Valley View Skilled Nursing And Rehabilitation

Based on observation, interview, and record review the facility failed to ensure 1 supplemental resident of 1 resident (Resident 6) reviewed for non-pressure skin alterations and 1 of 1 resident (Resident 5) reviewed for constipation/diarrhea (loose stools) were provided quality care and services. The failure to ensure resident skin issues were assessed, treated, and/or monitored, and the failure to initiate the facility bowel care protocol left residents at risk for unmet care needs, pain/discomfort from constipation, and a decreased quality of life.Findings included.<Facility Policy>Review of the facility's Wound Treatment Management policy, revised 01/2026, showed the facility would promote the healing of various types of wounds. The policy showed licensed staff would notify the physician and obtain treatment orders for wounds without treatment orders.<Non-Pressure Skin> <Resident 6> According to the 01/07/2026 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 6 had diagnoses including a progressive disorder causing cognitive decline, poor blood circulation to their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents were free of accident hazards for 3 of 7 (Residents 26, 19, & 9) residents reviewed for accidents. This failure to ensure resident rooms were free of no longer needed safety interventions, resident mattresses were placed correctly on bed frames, and periodic safety assessments were completed placed residents at risk of injury, unmet needs, and diminished quality of life.<Facility Policy>According to the facility's revised 01/2026 Incidents and Accidents policy, falls and accidents would be investigated and new interventions determined to be necessary to prevent recurrence would be documented in the resident's record.Findings included. <Resident 26> According to the 02/12/2026 admission Minimum Data Set (MDS – an assessment tool), Resident 26 had impaired vision and intact cognition, and had a fall with no injury since admission. The MDS showed Resident 26 was frequently incontinent of bladder and always incontinent of…

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

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for Pressure Ulcer/Pressure Injury (PU/PI) was provided with the necessary treatment and services consistent with professional standards of practice to promote healing and/or prevent worsening. The failure to establish a routine monitoring procedure necessary when using an air mattress (a specialized bed surface with inflatable air chambers that inflate and deflate in cycles to continuously redistribute a person's weight, preventing pressure sores [bedsores] by improving circulation and relieving sustained pressure on vulnerable areas like hips, shoulders, and heels, especially for bedridden individuals) and ascertain its proper functioning placed residents at risk for deterioration in skin condition, pain, and a diminished quality of life. Findings included.<Facility Policy>The facility policy titled, Pressure Injury Prevention and Management, revised 11/2024, showed the facility was committed to provide treatment and services to heal PU/PI and to prevent avoidable PU/PI,…

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 prepare and serve food under sanitary conditions for 1 of 4 nursing units (West One Unit) observed during mealtime. Failure to cover food items, secure lids of the dirty wash rag bin, ensure staff distributed and served food under sanitary conditions, and maintained a clean/sanitary meal cart placed residents at risk of acquiring food-borne illnesses and a diminished quality of life. Findings included . <Facility Policy> According to the facility policy titled, Food Preparation and Service, revised April 2019, the food and nutrition services employees would prepare and serve food in a manner that complied with safe food handling practices. The policy showed appropriate measures were used to prevent food contamination and that both the food and nutrition services staff and the nursing services personnel would adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness including washing their hands before…

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 food under sanitary conditions in 1 of 1 kitchen. Failure to perform proper hand hygiene and glove use, properly clean kitchen equipment, adequately monitor food cooking temperatures, and ensure staff distributed and served food under sanitary conditions. These failures placed residents at risk of decreased nutritional intake, cross contamination leading to food-borne illness, and a diminished quality of life. Findings included . <Hand Hygiene> <Facility Policy> Record review of the facility's 5/21/2021 policy titled, Food Safety Requirements, showed staff would adhere to hygienic practices that prevent contamination of foods from hands or physical objects by proper hand washing and the appropriate use of gloves including changing them to reduce cross contamination. Observations on 12/11/2024 at 9:20 AM, showed Staff CC (Dietary Cook) preparing food. They removed their gloves, and, without performing hand hygiene, put on new gloves to continue preparing food. At 12/11/2024 at 9:26 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 ensure newly admitted residents were informed in a timely manner (prior to or upon admission) of their rights and responsibilities and provided services as a resident in the facility for 3 (Resident 85, 139, & 339) of 5 residents reviewed. This failure placed residents at risk of not understanding their rights, a reduced ability to self-advocate, and a diminished quality of life. Findings included . Review of the facility's 03/17/2022 admission Packet provided by staff, showed information and consent forms for the admission policies, resident rights, rules and operations of the nursing home, grievance process, right to choose their physician or contact information for the facility physician, charges for services, advanced directives and designation of a resident representative, privacy practices, healthcare privacy act, consent for release of medical information, bed hold policy, facility-initiated discharge policy, designation of funeral home, laundry…

