Burlington Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure 5 (R15, R16, R27, R34, and R8) of 20 residents received necessary care and treatment in accordance with professional standards of practice, a comprehensive person-centered care plan or facility policies and procedures. *R15 was observed not wearing compression stockings during the survey per physician orders and R15's plan of care. *R16 was observed not wearing compression stockings during the survey per physician orders and R16's plan of care. *R27 was observed not wearing compression stockings during the survey per physician orders and R27's plan of care. *R34 did not have a treatment completed to R34’s vascular/venous statis ulcer on 8/8/25. On 7/18/25, a physician order was obtained for R34 to receive an air mattress and R34 did not receive an air mattress until 7/21/24. *R8 had an unwitnessed fall on 4/8/25 and no neurological checks were documented as completed for R8. Findings include: The facility’s Provision of Quality Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interviews the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 6 medication carts reviewed. Insulin vials and pens were not labeled, dated when opened and/or were expired. Findings include:On [DATE], at 8:42 AM, Surveyor observed the unit 5 medication cart. In the right-side drawer, Surveyor located the following:Lispro insulin vial belonging to R75 was open and used but not dated when opened. Lispro insulin pen with no label. Surveyor noted a handwritten residents' first name in black marker. The insulin pen was open and used but not dated when opened. Lantus insulin pen belonging to R6 was open and used but not dated when opened. Lantus insulin pen belonging to R33 was open and used but not dated when opened. Lispro insulin pen belonging to R33 was open and used but 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.

Based on observation and interview the facility did not ensure 1 (R27) of 3 Residents reviewed for indwelling catheters were treated with dignity and respect.*R27's urinary catheter bag was left uncovered with yellow urine in the catheter bag visible to peers, staff, and visitors.Findings Include:R27's quarterly minimum data set (MDS) completed 5/31/25 documents R27 has an indwelling catheter.R27's comprehensive care plan documents:R27 has indwelling catheter due to diagnosis of Neurogenic BladderInitiated 11/23/24 Revised 6/11/25On 8/11/25, at 9:55 AM, Surveyor observed Certified Nursing Assistants (CNA) - X and (CNA) - Y bring R27 out of R27's room. R27 was in a wheelchair that was reclined. Surveyor observed CNA-X push R27 down the hall, turn left at the nurse's station, and continue pushing R27 down the hallway and placed R27 in the activity room. Surveyor observed other Residents in the activity room. Surveyor observed R27's catheter bag laying at the bottom of R27's legs with the urine side facing up which would be visible to other Residents, visitors, and staff. R27's foley…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not promote and facilitate 1 (R65) of 1 Resident's right to self-determination through support of R65's choice about an aspect of R65's life that is significant to R65.R65 changed rooms in the facility on 7/25/25. R65 had boxes with items important to R65 on R65's dresser and closet area. R65 went to a group activity in a common area on 8/4/25. When R65 returned to R65's room, R65's boxes and items important to R65 were gone. R65 informed Surveyor that Social Worker (SW)-J and Nurse Technician (NT)-BB entered R65's room without permission and removed R65's items. Findings include:The facility policy with a last reviewed date of 7/1/25 titled, Resident Rights documents, in part: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The resident has the right 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 did not ensure formulated advance directives were documented accurately for 1 (R3) of 20 residents reviewed for code status.Documentation in R3's medical record indicated R3 desired to be a full code (cardiopulmonary resuscitation to be administered) and a do not resuscitate (DNR). Findings include:The facility policy and procedure titled Residents' Rights Regarding Treatment and Advance Directives dated [DATE] documents: Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate and advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. 7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 (R5, R34 and R65) of 3 residents. *R5’s wall and heat register in R5’s room was observed to be coated with dirt and a thick layer of dust. R5’s curtains hanging over the heat register was observed to be coated with dirt and black spots. *R34’s window in R34’s room was observed to have a thick white film and appears cloudy. The outside of the window was observed to be dirty. Near R34’s window, there is a cobweb with two dead flies hanging from it. R34’s window blinds appear to be broken and not functional. *R65’s air conditioning and heating unit on R65’s wall in R65’s room was observed to be disconnected and coming off the wall on the left side. On the left side of the unit, Surveyor observed an exposed metal pipe covered in dirt and cobwebs. R65’s shared bathroom flooring is curved up to meet the tile on the walls. The flooring was observed to be peeling off the wall, exposing dirt and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R53) of 2 residents with allegations of abuse were reported to the Nursing Home Administrator (NHA)-A per facility policy, the state agency and one or more law enforcement entities.*On 7/2/25, R59 informed 3 different facility staff members that CNA-FF was rough with R59. This allegation was not reported to the Nursing Home Administrator (NHA)-A, the state agency and one or more law enforcement entities. Findings include:The facility policy, with a last reviewed/revised date of 7/1/25, titled Abuse, Neglect and Exploitation documents, in part: It is the guideline of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has a zero-tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 (R59) of 2 residents reviewed.R59 informed Surveyor that Certified Nursing Assistant (CNA)-FF was rough when caring for R59. On 7/2/25, R59 informed 3 different facility staff members of the alleged abuse incident. The allegation of abuse was not reported to Nursing Home Administrator (NHA)-A and the facility did not complete a thorough investigation into R59's allegation of abuse.Findings include:The facility policy, with a last reviewed/revised date of 7/1/25, titled Abuse, Neglect and Exploitation documents, in part: It is the guideline of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has a zero-tolerance stance around founded abuse, neglect, exploitation 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 record review and interview, the facility did not accurately screen residents for a mental disorder for 2 (R4 and R9) of 2 residents reviewed for Preadmission Screen and Resident Review (PASARR) Level I and requiring a Level II screening.R4 was admitted to the facility with diagnoses of mental disorders and was not evaluated on the PASARR Level I screen as having any mental disorders. The Level II PASARR was never completed due to the inaccurate PASARR Level I screen.R9 was admitted to the facility with diagnoses of mental disorders and was evaluated as having a serious mental disorder on the PASARR Level I screen. R9 did not have a completed Level II PASARR screen when identified as having a positive Level I PASARR screen.Findings include:The facility's policy and procedure entitled, Resident Assessment - Coordination with PASARR Program dated 9/18/24, documents:The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure 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 observations, interviews, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R1, R16 and R53) of 5 residents reviewed for pressure injuries. *R53 developed a facility acquired, Suspected Deep Tissue Injury (DTI) on 7/22/25. The pressure injury was incorrectly staged on 7/29/25 when it developed slough and continued to be staged as a DTI. The wound treatment was recommended to be changed but facility staff continued treating the wound with skin prep as previously ordered. On 8/5/25, the facility documented the same measurement of an unstageable wound and documented an area of DTI with a new measurement. With the changes in R53’s wound, R53’s care plan was not updated. On 8/13/25, Surveyor was provided with a late entry progress note from R53’s MD documenting a stage 2 wound in the sacral area. Surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure 1 (R24) of 4 Residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.