Pine Lodge

Based on observation, resident interview and staff interview, the facility failed to ensure an accident-free environment, of which it has control, for storage of medication for Resident #10. This was a random opportunity for discovery. Resident Identifier: #10. Facility Census: 117.Findings Include: a) Resident #10On 05/17/26 at 12:10 PM, an initial interview was held with Resident #10. An observation of two (2) inhalers and a medication cup containing one (1) TUM at the bedside. At this time, the resident was asked, Do you keep medication at the bedside? The resident responded, I haven't taken them yet .I was getting dressed and putting lotion on. On 05/17/26 at 12:13 PM, Licensed Practical Nurse (LPN) #75 was asked to come into the resident's room. LPN #75 was asked, Is this resident supposed to have medication at bedside? LPN #75 stated, My bad. On 05/17/26 at approximately 12:30 PM, the Director of Nursing (DON) was notified of the medication at the bedside. The DON stated, Medication is not supposed to be at bedside.

Based on observation, record review and staff interview, the facility failed to ensure oxygen therapy was maintained for Resident #124 and #15. These were random opportunities for discovery. Resident Identifers: #124 and #15. Facility Census: 117,Findings Include: a) Resident #124 On 05/17/2026 at 12:10 PM, an initial interview was conducted with Resident #124. An observation of the oxygen concentrator found the humidy bottle was empty. An interview was held with Licensed Practical Nurse (LPN) #75 regarding the oxygen therapy and the humidity bottle on 05/17/26 at 12:13 PM. LPN #75 stated, let me go get a new bottle .it should be on there. On 05/17/26 at approximately 2:00 PM, the Administrator was notified. The Administrator confirmed the humidy bottle should not be empty if used with oxygen therapy. b) Resident # 15 During the initial surveyor process, Resident #15 reported she was on four (4) liters of oxygen and she had difficulty breathing at times. The resident's oxygen concentrator was set on 3.5 liters upon observation. Licensed Practical Nurse (LPN) #22 reported she thought…

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 medication used in dialysis patients to help decrease the phosphate levels in a residents blood which was ordered to be given outside of the recommened dose or freqency was given only after consultation with the dialysis provider. This was true for one (1) of one (1) residents reviewed for the care area of dialysis during the long term care survey. Resident Identifier: #102. Facility Census: 117. Findings included: a) Resident #102 A review of Resident #102's medical record found he was discharged to the hospital on [DATE] and returned on 04/28/26. A review of the physician orders found a physician order for Sevelamer Carbonate Oral Tablet 800 MG (Sevelamer Carbonate) (Generic for Renvela): Give 1 tablet by mouth with meals for Hyperphosphatasemia, starting 01/17/26. This was the current order when the resident was sent to the hospital on [DATE]. Upon his readmission to the facility the following order was entered into the medical record:…

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

Based on record review, observation and resident interview, the facility failed to ensure a diet was provided that took into the consideration the resident's preferences. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #22. Facility Census: 117. Finings included: a) Resident #22 - On 05/19/26 at 7:25 AM, Resident #22 was observed in the dining room and was not eating her breakfast. The resident stated she received cornflakes and did not like them and would not eat them, The resident reported she disliked hard boiled eggs. The resident's Tray Card stated, 2 bowls of fruit loops (with 'out' handwritten), NO EGGS or pork. and Assorted fruit juices - 8oz. The resident was served cornflakes, two (2) boiled eggs and no juice. Following surveyor intervention, the resident received two bowls of fruit loops since the delivery truck had just run. Registered Nurse #5 confirmed the resident's tray card and the food the resident was served. b) The facility's policy and procedure for Dining Service Standards stated, 8.1 Meal Selection: meal…

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 residents received therapeutic diets as ordered by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #31 and #68. Facility Census: 117.Findings included: a) Resident #31 On 05/17/2026 at 11:45 AM, during the initial investigation process, Resident #31's lunch tray and tray card were observed. The resident's tray card stated, Large portions for meals. The resident did not receive large portions. Registered Nurse #3 confirmed the resident received a regular size serving of food on her tray. The resident's care plan stated, Resident is of nutrition concern related to potential for inadequate po intake, GERD. The resident's diet order stated, Regular/Liberalized diet, Regular Texture texture, Standard Thin Liquids consistencyLarge portions. b) Resident #68 On 05/17/26 at 11:30 AM, Resident #68 was observed in the dining room at the lunch meal. the residents tray card stated, Large Protein. The resident was served a regular size portion…