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 <room [ROOM NUMBER]- Bathroom> Observations on 12/08/2024 at 9:39 AM and 12/09/2024 at 2:12 PM showed a long screw with a pointed sharp tip sticking out of the wall between the toilet and the sink. In an interview on 12/13/2024 at 9:51 AM, Staff L stated there was a missing hook that should be covering the screw. <room [ROOM NUMBER]> Observations on 12/08/2024 at 10:04 AM showed room [ROOM NUMBER] bed B with deep gouges and exposed drywall under the resident's wall light. In an interview and observation on 12/13/2024 at 9:51 AM, Staff L stated the area needed to be repaired. <room [ROOM NUMBER]> Observations on 12/09/2024 at 8:48 AM showed room [ROOM NUMBER] bed B with deep gouges and exposed drywall on the wall at the head of resident's bed. In an interview and observation on 12/13/2024 at 9:51 AM, Staff L stated the area needed to be repaired. <room [ROOM NUMBER]> Observations on 12/09/2024 at 10:30 AM showed room [ROOM NUMBER] bed A with deep gouges and exposed drywall on the wall at the head of resident'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 the menu was followed for 3 of 6 residents (Residents 83, 3, & 16) whose meals were observed during tray line. Failure to follow the menu as directed, according to the dietician approved spreadsheet, and provide accurate portion sizes, placed residents at risk of unmet nutritional needs, and potential negative outcomes. Findings included . <Facility Menu> Review of the facility's menu showed for lunch on 12/11/2024 beef stroganoff over noodles, buttered brussel sprouts, peach cobbler made from fresh, peeled, pitted, and sliced thin peaches, and a dinner roll would be served. The 12/11/2024 lunch menu showed low concentrated sweet diets had a canned peach cobbler instead of the fresh peach cobbler. <Following Menu> According to the facility's diet spreadsheet form provided by staff on 12/08/2024, all residents, except those who were on the low concentrated sweets diet, should receive a full serving of the peach cobbler dessert, which was to be made with fresh, peeled, pitted, and sliced thin peaches,…

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 food in a manner that ensured meals were appetizing and palatable for 4 of 6 residents (Resident 43, 6, 74, 85) reviewed. This placed residents at risk for a decreased nutritional intake and dissatisfaction with meals. Findings included . Review of the facility's December 2024 food temperature log form showed directions to staff to place food on the tray line no more than 30 minutes prior to meal service. <Resident Interviews> <Resident 43> In an interview on 12/08/2024 at 10:18 AM, Resident 43 stated the quality of the food was not good at the facility. <Resident 6> In an interview on 12/08/2024 at 12:53 PM, Resident 6 stated they were unhappy with the food at the facility. <Resident 74> In an interview on 12/08/2024 at 1:30 PM, Resident 74 stated they were very unhappy with the food and stated it was too bland and often overcooked. <Resident 85> In an interview on 12/09/2024 at 9:15 AM, Resident 85 stated, this is the worst food, and stated they ordered food from outside the facility most 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.

Based on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 3 of 3 residents (Resident 49, 23, and 43) reviewed for arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement. This failure placed residents at risk for lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life. Findings included . <Facility Policy> The facility's 08/08/2022 Binding Arbitration Agreements policy showed the facility would explain to residents and their representatives the arbitration agreement upon admission to the facility in a form and manner that the resident understood, including in a language they understood. The policy showed the admissions coordinator was responsible for any questions the resident may have about the contract. <Resident 49> According to the 11/27/2024 Quarterly Minimum Data Set (MDS -…

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

Based on observation, interview, and record review the facility failed to implement their Grievance policy for 1 of 2 residents (Resident 1) reviewed for grievance reporting. The failure to report, initiate, investigate, and log grievances placed residents at risk for not having grievance resolution delayed or incomplete, feelings of frustration, and a diminished quality of life. Findings included . <Facility Policy> Review of a facility policy titled, Resident and Family Grievances, revised March 14, 2023, showed residents may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished regarding their Long Term Care (LTC) facility stay. The staff member receiving the grievance would record the nature and specifics of the grievance on the designated grievance form or assist the resident to complete the form. The grievance form would be forwarded to the grievance official as soon as practicable. The grievance official or designee would keep the resident appropriately apprised of progress towards resolution 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.

