Bethany At Silver Lake

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promptly report and document resident grievances for 1 of 3 sampled residents (Resident 35) reviewed for grievance resolution. The failure of staff to initiate resident grievances resulted in delays in grievance resolution and an extended period where a resident went without their missing property and placed residents at risk for frustration and diminished quality of life. Findings included . Review of the facility policy, titled, Grievance Policy and Procedure for Residents, revised date of June 2022, showed any employee that is informed of a grievance by a resident will immediately initiate the procedures for resolution of a grievance. Resident 35 admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 12/06/2024, the resident was cognitively intact. In an interview on 12/16/2024 at 2:34 PM, Resident 35 stated they were missing a left-hand arthritis glove, and it had been missing for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (Resident 82) reviewed for blood sugar (BS) monitoring received BS checks per standards of practice/care. This failure exposed residents to an increased risk of inaccurate insulin administration and the potential for decreased blood sugar. Finding Included . A review of the facility policy, titled Timely Administration of Insulin, dated June 2020, stated that insulin administration will be coordinated with mealtimes and snacks. Resident 82 admitted to the facility on [DATE] with diagnoses to include diabetes type 2 (a chronic disease that occurs when the sugar level in the blood stream was too high.) In an observation and interview on 12/19/2024 at 12:56 PM, Staff Q, Licensed Practical Nurse (LPN) assessed Resident 82's BS after they had eaten their lunch. Staff Q then administered sliding-scale (an insulin prescription that adjusts the amount of insulin a person receives based on their blood sugar level) insulin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 respiratory care consistent with professional standards of practice for 1 of 2 sampled residents (Resident 40) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration, undated, showed oxygen would be administered to resident's who needed it, consistent with professional standards of practice, the comprehensive care plan and the resident's goals and preferences. The explanation and guidelines outlined in the policy showed oxygen was administered under orders of a physician. Resident 40 admitted to the facility on [DATE] with diagnoses that included heart failure and chronic obstructive pulmonary disease (COPD-progressive lung disease that limits airflow and makes it difficult to breath). On 12/16/2024 at 1:51 PM,…

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

Based on observation, interview, and record review, the facility failed to provide a dignified and homelike dining experience in 2 of 3 (Southeast and South) dining rooms during 3 of 3 dining observations for dignity. These failures placed residents at risk for feelings of frustration, diminished self-worth, embarrassment, and a potential decline in nutritional status. Findings included . <SOUTHEAST DINING ROOM> Observation on 10/24/2023 at 11:37 AM, Resident 101's meal tray was served. The resident's tablemates, Resident 76, and Resident 33, were observed to watch Resident 101 eat until their lunch arrived at 11:43 PM, six minutes later. The resident's food and drinks were not removed from the serving tray for the dining experience. Observation on 10/27/2023 at 11:28 AM, trays were delivered to the unit. Resident 33's meal was served at 11:30 AM, followed by their tablemates Resident 76's at 11:34 AM and Resident 1's meal at 11:35 AM. At the same table Resident 101 was staring at their tablemates eating and inquiring as to where their food was. Collateral Contact 1 (CC1), 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 interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (AD's) for 5 of 12 sampled residents (Residents 160, 32, 75, 6 and 100) reviewed for AD's. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . <RESIDENT 160> Resident 160 was admitted to the facility on [DATE] with diagnosis including aftercare following left leg amputation. Resident 160's profile information records showed the resident was self- responsible in making their own decisions. Review of Resident 160's records on 10/25/23 and 10/31/2023, showed no documentation of AD's. Review of email received on 10/31/2023 at 12:02 PM, Staff A, Administrator, indicated Resident 160's admission paperwork had not yet been completed that included information regarding AD's. <RESIDENT 32> Resident 32 admitted to the facility on [DATE] with diagnoses including depression and heart failure. 