21). Findings include: 1. Per record review Resident #47's care plan reveals two separate activities focus problems. #1 states I have the potential for alteration in activities related to Parkinson's, heart disease, lumbar fracture, osteoarthritis, anxiety disorder, and artificial knee joint. The goal states I will interact with others on a daily basis and have positive social experiences. I will interact with family and friends via visits, mail, and phone calls. Interventions include My faith is: Catholic. Religious Services Attendance - Mass. The 2nd Activities focus problem states Activities-Leisure: I have potential barriers related to my leisure activities of choice related to cognitive skills Goals include I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene for 3 of 35 sampled residents (Residents #111, #7, and #269). Findings include: 1. Per record review, Resident #111 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, muscle weakness, and abnormalities of gait and mobility. Per Resident #111's MDS (Minimum Data Set; a comprehensive assessment used as a care-planning tool) dated 10/17/23, s/he requires supervision or touching assistance for showering. Per interview on 12/18/23 at 8:40 AM, Resident #111 expressed that she would like to get showered more. Per review of Licensed Nursing Assistant (LNA) documentation, there are zero documented showers for Resident #111 in October 2023, zero showers in November 2023, and only 2 showers are documented in December 2023. 2. Per record review, Resident #7 has diagnoses that include spastic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide range of motion rehabilitation services for 2 of 35 sampled residents (Resident #81 and #43). Findings include: 1. Per record review Resident #81 has diagnoses that include acute transverse myelitis (inflammation of the spinal cord; symptoms may include pain), anxiety, and lower back pain. Per interview on 12/19/23 at 10:45 AM, Resident #81 stated that s/he is concerned that staff are not doing ROM (range of motion) exercises with him/her. S/He explained that his/her goal is to at least do some stretches and s/he has declined in his/her ROM. S/He revealed that s/he had been told by staff that they have to be trained to do the exercises with him/her and there are not enough trained staff to do the ROM with him/her. Resident #81 has the following care plan focus RANGE OF MOTION: I have limitations or I am at risk for limitations in my ROM related to progressive weakness neurological, created 4/3/21, with the following intervention, NURSING REHAB:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide respiratory care consistent with professional standards of practice and per medical orders for 2 of 35 sampled residents (Resident #23 & Resident #66). Findings include: 1. Resident #23 has diagnoses that include pericarditis (inflammation around the heart), and congestive heart failure (failure of the heart to provide sufficient blood flow caused by an impairment of the heart's pumping function). On 11/10/23 the following order was placed - BiPap-Apply at HS (bedtime), monitor placement and usage. Remove in AM. Settings BIPAP auto titrate IPAP max 24 EPAP min 4 PS 8 with 3 L bleed. At bedtime for SOB (shortness of breath)/COMFORT O2 (oxygen) at 3 L (liters per minute), 15 tube type, ramp 4 time 0:05. These settings are highly complex therefore on 12/21/23 at 10:15 AM the Surveyor and the Unit Manager viewed the machine (Dream Station) together to allow the Unit Manager to demonstrate how the settings are applied. The Unit Manager was unable to provide an explanation or a demonstration of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policies, the facility failed to ensure that a physician reviewed the total program of care during the required regulatory visits for 9 of 37 sampled residents (Residents #7, #31, #111, #99, #1, #43, #50, #107, and #21). Findings include: Facility policy titled, Attending physician Medical Services Responsibilities- [NAME], last modified on 4/28/23 states Documentation of mandated visits must include documentation showing evidence that the provider reviewed the total plan of care . Per record review of 40 physician notes for the above 9 residents between 6/1/23 and 1/9/24, which were provided by the facility to this surveyor, a majority of them did not contain evidence that the physician reviewed the resident's total program of care, including the resident's progress and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident's current medical regimen. Many…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents who are receiving as-needed psychotropic medications have a 14-day stop date for 5 of 5 residents sampled. (Residents #2, #5, #6 #7 and # 8) Per record review on 3/7/24 Resident #7 has a Physician's order that started on 2/28/24 for Lorazepam (an anti-anxiety psychotropic medication) give 0.25 milligrams (mg) sublingually (SL) a route of administration in which the medication is placed under the tongue and is absorbed through the mucous membrane) every 4 hours as needed (PRN) for anxiety/SOB (shortness of breath). There is no 14-day stop date included in the order. Resident #7 also has a Physician order started on 2/28/24 for