Majestic Care of Beckley

Based on observation, record review, and staff interview, the facility failed to ensure each resident was treated with dignity and respect. Resident #48 visibly soiled for an extended period of time in the little dining room on the third floor. This was a random opportunity for discovery. Resident identifier: #48. Facility census: 51. Findings included: a) Resident #48 At approximately 9:15 AM on 08/13/24, this surveyor entered the dining room on unit 3-C of the facility, where Resident #48 was parked in the geri chair. Resident #48 was noted to be in the geri chair, with the lap tray down, and his pants visibly soiled/wet in the groin area. At approximately 9:21 AM, Resident #48 attempted to stand up from the geri chair but was unable to due to the lap tray. At this time, Resident #48's right leg began to bounce up and down, anxiously. The resident attempted to stand again, unsuccessfully, at which time his right leg began to bounce up and down at a faster pace. Resident #48 attempted to stand a third time and was unsuccessful, at which time his leg bounced up and down faster. 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 and staff interview the facility failed to ensure the residents were provided a safe, clean, comfortable and homelike environment. A wall was in poor repair in a residents room. This was a random opportunity for discovery during the long term care survey process. Identifier: Room C 316. Facility census: 51. Findings included: a) Room C 316 During a tour of the facility, Room C 316 was observed to have an area on the wall under the air conditioner which was approximately two (2) feet by two (2) feet in size which was not covered by paint and exposed the white wall plaster underneath. This area was extremely rough in texture and some of the wall plaster was missing. On 08/13/24 at 12:53 PM, during an interview with Certified Nursing Assistant #8, she agreed the wall area was not a pleasant homelike environment and stated she would let maintenance know. During an interview with the Director of Nursing (DON) on 08/13/24 at 1:03 PM the DON stated she would also make maintenance aware of the wall condition.

Based on observation, record review, and staff interview, the facility failed to ensure each resident was free from abuse and neglect by leaving Resident #48 visibly soiled for an extended period of time. This was a random opportunity for discovery. Resident identifier: 48. Facility census: 51. Findings included: a) Resident #48 At approximately 9:15 AM on 08/13/24, this surveyor entered the dining room on unit 3-C of the facility, where Resident #48 was parked in a geri chair. Resident #48 was noted to be in the geri chair, with the lap tray down, and his pants visibly soiled/wet in the groin area. At approximately 9:21 AM, Resident #48 attempted to stand up from the geri chair but was unable to due to the lap tray. At this time, Resident #48's right leg began to bounce up and down, anxiously. The resident attempted to stand again, unsuccessfully, at which time his right leg began to bounce up and down at a faster pace. Resident #48 attempted to stand a third time and was unsuccessful, at which time his leg bounced up and down faster. At this time, Resident #48 attempted to stand…

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 properly investigate an allegation of injury of unknown origin. This was a discovered during an investigation of a facility reported incident. Resident identifier: #55. Facility census: 51. Findings include: a) Resident #55 On [DATE] 8:24 AM, a review of care plan revealed the following: -Resident exhibits behaviors of refusing showers, treatments and/or medications. Her guardian has reported this is a lifelong issue. Resident will also make false accusations against staff. Resident has stated on several occasions staff pull her up by her arms and upon further investigation will identify someone has not worked in the facility for a long period of time. Effective [DATE] -Resident is at risk for cognitive loss, alteration in thought process related to diagnosis of Affective Psychosis, Mild Cognitive Disorder, Dementia, Bipolar Disorder and recurrent depression. Effective [DATE] -Resident's community history involves surviving a rape, house fire…

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 the admission Preadmission Screening and Resident Review (PASSR) contained all pertinent diagnoses. This was true for one (1) of seven (7) PASSRs' reviewed during the long term care survey process. Resident Identifier: #42 Facility Census: #51 Findings Include: a) Resident #42 On 08/13/24 at 8:23 AM record review shows Resident #42 has the following medical diagnosis: Schizophrenia 12/10/19 Dementia 12/10/19 Intellectual disabilities 08/28/23 The PASSR provided by the Director of Social Work #63, which was dated 10/22/19 did not contain a dementia diagnosis. The following diagnoses were on the PASSR: mental disorders delusions Schizophrenic disorder Schizophrenia Unspecified neurocognitive disorder unspecified symptoms and signs involving cognitive functions and awareness This was confirmed with the Director of Social Work on 08/23/24 at 3:30 PM, who agreed that the dementia diagnosis should have been on the PASSR dated 10/22/19.

