Maplewood Center

Based on observation and interview the facility did not ensure a safe, clean, comfortable, and homelike environment for 5 (R34, R105, R78, R73, & R38) of 6 residents. The base of R34, R105, R78, R73, & R38's tube feeding poles were observed with dried feedings on multiple days. Findings include: Surveyor requested facility policy regarding cleaning resident equipment. Surveyor was provided with the facility's policy titled Wheelchair and [NAME] Cleaning and Maintenance reviewed 4/25. This policy does not address resident's tube feeding poles. No other policy was provided. On 4/21/25, at 11:40 a.m., Surveyor asked Housekeeping Aide (HA)-GG, who was working on the vent unit, if she is responsible for cleaning resident's tube feeding poles. HA-GG replied ya but we just started this vent unit. Surveyor asked when they started cleaning the vent unit. HA-GG informed Surveyor a month ago and explained those poles were on SunnyView 2. HA-GG stated I'll start cleaning its all stuck on there. Surveyor asked HA-GG in the last month has she cleaned any of the tube feeding poles. HA-GG replied…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.) R73's nurses note dated 2/28/25 at 4:05 a.m. indicates R73 was transferred to the hospital for a change in condition. Note indicates unit nurse will update POAH (power of attorney health) and will call the hospital for nurse to nurse report. R73's nurses note dated 3/1/25 at 12:35 a.m. by Registered Nurse (RN)-X documents F/U (follow up): Call place to [hospital initials], update; pt (patient) admit w/ (with) acute Hypoxia 2/2 (secondary to) Chronic Resp (respiratory) failure. R73 was readmitted on [DATE]. Surveyor was unable to locate in R73's medical record R73 or R73's representative had been notified of the hospital transfer in writing. On 4/17/25, at 1:00 p.m., Surveyor asked Licensed Practical Nurse (LPN)-JJ who would notify a resident or their resident representative of a transfer to the hospital in writing. LPN-JJ replied I don't know and informed Surveyor if the resident was their own person she would tell them if not she would verbally tell their family. On 4/17/25, at 3:00 p.m., during the end of…