Based on observation, record review, and interview the facility failed to ensure missing narcotics were reported to the State Survey Agency (SSA) within the required timeframe for 1 of 2 Narcotic Ledgers (East 2 Narcotic Ledger) reviewed for accuracy. Failure to complete required reporting of missing resident narcotics placed the residents at risk for further misappropriation of resident narcotic medications and the potential for uncontrolled pain. These failures placed the facility at risk for possible diversion of controlled substances. Findings included . <Policy> Review of the facility policy titled, Controlled Medication Storage, dated 01/2024, controlled substances were subject to special record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. The policy showed any discrepancies in controlled substance medication counts would be investigated by the Director of Nursing and every reasonable effort would be made to reconcile the discrepancies. According to a facility policy titled, Incidents and Accidents, revised 01/2023, 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, record review, and interview the facility failed to complete a thorough investigation of missing controlled substances (Narcotic Medications) for 1 of 2 Narcotic Ledgers (East 2 Narcotic Ledger) reviewed for accuracy. Failure to complete a thorough investigation placed residents at risk for uncontrolled pain, further misappropriation of resident narcotic medications, and possible staff diversion of controlled substances. Findings included . <Policy> According to a facility policy titled, Incidents and Accidents, revised 01/2023, the facility would complete incident reporting to ensure appropriate and immediate interventions were implemented and corrective actions were taken to prevent recurrence. The policy showed the facility would meet regulatory requirements for analysis and reporting of incidents. The policy showed the facility would complete an investigation for incidents that occurred on facility property and that involved a resident. Review of the facility policy titled, Controlled Medication Storage, dated 01/2024, controlled substances were subject 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 ensure a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable for 3 of 4 residents (Residents 65, 18, and 39) reviewed for hospitalizations and 1 supplemental resident (Resident 139) reviewed. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> Review of a 09/01/2021 facility, Transfer and Discharge policy, showed for emergency transfers/discharges, the facility would provide a transfer notice as soon as practicable to the resident and their representative. <Resident 65> According to a 10/19/2024 Discharge Minimum Data Set (MDS - an assessment tool), Resident 65 was discharged…

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 the resident's representative with a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 3 of 4 sample residents (Resident 65, 18, & 39) reviewed for hospitalization and 1 supplemental resident (Resident 139) reviewed. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making. Findings included . <Facility Policy> Review of a 12/2022 revised facility, Bed Hold Notice Upon Transfer policy, showed at the time of transfer for hospitalization or therapeutic leave, the facility would provide to the resident and/or the resident representative written notice which specifies the duration of the bed hold policy and addresses information explaining the return of the resident to the next available bed. This policy showed in the event of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Care Plans (CP) were updated as needed to reflect changes in residents' care needs for 2 of 5 residents (Residents 3 & 39) reviewed for CP's. The facility failed to provide care conferences for 2 of 5 residents (Residents 39 & 49) reviewed. The failure to update CPs with changes in residents' health status and conduct care conferences placed residents at risk for unmet care needs, unnecessary care, and frustration. Findings included . <Facility Policy> Record review of the facility's 4/01/2021 policy titled Care Planning - Resident Participation showed the facility would support residents' right to be informed about and actively participate in their CP and treatment decisions. The CP process would include an assessment of the residents' strengths and needs and incorporate the residents' preferences. Record review of the facility's 3/17/2024 admission Agreement showed residents had the right to participate in developing and being…

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 cleanliness and grooming for 3 (Residents 18, 22, & 3) of 18 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 18), bathing (Residents 22 & 3), and nail care (Resident 18), placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life. Findings included . <Facility Policy> According to the facility's revised 08/2024 ADL policy, a resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's 2/2021 policy titled, Dignity, showed that the requirement for facility staff was to honor resident preferences. The policy stated that the facility would ensure residents were groomed as they wished and encouraged to dress in clothing 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 observation, record review, and interview the facility failed to follow provider orders for 1 of 2 residents (Resident 35) reviewed for bed rails, failed to provide oxygen monitoring for 1 of 1 residents (Resident 27), failed to follow treatment as ordered by the physician, monitor, and document bruises for 3 of 12 residents (Residents 139, 15, and 45) reviewed for skin issues, and failed to provide interventions for nutrition refusals for 1 of 7 residents (Resident 71) reviewed for nutrition. These failures placed the residents at risk for poor clinical outcome and a decreased quality of life. Findings included . <Policy> According to a facility policy titled, Proper Use of Bed Rails, revised 11/2024, the facility would ensure correct installation, use, and maintenance of the bed rails. <Following Provider Orders> <Resident 35> According to a 11/13/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 35 had no bed rails in use. The MDS showed Resident 35 was dependent on staff to roll…

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 with vision deficits were assessed and provided assistive devices to maintain vision abilities for 1 of 2 residents (Resident 39) reviewed for vision needs. These failures placed Resident 39 and other residents at risk for unmet care needs and a decreased quality of life. Findings included . <Policy> According to a facility policy titled, Hearing and Vision Services, revised 12/2022, the facility would identify and assess a resident's vision abilities through ongoing monitoring of sensory problems. The policy showed the social worker was responsible for assisting residents and their representatives in locating and utilizing any available resources for the provision of the vision services the resident needed. The policy showed the social worker would assist residents by making appointments and arranging transportation to and from vision provider services. The policy showed employees would assist the resident with the use of adaptive equipment needed to maintain vision such as talking books 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.

