Port Washington Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide consistent specialized services for 1 of 3 residents (Resident 1) reviewed for rehabilitation therapies. This failure placed residents at risk for delayed maximum function and a diminished quality of life. Findings included.Resident 6 was admitted to the facility on [DATE] with diagnoses to include a fractured femur (leg bone) and legal blindness. The 5-day Minimum Date Set (MDS), an assessment tool, dated 9/02/2025, showed Resident 6 was moderately cognitively impaired. Resident 6 needed extensive assistance for Activities of Daily Living (ADLs). Review of the Occupational Therapy (OT) and Physical Therapy (PT) care plans and orders showed Resident 6 was to receive services five times per week for four weeks for each therapy. The services start date was 9/1/2025 and ended on 9/29/2025, the certification period. Review of the OT progress notes showed Resident 6 received a total of nine visits from OT during the certification period, 11 visits…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacy procedures that ensured medications were timely and accurately received, dispensed and administered to meet the needs of 7 of 7 residents (Residents 1, 2, 3, 4, 5, 6 & 7) reviewed for admission medication reconciliation. These failures placed residents at risk for ineffective or subtherapeutic treatment of underlying medical conditions due to omissions of time-sensitive and high-risk medications. Findings included. Review of the facility's undated and untitled pharmacy order timelines and procedures quick reference form showed the facility had two scheduled pharmacy deliveries per day Monday - Friday. Medications ordered prior to 10:00 AM would be delivered between 7:00 PM - 9:00 PM, and medications ordered after 10:00 AM but prior to 7:30 PM would be delivered between 2:00 AM - 4:00 AM. Medications ordered after the 7:30 PM, the cutoff time, would be delivered on the next scheduled delivery (7:00 PM - 9:00 PM) 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 and record review, the facility failed to protect resident's property from loss or theft for 1 of 3 residents (Resident 1) reviewed for abuse, neglect, and/or exploitation. This failure placed residents at risk for financial loss and diminished sense of security within the facility. Findings included.Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (an assessment tool), dated 08/13/2025, showed Resident 1 was cognitively intact.During an interview on 09/03/2025 at 7:22 PM, Resident 1 said they were unable to lock the top drawer of their nightstand. Resident 1 said in June of 2025, they had made at least two requests for maintenance to install a lock. Resident 1 said at the beginning of July 2025, they had 376 dollars in the top drawer of their nightstand. Resident 1 said they had a witness, Resident 2, that knew the money was there. Resident 1 said on 07/07/2025 they were sent to the hospital and returned on 07/15/2025. Resident 1 said upon return to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on interview and record review, the facility failed to log and investigate grievances for 1 of 1 resident (Resident 22) reviewed for grievances and for 3 of 8 Resident Council monthly meeting minutes (Months: March 2025, May 2025, & June 2025) reviewed for grievances. This failure placed residents at risk of abuse and neglect, grievances to not be responded to timely or at all, and a diminished quality of life. Findings included . Review of the facility's policy titled “Grievance,” dated 03/2025, showed the purpose of grievances was “to assure the concerns are quickly and thoroughly evaluated and acted upon in order to resolve issues which affect the quality of life and care for residents in our facility.” <Resident 22> Resident 22 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set Assessment, dated 04/06/2025, showed they were cognitively intact and required substantial to maximal assistance with toileting hygiene. During an interview on 07/16/2025 at 1:28 PM, Resident 22 reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on interview and record review, the facility failed to ensure psychotropic medications (any drug affecting mental processes, emotions, and behavior) were adequately monitored, documented non-pharmacological interventions (NPIs, non-medication interventions to decrease behavior episodes), and/or had consent obtained for 5 of 7 residents (Residents 61, 22, 1, 2 & 3) reviewed for unnecessary medication or behaviors. This failure placed residents at risk of unnecessary medications, medication complications, and a diminished quality of life.Findings included.1) Resident 61 was admitted to the facility on [DATE] with diagnoses of anxiety, depression, and unspecified disorder of adult personality and behavior (a diagnosis when a resident does not fit criteria for any specific personality disorder but still has significant impairment in social, occupational, or other important areas of functioning). The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 61 was moderately cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report allegations of abuse, neglect, misappropriation (taking money or assets) and accidents to the State Agency within 24 hours, to log the allegation and/or accident in the facility's reporting log as required for 6 of 8 residents (Residents 61, 33, 58, 60, 20 and 63) when reviewed for abuse/neglect. This failure placed residents at risk for unaddressed abuse, neglect, misappropriation, psychosocial harm, decreased quality of life and other negative outcomes. Review of the facility's policy titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program“, revised September 2024, showed the facility was to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility was to investigate and report any allegations within time frames required by federal requirements. <Resident 61> Resident 61 admitted to the facility on [DATE]. Review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on interview and record review the facility failed to conduct a thorough investigation for 6 of 7 sampled residents (Resident 45, 2, 58, 60, 61 & 63) reviewed for incident investigations. Failure to conduct a thorough investigation, to identify the root cause(s) and all contributing factors related to incidents and investigations placed residents at risk for unidentified abuse or neglect, risk for injury, unmet care needs and a diminished quality of life.Findings included . Review of the facility's policy titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program”, Revised September 2024, showed regarding abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation (taking money or assets) the facility was to thoroughly investigate all allegations and the administrator initiates investigations. “The individual conducting the investigation at a minimum: a. reviews the documentation and evidence b. reviews the resident's medical record to determine 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 and record review, the facility failed to provide written notice of transfer at the time of transfer to the hospital for 3 of 3 sampled residents (Residents 10, 63 and 68) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge related to discharge and transfer status.Findings included .1) Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE]. Review of Resident 10's Minimum Data Set (MDS, an assessment tool) showed hospitalizations on 06/10/2025 with readmission to the facility on [DATE] and 06/19/2025 with readmission to the facility on [DATE]. There was no documentation showing a written notice detailing the transfer was provided to the resident.2) Review of the EHR showed Resident 63 admitted to the facility on [DATE]. Review of Resident 63's discharge MDS showed hospitalization with Return Anticipated on 07/07/2025 and readmission to the facility on [DATE]. There was no documentation showing a written…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, the facility failed to provide a written bed hold notice, at the time of transfer to the hospital, for 3 of 3 sampled residents (Residents 10, 63 and 68) reviewed for hospitalization. This failure placed the residents at risk for not knowing their right to hold their bed while in the hospital and a diminished quality of life.Findings included . 1) Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE].Review of Resident 10's Minimum Data Set (MDS, an assessment tool) showed hospitalizations on 06/10/2025 with readmission to the facility on [DATE] and 06/19/2025 with readmission to the facility on [DATE]. There was no documentation showing a bed hold notice was provided to the resident.2) Review of the EHR showed Resident 63 admitted to the facility on [DATE]. Review of Resident 63's discharge MDS showed hospitalization with Return Anticipated on 07/07/2025 and readmission to the facility on [DATE]. There was no 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 accurately assess 4 of 18 residents (Residents 47, 3, 31, & 28) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. Failure to ensure accurate assessments regarding active diagnoses (Residents 3 and 31), restorative services (Resident 47), and mobility status (Resident 28), and placed residents at risk for unidentified and/or unmet care needs. Findings included . Review of the Resident Assessment Instrument [a manual that directs nurses how to accurately code a MDS) showed that in order to code a restorative nursing program the following must be met:a) A measurable and objective goal must be documented in the care plan and medical record.b) Evidence of periodic evaluation by the licensed nurse must be present in the resident's medical record. 1) Resident 47 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident received a restorative walking program on seven of seven days, and a restorative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Level 1 Pre-admission Screening and Resident Review (PASRR, document that screens resident for needing further mental health evaluations) were accurate and complete for 4 of 7 residents (Residents 3, 22, 53 & 61) reviewed for PASRR. This failure placed residents at risk of unidentified and unmet care needs related to mental health, and a diminished quality of life.Findings included.1) Resident 3 was admitted to the facility on [DATE], and had a diagnosis of depression. Resident 3 had sertraline, an antidepressant, prescribed since 10/17/2024. Review of Resident 3's Level 1 PASRR, dated 02/21/2024, showed no serious mental illness boxes were selected. Review of the electronic health record (EHR), showed no other Level 1 PASRRs were completed.During an interview on 07/21/2025 at 11:31 AM, Staff F, Social Services Director, reviewed Resident 3's Level 1 PASRR and said there were no serious mental illnesses selected on the form, and no Level 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 7 of 18 sample residents (Residents 3, 63, 61, 31, 1, 42 & 47) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.Findings included . 1) Review of Resident 3's pressure ulcer care plan, revised 06/19/2025, showed Resident 3 had an unstageable left heel pressure ulcer, which was treated with a wound vac (device used to promote wound healing by applying negative pressure to the wound bed), that was to be changed three times a week. Review of the electronic health record (EHR) showed the wound vac had been discontinued on 06/17/2025. A 06/24/2025 wound consult note documented Resident 3's left heel wound bed was now visible and that the wound had progressed from unstageable to a full thickness stage 3 pressure ulcer. On 07/28/2025 at 12:21 PM, Staff J, Unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services provided met professional standards of practice for 7 of 18 sampled residents (Residents 45, 41, 3, 31, 63, 47 & 22) reviewed. The failure to obtain vital signs when required, follow medication hold parameters, notify providers when medications were held, administer oxygen at the ordered rate, clarify incomplete or conflicting orders, and only sign for tasks that were completed, placed residents at risk for medication errors and associated complications, unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy titled, “Vital Signs Monitoring Policy”, dated 06/01/2025, defines vital signs as temperature, pulse, respirations, blood pressure, oxygen saturation, and pain level. Vitals were to be obtained and documented on admission, as ordered by the physician, when there was a change in condition, before and after administration of medications that affect vital signs, before 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 interview and record review, the facility failed to ensure residents received the care they were assessed to require regarding cognitive services, laboratory testing, bowel management, podiatry services, dialysis services, and peripherally inserted central catheter (PICC) management for 8 of 18 sample residents (Resident 61, 22, 63, 3, 31, 4, 44 & 42) reviewed. These failures placed residents at risk for unidentified and unmet care needs, and a decreased quality of life.Findings included. <Cognitive Services> >Resident 61< Resident 61 was admitted to the facility on [DATE] with diagnoses of anxiety, depression, and unspecified disorder of adult personality and behavior (a diagnosis when a resident does not fit criteria for any specific personality disorder but still has significant impairment in social, occupational, or other important areas of functioning). The Quarterly Minimum Data Set (MDS, an assessment tool), dated 05/09/2025, showed Resident 61 was moderately cognitively impaired. Resident 61…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services were provided to increase range of motion (ROM) and/or to prevent further decrease in range of motion for 4 of 4 sampled residents (Resident 61, 47, 2 & 53) reviewed for limited range of motion. These failures placed residents at risk for a decline in functional abilities, discomfort and a diminished quality of life.Findings included… <Resident 61> Resident 61 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, as assessment tool), dated 05/09/2025, documented Resident 61 was moderately cognitively impaired and required extensive assistant with most cares. During interview and observation on 07/16/2025 at 12:28 PM, Resident 61 said their right-hand fingers had become more contracted since being at the facility, and they had repeatedly asked for an appointment with the Medial Director. Resident 61 said they had been told “no” when they asked to see the Medial Director and that they could soak 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 and record review, the facility failed to ensure residents were assessed and potential accident hazards/falls were thoroughly investigated for 3 of 3 residents (Resident 61, 58 & 20) reviewed for fall investigations. This failure placed residents at risk of falls, injury, and a diminished quality of life.Findings included.Review of the facility's policy titled Smoking Policy-Residents, revised 08/2022, showed the facility was to fill out Safe Smoking Evaluation forms on admission, quarterly, upon significant change, and as determined by staff. 1) Resident 61 was admitted to the facility on [DATE] with a diagnosis of weakness. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 61 was moderately cognitively impaired. Resident 61 smoked cigarettes. Review of progress notes before the 01/14/2025 fall, showed on 12/17/2024 Resident 61 had requested to see a doctor regarding the fingers on their right hand.Review of a psychiatry visit note on 01/09/2025, showed 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, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 10 sampled residents (Resident 45, 22, 47, 63, 4, 53, 31, 41, 66 & 58) interviewed, and 8 staff (Staff MM, NN, LL, GG, X, S, L & T) interviewed. The facility had insufficient staff to ensure residents received assistance with activities of daily living, restorative services and staff documentation. These failures placed residents at risk for unmet care needs and a diminished quality of life.Findings included .<Resident Interviews> On 07/16/2025 at 10:59 AM, Resident 45 said there were not enough staff, especially on night shifts. The Certified Nursing Assistants (CNAs) will sometimes respond in a timely manner, but the nurses take a long time. Resident 45 said they have waited for nurses to respond anywhere between 30 minutes to 3 hours. On 07/16/2025 at 1:12 PM, Resident 22 said the facility was always understaffed and the wait times for call lights…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete annual performance evaluation reviews for 3 of 3 sampled certified nursing assistants (CNAs) (Staff W, HH & JJ) reviewed for nurse aide performance reviews. This failure placed residents at risk for receiving care from unskilled staff and a diminished quality of life.Finding included .Staff W, CNA was hired 09/26/2016. Staff W's performance review was completed on 04/17/2024.Staff HH, CNA, was hired on 03/28/2023. Staff HH's last performance review was completed on 04/17/2024Staff JJ, CNA, was hired on 08/20/2021. Staff JJ's last performance review was completed on 04/17/2024On 07/28/2025 at 12:26 PM, Staff A, Administrator, said all staff records provided were full and complete records. Staff A said staff were reviewed annually. When shown the last annual review for the staff listed above, Staff A said all staff should have had their yearly performance reviews completed and documented. Reference WAC 388-97 -1680 (1), (2)(a-c).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on interview and record review, the facility failed to ensure monthly pharmacists recommendations for medication gradual dose reductions (GDRs) were responded to with accurate resident information and/or with completed resident-specific rationales for 3 of 4 (Residents 22, 61, & 41) reviewed for GDRs. This failure placed residents at risk of unnecessary medications and a diminished quality of life. Findings included.<Resident 22> Resident 22 was admitted to the facility on [DATE], with diagnoses including depression, anxiety, and bipolar disorder (mental health condition with extreme mood swings). The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed they were cognitively intact. Resident 22 was taking scheduled psychotropic medications that included: one anticonvulsant/mood stabilizer, one antipsychotic, two antidepressants, and one antianxiety medication. Review of Resident 22's GDR review on 04/15/2025, showed the provider had declined the recommendations above because a GDR was…