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

Based on interview and record review, the facility did not ensure sufficient nursing staff was provided to allow residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect 2 of 6 units at the facility. *On 04/15/2025, staff member informed Surveyor that 4 residents, who required an assistance of 2 staff with a mechanical lift, remained in bed due to not having a second staff assistance available. *On 04/17/2025, Surveyor observed residents receiving meal trays 1.5 hours after breakfast was scheduled- due to staff being unavailable to help pass trays and/or assist residents with eating. *On 03/31/2025, The Facility's schedule documented residents were unable to be rounded on, due to staffing. Findings include: On 04/15/2025, at 12:46 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-W. Surveyor asked CNA-W how the staffing is at the Facility. CNA-W indicated horrible. Surveyor asked CNA-W to elaborate on what horrible means. CNA-W informed Surveyor that there is only CNA on TV1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication for 4 (R93, R514, R8 & R72) of 6 Residents reviewed. * R93 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. * R514 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. * R8 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. * R72 is currently prescribed Eliquis an anticoagulant and has no documented monitoring for the side effects to the medication, such as monitoring for bleeding or bruising as directed by their care plan. Findings include: On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 3 of 6 medication carts and 2 of 2 medication refrigerators located in the nurses station. Concerns include: * An expired Basaglar insulin pen for R22 with an open date of [DATE]. * Used Lantus Solostar insulin which was not labeled with a resident's name and an expired bottle of Humalog insulin for R42 with an open date of 11/23. * A bottle of Extra Strength Rapid Release Tylenol 500 mg (milligrams) with the expiration date of 8/2024. * A used Semglee insulin pen for R13 that was not dated when opened and a used bottle of Lispro insulin for R13 that was not dated when opened. * Inside a plastic bag marked with R1's name is a bottle of used Lispro insulin that is not labeled with a resident's name or dated when opened. Inside R1's bag there is also a bottle of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to store and serve food in accordance with professional standards for food service safety for 95 of 108 residents that receive food from the kitchen. * In the facility's main kitchen, observations of partially used and undated food were made in the dry storage and walk-in freezers/coolers. Several food items were observed in the facility's dry storage uncovered open to air and undated. * Inadequate hand hygiene was observed by multiple kitchen staff working in the main kitchen area. * Contaminated utensils were placed back into food ready to be served to residents. Findings include: Facility policy titled; Food Services: Food and Supply Storage Effective 7/21 Revised 7/21 Reviewed 4/25 Policy: All food, non-food items, and supplies used in food preparation shall be stored in such a manner as to maintain the wholesomeness of the food for human consumption. To ensure food and supplies are stored according to facility, state and federal guidelines Procedures:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.) R414 was admitted to the facility on [DATE]. Diagnoses includes pleural effusion (fluid accumulates between lungs & chest wall), acute respiratory distress, malignant neoplasm (cancer) of unspecified ovary, anxiety disorder, and depression. The hospital assessment/plan not dated under recommendations documents (1) Pleurx (drainage catheter) placed -Drain daily -Up to 1L drainage -Bedside nurse to complete self education for patient and patient's son -Interventional Pulm (pulmonary) f/u (follow up) as outpatient. (2) Neoadjuvant therapy (treatment given before the main treatment) for metastic ovarian cancer per Gyn/Onc (Gynecology/Oncology). R414's pre admit note dated 3/20/25, at 1:28 p.m., written by Director of Admissions/ Licensed Practical Nurse (LPN)-FF for admission diagnosis document R (right) pleural effusion. For PICC (peripherally inserted central line catheter) documents R brachial double lumen. Under notes documents R side chest tube-hospital sending back up Pleurx kit, NO chemo planned while in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.) R614 was admitted on [DATE] with diagnoses that included: Cognitive Communication Deficit and Alzheimer's Disease. R614's MDS (Minimum Data Set) assessment with an assessment reference date of 3/31/25 documents: Section C cognitive patterns a BIMS (Brief Interview for Mental Status) score of 6, indicating severe impairment of cognition for R614. Section B Hearing, Speech and Vision documents R614's ability to hear as moderate difficulty (speaker has to increase volume and speak distinctly). Section B Hearing, Speech and Vision documents R614's hearing aid or other hearing appliance used as yes. R614's Physician's Order dated 3/29/25, at 05:49 PM, documents: Right hearing aide {SIC}: Nurse to ensure HA (hearing aid) is in place in the AM and off @ HS (hour of sleep) and return back to designated container in medication cart. Frequency: twice a day. Special Instructions: Hearing Impairment. R614's April 2025 Medication Administration Record (MAR) documents: Right hearing aide {SIC}: Nurse to ensure HA (hearing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R100) of 3 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. Range of motion was not provided to R100 during two personal care observations per R100's plan of care. Findings include: The facility's policy titled, Range of Motion and reviewed 4/25 under policy documents Therapeutic care will be provided to assist residents in maintaining ADL's (activities daily living) and to prevent contractures and maintain the flexibility needed to perform self-cares and maintain mobility. Under the section General Information includes documentation of 4. Move each joint through its range of motion about 5 to 10 repetitions or as tolerated by residents when resistance is felt. R100 was admitted to the facility on [DATE] with diagnoses which include chronic respiratory failure, dependence on respirator (ventilator), Encephalopathy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews the facility did not provide pharmaceutical services, including services that assure the accurate storage, dispensing and administering of all drugs and biological's to meet the needs of residents for 1 of 22 residents (R10) investigated for proper medication administration. *R10 did not have the correct order for her B12 injection transcribed Findings include: R10 was admitted to the facility on [DATE] with diagnoses that included Vitamin B Deficient Anemia due to Intrinsic Factor Deficiency. R10's Significant Change in Status Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status Score of 15 (fully intact long and short term memory), R10 is able to make her own care and financial decisions. On 4/22/25 at 1:30 PM R10's Vitamin B injectable medication was observed in R10's room where she stores it. The bottle documented: methylcobalamin (Vitamin B12) 20 milligrams (mg) per milliliter (ml) inject 1 ml daily (20,000 micrograms) (mcg). R10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate monitoring for adverse reactions/side effects of psychotropic medications, or behavior monitoring required for use of psychotropic medications for 1 (R1) of 6 residents reviewed for psychotropic medications. R1 does not have any behavior monitoring in place related to their use of psychotropic medication (Buspar). Findings include: R1 was admitted to the facility on [DATE] with diagnoses including anxiety disorder and major depression. R1's Quarterly MDS (Minimum Data Set) Assessment with an assessment reference date of 1/16/2025 indicates R1 received an antidepressant medication during the assessment period. Surveyor reviewed R1's electronic medical record and could not locate a person-centered care plan addressing the need to monitor for adverse side effects related to the use of an antidepressant. R1's medical record was reviewed including physician orders, MARs (Medication Administration Records) TARs (Treatment Administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was a medication error rate below 5 percent. There were 3 medication errors in 35 opportunities which resulted in a medication error rate of 8.57%. Medication errors were identified for