*R24 was not wearing R24's right hand splint/ right elbow brace during the survey. There was no documentation R24 was provided with physician ordered neck exercises. Surveyor did not observe any range of motion being performed.Findings include:Surveyor reviewed the facility's Prevention of Decline in Range of Motion policy and procedure revised 11/11/24:.PolicyResident who enters the facility without limited range of motion will not experience a reduction in range of motion unless the Resident's clinical condition demonstrated that a reduction in range of motion is unavoidable.Policy Explanation and Compliance Guidelines1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 (R8, R24 and R81) of 5 residents reviewed for falls. *R8 requires the assistance of 2 with a toilet transfer. R8 was transferred to the toilet on 4/8/25 and left alone in the bathroom. R8 sustained an unwitnessed fall 2 minutes later. In interviews with Director of Rehab, Director of Nursing and other staff members, facility staff indicated R8 should not be left alone in the bathroom. R8’s care plan was not updated with a resident specific intervention after this fall. *R24’s fall interventions were not in place during Surveyor observations. *R81’s fall interventions were not in place during Surveyor observations. Findings include: The facility polity with a last reviewed/revised date of 12/3/24, titled “Fall Prevention Program” documents, in part: Each resident will be assessed for fall risk and will receive care and services in accordance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not provide the necessary respiratory care and services for 1 (R34) of 2 Residents receiving oxygen (O2) therapy.*On 8/7/25, Surveyor observed R34's humidifier bottle completely empty and the humidifier bottle should have been changed on 8/6/25 per physician orders.Findings Include:The facility's Oxygen Administration policy and procedure reviewed and revised 1/8/24 documents:Policy:Oxygen is administered to Residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the Resident's goals and preferences.Policy Explanation and Compliance Guidelines:1. O2 is administered under orders of a physician, except in the case of an emergency. In such case, O2 is administered and orders for O2 are obtained as soon as practicable when the situation is under control.2. Staff shall document the initial and ongoing assessment of the Resident's condition warranting oxygen and the response 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 did not ensure 1 (R9) of 3 residents was provided pain management consistent with professional standards of practice.R9 reported being in constant pain that frequently affected sleep and day to day activities. R9 was consistently receiving Oxycodone for pain management, which was prescribed on [DATE], and later discontinued on [DATE]. R9 was documented as having pain 10 out of 10 and went without Oxycodone pain medication on [DATE] and [DATE], after Oxycodone was discontinued on [DATE], which resulted in R9 going to the emergency room (ER) for pain management on [DATE].Findings include:R9 was admitted to the facility on [DATE], and has diagnoses that include paralytic syndrome (a condition where there's a loss of muscle function, resulting in the inability to move part or all of the body), fracture of 1st cervical vertebra and 7th cervical vertebra (a break in the vertebrae in the neck, otherwise known as a broken neck), intervertebral disc degeneration 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 did not assess the risk for possible entrapment, the continued need, review the risks & benefits, and obtain consent on a quarterly basis for 3 (R24, R27, and R81) of 8 Residents reviewed having enabler bars.Findings Include:The facility's Proper Use of Bed Rails/Enabler Bars/Assist Bars reviewed/revised 3/14/25 documents:.Guideline:It is the guideline of this facility to utilize a person-centered approach when determining the use of bed rails (may also be referred to side rails, safety rails, grab bars, assist bars, transfer bars). Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails.Informed Consent .7. Informed consent from the Resident or Resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails.9. Upon receiving informed consent, 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 menus were followed and served as posted for 2 (R65 and R59) of 2 residents reviewed. *R65’s meal tray did not match the facility’s planned menu on 8/7/25 breakfast tray, 8/11/25 breakfast tray and 8/11/25 lunch tray. *R59’s food preferences were not followed. On 8/6/25 Surveyor observed white bread on R59's tray when white bread is one of R59’s dislikes. R59’s meal tray did not match the facility’s planned menu on 8/7/25 breakfast tray and 8/11/25 lunch tray. Findings include: The facility policy with a revised date of 10/2022, titled “Menus” documents, in part: Menus will be planned in advance to meet the nutritional needs of the resident/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. … Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 (R8) of 3 residents reviewed for hospice.R8's hospice visit documentation, hospice plan of care, hospice responsibilities and services being provided, and hospice daily nursing visit notes, were not kept in R8's facility's electronic medical record or in R8's hospice binder.Findings include:The facility's policy, titled Hospice Services Facility Agreement, and dated 07/10/2024, documents: .4. The written agreement(s) will set out at least the following:a. The services the hospice will provideb. The hospice's responsibilities for determining the appropriate hospice plan of care.c. The service the facility will continue to provide based on each resident's plan of care.d. A communication process, including how the communication will be documented between the facility and the hospice provider, to ensure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and review of facility policy, the facility failed to ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing a pressure ulcer dressing change for one Resident (R) 6 out of three reviewed for enhanced barrier precautions (EBP). This had the potential for cross contamination and risk for infection. Findings include: Review of the facility policy titled, Enhanced Barrier Precautions, last revised 02/05/25, revealed, It is the guideline of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds such as pressure ulcers .…

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

Based on interview and record review, the facility failed to ensure a Dietary Manager (DM) was designated to act as the director of food and nutrition services, when the DM position was vacant. This had the potential to affect 89 of 89 residents in the facility. Findings include: Review of a document provided by the facility titled job description for Food Service Manager indicated . The primary purpose of your job position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner. Graduate of an accredited course in dietetic training approved by the American Dietetic Association. Review of an employee file provided by the facility and referred to as the employee file for the former Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, menu review, interview, and facility policy review, the facility failed to ensure the menus and menu extensions were followed which included providing appropriate approved food substitutions and ensuring recipes were followed for 89 out of 89 residents. This failure had the potential to cause residents to lose weight. Findings include: Review of an undated facility policy titled, Menu indicated, . Menus will be planned to meet the nutritional needs of the residents/patients in accordance with established national guidelines . Review of a document provided by the facility, referred to as the weekly menu for 05/06/25, indicated the residents were to be served the following meal items: baked potato, crusted fish, rice pilaf, steamed zucchini and tomatoes, a dinner roll, and bread pudding. A tray line observation was conducted on 05/06/25 at 11:53 AM. [NAME] 1 began to serve resident meals. Kitchen staff had placed mixed fruit on resident trays at this time. [NAME] 1 stated the bread pudding was to be made the night before, and it was not available. [NAME] 2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary condition to prevent the potential spread of foodborne illness. This had the potential to affect 89 of 89 residents. Specifically, the facility failed to label, date, and store food properly. Findings include: Review of a facility policy titled, Food Storage: Dry Goods, dated 02/2023, indicated . All dry goods will be appropriately stored in accordance with the FDA Food Code . Review of a facility policy titled, Food Storage: Cold Foods, dated 02/2023, indicated . All time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code . All food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . During the initial tour of the kitchen on 05/06/25 at 10:30 AM with the current Dietary Manager, the following was observed: The dry storage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility policy review, the facility failed to assess two of 18 sampled residents (Resident (R) 11 and R6) who were observed with medications at the bedside for the safe self-administration of medications. This failure could potentially lead to medications being left by staff at the residents' bedside where other residents could access them. Findings include: Review of a facility policy titled, Resident Self-Administration of Medication, dated 05/2025 indicated, . It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medication after the facility's interdisciplinary team has determined which medication may be self-administered safely. 