Beckley Healthcare Center

Based on observation, record review, and staff interview, the facility failed to ensure medications were labeled properly. A multi-dose vial of insulin had two (2) different dates to indicate when the vial had been opened and two (2) different dates to indicate when the vial would expire. This was a random opportunity for discovery. Resident Identifier: #90. Facility Census: 138. Findings included: a) Resident #90 On 01/12/2026 at 10:23 AM, the F even medication cart was inspected. Registered Nurse (RN) #29 was in attendance. A multi-dose vial of Humulin Regular insulin for Resident #90 was noted to have two (2) dates to indicate when the vial had been first accessed and two (2) dates to indicate when the vial would expire. On the box were written the opening date of 12/10/25 and expiration date of 01/07/26. An opening date of 01/04/26 and expiration date of 02/02/26 were also written on the box. These dates were also written on the vial itself. The box had been filled by the pharmacy on 11/22/25. According to the Humulin Regular insulin package insert, available on the Food and…

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

Based on record review and staff interview, the facility failed to offer the pneumococcal vaccination to Resident #4. This was true for one (1) of five residents reviewed under the care area of infection control. Resident Identifier: #4. Facility Census: 138. Findings Include: a) Resident #4 On 01/05/26 at 2:30 PM, a record review was completed for Resident #4. The review found Resident #4 was eligible for a pneumococcal 20 vaccination in 09/2025. However, the resident was not offered the pneumococcal vaccination. On 01/06/26, at 1:30 PM, Corporate Nurse #220 confirmed the vaccination was not offered to the resident.

Based on record review and staff interview, the facility failed to ensure enteral (tube) feeding was provided in accordance with professional standards of practice. Documentation of the amount of enteral feeding infused was not accurately recorded. This deficient practice had the potential to affect (2) of (2) residents reviewed for the care area of tube feeding. Resident identifiers: #1 and #8. Facility census: 139. Findings included:a) Resident #8 Review of Resident #8's physician's orders showed the following order written on 01/31/25, Enteral Feed Order one time a day, Jevity 1.5 @ [at] 80 ml/hr [milliliters per hour] x [times] 10 hours via pump, up at 9 PM down at 9 AM or when total volume infused 800 ML to provide 1200 calories. to provide 1400 ml total volume, 2100 kcals [calories]. The administration times were 9:00 AM and 9:00 PM. The following order was also written on 01/31/25, Enteral Feed Order one time a day at 9:00 PM, confirm rate programmed at 80 m/hour, confirm total volume programmed in at 800 ml, and clear volume fed in the last 24 hours back to 0. 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 observation, staff interview, the facility failed to ensure that baking pans were stored in a sanitary manner by stacking them while still wet (wet nesting). This practice had the potential to contaminate food-contact surfaces and cause foodborne illness. This failed practice had the potential to affect more than a minimal number of residents residing in the facility. Facility census: 139.Findings include: On 09/08/2025 at 10:29 AM, during a kitchen observation with the Dietary Manager, two (2) baking pans were observed stacked while wet. Wet nesting creates an environment that can support bacterial growth and contaminate food prepared in the pans.On 09/08/2025 at 10:42 AM, the Dietary Manager confirmed the pans should have been completely dried prior to storage and stacking. The pans were removed and rewashed at that time.

Based on observation and staff interview, the facility failed to ensure safe infection control practices were followed to prevent the spread of diseases and infections. This was a random opportunity for discovery and has the potential to affect more than a limited number of residents. Facility Census: 139. a) Ice Chest On 9/08/25 at 3:30 PM an observation of the ice chest on F wing of the facility found the scoop for the Ice was stored in the chest with the clean Ice. An immediate interview with Registered Nurse #300 confirmed the scoop was not stored properly to prevent the spread of infection.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure Resident #151's physician orders reflected her wishes concerning the end of life care. This was true for one (1) of five (5) residents reviewed for the care area of advance directives during the long term care survey process. Resident identifier: #151. Facility census: 139. a) Resident #151 A review of Resident #151's medical record on [DATE] found a Physician Orders for Scope of Treatment (POST) form which was completed by the resident on [DATE] and signed by the Nurse Practitioner on [DATE]. On this form Resident #151 indicated she did not want Cardiopulmonary Resuscitation (CPR) should her heart stop. She also indicated she would want full intervention prior to her heart stopping. Further review of the medical record found a physician's order dated [DATE] which read CPR. This order directed nursing staff to perform CPR on the resident should her heart stop. This order did not align with the resident's directive contained on the post…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview and policy review the facility failed to implement their Abuse Prohibition policy in regards tot he reporting of neglect. This was a random opportunity for discovery and was true for Resident #145. Resident Identifier: #145. Facility Census: 139. a) Policy Review A review of the facility's policy titled, Abuse, Neglect, and Misappropriation found the following pertaining to the identification and reporting of abuse: IV Identification of Incidents and allegations 1. The accurate and timely identification of any even which would place our residents at risk is a primary concern of the facility. 2. The following procedures will assist the staff in the identification of incidents and direct them to the appropriate steps of intervention. a. Each occurance of resident incident, bruise, abrasion or injury of unknown source, or report of alleged abuse, neglect or misappropriation of funds will be identified and reported to the supervisor and investigated timely. b. The supervisor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview the facility failed to identify and report a situation of potential neglect. This was a random opportunity for discovery found during the long term care survey process. This was true for Resident #145. Resident Identifier: #145. Facility Census: 139. a) Resident #145 Resident #145 was selected as a closed record review for the care area of hospitalization during the long term care survey process. A record review completed during the investigation of this care area found the resident was sent to the emergency room (ER) on 07/18/25. The transfer form completed by the facility indicated the resident was sent to the local hospitals ER at 1:10 pm on 07/18/25. The reason for the transfer was listed as, unresponsive. Further review of the medical record found an Emergency Department Record from the local hospital in the scanned documents in the medical record. A review of the document found it was faxed to the facility on [DATE] at 8:30 am. This document had been scanned into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident interview, record review, and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment in the area of dialysis for one (1) of one (1) residents reviewed for the care area of dialysis. Resident Identifier: #135. Facility census: 139. Findings included: a) Resident #135 During an interview on 09/08/25 at 4:14 PM, Resident #135 stated he was receiving dialysis treatments. Review of Resident #135's physician's orders showed the resident had been receiving dialysis treatments since admission on [DATE]. Resident #135's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 08/27/25 indicated the resident was not receiving dialysis treatments. On 09/09/2025 at 1:10 PM MDS Nurse #182 confirmed Resident #135's MDS with ARD 08/27/25 was incorrect and should have indicated the resident was receiving dialysis treatments. No further information was provided through the completion of the survey process.