R38 & R82. * R38's Sodium Chloride was crushed. * R82 received the incorrect dosage of Vitamin D and was administered multivitamin with minerals instead of adult multivitamin Findings include: 1. On 4/17/25, at 11:06 a.m., Surveyor observed Licensed Practical Nurse (LPN)-DD prepare R38's medication which consisted of one tablet Baclofen 20 mg (milligrams), one capsule Mexiletine 150 mg, and Sodium chloride 1 gm (gram). LPN-DD opened the capsule Mexiletine 150 mg and crushed Baclofen 20 mg & Sodium Chloride 1 gm separately and then poured all three medications together in one medication cup. At 11:13 a.m. LPN-DD washed her hands and placed the appropriate PPE (personal protective equipment) on. LPN-DD flushed the G (gastrostomy) & J (jejunostomy) tube with 30 cc (cubic centimeters) of water and administered R38's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the Hospice communication process was followed for 1 (R41) of 2 residents reviewed for Hospice services. The facility did not ensure Hospice required documentation was maintained in R41's medical record. The facility did not have a communication process in place between the facility and Hospice. Findings include: Surveyor reviewed the Signed contract between the facility and Hospice dated 12/12/2018. The following is documented: - . 2.1.5 Medical Records Documents (Page 5)- (Hospice) shall retain responsibility for ensuring that applicable requirements related to hospice medical records are met. Facility shall allow (Hospice) to access to appropriate medical records and permit the inclusion of (Hospice) care plans and other appropriate documentation in the Hospice Patient's Facility medical record. (Hospice) shall coordinate with the facility to ensure documentation of services is completed . - 3.2 Clinical Records (Page 16)- The parties will each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (R614, and R83) of 3 residents observed. * R614 was not placed in Enhanced Barrier precautions with a foley catheter and a Physician's order for R614 to be in Enhanced Barrier precautions until Surveyor brought it to the facility's attention. *R83 has been placed in Enhanced Barrier Precautions (EBP) and staff did not put a gown on when assisting with cares. Finding Include: The Facilities Policy titled, Infection Control policy and procedure. Subject: enhanced barrier precautions. Effective 6-20. Revised Reviewed 11-24. Documents: Policy: To prevent the spread of infection within the facility through the use of enhanced barrier precautions with residents when appropriate. Background: Residents in nursing homes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that food was prepared to conserve nutritive value and flavor. This has the potential to effect 95 out of 108 residents service by the facility kitchen. *The Lead Cook-VV did not follow a recipe for preparing texture and modified consistency of pureed food to ensure nutritive value and consistency. Food on Surveyor's test tray was cold and lacked flavor. *Resident council complained to Surveyor that food was consistently cold and lacked flavor. Findings Include: The Facility's Policy titled, Food services policy and procedure, subject: Standardized recipes effective 7/92, revised 9/21, reviewed 10/21, documents: Policy: Standardized recipes are used for the preparation of all food items to ensure consistent quality and quantity of the food. Procedure: 1. Standardized recipe books are maintained in the facility kitchen according to classification. 2. A standard recipe has the following characteristics: a, Ingredient amounts are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written notice to residents and offer them a choice in a change of room for 4 (R7, R8, R9, and R10) of 4 residents reviewed for room change. R7, R8, R9, and R10 were moved from one unit to another without having taken resident preference into account or offering to show the possible rooms to the resident/resident representative prior to the move. Findings include: In a letter to residents and families of the facility dated 2/3/2025, the letter documents: In our ongoing commitment to enhancing the quality of care for our residents, we have implemented a reorganization plan aimed at better meeting their needs. This plan will be rolled out in two phases. Phase one is anticipated to be completed during the week of February 24th. During this phase, all ventilator residents currently on Sunnyview 2 will be relocated to Parkview 2. Phase two will involve transitioning all tracheostomy patients from Sunnyview 2 to the general population…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 right to refuse transfer to another room in the facility when the purpose of the move is solely for the convenience of staff for 4 (R7, R8, R9, and R10) of 4 residents reviewed for room change. R7, R8, R9, and R10 were moved from one unit to another without having the opportunity to refuse the transfer. Findings include: In a letter to residents and families of the facility dated 2/3/2025, the letter documents: In our ongoing commitment to enhancing the quality of care for our residents, we have implemented a reorganization plan aimed at better meeting their needs. This plan will be rolled out in two phases. Phase one is anticipated to be completed during the week of February 24th. During this phase, all ventilator residents currently on Sunnyview 2 will be relocated to Parkview 2. Phase two will involve transitioning all tracheostomy patients from Sunnyview 2 to the general population between the 1st and 2nd floor, depending on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not allow 4 (R7, R8, R9, and R10) of 4 residents reviewed for room change the right to make a choice regarding moving within the facility. R7, R8, R9, and R10 were moved from one unit to another without taking resident preference into account or offering to show the possible rooms to the resident/resident representative prior to the move. Findings include: In a letter to residents and families of the facility dated 2/3/2025, the letter documents: In our ongoing commitment to enhancing the quality of care for our residents, we have implemented a reorganization plan aimed at better meeting their needs. This plan will be rolled out in two phases. Phase one is anticipated to be completed during the week of February 24th. During this phase, all ventilator residents currently on Sunnyview 2 will be relocated to Parkview 2. Phase two will involve transitioning all tracheostomy patients from Sunnyview 2 to the general population between the 1st and 2nd…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a through investigation was completed for 1(R1) of 3 facility self-reports reviewed. * The facility did not thoroughly investigate an allegation of neglect reported for R1 on 2/4/2025. Findings include: * R1 was admitted to the facility on [DATE] and has diagnoses that include acute on chronic respiratory failure with hypoxia, ataxia following cerebral infarction, quadriplegia, legal blindness, anoxic brain injury, and epileptic seizures. R1 has a tracheostomy (non-ventilator dependent/requires trach mask hooked up to oxygen), gastrostomy and jejunostomy tube, R2 is non-verbal and not able to make needs known. Surveyor reviewed the facility self-report the facility submitted on 2/4/2025 at 2:23 PM which documents: - R1's family member-J reported to social worker (SW)-GG that when R1 was sent to the hospital and when R1 arrived R1 was wet, and the hospital staff had to clean R1 up and put a new hospital gown on and R2 was sent to the hospital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise care plans for 1 (R1) of 7 residents care plans that were reviewed. * R1's family was observed by facility staff suctioning R1. R1's care plan was not revised, or interventions implemented to indicate to staff what to do if family is observed suctioning R1 again unassisted. * R1 was care planned to have an Alexa device/camera in room to communicate with family. Facility policy was changed, and video cameras not allowed- R1's care plan was not revised to indicate this change. Findings include: 1.) R1 was admitted to the facility on [DATE] and has diagnoses that include ataxia following cerebral infarction (brain damage after stroke), quadriplegia, and acute and chronic respiratory failure requiring tracheostomy (Trach mask on oxygen/ non-ventilator dependent). R1's quarterly minimum data set (MDS) dated 1/10/2025 indicated R1 had severely impaired cognition, R1 was non-verbal and could not make needs known. The facility assessed R1 needing extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff followed infection