Based on resident interview, staff interview and observation, the facility failed to update and implement a person-centered comprehensive care plan to meet the resident preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Resident identifiers: Resident #26 and Resident #48. Facility Census: 51. Findings include: a) Resident #26 On 08/12/24 at 10:18 AM, an observation and interview was conducted with Resident #26 which revealed Resident #26 had whiskers on his face, hair was unkempt and clothing was stained. In addition, this Surveyor smelled a strong odor. Upon entering the room, Resident #26 stated I need a hair cut, shave and I shit. I need a shower too. On 08/13/24 at 11:25 AM, a record review for Resident #26 was conducted revealing a shower schedule for every Wednesday and Saturday, evening shift. In addition, Resident #26 is noted to be an assist of 1 (one) person for bathing. Upon reviewing the Nurse Assistant (NA) documentation for the month of July 2024, multiple refusals by Resident #26 were noted to be documented, 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 staff interview, the facility failed to ensure a resident did not have an Activities of Daily Living (ADL) decline unless unavoidable, due to Resident #48 being physically restrained in a geri chair with a lap tray. This was true for one (1) of one (1) residents reviewed for ADL decline during the survey process. Resident identifier: 48. Facility census: 51. Findings include: A) Resident #48 At approximately 12:00 PM on 08/12/24, during review of the resident matrix (resident census and conditions of residents) provided by the facility, it was determined the facility had Resident #48 marked as being in physical restraints. Upon review of Resident #48's record, it was determined the resident was in a geri chair with a hard lap tray across it, preventing the resident from standing. The order for the restraint reads as follows: When OOB (Out of Bed): GERICHAIR BILAT HIPSTERS & LAP TRAY FOR SAFETY. CHECK RES (Resident) Q30 MIN (Every 30 minutes) FOR PROPER POSITIONING OF RES & LAP TRAY…

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 Actiity of Daily Living (ADL) care for dependent residents, by leaving Resident #48 soiled for an extended period of time. This was a random opportunity for discovery. Resident identifier: 48. Facility census: 51. Findings include: A) Resident #48 At approximately 9:15 AM on 08/13/2024, this surveyor entered the dining room on unit 3-C of the facility, where Resident #48 was parked in the geri chair. Resident #48 was noted to be in the geri chair, with the lap tray down, and his pants visibly soiled in the groin area. At approximately 9:21 AM, Resident #48 attempted to stand up from the geri chair but was unable to due to the lap tray. At this time, Resident #48 ' s right leg began to bounce up and down, anxiously. The resident attempted to stand again, unsuccessfully, at which time his right leg began to bounce up and down at a faster pace. Resident #48 attempted to stand a third time and was unsuccessful, at which time his leg bounced up and down faster. At this time, Resident #48 attempted to stand up from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to provide a dignified dining experience for four (4) of 50 residents. These were random opportunities for discovery. Resident Identifiers: #8, #1, #41, #50 and #30. Facility Census: 50. Findings Included: a) Resident #8 On 08/28/23 at 12:38 PM, an observation of lunch trays being passed in dining room [ROOM NUMBER]B was made. Resident #8 was sitting at the same table as Resident #14. Resident #14 received his lunch tray first. After approximately 10 minutes, Resident #8 received her lunch tray. The lunch trays were being passed by Nurse Aide (NA) #70 and NA #88. On 08/28/23 at 1:15 PM, the Hospital Administrator Assistant #62 was notified and stated, they have been trained .I don't know why they didn't do it correctly. b) Resident #1 On 08/28/23 at 12:38 PM, an observation of lunch trays being passed in dining room [ROOM NUMBER]B was made. Resident #1 was sitting in a wheelchair at the same table as Resident #22. Resident #22 received his lunch tray…

