Bluestone Health And Rehabilitation

Based on record review and staff interviews, the facility failed to ensure Resident #3 received food in the form to meet her needs. This was a random opportunity for discovery during the Long-Term Care Survey Process. Census: 57 Resident identifier: #3Findings include: a) Resident #3 A review of the progress notes dated 04/26/26 for Resident #3 reads, Resident was given grilled cheese on dinner tray. Her diet order is for mechanical soft. Resident ate some of the grilled cheese before the [Certified Nurse Aid] CNA noticed and she coughed a few times and then was fine. CNA took the tray and got her another one that she could eat without problem. Lumina contacted and spoke with [the provider] and she ordered to document situation and if there were any further coughing or congestion episodes to call back. The diet orders for Resident #2 include mechanical soft texture (this diet consists of foods that are moist, soft-textured and easily formed into a bolus).The Diet and Nutrition Care Manual for a mechanical soft diet lists grilled sandwiches as foods to avoid. An interview with…

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

Based on observations and staff interview the facility failed to ensure pans were dry before stacking rusulting in Wet nesting a dangerous practice of stacking or storing washed, wet items (like bowls, plates, or pots) together before they are fully dry. This trapped moisture creates a dark, low-air environment that allows bacteria to grow rapidly this failed practice had the potential to affect more than a minimal number of residents residing in the long termcare facility. Facility censuse:57During the initial tour of the kitchen on 04/20/26 with the Dietary Manager, two (2) metal pans and one clear plastic serving container was observed on the shelf stacked and wet. The Dietary Manager pulled them and stated, I'll take care of these now. On 04/21/26 at 10:00 AM during a follow-up kitchen tour, another metal pan was observed wet on the shelf. The Dietary Manager confirmed the pan was wet and removed it.

Based on observations and staff interview the facility failed to ensure call light was within reach of Resident #54. This was a random opportunity for discovery. Resident identifier: #54 Facility census: 57Findings Include: a) Resident #54On 04/22/26 at 2:10 PM the surveyor observed Resident #54 in a geri chair beside his bed. The call light was hanging off the back of the headboard, out of reach.During an interview on 04/22/26 2:30 PM with Nurse Aide (NA) #30 this surveyor asked where his call light was, NA#30 stated, We normally hook it to his shirt but he can point and tell us what he needs,it should be within reach to get our attention. An interview with the Director of Nursing (DON) on 4/23/26 at approximately 11:00 AM confirmed that the call light should be within resident's reach.

Based on record review, staff and resident interview, the facility failed to ensure a resident's right to receive written notice, including reason for change, before resident's room or roommate is changed. Resident identifiers: #45, and #25. Facility census: 57. Findings included: a) Resident #45 On 04/20/26 at 1:59 PM, Resident #45 reported she was not notified that her room was being moved until the facility came to move her room on 03/05/26 and was never notified in writing. On 04/23/26 at approximately 12:30 PM, during an interview, the Social Worker reported she notified Resident #45 verbally prior to changing her room that she would be moving that day to another room because this room was needed for isolation on 03/05/26. She reported she did not notify Roommate #25 that she was getting a roommate and did not notify either party in writing. Review of document titled Hill Valley Healthcare Room Change/Roommate Assignment revealed the following: Specific Procedures/Guidance2. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g.,…

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, resident interview and staff interview, the facility failed to allow a resident and/or their responsible party to exercise his or her right to file an anonymous grievance for facility and follow grievance policy on a grievance completed for another resident. Resident identifier: #22. Facility census: 57. a) Resident Council Resident Council meeting was held on 04/21/2026 at 11:00 AM with a group of 11 (eleven) residents who reported they had no method to anonymously file a grievance. Residents reported they did not want to report complaints for fear of retaliation. They felt concerns brought up in the resident council were not taken seriously. An interview with the Social Worker on 04/21/26 at 6:39 PM revealed there was no method for an anonymous grievance. She reported residents and family members had to ask a nurse or department head for a grievance form.Review of the Facility policy titled Grievances/Complaints states that residents and their representatives have the right to file grievances, either orally or in writing, with facility staff or the agency…

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

Based on resident interview and record review the facility failed to report a resident allegation of neglect involving not having a brief changed and an instance where a resident was given the wrong consistency of food. The facility also failed to report the reasonable suspicion of a crime where a resident brought in THC gummies and distributed them to other residents. Resident identifiers: #3 and #1. Facility census: 57. Findings Included: a) Resident #1 A policy titled, Abuse includes a definition for neglect that reads, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.The policy also reads, the organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than [two] 2 hours after allegation is made, if the events that cause the allegation…