1. Review of R11's Face Sheet, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included a left ischium wound. Review of R11's admission Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure documentation of pre- and post-dialysis assessments and failed to ensure communication occurred between the facility and the dialysis center for one of two residents (Resident (R) 17) reviewed for dialysis out of total sample of 18. This had the potential to affect the health of residents receiving dialysis. Findings include: Review of the facility's policy titled, Hemodialysis, revised 02/15/25, revealed, . The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a.timely medication administration [initiated, held or discontinued] by the nursing home and/or dialysis facility; b. physician/treatment orders, laboratory values, and vital signs; c. advance directive and code status; specific directive about treatment choices ; and any changes or need for further discussion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility policy review, the facility failed to have medications available to administer as ordered for three of four residents (Resident (R) 7, R18, and R2) reviewed for medication availability out of a total sample of 18. This had the potential to result in adverse health outcomes. Findings include: Review of the facility's policy titled, Medication Reordering, dated December 2024, revealed, . Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. Each time a nurse is administering medications and observes [6] or less doses left of one kind, that nurse will reorder the medication, time permitting . For stat medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container [may be used if applicable] . 1. Review of R7's admission Record, located in the electronic medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 7) reviewed for medications was free from significant medication errors when medications were not available and/or were not administered per physician orders. This had the potential to result in adverse health outcomes. Findings include: Review of the facility's policy titled, Medication Error Reporting and Counseling Procedure, reviewed/revised 12/2024, revealed a significant medication error meant one which caused the resident discomfort or jeopardized his or her health and safety. The policy recorded, . The relative significance of medication errors is a matter of professional judgment. Three general guidelines in determining whether a medication error is significant or not: resident condition, drug category, and frequency of error . Review of R7's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R7 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and policy review, the facility failed to ensure care and services were documented for four Resident (R)1, R4, R5, and R9) of 11 residents reviewed for documentation of treatments as ordered by the physician. Failure to document medication administration and treatments to residents does not ensure the treatment or medication has been completed, and could cause a delay in treatment or medication. Findings Include: Review of the facility's policy titled, Documentation in Medical Record dated [DATE], revealed, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of the facility's policy titled Medication Administration dated 01/24, revealed The resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR), is initialed by the person administering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure 5 (R11, R15, R16, R3, and R7) of 12 Residents reviewed received a prompt resolution to grievances. *On 5/17/24, it is documented R11 answered yes to the question 'Do you have any concerns?' There is no evidence if the concerns were confirmed. The facility did not have any documentation the concerns/grievance was investigated promptly and resolved. *On 5/17/24, it is documented R15 answered yes to the question 'Do you have any concerns?' There is no evidence if the concerns were confirmed. The facility did not have any documentation the concerns/grievance was investigated promptly and resolved. *On 5/17/24, it is documented R16 answered yes to the question 'Do you have any concerns?' There is no evidence if the concerns were confirmed. The facility did not have any documentation the concerns/grievance was investigated promptly and resolved. *On 7/11/24, R3's representative filed a grievance with the facility and there is no evidence if 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 did not ensure an allegation of abuse for 2 of 5 investigations reviewed, included steps that were taken by the facility to ensure safety of the facility residents. * Visitor-HH alleged facility housekeeper-N was sexual inappropriate to the visitor when visiting a resident in the facility. The facility did not complete a thorough investigation of the allegation/actions of housekeeper-N by ensuring current facility residents were interviewed to determine if they had concerns or similar allegations regarding housekeeper-N. *R10 made an allegation of rough care that was reported to a registered nurse. This was not thoroughly investigated by the facility. This deficient practice had the potential to affect 73 of 73 residents in the facility. Findings include: On 10/2/24, the facility's Abuse, Neglect and Exploitation policy and procedure implemented on 9/18/23 and notes the following in regards to reporting requirements: .Policy: It is the policy of this facility to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not provide pharmaceutical services to assure accurate dispensing and administering medications to meet the needs of each resident. This has the potential to affect R3, R7, 17 residents who reside on the 400 unit & R17. * R3's Bisacodyl (Dulcolax) 10 mg (milligram) suppository was transcribed incorrectly on 8/20/24 when R3 was readmitted from the hospital. *The Facility did not provide R7 with the ordered Coban wraps, per the physician's order. * Medications were left on top of medication cart unattended. * R17's glucose monitor was not labeled to identify it was R17's glucose monitoring device. 1.) R3 was readmitted to the facility on [DATE] with diagnosis which includes C Diff (clotridoides difficile). The after visit summary for date of discharge of 8/20/24 for discharge medications under continue taking these medications which have not changed includes Bisacodyl 10 mg (milligrams) suppository. Commonly known as: Dulcolax. Under details…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure 1 (R3) of 1 Resident's resident representative was notified when there was a need to alter treatment. R3's POA (Power of Attorney) was not notified when occupational therapy was discontinued on 6/26/24 and physical therapy was discontinued on 7/2/24. Findings include: The facility's policy titled, Notification of Changes and last reviewed/revised 8/27/24 under policy documents The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. R3 was admitted to the facility on [DATE]. R3's diagnoses includes congestive heart failure,diabetes mellitus, and end stage renal disease. R3's power of attorney for health care was activated on 7/19/23. Surveyor reviewed R3's medical record and was unable to locate therapy progress notes to determine when R3 had previously been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility did not ensure that 1 allegations of abuse involving 2 Residents (R10 and R8) of 5 allegations of abuse were reported immediately. *On 5/16/24, Certified Nursing Assistant (CNA)-V notified Registered Nurse (RN)-S that R10 voiced an allegation that CNA-V was rough with cares. RN-S informed CNA-V that was R10's behavior. CNA-V went back and continued cares for R10 and other Residents on CNA-V's assignment. On 5/17/24, Social Services notified Nursing Home Administrator (NHA)-A of the allegation. Findings Include: The facility's policy Abuse, Neglect, and Exploitation implemented 9/18/23 documents: .Policy: It the policy of this facility to provide protections for the health, welfare and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure 1 (R10) of 2 Residents reviewed for discharge received a complete discharge summary. *R10 was discharged to an adult living home on 6/4/24 without a completed discharge summary and list of medications to allow for coordination of care and to effectively transition R10 to post-facility care. Findings Include: The facility's policy Transfer and Discharge implemented 10/26/2022, and last revised on 1/2024 documents: 14 Anticipated Transfers or Discharges -Resident -initiated discharges a. Obtain physicians' for transfer or discharge and instructions or precautions for ongoing care. b. A member of the interdisciplinary team(IDT) completes relevant sections of the Discharge Summary. The nurse caring for the Resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the Resident's stay that includes diagnoses, course of illness/treatment or therapy, 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 did not ensure residents received treatment and care in accordance with professional standards of practice for 2 (R3 & R7) of 16 residents. * Staff did not place tubi grips on R3's bilateral lower extremities on 10/1/24 & 10/2/24. * R7's non pressure wounds were not comprehensively assessed for 7 days. There is no order for R7's PICC (peripherally inserted central catheter), the PICC dressing, & care of PICC line. Facility staff were wrapping R7's legs with ace bandages when the physician's orders documented Coban. Findings include: 1.) R3's diagnoses includes congestive heart failure,diabetes mellitus, and end stage renal disease. The resident has an ADL (activity daily living) self-care performance deficit care plan initiated 5/17/24 includes an intervention of *DRESSING: The resident requires assistance by 1 staff to dress. Assist x (times) 1 with UB (upper body) and LB (lower body) dressing, Assist x1 with grooming, Tubi Grips to BLE (bilateral lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure residents received adequate assistance with devices to prevent accidents for 1 (R5) of 1 resident observed for accidents. R5 required assistance of 2 staff to be transferred using a Hoyer lift. Facility staff were observed walking away from R5 during the transfer process to address other issues leaving R5 suspended in the sling and creating a potential unsafe transfer. Findings include: R5's most recent admission to the Facility was on 05/16/2022. R5's annual Minimum Data Set (MDS), dated [DATE], documents R5 has a Brief Interview for Mental Status (BIMS) of 15 with a primary medical condition category of Traumatic Spinal Cord Dysfunction. R5 has functional limitations in bilateral upper and lower extremities, and is dependent with transfers from bed to chair. Surveyor reviewed R5's care plan and noted R5 requires the assist of 2 staff for transfer with a Hoyer. Full body sling / Xlarge. No Ambulation. On 10/01/2024, at 11:06 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 observation, interview, and record review the facility did not ensure 1 (R3) of 1 resident was provided with appropriate food items for a renal/LCS (low concentrated sweets) diet as prescribed by the physician. R3 was served french fries and a tomato slice on 10/1/24. Findings include: The Renal Diet/Liberal Renal Diets/Renal LCS (low concentrated sweets) from [Name] Food Service not dated under description documents The renal/liberal rental diets regulate sodium, potassium, and fluid intake. The renal diet also regulates protein. These diets are primarily prescribed to patients with renal (kidney) disease. There are many stages of renal disease ranging from Acute Renal Failure to End-stage Renal Disease. However, a protein-restricted diet is generally only used for patients with acute or chronic renal failure who are not on dialysis. It is is important to follow the appropriate individualized guidelines set by a physician and registered dietitian nutritionist knowledgeable in treating patients with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not provide the necessary respiratory care and services for 1 (R3) of 1 residents with a tracheostomy. The facility did not change R3's HME (heat moisture exchanger) trach valve daily according to physician orders. Findings include: R3 was admitted to the facility on [DATE]. R3's diagnoses include chronic respiratory failure, morbid obesity, and paralysis of vocal cords and larynx. The physician orders include with an order date of 5/17/24 Change HME trach valve daily one time a day for tracheostomy care. An HME trach valve traps the moisture and heat from exhaled gas allowing it to be recycled on inspiration and also helps keep large particles out of the lung such as food particles. Surveyor reviewed R3's May 2024, June 2024, July 2024, August 2024, September 2024 & October 2024 MAR (medication administration record) and noted licensed staff are checking & initialing the HME trach valve is being changed daily with a scheduled time of 0800 (8:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure each Resident's drug regimen was free from unnecessary drugs for 1 (R6) of 5 Residents reviewed for antibiotic use. *R6 began having Urinary Tract Infection (UTI) symptoms on 7/16/24. R6 had a urinalysis (UA) and culture lab test collected by the facility staff on 7/17/24 and Rocephin (an antibiotic medication) was ordered to start on 7/18/24. R6 requested to go to the emergency room (ER) on 7/17/24 due to R6's UTI symptoms. The ER doctor prescribed Bactrim (an antibiotic medication) to start on 7/18/2024. On 7/19/24, R6 received Rocephin and Bactrim for R6's UTI symptoms. On 7/20/24, R6's urinary culture results came back and Macrobid (an antibiotic medication) was ordered to start on 7/20/2024 by the on-call Medical Doctor (MD). On 7/20/24, R6 received Rocephin, Bactrim and Macrobid for R6's symptoms of UTI. On 7/21/24, R6 requested to return to the ER and was prescribed Fosfomycin (an antibiotic drug). On 7/21/24, R6's doctor, MD-U identified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure its medication error rates are not 5 percent or greater. The facility medication error rate was 20%. *R14 received crushed Depakote (delayed release) and administered 8AM scheduled medications, including Carbidopa-levodopa, at 10:04 AM. *R8 received 8AM scheduled Gabapentin and Tramadol medications at 10:26 AM. *On 10/1/24 R3 did not receive Complex B-100 extended release with biotin & folic acid per physician orders and did not receive the correct dosage of Carvedilol. Findings include: The Facility Policy titled, Medication Administration dated 01/24, documents in part, . Medication Preparation: . 5. b. Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. Medications Administration: . 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R3) of 1 residents were free of significant medication errors. R3 was readmitted to the facility on [DATE] with discharge medications to include Carvedilol 25 mg every 12 hours. The facility did not change the dosage when R3 was readmitted and continued the previous dose of 12.5 mg. R3 received the incorrect dosage from 8/20/24 until 10/3/24 when DON (Director of Nursing)-B spoke with R3's physician on the telephone. R3 received the incorrect dose of Carvedilol 69 times during August and September 2024. Findings include: R3 was readmitted to the facility on [DATE]. Diagnoses includes bilateral lower extremity edema, hypertension, and congestive heat failure. Under hospital course for date of discharge 8/20/24 under the section PCP (primary care physician) to Follow up: documents: -Maintain care of tracheostomy and re-evaluate need for continued use. -re-evaluate need for Keppra. -maintain COVID-19 precautions -Medication changes: -complete 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.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 2 Residents. * Appropriate hand hygiene was not observed during trach & incontinence cares for R3 who is on contact isolation for C diff (Clostridioides difficile). Findings include: The facility's policy titled, Management of C. (Clostridioides) Difficile Infection and not dated under policy documents This facility implements facility-wide strategies for the prevention and spread of Clostridioides difficile (C. difficile) infections. Under #5. General principles related to contact precautions for C. difficile: b. documents Hand hygiene shall be performed by hand washing with soap and water in accordance with facility policy for hand hygiene. The facility's policy titled Hand Hygiene and date implemented 12/23/22 under policy documents All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure 1 of 3 residents (R1) reviewed for potential sexual abuse was provided medically related social services to assist R1 in attaining or maintaining their mental and psychosocial health. * On 5/18/24, R1 was approached by her spouse to have sexual relations while R1 resided at the facility. The facility was made aware of R1's spouse's intentions to have sexual relations with R1 prior to 5/18/24 but took no steps on 5/18/24 to ensure that R1 could consent to having sexual relations. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis that included Left Hand Contracture, Bipolar Disorder, Anxiety Disorder, Schizophrenia, Unspecified Dementia without Behavioral Disturbance, Mood Disturbance and Anxiety. R1's Annual MDS (Minimum Data Set) dated 3/15/24 documents a BIMS (Brief Interview for Mental Status) score of 00, indicating that R1 is severely cognitively impaired. Section E (Behavior) documents that R1…