Based on observation, interview and record review the facility failed to ensure 2 of 5 residents (Resident 71 & 1) reviewed for Pressure Ulcers (PU- injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to timely monitor, assess, report, and implement wound prevention recommendations and interventions placed residents at risk for deterioration in skin condition(s), pain, and diminished quality of life. <Facility Policy> Review of the revised 11/2024 Pressure Injury Prevention and Management policy, the facility was committed to the prevention of avoidable pressure injuries and to provide treatment and services to heal the injury, prevent infection and the development of additional pressure ulcers/injuries. The facility would establish and utilize a systematic approach for pressure injury prevention and management including prompt assessment and treatment. Nursing assistants would inspect the skin during baths 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 ensure the resident environment was free of accident hazards for 2 of 6 units (East Central 2 & [NAME] Central 2) sampled for accidents. This failure to store chemicals safely, placed residents at risk for exposure to unsafe chemicals. Findings included . <Facility Policy> Review of a facility policy titled, Environmental Services Safety Procedures, revised December 2024, showed the facility would validate general safety procedures were followed while performing housekeeping and/or laundry duties. Staff would validate the chemicals were properly stored and not left unattended in areas that were accessible to residents. When not in use, chemicals would be stored in a locking closet, cabinet or storage area for safety. Chemicals would be stored out of reach of residents and always locked up while in storage. Observation on 12/08/2024 at 8:30 AM, showed the second-floor central hall had a facility cabinet sink located by room [ROOM NUMBER].…

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, record review, and interview the facility failed to ensure Narcotic Ledgers were accurate for 1 of 2 Narcotic Ledgers (East 2 Narcotic Ledger) reviewed for accuracy. Failure to ensure accurate account of resident narcotic medications placed the residents at risk for uncontrolled pain, decreased quality of life, and possible diversion of controlled substances. Findings included . <Policy> Review of the facility policy titled, Controlled Medication Storage, dated 01/2024, controlled substances were subject to special record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. <East 2 Narcotic Ledger> Observation and record review on 12/09/2024 at 3:13 PM of the East 2 narcotic lock box and ledger showed page 83 with 30 tablets remaining transferred to page 101. Review of page 101 showed the starting count was 29 tablets, 1 tablet missing from the remaining balance from page 83. Page 96 showed 14 tablets remaining with the whole page crossed off and no card of medications in the lock box for page 96. Page 99 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 observation, record review, and interview the facility failed to ensure expired medications were removed timely from use in 2 of 2 medication carts (West 1 & East 2), 1 of 2 medication storage rooms (East 2 medication room), and cleanliness was maintained for 2 of 2 medications carts (West 1 & East 2 carts) reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective medications, potential infections, and a diminished quality of life. Findings included . <Policy> According to a facility policy titled, Medication Storage/Storage of Medications, dated 01/2023, showed expired, contaminated, discontinued, or deteriorated mediations and supplies would be immediately removed and disposed of. The policy showed staff would keep all medication storage areas clean. The policy showed medication storage conditions would be monitored and corrective action would be taken for problems identified. < [NAME] 1 Medication Cart> Observation, record review, and interview on 12/09/2024 at 1:22 PM showed a 09/30/2024 expired bottle of…

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

Based on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 1 of 5 residents (Resident 39) reviewed for dental services. This failure placed residents at risk for oral discomfort and a diminished quality of life. Findings included . <Policy> Review of a facility policy titled, Dental Services, revised 12/2022, showed the facility would assist residents in obtaining routine and emergency dental care. The policy showed residents dental needs would be identified through a physical assessment and, oral and denture care would be provided in accordance with the resident's identified needs. The policy showed referrals to dental providers would be made by the facility for residents. The policy showed all actions and information regarding dental services, including any delays related to obtaining dental services, would be documented in the resident's medical records. <Resident 39> According to the 10/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 39 was able to make themselves understood and understood…

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 keep all Protected Health Information (PHI) in the residents' records confidential and out of view from unauthorized individuals for 4 of 84 residents (Resident 340, 80, 10, & 39). This failure placed all former and current residents at risk for a violation of their right to privacy. Findings included . <Facility Policy> Record review of the facility's 9/1/2021 policy titled Health Information Portability and Accountability Act-HIPAA Security Measures policy showed that the facility would implement appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and/or records that were in electronic format. Record review of the facility's 2/2021 policy titled Dignity policy showed that the staff would protect confidential clinical information. Record review of the facility's 3/17/2024 admission Agreement showed the resident has the right to personal privacy and confidentiality of their personal and clinical records. <Resident 340> An…