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

Based on observation, interview and record review, the facility failed to ensure medications were dated when opened when required, and expired medications were discarded in accordance with professional standards of practice for 1 of 1 medication room, and 1 of 2 medication carts (B Hall Cart) reviewed. Additionally, facility staff failed to ensure treatment carts were closed and locked when left unattended and unsecure medications were not left at bedside. These failures resulted in residents having unsupervised access to medications and biologicals not intended for their use, and for receiving expired/outdated medications. Findings included .<Medication Room> Observation of the Medication Room on 07/28/2025 at 1:45 PM, with Staff H, Medication Technician, revealed the following:1) A multiuse vial of Tuberculin Purified Protein Derivative (PPD) with an open date of 06/23/2025. 2) A multiuse vial of Tuberculin PPD with an open date of 06/25/2025.3) A multiuse vial of Tuberculin PPD that was opened and undated.Review of the Tuberculin PPD package insert, showed vials were to be dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare and serve palatable food under sanitary conditions when reviewed for kitchen. These failures placed residents at risk of foodborne illness, meal displeasure and a diminished quality of life.Findings included .<Brief Initial Tour>Observation on 07/16/2025 at 9:37 AM, showed 10 loaves of undated opened and unopened bread.Observation on 07/16/2025 at 9:38 AM, showed a shop fan with visible debris blowing in the direction of freshly baked uncovered rolls.<Follow Up Visit>Observation on 07/18/2025 at 9:45 AM, showed Non-Staff Member RR, sitting in the kitchen on their cellphone without a hair restraint.Observation on 07/18/2025 at 9:47 AM, showed Staff C, Dietary Manager assisting in the kitchen without a hair restraint.Observation on 07/18/2925 at 9:49 AM, showed Staff PP, Dietary Aide, in the kitchen assisting with dishes with a long unrestrained beard.Observation on 07/18/2025 at 10:43 AM, showed Staff SS, Dietary Assistant Director, put multiple slices of pork in a Black and Decker blender and turned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their antibiotic stewardship program tracked and monitored infections by completing monthly antibiotic line lists (a system to track all the infectious organisms in the building, to make sure they met criteria for antibiotic usage) with complete lists of symptoms, reevaluating residents for continued antibiotic use, and/or ensuring antibiotic stewardship by following up with staff with education regarding proper containers for urine cultures for 3 of 3 months (Months: April 2025, May 2025, and June 2025) reviewed. This failure placed residents at risk of unnecessary medication, the development of multidrug resistant organisms (MDROs), and a diminished quality of life.Findings included.During an interview on 07/17/2025 at 1:18 PM, Staff B, Director of Nursing Services, said the facility used McGeer's criteria for screening residents for antibiotic usage. Review of the April 2025 Antibiotic Line List, showed Resident 49 did not meet criteria 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 interview and record review, the facility failed to ensure they had a designated infection preventionist (IP) for the facility, to ensure the program monitored, tracked, and trended antibiotics and infections throughout the entire facility for 2 of 3 months reviewed (May 2025 and June 2025). This failure placed residents at risk of infection, unidentified care needs, and a diminished quality of life.Findings included.During the Entrance Conference on 07/16/2025, Staff A, Administrator, provided a staff name for the IP role. After the Entrance Conference, at 11:37 AM, Staff A sent an email with another staff name listed as IP. During an interview on 07/17/2025 at 12:39 PM, when asked who they reported an antibiotic resistant organism or contagious disease to, Staff K, Licensed Practical Nurse, said infection control, which was now being handled by the unit managers. During an interview on 07/17/2025 at 12:52 PM, when told their name was provided (after two other names) as the current IP, Staff B, Director of Nursing Services (DNS), said they would clarify that they were 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 and record review, the facility failed to ensure residents received COVID-19 vaccinations for 3 of 6 residents (Residents 4, 22, & 39) reviewed for vaccinations. This failure placed residents at increased risk of complications from contracting COVID-19 and diminished quality of life.Findings included.Review of the facility's infection surveillance documentation, from a COVID-19 outbreak in February 2025, showed 38 residents tested positive for COVID-19. For vaccination status listed, only 1 resident of the 38 was listed as up to date.1) Resident 4 was admitted to the facility on [DATE].Review of Resident 4's electronic health record (EHR), showed they tested positive for COVID-19 on 02/08/2025.Review of Resident 4's documents from admission, showed they had a COVID-19 vaccine on 02/02/2021. Review of Resident 4's COVID-19 vaccination record, showed they had not had the vaccine while at the facility. Review of Resident 4's progress notes from 07/01/2025, showed they were requesting 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 and interview, the facility failed to ensure kitchen equipment was maintained in a safe, functional, and working condition for 1 of 1 sampled freezer when reviewed for kitchen. This failure placed residents at risk of inadequate meal quality and a diminished quality of life.Findings included .Observation during the brief initial tour on 07/16/2025 at 9:34 AM, showed no thermometer in the freezer.Review of the freezer temperature log on 07/16/2025, showed the log was completed for the dates 07/16/2025 and 07/17/2025 with documented temperatures of zero degrees.During an interview on 07/16/2025 9:45 AM, Staff C, Dietary Manager, said they could not locate a thermometer for the freezer and had no knowledge of which staff member had documented the temperatures for 07/16/2025 and 07/17/2025. Staff C said the expectation was for staff to take the freezer temperatures every morning and afternoon, and document them accurately.During an interview on 07/16/2025 at 2:15 PM, Staff G, Corporate Maintenance, said the walk-in freezer temperature was between 15-17 degrees.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 they informed and provided written information to residents on their right to formulate an advance directive (AD, written instruction for the provision of health care when the individual is incapacitated, such as a living will or durable power of attorney (POA) for health care) for 2 of 4 residents (Resident 4 & 1) reviewed for advance directives. This failure placed residents at risk for not having their choice of who to care for them when incapacitated, not having their health care wishes honored, and a diminished quality of life. Findings included . <Resident 4> Resident 4 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 04/11/2024, documented Resident 4 was cognitively intact. Resident 4's AD care plan documented the resident did not have an AD and declined to formulate an AD. The electronic health record (EHR) showed no documentation Resident 4 was offered and had accepted or declined to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview and record review, the facility failed to provide personal privacy during personal care for 1 of 1 sampled resident (Resident 45) reviewed for privacy. This failure placed residents at risk of loss of privacy during personal care, embarrassment and a decreased quality of life.Findings included .Resident 45 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (an assessment tool), dated 05/01/2025, documented Resident 45 was cognitively intact.On 07/16/2025 at 11:08 AM, Resident 45 said they had an incident with Staff F, Social Services Director (SSD), Staff Z, Unit Manager (UM) and an unidentified Certified Nursing Assistant (the CNA was later identified as Staff AA). Resident 45 said all three staff members had taken them to the shower room for a shower. While in the shower room, Staff F had taken the hose with the spray nozzle and was spraying them down with the hard force of the water from the nozzle head, telling the CNA, This is how you shower a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview and record review, the facility failed to ensure pressure injuries (PIs) were consistently assessed, and ordered pressure redistribution measures and equipment were in place and functional for 1 of 2 residents (Resident 3) reviewed for PIs. The failure to ensure an ordered low air loss mattress was in place and functional and to routinely assess identified PIs, detracted from the ability to determine if current treatments and interventions were effective and appropriate. This failure placed residents at risk for prolonged wound healing, unidentified decline, development of avoidable PIs, pain and decreased quality of life. Findings included . The National Pressure Injury Advisory Panel (NPUIP) provided the following PI stage descriptions:- PI- localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device, because of intense and/or prolonged pressure or pressure in combination with shear.- Stage 1 Pressure Injury:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview, and record review the facility failed to ensure 1 of 1 residents (Resident 31) reviewed for indwelling urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag) had a valid medical justification for urinary catheterization, was assessed for removal of the catheter timely, and received catheter care in accordance with professional standards of practice. These failures placed residents at risk for loss of bladder tone and normal bladder function, urethral trauma and tearing and other negative health outcomes.Findings included .Review of the facility's policy titled, Catheter Care, Urinary, revised August 2022, staff would:a) Ensure that the catheter remained secured with a securement device to reduce friction and movement at the insertion site.b) Review and document the clinical indication(s) for catheter use.c) Nursing and the interdisciplinary team would assess and document ongoing need for a catheter that was in place.d) Remove 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 and record review, the facility failed to ensure pain was appropriately addressed, monitored, and recorded, or to ensure side effect monitors were in place and non-pharmacological interventions (NPI's, non-medication interventions for pain) were documented for pain medications for 2 of 6 residents (Residents 47 & 2) reviewed for unnecessary medications or pain management. This failure placed residents at risk for an increase in pain, inability to perform therapy services, medication complications, and a diminished quality of life. Findings included.<Resident 47> Resident 47 was admitted to the facility on [DATE], with a diagnosis of chronic pain. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 47 was cognitively intact, and was receiving restorative nursing programs that included seven days of active range of motion and three days of walking. Review of Resident 47's Medication Administration Record (MAR), showed they were receiving scheduled acetaminophen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to provide food in accordance with preferences for 1 of 11 sampled residents (Resident 20) reviewed for dining. This failure placed residents at risk for potential dissatisfaction with meals and a diminished quality of life.Findings included .Review of the electronic health record (EHR) showed Resident 20 admitted to the facility on [DATE]. Resident 20 was able to make needs known. Observation of the lunch meal on 07/16/2025 at 12:30 PM, showed Resident 20's tray card had allergies/dislikes of cheese, dairy, pork and processed meats. Resident 20 was served salad, a baked potato to include sour cream, cheese and green onions, chocolate pudding with whipped topping and beef.During an interview on 07/16/2025 at 12:45 PM, Resident 20 stated, I don't make it a big deal anymore they've given me things I've told them I don't like over and over.During an interview on 07/16/2025 at 1:02 PM, Staff D, Dietetic Technician, said the sour cream, cheese and pudding with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets as ordered by the physician for 2 of 10 residents (Residents 1 and 47) reviewed for dining. This failure placed the residents at risk for medical complication or nutritional deficits.Findings included .Observation of the lunch meal service on 07/18/2025 showed the primary lunch meal consisted of bratwurst, oven browned potatoes, sauerkraut, lemon chiffon pie and a dinner roll. According to the menu for Consistent Carbohydrate Diet (CCHO, a diet that aids in controlling blood sugar) residents would receive wheat bread in place of the dinner roll. Staff OO, Cook, was plating the food and was assisted by Staff C, Dietary Manager. Tray line was observed from 12:06 PM-1:30 PM and showed the following:<Resident 1>Resident 1 was admitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood). The 5-Day Minimum Data Set (MDS, an assessment tool), dated 06/30/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive skin assessments were completed for 3 of 3 residents (Resident 1, Resident 2, and Resident 3) sampled for services meeting professional standards. This failure placed the residents at risk for unidentified skin impairments, worsening skin impairments, and rehospitalization.Findings included .