Haldol (an antipsychotic psychotropic medication given for agitation) give 0.5 milliliters (ml) by mouth every 6 hours as needed for agitation. There is no 14-day stop date for this psychotropic medication order. Per record review Resident #6 has a physician's order that started on 12/9/23 for Haldol to give one 1 tablet (0.5mg) by mouth every 4 hours as needed for agitation. There is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that all drugs and biologicals are kept in locked compartments only accessible to authorized personnel for one applicable treatement cart; failed to ensure that medications and biologicals were removed from use when expired for 2 of 3 units; and failed to ensure medications were properly stored for 2 of 35 sampled residents (Resident #31 and #81). Findings include: 1. The facility's treatement cart was not kept locked or under direct observation of authorized staff in an area where residents could access it. Per observation on 12/17/23 at 5:43 PM, a treatment cart in the common area of Unit A was observed unlocked making the items in the drawers accessible. There were noted to be prescription medication ointments in the unsecured drawers. At 5:43 PM the Licensed Practical Nurse (LPN) was notified that the cart was not locked. The LPN stated, It's the other nurse's cart. The LPN walked away without locking the cart. At 6:03 PM the 2nd LPN on duty was shown that the treatment cart was not locked and 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 of 3 residents on precautions (Resident #50) and throughout the facility; failure to use proper hand hygiene during medication administration; and the failure to clean respiratory equipment (C-PAP and Bi-PAP) machines per orders and facility policy for 3 of 3 sampled residents (Residents #69, 5, & 23). Findings include: 1. Staff did not wear the appropriate PPE in the facility when there was active COVID-19 and influenza. Per observation, on entry to the facility on [DATE] through 12/21/23 and 12/26/23, signs are posted to inform all entering of the use of facemasks facility wide. Record review reveals that Resident #50 tested positive for influenza 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 interview and record review, the facility failed to ensure that 3 eligible residents (Residents #50, #271, and #37) on one unit received the COVID-19 vaccine. 1. Per record review, Resident #50, who is [AGE] years old, was admitted to the facility on [DATE] with diagnoses that include diabetes and severe kidney disease. Resident #50 is considered high risk for COVID-19 complications because of his/her diagnoses and age. An undated form titled Vaccination Review: Consent/Declination Resident Form, entered into Resident #50's medical record with the effective date of 11/20/23, reveals that his/her vaccination history was assessed for influenza, COVID-19, and pneumococcal. The form indicates that s/he did not receive a 2023 COVID-19 vaccine. Under decision to vaccinate, the choices not eligible, consented, and declined are all left blank. The resident, nor their representative, did not sign off that they were provided education or that they consented or declined the administration of the COVID-19 vaccine.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and review of the facility assessment, the facility failed to ensure that staff had effectively been trained in trauma informed care. Findings include: The facility's Facility Assessment (an assessment that determines what resources are necessary to care for the residents competently during both day-to-day operations and emergencies), last reviewed 10/2/2023, indicates that the facility is able to provide care and services for individuals with psychiatric mood disorders that include post traumatic stress disorder (PTSD) and behaviors that needs interventions. Section titled Education/In-services describes the staff education and training necessary to maintain the level and the types of support and care needed for the resident population. Included in both the general orientation and the annual education program is the topic behavior stress management. The trauma informed care education that is incorporated into the general orientation includes 2 basic slides that describe the definition of trauma and general symptoms of trauma, depression, and PTSD.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review, the facility failed to schedule timely care plan meetings and facilitate the inclusion of the resident's representatives to attend the meeting. Findings include: Per record review, Resident # 65 has resided at the facility since 09/15/2021 with a diagnosis of vascular dementia. Per an interview on 12/18/2023 at 10:44 AM with a family member, s/he explained that Resident #65 was cognitively impaired due to dementia and often declined to participate in the meetings. S/he made decisions regarding financial and medical issues. Her/his work schedule needed to have advance notice to allow for attendance. The meetings were canceled often or not scheduled at all. Per record review, a care plan meeting was held on 3/23/2023 and 10/27/2023; there was no evidence of a care plan meeting between March and October. A review of Resident 65's care plan