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

Based on record review, observation and interview the facility did not distribute and serve food in a manner that prevents foodborne illness to 74 out of 74 (census 76, 2 NPO) residents who receive their meals from the main serving kitchen. *Cook-K was observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. *Dietary Aide-M was observed touching nose with gloved hands while transferring yogurt from large container to individual service containers. Findings include: The facility policy titled, Food Safety-Food Handling with revision date, 7/20/2019, states in part: Purpose To ensure food handling practices are consistent with USDA Food Code guidelines. To comply with federal and state regulations governing food safety and prevention of foodborne illness and to comply with state and local ordinances governing food safety. Policy 1. Food handling practices shall be completed in a manner to protect food safety and avoid cross contamination. 2. Safe food practices shall be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that 6 (R2, R12, R33, R35, R39, & R46) of 13 Residents reviewed for a room change within the facility, were provided with prior written notice, including reason for the room change. *R2 transferred to another room on 4/12/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer. There is no documentation that R2's guardian was provided written notice. *R12 transferred to another room on 2/28/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer. There is no documentation that R12's guardian was provided written notice. *R33 transferred to another room on 4/9/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer. *R35 transferred to another room on 4/30/24 and did not receive prior written notice, was not given…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4.) R52 was re-admitted to the facility on [DATE] with diagnosis that included Cerebral palsy, asthma, blindness right eye, major depressive disorder, bipolar disorder, developmental disorder, anxiety, seizures. R52 was originally admitted to the facility on [DATE]. Surveyor conducted a review of R52's plan of care that indicates R52 has the potential for falls, accidents and incidents due to immobility, impaired cognition, unaware of safety needs. Interventions included padded side rail to prevent bruising to extremities from swatting/ hitting when anxious. The need for padded side rail was added on 8/10/23. The plan of care also states that R52 has self- care deficit due to cognitive deficits, disease process/ progression due to his cerebral palsy, blind in both eyes. Interventions include that R52 needs the assist of 1 for bed mobility. Also the use of 1/4 side rails to aide in positioning was added to the plan of care on 2/13/23. The admission/ readmission/ routine head to toe evaluation, dated 3/2/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure that 2 (R47 &R322) of 7 facility reported incidents investigations reviewed were reported to the State Survey Agency, within 5 working days of the incidents, after the initial reporting and with the results of the investigations of each alleged violation. Findings include: The facility's policy with no date and titled Abuse, Neglect and Exploitation documents: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes . B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1. R47 was readmitted to the facility on [DATE] with a diagnosis that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into a Resident's assessment, care planning, and transitions of care for 1 (R52) of 1 Resident reviewed with PASARR level 2 recommendations. *R52's PASARR dated 7/21/21 determination states R52 needs specialized services to address R52's developmental disability needs. Findings Include: Policy Review: Specialized Rehabilitative Services ( date implemented- blank, Date reviewed- blank, Date revised- blank) Policy: The facility shall provide or obtain services from an outside resource for specialized rehabilitative services if required by the resident's comprehensive assessment and care plan to assist them to attain, maintain or restore their highest practicable level of physical mental functional and psycho- social well- being, as well as ensure that residents with Mental Disorder ( MD), Intellectual Disability ( ID) or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility did not ensure a complete baseline care plan was developed and addressed all of the resident's needs within 48 hours of admission for 1 (R371) of 2 sampled residents for new admission. R371's baseline care plan did not address R371's enabler bar usage on the baseline plan of care. Findings include: The facility policy titled, Baseline Care Plan, with implementation date, February 2023, states in part: Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b.Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i.Initial goals based on admission orders. ii.Physician orders . 2 b. Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury . ii. Any identified needs for supervision . iii. Any special needs such as IV…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure 1 (R32) of 1 Resident reviewed for communication with the use of hearing aides, received proper treatment and assistive device to maintain R32's hearing abilities. Findings Include: R32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Hypo-osmolality and Hyponatremia, and Gastro-Esophageal Reflux Disease. R32 has an activated health care power of attorney(HCPOA). R32's Significant Change Minimum Data Set(MDS) dated [DATE] documents R32's Brief Interview for Mental Status(BIMS) score to be a 0 indicating R32 demonstrates severely impaired skills for daily decision making. R32 has no behaviors documented. R32's Patient Health Questionnaire(PHQ-9) score is 8 indicating mild depression. R32 has no range of motion(ROM) impairment on upper extremities, and does have ROM impairment on bilateral lower extremities. R32's MDS documents R32 is dependent for dressing, mobility 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 record review and staff interviews, the facility did not always ensure that , based on a comprehensive assessment, provided the appropriate treatment and services to restore continence , to the extent possible, for 1 out of 2 residents ( R19) reviewed for bowel and bladder incontinence. This is evidenced by: Policy Review: Incontinence Date implemented: ( blank), Date Reviewed/ Revised ( blank). Policy: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Policy Explanation and Compliance Guidelines: ( includes) 1. The facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility did not ensure a Resident with a gastrostomy tube received the appropriate care and services for 1 (R60) of 3 Residents with gastrostomy tubes. *R60's water flush bag and tube feeding was not labeled for two days during the survey process. R60's tube feeding pump had not been calibrated to ensure proper flow rate. Findings Include: Surveyor reviewed the facility's undated Care and Treatment of Feeding Tubes policy and procedure and notes the following: 10. Direction for staff regarding how to manage and monitor the rate of flow will be provided: a. Use of gravity flow b. Use of a pump c. Periodic evaluation of the amount of feeding being administrated for consistency with practitioner's orders d. Calibration of enteral feeding pumps to ensure that pump settings accurately provide the rate and volume consistent with the Resident's care plan. e. Periodic maintenance of feeding pumps consistent with manufacturer's instructions to ensure proper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not provide dialysis services consistent with professional standards of practice for 1 (R321) of 1 Residents reviewed for dialysis. * R321 receives dialysis three times per week. R321's dialysis center communication records are not being completed by Facility nurses. Findings include: 1. R321 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, diabetes mellitus and encephalopathy. R321 is dependent upon renal dialysis and attends dialysis three times per week. On 5/9/24, Surveyor reviewed R321's medical record, including physician's orders and comprehensive care plans. Surveyor was unable to locate any dialysis communication forms for R321 in R321's medical record. On 5/9/24 at 12:45 PM, Surveyor requested R321's dialysis communication forms that are to be completed on R321's dialysis days. On 5/9/24 at 2:25 PM, Nurse Consultant-C approached Surveyor for interview. Nurse Consultant-C told Surveyor that the facility had not been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmacist recommendations made during the monthly record review were not reported to the attending physician and were not acted upon for 1 of 5 (R37) residents reviewed for unnecessary medications. R37's pharmacy recommendations were not acted upon by the physician. Findings include: The facility policy titled Medication Regimin Review (not dated) documents (in part) . .The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. 1. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: a. Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication erros, or other irregularities. 4. The pharmacist shall document, either manually or electronically, that each medication regimen review has…

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

Based on interviews and record review the facility did not ensure that residents are free of any significant medication errors for 2 of 2 (R3 and R37) residents reviewed. Morning medications are not administered within timeframe specified and are often administered after 11 AM along with noon medications. The facility policy titled Medication Administration (not dated) documents (in part) . .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. On 5/8/24 at 9:43 AM, during initial interview, R3 reported the Assistant Director of Nursing (ADON) is an idiot because she has only 1 nurse for wings 1 and 2. R3 stated: Sometimes I don't get my 8 AM (morning) meds (medications) until 2 PM (afternoon) and sometimes I don't get my…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure 3 of 3 medication carts had insulin vials dated with the open date and insulin pens that have expired after being open removed from the medication cart. This affected 4 residents (R35, R30, R56 and R29) On [DATE] Surveyor observed medication carts from 200, 300, and 400 hall. The 200 hall had insulin vials opened and not dated. The 300 hall had an insulin pen that expired after it was opened on [DATE]. The 400 hall had an insulin pen that expired after it was opened on [DATE]. Findings include: On [DATE] at 8:55 a.m. Surveyor observed the 200 hall medication cart. Surveyor observed R30 humalog insulin vial opened but not dated. Surveyor also observed R35 lispro insulin vial opened but not dated. Surveyor showed RN(Registered Nurse)-G the insulin vials open and not dated and asked what is the facility's policy regarding insulin vials. RN-G stated once an insulin vial is opened it is dated with the date it was opened and only good for 28…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not ensure hospice services providing end of life were coordinated for 1 (R32) of 3 sampled Residents receiving hospice services. *R32 was admitted on hospice on 4/8/24. R32's hospice binder did not have a physician certification of terminal illness, physician orders, documentation of visits, schedule of hospice visits with hospice team listed, and the facility did not designate a specific individual of the facility's interdisciplinary team to act as a liaison between the facility and the hospice provider. Findings Include: Surveyor reviewed the facility's Hospice Program policy and procedure and notes the following applicable: .Policy Interpretation and Implementation 9. In general, it is the responsibility of the hospice to manage the Resident's care as it relates to the terminal illness and related conditions, including: a. Determining appropriate hospice plan of care b. Changing the level of services provided when it is deemed appropriate c. Providing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not implement effective infection prevention measures. This included observation of a nurse touching medications with bare hands during medication pass on two occasions. Observation of two residents having their catheter bag on the floor multiple times during the survey affecting 2 of 4 residents sampled with catheter bags. * The facility did not ensure R371 and R372's catheter bags were maintained in a sanitary manner. Findings include: The facility policy titled, Indwelling Catheter Use and Removal, with no implementation or revision date, states in part: Compliance Guidelines: .4. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures . .7.e. Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the bladder . Surveyor notes no further infection prevention guidelines in policy. 1) .On 05/08/24 at 09:44 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 This is an uncorrected deficiency from survey event: VLJH12. Based on interview and record review, the facility did not ensure that 1 of 1 allegations of abuse involving R32 was reported immediately to the State Survey Agency. On 10/2/23, it is documented that a male Resident who was monitored to not be on R32's wing was found in R32's bed. Findings Include: Surveyor reviewed the facility's Abuse, Neglect and Exploitation policy and procedure implemented 9/18/23 and notes the following in regards to reporting requirements: .Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property. III Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of Resident property, and exploitation 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 This is an uncorrected deficiency from survey event: VLJH12 Based on record review and staff interview, the facility did not ensure an allegation involving potential sexual abuse was thoroughly investigated for 1 of 1 Resident (R32) reviewed for allegations of abuse. Findings Include: Surveyor reviewed the facility's Abuse, Neglect and Exploitation policy and procedure implemented on 9/18/23 and notes the following in regards to reporting requirements: .Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property. III Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of Resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2) R2 was originally admitted to the facility on [DATE] with a readmission date of 10/19/23. Diagnoses includes paraplegia, anxiety disorder, other psychoactive substance abuse, depressive disorder, diabetes mellitus, and hypertension. R2 does not have an activated power of attorney for healthcare. The resident requires assistance with discharge planning care plan created 2/5/20 and initiated & revised on 10/19/23 documents the following interventions: * Assist resident with adjustments to the residential setting so that he has a sense of control that is maintained throughout. Created 2/5/20 and initiated & revised 10/19/23. * Consult with the physician, therapy, and other disciplines regarding progress toward discharge goals. Make arrangements for appropriate placement and update. Created 2/5/20 and initiated & revised 10/19/23. * When discharging o [sic] (to) the community, provide for continuity of care after discharge. Provide medication list and information on scheduled appointments and on-going treatments.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 1 (R1) resident's employed by the facility did not have a care plan or appropriate job description before employment at the facility began. This deficient practice has the potential of affecting all 97 residents in the building. * R1 has a history of resident-to-resident abuse and excessive alcohol consumption while in the facility. Before employment, the facility had R1 sign a job description for a Certified Nursing Assistant (CNA) and a policy that indicated R1 would answer call lights of other residents. Finding include: R1 was admitted to the facility on [DATE] with diagnoses that included alcohol abuse and left foot amputation. R1's annual Minimum Data Set (MDS) dated [DATE] was reviewed and R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated R1's cognitive status for daily decision making skills was fully intact with both long- and short-term memory. R1's medical record was reviewed and indicated that on 6/22/23, R1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not thoroughly investigate 4 of 7 reportable incidents reviewed for abuse and misappropriation involving R10 and R15. * R10 was in a sexual relationship with an employee at the facility, Dietary Aide (DA)-O. Nursing Home Administrator (NHA)-A was made aware of inappropriate incidents on 6/28/23 and 7/22/23 between DA-O and R10 