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, resident interview and staff interview the facility failed to provide a safe, clean, comfortable home like environment by not taking reasonable care to protect residents personal property from loss, and by not ensuring comfortable temperatures in the dining area. This failed practice was found true for (1) one of (3) three residents reviewed for personal property and was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #108. Facility census 113. Findings Include: a) Resident #108 During the initial interview on 06/16/25 at 12:19 PM, Resident #108 stated, I came here in march and some of my stuff is still missing. They say the washing machine is broken and that it will be down for 6 months. They say they are looking for my stuff, but how long do I have to wait? A review of the Grievance Log on 06/17/25 at 8:30 AM, revealed a grievance filed by Resident #108 dated 06/05/25 and reads that Resident #108 was missing the following…

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

Based on record review and staff interview, the facility failed to ensure the resident's right to formulate an advanced directive. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #111 and #65. Facility Census: 3. Findings included: a) Resident #111 On 06/16/25 at 02:38 PM, Advanced Directives were not found on the electronic chart for Resident #111. The resident was coded as a Full Code. On 06/17/25 at 9:42 AM, the Interim Administrator confirmed there was no Advanced Directive completed on the medical chart. The Interim Administrator reported without an advanced directive; the resident is automatically made a full code. b) Resident #65 On 06/16/25 at 4:14 PM, Advanced Directives were not found on the electronic chart for Resident #65. The resident was coded as a Full Code. On 06/17/25 at 09:42 AM, the Interim Administrator confirmed there was no Advanced Directive completed on medical chart. The Interim Administrator reported without an advanced directive; the resident is automatically made a full code.

Based on resident interview, staff interview and record review the facility failed to provide treatment in accordance with professional standards of practice by not passing medications at their scheduled administration times. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #70. Facility Census 113. Findings include: a) Resident #70 During the initial interview on 06/16/25 at 11:17 AM, Resident #70 stated, Sometimes I have to wait a long time on my medicine. Our medications are never on time. A record review on 06/18/25 AT 11:30 AM, of Resident #70's Medication Administration Audit Report (MAAR) revealed the following: -04/06/25 Lyrica Capsule 50 Milligrams (MG) was to be given at 6:00 AM and was not administered until 8:16 AM -04/07/25 Lasix oral tablet 20 MG was to be given at 12:00PM and was not administered until 2:27 PM. -04/24/25 Cholecalciferol Oral Capsule 1.25 MG was to be given at 8:00 AM and was not administered until 2:20 PM -04/30/25 Potassium Chloride 10 MEQ, Sennosides-Docusate Sodium Tablet 8.6…

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 catheter had proper drainage during a transfer. This was a random opportunity for discovery during the Long-Term Care survey and had the potential to affect a minimal number of residents. Resident Identifier: #104 Facility Census: 113 Findings Include: During an observation on 06/19/25 at 10:55 AM the surveyor observed therapy staff transferring Resident #104 from their wheelchair to stretcher. While transferring the catheter bag was hooked to the transfer belt staff was using to transfer Resident #104. The transfer belt was placed above the waste and not allowing proper drainage that can allow for the possibility for a UTI. Interview with the Director of Nursing (DON) on 06/19/25 at 11:30 AM confirmed the catheter back should have been below the waste to maintain proper flow stating, I have already educated staff when i heard this had happened.

Based on observation, staff interview and record review, the facility failed to ensure refrigerator temperatures in a resident's room were maintained and logged in accordance with professional standards for food service safety. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: 36. Facility Census: 113. Findings included: a) On 06/17/25 at 09:04 AM, the Refrigerator/Freezer Temperature Log for Resident # 36's personal refrigerator for June 2025 was reviewed and the following temperature and dates were recorded on the log: Temperatures recorded: 06/05/25 - 45 degrees 06/06/25 - 45 degrees 06/09/25 - 48 degrees 06/10/25 - 46 degrees No temperatures were recorded for 06/03/25, 06/04/25, 06/07/25, and 06/08/25. On 06/17/25 at 9:00 AM, Nursing Assistant #1 confirmed the missing dates, and the temperatures recorded on the Refrigerator/Freezer Temperature Log. b) The facility's policy and procedure for 'Refrigerators: Patient In-Room' stated, 4.1 A Refrigerator/Freezer Temperature Log will be maintained for every…