shows the following under Cognitive Skills: I am significantly Impaired, and my son makes decisions regarding my financial needs and medical care related to vascular dementia. Per interview on 12/26/2023 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure accurate advanced directive choices were indicated for 1 of 35 sampled residents (Resident #7). Findings include: Record review reveals that Resident #7 has two conflicting code statuses in their medical record and facility documentation. Their most recent COLST form (clinician orders for life sustaining treatment), entered into Resident #7's electronic medical record (EMR) on [DATE], reveals that Resident #7 gave informed consent for a DNR (do not attempt resuscitation) and no intubation or ventilation interventions. This was signed by the Attending Physician. This COLST form is also in a binder located at the nursing station with the unit's residents' most up to date COLST forms. Physician orders and the resident profile banner in the EMR do not reveal a DNR order; instead, the code status order that appears in the EMR is CPR/Full Code, created on [DATE]. The unit assignment sheet that nursing staff use on a daily basis also indicates…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the resident for 1 of 35 sampled residents (Residents #50). Findings include: Per record review, Resident #50 was admitted to the facility on [DATE] for rehabilitation services following a below-knee amputation (BKA) with diagnoses that include diabetes, osteomyelitis (bone infection), and severe kidney disease. A 11/20/23 form titled Braden Scale for Predicting Skin Ulcers, (a tool used to identify the level of risk a resident has for developing pressure ulcers), reveals that Resident #1 is at risk. A 11/20/23 skin assessment form reveals that Resident #50 has four skin issues: two moisture associated skin damage areas, an abrasion, and a surgical incision. Vital signs reveal that Resident #50 experienced 10 out of 10 pain within the first 48 hours of admission [DATE]). While a baseline care plan…

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

Based on record review and interview the facility failed to provide services that meet professional standards of quality related to the Social Services for 1 of 35 residents sampled (Resident # 28). Findings include: Per record review on 12/5/23 Resident #28 stated thier roommate made the room smell like mold, and on 12/12/23 Resident #28 called the roommate a fat slob. On 12/17/23, Resident #28 was reported by a Licensed Nurse Assistant to have thrown a full cup of fluid at and utilized verbally abusive language towards the roommate, necessitating a room change. During an interview on 12/22/23 at 12:00 PM with the facility's Social Service team, they were asked about the behaviors displayed by Resident #28 towards his/her roommate. The Social Service team admitted they were not aware of the behavior that had occurred precipitating the room change 4 days earlier. They were not aware that the care plan for Resident #28 had been revised on 12/17/23 to state monitor/document/report to the Medical Provider of danger to self and others as needed indicating a significant psycho-social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and record review, the facility failed to provide activities that support each resident's physical, mental and psychosocial well-being for 1 of 35 sampled residents (Resident #65). Findings include: Per record review, Resident #65 has resided in the facility since 9/15/21 and has diagnoses that include vascular dementia, memory deficit related to a cerebral infarct (stroke), and cognitive communication deficit. A review of his/her care plan reveals that s/he yells or calls out to staff for attention. Resident #65's care plan states, I prefer social and entertainment activities involving music, happy hour, parties, outdoor parties, and socials. In an observation of Resident # 65 on 12/18/2023 at 9:12 AM, the resident was heard yelling, Help, help, help. staff were observed entering the room several times for such calls over the next few hours. An interview with a family member on 12/18/2023 at 10:51 AM revealed concerns that the facility was not adequately attempting to engage Resident # 65 in less isolating activities. An interview with the charge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and treatment consistent with the resident's physician orders and professional standards of practice, placing the resident at risk for infection for 1 of 4 residents in the sample (Resident #4). Findings include: During an interview with Resident #4 on 3/6/24 at 11:40 AM it was noted that they had a dressing on their lower right leg with a date of 3/3/24 written on it indicating that the dressing was last changed on 3/3/24. Per record review, both the physicians orders and Treatment Administration Record (TAR) indicate that Resident #4 has a wound on their left leg [instead of the right] and that the dressing should be changed daily. A physician's order dated 2/28/24 states LLE (left lower extremity) Wound Care: Cleanse with NS (normal saline), and skin prep around open area, apply non-adherent, cover with coversite, every day shift for Wound Care. The TAR also reflected that nursing staff had been signing that the dressing on the left lower leg had been changed daily through 2/28/24 - 3/6/24.