Lea Hill Rehabilitation And Care Center

Based on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs - i.e. grooming, bathing, eating, etc.) received the assistance they required for 3 of 7 sample residents (Residents 2, 8, & 7) reviewed for ADLs. The failure to provide nailcare, bathing, getting out of bed, and shaving left residents at risk of embarrassment, poor personal hygiene, decreased quality of life, and other negative health outcomes.Findings included .<Facility Policy>According to the facility's 09/18/2025 revised ADLs Policy, residents who were unable to perform ADLs independently would receive the necessary services to maintain mobility, good nutrition, grooming, and personal hygiene as they required. The policy showed based on resident's assessment, the facility would ensure resident's abilities in ADLs would not deteriorate unless deterioration was unavoidable. <Resident 2> According to the 06/10/2025 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 2 had weakness on right side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure weekly skin assessments were completed for 1 (Residents 15) of 1 residents reviewed and 1 (Resident 5) supplemental resident who were reviewed for skin impairments, ensure post fall assessments were completed for 1 (Resident 20) of 4 residents who were reviewed for falls, ensure the therapy department provided a referral for a restorative nursing program to maintain range of motion once a resident discharged from therapy services for 1 of 4 residents (Resident 31), and ensure accurate weight monitoring was done per physician orders for 1 of 1 residents (Resident 7) reviewed for nutritional status. These failures placed residents at risk for skin breakdown, injuries, malnutrition, decreased range of motion, and decreased quality of life.Findings included.<Weekly Skin Checks> <Resident 5> According to the 08/18/2025 admission Minimum Data Set (MDS – an assessment tool), Resident 5 had diagnoses including malnutrition and cancer. The…

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

Based on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach) was administered in accordance with physician orders and professional standards for 1 of 1 resident (Resident 7) reviewed for enteral nutrition. The facility failed to accurately document the amount of enteral formula (liquid food products) and fluids a resident received were reconciled with the amount they were ordered to receive and deliver per physician order. This failure placed residents at risk for inadequate nutrition, dehydration, and other adverse outcomes.Findings included.<Policy>According to the facility policy titled, Care and Treatment of Feeding Tubes, dated 09/18/2025, the facility would ensure tube feedings were administered per physician orders. The policy showed staff would evaluate the amount of feeding administered to ensure the resident received the correct enteral nutrition consistent with and following the physician orders. <Resident 7>According to a 08/08/2025 Quarterly Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper storage of medications for 1 of 2 staff (Staff F - Registered Nurse) observed during medication administration and proper labeling of medications on 1 of 1 medication carts (West Medication Cart) reviewed for medication storage. These failures placed residents at risk of injury, receiving expired medications, and a diminished quality of life.Findings included.<Policy>According to the facility policy titled, Medication Storage, dated 09/18/2025, the facility would ensure all medications and biologicals would be stored in locked compartments. The policy showed only authorized personnel would have access to the medications and keys to locked compartments. The policy showed the facility would ensure all outdated and mislabeled medications were destroyed in accordance with federal and state requirements. <Staff F>In an observation and interview on 09/15/2025 at 8:59 AM Staff F prepared medications for a resident by dispensing pills and liquid medications into a small pill cup and pulling 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 observation, interview, and record review the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 3 residents (Resident 46, 7, & 19) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms), ensure staff used appropriate Hand Hygiene (HH) during resident care/resident contact (Staff D - Certified Nursing Assistant - CNA & Staff N - CNA) who were observed for care, and staff failed to provide sanitary practices when delivering meals to residents (Staff N) who were reviewed. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.Findings included .<Facility Policy>According to the facility's Enhanced Barrier Precautions policy, revised 12/07/2022, the facility would implement EBP to prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 system to ensure residents received required written notices at the time of transfer/discharge, or as soon as practicable for 2 (Residents 21 & 29) of 2 residents reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> According to a revised 09/06/2023 facility Transfer and Discharge (including AMA [Against Medical Advice]), policy, the facility would provide a written transfer notification to the resident or resident representative in a language and way they could understand. The policy showed the notification would include the reason and basis for transfer, effective date of transfer, and the location to which the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident meals were prepared in accordance with professional standards of food safety for 2 of 2 facility kitchens. The failure to ensure surface sanitizer solutions