Based on record review, observation and staff interview the facility failed to ensure Resident #16's care plan in regards to falls was implemented. This was true for one (1) of five (5) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifier; #16. Facility Census: 139. a) Resident #16 A review of Resident #16's medical record found the following care plan: Focus Statement (First Name of Resident #16) has had falls and is at risk for further falls secondary to dementia with severe impaired cognitive function, unsteadiness on feet, muscle weakness, episodes of incontinence, difficulty hearing, episodes of pain. (Resident #16) has hypertension, panic disorder, anxiety, osteoarthritis, anemia, depression, hx of CVA. She has use of medications that carry side effects that increase risk for falling. Resident has poor safety awareness. Date Initiated: 09/15/23.Goal associated with this Focus Statement: (First Name of Resident #16) will not sustain major injury related to falls through review date Date Initiated: 09/15/2023 Revision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to store medications in accordance with accepted standards of practice. A multiuse vial of Tuberculin Purified Protein Derivative was not dated when opened. Facility census: 139.Findings included: a) Medication Room On 09/09/2025 at 8:22 AM, the building 2 medication room was inspected with Licensed Practical Nurse (LPN) #84 in attendance. In the medication room refrigerator was an opened multiuse vial of Tubersol Purified Protein Derivative that had not been dated when opened. This was confirmed by LPN #84. The vial was delivered by the pharmacy on 07/09/25. Tubersol Purified Protein Derivative is used to screen for tuberculosis infection. According to the medication package insert, available on the Food and Drug Administration (FDA) Website, a vial of Tubersol which has been entered and in use for 30 days should be discarded. No further information was provided through the completion of the survey process.

Based on record review and staff interview the facility failed to notify Resident #114's attending physician of a urine culture which identified the resident of having ESBL in her urine. This was true for one (1) of five (5) residents reviewed for the use of a catheter during a complaint survey. Resident identifier: #114. Facility Census: 145. a) Resident #114 A review of Resident #114 medical record found since 01/01/25 Resident #114 had two (2) urine cultures ordered. The first was ordered on 02/26/25 and was obtained on 02/28/25 as directed by the order. A review of the results for this urine culture found the following, .ATTN. ESBL !!! Follow Contact Precautions. The results of this culture were verified on 03/03/25 and had a print date and time of 03/04/25 at 6:03 am. Handwritten on the lab result was the following, 03/18/25 5:30 PM DR. (Last Name of attending physician) notified order to change F/C (foley catheter) tonight and obtain UA and C and S. This note was written by Registered Nurse (RN) #52. Further review of the medical record found the following progress notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview the facility failed to ensure they implemented their infection control policy to prevent the spread of disease. This was found during the investigation of a complaint and had the potential effect more than an isolated number of residents currently residing in the facility. Resident Identifier: #32. Facility Census: 45. Findings Include: a) Resident#32 At approximately 3:15 PM on 06/16/25, Nurse Aide #1 and Nurse Aide #3 was observed entering the room of Resident #32. Nurse Aide #1 was overheard telling Resident #32 they were going to assist her to bed. On Resident #32's door was a sign which indicated someone in the room was ordered enhanced barrier precautions. Beside Resident #32's name on the name plate of the room was a yellow sticker. The yellow sticker identified which of the two residents in the room was ordered EBP. This was confirmed with the Nurse Practice Educator. The signage on the door indicated if the staff were performing care such as a transfer the should wear gloves and a gown. The surveyor obtained permission from Resident…

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

Based on record review and staff interview the facility failed to thoroughly investigate all allegations of neglect thoroughly. This was true for one (1) of 10 reportable incidents reviewed. Resident Identifier: #19. Facility Census: 144. Findings Include: a) Resident #19 A review of a facility reported incident dated 05/22/25 revealed Resident #19's sister had alleged the resident left the facility for a medical appointment and was dirty (socks had not been changed for several days and he was not cleaned up for his appointment). The facility reported the incident involving Resident #19 immediately when it was brought to their attention by the resident's sister. The investigation was reviewed. Statements were taken from the staff who were working with the resident prior to him leaving for his appointment. They indicated the resident was clean and dry when he left the facility. The facility indicated the allegation was no not verified due to the statements taken from the resident, the resident's sister, and the facility staff. The statement taken by the facility indicated the sister…