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

Based on resident interview and record review the facility failed to identify and thoroughly investigate allegations of neglect which included two (2) residents not receiving timely incontinence care and a resident receiving the incorrect texture of food. Resident identifiers: #1, #3 and #22. Facility Census 57. Findings Included: Findings include: a) Resident #1 A policy titled, Abuse includes a definition for neglect that reads: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This policy also states, Designated staff will immediately review and investigate all allegations or observations of abuse. The results of all investigations are to be communicated to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within [five] 5 working days of the incident. During the initial interview with Resident #1 on 04/20/26 at 1:55 PM, he…

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 recognize standards of practice that address the identified limitations in ability to perform activities of daily living (ADL) to ensure Resident #57 received assistance with meals. This was true for one (1) of four (4) sampled for nutrition during the Long-Term Care Survey Process. Census: 57 Resident identifier: #57Findings include: a) Resident #57 The surveyor watched the lunch service on 04/22/26. Resident #57 was served his tray at 12:02 PM. Resident was observed falling asleep periodically during this meal. He finished his meal at 1:27 PM, and staff picked up the tray after he ate 51-75% of the meal. Staff provided no cueing during this time nor offered to reheat his meal. In an interview with Occupational Therapy Assistant (OTA) #20 on 04/23/26 at approximately 3:30 PM, she stated she had dinner with Resident #57 on 04/22/26. She stated she spent 30 minutes in the room and provided cueing for Resident #57 to finish approximately 50% of his meal. In an interview with CNA #4 on 04/28/26 at 11:51 AM,…

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

Based on observation, record review and staff interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards. This failure occurred because orders and a care plan directed applying a splint to the wrong hand for Resident #18. The facility also failed to notify the medical provider when a resident's blood sugar was over 400. Resident identifiers: #18 and #27. Facility census: 57.Findings included: a) Resident #18 During initial interviews on 04/20/26 at 2:20 PM, observeration noted that Resident #18's right hand was tightly fisted and lacked a splinting device. A record review of Resident #18's orders revealed orders to apply and remove a splint to the left hand as tolerated every night shift for mobility. Resident #18 has a diagnosis of a right hand contracture listed in the medical record. The care plan for Resident #18, revised on 03/09/26, reads: left hand splinting as ordered. During an interview with Occupational Therapist (OT) #62 on 04/22/26 at 1:27 PM, she confirmed the splinting order should be for the right hand.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, record review and staff interviews, the facility failed to provide appropriate equipment to maintain mobility with the maximum practicable independence regarding Resident #2's bed rails. This was true for one (1) of three (3) residents sampled for activities of daily living during the Long-Term Care Survey Process. Census: 57 Resident identifier: #2Findings include: A policy titled, Bed Rail Risk and Safety reads: any resident being considered for using a bed with bed rail(s) is evaluated by the facility's interdisciplinary team to determine whether the resident's functional status and bed mobility is improved through the use of bed rail(s), to identify any bed rail that might constitute physical restraint, and to identify individual characteristics that may increase the risk of entrapment by bed rails or mattress. During an interview with Resident #2 on 04/23/26, he stated someone came in and took one of his bed rails which he used to roll on to his side for the aides to clean him…

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 interviews, the facility failed to ensure Resident #48 and Resident #57 received adequate hydration. This was true for two (2) of four (4) residents sampled for hydration during the Long-Term Care Survey Process. Resident identifiers: #48, #57. Census: 57. a) Resident #48 A policy titled, Resident Hydration and Prevention of Dehydration states that nursing staff will provide and encourage intake of bedside, snack, and meal fluids, on a daily and routine basis as part of daily care. During the initial tour of the facility on 04/20/26 at approximately 1:00 PM, it was noted that Resident #48 did not have water at his bedside while in bed. Resident #48 stated that if he needed water, he had to ask for it. He also stated he needed a lot of water because he had undergone a kidney transplant. Again on 04/23/26 at 9:15 AM, it was observed that Resident #48 was in bed without water available at his bedside. Registered Nurse Consultant #86 confirmed that Resident #48 did not have water within reach at 9:21 AM on 04/23/26. During a record review,…

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 proper infection prevention by leaving Resident #54's tube feeding syringe open to the elements, this was a random opportunity of discovery during the long term care survey process. Resident Identifier: #54. Facility Census: 57 Findings include;a) Resident #54On 04/20/26 at 1:30 PM observed resident tube feeding syringe was laying out exposed and not covered/bagged and left open to the elements Further observation on 04/20/26 at 2:20 PM showed the tube feeding syringe continued to be exposed to the elements. During an interview with Licensed Practical Nurse (LPN) #65, the LPN stated, I was just in there; I will throw it away, get a new one and date it. This confirmed the tube feeding syringe was not covered.