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 a correct and complete medical record was maintained for residents. This was true for two (2) of thirty (30) residents reviewed. This failed practice had the potential to affect a limited number of residents. Resident identifiers: # 65 and # 111. Facility census: 113. Findings included: a) On 06/17/25, Advance Directives were not located for Resident # 65 and Resident #111 on the electronic medical chart. On 06/17/25 9:42 AM, the Interim Administrator confirmed there were no advanced directives for Resident #65 and #111 on the medical record The facility's policy and procedure purpose for Code Status Orders is To ensure that the patient's desired resuscitation wishes are documented in the medical record.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interviews, staff interviews and observations, the facility failed to ensure all staff were competent and there were Sufficient nursing staff relate: to extremely late and omitted medications, Nursing staff failed to notify the physician and/or not done timely when blood glucose levels are not in the set parameter, showers not provided for dependent residents, missed treatment, lacking in meaningful activities, catheter care, care for tube feedings, staff adhering to infection control practices (including residents that are positive for COVID-19), and staff failed to document and dispense night time ordered snacks. Facility census 117. Findings included: I) F677 a) Resident #24 During an interview on 11/12/23 at 11:44 AM, Resident # 24 stated I don't get showers or bed baths. Observation revealed Resident #24's hair was disheveled and sticking up everywhere. During an interview on 11/13/23 at 10:35 AM, Resident # 24 stated, The night shift (Nurse Aide (NA) #76's name) left me…

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, facility document review, and staff interview the facility failed to post a staff posting that included the census, total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This was true for the last quarter and currently. These failed practices had the potential to affect all residents. Facility census 117. Findings included: a) Staff postings On 11/12/23 at 10:30 AM it was noted the staff posting located at the front lobby of the facility did not contain the information of a daily census, number of nurse aides, number of nurses, and the total hours worked per day. On 11/12/23 at 11:00 AM, the staff posting for the last week and every weekend of the last quarter was requested from the person in charge Registered Nurse #19. On 11/13/23 at 9:00 AM, the above was requested again to the Administrator. On 11/14/23 at 12:30 PM, again the staff postings were requested. On 11/14/23 at 2:20 PM, the Administrator provided the staff postings; however, they did not contain the information needed, such as the daily…

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 review and update the Facility Assessment Tool as required. This has the potential to affect all Residents at the facility. Facility Census: 115. Findings Included: a) Facility On 11/12/23 the Facility Assessment Tool was provided by the Director of Nursing. Upon review, it was noted that the information on the Assessment Tool was incorrect and had not been updated since 06/21/22. According to the regulation, the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The Facility Assessment Tool provided stated the following: Date of assessment or update is 06/21/22 Date(s) assessment reviewed 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 observation and staff interview, the facility failed to maintain a safe and sanitary environment to help prevent the development and transmission of diseases, including Covid-19, during an active Covid-19 outbreak. Linens were not handled appropriately within the laundry room or during transport. Medication administration for Covid-19 positive Resident was not done correctly to prevent the possible spread of Covid-19. Personal Protective Equipment (PPE) was not appropriately worn and discarded after Resident care. Continual Infection Surveillance was not completed for evaluation of proper hand hygiene performance. These failed practices had the potential to affect all residents. Resident identifiers: #28, #167. Facility census: 115. Findings included: a) Laundry Room Record review of the facility's policy titled Infection Control Policies and Procedures, Linen Handling, revised on 05/01/23, showed direction for facility staff to keep clean linen covered and keep clean storage area separate from other soiled areas. During tour of the office/clean linen storage area of the…

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

Based on record review and staff interview, the facility failed to develop and implement an antibiotic stewardship program that promoted the appropriate use of antibiotics including a system of tracking and monitoring outcomes. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115. Finding included: On 11/15/23 at 11:26 AM, the Director of Nursing stated the facility had been without an Infection Preventionist (IP) since September 2023, and there was not anything done with the antibiotic stewardship stuff in October 2023. The DON further stated once she realized they expected her do it, she started keeping track of the antibiotic use again in November 2023. Review of the facility's antibiotic stewardship surveillance log showed no documentation for antibiotic use for the month of October 2023. The DON verified there was possibly twenty-six (26) Residents that were administered antibiotics for the month of October 2023, as evidenced by a report she ran from the Electronic Medical System.

Based on record review and staff interview, the facility failed to designate one or more individual(s) as the infection preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115. Findings included: Record review showed no designated IP on the employee roster. During an interview on 11/13/23 at 1:35 PM the Administrator was asked who the infection preventionist was for the facility? The Administrator replied, We don't have one. We have been without one for a while. The administrator further stated she had to terminate the last IP on 09/28/23.