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

Based on record review and staff interview the facility failed to ensure Resident #114's lab work was addressed and acted upon timely. In addition the failure to treat the Urinary Tract Infection (UTI) identified by the lab testing caused a delay in Resident #114 receiving a required procedure to remove kidney stones. This was true for one (1) of five (5) residents reviewed for the use of a catheter during a complaint survey. Resident #114. Facility Census: 145. a) Resident #114 A review of Resident #114 medical record found since 01/01/25 Resident #114 had two (2) urine cultures ordered. The first was ordered on 02/26/25 and was obtained on 02/28/25 as directed by the order. A review of the results for this urine culture found the following, .ATTN. ESBL !!! Follow Contact Precautions. The results of this culture were verified on 03/03/25 and had a print date and time of 03/04/25 at 6:03 am. Handwritten on the lab result was the following, 03/18/25 5:30 PM DR. (Last Name of attending physician) notified order to change F/C (foley catheter) tonight and obtain UA and C and S. This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interviews, the facility failed to ensure Resident #2 was treated with respect and dignity. This was a random opportunity for discovery. Resident identifier: #2. Facility Census: 145. Findings included: a) Resident #2 04/10/25 at approximately 11:00 am the surveyor and the Assistant Director of Nursing (ADON) #47 were walking past Resident #2's room. As the surveyor and ADON #47 were walking past Resident #2's room a nurse-aide was observed standing at the doorway of the room. She yelled into the room, Every time he is in a gown he totals the bed (Totals the bed is often used by staff in healthcare settings to indicate the resident has been incontinent and the fluid and/or stool has soiled the entire bed requiring the entire bed to be changed.) She reentered the room where other exchanges happened between the nurse aide at the door and the nurse aide inside the room. The surveyor was unable to hear the exchanges enough to quote them. The surveyor asked ADON #47 if a resident was in the room. As we reapproached the room, another voice as overheard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident representative interview, and staff interview, the facility failed to allow the resident's representative to make decisions regarding the resident. This was true for one (1) of one (1) resident reviewed for the care area of elopement. The incident was determined to be past non-compliance. The incident occurred on 12/25/24. Staff education to prevent reoccurrences of the incident was completed on 04/07/25. Resident identifier: #78. Facility Census: 145. Findings included: a) Resident #78 The facility's policy and procedure titled, Resident Leave of Absence, with no implementation given, stated that families and friends may escort the resident on an outing with an order from the physician and the approval of the resident's responsible party. Review of Resident #78's medical records showed on 07/19/24 the resident was deemed by the physician to demonstrate incapacity to make medical decisions. A guardian was appointed to make the residents' medical decisions. Review of Resident #78's progress notes showed a nurses note written on 12/25/2024 at 10:55 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.

Based on record review and resident, staff, and family interview, the facility failed to report an allegation of abuse against Resident #48. This was true for one (1) of seven (7) residents reviewed for abuse during the survey process. Resident identifier: 48. Facility census: 145. Findings include: a) Resident #48 Resident #48 has a Brief Interview for Mental Status (BIMS) score of 15, indicating she is cognitively intact, and has been deemed competent to make her own decisions. At approximately 3:00 PM on 04/07/25, an interview was conducted with Resident #48. During the interview, the resident stated, Most of the staff are good to me but stated there was one she recently had an incident with. The resident stated there was a Nurse Aide (NA) that came into her room one the night of 03/30/25 into 03/31/25 to provide care for her. The resident stated she had been constipated and was in pain. She stated the NA tried to remove stools from her, but it was causing her pain in the process. She stated, She was trying to get it out of me and it hurt. She was hurting me, and I told her 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.

Based on resident interview, record review and staff interview the facility failed to ensure Resident #139 received proper treatment and assistive devices to maintain vision and hearing abilities. This was true for one (1) of one (1) resident reviewed for the vision and hearing care area during the long-term care survey. Resident identifier: #139. Facility Census: 145. Findings Include: a) Resident #139 During an interview with Resident #139 on 04/07/25 at 1:14 pm she stated that she needed new glasses, and she had been waiting a long time to get them, and she did not understand why it was taking so long. An interview with Social Worker #51 on 04/09/25 in the morning found the resident had seen the eye doctor on 01/28/25. Social Worker #51 stated, (Name of the eye doctor) is old school and he mailed the consults back. She indicated there was a nursing date noted 03/25/25 which indicated the consult was received by the facility on 03/25/25. She later provided the consultation from the eye doctor with a notation from facility staff indicating the consult was received 03/25/25. Social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to follow the physician-prescribed therapeutic diet for one (1) of 14 residents reviewed for the care area of food. Resident identifier: #78. Facility census: 145. Findings included: a) Resident #78 Review of Resident #78's physician's orders showed an order written on 01/08/25 for Regular diet, Regular texture, Thin liquids consistency, sugar sub [substitute]; no oranges, OJ [orange juice], bananas, tomatoes. During breakfast observation on 04/09/25 at 8:22 AM, Resident #78 was observed eating in his room. He had a glass of orange juice with his meal. Resident #78's tray ticket stated, Regular. Sugar sub; NO Citrus, Bananas, Tomatoes. Licensed Practical Nurse (LPN) #107 was notified. LPN #107 took the orange juice away and stated that he would get the resident something different to drink. On 04/09/25 at 8:32 AM, the administrator stated the diet restriction of no orange juice was ordered when the resident was considering dialysis treatment. However, the resident had elected to receive hospice services…