<Resident 1>Resident 1 was admitted to the facility on [DATE] with several chronic wounds to the lower extremities. The quarterly Minimum Data Set (MDS, an assessment tool), dated 03/04/2025, showed Resident 1 was cognitively intact and needed substantial assistance for most Activities of Daily Living (ADL's). Resident 1 discharged to the hospital on [DATE] for surgical intervention for the wounds.An admission note, dated 11/26/2025, showed Resident 1 admitted to the facility with wounds to the right lower leg, left lower leg, left heel, left large and 5th toes. Measurements were provided. Contracted wound management company did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 4) were free of significant medication errors. This failure placed residents at risk for receiving medications not ordered by a provider, overdosing, and possible medical complications. Resident 4 was admitted to the facility on [DATE] with diagnoses to include an old myocardial infarction (heart attack) and heart disease. An assessment by social services on 07/04/2025 showed Resident 4 was mildly cognitively impaired. Resident 4 was sent to the emergency department at 12:30AM on 07/05/2025 for angina (chest pain). Review of the nursing progress note, dated 07/04/2025, showed Resident 4 began complaining of angina and 911 was called at 11:40PM. Staff G, Agency Licensed Practical Nurse (LPN), administered 81mg of chewable aspirin every five minutes for a total of 324mg. Review of the Medication Administration Report showed Resident 4 had an order for 81mg of chewable aspirin daily in the morning for heart 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to provide the equipment needed by 1 of 3 residents (Resident 1) to maintain or improve mobility. This failure placed residents at risk for decline in functional ability, frustration, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with a diagnosis of paraplegia (loss of muscle control to the legs). The annual Minimum Data Set, an assessment tool, dated 03/15/2025, showed Resident 1 was dependent for transfers and required a Hoyer lift (mechanical device used to safely transfer individuals with limited mobility). It showed Resident 1 was not receiving any type of restorative services. On 04/25/2025 at 2:16PM, Resident 1 expressed frustration over the fact that they had been asking for a standing frame (a medical device that helps residents with limited mobility achieve and maintain an upright, standing position) for several months. The facility had loaned the standing frame to a sister…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 9 residents who smoked (Resident 2 and Resident 3) were assessed and subsequent safety interventions were followed. The facility failed to ensure residents who smoked smoked in the designated smoking area and that smoke was not drifting through open windows. These failures put residents at risk for burns, fires, second hand smoke inhalation and a decreased quality of life. Findings included . The Smoking Policy, dated 08/2022, stated smoking would be permitted in designated areas outside of the facility. The policy documented the designated smoking structure was in the right corner of the back courtyard and was large enough to fit three wheelchairs at a time. The facility did not have any restrictions on smoking hours or the number of residents who could smoke at the same time. Resident 2 admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS), an assessment tool, dated 2/6/2025, showed Resident 2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to store medications appropriately for 1 of 3 residents (Resident 1) reviewed for safe delivery of medications. This failure placed residents at risk for negative therapeutic outcomes and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. They had a history of gastric ulcers (open sore in the stomach lining), type 2 diabetes, and anemia (lack of red blood cells in the body). The annual Minimum Data Set, an assessment tool, dated 03/15/2025, showed Resident 1 was cognitively intact. On 04/25/2025 at 2:45PM, Resident 1 said they had told the nursing staff and the medical provider the only medication they wanted to take was the weekly Mounjaro (for type 2 diabetes) injection. Resident 1 pulled a regular sized garlic seasoning bottle from a Kleenex box on the side table that was a third of the way filled with a variety of pills. Resident 1 said those were the pills they did not want to take.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 equipment in a fully functional manner for 4 of 4 mechanical beds (room [ROOM NUMBER] bed 1, room [ROOM NUMBER] bed 2, room [ROOM NUMBER] bed 1, & room [ROOM NUMBER] bed 1) reviewed for safe operating condition. This failure placed residents at risk for injury and a decreased quality of life. Findings included . On 03/24/2025 at 2:07 PM, Resident 1 said on 03/11/2025 at 11:05 PM they were sitting on the edge of the bed when it collapsed. Staff came into the room and tried to determine what the issue was but were unable to. Resident 1 was moved to another bed in the room. On 03/25/2025 at 3:11 PM, Staff F, Maintenance Director, said a notification came through on the TELS Platform (a system used to request and document maintenance services) on 03/12/2025 regarding Resident 1's broken bed. A part was ordered, and the bed was fixed on 03/18/2025. Staff F said there was no way to anticipate the bed would collapse, but estimated 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 and record review, the facility failed to implement proper procedures for a medical device for 1 of 1 residents (Resident 1) reviewed for services provided met professional standards. This failure placed the resident at risk for discomfort, infection, and a decreased quality of life. Findings included . Resident 1 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 02/26/2025, showed Resident 1 was cognitively intact and needed moderate assistance for activities of daily living. Record review showed Resident 1 had a peripheral intravenous access (IV) device (placed in the vein to enable medication delivery) inserted by an outside provider on 03/05/2025. The duration of the access was to be for less than six days. The treatment administration record showed the device was used from 8 PM on 03/05/2025 to 6 AM on the 03/12/2025, more than 6 days. The Peripheral Intravenous Catheter Flushing Policy, dated 1/15/2004, said specific orders needed to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3 of 7 staff members (Staff A, B and C) used personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) infections. This failure placed residents and staff at risk for contracting and spreading COVID 19. Findings included . A 06/24/2024 CDC update titled, Infection Control Guidance: SARS-CoV-2 (the virus that causes COVID 19), showed residents should be placed on transmission based precautions and when health care personnel enter the room of a patient with suspected or confirmed COVID 19, they should use a N95 respirator (a mask that filters 95% of airborne particles), gown, gloves, and eye protection. A 04/12/2024 CDC guidance titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, showed staff were to remove and discard PPE, other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide assistance with Activities of Daily Living (ADL) related to incontinent care, cleanliness and positioning in bed for 2 of 3 residents (Resident 1 and 2) reviewed for ADLs. This failure placed residents at risk for poor hygiene, impaired skin integrity, discomfort and loss of dignity. Findings included . <RESIDENT 1> Resident 1 was admitted on [DATE] with diagnoses including failure to thrive. The Minimum Data Set (MDS), an assessment tool, dated [DATE], showed the resident was cognitively intact, required substantial/maximal assistance with dressing, personal hygiene, toileting hygiene and rolling side to side. The MDS showed the resident was always incontinent of urine and bowels. Resident 1's [NAME] (care instructions for staff), dated [DATE], showed the resident required extensive assistance with bed mobility, personal hygiene, toilet use and was to be checked and changed every two hours and as needed for incontinence. 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 and record review, the facility failed to follow physician orders and monitor clinical conditions for 2 of 4 residents (Resident 3 and 4) reviewed for quality of care. This failure placed residents at risk of medical complications, infection, pain and a diminished quality of life. Findings included . <RESIDENT 3> Resident 3 was admitted on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 10/21/2024, showed the resident was cognitively intact. Resident 3's Communication Form, dated 11/22/2024, and completed by the licensed nurse, showed the resident wanted to speak with the medical provider because they thought they had a possible bladder infection. The form showed the medical provider indicated they would see the resident that day. Resident 3's physician order, dated 11/22/2024, showed an order to obtain UA [urinalysis] for dysuria (pain when urinating). Physician orders, dated 11/26/2024, showed an order for a medication for three days for dysuria. Review of Resident 3'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 observation, interview and record review, the facility failed to implement interventions to prevent pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure) from developing for 1 of 3 residents (Resident 1) reviewed for wounds. This failure placed the residents at risk of clinical complications, pain and a diminished quality of life. Findings included . Review of the facility's policy titled, Wound Prevention and Treatment, revised 02/03/2024, showed the center will consider all residents at risk for skin impairment and will implement the following interventions to prevent the development of pressure ulcers: reduce occurrence of pressure over bony prominence to minimize injury, protect against the adverse effects of external mechanical forces (pressure, friction, shear). The policy showed the center recognizes even the most vigilant nursing care may not prevent the development and/or worsening of pressure ulcers in some residents, in those cases, intensive efforts will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control standards were followed related to use of required personal protective equipment (PPE) with residents on transmission-based precautions (TBP) for 2 of 3 residents (Resident 1 and 2), reviewed for infection control. This failure placed residents, staff and visitors at risk for contracting and spreading infections. Findings included . Review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, revised October 2018, showed transmission-based precautions were additional measures that protect staff, visitors and other residents from becoming infected and when a resident was placed on transmission-based precautions, appropriate notification was placed on the room entrance door so that personnel and visitors were aware of the need for and the type of precaution. The signage informs the staff of the type of CDC [Centers for Disease Control] precaution(s), instructions for use of PPE,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a call light (device to request help as needed) within reach and failed to provide a bed extender for 1 of 5 residents (Resident 3) reviewed for environment. This failure placed the resident at risk for unmet care needs, pain and pressure injury, and a diminished quality of life. Findings included . Resident 3 admitted to the facility on [DATE] with diagnoses including hemiparesis (weakness or paralysis to one side of the body) and hemiplegia (complete paralysis to one side of the body) of the left side due to a stroke (damage to the brain due to lack of blood flow). The quarterly Minimum Data Set (an assessment tool), dated 07/19/2024, indicated Resident 3 needed extensive assistance for most activities of daily living. Resident 3 was cognitively intact. On 09/11/2024 at 10:15 AM, Resident 3's call light was observed on the left side of the bed, wedged in the frame, with the end dangling towards the floor. On 09/11/2024 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 interview and record review, the facility failed to develop a personalized discharge plan based on each resident's identified needs, goals and preferences and implement it timely for 2 of 3 residents (Resident 1 and 2) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident Discharge, revised 05/18/2023, showed the facility must initiate discharge planning at the request of the resident and prepare a detailed, written transfer or discharge plan for the resident and ensure the plan was an integral part of the resident's comprehensive plan of care and as such, include measurable objectives and timetables for completion and incorporate in the plan the resident's preferences, support system, assessments and plan of care and availability of appropriate resources to match the resident's preferences an needs. <Resident 1> Resident 1…