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 Based on interview and record review, the facility failed to ensure 4 of 5 residents (Resident 86, 14, 83, and 73) were free of unnecessary drugs due to: 1) lack of specific target behavior monitoring, 2) not obtaining the monthly orthostatic vital signs, 3) not developing and implementing non-medical behavioral interventions, and 4) not having appropriate indication, documentation, and goals for use of psychotropic medications. These failures placed residents at risk for receiving unnecessary medications and for experiencing medication-related adverse side effects. Findings included . Review of the Food and Drugs/Drug (FDA) Safety Information reference, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there was little chance that they would be effective, 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 monitor the medication refrigerator temperatures and ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 3 (Central/South and Southeast) medication refrigerator observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency. Findings included . In an observation on 10/26/2023 at 1:31 PM, the thermometer in the shared Central/South medication room's refrigerator temperature was 48 degrees Fahrenheit (F). The refrigerator contained vaccines, resident medications, and over the counter medications. The refrigerator temperature form showed temperatures should range from 36 degrees F to 46 degrees F with instructions to notify maintenance if recorded temperatures are above or below range on 2 sequential readings 30 minutes apart. Review of the shared Central/South Unit medication room refrigerator temperature log, dated 10/01/2023 through 10/26/2023, showed 20 missing readings with 10 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 observation, interview, and record review, the facility failed to ensure residents had access to their call lights for 2 of 3 sample residents (Resident 75 and 94), reviewed for quality of life. This failure placed residents at risk of unmet care needs and diminished quality of life. Findings included . <RESIDENT 75> Resident 75 admitted to the facility on [DATE], most recently readmitted on [DATE], diagnoses included hypertension (high blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm), and weakness. Review of Resident 75's care plan, dated 04/18/2022, showed the resident had a deficit in their ability to care for themselves related to weakness and was at risk for falls. Interventions included to encourage Resident 75 to use their call light for assistance and to have their call light within reach. In an observation and interview on 10/25/2023 at 11:21 AM, Resident 75's call light was observed on the floor. Resident 75 stated they would like a glass of cold ice water.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their abuse/neglect policy and procedure to thoroughly investigate injuries of unknown source for potential abuse/neglect for 2 of 4 residents (Resident 57 and 75) reviewed. Failure to thoroughly investigate injuries of unknown source placed residents at risk for continued abuse/neglect. Findings included . Review of the facility policy titled, Policy and Procedure Abuse, Neglect, Abandonment, Financial Exploitation and Misappropriation of Resident Property, dated January 2017, showed the facility will ensure that all alleged violations involving abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and injuries of unknown sources are reported immediately to appropriate agencies in accordance with federal and state law. <RESIDENT 57> Resident 57 admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnosis to include Alzheimer's disease (a progressive disease that destroys memory 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 provide a written notice of transfer to the resident and/or the resident's representative describing the reason for transfer for 2 of 2 sampled residents (Residents 48 and 6) reviewed for transfer notifications regarding hospitalization. This failed practice disallowed the residents and/or their representative an opportunity to fully understand the rationale and resident rights associated with the discharges. Findings included . <RESIDENT 48> Resident 48 was admitted to the facility originally on 06/24/2021 and then again on 08/22/2022 following hospitalization. Review of Resident 48's medical records showed the resident transferred to the hospital on [DATE] related to acute changes in their medical status. The medical record did not show documentation that a written notice of transfer and discharge was provided to Resident 48, their representative, and to the Office of the State Long-Term Care Ombudsman. In an interview on 10/31/2023 at 9:40 AM 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 provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 1 of 2 residents (Resident 48) reviewed for hospitalizations. This failed practice placed residents at risk for lack of knowledge regarding the right to hold their beds while they were at the hospital. Findings included . A review of Resident 48's nursing progress notes and admission/discharge history notes, showed the resident discharged from facility to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident 48's medical records revealed no documentation the resident or the resident's representative had been provided with a written bed hold notification at time of discharge or within 24 hours of discharge. In an interview on 10/31/2023 at 9:12 AM, Staff L, Registered Nurse/Resident Care Manager, stated the nurse sending a resident to the hospital was responsible to notify the resident and/or 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 complete an updated Pre-admission Screening and Resident Review (PASRR - a screening tool used to determine if a person has an intellectual disability or has indicators for serious mental illness) for 1 of 5 residents (Resident 73) reviewed for PASRR accuracy who required a Level II evaluation (Level II evaluation - more in depth mental health evaluation than the screening PASRR) due to a new mental health diagnosis. This failed practice placed the resident at risk of not receiving specialized mental health services, for unidentified needs, and for a decrease