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

Based on record review and staff interview, the facility failed to maintain an accurate medical record pertaining to a diagnosis. This was true for 1 (one) of 38 (thirty-eight) records reviewed during this survey process. Resident identifier: #118. Facility census: 145. Findings included: a) Resident #118: As of the date of the survey, the Resident had these diagnoses: Anxiety disorder Excoriation (Skin-Picking) disorder Schizoaffective disorder, bipolar type Mild neurocognitive disorder due to known physiological condition with behavioral disturbance. Physician orders included: Cymbalta Oral Capsule Delayed Release Particles 30 MG (Duloxetine HCI) Give 30 mg by mouth one time a day for depression. Pertinent information from the Care Plan: Focus areas listed included schizoaffective disorder, bipolar type; mild neurocognitive disorder with moderate cognitive impairment, anxiety disorder, depression, skin picking disorder. The resident uses anti-depressant medication: depression. In summary, there was no diagnosis for depression, even though the resident had been prescribed Cymbalta…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident, family, and staff interviews, the facility failed to deploy sufficient nursing staff to meet the needs of the residents residing there. This has the potential to affect more than a limited number of residents. Resident identifiers: #139, #23, #6. Facility census: 181. Findings included: a) Resident #139 At approximately 2:50 PM on 10/07/24, an interview was conducted with the Healthcare Surrogate (HCS) for Resident #139. During the interview, the HCS stated Resident #139 will need help and sometimes it takes a long time for the staff to respond. The HCS stated she was recently visiting the facility and had kids with her during the visit. The HCS stated Resident #139 had a bowel movement in her brief and the call light was pressed so staff could come in and provide incontinence care to the resident. The HCS stated No one came, so after about twenty (20) minutes, I started asking people in the hallway if they could come help her, but they kept telling me they weren't her aide, or they weren't her nurse, and they wouldn't help. The HCS stated, After…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, the facility failed to ensure the environment remains as free of accident hazards as is possible and that each resident receives adequate assistance and devices to prevent accidents. put proper interventions in place to prevent falls with injury for Resident #93, such as upon return from hospitalization status post fall, therapy determined Resident #93 needed maximum assistance with transfers however Resident #93's independent functional status for transfers. This is true for (5) five of seven (7) residents reviewed for falls during the survey process. Resident identifier: Resident #93,#163, #240, #88, and #141. Facility census: 181. Findings included: a) Resident #93 On 10/07/24 at 03:26 PM, a record review was conducted for Resident #93 which revealed two falls occurring on 09/07/24 resulting in Resident #93 being hospitalized status post fall with a diagnosis of wedge compression fracture of first lumbar vertebra with kyphoplasty. Further review of Resident #93's…

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

Based on record review and staff interview the facility failed to develop and implement the individualized comprehensive care plan. This was true for five (5) of twelve (12) residents reviewed for history of illicit drug usage. Resident Identifiers: Resident #40, #52, #70, #91, and #93. Facility Census: 195. Findings Include: a) Resident #40 On 04/15/24 at approximately 10:00 AM during a review of the facility identified residents with a diagnosis of illicit drug use, Resident #40 was identified to have a diagnosis of other psychoactive substance abuse in remission, onset of 08/23/23. During a review of Resident #40's care plan dated 08/24/23, it was identified that the facility failed to develop or implement an individualized comprehensive care plan for this diagnosis. b) Resident #52 On 04/15/24 at approximately 10:00 AM during a review of the facility identified residents with a diagnosis of illicit drug use, Resident #52 was identified to have a diagnosis of other psychoactive substance abuse with psychoactive substance-induced persisting dementia, onset of 12/01/22. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review and staff interview, the facility failed to maintain appropriate infection control standards during a COVID-19 outbreak. This failed practice had the potential to affect more than an isolated number of residents. These were random opportunities for discovery. Facility Census: 195. Findings Include: Upon arrival to the facility on [DATE] at 9:30 PM, Receptionist #8 advised the surveyors the facility was in a COVID outbreak. Receptionist #8 stated, everyone has to wear a surgical mask while in the facility. The Administrator confirmed the COVID outbreak began on 04/04/24. On 04/16/24 at approximately 10:45 AM, a tour of the facility units was conducted. During the tour of the units, nurses' station 1 (one) was approached at approximately 11:10 AM. Two (2) employees were observed with their surgical masks pulled down below their noses. The two (2) employees were Licensed Practical Nurse (LPN) #128 and Nurse Aide (NA) #27. NA #27 stated, I pulled it down I have allergies. On…

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

Based on observation and staff interviews the facility failed to provide a safe, clean comfortable, and homelike environment. A resident room door entrance rubber threshold was partially unadhered from floor and presenting a trip hazard. Room Identifier #E9. Census: 195. Findings Include: During a tour of the facility on 04/16/24 at approximately 12:29 PM the rubber threshold at the door entrance of Room #E9 was observed to be partially unadhered from the floor and laying out in the egress presenting a trip hazard. During an interview with Maintenance Technician (MT) #106 on 04/16/24 at approximately 12:30 PM, he agreed this presented a trip hazard and began to repair the rubber threshold.

Based on observation and staff interview, the facility failed to ensure each resident was afforded the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. The call light system device was not accessible for a resident while in bed. This was a random opportunity for discovery and was true for Resident #109. Resident identifier: # 109. Facility Census: 191. Findings included: a) Resident #109 During a tour of the building, on 02/27/24 at approximately 09:39 AM, Resident #109 was observed to be hanging out of his bed sideways and banging his trash can on the floor. The resident's call light at this time was observed to be attached to the very top of the edge of the head of his bed and out of his reach. When asked if the resident needed assistance, he nodded his head yes. On 02/27/24 at approximately 9:45 AM, the Registered Nurse (RN) #129 stated Resident #109 has behaviors, and he (RN #129) has been back there several times already but would go back again. Upon entering the room, Resident #109 was repositioned in his bed…