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

Based on observation and interviews, the facility failed to ensure dining services were provided in a respectful and dignified manner for 5 of 14 residents (Residents 54, 33, 15, 60, and 22) eating in the dining room. This failure placed residents at risk for feelings of dehumanization and a diminished quality of life. Findings included . The facility's Admissions Packet, undated, documented, You have the right to be treated with respect. On 06/10/24 at 12:22 PM, 14 residents were seated in the dining room at six different tables. Table 1 had one resident, Table 2 had two residents, Table 3 had one resident, Table 4 had two residents, Table 5 had two residents, Table 6 had six residents. Staff EE, restorative aide, and Staff FF, restorative aide, began passing out trays at 12:32 PM. Nine of the 14 residents were served at various tables at that time. At 12:35 PM, Staff FF said they pass trays from the cart according to how they were loaded. Staff FF stated, we can't pull a tray out and set it to the side to pull out the one behind it. At 12:43 PM, Residents 54, 33, 15, 60, and 22…

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

Based on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 4 of 4 sampled residents (Residents 11, 37, 43 and 46) reviewed for personal funds. This failure placed residents at risk of not having an accurate accounting of their personal funds held in a trust account by the facility. Findings included . During a resident council meeting on 06/17/2024 at 2:56 PM, when asked about quarterly statements, Residents 11, 37 and 43 said they had never received a quarterly statement for their trust account balance. Resident 46 stated, I didn't even know I had a trust account. Review of a document provided by the facility titled, Trial Balance, dated 06/10/2024, showed Residents 11, 43, and 46 all had a balance in their trust fund. Resident 37 had a trust fund with a balance of zero dollars. On 06/17/2024 at 3:16 PM, Staff F, Business Office Manager, said they provided quarterly statements to residents with trust accounts every three months. Staff F said the most recent documentation they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents/resident representatives a written notice detailing the reasons for discharge/transfer and/or to provide a copy of the notice to the state Ombudsman office as required, for 6 of 8 residents (Residents 18, 19, 73, 16, 67 and 30) reviewed for hospitalizations. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options related to bed-holds. Findings included . <Resident 18> Resident 18 was admitted on [DATE]. The Significant Change Minimum Data Set (MDS), an assessment tool, dated 05/10/2024, showed the resident was cognitively intact. Resident 18 was hospitalized from [DATE] to 05/03/2024 due to a fall. The Electronic Health Record (EHR) showed no documentation of Ombudsman notification. On 06/17/2024 at 10:37 AM, Staff B, Director of Nursing Services (DNS), said social services was responsible for contacting the Ombudsman and to ask social services for any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the resident and/or resident representative, a written notice of the facility's bed-hold policy at the time of transfer for 4 of 8 residents (Residents 18, 19, 30, and 73) reviewed for hospitalizations. This failure placed residents at risk for emotional distress and a diminished quality of life. Findings included . <Resident 18> Resident 18 was admitted on [DATE]. The Significant Change Minimum Data Set (MDS), an assessment tool, dated 05/10/2024, showed the resident was cognitively intact. A review of the Electronic Health Record (EHR) showed Resident 18 was hospitalized from [DATE] to 05/03/2024 due to a fall. The bed hold was filled out on 04/27/2024 at 7:57 PM, after the patient had already left the building at 6:40 PM. The registered nurse signed as the nursing home administrator/designee that the notice was presented 04/27/2024. The section of the bed hold for the 'notice provided to resident or resident representative' was blank. 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 implement a system in place that ensured periodic reconciliation and accounting for all controlled medications, for 2 of 2 medication carts (C cart & A cart) reviewed. Facility nurses' failure to consistently reconcile controlled medications at shift change and to co-sign the ledger to show both nurses validated the accuracy of the controlled medication count, placed residents at risk for misappropriation of their medication and detracted from the facility's ability to promptly identify potential diversion. Findings included . Review of the C-cart controlled medication ledgers for May and June 2024, showed facility nurses failed to count controlled medication at shift change, and/or failed to sign the ledger to validate the count was accurate, for one or both shifts, on the following dates: May-5/02/2024, 5/04/2024, 5/06/2024, 5/09/2024, 5/10/2024, 5/18/2024, 5/20/2024, 5/25/2024, 5/26/2024, and 5/31/2024. June- 06/03/2023, 06/09/2023, 06/03/2023, 06/14/2023, 06/15/2023, 06/16/2023, 06/17/2023, and 06/18/2023. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY <Resident 62> Resident 62 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented the resident was cognitively intact. Resident 62 was prescribed mirtazapine for depression (a constant feeling of sadness or loss if interest) and to increase their appetite. Resident 62's EHR showed no orders for monitoring of target behaviors or side effects for the antipsychotic medication. On 06/17/2024 at 11:44 AM, Staff B, DNS, said she did not see orders for behavior or side effect monitoring for Resident 62 and her expectations is for there to be monitoring orders in the EHR. <Resident 68> Resident 68 was admitted to the facility on [DATE]. The admission MDS, an assessment tool, dated 05/21/2024, documented Resident 68 was moderately cognitively impaired. Resident 68 was prescribed quetiapine (atypical antipsychotic, mind altering substance) for dementia and psychosis (a mental disorder characterized by a disconnection from reality). Resident 68's EHR showed no orders for monitoring of target…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 drugs and biologicals were labeled and dated in accordance with accepted professional standards of practice, and expired medications were discarded for 1 of 1 medication room and 2 of 3 medication carts (C1 & C2) that were observed. These failures placed residents at risk to receive expired medications and negative health outcomes. Findings included . <Medication Room> Observation of the Medication room on 06/13/2024 at 1:47 PM, with Staff T, Registered Nurse, revealed the following expired and/or undated medications: 1) Resident 26- An opened Byetta pen, dated 3/13/2024. Per manufacturer should have been discarded 30 days after opening. 2) Resident 30- an opened vial of Humulin R insulin, dated 08/26/2023. 3) Resident 69- five bags of intravenous (IV) ceftriaxone (antibiotic), which were brown and discolored. On 06/13/2024 at 1:53 PM, Staff T, Registered Nurse, confirmed Resident 26's Byetta pen was opened greater than 30 days prior, Resident 30's vial of Humulin R insulin was opened greater than 28 days prior, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to establish and maintain effective infection prevention and control practices to prevent the spread of infections and communicable diseases. Facility staff failed to follow accepted infection control practices during the provision of wound care for 3 of 3 residents (Residents 62, 40 & 69) reviewed for wound care, failed to perform hand hygiene after contact with residents and/or their environmental surfaces (Staff AA), and failed to wear required personal protective equipment (PPE) when providing care to residents on transmission based precautions for 3 of 3 residents (Residents 324, 53 & 10) reviewed for transmission based precautions. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . Review of the facility's Handwashing/Hand Hygiene policy, revised 08/2019, showed all facility personnel would be trained, regularly in-serviced, and shall follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 mail was delivered unopened for 4 of 7 residents (Residents 25, 30, 43 and 46) reviewed for resident rights. This failure placed the residents at risk for lack of privacy and a diminished quality of life. Findings included . Review of the Resident Rights policy, dated 08/2022, showed centers will comply with resident rights under Federal law at 42 U.S.C 483.10 (Resident Rights) and communicate those rights to patients in language/and or by a means of communication that ensures understanding. Review of 42 U.S.C 483.10 section (h)(2) (Privacy and Confidentiality) showed the facility must respect the residents' right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. During the resident council interview on 06/17/2024 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 interview and record review the facility failed to provide an Advanced Directive (AD, a written instruction of health care directions) for 2 of 9 residents (Residents 59 and 62) reviewed for ADs. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . <Resident 59> Resident 59 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 05/15/2024, documented the resident was mildly cognitively impaired. A review of the Electronic Health Record (EHR) showed a document titled, Resident Rights-Advanced Directives, which was signed by Resident 59 on 05/08/2024, and indicated the resident had an AD. No record of the AD was in the EHR. A copy of the AD was requested from the facility on 06/12/2024, 06/13/2024, and 06/14/2024. On 06/17/2024 at 2:47 PM, Staff B, Director of Nursing Services (DNS), said they did not see the AD in the EHR and stated, we don't have 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 and record review, the facility failed to file a grievance and to make a prompt effort to resolve the resident's grievance for 1 of 3 sampled residents (Resident 18) reviewed for personal property. This failure placed residents at risk for a diminished quality of life. Findings included . Resident 18 was admitted to the facility on [DATE] with diagnoses including depression and psychosis (a mental disorder characterized by a disconnection from reality). The Significant Change Minimum Data Set (MDS), an assessment tool, dated 05/10/2024, showed the resident was cognitively intact and was able to recall. On 06/11/2024 at 8:57 AM, Resident 18 said they came to the facility with two phones, that the one that worked better and was pretty was the phone that went missing. Resident 18 recalled multiple staff members had helped the resident look for the phone, but they were unable to locate it. Resident 18 said a grievance was filed with the activity person, and that there had been no follow up or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a Significant Change Minimum Data Set (MDS), an assessment tool, for 1 of 2 residents (Resident 10) reviewed for hospice and end of life. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life. Findings included . According to the Resident Assessment Instrument manual (a document directing staff when assessments of resident status are required), a Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains a resident at the nursing home. Resident 10 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed the resident was severely cognitively impaired. The Electronic Health Record (EHR) showed Resident 10 was admitted to hospice on 05/11/2024, requiring a Significant Change MDS assessment within 14 days. The EHR showed an admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Sets (MDS), an assessment tool, accurately reflected residents' health status and/or care needs for 2 of 28 sampled residents (Residents 73 and 18) reviewed for MDS accuracy. The failure to accurately assess if residents had a terminal diagnosis or fall with major injury, placed residents at risk for unidentified and/or unmet care needs. Findings included . <Resident 73> Resident 73 re-admitted to the facility on [DATE]. Review of the Significant Change MDS, dated [DATE], showed the resident was cognitively intact, received hospice services, but did not have a physician documented condition or chronic disease that may result in a life expectancy of less than six months. A Hospice Comprehensive Assessment and Plan of Care Update Report, revised 12/28/2023, showed the hospice physician documented that Resident 73 remained eligible for hospice services, with a prognosis of six months or less to live, if the terminal diagnosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected the resident's mental health diagnoses for 1 of 7 residents (Resident 73) reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary mental health services to meet their individualized mental health needs. Findings included . Resident 73 re-admitted to the facility on [DATE]. Review of the 01/04/2024 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had a diagnoses of anxiety and depressive disorders, and received antidepressant, antianxiety, and antipsychotic medication during the assessment period. Review of Resident 73's electronic health record showed the following 12/27/2023 physicians orders: duloxetine (an antidepressant medication) daily for depression; lorazepam (an antianxiety medication) every four hours as needed for anxiety; 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 interview and record review, the facility failed to develop and implement a care plan that was comprehensive and individualized, with measurable objectives, interventions and timeframes for how staff would meet the residents' needs related to opioids, for 1 of 4 sampled residents (Resident 18) reviewed for pain. This failure placed residents at risk for possible side effects of opioids, lack of follow up interventions related to opioids, for no reevaluation of care area, or of unidentified and unmet care needs and of a diminished quality of life. Findings included . Resident 18 was admitted on [DATE] with diagnoses including fall and fracture of the right femur (large thigh bone), requiring surgical intervention during hospitalization from 04/27/2024 to 05/03/2024. The Significant Change Minimum Data Set (MDS), an assessment tool, dated 05/10/2024, showed Resident 18 was cognitively intact, was on a scheduled pain medication regimen with as needed (PRN) pain medications and non-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 record review and interview, the facility failed to provide a Care Conference (a conference where staff and residents/families talk about life in the facility, review the progress of each patient and make adjustments, as needed, to the care plan), for 2 of 2 sampled residents (Resident 10 and 38) reviewed for care plan timing and revision. This failure placed residents at risk for unmet needs, diminished quality of care and a decreased quality of life. Findings included . <Resident 10> Resident 10 was admitted to facility 04/17/2024. The admission Minimum Data Set (MDS), an assessment tool, dated 04/24/2024, showed the resident was severely cognitively impaired. The medical conditions of the resident included Crohn's disease (a condition of the stomach and digestive tract) and cellulitis (a skin infection) of the buttocks. The Electronic Health Record (EHR) showed there was no documentation of a care conference being done after admission to facility. On 06/12/2024 at 9:31 AM, Staff H, Social Services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide pressure ulcer treatment and services in accordance with professional standards for 2 of 7 sampled residents (Residents 10 and 40) reviewed for pressure ulcers. This failure placed residents at risk for untreated pressure ulcers, pain, and a diminished quality of life. Findings included . <Resident 69> Resident 69 was admitted to the facility on [DATE] with diagnoses including infection of the left knee and malnutrition. The admission Minimum Data Set (MDS), an assessment tool, dated 05/24/2024, showed the resident was cognitively intact, had a stage 2 pressure ulcer (bedsore), was at risk for developing pressure ulcers, was impaired on one side of their lower extremity, required substantial/maximum assistance with lower body dressing, and required partial/moderate assistance with rolling from left to right. Resident 69's orders for wound care to their coccyx (tailbone), in the Electronic Health Record, included to Cleanse 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 timely identify, assess, and address the nutrition of residents with significant and/or trendable weight loss for 2 of 6 residents (Residents 69 and 61) reviewed for nutrition. The facility failed to ensure resident weights were consistently and accurately obtained, to honor residents' diet preferences, and to implement nutritional intervention recommended by the Registered Dietician (RD). These failures placed residents at risk for continued and/or unidentified weight loss, delayed nutritional intervention, and unmet nutritional needs. Findings included . <Resident 69> Resident 69 was admitted to the facility on [DATE] with diagnoses including post (after) bariatric surgery status (a surgery that removed part of the stomach and decreased it's size), severe sepsis with septic shock (infection of the blood causing organ failure and low blood pressure), infection of left knee, chronic iron deficiency anemia (not enough iron in the blood),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide pain management that met professional standards including the failure to monitor or reassess effectiveness of pain medication, to use non-pharmacological interventions when indicated, and to work with the practitioner to taper analgesics (pain relieving medications) when medically indicated, for 1 of 4 sampled residents (Resident 18) reviewed for pain. This failure placed residents at risk for side effects of medications for pain, unidentified and unmet care needs, and a diminished quality of life. Findings included . Resident 18 was admitted on [DATE] with diagnoses including fall and fracture of the right femur (thigh bone), requiring surgical intervention during hospitalization from 04/27/2024 to 05/03/2024. The Significant Change Minimum Data Set (MDS), an assessment tool, dated 05/10/2024, showed resident was cognitively intact, was on a scheduled pain medication regimen with as needed (PRN) pain medications 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, interview, and record review the facility failed to ensure a medication error rate of less than five percent when 1 of 2 nurses (Staff P) incorrectly administered 3 of 25 medications in accordance with physician orders and/or manufacturer's guidelines for 1 of 3 residents (Resident 39) observed during medication pass. This resulted in a medication error rate of 8 percent. These failures placed residents at risk for ineffective treatment of underlying medical conditions and/or adverse side effects. Findings included . <Resident 39> On 06/18/2024 at 7:41 AM, Staff P, Licensed Practical Nurse (LPN), prepared to administer cyclosporine ophthalmic emulsion (used for allergic eye conditions.) Staff P administered three drops into Resident 39's left eye and two drops into the right eye. After waiting 33 seconds, Staff P then administered two drops of Refresh ophthalmic solution (lubricating eye drops) into the resident's right eye and four drops into the left eye. Review of the June 2024 Medication Administration Record (MAR) showed an order for cyclosporine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the quality and timeliness of laboratory services for 1 of 8 sampled residents (Resident 19) reviewed for urinary catheter or Urinary Tract Infection (UTI). This failure placed residents at risk for delay in diagnosis of infection, of sepsis, of potential complications, of increased length of stay, and of a diminished quality of life. Findings included . Resident 19 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 05/25/2024, showed the resident was cognitively moderately impaired and had an indwelling urinary catheter. Timeline of Events: 4/30/2024 Complete Blood Cell Count (CBC) collected, 05/01/2024 received by lab, 05/01/2024 reported to facility - elevated white blood cell count (WBC) at 11.1. 05/03/2024 Urinalysis with culture (UA) ordered, 05/06/2024 no successful completion of UA was documented by provider. 05/06/2024 UA ordered STAT (quickly), no record of any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promptly notify the provider of laboratory results that fell outside of normal ranges for 1 of 8 sampled residents (Resident 19) reviewed for urinary catheter or Urinary Tract Infection (UTI). This failure placed residents at risk for potential complications, of increased length of stay, and of a diminished quality of life. Findings included . Resident 19 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 05/25/2024, showed the resident was cognitively moderately impaired and had an indwelling urinary catheter. On 05/30/2024, a urinalysis and culture were ordered, on 05/31/2024 collected, on 06/02/2024 received by lab, and on 06/04/2024 at 9:29 AM, reported to facility. Laboratory/Diagnostic Test Values-Monitoring Policy, undated, reported that the nurse was responsible for documenting a nurse note that included receipt of lab/diagnostic test result, provider notification, resident representative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 sufficient dietary staff were trained and competent in the preparation and provision of puree (food made to consistency of pudding) diets for 2 of 2 residents (Residents 35 & 125) reviewed for pureed diets. The failure to have sufficient staff available to ensure dietary staff were supervised until they were trained and competent in their duties, resulted in residents being provided the incorrect diet texture, and placed residents at risk for aspiration, choking risk and for food borne illness. Findings included . Resident 35 admitted to the facility on [DATE] and had a 04/04/2024 order for a regular, pureed diet, with thin liquids. Resident 125 admitted to the facility on [DATE], with an order for a regular, pureed diet, with thin liquids. Observation of the breakfast meal on 06/14/2024 from 8:18 AM - 8:50 AM, showed Resident 35 and 125 were served regular texture scrambled eggs, chopped sausage, with pureed pancakes. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure that 1 of 3 sampled residents (Resident 67) received foods that accommodated the residents' preferences and allergies. This failure placed residents at risk for meal dissatisfaction, allergic reaction, and a diminished quality of life. Findings included . Resident 67 was admitted to the facility on [DATE]. The admission Minimum Data Set, dated [DATE], documented Resident 67 was cognitively intact. On 06/11/2024 at 9:07 AM, Resident 67 was observed with three unopened apple juice containers on the bedside table. Resident 67 said they were on a cardiac diet and had allergies to apples but still received apple juice every day with breakfast. On 06/12/2024 at 3:09 PM, Resident 67 was observed with two unopened containers of apple juice sitting on the bedside table. On 06/14/2024 at 7:39 AM, Resident 67 was observed with one unopened container of apple juice on the breakfast tray. A Life Enrichment Evaluation, dated 05/03/2024, showed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure rooms were clean and linens changed timely for 4 of 9 residents (Residents 5, 6, 2, and 1) reviewed for physical environment. This failure placed residents at risk for dissatisfaction with their living environment, compromised dignity and a diminished quality of life. Findings included . <RESIDENT 5> On 05/17/2024 at 2:02 PM, Collateral Contact 1 (CC1), said Resident 5 was often ignored and left in their room without care. CC1 said the resident's room and sheets were filthy. On 05/20/2024 at 9:34 AM, Resident 5's room was observed to have a sticky, red substance covering the bedside table and on the floor. The floor was littered with a Kleenex box and paper. The bed next to Resident 5 was a bare mattress without linens. The curtains were closed, and the lights were off. At 11:27 AM, the sticky, red substance remained on the bedside table and floor, Kleenex box and paper were on the floor. The pad underneath Resident 5 appeared wet with dark yellow colored liquid and the room smelled of urine. At 1:00 PM, the bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interviews and record reviews, the facility failed to provide bathing assistance for 3 of 8 residents (Resident 1, 2 and 3) reviewed for bathing. This failure placed residents at risk for poor hygiene, skin conditions and a diminished quality of life. Findings included . <RESIDENT 1> Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 04/26/2024, showed Resident 1 was cognitively intact and required substantial assistance of staff to bathe. On 05/20/2024 at 1:51 PM, Resident 1 said since their admission they maybe had two or three showers and the staff did not routinely offer showers. Resident 1 said they would like more showers, but the staff made them feel bad because there were so many other residents ahead of them. Resident 1's Bathing Record, dated 04/24/2024 through 05/21/2024, showed Resident 1 was to receive showers on Tuesday and Friday evenings. The record showed the resident received one shower during that time frame. <RESIDENT 2>…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, the facility failed to provide wound care per physician orders for 2 of 2 residents (Resident 2 and 4) reviewed for wound care. This failure placed the residents at risk for medical complications and infection. Findings included . <RESIDENT 2> Resident 2 was admitted to the facility on [DATE] with diagnosis of surgical repair for a fracture of their right leg. The Minimum Data Set (MDS), an assessment tool, dated 05/10/2024, showed the resident was cognitively intact. Resident 2's physician's orders, dated 05/16/2024, showed an order for staff to change the wound dressing to the resident's right hip daily. On 05/20/2024 at 11:45 AM, Resident 2 was observed with a wound dressing on their right leg, dated 05/18/2024. Resident 2 said the wound dressing was not changed daily, that has not happened since I got here. <RESIDENT 4> Resident 4 was admitted to the facility on [DATE]. Resident 4's Wound Specialist's progress report, dated 05/14/2024, showed Resident 4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 5 sampled residents (Resident 2) reviewed for care and services. The failure to follow physician's orders placed residents at risk for clinical complications, medication errors and a diminished quality of life. Findings included . Resident 2 was admitted on [DATE] with diagnoses including heart failure. On 03/05/2024 at 7:24 AM, Collateral Contact 3 (CC3), Advanced Registered Nurse Practitioner, said they were Resident 2's heart failure specialist and monitored the resident's condition regardless of the location. CC3 said they saw the resident in their clinic on two separate occasions while the resident was a resident of the facility and sent orders to the facility following the appointments. CC3 said on both occasions the facility failed to implement the orders and/or contact CC3. On 03/14/2024 at 11:09 AM, Staff D, Licensed Practical Nurse, said when a resident returned from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate supervision and assistance at a community appointment for 1 of 3 resident (Resident 1) reviewed for supervision. This failure placed residents at risk for avoidable accidents, injury, pain, and emotional distress. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including sepsis (infection in blood) and encephalopathy (change in how the brain functions). The Minimum Data Set assessment (MDS), dated [DATE], showed the resident required substantial assistance to stand and transfer and staff had not attempted to walk with the resident due to a medical condition or safety concerns. The MDS showed the resident was always incontinent of bladder and bowel and did not use a wheelchair. On 02/28/2024 at 2:18 PM, Collateral Contact 1 (CC1), documented Resident 1 was dropped off on 02/26/2024 at the hospital for a medical appointment. CC1 documented the resident was found two hours later in the parking garage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 hand hygiene was performed during medication administration for 2 of 3 sampled residents (Resident 5 and 6) reviewed for infection control. This failure placed the residents at risk for exposure to communicable diseases. Findings included . Record review of the facility policy titled, Handwashing/Hand Hygiene, revised August 2019, showed staff were to use an alcohol-based hand rub or soap and water before preparing or handling medications. Record review of the facility policy titled, Medication Administration, revised December 2022, showed staff were to wash hands prior to administering medications and sanitize their hands upon completion of the task. On 02/07/2024 at 12:04 PM, Staff B, Registered Nurse (RN) was observed entering Resident 5's room and informed the resident they were going to administer medications. Staff B took the medication cart keys from the pocket of their sweatshirt, grabbed a medication cup with their bare hands touching the lip of the medication cup, unlocked the medication cart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and record review, the facility failed to consistently provide palatable food for 5 out of 7 residents (Resident 1, 2, 3, 4 and 5) reviewed for food. This failure placed residents at risk for weight loss, inadequate nutrition and a diminished quality of life. Findings included . RESIDENT INTERVIEWS 1. On 01/22/2024 at 11:57 AM, Resident 1 said the food was not good and lacked flavor. The resident said they could not cut the hamburger patties and it was the worst food they had ever eaten. 2. On 01/22/2024 at 12:45 PM, Resident 2 said the food continued to taste bad. The resident said when they requested alternatives to the main dish, they were frequently told the kitchen did not have it. The resident said nothing had changed. 3. On 01/22/2024 at 12:48 PM, Resident 3 said the food was worse than prison food and it was unacceptable. The resident said they did not want to eat the food most of the time. 4. On 01/22/2024 at 1:47 PM, Resident 4 said the food lacked taste and seasoning. Resident 4 said they had to ask repeatedly for the food to be seasoned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inform the resident's representative of treatment decisions and discharge for 1 of 3 residents (Resident 6) reviewed for resident rights. This failure placed all residents and or their representatives at risk for not being included in their health care decisions and discharge planning. Findings included . Resident 6 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood). Resident 6's Cognitive Patterns evaluation, dated 01/04/2024, showed Resident 6 with a score of four, indicating severe cognitive impairment. On 01/18/2024 at 12:37 PM, Collateral Contact 1 (CC1) said they were the paid caregiver for Resident 6. CC1 said when the resident was admitted to the facility from the hospital a relative of CC1, Collateral Contact 2 (CC2), went to the facility to be present at the admission because CC1 was not able to be at the facility. CC1 said facility staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure sufficient staff were available to provide necessary care and services for 5 of 9 sampled residents (Residents 1, 3, 4, 5 and 6) reviewed for nursing services related to sufficient staffing. This failure placed residents at risk for unmet care needs, discomfort, and a diminished quality of life. Findings included . <RESIDENTS> On 10/02/2023 at 1:11 PM, Resident 1 said at times they had to wait one to two hours for care while sitting in wet pants. Resident 1 said there were days they were unable to get out of bed and staff would say the reason was that they were short staffed and they did not have the time or staff to assist with the transfer. Resident 1 also said showers were hit and miss and the previous week the resident did not receive a shower because the staff, ran out of time. At 1:15 PM, Resident 3 said they had waited as long as three hours for assistance with care. The resident said they felt trapped when they were not able to get out…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess and monitor non-pressure wounds for 3 of 3 residents (Resident 1, 2 and 3) reviewed for wound care. This failure placed residents at risk for worsening skin conditions, medical complications, and unnecessary pain. Findings included . Record review of the facility's policy entitled, Wound Prevention and Treatment, dated 02/03/2023, showed that wounds will be monitored weekly, documentation of size, color, odor and healing progression and other pertinent information related to the skin conditions will be documented in the electronic medical record (EMR). <RESIDENT 1> Resident 1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS), an assessment tool, dated 08/04/2023, showed the resident was cognitively intact. On 08/29/2023 at 12:43 PM, Resident 1 stated that they told staff for months their bottom hurt, it was raw and was not getting better. On 08/29/2023 at 2:33 PM, Staff A, Licensed Practical Nurse, stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure resident rooms were repaired and maintained for 3 out of 3 halls (Halls A, B and C) reviewed for homelike environment. This failure placed the resident at risk for compromised dignity and a diminished quality of life. Findings included . During a facility tour on 06/02/2023 at 8:35 AM, observation showed multiple rooms with scuffed/scraped or dented door jambs. A Wing Resident rooms 6, 7, 18, 16, 15, 14 and 17 all had scuffed, scraped, or dented door jambs. The shower and soiled linen rooms' door jambs were also observed to be scuffed/scraped. B Wing Resident rooms 23, 29, 24, 25, 30, 32, 33 and 34 were all observed with scuffed, scraped, and/or dented door jambs, as were the central supply and shower room door jambs. C Wing Resident rooms 38, 39, 40, 41 and 50 were all observed with scuffed, scraped, and/or dented door jambs, as were the dining room, shower room and hair salon. In addition, the wood at the bottom of rooms [ROOM NUMBERS]'s doors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 initiate, log, and timely resolve grievances voiced by residents during resident council. These failures left residents at risk for unresolved grievances, unmet needs, and frustration. Findings included . Facility Policy Review of a policy titled, Resident Council, revised on 01/23/2023, showed that the facility would designate a staff person to be responsible to provide assistance and respond to request from the resident council. The Executive Director and/or Director of Nursing would then communicate its decisions to the Council. The Council was designated as an activity assisted meeting and report requests to the Executive Director and/or responsible department, were required to prepare a response to any requests from the Council in writing to requests of the Resident Council within time frame indicated in the Grievance procedure. Resident Council During a meeting on 06/05/2023 at 2:05 PM, with the facility's Resident Council President Resident 46 and resident council attendees Residents 19 and 50 stated that they had…