were maintained at effective concentrations, food was stored in a manner to preserve its quality, and food preparation areas were free from potential contaminants, placed residents at risk for food contamination, food borne illnesses, and spoiled food. Findings included . Observation on 06/26/2024 at 9:12 AM showed dietary staff cleaning up after breakfast service. At that time Staff P (Dining Services Director) reached for a test strip to verify the kitchen's surface sanitizer was at the correct consistency (100-440 PPM - Parts Per Million). The test strip package was empty. Staff P then looked in the desk drawer of their office before departing the kitchen. Staff P returned at 9:16 AM. Staff P tore off a strip of orange test paper from the container and held it in a sanitizer bucket for over 10 seconds. The strip remained orange and did not turn green…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Physician's Orders (POs) were clarified as needed for 3 residents (Residents 2, 242, 238) of 13 sample residents reviewed, followed for 6 residents (Residents 13, 240, 8, 28, 238, & 240) of 13 sample residents reviewed, and nurses signed only for care provided for 1 resident (Resident 8) of 13 sample residents. These failures left residents at risk for unmet care needs, unnecessary care, and other negative health outcomes. Findings included . <Clarifying POs> <Resident 2> According to the 05/24/2024 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 2 had diagnoses including heart failure and dementia. The MDS showed Resident 2 received pain medication. Record review showed Resident 2 had two orders for pain medication: a 05/20/2024 PO for a non-narcotic pain medication, give 650 milligrams every six hours as needed for pain, and a 05/20/2024 PO for an opioid pain medication, give 0.25 milliliters as needed for pain. Neither PO had parameters directing staff when each medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently perform Hand Hygiene (HH) before and after resident care/contact, change gloves after dirty care/before clean care, and failed to ensure glucometers were maintained clean and sanitary. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . <Facility Policy> According to a facility policy titled, Hand Hygiene, revised 10/01/2022, showed the facility would perform proper HH procedures to prevent the spread of infection. The policy showed HH applied to all staff working in all locations within the facility. The policy showed that using gloves does not replace HH and staff would perform HH before and after care provision, prior to donning gloves, and immediately after removing them. The policy showed HH would be performed between resident contacts, after handling contaminated objects, and when, during resident care, moving from a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain and/or have Advanced Directives (AD - a document describing a resident's wishes for care if they became incapacitated) readily available in resident records for 3 of 5 residents (Residents 240, 241, & 13) and 1 supplemental resident (Resident 238) reviewed for ADs. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end-of-life care. Findings included . <Facility Policy> According to the facility's revised 03/23/2023 Residents' Rights Regarding Treatment and AD policy, if a resident had an AD in place upon admission, copies would be made and added to the chart, and communicated to the staff. <Resident 240> Resident 240 was admitted to the facility on [DATE]. According to the 06/24/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 240 was assessed with no memory impairment, clear speech, was understood by others, and able to understand others conversation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate unwitnessed falls for 1 of 2 sampled residents (Resident 3) reviewed for falls, and 1 supplemental resident (Resident 13). Facility failure to complete thorough investigations placed residents at risk for further falls and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 05/01/2024 Accidents and Supervision policy, the facility would implement a system to minimize the risk of resident accidents. The policy showed the facility would make a reasonable effort to identify the hazards and risk factors for each resident. The policy showed the facility would evaluate resident accident risk by examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents . The facility's 11/30/2022 Incidents and Accidents policy showed documentation and data to be collected after an accident should include the date, time, nature of…

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

Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment accurately reflected the residents' mental health conditions for 1 (Resident 238) of 5 residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 238> According to a 06/25/2024 admission Minimum Data Set (an assessment tool), Resident 238 had multiple medically complex diagnoses including depression and required the use of an antidepressant medication. Review of a June 2024 Medication Administration Record showed Resident 238 received an antidepressant medication for depression. Review of a 06/20/2024 Level 1 PASRR, completed prior to admission showed Resident 238 had no Serious Mental Illness (SMI) indicators. Upon admission, 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 observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated as needed to reflect current care needs for 2 residents (Residents 3 & 21) of 13 sample residents reviewed. The failure to ensure CPs were updated as needed left residents at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 11/01/2022 Comprehensive CPs