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

Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. A closet door was broken, and a Packaged Terminal Air Conditioner (PTAC) unit had several broken grids on top of the unit. This was a random opportunity for discovery. Room identifiers: #C11 and #G7. Facility Census: 191 Findings included: a) C 11 During a tour of the building, on 02/27/24 at 9:34 AM, Room #C11's closet door was observed to be broken and off track. During an interview with Registered Nurse (RN) #3 on 02/27/24 at approximately 9:35 AM, she agreed the closet door was broken. b) G 7 During a tour of the building on 02/28/24 at 11:00 AM, the PTAC unit in Room G7 was observed to have several broken and/or missing grids along the top of the protective covering. During an interview with Regional Admissions Director (RAM) #165 on 02/27/24 at approximately 11:01 AM, she acknowledged the cover had broken/missing areas.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to implement the individualized comprehensive care plan. This was true for two (2) of four (4) resident care plans reviewed for wound care. Resident Identifier: #30 and #201. Facility Census: #191 Findings included: a) Resident #30 On 02/27/24 at 9:30 AM, a review of Reisdent #30's medical record found an active order to cleanse stage 3 to left gluteal fold with in house wound cleanser (IHWC), pat dry, apply bordered dressing every Monday/Wednesday/Friday and PRN as needed and cleanse stage 4 to the sacrum with IHWC, pat dry, apply Hydrofera blue, and cover with border dressing every Monday, Wednesday, Friday and PRN as needed. The facility Skin Care and Wound Management Policy #NS 1400-00 states: Policy: The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds . Each resident/patient is evaluated upon admission and weekly thereafter for changes in skin condition. During an interview 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.

Based on record review and staff interview the facility failed to revise the individualized comprehensive care plan. This was true for one (1) of four (4) resident care plans reviewed for wound care. Resident identifier: #65. Facility Census: #191 a) Resident #65 On 02/27/24 at 9:30 AM, a record review for Resident #65 found an active order to cleanse stage 4 to sacrum with in house wound cleanser (IHWC), pat dry, apply santyl, mupirocin, Hydrofera blue, and cover with border dressing every Tuesday, Thursday, Saturday and PRN as needed. The facility Skin Care and Wound Management Policy #NS 1400-00 stated: The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds . Each resident/patient is evaluated upon admission and weekly thereafter for changes in skin condition During an interview with the Director of Nursing, on 02/27/24 at 3:35 PM, she stated if a new skin wound was identified, the nurse did a Skin Grid Sheet. This was usually identified during a shower or bath. They did a Weekly Skin Check Sheet if the resident has a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to provide treatment and services to prevent or heal pressure ulcers in accordance with professional standards of care. This was true for three (3) of four (4) residents reviewed for wound care. Resident identifiers: #30, #65 and #201. Facility Census: #191 Findings included: a) Resident #30 On 02/27/24 at 9:30 AM, a record review for Resident #30 found an active order to cleanse stage 3 to left gluteal fold with in house wound cleanser (IHWC), pat dry, apply bordered dressing every Monday/Wednesday/Friday and PRN as needed and cleanse stage 4 to the sacrum with IHWC, pat dry, apply Hydrofera blue, and cover with border dressing every Monday, Wednesday, Friday and PRN as needed. There are orders for a wound care consult, air mattress to bed, and an overhead bed trapeze of which all are present. The facility Skin Care and Wound Management Policy #NS 1400-00 states: Policy: The facility staff strives to prevent resident/patient skin impairment and 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 staff interviews and medical record review, the facility administration (Administrator and Director of Nursing) who knew illegal drugs were being used and brought into the facility, failed to administer the facility in such a manner as to protect other residents and promote their highest practicable level of mental and physical well-being. In addition, two (2) residents had to be administered Narcan and sent to the local hospital after using illegal drugs. Resident identifiers: #300 and #301. Facility census: 191. Findings include: a) Resident #300 and #301 Residents #300 and #301 were observed using illicit/illegal drugs at the facility. Both Residents received Naloxone for a suspected drug overdose. Resident #300 was diagnosed with a Fentanyl overdose. According to facility documentation Resident #301 admitted to using Fentanyl. Fentanyl was not prescribed by the facility for either resident. In addition, both residents were observed to be using a marijuana vaping device. No interventions were put 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.

Based on observation and staff interview, the facility failed to ensure the resident call system was operable. This was a random opportunity for discovery. Resident identifier: #125. Facility census: 191. Findings included: a) Resident #125 While obtaining the water temperatures in Room B-5 with the maintenance director (MD) #124. Resident #125 was asking to be pulled up in bed and stated, I can't do it myself. The surveyor asked if she had turned on her call light to ask for help. Observation revealed the call ligh was broken and could not be used to summon help from staff. The resident was unable to say how long the call light had not been working. MD #124 stated he would fix this immediately. At 12:23 PM on 2/28/24, the administrator was advised of the above observations.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment, by failing to maintain a sanitary, orderly, and comfortable interior. This has the potential to affect more than a limited number of residents. This was a random opportunity for discovery. Rooms: A1,A2,A3,A13, B10, C7, D1, D5, E4 E6, E14, E15,F2 ,G1, G3, G Hallway . Facility census: 199 Findings included: A) Room A2 On 01/08/23 at approximately 11:23 AM, a cup full of tobacco was observed as being turned over underneath a bed in the room. A brown substance was observed running out of the cup. Two cups full of tobacco, and tobacco spit, were observed sitting on top of the bedside table. A wet, dark brown substance was observed on the bedside table. The trash cans in the room had not been emptied and were overflowing with trash. There was tobacco, a dark brown wet substance, and excessive debris on the fall mat on the floor. Nursing Home Administrator (NHA) #44 confirmed the condition of the room at approximately 11:32 AM. B) Room A3 On 01/08/23 at…

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

Based on observation, record review, and staff interview, the facility failed to ensure the resident environment remains as free of accident hazards as possible, by failing to keep treatment carts locked when they were not in use and out of sight of nursing staff. The had the potential to affect more than a limited number of residents. This was a random opportunity for discovery. Facility census: 199 Findings included: a) On 01/08/23 at approximately 11:37 AM, an observation of the A,B Treatment Cart found the cart to be unlocked while not in use. The treatment nurses were in the office with the door closed and the cart was observed sitting in the hallway. Treatment supplies such as bandages and ointments were in the cart when it was opened. The Nursing Home Administrator (NHA) #44 confirmed the cart was unlocked at approximately 11:38 AM. At approximately 2:36 PM, the Director of Nursing (DON) #100 presented a list of residents who wander in the facility. According to the list, there were ten (10) residents that reside where the unlocked treatment cart was located.