control procedures for 1 (R4) of 2 Residents. * Appropriate hand hygiene was not observed during incontinence cares for R4. Findings include: The Facility's policy titled, Hand hygiene, dated 08/18/2024, documents in part, . Hand hygiene is a general term used by the Center for Disease Control and Prevention (CDC) and World Health Organization (WHO) to refer to handwashing, antiseptic handwashing, antiseptic hand rubbing, and surgical hand asepsis. The hands are conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient, and from a staff member to a patient. Because of this, hand hygiene is the single most important procedure to prevent infection. To protect patients from healthcare-associated infection, hand hygiene must be performed routinely and thoroughly. Washing with soap and water is appropriate when the hands are visibly soiled or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility did not ensure 1 (R3) of 3 Resident's representative was notified when there was change in condition and a need to alter treatment. On 11/11/24 R3 vomited in the morning and a KUB (kidney, ureter, bladder) was ordered. R3's resident representative was not notified. Findings include: The facility's policy titled, Nursing Policy & Procedure, Subject: Notification of Changes and last revised/reviewed 11/24 under Policy documents It is the policy of this facility that changes in resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The resident and/or their representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. R3 is a [AGE] year…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R1 and R5) of 5 Residents who filed grievances with the facility had investigations into their grievances which included details on the steps taken to resolve the grievance, a summary of pertinent findings regarding the concern, a statement as to whether the grievance was confirmed or not, corrective action to be taken as a result of the grievance, and prompt attempts to resolve the grievance. Findings include: On 11/12/24 the facility's policy and procedure titled Grievance Procedure was reviewed and documented: The grievance official will initiate the appropriate notification and investigation processes per individual circumstance and facilities policies. The investigation will consist of at least the following: An interview with the person or persons reporting the incident, if applicable. Interviews with any witnesses to the incident or concern. An interview with staff members having any contact with the resident during the relevant periods…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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.) R3 is a [AGE] year old male with diagnoses which includes acute & chronic respiratory failure with hypoxia, ataxia following cerebral infarction, quadriplegia, legal blindness, anoxic brain injury, obesity, and epileptic seizures. R3 has a tracheostomy, gastrostomy & jejunostomy tube, and is non verbal. The significant change MDS (minimum data set) with an assessment reference date of 10/22/24 assesses R3 as having short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R3 is dependent for toileting hygiene, roll left and right, chair/bed to chair transfer and is always incontinent of urine & bowel. On 11/11/24, at 9:53 a.m., Surveyor called R3's resident representative to discuss R3. R3's representative informed Surveyor she is coming to the facility. R3's representative explained she had problems last night and came to the facility at 2:30 a.m. R3's representative informed Surveyor her son was wet with bowel movement and staff didn't change R3. R3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not ensure a thorough investigation was completed for allegations of abuse/neglect for 2 (R1 & R2) of 2 residents reviewed for alleged abuse investigations. *The Facility did not ensure a thorough investigation was completed for an allegation of verbal abuse of R2 on 09/22/2024 and 10/10/2024 by R2's family member. *R1 reported to the night nursing supervisor (RN)- C that on the night shift of 11/3-11/4/24, R1 overheard Certified Nursing Assistant (CNA)-Z be verbally abusive to R8. The allegation of verbal abuse was not investigated thoroughly including obtaining staff statements and conducting Resident interviews. Findings include: The Facility policy, titled, Abuse, Mistreatment, Neglect and Misappropriation of Resident/Client Property/Funds, Injury of Unknown Origin, with a last revised date of 09/2023, documents in part, POLICY: In keeping with our mission of caring for residents with respect and dignity, residents have the right to be free from abuse,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive assessment the facility did not ensure 1 (R3) of 7 residents received treatment and care in accordance with professional standards of practice. On 11/11/24 R3 was observed with a foam dressing on R3's mid back which was dated 11/3/24. There is no physician order for the foam dressing. Findings include: R3 is a [AGE] year old male with diagnoses which includes acute & chronic respiratory failure with hypoxia, ataxia following cerebral infarction, quadriplegia, legal blindness, anoxic brain injury, obesity, and epileptic seizures. R3 has a tracheostomy, gastrostomy & jejunostomy tube, and is non verbal. The nurses note dated 10/26/24, at 14:06 (2:06 p.m.) documents 11:15 am - Pts (patients) Mother insisted she look at pts. back wound, Pt turned as far over as comfortably possible. She then opened the bandage and touched the wound w/ (with) her ungloved hands. Stated she still couldn't see it good enough to take a clear picture and tried to push him over more. Writer asked her to stop due 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 1 of 1 resident (R4)'s environment remains free of accident hazards. * R4 was admitted to the facility ventilator wing on 5/29/24 with a diagnosis of Chronic Respiratory Failure. The facility did not ensure R4's room remained free of accident hazards after a heating and air conditioning condensation valance, located on the wall near the ceiling, fell open on 07/10/24 splashing condensate on R4's bed. The condensation valance fell open again on 08/08/24 splashing condensate and debris on R4. Findings include: The facility's policy and procedure titled; Hazardous Surveillance Inspection last reviewed 07/24: documents the following Policy: The Buildings and Grounds Department recognizes that it has the responsibility to the associates, residents, and visitors of this facility to provide equipment that is in good working condition. Procedure: In order to ensure that equipment is maintained in a state of good repair, it is incumbent upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services to assure accurate dispensing and administering medications to meet the needs of each resident and did not ensure drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 (R2 & R3) of 2 residents reviewed. *The Facility did not have records to account for R2's controlled medication administration. *R3 did not receive Mexiletine 150 mg on 11/10/24 at 12:00 p.m., 6:00 p.m., 11/11/24 at 12:01 a.m., 6:00 a.m., 6:00 p.m., 11/12/24 12:01 a.m., & 6:00 a.m. as the medication was not available. Findings include: 1.) R2 was admitted to the facility on [DATE] for after care of a femur fracture. R2's admission Minimum Data Set (MDS), dated [DATE], documents R2 has a Brief Interview for Mental status (BIMS) of 00. R2's admissions MDS documents R2 was on a scheduled pain medication regimen, received as needed pain medication and did not receive nonpharmacological pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was a medication error rate below 5 percent. There were 4 medication errors in 25 opportunities which resulted in a medication error rate of 16%. Medication errors were identified for R9, R10, & R11. * On 11/12/24 R9 was not administered Sennosides 8.6 mg (milligram)-docusate sodium 50 mg and only 20 cc (cubic centimeters) was added to Polyethylene Glycol 3350 17 grams. * On 11/12/24 Licensed Practical Nurse (LPN)-W added only 30 cc (one ounce) to R10's Polyethylene Glycol 3350 17 grams. * R11 did not receive Aspirin 81 mg tablet delayed release on 11/12/24. Findings include: According to https://dailymed.nlm.nih.gov under directions for Polyethylene Glycol 3350 documents 1. Note: This product cap is for dosing. A capful contains about 17 grams of powder. 2. Daily dose is 17 grams per day or as directed by a physician. 3. Pour 17 grams (about 1 heaping tablespoon) of powder into a cup. 4. Stir the powder in 4 to 8 oz of water, juice, soda, coffee or tea until completely dissolved. 5. Drink the…