Based on record review, staff interview, and resident interview, the facility failed to consider the views of resident council and act promptly upon the grievances and recommendations of the resident council concerning issues of resident care and life in the facility. This failed practice had the potential to affect more than a limited number of residents. Facility census: 115. Findings included: a) During the resident council meeting on 11/13/23 at 1:00 PM, numerous residents stated they do not feel that their grievances and concerns are being taken care of. We complain here, and no one does anything about it. Review of the council meeting minutes from 06/06/23, 07/05/23, 08/01/23, 09/05/23,10/03/23, and 11/07/23 had multiple resident concerns which included the following: -TV channels are messed up -food is not hot and cold food is not cold - floors need swept and mopped better, floors are sticky -personal clothes are not coming back timely -not getting showers, call lights not answered timely There was no documentation to indicate a response from any departments had been made 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 record review and staff interview, the facility failed to notify the physician of an elevated blood glucose level. This was true for three (3) of five (5) residents reviewed for unnecessary medication. Resident identifiers: #56, #42, and #73. Facility census 117. Findings included: a) Resident #56 Medical record review revealed there were multiple times the Residents blood glucose levels were greater than 400. The order from the facility physician stated to call if blood sugars were greater than 400. A review of the Medication Administration Record (MAR) found the following times the blood glucose levels were over 400 and the physician was not notified or the physician was not notified timely: 09/30/23 at 4:30 PM, blood glucose was 488. No note about notifying the physician. 10/06/23 at 4:30 PM blood glucose was 504. The physician was notified at 6:08 PM. 10/07/23 at 6:30 AM blood glucose was 428. No note about notifying the physician. 10/07/23 at 4:30 PM blood glucose was 484. The physician was notified at 6:43 PM. 10/09/23 at 4:30 PM blood glucose was 486. The physician…

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.

m) Resident #57 On 11/12/23 at 12:49 AM, observation was made of Resident #57's mattress and it was heavily soiled. The bed was occupied by Resident #57. The mattress was bare with no sheets or blankets. Resident stated, I don't want sheets or blankets, I like it this way because of my skin breaking out. The mattress had what appeared to be white/cream colored dried flakes of skin outlining his body. A dried liquid substance was running down the left and right side of the mattress, and the surface of the mattress at the Resident's midsection was covered with a dried white substance and food particle. The soiled mattress was verified by Licensed Practical Nurse (LPN) #27. LPN #27 stated, I'll let someone know it needs cleaned. During observation of care on 11/13/23 9:52 AM, Resident #57's mattress was found to be soiled and dirty. Nursing Aide (NA) #143 stated, Yell, that needs cleaned, we have to use a special cleaning solution because of his skin allergies. On 11/14/23 at 10:39 AM, observation was made in the presence of the Administrator of Resident #57's soiled bed mattress.…

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, resident interview and staff interview the facility failed to provide care to residents that was required to maintain hygiene to a resident who was dependent for Activities Of Daily Living (ADL) care. This is true for four (4) of eight (8) reviewed for ADL care area during the Long Term Care Survey Process (LTCSP). Resident Identifiers: #24, #61, #1, and #66. Facility Census: 115. Findings Included: a) Resident #24 During an interview on 11/12/23 at 11:44 AM, Resident # 24 stated I don't get showers or bed baths. Observation revealed Resident #24's hair was disheveled and sticking up everywhere. During an interview on 11/13/23 at 10:35 AM, Resident # 24 stated, The night shift (Nurse Aide (NA) #76's name) left me shitty since two (2) AM, and I am still not changed, and I still have not gotten a shower or bed bath. This surveyor asked Resident # 24 to turn on the call light at 10:37 AM. The Administrator in Training (AIT) #97 came into the room at 10:39 AM and stated I saw your call light on what do you need? Resident # 24 stated, I have not been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for six (6) of six (6) Residents reviewed for the Activity Care Area during the Long term care survey process. Resident Identifier: Resident #85, Resident #62, Resident #96, Resident #22, Resident #82, and Resident #73 . Facility Census: 115. Findings Included: a) Resident #85 During an interview on 11/12/23 at 11:56 AM, Resident # 85 stated there are no activities, I do stuff in my room to keep busy, but they don't do anything. During a record review on 11/15/23 9:30 AM , Resident #85's medical record revealed an recreation comprehensive assessment dated [DATE] with the Resident Preferences coded were listed as follows: -bingo -doing things with groups of people -Social gatherings -Outside for fresh air -Attend…