Based on observation, resident interview, and staff interview the facility failed to ensure a safe, clean, comfortable, homelike environment by not maintaining appropriate temperatures in the residents shower room. This failed practice was a random opportunity for discovery and had the potential to effect more than a limited number of residents during the complaint survey. Facility Census 59. Findings Include:a) Short hall shower roomA tour of the short hall shower room on 12/15/25 at 11:45 AM, found that when you walk in the door of the shower room, it felt to be a good temperature. In the shower stall where the residents sit under the water felt to be cool. The Director of Maintenance (DOM), took the temperature of the room and confirmed that where the residents shower, was currently at 61 degrees Fahrenheit. The , Director of Maintenance (DOM) stated, That is absolutely to cold to take a shower in. I don't know what else to do. We put in this (2) two water proof heaters. The other shower room is warmer, but this one is bigger and everyone likes to use it. Maybe I can get up 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 observation, resident interview, and record review the facility failed to provide Activities of Daily Living (ADL) care to dependent resident in a timely manner. This failed practice was found true for (5) five of (5) five residents reviewed for ADL care during the complaint survey. Resident identifiers #19, #17, #49, #2, #10, #37. Facility census 59. Findings Include: Findings Include:a) Resident #19On 12/11/25 Program Manager II was on the phone with Resident #19 for 52 minutes. The call started at 8:32 AM. Resident #19 said she currently had a Urinary Tract Infection (UTI) and was soiled. She said they (nurse aides) had taken people out to smoke, and no one was answering her call light. Resident #19 confirmed that her call light was on. During the 52-minute phone call the only staff member who came in was from dietary and they were asking about her preferences for the lunch and dinner meal. After approximately 45 minutes Program Manager II had Health and Human Resource Associate (HHRA) call the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, family interview, and staff interview the facility failed to assure that there is sufficient nursing staff available at all times to provide nursing and related services to meet the needs of the residents. This failed practice was a random opportunity for discovery and had the potential to effect all residents currently living in the facility during the complaint survey process. Resident identifiers #60, #37, #19, #10, #19, #49, #2. Facility Census 59. Findings Include:a) Resident #60During an interview on 12/15/25 at 1:08 PM, Resident #60's Medical Power of Attorney (MPOA) stated, It was a constant battle .there were always issues especially on night shift with getting him changed. He would watch the clock, and it has been from 2 hours to 11 hours waiting to be changed. They always seemed short-staffed and constantly new staff. Dad felt they had not been trained. I am very upset because there were always issues. He will not be going back there.During an interview 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 provide an accurate and complete documentation for three (3) of 11 residents. Resident #60, #17 and #2. Facility Census: 59. Findings Include:a) Resident #60On 12/15/25 at 1:00 PM, a record review was completed for Resident #60. The review included a complaint dated 12/04/25 as well as a facility-reported incident (FRI) dated 12/02/25. The allegation was neglect; not providing incontinence care on 12/01/25 as well as 12/02/25. The facility did complete the investigation and found the resident was provided care. The NAs were not documenting each time care was provided to Resident #60. No documentation was found for the following dates and times:--12/01/25 at 12:53 PM--12/02/25 at 9:30 AM--12/02/25 at 2:44 PM--12/02/25 at 3:38 PM--12/02/25 at 3:59 PMOn 12/16/25 at 9:05 AM, an interview was held with the Administrator and the Director of Nursing (DON). The Administrator stated, This was a documentation error .the care was provided .we aren't taking credit for the care we provide.b) Resident #17On 12/15/25 at 3:00 PM, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain an infection control program. Staff were observed transporting soiled linen through the 100 Hallway while wearing soiled gloves. Trash Barrells sitting in resident a hallway full of soiled briefs were unable to be closed due to being so full. In addition, the 100 Hall Shower Room had a soiled washcloth, candy wrapper and open bottle of shampoo present. These were random opportunities for discovery that had the potential to affect more than an isolated number of residents. Facility Census: 59. a) 100 hall shower roomOn 12/15/25 at 11:44 AM, a tour of the shower room in 100 hall was completed. The tour found a soiled washcloth under the sink, a used hand wipe and candy wrapper on the floor, and an open bottle of soap sitting on the shower bar.On 12/15/25 at 11:45 AM, the Administrator was notified and entered the shower room. The Administrator began picking up the objects throughout the shower room.b) Soiled linen and soiled glovesOn…