in their quality of life. Findings included . Review of the facility policy titled Resident Assessment - Coordinator with PASRR Program, undated, showed that any resident that shows newly evident or a possible mental health disorder would be referred promptly to the state mental health authority for a Level II resident review. Resident 73 was admitted to the facility on [DATE] with diagnoses 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 interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans to meet the needs of 2 of 4 residents (Resident 86 and 32) reviewed for care planning. This failure placed residents at risk for weight loss, inadequate tube feeding (a flexible tube placed into the stomach to help get nutrition when a person was unable to eat) management, unmanaged pain, not honoring resident's preferences, not receiving necessary care and services, and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, dated February 2023, showed the care planning process is to develop and implement a comprehensive person-centered care plan (a means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives) for each resident within 21 days of admission. All Care Assessment Areas (CAA - a systematic process to interpret the triggered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and revise care plans for 2 of 5 residents (Resident 53 and 57) reviewed for care planning. These failures placed the residents at risk for unmet care needs, adverse health effects and a diminished quality of life. Findings included . Review of the facility policy titled Comprehensive Care Plans, dated February 2023, showed the care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS - an assessment tool) assessment. The policy did not include care plan revisions for changes in the residents' conditions. <RESIDENT 53> Resident 53 admitted on [DATE] with diagnoses to include a stroke resulting in left side weakness and paralysis. Review of Resident 53's admission MDS assessment, dated 10/16/2023, showed the resident had an indwelling catheter (a tube inserted into the urinary bladder to drain urine). Review of Resident 53's treatment administration records (TAR)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oral hygiene was performed for 1 of 1 resident (Resident 33) reviewed for Activities of Daily Living (ADLs). This failure placed the resident at risk for poor oral hygiene, dental complications, decreased self-esteem, and diminished quality of life. Findings included . Resident 33 admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease (progressive disease that destroys memory and other important mental functions). Review of Resident 33's care plan, dated 07/11/2023, showed the resident had their own teeth and required total assistance with oral care. Review of Resident 33's Documentation Survey Report v2 (a comprehensive report that detailed cares provided for a resident) for October 2023, showed Resident 33's oral hygiene was not completed on 10/11/2023 day and evening shift. On 10/15/2023 Resident 33 was noted to be independent with their oral hygiene. In an interview on 10/24/2023 at 11:23 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly provide professional standards of care and services for 2 of 5 residents (Resident 28 and 73) reviewed for unnecessary medications and 1 of 1 resident (Resident 86) reviewed for medication management. The facility failed to obtain laboratory samples per physician orders, and to recognize low blood pressure (BP) results, reassess abnormal BP values, and notify the provider of abnormal findings. This failed practice placed residents at risk for medication complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Vital Signs, dated 2021, showed licensed nurses were responsible for knowing the usual range of a residents vital signs, analyzing, and interpreting routine vital signs, and notifying the physician of abnormal findings. <MEDICATION MANAGEMENT> Resident 86 was admitted to the facility on [DATE] with cardiac diagnoses to include hypertension (high b/p) and vascular disease (disease of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services were provided to maintain, increase, and/or prevent further decrease in range of motion for 1 of 1 resident (Resident 100) reviewed for limited range of motion. This failure placed the resident at risk for a decline in their functional ability and their quality of life. Findings included . Review of a facility policy titled Restorative Nursing Documentation, undated, showed the facility was to maintain complete, accurate, and organized documentation of restorative treatments and the response to those treatments. Resident 100 admitted to the facility on [DATE] with diagnoses to include Rhabdomyolysis (damaged muscles that release protein into the blood), a fall at home, and a failure to thrive (a term used to describe broad declines in multiple areas to include weight loss, decreased appetite, poor nutrition, and inactivity). Review of Resident 100's admission Minimum Data Set assessment (an assessment tool), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 3 of 3 (Resident 53, 33, and 67) residents reviewed for urinary catheters (flexible tubes inserted into the bladder to drain urine) received the necessary care and services to achieve their optimal level of urinary function. Failure to identify the reason for a resident's treatment with a urinary catheter, to maintain documentation to support why an indwelling catheter was replaced and a trial void order