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

Based on observation, interview, and record review the facility failed to ensure that the environment was free from accident hazards for 3 of 5 residents (Resident 2, 22, & 28) reviewed for accident hazards. This failure placed the residents at risk for an unsafe environment and diminish quality of life. Findings included Resident 2 Observation on 06/01/2023 at 09:25 AM, showed 2 using an electric powered wheelchair. During an interview on 06/01/2023 at 09:26 AM, the resident stated, I use my electric powered wheelchair when I am out of bed to get around the building. Review of Resident 2's electronic health record (EHR) on 06/01/2023 showed no updated evaluation was completed for the use of an electric power wheelchair. The EHR showed that the last evaluation was dated 12/20/2016. Review of Resident's care plan in the EHR showed that an evaluation for the use of an electric powered wheelchair and self-releasing seat belt safety device was to be completed quarterly and as needed. During an interview on 06/05/2023 at 10:49 AM, Staff P, Director of Rehabilitation Services (DRS) stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen therapy was provided in accordance with Physician's orders and accepted professional standards of practice for 2 of 2 residents (Residents 31 & 3) reviewed for respiratory care. Facility staff failed to administer oxygen at the ordered rate, to accurately record the flow rate of oxygen administered, to ensure oxygen concentrators had functional air filters, and to change oxygen tubing at the ordered frequency. These failures resulted in residents not receiving the ordered amount of oxygen and placed them at risk for adverse side effects related to oxygen therapy and unmet respiratory needs. Findings included . Resident 31 Resident 31 admitted to the facility on [DATE]. According to the 05/04/2023 quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had a diagnosis of chronic lung disease and required the use of supplemental oxygen. During an observation and interview on 06/01/2023 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.

Based on observation, interview and record review, the facility failed to ensure there was a Registered Nurse (RN) working a minimum of eight hours each day for nine of 30 days reviewed for staffing. This failure placed residents at risk for delayed assessments/treatments and a diminished quality of care. Findings included . Review of document titled, Staffing Pattern on 06/07/2023 at 11:47 AM showed that there was no RN that was scheduled or had worked nursing duties the minimum eights hour on the following days: 05/01/2023, 05/02/2023, 05/06/2023, 05/07/2023, 05/10/2023, 05/13/2023, 05/14/2023, 05/21/2023 and 05/28/2023. During an interview on 06/05/2023 at 10:05 AM, Staff B, Director of Nursing (DON), stated that the facility did not have, at times, adequate RN coverage especially on the weekends nor on the dates that were submitted on the staffing pattern document 30 day look back period. During an interview on 06/07/2023 at 10:49 AM, Staff A, Administrator, stated that they had RN coverage within the facility however on the weekend they had issues with getting RN coverage.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 serve foods that were palatable, and at the proper temperature. Observation of meal preparation and interviews with 5 residents (Residents 12, 53, 28, 7 & 71) revealed concerns about the temperature and palatability of food served by the facility. These failures placed residents at risk for weight loss, decreased meal satisfaction and for diminished quality of life. Findings included . Resident Interviews Resident 12 During an interview on 05/31/2023 at 11:51 AM, Resident 12 stated, the food is terrible .the gravy is too salty, and I'm supposed to get plenty of protein. Resident 53 During an interview on 06/01/2023 at 9:20 AM, Resident 53 stated that the food was horrible, the eggs smelled, the sausage was not fully cooked, and that they only offered chicken and pork. Resident 28 During an interview on 05/31/2023 at 11:31 AM, Resident 28 stated that the food was bad, and the servings were too small. Resident 7 During an interview on 06/01/2023 at 8:56 AM, Resident 207 said The food was not good, they only…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received foods in the appropriate form and/or nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's nutritional needs. Failure to ensure residents' received physician ordered therapeutic diets or portion sizes placed residents at risk for medical complications or nutritional deficits. Findings included . Observation of the lunch meal service on 06/02/2023 revealed the primary lunch meal consisted of Turkey [NAME] Casserole, baked sweet potato, fruit cup, choice of milk and beverage of choice. According to the menu, renal diets, received roasted turkey, no sweet potato, and carbohydrate-controlled diets (CC) receive an unsweetened beverage. Observation Tray service for the lunch meal on 06/02/2023 started at 11:32 AM. Staff M, Cook, prepared the residents food plate, and was assisted by Staff N, Dietary Aide. Tray line was observed until 12:45 PM and showed the following: Renal Diet Staff M was observed preparing Resident 175 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, interview, and record review, the facility failed to provide grooming/personal hygiene needs and respectful resident care in a manner that promoted the resident's dignity for 2 of 2 residents (Residents 3 & 26) reviewed for dignity. This failure placed the residents at risk for embarrassment, diminished self-esteem, and a decrease in quality of life. Findings included . Resident 3 During an observation and interview on 06/05/2023 at 1:13 PM, Resident 3 was observed sitting at the edge of their bed and stated that they needed assistance to the restroom because they were feeling shaky. Resident 3 stated that Staff R, Certified Nursing Assistant (CNA), answered the call light but indicated staff were busy with passing lunch trays. Staff R, CNA, overheard the conversation and informed the resident that someone would be coming to assist. Resident 3 yelled I can't keep holding it, I'm going to have an accident. An observation on 06/05/2023 at 1:18 PM, showed Staff Q, CNA, go into Resident 3's room, set down the lunch tray and then attempted to exit the room. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to inform a resident in advance of the risks and benefits associated with proposed psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), wander guard placement (a device designed to help protect memory care residents against elopement) and obtain resident consent prior to implementing the proposed treatments/therapies for 1 of 5 Residents (Resident 18) reviewed for unnecessary medications. The failure of facility staff to obtain Resident 18's consent for an antidepressant medication prior to administering it, and to obtain consent to place a wander guard prior to implementing it, detracted from the resident's ability to exercise their right to make an informed decision about proposed treatments and prevented the resident from exercising their right to decline the treatments/therapies. Findings included . Resident 18 Resident 18 admitted to the facility on [DATE]. According to the 02/28/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to honor bathing preferences for 2 of 2 residents (Residents 31 & 18) reviewed for choices. The failure to promote and facilitate resident self-determination, by honoring residents' choices related to bathing frequency, placed residents at risk for poor hygiene, feelings of powerlessness, and diminished quality of life. Findings included . Resident 31 Resident 31 admitted to the facility on [DATE]. According to the 05/04/2023 quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, required physical assistance with bathing, and choices related to bathing were identified as Very important. During an interview on 06/01/2023 at 9:55 AM, Resident 31 said that they would like three showers a week, but currently were scheduled to be showered twice a week, on Tuesdays and Thursdays. According to Resident 31 it wouldn't do any good to request three showers a week because they were lucky to even get one. Resident 31 stated that on…