Based on observation and staff interview, the facility failed to maintain appropriate infection control standards for the storage of a urinary drainage bag for Resident #142, not placing gloves on while preparing a sandwich for Resident #69, and failure to complete hand hygiene during medication administration for Resident #85 and placing a dirty food tray for Resident #142 back on the clean food cart. This was a random opportunity for discovery. Resident identifiers: #142, #69, #85 and #142. Facility Census: 199. Findings included: a) Resident #141 On 01/08/24 at 5:10 PM, Resident #141 was observed propelling herself in the hallway throughout the facility. As Resident #141 propelled herself down the hallway, an observation of her urinary drainage bag touching the floor was made. On 01/08/24 at 5:12 PM, Assistant Director of Nursing (ADON) #184 was notified. ADON #184 stated, let me fix it. On 01/08/24 at 5:20 PM, the Director of Nursing (DON) was notified and confirmed the urinary drainage bag should not be touching the floor. b) Resident #69 On 01/10/24 at 12:12 PM, an observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to treat each resident with dignity and respect by failing to serve meals to Residents #58 and #108 at the same time. Residents #58 and #108 were roommates. This was true for two (2) of two (2) residents observed for dignity and respect. This was a random opportunity for discovery. Resident identifiers: #58, #108. Facility census: 199 Findings included: a) Resident #58 On 01/09/24 at approximately 11:57 AM Nurse Aide (NA) #103 and NA #97 were observed passing lunch trays to residents in their rooms. NA #97 delivered a tray to Resident #58's roommate, returned to the tray cart to retrieve a tray, and delivered it to another room, leaving Resident #58 without a lunch tray. At approximately 12:02 PM, NA #97 delivered a tray to Resident #58. Resident #58 waited 5 minutes to receive a tray after their roommate received theirs. An interview was conducted with NA #97 and NA #103, at approximately 12:05 PM, in which they stated they were delivering trays based on our assignments instead of serving one room at a time. NA #97 and…

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

Based on record review and staff interview, the facility failed to notify the Medical Power of Attorney (MPOA) of a new physician's order for medication for Resident #54. This was true for one (1) of 12 residents reviewed during the survey process. Resident Identifier: #54. Facility Census:199. Findings Included: On 01/08/24 at 1:00 PM, a list of the facility reportables were reviewed. The review found a reportable dated 01/04/24 regarding Resident #54 stating,Healthcare Surrogate reports that facility gave incorrect medication and that facility is creating unnecessary emergency room visits. (Typed as written.) Upon reviewing the current physician's orders, the medication Trazodone (antidepressant) was restarted on 01/05/24 when the resident returned from hospital leave. However, the physician's determination of capacity for Resident #54 was completed on 12/21/23. The resident was determined to not have capacity. The five (5) day follow-up dated 01/08/24 of the reportable listed the outcome/results of investigation states, As a result of the investigation, abuse/neglect was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to develop a comprehensive care plan regarding dialysis for Resident #45 and a new medication for Resident #54. This was true for two (2) of 12 residents reviewed during the survey process. Resident identifiers: #45 and #54. Facility Census: 199. Findings included: a) Resident #45 On 01/09/24 at 10:00 AM, a record review was completed for Resident #45. The resident was readmitted to the facility on [DATE]. The record review found a diagnosis of dependence upon renal dialysis. A physician's order dated 01/06/24 states, Dialysis M (Monday), W (Wednesday), F (Friday) (Name of dialysis center) at 7:20 (telephone number of dialysis center) one time a day every Mon, Wed, Fri. (Typed as written.) Resident #45 was admitted to an acute care facility from 11/21/23 through 01/05/24. However, the resident had received hemodialysis prior to leaving the facility. On 01/09/24 at 2:00 PM, the Director of Nursing (DON) and the Administrator were notified and…

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

Based on observation, record review, and staff interview, the facility failed to ensure the care plans of Residents #4 and #164 were followed or revised to reflect dialysis orders and to address meals while at dialysis.The facility failed to ensure proper equipment was available for residents based on care plans and dialysis orders. This was true for two (2) of two (2) residents reviewed for care plans.Resident identifiers: 4, 164. Facility Census: 199 A) Resident #4 On 01/08/24 at approximately 2:00 PM, a record review was conducted for Resident #4. The review indicated there were no orders for a meal while at dialysis, even though the care plan indicates they should get a meal on Tuesdays, Thursdays, and Saturdays for dialysis appointments. Record review indicated there were no orders in place, nor was the care plan revised to reflect the need for hemostats to be readily available in Resident #4's room, in the instance they were needed. On 01/09/24 at approximately 9:09 AM, an observation was conducted in Resident #4's room. No hemostats were found in the room. An interview was…