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

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 2 (R3 & R10) of 4 Residents. * Staff did not wear appropriate PPE (personal protective equipment) when providing incontinence cares and changing a dressing for R3. R3 is on EBP (enhanced barrier precautions). * Staff did not wear appropriate PPE when administering R10's medication via the feeding tube. R10 is on EBP. Findings include: The facility's policy titled, Infection Control Policy & Procedure, Subject: Enhanced Barrier Precautions and last revised/reviewed 11/24 under Policy documents To prevent the spread of infection within the VMP facility through the use of Enhanced Barrier Precautions with residents, when appropriate. Under Procedure documents Enhanced Barrier Precautions (EBP) expand the use of PPE (personal protective equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable disease and infections for 1 (R3) of 1 residents reviewed. * Incorrect transmission-based precaution sign observed on R3's door. * Staff was observed interacting with R3 while not wearing a mask and when R3 was coughing. * R3 was observed in hall unattended, without a mask coughing and grabbing a hand railing. * Staff was observed assisting R3 in a wheelchair, then assisting another resident, without performing hand hygiene in between tasks. * Staff were unaware of R3's proper transmission-based precaution status. This has the potential to affect 31 residents residing on the affected unit in the facility at the time of the survey. Findings include: The facility's policy titled: Infection Control Policy & Procedure with a last revision date of 04/2024, documents, Policy: It is the policy of this facility that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that the PASRR (Pre-admission Screen and Resident Review) for 1 (R2) of 1 residents were conducted accurately and did not ensure the completion of Level II Screen after the level one PASRR screen identified R2 as having a mental illness or developmental disability. * R2's Level 1 PASRR Screen dated 12/8/20 documents R2 has a serious mental illness with psychotropic medication(s) and 30 day exemption was checked. A new PASRR Level I Screen was initiated after the 30 days which would have generated a Level II Screen. Findings include: The Preadmission Screen and Resident Review (PASRR) Level 1 form revised in 7/2017 documents the following: Nursing facilities MUST NOT admit any new Resident who is suspected of having a serious mental illness or a developmental disability unless the State mental health authority, State developmental disability authority or designee has evaluated the person and determined if the person needs nursing facility placement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R2) of 1 residents reviewed received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. *R2's hospital discharge paperwork dated 1/7/24 has instructions for R2 to follow-up for a gastrointestinal(GI) consult scheduled on 3/6/24 at 1:20 PM. R2 did not have the GI consult until 5/15/24. Findings Include: 1.) R2 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, Adjustment Disorder, Anxiety Disorder, Depression, Chronic Pulmonary Disease, Chronic Kidney Disease, Stage 3, Fibromyalgia, Chronic Fatigue, and Morbid Obesity. R2's Quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status(BIMS) score of 15, indicating R2 is cognitively intact for daily decision making. R2's Patient Healthcare Questionnaire(PHQ-9) score during this assessment period is 1, indicating minimal depression. Section GG (Functional…

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

Based on observation, record review and interview, the facility was unaware that the dish machine was not working, and the facility did not have a process in place to ensure the high temperature dish machine was properly working for 1 of 1 kitchen which has the potential to affect all 95 residents within the facility. *During an observation of the high temperature dish machine, the temperature gauges outside of the dish machine were not indicating that the dish machine was reaching an appropriate temperature. *The facility did not have a process in place to verify the temperature of the high temperature dish machine. Findings include: The facility police, entitled Food Services Policy and Procedure, revised date 8/21, states: Dish machine wash and rinse water should be maintained at temperatures. Manufacturer's instructions must always be followed. High Temperature Dishwasher (heat sanitization) use hot water to clean and sanitize. The temperature of the final sanitizing rinse must be at least 180F. Prewash cycle - 150F minimum Wash cycle - 160 F minimum Rinse cycle - 160F minimum…

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

Based on observations, interview, and record review the facility does not have a comprehensive water management plan, transmission based precautions for COVID were not followed, and the N95's in use were not fit tested for staff. This deficient practice has the potential to affect all 95 residents residing in the facility at the time of the survey. * The facility does not have a current water management team that meets on a regular basis, there were no flow charts specific to the facility to determine areas of concern or interventions implemented on closed units to prevent the spread of opportunistic pathogens (Legionella) in the facility's water systems, and the water management plan was not included in the facility assessment. * R18 tested positive for COVID-19. Certified Nursing Assistant (CNA)-I and CNA-J were observed entering R18's room without wearing the appropriate personal protective equipment. Staff had not been fit tested for N95's on an annual basis and Registered Nurse-K was observed wearing an N95 mask that RN-K had not been fit tested for. Findings include: The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure residents were protected from potential abuse while an investigation of an allegation of abuse was being conducted for 1 of 2 Facility Reported Incidents reviewed. R34 made the allegation on 2/29/2024 at 7:00 PM that R100 entered R34's room and hit R34 in the head and twisted R34's left arm. R100 was moved to another unit/floor after the incident without increased supervision during the investigation into the allegation potentially putting the eight residents on the unit at risk for abuse. Findings: On 2/29/2024 at 10:23 PM in R34's progress notes, nursing charted around 6:55 PM, the nurse heard a noise of someone yelling and the nurse came out of the nurses' station and saw a Certified Nursing Assistant walking into R34's room to respond to R34. Nursing charted a little time after the nurse saw the supervisor and the police that R34 had called respond to R34 stating another resident had attacked R34. The nurse charted the nurse went to R34's room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all alleged violations involving abuse were reported to the State Survey Agency within the 2-hour time frame for 1 of 2 Facility Reported Incidents reviewed. R34 made the allegation on 2/29/2024 at 7:00 PM that R100 entered R34's room and hit R34 in the head and twisted R34's left arm. The alleged abuse was not reported to the State Agency until 3/1/2024 at 2:05 PM. Findings include: The facility policy and procedure entitled Abuse Mistreatment, Neglect and Misappropriation of Resident/Client Property/Funds, Injury of Unknown Origin dated 9/2024 states: Reporting: When an employee suspects abuse has taken place, the situation and circumstances must be reported immediately to the Administrator or designee. 1. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of property will be reported by Administration to the Division of Quality Assurance (DQA) as soon as required by law.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 admitted to the facility with an indwelling catheter are assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and an indwelling catheter is not used unless there is valid medical justification for catheterization. In addition, the facility did not ensure residents with fecal incontinence and constipation received appropriate treatment and services to restore as much normal bowel function as possible for 1 of 1 (R87) residents reviewed for bowel and bladder. R87 admitted to the facility with a Foley catheter. There was no diagnosis or medical justification for the catheter, no size indicated, and no assessment or plan for removal of the catheter. The facility did not comprehensively assess R87's bowel pattern and a care plan for constipation was not developed. Findings include: R87 admitted to the facility on [DATE] with diagnoses 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.