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

Based on interview and record review, the facility failed to ensure conveyance (the act of legally transferring property from one entity to another) of a resident's trust funds, including a final accounting of those funds within 30 days of discharge for 1 of 1 discharged resident (Resident 75) reviewed for trust accounts. This failure prevented the resident from having access to their funds for an extended period of time. Findings included . Resident 75 Review of Resident 75s 12/30/2022 discharge tracker Minimum Data Set (MDS, an assessment tool), showed the resident had a planned discharge to the community with return not anticipated on 12/30/2022. Review of Resident 75's trust account ledger showed at the time of discharge, the resident had a balance of 26 dollars. Review of the check conveying the balance of Resident 75's trust to the resident was dated 03/09/2023, 69 days after discharge. During an interview on 06/06/2023 at 9:16 AM, when asked if the facility conveyed Resident 75's trust fund balance to the resident, along with a final accounting of those funds within 30 days…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 3 of 25 sampled residents (Residents 12, 32 & 65) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. Failure to ensure residents' cognitive patterns, mood, preferences, and medication use were assessed and/or accurately assessed, placed residents at risk for unidentified and/or unmet care needs. Findings included . Resident 12 Resident 12 admitted to the facility on [DATE]. According to the 05/07/2023 MDS, the resident had a diagnosis of diabetes (a group of diseases that result in too much sugar in the blood) and required insulin injections (medication that lowers blood sugar levels) on four of seven days during the assessment period. Review of Resident 12's May 2023 Medication Administration Record (MAR) showed the resident did not receive any insulin injections during the MDS assessment period (05/01/2023 - 05/07/2023.) During an interview on 06/06/2023 at 10:35 AM, Staff C, Resident Care Manager (RCM), stated 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 interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for one of 25 residents (Resident 62) reviewed for new admissions. Failure to ensure an initial care plan addressed wound care to the residents left knee wound site placed the resident at risk for unmet needs and a diminished quality of life. Findings included . Resident 62 Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 05/17/2023, showed that Resident 62 admitted on [DATE] with multiple health conditions to include a non-pressure chronic wound to the upper left knee medial aspect [pertaining the middle or center of the body]). The resident was able to make needs known and required extensive assistance with activities of daily living. Review of the provider orders dated 5/24/2023 showed that the licensed staff were to cleanse the site (left medial knee wound) with normal saline solution and apply skin preparation to the wound. The Licensed Nurse was ordered to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected resident care needs for 5 of 25 sampled residents (Residents 18, 31, 3, 28 & 22) whose CPs were reviewed. These failures placed residents at risk for unidentified/ unmet care needs and a diminished quality of life. Findings included . Resident 31 Resident 31 admitted to the facility on [DATE]. According to the 05/04/2023 quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, required assistance with oral care and had obvious or likely cavities and/or broken natural teeth. During an interview on 06/01/2023 at 10:26 AM, Resident 31 stated that they had some natural lower teeth, of which, one or two were cracked and had cavities, and indicated they had no natural upper teeth. According to Resident 31 they were supposed to have upper dentures made over a year ago, but the appointment was never scheduled. Review of Resident 31's…

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

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 4 of 21 sample residents (Residents 61, 31, 32, & 54) reviewed. The failure to obtain, follow, and clarify Physician's orders when indicated, only sign for those tasks that were completed, and failure to notify the physician when residents' medications were held, placed residents at risk for medication errors, delayed treatment, and adverse outcomes. Findings included . Resident 61 Review of Resident 61's May 2023 Physician's orders showed: an order for a diuretic medication (medication that helps move extra fluid and salt out of the body) daily, with direction to hold the medication if the resident's systolic blood pressure (SBP) was less than 100 or the pulse was less than 60; and an order for a blood pressure medication twice a day, with direction to hold the medication if the resident's SBP was less than 100 or the pulse was less than 60. Review of Resident 61's May 2023 Medication Administration Record (MAR) showed on 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 interview and record review, the facility failed to ensure 1 of 5 residents (Residents 18) reviewed for unnecessary medications, were free from unnecessary psychotropic drugs. Facility staffs' failure to identify and monitor the target behaviors that the medication was intended to treat detracted from staffs' ability to monitor the effectiveness of the medication and the need for continued use. This failure placed the resident at risk to receive unnecessary medications and/or experience adverse side effects. Findings included . Resident 18 Resident 18 admitted to the facility on [DATE]. According to the 02/28/2023 admission Minimum Data Set (MDS, an assessment tool) the resident had a diagnosis of depression, demonstrated no behaviors, and received anti-depressant medication on seven of seven days during the assessment period. Review of Resident 18's Physician's orders showed the following 03/07/2023 orders for: Amitriptyline (an antidepressant medication) daily at bedtime for neuropathic pain, 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, the facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional standards of practice and that expired medications were discarded for 2 of 2 medication carts and 1 of 1 medication room observed. These failures placed residents at risk to receive expired medications and to experience adverse side effects and other potential negative health outcomes. Findings included . Medication Room Observation of the Medication room on 06/05/2023 at 06:56 AM, showed an opened, undated multiuse vial of tubersol (tuberculosis skin test.) In an interview on 06/05/2023 at 06:56 AM, Staff B, Director of Nursing, stated tubersol must be discarded 30 days after opening and acknowledged the vial of tubersol in the medication room refrigerator was opened and undated. Staff B then removed the vial of tubersol for disposal. Medication cart C Observation of Medication cart C on 06/05/2023 at 7:01 AM with Staff F, Licensed Practical Nurse (LPN), revealed the following expired medications: 1) An opened, undated Anoro Ellipta inhaler…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dental services were provided for 1 of 2 Medicaid residents (Residents 31) reviewed for dental services. Facility staffs' failure to follow up on dental referrals and to timely schedule an appointment with a denturist, placed the resident at risk for difficulty chewing, oral pain, decreased self-image and diminished quality of life. Findings included . Resident 31 Resident 31 admitted to the facility on [DATE]. According to the 05/04/2023 quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, required assistance with oral care and had obvious or likely cavities and/or broken natural teeth. During an interview on 06/01/2023 at 10:26 AM, Resident 31 stated that they had some natural lower teeth, of which one or two were carious and cracked, and no natural upper teeth. According to Resident 31 they were supposed to have upper dentures made over a year ago, but the appointment was never scheduled.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor resident food preferences for 2 of 7 residents (Resident 6 & 18) reviewed for food. This failure placed the residents at risk of not having preferred foods, lack of dietary intake and a diminished quality of life. Findings included . Review of a document titled, Food Preferences, dated 03/2023 showed, Information will be gathered upon admission to inform the food and nutrition services department of the individual's food preferences, allergies, intolerances, cultural preferences, and diet history. Food preferences will be updated periodically as needed or upon reassessment. During an interview on 06/01/2023 at 9:20 AM, Resident 6 stated, I don't like the food the kitchen served to me, I gave them a list of my likes. Resident 6 stated that, I don't like getting eggs for breakfast, but they still give them to me on my plate. During an interview and observation on 06/06/2023 at 12:21 PM, Staff D, Dietary Manager (DM), stated that the menu for breakfast consisted of various food items to include eggs for…

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

Based on observation and interview the facility failed to prepare and serve food under sanitary conditions. Additionally, the facility failed to ensure the use of hair net during meal preparation in the kitchen. These failures placed residents at risk for cross-contamination and foodborne illnesses. Findings include . Observation of preparation of the lunch tray service on 06/02/2023 at 11:32 AM showed Staff M, Cook, prepared the food, and was assisted by Staff N, Dietary Aide. Staff N was observed setting up resident meal trays and serving items such as beverages and fruit on trays. During that time, Staff N was observed not wearing a hair net or any other head covering, as required when preparing and serving food. Observation on 06/06/2023 at 9:35 AM showed Staff N left the kitchen to restock water and coffee at the nurse's station. Staff N wore a hat with a long hair exposed. Observation of the lunch meal in the dining hall on 05/31/2023 at 12:24 PM showed Staff L, Restorative Aide touch the arm rest of a resident's wheelchair and then touched a different resident's silverware to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure standard infection control practices were followed related to: screening of staff /visitors upon entering the facility; performance of hand hygiene for 1 of 1 resident (Resident 62) observed during wound care and 1 of 3 residents (Resident 54) observed during medication pass; and sanitization of shared resident equipment after use, for 1 of 3 residents (Resident 54) observed during medication pass. These failures placed the residents, staff members and visitors at potential risk for acquiring and spreading bacteria and infectious diseases. Findings included . HAND HYGIENE DURING WOUND CARE RESIDENT 62 Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 05/17/2023, showed that Resident 62 admitted on [DATE] with multiple health conditions to include pressure ulcers (wounds that occur from prolonged pressure on the skin due to prolonged immobility that can grow and lead to infections) on the buttocks,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a safe environment for residents and visitors on 1 of 3 Wings (C-Wing) reviewed for environment. This failure placed residents and visitors at risk for accidents, injury, and diminished quality of life. Findings included . During a facility tour on 06/02/2023 at 8:35 AM, observation showed an uneven surface of tiles with a small lip approximately 14 inches in length by 14 inches in width in the north end of the C-Wing. Further observation showed several more uneven surface bumps in the tile in the same location in front of resident rooms 41, 42 ,44 and 45. During an interview on 06/06/2023 at 7:35 AM, Staff J, Maintenance Director, stated that the roof had just been replaced and that the C-hall flooring was affected by the leak causing water damage. Staff J further stated that he planned to make the floor repair a priority because the area can be unsafe for residents with front wheel walkers. During an interview on 06/07/2023 at 8:27 AM, Staff A, Administrator stated that they recently hired the maintenance director,…

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