policy, the facility would ensure the CP would describe the care and services each resident currently required. The policy showed the facility would develop resident-specific interventions to meet residents' care needs. <Resident 3> According to the 05/15/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 3 could hear with minimal difficulty using hearing aids, had impaired vision, and wore glasses. The MDS showed Resident 3 had severe memory impairment and wandered occasionally. The MDS showed Resident 3 required partial/moderate assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 resident (Resident 3) of 3 reviewed for vision and hearing were provided the assistance and/or adaptive devices they were assessed to require. This failure left Resident 3 at risk for unnecessary barriers to communication and frustration. Findings included . <Facility Policy> According to the facility's revised 11/07/2022 Hearing and Vision Services policy, the facility would ensure all residents had access to hearing and vision services, and received the adaptive equipment (such as glasses or Hearing Aids - HAs) they required. The policy showed facility staff would assist residents to use any adaptive equipment required. <Resident 3> According to the 05/15/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 3 had severe memory impairment and medically complex diagnoses including dementia. The MDS showed Resident 3 heard with minimal difficulty when using their HAs. The revised 05/25/2022 communication Care Plan (CP) included a goal for Resident 3 to maintain the ability to make 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 <Resident 21> According a 04/18/2024 Significant Change MDS, Resident 21 had moderate memory impairment. The assessment showed Resident 21 had a diagnosis of non-Alzheimer's dementia. Review of a revised 04/18/2024 Fall CP showed, Resident 21 was at risk for falls and had two unwitnessed falls since admission. The CP showed to keep the bed in the lowest position as a preventative fall intervention. Review of Resident 21's medical records showed a PO to keep bed in lowest position while resident was in bed initiated on 07/11/2023. Observations on 06/26/2024 at 12:59 PM, 06/27/2024 at 8:56 AM, 06/27/2024 at 12:37 PM, 06/28/2024 at 9:28 AM, and 07/01/2024 at 8:17 AM showed Resident 21 in bed with the bed raised halfway between medium and maximum height. In an interview on 07/01/2024 at 8:17 AM Staff M (CNA) stated the CP directed them to keep Resident 21's bed in the lowest position because they were a fall risk. Staff M stated the bed was not in the lowest position but should be. In an interview on 07/01/2024 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, interview, and record review, the facility failed to ensure continent residents were provided toileting for 3 of 4 residents (Residents 339, 340, & 18) reviewed for Urinary Catheters (tube inserted into the bladder to empty the bladder) and Urinary Tract Infections (UTI). These failures placed residents at risk for UTI, dignity issues, and a decreased quality of life. Findings included . <Facility Policy> According to a facility policy titled, Activities of Daily Living (ADL's), revised [DATE], the facility would provide toileting care and services based on individual resident's comprehensive assessments and consistent with the resident's choices. According to a facility policy titled Helping a Resident with Toileting Needs, revised [DATE], the facility would assist residents with toileting needs to maintain the resident's dignity and proper hygiene. <Resident 339> According to a [DATE] admission Minimum Data Set (MDS - an assessment tool), Resident 339 was dependent on staff for transfers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess, monitor, and record intake for 1 (Resident 8) of 1 resident reviewed for enteral feeding (a medical process used to provide nutrition for residents who cannot obtain nutrition orally) services. These failures placed Resident 8 at risk for inadequate nutritional support and adverse consequences. Findings included . <Resident 8> According to Resident 8's 05/22/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 8 had impaired thinking abilities, was usually understood, and could usually understand others in conversation. This MDS showed Resident 8 had diagnoses including a stroke and was unable to move one side of their body. The MDS showed Resident 8 had difficulty swallowing and required enteral feedings via a feeding tube. Review of Resident 8's revised 03/12/2024 Nutritional Problem Care Plan (CP) showed Resident 8 was to receive 720 Milliliters (mL) of the enteral feeding formula over 12 hours. This CP showed Resident 8 was to receive 547 mL of free water administered congruently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3 of 3 residents (Residents 2, 88, & 241) reviewed for oxygen were provided care consistent with professional standards of practice. Failure to provide oxygen treatments as ordered (Resident 2 & 241) and place oxygen signs outside the rooms of residents using supplemental oxygen (Residents 2, 88, & 241) left residents at risk for over or under oxygenation, respiratory discomfort, oxygen-related accidents, and a decreased quality of life. Findings included . <Facility Policy> According to the facility's 09/01/2023 Oxygen Administration policy, oxygen therapy required a Physician's Order (PO) for use. The policy showed Oxygen warning signs must be placed on the door . of the room for any resident receiving oxygen therapy. <Providing Oxygen as Ordered> <Resident 2> According to the 05/24/2024 Significant Change in Status Minimum Data Set (MDS - an assessment tool) Resident 2 had cardiorespiratory