Based on record review and interview, the facility did not ensure medications were administered timely for 1 (R34) of 6 residents reviewed for medication administration. R34 did not receive 8 PM or bedtime medications until 11:00 PM. Findings: The facility policy and procedure entitled Medication Administration dated 4/2024 states: 10. Miscellaneous: . g) Medication administration times will be a variation of the list below based on resident centered care or will follow a physician's order if a specific time is indicated. PM - 1500-2100 (3:00 PM-9:00 PM), HS (bedtime) - Upon retiring. Surveyor reviewed R34's Medication Administration Record (MAR) for 3/24/2024. Surveyor compared the signatures on the MAR to the nursing schedule for 3/24/2024. Surveyor noted the 8 PM and HS medications were signed out by Licensed Practical Nurse (LPN)-G. LPN-G was on the nursing schedule for the night shift on 3/24/2024 from 11:30 PM to 6:30 AM. On 3/24/2024, LPN-G signed out the following medications: 8 PM -lidocaine patch to be removed. -metoprolol tartrate 25 mg -Senna 8.6 mg HS -atorvastatin 80…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep 2 (R401 and R33) of 5 residents reviewed free from unnecessary drugs. 1. On 3/26/24 R401 was prescribed Memantine 5 mg by mouth every day for depression. Depression was not included on R401's diagnoses. 2. On 5/6/23 R33 was prescribed Phenytoin 100 mg by mouth three times a day for seizures. Seizures was not included on R33's diagnoses. Findings include: 1. R401 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, congestive heart failure, muscle weakness, dementia, and pulmonary hypertension. Surveyor reviewed R401's physician orders and noted on 3/26/24, R401 was prescribed Memantine 5 mg by mouth every day for depression. Surveyor noted R401 did not have a diagnosis of depression. R401's admission MDS (minimum data set) dated 3/29/24 indicates a BIMS (brief interview for mental status) score, which indicates R401 is cognitively intact. R401's MDS indicates she has no hallucinations, delusions, or…