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 follow Physicians orders in the areas of neurological checks, medication administration, and skin/wound treatments. Resident identifiers: #42, #67, #1, #56, #73, #86, #18 and #28. Facility Census: 115 Findings Included: a) Resident #42 1) Record review on 11/14/23 at 01:04 PM shows resident #42 had an unwitnessed fall on 08/08/23 at 12:45 PM. Status post of the fall he complained of right leg and back pain. He was sent to the local emergency room for X-rays, which were negative, and he returned to the facility on [DATE] at 06:50 PM. Facility policy NSG204 Neurological Evaluation, revision date of 06/01/21 states: Neurological evaluations will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed: Every 15 minutes X two (2( hours, then Every 30 minutes X two (2) hours, then Every 60 minutes X four (4) hours, then Every eight (8) 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, medical record review, staff interview and resident interview the facility failed to ensure the environment is free from accident hazards over which it has control. Resident #111's cigarettes were in the room and Resident #28's inhaler was left in the room. This failed practice had a potential to affect more than an isolated number of residents. Resident identifier: Resident #111 and Resident #28. Facility Census: 115. Findings Included: a) Resident #111 During the initial tour 11/12/23 at 11:42 AM, Resident #111 had three (3) cigarettes laying on the over bed tables. There was no lighter found. During another observation on 11/13/23 at 10:55 AM , Resident #111 one (1) cigarette was laying on the over the bed table. During an observation on 11/13/23 at 2:00, Resident #111 had no cigarettes on the over the bed table. During an interview on 11/13/23 at 2:01 PM, Resident # 111 stated I don't smoke here. I am not allowed. During an interview on 11/13/23 at 3:52 PM the Administrator stated there was no smoking evaluation completed because resident #111 does 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, record review, resident interview and staff interview the facility failed to serve food and drink that was palatable and at a safe and appetizing temperature. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Resident Identifiers: Resident #85, Resident #266 and Resident #22. Facility Census: 115. a) Test tray On 11/12/23 at 1:08 PM, the temperatures were obtained on the lunch meal tray at the time of service. The following temperatures were obtained by the Dietary Account Manager #108 using her thermometer: -chicken cacciatore: 124 degrees Fahrenheit -mixed vegetables: 110 degrees Fahrenheit -peach slices: 54.5 degrees Fahrenheit -chicken noodle soup: 125 degrees Fahrenheit. During an immediate interview the Dietary Account Manager #108 acknowledged the temperatures were not at the appropriate serving temperatures. And stated the hot foods should be over 120 degrees and the cold foods below 50 degrees. b) Interviews: During an interview on 11/12/23 at 11:56 AM, Resident #85 stated the food…

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 respect the Residents right to be treated with respect and dignity. This was a random opportunity for discovery. Resident Identifier: #48. Facility Census: #115 Findings included: a) Resident #48 On 11/13/23 at 08:00 AM, observation was made of Nurse Aid (NA) #91 assisting Resident #48 with his breakfast meal. NA #91 was standing while feeding him. This was confirmed immediately with NA #91. Her response was, I can't, I didn't know that? According to the Genesis Procedure: Feeding a patient/resident revision date 06/01/21 states 6. Sit in chair at eye level with the patient . This was confirmed with the Administrator on 11/13/23 at 09:15 AM, who agreed that NA #91 should be sitting down while feeding the Resident and stated she will re-educate the NA. No additional documentation was provided prior to exiting the survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to complete a Pre admission Screening and Resident Review (PASARR) for new diagnosis of Bipolar disorder. This was true for 1 of 2 residents reviewed for PASARR. Resident identifier: #22. Facility Census 115. Findings Include a) Resident #22 A record review on 11/13/23 at 10:00 AM, revealed that Resident #22 received a new diagnosis of Bipolar Disorder on 05/09/22. The Resident was admitted to the facility on [DATE]. A record review on 11/13/23 at 10:00 AM found Resident #22's initial PASARR upon admission did not indicate a diagnosis of Bipolar Disorder. A record review on 11/13/23 at 10:00 AM, of Resident #22 admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/13 did not indicate an active diagnosis of Bipolar Disorder. A record review on 11/13/23 at 10:00 AM, of Resident #22 last MDS which was a Significant change with an ARD of 10/06/23 revealed that Section I for Psychiatric/mood disorder section 15900 is marked for…