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 staff interview the facility failed to provide a safe and comfortable homelike environment by not completing repairs to the physical appearance of the facility. This was a random opportunity for discovery. Facility Census: 50 Findings included: a) Unit B dining room On 08/28/23 at 1:00 PM and 08/29/23 at 9:30 AM, a walk through tour of the facility found the Unit B dining room to be clean, however there were physical repairs that are needed in order to provide a safe and comfortable homelike environment. 1) Unit B dining room has a large section of the tile missing from the middle of the floor. This is located directly in front of the television. 2) As you enter the dining room there is tile missing on the right walk way along the window. 3) There is a bolt missing from the hand rail on the left walkway along the window which causes the hand rail to be unsecured representing an unsafe environment. 4) There is a large crack in the tiles running across the dining room floor from left…

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 #28 when administering medications while the resident was eating in the dining room in the presence of two table mates. This was a random opportunity for discovery. Resident identifier: #28. Facility census: 51 Findings included: a) Resident #28 On 09/20/22 at 12:38 PM Licensed Practical Nurse (LPN) #30 entered the dining room on B hall with the medication cart. LPN #30 then walked over to the dining table where Resident #28 was sitting eating his lunch. LPN #30 stood over top of Resident #28 and came in from the Resident's right side with a spoon full of pudding containing mediation in her hand. LPN #30 waved the spoon in front of Resident #28's face startling him. LPN #30 stated to Resident #28, Here, look here, take this. and proceeded to place the spoonful of pudding with medications into the Residents mouth as he opened his mouth to take a bite of noodles he was eating. During an interview at 12:40 PM, LPN #30 stated, I gave him [Resident #30] Clonidine 0.1mg in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, facility documentation review, staff interview and resident interview, the facility neglected to use a lift to transfer a Resident resulting in a fractured foot. The facility also neglected to provide pain medication for a resident with a fractured foot. This was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #18. Facility census: 51. Findings included: a) Lift Review of Resident #18's medical record showed a physician order with a start date of 01/31/22 and an end date of 07/22/22. The physician order stated, May use Sara lift for transfers if Resident tolerates if not use maxi lift. Facility documentation review showed a reportable dated 07/19/22. The investigation notes dated 07/22/22 completed by Social Worker #27 stated, It was determined that this fracture occurred during a transfer from Resident #18's bed to the shower chair. Resident #18 identified both Nurse Aides (NA) Nurse Aide #92 and Nurse Aide #73 as the two (2) that transferred her…

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 interview and staff interview the facility failed to report an allegation of emotional abuse within the appropriate timeframe. The failed practice was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #18. Facility census: 51. Findings included: a) Resident #18 During an interview on 09/21/22 at 10:00 AM, Resident #18 stated that two (2) Nurse Aides broke her heel and her heel turned black almost immediately. Resident #18 stated what bothered me the most was the Nurse Aides laughed at me when they hurt me, so I replied I was going to sue them and they replied go ahead we don't got no money. Facility documentation review showed a reportable dated 07/19/22. Included with the reportable was Resident #18's documented statement when interviewed by Social Worker #27 about the incident that occurred on 07/17/22 when her foot was fractured. Resident #18 stated to Social Worker #27 twice in the documented statement on 07/20/22, They twisted it and then laughed at me. I told them that it hurts and they just laughed at me. During…

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 interview and staff interview the facility failed to investigate an allegation of emotional abuse. The failed practice was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #18. Facility census: 51. Findings included: a) Resident #18 During an interview on 09/21/22 at 10:00 AM, Resident #18 stated that two (2) Nurse Aides broke her heel and her heel turned black almost immediately. Resident #18 stated what bothered me the most was the Nurse Aides laughed at me when they hurt me, so I replied I was going to sue them and they replied go ahead we don't got no money. Facility documentation review showed a reportable dated 07/19/22. Included with the reportable was Resident #18's documented statement when interviewed by Social Worker #27 about the incident that occurred on 07/17/22 when foot was fractured. Resident #18 stated to Social Worker #27 twice in the documented statement on 07/20/22, They twisted it and then laughed at me. I told them that it hurts and they just laughed at me. During an interview on 09/21/22 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 medical record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one (1) of 20 residents in the long-term care survey sample. Resident identifier: #47. Facility census: 51. Findings included: a) Resident #47 Review of Resident #47's medical records showed the resident had experienced a fall on 08/16/22. Resident #47's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 08/26/22 stated the resident had no falls since the prior MDS assessment, which was on 05/18/22. During an interview on 09/21/22 at 1:30 PM, the MDS nurse confirmed Resident #47's MDS assessment with ARD 08/26/22 was incorrect and should have showed the resident had experienced a fall. .