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

Based on record review and staff interview, the facility failed to follow physician's orders regarding medication administration for Resident #53, #54, and #108. This was true for three (3) of three (3) residents reviewed during the complaint survey. Resident identifiers: #53, #54, #108. Facility census: 199. Findings included: A) Resident #53 At approximately 01:30 PM on 01/08/23, a record review of the facility's Medication Administration Audit Report was conducted for Resident #53. The report was reviewed from 12/01/23 through 12/31/23 and found the following medications were administered late or missed: Nystatin External Cream 100000 UNIT/GM- Apply topically every shift for Moisture Associated Dermatitis for 14 days, scheduled at 7 AM and 7 PM: - 12/04/23 completed at 10:05 PM, 3 hours and 5 minutes late. - 12/05/23 completed at 1:15 PM, 6 hours and 15 minutes late, and 1:16 AM on 12/06/23, 6 hours and 16 minutes late. - 12/06/23 completed at 3:38 PM, 8 hours and 38 minutes late. 7 PM not given. - 12/08/23 completed at 11:45 AM 4 hours and 45 minutes late, and 10:06 PM, 3 hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for three (3) of three (3) residents reviewed under the care area of dialysis. Resident Identifiers: #4, #164 and #45. Facility Census: 199. Findings Included: a) Resident #4 On 01/09/24 at 11:30 AM, a record review was completed for Resident #4. The review found the resident received renal dialysis weekly on Tuesday, Thursday, and Saturday at 11:45 AM. The review also, found the resident had a port for dialysis and not an arteriovenous (AV) fistula. Resident #4 was interviewed on 01/10/24 at 9:00 AM. The resident was asked do they always keep hemostats available in case of an emergency. The resident responded, I have never seen any. On 01/10/24 at 9:10 AM, Licensed Practical Nurse (LPN) #101 was asked where are the hemostats kept for Resident #4? LPN #101 stated, I don't know .maybe in (Name of Assistant Director of Nursing (ADON) #184) office .I don't know what they are used for. On 01/10/24 at 9:25 AM, ADON #184 was interviewed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to maintain professional standards of practice during medication administration. These were random opportunities for discovery. Resident identifiers: #163, #161 and #28. Facility Census: 199. Findings included: a) Medication Cart On 01/10/24 at 8:36 AM, while observing medication administration on A Wing, Licensed Practical Nurse (LPN) #39 opened the medication cart. Upon opening the medication cart, three (3) pre-poured medications were observed. The first medication cup contained multiple pills inside and LPN #39 stated, those are for Resident #163 .he was in the bathroom. The second medication cup contained multiple pills inside and LPN #39 stated, Resident #161 was still sleeping. The third medication cup contained five (5) red, round pills inside, LPN # 39 stated, those are senna .I'll get rid of them. On 01/10/24 at 8:41 AM, the Assistant Director of Nursing (ADON) #132 was notified and observed the three pre-poured medication cups. ADON #132 stated, those should not be pre-poured and in the…

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

Based on observation and staff interview, the facility failed to ensure the call lights were within reach of Resident #92, #129 and #108 for safety measures. These were random opportunities of discovery. Resident identifiers: #92, #129 and #108. Facility Census: 199. Findings included: a) Resident #92 On 01/08/24 at 11:30 AM, an observation was made of the call light being on the floor by the wall in Resident #92's room. On 01/08/24 at 11:33 AM, the Administrator was notified and clipped the call light to the resident's blanket. b) Resident #129 On 01/08/24 at 11:50 AM, an observation was made of the call light being on the floor beside the bed in Resident 129's room. On 01/08/24 at 11:53 AM, the Administrator was notified and clipped the call light to the resident's fitted sheet. c) Resident #108 On 01/08/24 at 12:00 PM, an observation was made of the call light being on the floor by the wall in Resident #108's room. On 01/08/24 at 12:02 PM, the Administrator was notified and clipped the call light to the resident's fitted sheet. No further information was obtained during the…

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

Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #160. This was a random opportunity for discovery. Resident Identifier: #160. Facility Census: 191. Findings Included: a) Resident #160 On 11/27/23 at 1:00 PM, Resident #160 was lying in bed. Licensed Practical Nurse (LPN) #170 was observed standing while feeding Resident #160. On 11/27/23 at 3:55 PM, the Director of Nursing (DON) was notified and confirmed the staff should not be standing while feeding a resident. No further information was obtained during the survey process.

Based on observation and staff interview, the facility failed to maintain appropriate infection control standards for the disposal of soiled linen. This was a random opportunity for discovery. Resident Identifier: #50. Facility Census: 191. Findings Included: a) Resident #50 On 11/28/23 at 9:13 AM, soiled linens were observed laying on the floor next to bed F-12A. On 11/28/23 at 9:15 AM, Nurse Aide (NA) #129 confirmed the soiled linens were laying on the floor. NA #129 stated, I'm getting ready to pick them up. On 11/28/23 at approximately 9:20 AM, the Director of Nursing (DON) was notified and confirmed soiled linens should not be on the floor. No further information was obtained during the survey process.

Based on observation and staff interview the facility failed to ensure a safe, functional, sanitary environment for residents. This had the potential to affect more than an isolated number of residents. Resident identifiers: #31, #53, and #56. Facility census: 192. Findings included: a) Throughout the survey from 09/18/23 - 09/21/23 various maintenance issues were observed in resident rooms and outside the rooms on the following halls: A, B, C, D, E, F and G. An observation of Resident #31 on 09/18/23 revealed her wheelchair was dirty. Dirt and debris were observed on the wheelchair. Observation of Resident #53 at 11:37 Am on 09/18/23 revealed cracked wheelchair arm. On 09/20/23 during the lunch meal Resident #56 dirty breakfast tray was observed in Resident #30's room. On 09/20/23 at approximately 3:00 PM a soiled tray transport cart with dirty trays was observed sitting in the dining room area of building two (2). The cart was open and trays were accessible to residents passing by. The soiled handling room was observed open at various times on 09/19/23 and 09/20/23. Soiled linen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, care plan review and minimum data set review the facility failed to ensure residents who needed assistance with activities of daily living (ADLs) received the assistance needed for good grooming and hygiene. Resident identifiers: #76, #129, #68, and #145, and #165. Facility census: 92. Findings included: a) Resident #76 During an observation on 09/20/23 at 2:30 PM Resident #76 was in bed with a sheet over him. Licensed Practical Nurse (LPN) #114 was administering the resident's medication. After leaving the room the surveyor commented to LPN #114 about the foul odor in the room. The LPN commented, I'm glad I'm not the only one who thought that he had an odor and needed a shower. Upon entering the room again Resident #76 was asked about getting a bath/shower and he said he would like to have one. b) Resident #145 On 09/20/23 at 1:00 PM Resident #145 was observed in bed and an observation of her feet revealed long toenails. She said she would like to have them cut. c) Resident #165 On…