that were not fully investigated. NHA-A was also aware that R10 had been to DA-O's home and did not investigate the incident. * On 8/9/23 R15 reported missing $30.00. The facility's investigation did not include interviews with direct care staff to see if they had any knowledge of R15's missing money. The facility's investigation did not include interviewing other residents on R15's unit to see if any other resident may have had missing money/items. Findings include: Surveyor reviewed facility's Policy and Procedure: Abuse and Neglect Reporting and Investigating with a revision date of 5/9/19. Documented was: .IDENTIFICATION,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not complete a performance review for 5 of 5 CNAs (Certified Nursing Assistants) reviewed. This had the potential to affect a pattern of all 85 residents who reside in the facility as the 5 CNA's work throughout the building as needed. Findings include: On 8/28/23, the facility policy titled Competency Evaluation, dated 12/22 was reviewed and read: Subsequent and or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. Employee competency forms are maintained by the Staff Development Coordinator's office for the current training year, then forwarded to the Human Resources Director for placing into the employee's personnel file. On 8/28/23 at 9:00 AM, the Surveyor asked for the performance reviews for: CNA-N who was hired by the facility on 10/08/21, CNA-W who was hired by the facility on 01/02/07, CNA-X who was hired by the facility on 10/13/09, CNA-Y who was hired by the facility on 01/24/19, and CNA-Z who was hired by 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 record review and interview, the facility's assessment, last updated 8/8/23, indicates the number/average range of residents the facility can care for with active or current substance use disorders is 15 residents. The facility's assessment was not specific in regards to residents with substance abuse disorders and the level of care they are able to provide for those residents. The facility assessment does not include available resources for narcotic substance abuse that is available to the residents for support services. The facility assessment does not indicate if the facility has a professional in substance abuse with drug and treatment expertise who would be able to assist with resident support and facility resources. This deficient practice has the potential to affect the 15 residents (per facility assessment) who are active with or experience substance disorders. Findings include: During this onsite complaint investigation, the survey team was informed of two (R10 and R11) residents residing in the facility with diagnosis of substance disorders and who had repeated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure that staff promptly consulted with a physician when residents experienced significant changes of condition for 1 (R11) of 4 residents reviewed for change of condition. R11 had a history of drug and alcohol abuse and had an order to update the MD if any signs and symptoms were noted of drug use. The facility did not update the MD on 9 different occasions when staff documented R11 had overdose signs and symptoms. Findings include: R11 was admitted to the facility on [DATE] with diagnoses that included Chronic Multifocal Osteomyelitis, Hypertensive Urgency and Anxiety. Surveyor reviewed R11's MDS (Minimum Data Set) Assessment with an assessment reference date of 3/2/23. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact. R11 had a history of substance abuse and overdosed on 11/19/22, 3/17/23, 5/4/23 and 8/3/23 under the influence of drugs and alcohol. Surveyor reviewed R11's MD Orders.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not report 3 of 7 reportable incidents (involving R10), reviewed for abuse to the State Agency. * R10 was in a sexual relationship with an employee at the facility, Dietary Aide (DA)-O. Nursing Home Administrator (NHA)-A interviewed DA-O on 6/28/23 and 7/22/23 and asked questions about the relationship. NHA-A was also aware that R10 had been to DA-O's home; that was confirmed during an interview on 8/8/23. The facility did not investigate these allegations and did not report any of the allegations of abuse to the State Agency. Findings include: Surveyor reviewed facility's Policy and Procedure: Abuse and Neglect Reporting and Investigating with a revision date of 5/9/19. Documented was: .IDENTIFICATION, INVESTIGATING, AND REPORTING OF ABUSE: Abuse is defined differently under both State and Federal law and Regulation. Please review the key definitions in this policy that should be considered when determining whether an event constitutes abuse. Definitions: Resident Abuse under the Federal Certification Guidelines 42 C.F.R.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility did not store food in accordance with professional standards for food service safety. This has the potential to affect all 108 residents. * Surveyor observed 18 unopened boxes on the floor of the freezer. Boxes were there for two days of the survey. * Surveyor observed large amounts of ice buildup in the freezer. Ice buildup was scattered across the ceiling, down the walls and on boxes of food. * Food brought in by residents and family members were stored in a refrigerator in the shared activity and dining room and food items were not discarded by the use by date of the food. Findings include: A facility policy, entitled Food Receiving and Storage, dated October 2017, specified: Foods shall be received and stored in a manner that complies with safe food handling practices. 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 6. Food in designated dry storage areas shall be kept off the floor . 12.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure a facility-wide assessment was conducted to determine what resources were necessary to competently care for its residents during both day-to-day operations and emergencies. This had the potential to affect all 108 residents residing at the facility. *The Facility Assessment Tool, dated 1/7/2023, did not identify the facility's need for the Infection Preventionist role or the designated hours per week necessary to perform their duties. An Infection Preventionist is responsible for managing the facility's Infection Prevention and Control Program. *The Facility Assessment Tool, dated 1/7/2023, did not include a completed facility-based and community-based risk assessment, utilizing an all-hazards approach to create an emergency preparedness plan, including a water management plan, that met current standards of practice. *Nursing Home Administrator (NHA)-A revised the Facility Assessment Tool during the survey in front of Surveyor without communication with the Medical Director, Director of Nursing (DON), or the Governing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure as part of their infection prevention and control program they had an effective water management plan based upon the individual characteristics of the facility. The facility failed to implement a Water Management program to prevent the transmission of Legionnaires Disease which has the potential to affect all 108 residents residing in the facility. Based upon observation and interview, the facility failed to provide infection control measures according to professional standards of practice for 1 (R29) of 4 Residents reviewed for wound care. The facility did not disinfect a scissors used during wound care when transitioning from dirty to clean supplies. Findings include: 1.) The facility policy and procedure entitled Legionella Water Management Program from MED-PASS ©2001 revised 7/2017 states: 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team will consist of at least the following…

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

Based on record review, interviews, and observations, the facility did not implement their abuse policy in regards to screening 3 of 8 employees (Certified Nursing Assistant(CNA)-AA, Licensed Practical Nurse (LPN)-J and CNA-BB. * CNA-AA was hired on 6/14/22. Caregiver and criminal background checks were not completed until 3/1/23. The Background Information Disclosure (BID) was not completed by CNA-AA until 3/1/23. * LPN-J was hired on 4/22/22. Caregiver and criminal background checks were not completed until 3/1/23. * CNA-BB was hired on 7/27/16. Caregiver and criminal background checks were not completed every 4 years. The Background Information Disclosure (BID) was not found by the facility. This had the potential to affect a pattern of residents residing at the facility. Findings include: On 3/1/23 the employee background information was reviewed for a sample of 8 employees the following employees did not have the required background check information available: * CNA-AA was hired on 6/14/22. Caregiver and criminal background checks were not completed until 3/1/23. 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 record review and interview, the facility did not ensure antibiotic protocols were used to prevent the unnecessary administration of antibiotics to 9 (R3, R34, R12, R11, R5, R84, R8, R38, and R13) of 19 residents reviewed for antibiotic usage. *R8, R38, R3, R34, R12, R11, R19, R84, and R13 did not meet the criteria for the use of an antibiotic. Findings include: The facility policy and procedure entitled Antibiotic Stewardship from MED-PASS ©2001 revised on 12/2016 states: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Policy Interpretation and Implementation: 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. 8. When a nurse calls a physician/prescriber…