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

Based on observation, interviews and record review the facility did not ensure that drugs and biological's used in the facility were labeled to include the expiration date when applicable, drugs were not expired, and drugs were stored under proper temperature controls for 2 of 4 medication carts and 1 of 2 medications rooms observed. The facility policy titled Medication Administration revised 4/24 documents (in part) . .Policy: The facility following current professional standards of practice, regulations and published drug administration guidelines will maintain a medication administration system that will safely prepare, administer, and store resident medication. 4. Safety j. Expiration dates on all medication packaging/vials/bottles/patches must be checked prior to administration. k. All medication must be labeled and dated when opened. 8. Injections - IM (intramuscular), Subcutaneous and/or Intradermal b. Insulins - follow pharmacy guidelines for expiration after opening. 10. Miscellaneous i). All medications that are stored in refrigerators must have refrigerator temps checked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and facility policy review, the facility failed to timely report an injury of unknown origin to the Administrator and the State Survey Agency for 1 (R4) of 2 sampled residents investigated for injuries of unknown origin. Findings include: The facility policy titled Abuse, Mistreatment, Neglect and Misappropriation of Resident/Client Property/Funds, Injury of Unknown Origin, revised in September 2023, revealed, .5. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of property will be reported by Administration to the Division of Quality Assurance (DQA) as soon as required by law. a) In the SNF, [Skilled Nursing Facility], the initial report will be sent to DQA no later than two (2) hours after the allegation is made if the event(s) that caused the allegation involves abuse or results in serious bodily harm; or no later than 24 hours if the event(s) that caused the allegation does not involve abuse 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, interviews, and facility policy review, the facility failed to prevent further potential abuse of residents following a report of injury for 1 of 2 sampled residents (R4) investigated for abuse. Findings include: The facility's Abuse, Mistreatment, Neglect and Misappropriation of Resident/Client Property/Funds, Injury of Unknown Origin, revised in September 2023, revealed, .1. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff; other residents; consultants or volunteers; staff or other agencies; family members; legal guardians; friends; or other individuals. .5. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of property will be reported by Administration to the Division of Quality Assurance (DQA) as soon as required by law. Further review revealed Investigation: 1. When a specific staff member is implicated in the alleged abuse, the person(s) involved will 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, record review, and facility policy review, the facility failed to ensure nursing staff documented the administration of medication for 1 (R3) of 3 residents sampled for medication review. Findings include: The facility policy titled, Medication Administration, revised in December 2023, indicated, .[Medications] must be signed immediately after administration on the MAR [Medication Administration Record] or TAR [Treatment Administration Record] .A report will be run routinely from EMR [Electronic Medical Record] to monitor for incomplete documentation for MAR/TARs. R3 was admitted to the facility on [DATE] with diagnoses that included, in part, spastic hemiplegia (one-sided muscle tightness/contractions) affecting an unspecified side, quadriplegia (paralysis of all limbs), personal history of traumatic brain injury, an unstageable pressure ulcer of the right upper back, low back pain, hyperlipidemia, cardiac arrhythmia (abnormal heart rhythm), and epilepsy (neurological condition causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation of video footage, and record review the facility did not ensure residents the right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 of 1 (R15) residents' advanced directives reviewed. R15 did not have an advanced directive signed by her Activated Health Care Power of Attorney (AHCPOA) at the time R15 sustained a choking episode which required medical intervention, including Cardiopulmonary Resuscitation. Findings include: R15 admitted to the facility on [DATE] and had diagnoses that included Parkinson's disease, chronic pain syndrome, neurocognitive disorder with Lewy Bodies, Dementia, Degenerative Joint Disease, Depression and Hypertension. The facility policy Emergency Response - Nursing Code One revised 9/19 and reviewed 9/23 documents: Policy: Immediate first aid procedures will be initiated for residents who have been injured or who have suddenly become ill. Procedure: 1. Staff discovering an individual in need of immediate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 self report to the State agency allegations of abuse for 1 (R16) of 4 Residents. R16's allegation of being treated roughly as her shoulder was yanked was not investigated. Findings include: The Abuse, Mistreatment, Neglect and Misappropriation of Resident/Client Property/Funds, Injury of Unknown Origin policy and procedure reviewed 9/23 under reporting documents When an employee suspects abuse has taken place, the situation and circumstances must be reported immediately to the Administrator or designee. 1. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of property will be reported by Administration to the Division of Quality Assurance (DQA) as soon as required by law. 2. In the SNF (skilled nursing facility), the initial report will be sent to DQA no later than two (2) hours after the allegation is made if the event(s) that caused the allegation involves abuse or results in serious bodily harm; or no later than 24 hours in the event(s) that caused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have evidence allegations of abuse were thoroughly investigated for 1 (R16) of 4 Residents reviewed for abuse. R16's allegation of R16's being treated roughly as her shoulder was yanked was not investigated. Findings include: The Abuse, Mistreatment, Neglect and Misappropriation of Resident/Client Property/Funds, Injury of Unknown Origin policy and procedure reviewed 9/23 under action documents 1. Upon receiving a complaint of alleged abuse, a Concern Review Form is completed by the manager/supervisor along with the person who initially reported the allegation of abuse, neglect, injuries of unknown origin or misappropriation of property. 2. The Administrator or designee will be notified immediately of incident. 3. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of property will be reported by, the online reporting system found on the Division of Quality Assurance (DQA) Misconduct Incident Reporting (MIR) system by Administration per State and Federal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 quality of care was provided for 2 (R7 & R11) of 16 Residents. * R7's bowel movements were not being monitored. * There was not an order or comprehensive assessment for R11's urinary culture originally obtained on 8/2/23 and 8/4/23. Findings include: The Facility does not have a bowel monitoring policy. On 9/27/23 at approximately 3:50 p.m. Surveyor was provided with the Workflow for monitoring of No BM (bowel movement) list not dated & signed by CCO (Chief Clinical Officer)-C which documents the following: 1. No BM list pulled daily at about 10:30pm by the supervisor. 2. Supervisor distributes No BM list to each unit nurse, instructing them if unfamiliar with unit or workflow. 3. Unit nurse then assess any resident flagging on the list. a. Can resident reliably remember when last BM was (if uses restroom independently)? b. Assess resident for s/s (signs/symptoms) constipation. c. Administer PRN (as needed) as ordered or other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility did not ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 1 (R8) residents reviewed for splints. R8 did not have splints applied on bilateral arms and hands as care planned. Findings include: R8 admitted to the facility 2/18/20 and has diagnoses that include traumatic brain injury, quadriplegia, spastic hemiplegia, cerebral infarction, and kyphosis. R8's Occupation Therapy evaluation and plan of treatment note dated 7/23/21 documents: Quadriplegia. Contractures right and left elbow and right and left hand. Surveyor was not provided a facility policy and procedure regarding splints prior to the end of survey. R8's current care plan dated 8/5/22 documents: Gentle passive range of motion BUE's (bilateral upper extremities) and BLE's (bilateral lower extremities), then apply forearm/wrist splints with carrot hand splints…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow proper sanitation in accordance with professional standards for food service safety to ensure dishes and utensils were properly sanitized by the facility's dishwashing machine. This had the potential to affect 103 of 119 Residents who receive nutrition orally from food prepared in the kitchen. The wash temperature did not meet manufacturer's minimum recommendations for proper washing. Staff were observed to put away dishware and utensils that were washed below the minimum recommended temperature of 160 degrees for the wash cycle. Findings Include: On 12/19/22 at 10:33 AM dishwashing was observed in the kitchen via the dishwasher. The dishwasher had instructions on it that read: wash minimum 160 degrees, rinse minimum 180 degrees. Kitchen Manager-T was observing the dishwasher with the surveyor and the temperature of the wash cycle only reached 140 degrees and said it should be 160 degrees. Staff had already put away various kitchen…