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 <Shower Room> Observations on 12/08/2024 at 9:36 AM showed a shower room on West-1 unit with a shower drain cover full of debris and dried hair. The floor was dry. A log documenting shower room cleaning was found in the room. Staff documented in this log the last date of cleaning was listed as 08/28/2023. Observations on 12/10/2024 at 8:27 AM showed staff assisting a resident in the West-1 unit shower room. On 12/10/2024 at 8:48 AM, staff brought the resident out of the shower room, at which time observations showed the shower drain still contained the same debris and hair previously noted from 12/08/2024, two days earlier. Observations on 12/10/2024 at 8:55 AM showed Staff J (Registered Nurse Manager) enter the West-1 unit shower room and upon exit the drain was clean. In an interview on 12/10/2024 at 9:00 AM, Staff J stated it was their expectation staff sanitize the shower drain and surrounding area after each resident use. Staff J stated they cleaned out the shower and indicated it had a lot of build up 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 observation and interview, the facility failed to ensure an effective pest control program was in place to prevent insects from entering and or gathering in resident rooms for 3 (Resident 49, 43, & 22 rooms) of 18 sample resident rooms and common areas (West Central Sink, Second Floor Hallway, [NAME] Central Office, & Kitchen/Dining Room) of the facility. This failure placed residents at risk of infection and contributed to a less than homelike environment. Findings included . <Policy> According to a facility policy titled, Pest Control Program, revised 09/01/2022, the facility would maintain an effective pest control program that eradicated common household pests and rodents. The policy showed the facility would maintain a report system of issues that arise in between scheduled visits with the contracted pest service and would treat as indicated. <Resident 49> In an observation and interview on 12/11/2024 at 6:57 AM Resident 49 stated there's bugs all over in their room (room [ROOM NUMBER]), they 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.

Based on interview and record review, the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS - a federal agency managing health care programs and health insurance standards) for Quarter 1 (January 1, 2024 through March 31, 2024) reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure effected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provision of resident care and services. Findings included . <CMS - PBJ Public Use Employee Detail File: Technical Specifications> According to the July 2023 PBJ guideline, Long-Term Care facilities must electronically submit to CMS through the PBJ system complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The guideline showed Employee Data File included…

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

Based on observation, interview, and record review, the facility failed to assess and document wound characteristics, monitor, and implement interventions to mitigate worsening of non-pressure skin issues for 4 of 6 sampled residents (Resident # 1, 2, 3 & 4) reviewed for skin and non pressure wound management. This failure placed residents at risk for unidentified wounds, wound decline, infection, and diminished quality of life. Findings included . The facility's Skin Assessment policy revised 04/23/2024 stated a full body, or head to toe, skin assessment would be conducted by a Licensed Nurse (LN) or Registered Nurse (RN) upon admission/re-admission and weekly thereafter. The assessment might also be performed after a change of condition. For documentation of skin assessment and monitoring, nursing staff were directed to enter Y (Yes) for new skin issues and follow the protocol for notification and to initiate an incident report as indicated, and mark N (No) for no new skin issues. <Resident 1> Resident 1 admitted to the facility 12/03/2022. Review of the 04/12/2024 Annual Minimum…

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

Based on observation, interview, and record review, the facility failed to maintain clean, sanitary surfaces and equipment in the kitchen in accordance with standards for food service safety. The failure to maintain a clean/sanitized kitchen placed residents at risk for cross-contamination (a physical spread of germs), food-borne illnesses. Findings included . <Dry Storage> Observation on 08/22/2023 at 7:22 AM showed the floor inside the dry storage area contained an unidentifiable residue on the floor. Four bulk bins were empty in the storage room and contained an unidentifiable substance in the bottom of the bins. <Housekeeping Closet> Observation on 08/22/2023 at 7:28 AM showed a small room with a sign on the door stating the door must remain shut. Inside the room were materials intended for cleaning the kitchen. The entire room was covered in a dark grime. A clear plastic bag, contained rags, was on the floor inside the closet. The floor was covered in a black unidentifiable grime. <North Wall> Observation on 08/22/2023 at 7:40 AM showed brown unidentifiable material spattered…

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 update the Facility Assessment (FA - a required document that comprehensively assesses the level and type of care provided, the demographic profile of the resident population, and the numbers and competencies required of the staff) to accurately reflect the resources the facility determined were necessary for day-to-day resident care and emergency operations. The failure to assess staffing needs according to the facility census placed the residents as risk for not receiving needed care, services, and resources. Findings included . Review of the updated 02/23/2023 FA showed the facility would provide enough qualified staff to care for the 75 residents residing in the facility. The FA showed the facility utilized agency staff to supplement the staffing needs of the facility. The FA showed the management team would gather input from residents, resident representatives or family members, certified nurse assistants, licensed nurses, and the local Long-Term Care Ombudsman regarding how the current staffing plan was working 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 interview and record review, the facility failed to inform residents of their rights and responsibilities, services provided by the facility and facility rules and regulations both orally and in writing and receive receipt of the information acknowledged in writing for 3 of 3 residents (Residents 2, 96, & 23) reviewed for arbitration agreements and 8 of 8 residents (Residents 3, 5, 32, 34, 36, 45, 73, & 82) represented at the Resident Council meeting. The failure to inform residents of the admission policies, resident rights, facility rules, and operations of the nursing home and the failure to ensure resident rights were reviewed and discussed regularly after admission and posted in a location accessible by all residents, placed all residents at risk of poor understanding and inability to execute their rights, lack of access to information required to make decisions about care, and a diminished quality of life while living in the nursing home. Findings included . Review of the (undated) template of the facility admission Packet showed information and consent forms for the…