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, staff interview, resident interview, and observation the facility failed to properly secure Resident #23's indwelling urinary catheter device. This was true for one (1) of one (1) Residents reviewed for catheter care and had the potential to affect only a limited number of Residents. Resident identifier: #23. Facility census:115. Findings included: a) Resident #23 During observation of catheter care on 11/13/23 at 1:05 PM, Resident #23's urinary indwelling Foley catheter was found to not have an catheter securement device in use. The tubing going to the bed side drain bag was stretched tight across the Residents right leg, pulling at the Resident's penis causing tension. A previous adhesive catheter secure device was attached to the drain tubing, but not to Resident's leg. Resident #23 was asked if he preferred to wear an anchoring device for his catheter and he stated, I had one, but it came off. I would wear it if I had it The resident further stated he liked the straps that wrapped around his leg better like the hospital had but he will take what he can…

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 acceptable parameters of nutritional status by not completing weights/re-weights appropriately. This was true for one (1) of three (3) Residents reviewed for nutrition. Resident identifier: #58 Facility Census: #115 Findings Included: a) Resident #58 On 11/13/23 at 02:20 PM record review shows the following documented weights: 11/13/2023 14:44 150.2 Lbs Wheelchair 11/07/2023 14:12 153.0 Lbs Standing 10/03/2023 13:48 196.5 Lbs Standing 9/25/2023 12:35 199.6 Lbs Standing 9/21/2023 22:33 157.0 Lbs Mechanical Lift 9/26/2023 15:29 Correction The above documentation shows a 43.5 pound weight loss from 10/03/23 until 11/07/23. admission records from the hospital states Resident #58 weighed 162 pounds on 09/12/23. Re-weight on 11/13/23, during the survey, shows the Resident weighs 150.2 pounds. The facility Clinical System Process - Weights and Vitals dated 04/02/20 states If the re-weight verifies that the first weight (discrepant weight) was accurate, both entries will remain as entered in Point Click Care (PCC).…

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

Based on record review, observation and staff interview the facility failed to provide care in accordance with professional standards of practice to prevent complications of enteral feeding for Resident #96 and Resident #97. This was true for two (2) of two (2) residents reviewed for the care area of feeding tube during the long term care survey. Resident Identifier: #96 and #97. Facility Census: 115 Findings Included: a) Resident #96 A review of Resident #96's medical record found the following two (2) orders related to Resident #96 enteral feeding tube: -- Enteral Feed Order: Every 4 (four) hours water flush 240 ML (Milliliters), PEG (Percutaneous Endoscopic Gastrostomy) every 4 (four) hours after each bolus. -- Enteral Feed: Flush Tube with 30 ml of water before and after each medication pass. Flush Tube with a least 15 ml of water between each medication. An observation beginning 12:07 pm and concluding at 12:27 pm on 11/13/23 found Licensed Practical Nurse (LPN) #37 administered Resident #96 his 10:00 am medication. The residents received the following medications during 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 record review and staff interview the facility failed to ensure all Pharmacy recommendations were answered with a rationale and in a timely manner. This was true for two (2) out of five (5) Residents reviewed for unnecessary medication. Resident identifiers: #56, and #25. Facility census 117. Findings included: Facility Policy titled, LTC Facility's Pharmacy Services and Procedures Manual revision on 08/17/23. * Facility should alert the Medical Director where MRR's are not addressed by the attending physician in a timely manner. a) Resident #56 During of Resident #56's medical records revealed a pharmacy recommendation from 04/11/23. The pharmacist made recommendations concerning the multiple antidepressants. The facility physician accepted the recommendation on 09/15/23. During an interview 11/15/23 at 10:16 AM, the Administrator was asked for a policy for Medication Regimen Review (MRR). The Administrator agreed that took a long time for a response from the facility physician. b) Resident #25 A record review found Resident #25 received a recommendation from the…

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

Based on record review and staff interview the facility failed to obtain a consent for Physician ordered psychotropic drugs. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident Identifier: #42 Facility Census: 115 a) Resident #42 On 11/14/23 at 01:32 PM record review shows that Resident #42 has an order for Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 2 tablet by mouth one time a day for Depression and Buspirone HCl Oral Tablet 5 MG (Buspirone HCl) Give 1 tablet by mouth at bedtime for Generalized Anxiety Disorder (GAD.) Resident #42 has an active diagnosis for generalized anxiety disorder and major depressive disorder. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (Sertraline) (iii) Anti-anxiety; and (Buspirone) (iv) Hypnotic Upon record review on 11/14/23 at 02:00 PM, there were no consents available for the two (2)psychotropic drugs Resident #42…