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

Based on interviews, record reviews and facility document reviews, the facility did not implement measures to protect a resident from sexual abuse. This was discovered in 2 facility self reports involving (R23 & R76) of 9 facility self-report investigations. On 2/15/23 R23 touched R76 inappropriately in their genital area. R23 had a documented history of previously engaging in inappropriate activity with residents including kissing other residents. The facility had not assessed residents, including R76, for their ability to understand and consent to sexual activity/relations. The facility self report indicates the social worker sat down with R23 and R76 to clarify their relationship. The self report continues to indicate the power's of attorney for both R23 and R76 were contacted and stated they do not have an issue with their relationship but would prefer that the residents were not visiting in each others rooms. The consent for a relationship is not something that can be deferred to a responsible party. The facility did not take steps to prevent this incident from occurring as no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews/ and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 3 Residents (R162, R94 & R462) of 5 residents reviewed who potentially had a crime committed against them. R94 had a resident-to-resident verbal altercation in which R162 expressed being very afraid of R94. The facility did not notify the police of R94's threat to R162. Agency Certified Nursing Assistant (CNA) Z was verbally and physically abusive towards R94 and Agency CNA Z was asked to leave the facility. The facility did not call the police. Additionally, the facility did not investigate threats made to another resident by CNA Z that staff referenced in their statements. R45 had an allegation of misappropriation of R462's funds and the facility did not call the police and the investigation was not completed and submitted to the state agency. Findings include: The facility abuse policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 upon record review and interview, the facility did not ensure investigations of allegations of neglect involving 2 Residents (R61 & R42) of 2 allegations of neglect were reported timely to the state agency. The facility did not ensure investigated allegations of neglects involving R61 and R62 were submitted timely to the state agency as facility administration forgot to submit the investigations to the state agency. Findings include: 1.) R61 was admitted to the facility on [DATE] with diagnoses of epilepsy, depression, bipolar disorder, anxiety, and obesity. R61's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R61 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 00 and needed extensive assistance with bed mobility and cares. On 1/4/2023 at 8:22 PM in the progress notes, nursing charted R61 fell out of bed while receiving care by a Certified Nursing Assistant (CNA). The progress note at 9:25 PM stated the CNA was providing cares to R61 and while…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure residents received treatment and care in accordance with professional standards for 1 (R262) of 22 sampled residents. * R262 had an order on admission to have a shower daily. The order was not transcribed and R262 only received a weekly shower while in the facility. Findings include: R262 was admitted to the facility on [DATE] status post a cerebral shunt replacement and had a surgical wound to her head. On 3/1/23 R262's hospital discharge instruction dated 12/27/23 were reviewed and read: Post operative VP (Venticulooeritoneal) shunt instructions. Showering: please shower daily. Gentle cleaning and rinsing of the incision is ok. On 3/1/23 R262's treatment and daily care records were reviewed. Showering daily was not included in the records. Shower weekly on Tuesday was on the care record and documented as completed while R262 was at the facility. On 3/2/23 at 10:30 AM Regional Nurse Consultant-G was interviewed and indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure adequate supervision and assistive devised were used to prevent accidents for 3 (R61, R37, and R463) of 6 residents reviewed for falls. R61 fell out of bed on 1/4/2023 while receiving cares with the assist of one Certified Nursing Assistant (CNA). The facility staff were not following F61's plan of care: R61 required the assist of two CNAs when receiving cares per the Care Plan. R37 had three falls out of bed, 11/5/2022, 11/23/2022, and 12/15/2022, without having a body pillow in place. R37 was to have a body pillow in place per plan of care. Multiple observations were made during the survey of no body pillow in place when R37 was in bed. R463 fell on [DATE] when being transferred with no gait belt in place. R463 was to have a gait belt used when transferring per plan of care. Findings include: The facility policy and procedure entitled Falls and Fall Risk, Managing from MED-PASS ©2001 revised on 3/2018 states: Based on previous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure 2 (R17 and R262) of 7 residents reviewed for weight loss had their nutritional care needs recognized, evaluated, and addressed to provide adequate parameters of nutritional status. * A review of R17's admission weight on 8/10/22 was documented at 198 pounds in the medical record and the admission nutritional assessment documented an admission weight of 220 pounds. The Dietician disputed the admission weight value with no further follow up or reweigh. R17's documented weight on 8/30/22 was 177.6 pounds which was a 10.30% weight loss from 198 pounds. The facility did not implement an intervention until 10/25/22. * R262 was not assessed for fluid needs on admission. R262 was not screened for beverage preferences and there was no care plan for dehydration. Findings include: The facility policy, entitled Nutrition and Hydration Guideline, dated 10/3/22, states: Purpose: The intent of this requirement is that the resident maintains, to the extent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure that 1 (R85) of 5 residents reviewed receiving psychotropic medication were free from unnecessary drugs. *R85 had orders for a psychotropic medications and did not have specific documented targeted behavior monitoring and/or specific reasons for use of the medication in their medical records. R85 did not have specific targeted behaviors for administration of psychotropic medication addressed in her plan of care. Findings include: On 3/1/23 the facility's policy titled Psychotropic Management Guidelines dated 08/22 was reviewed and read: Upon admission the Licensed Nurse will implement the following: Physicians order for the medication including an approved diagnosis or Target Behavior. The Interdisciplinary Team will individualize the resident care plan and address the diagnosis and specific behavior for the drug. R85 was admitted on [DATE] with a diagnosis that included Dementia and Depression R85's Initial MDS (Minimum Data Set) dated 1/16/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure that medical records contained documentation related to Influenza and/or Pneumococcal immunizations for 3 (R20, R105, R85) of 5 residents reviewed for immunizations. R20's medical record did not contain documentation indicating the facility offered or administered the Influenza or Pneumococcal vaccine. R103's medical record did not contain documentation indicating the facility offered or administered the Pneumococcal vaccine. R85's medical record did not contain documentation indicating the facility offered or administered the Influenza or Pneumococcal vaccine. Findings include: The facility policy, entitled Pneumococcal Vaccine, revised October 2019 states: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/ pneumococcal infections. Policy Interpretation and Implementation 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will…

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