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

Based on observation, interview, and record review the facility failed to ensure the ombudsman information was reviewed with residents and information was discussed on how to file a complaint with the state agency for 8 (Resident 3, 5, 32, 34, 36, 45, 73, & 82) of 8 residents who regularly attended monthly Resident Council Meetings (RCMs). The failure to not provide accessible ombudsman information and not provide residents with information on how to file a complaint with the state agency, left residents at risk for not having rightful resources available to them. Findings included . <Facility Policies> Review of the 03/14/2023 Resident and Family Grievances facility policy showed the facility would support each resident's right to voice grievances. The policy showed resident rights regarding grievances would be posted in prominent locations throughout the facility. Information on how to file a grievance or complaint would be available to the resident. Information would include contact information of independent entities with whom grievances could be filed such as the pertinent…

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 the state survey inspection results were made available for 8 (Residents 3, 5, 32, 34, 36, 45, 73, and 82) of 8 residents who regularly attended monthly resident council meetings. Findings included . Review of the 05/2023 Resident Rights facility policy showed residents had a right to view the most recent survey results and any plan of correction in effect. Review of the 05/17/2023, 06/21/2023, 07/19/2023, and 08/16/2023 Resident Council Meeting minutes showed no documentation the state survey inspection results were discussed with residents or where the information was available for residents to review. During a Resident Council Meeting on 08/23/2023 at 2:00 PM, Resident 3, Resident 5, Resident 32, Resident 34, Resident 36, Resident 73, and Resident 82 stated they were unaware of where the state survey results were located. Resident 45 shook their head, no regarding knowledge of the survey results. Staff H (Activity Director) (who was present during the Resident Council Meeting) stated they did not…

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 a safe, clean, comfortable, and homelike environment without safety risks for 20 of 107 residents (Resident 65, 23, 53, 84, 3, 45, 74, 36, 37, 47, 91, 21, 6, 14, 41, 59, 46, 2, 92, & 16) reviewed for facility environment. The failure to maintain adequate lighting, clean carpets, absence of odors, working window blinds, and operational hand sanitizer dispensers placed residents at risk for unsatisfactory living conditions and diminished quality of life. Findings included . <Odor> Multiple observations on 08/22/2023 from 7:00 AM to 4:00 PM, on 08/23/2023 from 7:00 AM to 4:00 PM, on 08/24/2023 from 7:00 AM to 4:00 PM and 08/25/2023 from 8:00 AM to 1:00 PM showed an overwhelming odor of urine and feces smell on the second floor west, east, and central hallways. <Blinds> Observation and interview on 08/22/2023 at 2:36 PM showed Resident 65 stated there is nowhere to plug in the fan. The blinds do not open anymore- I have been here 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 interview and record review, the facility failed to provide written notification to residents or their Resident Representative (RR) of the reason for transfer/discharge and/or to properly notify the Office of State Long-Term Care Ombudsmen (SLTCO - an advocacy group for residents in a nursing home) of discharges to the hospital for 3 of 3 residents (Residents 6, 18, & 96) reviewed for hospitalization. These failures denied the resident and/or their RR information of their rights regarding transfer/discharge from the facility, placed residents at risk for diminished protection from being inappropriately discharged , prevented access to an advocate who could inform residents of their options and rights, and failed to ensure the SLTCO was aware of facility practices and activities related to transfers and discharges. Findings included . The 12/2022 facility policy Transfer and Discharge, showed the facility transfer/discharge notice was provided to the resident and the resident's representative in a language and manner they could understand. The notice would include 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 reassess 1 (Resident 48) of 5 residents reviewed for weight (wt) loss, identify interventions to prevent wt loss for two (Resident 17 & 48) of 5 residents reviewed for wt loss, and offer 2 (Resident 17 & 74) of 2 residents reviewed for food preferences, culturally appropriate foods, resulting in wt loss. Failure to identify wt loss interventions and offer culturally appropriate foods resulting in wt loss placed resident at risk for continued wt loss. Findings included . <Resident 17> Review of the admission Record showed Resident 17 was admitted to the facility on [DATE] with diagnoses including stroke, aphasia (a language disorder that affects a person's ability to communicate), and severe protein malnutrition. The 05/08/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 17 was assessed to require extensive assistance of one staff for eating, had greater than 51% of their intake through Tube Feeding (TF -a tube…