Based on medical record review and staff interview, the facility failed to ensure the development of the comprehensive care plan for one (1) of one (1) residents reviewed for the care area of elopement. Resident identifier: #29. Facility census: 51. Findings included: a) Resident #29 Review of Resident #29's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/22/22 showed the resident demonstrated the behavior of wandering daily during the look back period. Upon review, Resident #29's comprehensive care plan was not found to have a focus or interventions related to the behavior of wandering. During an interview on 09/20/22 at 2:01 PM, the administrator confirmed Resident #29's care plan did not have a focus or interventions related to the behavior of wandering. The administrator stated the resident goes up and down the hallway in his wheelchair. .

Based on medical record review and staff interview the facility failed to revise a comprehensive care plan to include use of hipsters as a safety intervention for the problem area of falls for Resident #23. This was discovered for one (1) of three (3) residents reviewed for the care area of accidents. Resident identifier: #23 Facility census: 51 Findings included: a) Resident #23 During a medical record review on 09/21/22, it revealed Resident #23 had an order to apply hipsters when out of bed. The care plan had not been revised to include the use of hipsters while out of bed as a safety intervention for falls. In an interview with the Director of Nursing (DON) on 09/21/22 at 2:40 PM, verified the care plan had not been revised to include the order for hipsters to be applied when Resident #23 was out of bed. .

Based on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was discovered for one (1) of three (3) residents reviewed for the care area of limited range of motion. The order to apply hipsters to Resident #23 when out of bed was not being followed. Resident identifier: #23 Facility census: 51 Findings included: a) Resident #23 During a medical record review on 09/21/22, revealed Resident #23 had an order for hipsters to be applied when resident was out of bed. Observations on 09/21/22 at 2:12 PM with Health Service Workers (HSW) #86 an #99, verified hipsters had not been applied to Resident #23 while out of bed. .

Based on observation, resident interview and staff interview, the facility failed to ensure the resident enviroment of which the facility had control was free from accident hazards. This was a random opportunity for discovery and had the potential to effect more than a limited number of residents. Resident #38. Facility Census: 51. Findings Included: a) Resident #38 On 09/19/22 at 11:56 AM, an observation was made while interviewing Resident #38. A medication cup containing pills was sitting on the over bed table by the resident's bed. There was no indication of what the pills were as well as how long the medication cup had been sitting there. On 09/19/22 at 12:00 PM, Resident #38 stated, they just left them there .I haven't taken them yet. On 09/19/22 at 12:22 PM, Licensed Practical Nurse #108 confirmed the medication should not have been left at bedside. On 09/20/22 at 3:13 PM, the Administrator was notified and confirmed the medication should not have been left at the bedside of Resident #38. On 09/20/22 at 3:18 PM, a list of wandering residents on the C hall was requested from…

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

Based on observation and staff interview the facility failed to maintain appropriate storage procedures for a bilevel positive airway pressure device (BiPap) mask for Resident #43. This was a random opportunity for discovery and the potential to affect only a limited number of residents. Resident identifier: #43. Facility census: 51. Findings included: On 09/19/22 at 12:00 PM, an observation was made of Resident #43's bilevel positive airway pressure (BiPap) device mask laying in the floor face down under the Resident's bed. The mask was not contained in a storage bag or any type of protective covering. On 09/19/22 at 12:12 PM Registered Nurse (RN) #66 observed the BiPap mask laying in the floor and confirmed the mask was not properly stored and should not be laying in the floor. RN #66 discarded the mask into the trash and stated a new mask would be obtained for use. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, staff interview and resident interview the facility failed to provide pain management to a resident when the resident complained of pain. The failed practice was true for one (1) of three (3) residents reviewed for pain. Resident identifier: #18. Facility census: 51. Findings included: a) Resident #18 Review of Resident #18's medical record showed Resident #18 had capacity and had a Quarterly Minimal Data Set (MDS) dated [DATE] that showed a Brief Interview for Mental Status (BIMS) of 14. A progress note dated 07/17/22 at 3:53 PM stated, Resident thinks she broke her heel when getting into the shower chair for her shower this nurse assessed her foot before she went into the shower room and she complained of pain. The Medication Administration Record (MAR) dated 07/17/22 showed no pain medication was provided to Resident #18. A progress note dated 07/18/22 at 8:12 PM stated, Resident complained of bruising and pain to right heel regarding incident from 07/17/22. This writer contacted…