diagnoses including heart failure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, 1 of 5 (Resident 13) residents reviewed for unnecessary medications was adequately monitored to prevent excessive duration of medication use. These failures placed residents at risk to receive unnecessary medications and/or adverse side effects. Findings included . <Resident 13> According to the 06/01/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 13 had diagnoses including a progressive memory loss disease. This MDS showed Resident 13 was usually understood and could usually understand others in conversation. Review of Resident 13's 06/27/2024 order summary showed a 05/31/2024 Physician Order (PO) directing staff to administer an over-the-counter sleep aid medication every day. This PO showed Resident 13 was prescribed the medication for difficulty sleeping. Review of the 06/27/2024 order summary showed no directions instructing staff to monitor the amount of hours Resident 13 slept each night. Review of Resident 13's comprehensive Care Plan (CP) showed a CP goal was not developed regarding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 (Residents 21 & 238) of 5 residents reviewed for unnecessary medications were free from unnecessary psychotropic medications. Facility staff failed to identify/monitor target behaviors or attempt a Gradual Dose Reduction (GDR) for an Antidepressant (AD) medication. These failures placed residents at risk to receive unnecessary psychotropic medications and experience adverse side effects. Findings included . <Facility Policy> According to facility policy titled Gradual Dose Reduction of Psychotropic Drugs revised 11/09/2022, the facility would gradually reduce the dose of psychotropic medications in an effort to discontinue those drugs. The policy showed the facility would attempt a GDR in two separate quarters (with at least one month between the attempts) within the first year of the resident being admitted or within the first year of a resident starting a psychotropic medication. <Resident 21> According to the 04/18/2024 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 21 had moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 expired foods were identified and discarded, did not ensure equipment was clean and secure, and ensure staff implemented proper hand hygiene practice. These failures placed residents at risk for consuming expired/spoiled foods, potential exposure to food borne illness, and safety hazards placing residents at risk for harm. Findings included . Expired food An observation on 03/27/2023 at 8:34 AM found the following foods identified as expired inside facility kitchen refrigerators; Cooked bacon, pork ham lunch meat, pickles, a pitcher of tomato juice, a pitcher of skim milk, a pitcher of orange juice, and three pitchers of instant tea. Staff S (Dining Service Director) stated in an interview on 03/31/2023 at 01:20 PM, their expectation was expired foods were removed prior to the date of expiration to prevent food borne illness. Secure and Sanitary Equipment An observation on 03/27/2023 at 8:48 AM, showed the ice machine in the kitchen was visibly soiled with a white crust. A cleaning log was available and indicated 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 incident investigations were completed according to professional standards for 2 of 5 residents (Residents 11 & 6) reviewed for accidents. The failure to 1) conduct timely and thorough investigations, 2) rule out abuse and/or neglect, 3) ensure the identified resident feels safe, 4) gather statements at the time of the incident from the staff, witnesses, identified resident, and other similar or affected residents, 5) implement immediate interventions related to the incident to prevent future incidents, 6) identify the root cause of the incident, and 7) maintain documentation that an alleged violation was thoroughly investigated, placed residents at risk for potential unidentified abuse or neglect, repeated accidents/incidents/injuries and resident's diminished quality of life. Findings included . Facility Policy Review of the 2022 facility policy Incidents and Accidents showed staff should report, investigate, and review any accidents that occurred on facility property or involved a resident. Staff would assure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement a competency-based education program to ensure 4 of 8 (Staff B, C, I & Z) and 1 supplemental (Staff D) nursing staff had the appropriate competencies and skill sets to provide nursing care and related services according to professional standards to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being determined by resident assessments and individual plans of care. The failure to ensure nursing staff were competent to: 1) perform pressure ulcer identification, assessment and documentation, 2) implement treatment and care according to physician orders, 3) perform fall/incident/accident investigations according to state and federal standards, 4) follow infection control measures and 5) provide safe transfers of residents by nurse aides, placed residents at risk for unmet care needs, unidentified and untreated pressure ulcers, unidentified change in resident conditions, unidentified risks of falls/accidents/incidents, and a decline in health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish and maintain infection control practices that provided for a safe and sanitary environment to help prevent and contain the transmission of communicable diseases. The facility failed to ensure 1 staff (Staff C) completed hand hygiene on 2 occurrences during wound evaluation and 1 staff (Staff N) on 5 occurrences during resident care for Resident 