was not completed as ordered, there was a lack of documentation why the physician was not notified per their physician order when there was a low urinary output, and there was a failure to documentation the facility had counseled the resident/representative of the risks and benefits of a urinary catheter. These failures placed residents at risk for infection, pain, discomfort, bleeding, and complications related to urinary catheter use, and a diminished quality of life. Findings included . Review of the facility policy titled,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 32) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure the resident received oxygen as it was prescribed by the physician and failed to ensure oxygen (O2) administration tubing was appropriately maintained, changed regularly, and dated. This failure placed residents at risk for contaminated care equipment, not receiving physician ordered services, unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration, undated, showed oxygen is administered under orders of a physician. Staff were to monitor ongoing assessment of the residents' oxygen use and notify if there is a need for changes. Oxygen tubing is changed weekly and as needed if it became soiled or contaminated. Staff were to initial and date the tubing. When oxygen tubing was not in use, it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an adequate rationale for not following pharmacist recommendations for 3 of 5 residents (Resident 86, 310, and 14) reviewed for unnecessary medications. This failure placed the residents at risk for experiencing the use of unnecessary medications and a potential diminished quality of life. Findings included . <RESIDENT 86> Review of the pharmacy consultant Medication Regimen Review (MRR), dated 10/12/2023, showed a request to evaluate citalopram hydrobromide (a medication used to treat depression) due to the off label/non-Food and Drug Administration (FDA) approved indication mood disorder being used. The pharmacist requested clarification if Resident 86 had a diagnosis of depression, or the medication was being used off label as mood disorder. Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner (ARNP), circled used off label for mood disorder. CC2 signed the pharmacist recommendation on 10/18/2023 as agree but did not include a…

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

Based on observation, interview, and record review, the facility failed to ensure cognitively impaired residents were fed by assistants that were properly trained for 2 of 4 sampled staff (Staff W and Staff X) observed providing feeding assistance to residents (Resident 26 and 28). This failure placed residents at risk of choking and aspiration (inhalation of food or fluid into the lungs) and a diminished quality of life. Findings included . In the entrance conference meeting on 10/24/2023 at 8:58 AM, Staff A, Administrator, stated they did not have any paid feeding assistants in the facility. <STAFF W> Review of Staff W's employee record showed they were hired on 03/16/2020. Staff W was currently employed as an activity assistant, and there was no record the staff had been trained as a paid feeding assistant. Review of Resident 26's Minimum Data Set (MDS - an assessment too) assessment, dated 10/11/2023, showed the resident had severe cognitive impairment. Review of Resident 26's nutritional assessment, dated 10/04/2023, showed the resident had an altered diet due to difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store food in accordance with professional standards for food service safety for 1 of 4 nutrition refrigerators/freezers (North Hall) reviewed for food storage. Failure to label foods with dates they were opened or discard dates, and discard expired food, placed residents at risk for food-borne illness. Findings included . Observation on 10/24/2023 at 10:10 AM, the North Hall Pantry Refrigerator/Freezer a sign on the refrigerator stated: Attention Staff -When a resident has food brought in, it must have their name on it. I will throw it away otherwise. All food will be thrown out after three days unless it has a manufacturer date on it, like yogurt or cheese sticks etc. All other items regardless of where it came from can only be in the fridge for 3 days. After 3 days, I toss out foods and put any container in the sink to be picked up. Only the resident's foods are allowed to be in the fridge. NO Staff food or drinks. Observation on 10/24/2023 at 10:10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, the facility failed to follow infection control standards during medication administration for 1 of 5 residents (Resident 116) observed for medication administration, and 1 of 1 residents (Resident 67) observed during care of a urinary catheter (a tube inserted into the bladder to drain urine.) This failure placed residents at risk for developing infections and for experiencing a decreased quality of life. Finding included . <RESIDENT 67> Resident 67 was originally admitted to the facility on [DATE] and most recently following hospitalization on 08/14/2023 with diagnoses to include heart disease/failure, urinary tract infection and presence of an indwelling urinary catheter (is a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag). In an observation and interview on 10/23/2023 at 1:05 PM, Staff FF, Nursing Assistant Certified (NAC), was observed providing catheter care (washing the external portion of catheter 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.