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance to prevent accidents for 2 of 35 sampled (Resident #5 & #47 ). Findings include: 1. On 12/18/23 at 2 PM Resident #5's room was noted to be very warm, it was also noted that a cord from the oxygen concentrator was resting on top of the heat vent along the wall. The heater was hot to touch and the cord was very warm and spongy. The Director of Maintenance was paged and using an infrared thermometer gun the heat vent temperature was measured to be 108 degrees fahrenheit. The Director of Maintenance confirmed the cord was very warm should not be resting on top of the heat vent and immediately moved it. 2. Per observation of Resident #47 on 12/17/23 at 5:10 p.m., the resident is sitting in a wheelchair at a table in a common area. S/he is sitting on the edge of his/ her wheelchair, s/he appears…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 7 sampled residents (Resident #31) with an indwelling catheter receives the appropriate care and services to prevent urinary tract infections to the extent possible. Findings include: Record review reveals that Resident #31 has diagnoses that include benign prostatic hyperplasia (enlarged prostate) and obstructive and reflux uropathy (blockage and reflux of the urinary system). A MDS (Minimum Data Set; a comprehensive assessment used as a care-planning tool) dated 10/5/23 reveals that Resident #31 has an indwelling catheter. Resident #31's care plan states INDWELLING URINARY CATHETER: I require an indwelling urinary catheter use r/t Urinary Retention, revised on 12/28/22. Interventions include Foley Catheter care every shift and as needed, revised on 11/3/23, and Urinary Output: Empty urine & Record every shift, initiated on 9/12/2023. Physician orders include: Urinary Output - verify documentation in POC and notify provider if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 applicable resident (Resident #7) a urostomy receives care consistent with the comprehensive person-centered care plan and professional standards of practice. Findings include: Per record review, Resident #7 has diagnoses that include spastic quadriplegic cerebral palsy (a physical disability that causes muscle rigidity that affects all four limbs and often a person's torso, facial, and oral muscles) and a history of bladder cancer requiring a urostomy (a surgically created opening to allow urine to exit the body). Measuring urinary output, providing urostomy care every shift, and changing the urostomy drainage bag can reduce the risk for developing the complications such as infection, stomal (opening in the body) problems and skin irritation in addition to alerting staff to other serious complications. Resident #7's care plan reveals the following focus: ELIMINATION: I have an alteration in bladder/bowel elimination r/t [related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain acceptable parameters of nutritional status as evidenced by failing to obtain weights as ordered, failing to consistently document resident meal intakes and meal refusals, and failing to update the physician of refusal of weights for one of the 35 residents sampled (Resident #92). Findings include: Per observation of Resident #92 on 12/18/23 at 11:43 am s/he was sitting in the common area in a wheelchair. S/he was thin, his/her face appeared drawn, and their clothes were loosely fitting. Resident #92 is not interviewable due to cognitive decline and inability to understand questions, with a BIMS (Brief Interview Mental Status) score of 10. Record review reveals Resident #92 had a significant weight loss of 10.66% in 6 months. His/her weight on 6/13/23 was 178.2 pounds and on 12/14/23 their weight was 159.6, a total loss of 18.6 pounds. Further record review reveals there is no documentation from the Physician that addresses the resident's significant weight loss. Resident # 92's Nutrition care plan…

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

Based on observstion, interview, and record review, the facility failed to ensure that the medical care of each resident is supervised by a physician for 1 of 35 sampled residents (Resident #92). Findings include: Per observation of Resident #92 on 12/18/23 at 11:43 a.m., s/he was sitting in the common area in a wheelchair. S/he was thin, his/her face appeared drawn, and their clothes were loosely fitting. Resident #92 is not interviewable due to cognitive decline and inability to understand questions, with a BIMS (Brief Interview Mental Status) score of 10. Record review reveals Resident #92 had a significant weight loss of 10.66% weight loss in 6 months. His/her weight on 6/13/23 was 178.2 pounds and on 12/14/23 their weight was 159.6, a total loss of 18.6 pounds. Further record review reveals that no documentation from the Physician addresses the resident's significant weight loss. Per the interview with the Director of Nursing (DON) on 12/21/23 at 11:46 a.m. DON reviewed Resident #92 Physician progress notes, and the DON confirms that the MD has not addressed Resident #92'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.