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, and resident interview, the facility failed to ensure safe and sanitary storage, handling, and consumption of food by not having up to date temperature logs for resident personal refrigerators. This was a random opportunity for discovery. This failed practice was true for 3 of 3 residents. Resident Identifiers #22, # 69, # 42. Facility census: 115. Findings Included: a) Resident #22 An observation on 11/12/23 at 11:45 AM, revealed that resident #22 had a personal refrigerator in her room with a Temperature log sheet filled out until 09/18/23. An interview on 11/12/23 at 11:45 AM, with Resident #22, who has a BIMS of 14 stated, They used to do those and then just stopped. During a record review on 11/13/23 at 2:00 PM, of Policy 031 Titled Food: Safe handling for Foods from Visitors #5 Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and have temperature monitored daily for refrigeration < 41 degrees Fahrenheit and Freezer < 0 degrees Fahrenheit. An interview on 11/13/23 at 2:00 PM, with housekeeper…

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 accurately record the amount of a prescribed snack that was consumed. This was a random opportunity for discovery and had the potential to affect a limited number of residents that currently reside at the facility. Resident identifiers: #66, #65, and #39. Facility census 117. Findings included: a) Resident #66 At the time of entering the facility on 11/12/23 at 10:30 AM, it was noted snacks were at the nursing station untouched and undelivered to the residents. The snack for Resident #66 was a cup of mixed fruit dated 11/11/23 labeled third snack. These snacks were seen and witnessed by Registered Nurse #19 at the time of discovery. A review of medical records revealed the staff documented Resident #66 consumed 100 percent of his third snack on 11/11/23. b) Resident #65 On 11/12/23 at 10:30 AM, it was noted that an oatmeal cake was labeled with the name of Resident #65 and dated 11/11/23 and called the third snack. These snacks were seen and witnessed by Registered Nurse #19 at the time of discovery on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview and staff interviews the facility failed to maintain equipment in safe operating conditions. Two (2) Heating, Ventilation and Air Conditioning (HVAC) units were not in safe operating conditions for room [ROOM NUMBER] and room [ROOM NUMBER]. This had the potential to affect a limited number of residents residing in those rooms. Facility Census: 115. Findings Included: a) room [ROOM NUMBER] During the initial tour on 11/12/23 at 11:56 AM, room [ROOM NUMBER]'s HVAC unit was void of a plastic guard. During an interview on 11/12/23 at 11:57 AM, Resident #85 stated, That heater has been missing the vents forever. During another observation on 11/13/23 at 10:56 AM, room [ROOM NUMBER]'s HVAC unit's plastic guard was not there. During an interview on 11/14/23 at 4:31 PM, the Maintenance Director acknowledged the HVAC plastic guard was missing. The Maintenance Director stated, I will replace the whole unit, I have a new one I will put in. b) room [ROOM NUMBER] During the initial…

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 #18, #66, #19 as well as wound care for Resident #35. This was true for four (4) of 11 residents reviewed during the complaint survey. Resident Identifiers: #18, #66, #19 and #35. Facility Census: 114. Findings Included: a) Resident #18 On 08/30/23 at 2:00 PM, a record review was completed for Resident #18. The Medication Administration Audit Report was reviewed from 08/15/23 through 08/29/23 and found the following medications and accuchecks for blood glucose administered late: --08/15/23 Accuchecks twice daily scheduled at 4:00 PM, completed at 6:23 PM, which is 2 hours and 23 minutes late --08/15/23 Lantus 40 units twice daily scheduled at 9:00 PM, administered on 08/16/23 at 2:41 AM, which is 5 hours and 41 minutes late --08/15/23 Clonidine 0.1mg two times daily scheduled at 9:00 PM, administered on 08/16/23 at 2:40 AM, which is 5 hours and 40 minutes late --08/15/23 Prevastatin 80mg at bedtime scheduled at 9:00 PM, administered 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 interview, the facility failed to maintain a safe and accident-free environment as possible. This was a random opportunity for discovery and had the potential to affect more than an limited number of residents. Facility Census: 114. Findings Included: On 08/29/23 at 12:30 PM, an observation of two unlocked (2) treatment carts were observed sitting by the nurses' station by the lobby at the entrance of the facility. No staff were in the vicinity of the treatment carts. On 08/29/23 at 12:40 PM, the Assistant Director of Nursing (ADON) #2 and Nurse Performance Educator (NPE) #3 witnessed the unlocked carts. The ADON #2 locked the treatment carts immediately. Both the ADON #2 and NPE #3 confirmed the treatment carts should be locked at all times when not attended by staff. No further information was obtained during the complaint survey.