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

Based on interviews and observations the facility failed to make sure all scales in the building were calibrated to measure residents' weights. In the areas of Hall B and E areas of the facility. This affected 192 residents. Census: 192 Findings included: a) An observation was conducted on 09/18/23 at approximately 10:45 A.M. The Surveyor witnessed the scale in the C Hall was not working properly. The 750 ds (lobat) low battery code was given. The weight was not able to be read. The scale on E Hall displayed 0.6 lbs. (pounds) on the scale and the surveyor pushed Zero the scale out. The scale continued to read 0.6 lbs. This scale appeared broken and needs to be fixed. An observation was conducted on 09/18/23 at approximately 11:15 A.M. The surveyor witnessed and weighed themselves on the scale on G hall was not working properly. The scale was set at .2 lbs. Before weighing. An interview was conducted on 09/18/23 at approximately 10:40 A.M. with the Certified Nursing Assistant #148. He/she stated that the scale is down on C Hall. They were just calibrated a couple weeks ago. I'm 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 staff interview the facility failed to ensure they had sufficient dietary staff to support the functions of the dietary department. This had the potential to affect residents on oral diets. Facility census: 192. Findings included: On 09/19/23 observations revealed lunch on A hall arrived at 1:30 PM. The dietary manager provided a meal service and tray cart delivery time schedule. According to the schedule the lunch service should have began at 12:40 PM on A hall and ended at 12:50 PM. According to the dietary manager the meal that was served for lunch on 09/19/23 was difficult to put on the resident plates. She said serving hot and cold foods together on the plate was difficult plus putting the lettuce and tomato for the hamburgers was a challenge because they do not put those items on the hamburger they lay them on the plate.

Based on observations and interviews the facility failed to adhere to the standard infection control guidelines such as hand hygiene and resident hygiene. This affected 192 residents. Census: 192 Findings included: An observation was conducted 09/19/23 at approximately 10:00 A.M. revealed multiple dirty gloves were found at nurses stations. Certified Nursing Assistant computer areas revealed multiple dirty gloves. Surveyors witnessed multiple Certified Nursing Assistants taking off gloves and placing the soiled gloves in their pockets. An interview was conducted on 09/19/23 at approximately 10:15 A.M. with Certified Nursing Assistant he/she stated I will move the gloves, they know they should not place this here. An observation conducted on 09/19/23 at approximately 10:15 A.M. of the facility revealed many of the employees donning gloves and placing them in pockets without sanitizing. An observation conducted on 09/19/23 at approximately 10:18 A.M. of the facility revealed many of the staff members taking off gloves and not sanitizing hands. An observation was conducted on 09/19/23…

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.

Based on observations and interview the facility failed to maintain all patient care equipment in safe operating condition. This practice had the potential to affect more than an isolated number of residents. Census: 192. Findings included: a) An observation was conducted on 09/18/23 at approximately 10:45 A.M. The Surveyor witnessed the scale on the D Hall was not working properly. The 750 ds lobat code (Low Battery) was given. The weight was not able to be read. The scale on E Hall displayed 0.6 lbs on the scale and the surveyor pushed zero the scale out. The scale continued to read 0.6 lbs. This scale was broken and needs to be fixed. An observation was conducted on 09/18/23 at approximately 11:15 AM The surveyor witnessed and weighed themselves on the scale which determined the E Hall was not working properly. The scale was set at 2 lbs. Before weighing. An interview was conducted on 09/18/23 at approximately 10:40 AM with the certified nursing assistant. He/she stated that the scale is down on C Hall. They were just calibrated a couple weeks ago. I'm not sure why they are 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 staff interview the facility failed to ensure residents were treated with dignity and respect. Observations were made of an that related to not respecting a residents dignity. This was a random opportunity for discovery. Resident identifier: #37. Facility census: 192. Findings included: a) On 09/21/23 at 6:15 AM a tour of the facility revealed Nurse Aide #181 sitting in Resident #37's room with feet propped up in a chair on a cell phone. On 09/2123 at 7:00 AM the Director of Nursing (DoN) indicated she was not pleased with the observation that was made and would be talking with the direct care staff regarding use of cell phone and being in a resident room on the phone when the resident is sleeping.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify the resident's change of condition to the physician. This affected one (1) out of six (6) residents. Resident identifier: #195. Census 192. Findings included: a) Resident #195 A record review was conducted on 09/20/23 for Resident #195. The record review revealed the resident was transported to a local emergency department on 07/11/23 due to being unresponsive at 9:09 PM on 07/11/23. A record review for Resident #195 revealed the resident returned to the facility on [DATE] at 4:30 A.M. unresponsive. The record review revealed a progress note that stated, the resident would not open her eyes on verbal commands. The note said the resident remained in bed with eyes closed. she remains in bed with eyes closed. A record review was conducted on 09/20/23 at approximately 9:25 A.M. of Resident #195 it revealed the resident stood up and fell from her scoop chair at 3:25 P.M. on 07/12/23. There was no documentation the physician was notified 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.