16. The facility failed to ensure 3 staff (Staff K, L, & M) followed the Transmission-Based Precautions (TBP) outlined for Resident 178. These failures placed the residents at risk for the development and transmission of infections and compromised the safety of residents, staff, and visitors. Findings included . Hand Hygiene Facility Policy According to the Infection Prevention and Control Program (IPCP), all staff should assume that all residents are potentially infected with an organism that could be transmitted during the course of providing resident care services, and hand hygiene should be performed in accordance with the facility's established hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform a resident or the resident's representative of treatment risks and benefits, treatment options, and treatment alternatives in a timely manner when concerns were expressed, questions were raised, and when a change in treatment was proposed for 1 of 1 resident (Resident 178) reviewed for resident rights. These failures prevented the opportunity for the resident to exercise their right to leave their room and to make an informed decision related to fluid restriction. The delayed communication from staff brought mental, emotional, and psychosocial distress (Resident 178), and placed all residents at risk for unmet care needs and a decreased quality of life. Facility Policy The 2022 Infection Prevention and Control Program (IPCP) facility policy: Isolation Protocol showed residents were placed on the least restrictive transmission-based precaution (TBP) for the shortest duration possible under the circumstances and as recommended by the current Centers for Disease Control and Prevention (CDC) guidelines. 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 develop and implement a process to ensure residents have an Advanced Directive (AD) for 3 of 15 residents (Residents 9, 11, & 20) reviewed for AD. The failure to obtain a copy of an existing AD and/or ask residents if they wish to formulate or decline to formulate an AD, placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored if they were not capable of making their own decisions. Findings included . Resident 9 The 02/20/2023 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 9 was cognitively impaired, did not speak English and had impaired decision making. A review of Resident 9's medical record showed no AD on file to designate a decision-maker if Resident 9 could not make medical decisions about their care. In an interview on 03/27/2023 at 8:57 AM, Resident 9 was interviewed and was not able to understand the questions asked in the interview. Staff G (Licensed Practical Nurse) was outside the room and stated Resident 9 does not speak or understand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify and assess changes in skin condition, follow Physician Orders (POs) for treatment, implement monitoring and interventions for skin care, and ensure residents received wound care consistent with professional standards of practice to prevent skin breakdown for 3 of 5 residents (Residents 20, 1 & 23) reviewed for skin integrity concerns. These failures resulted in worsening of wounds, pain, and a diminished ability to participate with therapy/rehabilitation to Resident 20, placed all residents at risk for unmet care needs and diminished quality of life. Findings included . Resident 20 According to the 03/09/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 20 admitted to the facility on [DATE] with complex medical diagnoses including pain on the right leg, peripheral vascular disease (PVD), dementia (a decision-making impairment), and was at risk for malnutrition. The assessment showed Resident 20 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were free from unnecessary psychotropic drugs (medications that affect mental state). The failure to provide non-medication behavior interventions for 1 of 5 residents (Resident 25), and the failure to have an As Needed (PRN) psychotropic medication re-evaluated every 14 days, for 1 of 5 residents (Resident 16) placed residents at risk for receiving unnecessary medications, experiencing medication-related adverse side effects, and diminished quality of life. Findings included Facility Policy The 2022 facility policy Use of Psychotropic Medication showed a psychotropic medication affects brain activities associated with mental processes and behavior. Psychotropic medications include antidepressant (AD) and antianxiety (AA) medications. Residents would receive non-medication interventions to facilitate reduction or discontinuation of the psychotropic medication. The pharmacist would conduct monthly medication reviews of psychotropic medication for effects on the resident. Nursing staff would evaluate the…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 1 of 2 nurses (Staff H) to properly administer 2 of 30 medications for 2 of 4 residents (Resident 5 and 17) observed during medication pass resulted in a medication error rate of 10%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . Facility Policy Review of the facility's 2022 Medication Administration policy, the Licensed Nurse was to compare medication source (bubble pack, vial, etc.) with the Medication Administration Record (MAR) to verify the resident's name, medication name, form, dose, route, and time. Resident 5 Observation of medication pass on 03/29/2023 at 8:40 AM showed Staff H (Registered Nurse) prepare and administer multiple medications to Resident 5, including one 500 milligram (mg) vitamin gummy. Review of Resident 5's March 2023 MAR showed directions to staff to administer two vitamin gummies…

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