Based on observation, policy review and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infections. These findings were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident Identifier: Resident #66. Facility Census: 114 Findings Included: a) Facility: On 08/31/23 at 08:18 AM while observing the breakfast meal tray pass on the South Unit (Rooms 100-121), it was observed that no hand hygiene was offered to the residents prior to their breakfast meal. This was confirmed with Certified Nursing Aide #77 at the time of discovery. On 08/31/23 at 09:00 AM, review of Facility Policy #IC 405 and in accordance with standard practice of care found, the staff will perform hand hygiene per the Centers for Disease Control and Prevention (CDC) guidelines and policy to provide hand hygiene prior to each meal. This was confirmed with the Administrator 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 record review, staff interview and policy review the facility failed to report a COVID-19 outbreak in their building to their Residents, their Representatives and Families. This failed practice had the potential to effect more than a limited number of residents. Facility Census: #114 Findings Included: a) On 08/31/23 at 01:45 PM a record review shows the facility had a staff member test positive for COVID-19 on 08/07/23. Further testing of staff and residents on the following days found an additional seven (7) staff members and fifteen (15) residents tested positive. The documented positive dates range from 08/07/23 through 08/21/23. During an interview with the Administrator on 08/31/23 at 2:00 PM, she confirmed notification was not complete to notify Residents, their Representatives and Families of the outbreak, other than to the Residents, their Representatives and Families of the positive residents. According to the Facility Infection Control Policy #IC 405, COVID-19 Reporting #32. states COVID-19 date required by Centers for Medicare and Medicare Services (CMS)…

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/or implement the care plan for skin care, respiratory complications, mobility and activities of daily living (ADLs). This was true for two (2) of 11 residents reviewed during a complaint survey. Resident Identifier: #115 and #21. Facility Census: 114. Findings Included: a) Resident #115 On 08/30/23 at 10:00 AM, a record review was completed. The review found Resident#115's care plan had not been developed in the following focus areas: --risk for respiratory complications --risk for skin breakdown --mobility --activities of daily living The focus area of risk for respiratory complications did not list specific and complete goals. The focus area of risk for skin breakdown was not complete and did not list specific and complete goals as well as completed interventions. The focus areas of mobility and ADLs did not specify if the resident needed assistance or if the resident was dependent for their needs as well as completed interventions. The focus area of mobility did not list specific and complete goals. 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 record review and staff interview, the facility failed to revise a care plan for Resident #115's pressure ulcers and alteration in comfort care plan and Resident #21's actual fall and alteration in comfort care plan. This was true for two (2) of 11 residents reviewed during a complaint survey. Resident Identifiers: #115 and #21. Facility Census: 114. Findings Included: a) Resident #115 A record review was completed for Resident #115. The review found the care plan had not been revised regarding the development of a deep tissue injury (DTI) on the right fifth digit and right lateral foot as well as the left heel. An admission documentation note dated 07/21/23 did not list any skin issues. A skin check dated 07/31/23 noted the resident had new skin wounds and no previously noted skin injuries or wounds. These were listed as the left heel, right fifth digit and lateral foot. An incident report regarding the DTI to the left heel dated 07/28/23 was reviewed. The incident report indicated the resident had been having pain for two to three days prior the incident report and also…

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 prevent the development of pressure ulcers for Resident #115. This was true for one (1) resident of 11 reviewed during the complaint survey. Resident Identifier: #115. Facility Census: 114. Findings Included: a) Resident #115 On 08/29/23 at 2:30 PM, a record review was completed for Resident #115. The review found the resident had development of a deep tissue injury (DTI) described as a dark purplish discoloration to the right fifth toe and right foot (measuring 4.76cm (centimeters) x 1.73cm x UTD (unable to determine) as well as the left heel measuring 3.46cm x 2.86cm x UTD. Scabbed areas were found on the second and third toe of the right foot. An admission documentation note dated 07/21/23 did not list any skin issues. A skin check dated 07/31/23 noted the resident had new skin wounds and no previously noted skin injuries or wounds. These were listed as the left heel, right fifth digit and lateral foot. An incident report regarding the DTI to the left heel dated 07/28/23 was reviewed. The incident report indicated…

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.