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 staff interviews the facility failed to serve foods at appetizing temperatures. Test trays temperatures revealed unacceptable temperatures for all the foods being tested. This had the potential to a limited number of residents receiving nourishment from the kitchen. Facility census: 51 Findings included: a) Appetizing food temperatures During the Resident Council meeting on 09/20/22 at 11:12 AM seven (7) residents reported they were being served cold food. In an interview on 09/20/22 at 12:30 PM the Health Service Worker (HSW) #40, reported for breakfast, lunch and dinner the last meal tray on the cart was always tested for temperatures. The Dietary Manager (DM) was observed on 09/20/22 at 12:30 PM, doing test tray temperatures on C hallway. Results: chicken and noodles at 118 degrees Fahrenheit (F), coleslaw at 55 degrees F, cream corn at 109 degrees F, and green beans at 122.6 degrees F. The test tray temperatures recorded for the B Hallway at 12:48 PM were in Celsius and converted to Fahrenheit. Results: chicken and noodles at 42 degrees Celsius (C)/107…

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 provide appropriate assistive device to resident #21 (small maroon spoon) to maintain his ability to independently eat. This is failed practice was a random opportunity for discovery. Resident identifier: #21. Facility census: 51. Findings included: a) Resident #21 During dining observation on 09/20/22 at 12:35 PM, Resident #21 was observed eating creamed corn with a regular silver spoon. Further investigation of Resident #21's meal tray showed the ordered assistive device, a maroon spoon, was unavailable for use. (Maroon spoon is an assistive device used for eating therapy with a shallow bowl that helps limit the amount of food on the spoon making sure users don't place too much food in their mouth. The flatter design of the spoon also makes it easier for users to get the food off the spoon). Resident #21 was using regular silver spoon to eat with. Nurse Aide (NA) #92 was asked to verify the type of spoon provided on the meal tray. NA #92 stated, Yea [resident #21] usually has the small maroon one…

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.

The facility failed to store, prepare. distribute and serve food in accordance with professional standards for food service. During the kitchen tour it was discovered food was not dated after opening, and a dirty shelving unit. This had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 51 Findings included: a) Kitchen tour During the kitchen tour on 09/19/22 at 11:20 AM, it was discovered the flour and sugar bags in the bins had not been dated after opening. Also baking pans, a large mixing bowl and steam table pans were stored rim down on a dirty shelving unit. In an interview with the Dietary Manager (DM) on 09/19/22 at 11:28 am, verified the flour and sugar bags in the bins had not been dated after opening and the shelving unit needed to be cleaned. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to ensure a resident's medication administration record accurately reflected the nursing progress note that indicated administration of medication. The failed practice was true for one (1) of 20 sampled residents. Resident identifier: #18. Facility census: 51. Findings included: a) Resident #18 Review of Resident #18's medical record revealed the following pain medication physician order: A physician order for Acetaminophen Tab 650 MG Oral Q6H PRN for pain with start date 07/19/22 and end date 07/20/22. Review of the July 2022 Medication Administration Record (MAR) showed the following: 07/19/22- No Acetaminophen was administered to Resident #18 07/20/22- No Acetaminophen was administered to Resident #18 A nursing progress note dated 07/19/22 with time 2:27 PM stated, Assessed bruising to right heel. Bruise measures 7.0 cm X 5.0 cm X 0.0, area is not pen surrounding skin normal color and normal temperatures. Resident complained of some pain 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.