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 schedule sufficient staff to provide care and services for 7 (Resident 3, 32, 36, 34, 82, 5, & 45) of 7 residents reviewed. This failure prevented residents from receiving; assistance with Activities of Daily Living (ADLs) for Resident 65, 100, 3, & 82; and restorative nursing services (a program that helped residents maintain or improve independence with ADLs) for Resident 52. This failure prevented the facility from maintaining an odor free environment on 1 of 2 floors in the building. These failures placed residents at risk for unmet care needs, diminished quality of life, and other negative outcomes. Findings included . <Facility Assessment (FA)> According to the updated 02/23/2023 FA, the facility would provide enough staff for a census of 75 residents. The FA showed the facility would gather input from residents, family members, and/or resident representatives, Certified Nurse's Assistants (CNAs), licensed nurses providing direct…

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 maintain a system of records for accurate reconciliation of narcotic drugs for 3 of 4 medication carts. The failure to count and acknowledge the count was accurate - narcotic drugs through reconciliation at shift change, placed residents at risk for potential financial loss, not receiving narcotic pain medication, and possible drug diversion. Findings included . In an observation and interview on 08/23/2023 at 8:52 AM, Staff AA (Licensed Practical Nurse - LPN) was at the Middle medication cart when a random narcotic reconciliation was completed. The narcotic ledger book showed nurses did not sign the narcotic count and acknowledge the count was accurate for narcotic medications at the beginning of the shift and end of the shift 5 times out of 19 days for July 2023. In August 2023 staff did not sign nine times out of 22 days. Staff AA stated two nurses were supposed to count all the narcotic medications in the medication cart in the beginning of the shift and at the end of the shift and sign the narcotic book to acknowledge…

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 being delivered timely and unopened to 1 (Resident 5) of 1 residents reviewed. By not ensuring mail was delivered, unopened, and in a timely manner placed residents at risk for lack of privacy and autonomy. Findings included . Review of the 06/2023 Mail Delivery facility policy showed residents had the right to privacy regarding written communications, and to promptly send and receive unopened mail. The policy showed the activity director or designee would coordinate resident mail delivery. Unopened mail would be delivered to the resident and/or outgoing mail would be postmarked within 24 hours on operational postal service days. Residents would be given the choice of reading their own mail or having a designated person read the mail to them. In an interview on 08/23/2023 at 2:00 PM, Resident 5 stated the facility was opening the resident's mail recently. Resident 5 stated the facility had an issue with the resident ordering over-the-counter vitamins and started opening their mail. Resident 5 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.

Based on interview and record review, the facility failed to ensure residents were informed and provided with written information concerning the right to accept, refuse, or formulate an Advanced Directive (AD - legal documents reflecting a resident's wishes if they became incapacitated) for 2 (Residents 52 & 74) of 27 residents reviewed for ADs. The failure to offer assistance to formulate an AD placed residents at risk of not having a Power of Attorney (POA - surrogate decision maker) when unable to make their own healthcare or financial decisions. Findings included . <Resident 52> According to the 06/07/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 52 was assessed to make their own decisions, was understood, and able to understand conversations. Review of the 01/25/2023 AD Care Plan (CP) showed the interventions included the facility would place their AD in their medical record. Record review showed no ADs were available for Resident 52. In an interview on 08/21/2023 at 10:32 AM, Resident 52 stated no staff talked to them about ADs and they were not offered…

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 provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF-ABN) to 1 of 4 residents (Resident 65) reviewed for beneficiary notices. The failure to provide residents the information regarding changes in their Medicare services, including potential financial liability and appeal rights, deterred residents from exercising their right to decide on continuation of skilled services and costs associated, as required by the Medicare Program. Findings included . <Resident 65> The 08/02/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 65 was assessed as cognitively intact and able to make their own decisions. Review of a Notice of Medicare Non-Coverage (NOMNC) signed by Resident 65 and dated 08/07/2023 showed a last covered day for skilled services on 08/10/2023. There was no ABN document found in Resident 65's record to show a SNF-ABN was also provided on 08/07/2023. Review of another NOMNC signed by Resident 65 and dated 08/15/2023 showed a last covered day for skilled services on 08/17/2023. There…