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

Based on observations, record review and interviews with staff and residents, the facility did not always ensure that they made prompt efforts to resolve grievances regarding cold food being served to residents and the appearance of the front entrance to the facility. This was expressed during the Resident Council meeting where 5 residents were in attendance and during 3 individual interviews out of a sample size of 24 residents. Resident Council members expressed concerns to Administration staff during Resident Council Meetings in August, September, October and December, 2022 regarding being served cold food and concerns with cigarette butts not being disposed of properly near the front entrance to the facility. Individual interviews were conducted with residents during the survey and statements were made that residents are still being served cold food. Observations were made of residents being served cold food as well as the facility entrance remained with several cigarette butts thrown on the ground, sidewalks and bushes. This is evidenced by: Surveyors interviewed various…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 all drugs and biologicals were in locked compartments for 2 of 6 units potentially affecting 31 of 119 residents. The medication carts on Park View-1 and Terrace View-1 units were observed to be unlocked and not under direct observation of authorized staff in an area where residents, other facility staff, and family members could have access to it. Findings include: The facility policy, entitled MEDICATION-STORAGE ON NURSING UNITS revised on 04/2000 states, Medications and biologicals are stored safely, securely and promptly in medication rooms on nursing units, following manufacturer's recommendations or those of the supplier. Medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 2. Only licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications are allowed access to medication. Medication rooms, carts and medication supplies are locked or attended by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that each resident received food that was palatable, attractive and served at an appetizing temperature. This had the potential to affect 103 out of 119 residents at the facility. Findings include: Cross-reference F585 for food complaints related to grievances that were not follow up on. On 12/20/22 at 10:29 AM. R451 attended the Resident Council group and expressed concern the food provided by the facility is cold and is delivered late to the rooms. R451 stated she has talked to staff about this but nothing has changed. On 12/20/22 at 12:47 PM a test tray was taken from the 2 floor food cart. The tray contained 1/2 of a baked potato, a brat, apple crisp, coffee and milk. The potato temperature was 92 degrees and did not taste warm. The brat temperature was 104 and tasted luke warm. The coffee temperature was 120 and was hot. The milk temperature was 50 degrees and cool to the touch but not cold. On 12/20/22 at 1:09 PM R21, who was eating lunch in her room, was interviewed and indicated her potato was cold but the rest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that Residents with limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion for 1 (R11) of 2 Residents reviewed with limited range of motion. R11 was observed not wearing bilateral soft hand splints as recommended by therapy on 12/19/22, 12/20/22, and 12/21/22. Findings include: Facility policy entitled, Therapy Policies and Procedures, revised on 09/2022 documents: 1. Indications for provision and fitting of splints include but are not limited to: a. Contractures and/or high potential to develop contractures . Procedure: Clinicians will follow the recommended procedure when fitting and providing splints: a. Obtain and verify physician's orders and the documented need for the splint . i. Apply the splint as ordered . Along with this policy, Surveyor was given a document entitled, Supportive and Protective devices, upper extremity, physical therapy, which was revised 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 interview and record review, the Facility did not provide dialysis services consistent with professional standards of practice for 1 (R70) of 3 Residents reviewed for dialysis. * R70 receives dialysis three times per week. R70's dialysis center communication records are not consistently completed by Facility nurses. Findings include: R70 was admitted to the facility on [DATE]. R70's diagnoses included chronic renal disease with dependence on renal dialysis. Surveyor reviewed R70's medical record, including physician's orders. R70's physicians orders indicate that R70 attends receives outpatient renal dialysis on Monday, Wednesdays and Fridays. On 12/22/22, Surveyor requested R70's dialysis communication forms that are to be completed on R70's dialysis days from 7/14/22 to 12/22/22. Facility provided R70's dialysis communication forms for the following dates: 7/22/22, 8/3/22, 8/5/22, 8/8/22, 8/12/22, 9/2/22, 9/9/22 and 12/2/22. Surveyor reviewed dialysis communication forms that facility provided.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of entrapment and review the risk & benefits for 1 (R80) of 1 Residents observed having bed rails. Examples of bed rails include but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. R80 was observed to have bilateral grab bars to upper bed without an assessment. Findings include: R80 was admitted to the facility on [DATE] with diagnoses that include: Quadriplegia, Anoxic Brain Damage and Chronic Respiratory Failure with ventilator dependency. R80's MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 10/07/2022 documents R80 needs total staff assistance for all activities of daily living and bedrails are not in use. On 12/19/22 at 11:05 AM, Surveyor observed R80 lying in bed on back with bilateral grab bars to the upper portion of the bed. R80's bilateral upper extremities were contracted. On 12/21/22 at 7:58 AM, Surveyor observed R80 lying in bed on back 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 ensure 1 (R52) of 5 residents reviewed for unnecessary medications had adequate behavior monitoring while receiving psychotropic medications. *R52 received psychotropic medications without adequate behavior monitoring. Findings include: R52 was admitted to the facility on [DATE]. R52 has diagnoses of Vascular Dementia, Depression and Anxiety disorder. R52 receives psychotropic medications including Sertraline and Clonazepam on a daily basis. On 12/22/22 at 10:25 AM. Surveyor reviewed R52's medical record. Surveyor asked DON (Director of Nursing) -B where behavior monitoring would be located in the medical record. DON-B told Surveyor that this information would be documented by nursing staff in the MAR (Medication Administration Record). Surveyor asked DON-B what the expectation would be for behavior monitoring for a resident receiving psychotropic medications. DON-B told Surveyor residents receiving psychotropic medications should have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were free of significant medication errors for 1 (R484) of 1 residents reviewed for insulin administration. On 12/20/2022 at 8:27 AM, R484 was administered 6 units of Levemir insulin (long-acting insulin) instead of the physician ordered, 6 units of Lispro (short acting insulin). Findings include: The facilities policy, entitled Medication Administration, revised on 9/2019 states: The facility following current professional standards of practice, regulations and published drug administration guidelines will maintain a medication administration system that will safely prepare, administer, and store resident medication. V. Medication Administration: A. The Nurse must observe 6 rights of medication pass: 1. The right resident 2. The right time 3. The right route 4. The right medication 5. The right dosage 6. The right dosage form B. The nurse must verify the medication label with the Medication Administration Record (MAR) 3…

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