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 the Preadmission Screening and Resident Review (PASRR - a screening process for residents who have indicators of intellectual disability, related disability, or serious mental illness) was followed for 1 (Resident 75) of 6 residents reviewed for PASRR. The facility failed to ensure a PASRR Level I was corrected upon admission to include serious mental illness which would have required a PASRR Level II (a more in-depth screening). This failure placed the resident at risk of not receiving the appropriate mental health services needed and placed them at risk for diminished quality of life. Findings included. Review of the 12/2022 facility policy Resident Assessment-Coordination with PASRR Program, showed This facility coordinates assessment with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the appropriate services to maintain and ensure that resident's ability to perform activities of daily living (ADLs) do not diminish, for two of three (Resident 17 & 74) residents reviewed as non English speaking residents. The facility failed to implement the use of alternative communication methods, such as a communication board in the language they understood to ensure their needs were met consistently. This failure placed the residents at risk of experiencing a decline in their physical well-being, psychosocial well-being, and their quality of life. Findings included . Review of the facility policy titled, Communicating with Persons with Limited English Proficiency. Dated 12/2022, showed, .It is the policy of this facility to take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs, and 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 hygiene according to resident needs and preferences for 2 of 4 residents (Resident 65 & 100) reviewed for Activities of Daily Living (ADL) for dependent residents. The failure to provide oral care and supplies to Resident 65 or provide showers and facial hair trimming to Resident 100 placed both residents at risk for poor self-esteem, isolation from others, infection, and diminished quality of life. Findings included . <Resident 65> The 08/02/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 65 was admitted on [DATE]. The MDS showed Resident 65 was able to understand and make self-understood, had no cognitive impairment, and had cavities and broken teeth upon oral exam. The MDS showed Resident 65 required set up for oral hygiene prior to admission. Resident 65 was assessed to require limited assistance of one person for hygiene during the assessment period. The 07/26/2023 ADL Care Plan (CP) 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 observations, interview, and record review the facility failed to communicate and implement individualized activity plans for 1 of 3 (Resident 74) residents reviewed for activities. Failure to consistently implement group or individual activity plans left the resident at risk for boredom, isolation, and a diminished quality of life. Findings included . <Resident 74> According to the 08/14/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 74 was cognitively intact. The MDS showed Resident 74's primary language was Amharic and they needed an interpreter to communicate with their physician and health care staff. The MDS showed participating in activities with a group of people, and listening to music was very important for Resident 74. Review of a 07/21/2023 Activities/Recreation Quarterly/Annual Review assessment showed Resident 74 liked to talk to others, listen to music in their language, and activity staff would provide one on one time with Resident 74 in their room. Staff would continue to encourage Resident 74 to participate in group activities…

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 6 (Resident 52) residents reviewed for Restorative Nursing Programs (RNP) received the care and services they were assessed to require. These failures placed residents at risks for declines in Range of Motion (ROM) or functional status, and other negative health outcomes. Findings included . <Resident 52> According to the 06/07/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 52 admitted to the facility on [DATE] and had multiple medical diagnoses including quadriplegia (symptom of paralysis affecting person's all limbs), and Osteoarthritis (form of arthritis causing joint pain and stiffness). The MDS showed Resident 52 had intact memory and was able to communicate and understand effectively. This assessment showed Resident 52 participated in RNP, Passive ROM (PROM) five times and splinting four times during the seven-day assessment period. In an interview on 08/22/2023 at 10:45 AM, Resident 52 stated the…

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

Based on observation, interview, and record review, the facility failed to ensure medications were secured for 3 of 25 (Resident 36, 74, & 89) residents observed with medications left in their rooms. This failure placed residents at risk for receiving wrong medications, and non-assessed, self-administration of medications by residents. Findings included . According to the revised 12/2022 Medication Storage facility policy, the facility was to ensure during medication pass, medications must be under the direct supervision of the person administering medications or locked in the medication cart. <Resident 36> On 08/22/2023 at 7:22 AM, two medicine cups containing pills and an inhaler were observed on the bedside table. Resident 36 was not in their room at that time. In an interview on 08/22/2023 at 7:36 AM, Staff GG (Licensed Practical Nurse - LPN) stated Resident 36 went to the dining room without taking their medications. Staff GG stated those were morning medications for Resident 36 and should not be left at the bedside. Staff GG took the medicine cups back to 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 and record review the facility failed to provide Specialized Rehabilitative (Rehab) Services according to Physician Orders (POs) for 1 of 3 residents (Resident 65) reviewed for therapy services. The failure to provide physical and occupational therapy to Resident 65 placed them at risk for decline in physical and functional mobility, deterioration of muscle strength and diminished quality of life. Findings included . The 08/02/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 65 required no physical assistance was needed with Activities of Daily Living (ADL - self care tasks such as mobility, dressing, and hygiene). The MDS showed Resident 65 required extensive assistance for all ADLs at the time of admission for skilled therapy services. The MDS showed direct care staff and Resident 65 both believed Resident 65 was capable of functional rehab to increased independence in ADL self-care. The MDS showed Resident 65 had a discharge plan to the community after completing rehab. The 07/27/2023 ADL Care Plan (CP) showed Resident 65 had 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.