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 implement the care plan for Resident # 2 regarding taking blood pressures in a restricted arm due to a mastectomy. This is true for one (1) of 11 residents reviewed during the survey process. Resident Identifier: #2. Facility Census: 59.Findings included:a) Resident #2On 12/16/25 at 1:00 PM, a record review was completed for Resident #2. The review found on the care plan under special instructions No B/P (blood pressure) or lab sticks in the left arm. The resident's left arm was restricted due to a mastectomy. The following dates the blood pressures were taken in the restricted arm:--09/14/25 at 2:59 PM--09/14/24 at 11:14 PM--09/15/25 at 9:06 AM--09/17/25 at 3:03 PM--10/21/25 at 6:14 PM--11/12/25 at 1:37 PM--11/13/25 at 2:42 PM--11/16/25 at 3:04 PM--11/18/25 at 2:05 PMOn 12/16/25 at 2:05 PM, the Director of Nursing (DON) was notified and confirmed the blood pressures should not have been obtained from the restricted arm.

Based on record review, and staff interview the facility failed to ensure it had a complete and accurate medical record. This failed practice was found true for (2) two of 11 residents reviewed for medical record accuracy during the Complaint Survey process. Resident identifiers #49, #2. Facility Census 59. b) Resident #2 On 12/16/25 at 1:00 PM, a record review was completed for Resident #2. The review found a physician's order dated 08/28/25 stating, No B/P (blood pressure) or venipuncture to left arm related to malignant neoplasm of unspecified site of left female breast. The resident's left arm is restricted due to a mastectomy. The following dates the blood pressures were taken in the restricted arm: --09/14/25 at 2:59 PM --09/14/24 at 11:14 PM --09/15/25 at 9:06 AM --09/17/25 at 3:03 PM --10/21/25 at 6:14 PM --11/12/25 at 1:37 PM --11/13/25 at 2:42 PM --11/16/25 at 3:04 PM --11/18/25 at 2:05 PM On 12/16/25 at 2:05 PM, the Director of Nursing (DON) was notified and confirmed the blood pressures should not have been obtained from the restricted arm. Findings Include: a) Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to provide a safe, clean, comfortable, homelike environment. This failed practice was a random opportunity for discovery, and had the potential to effect more than a limited number of residents during the complaint survey process. Facility Census 59. a) Packaged Terminal Air Conditioner (PTAC) unitsAn observation on 10/20/25 at 11:10 AM, revealed that the PTAC units in rooms 113, 125, 130, 131 and 132 had dirty filters that were covered with layers of dust. Additionally, room [ROOM NUMBER]'s PTAC unit had a dried, brown substance inside of the unit's vents.During an interview on 10/20/25 at approximately 11:20 AM, The Maintenance Director verified that room [ROOM NUMBER], 125, 130, 131, and 132 had dirty filters that were covered in dust and that the PTAC unit in room [ROOM NUMBER] had dried, brown substance inside of the vents. The Maintenance Director stated, Housekeeping normally cleans those vents when they clean the residents room.

Based on record review, and staff interview the facility failed to provide a staff posting that was accurate with actual nurse staffing numbers. This failed practice was a random opportunity for discovery during the complaint survey. Facility Census 59.a) Nursing staff postingsA review on 10/21/25 at 2:00 PM, of the Nurse Staff Postings from 09/2025 to present, revealed that of the 50 days reviewed, 16 of those appeared to be under the staff minimum of 2.25 for the day.Further review on 10/22/25 of the staff punch forms for the days in question, revealed punches for all days in questions, that put the staffing above the minimum. During an interview on 10/22/25 at 9:30 AM, the Director of nursing confirmed that the staff punch forms were correct and accurate and that the staff posting for the 16 days was incorrect.

Based on record review, family interview and staff interview the facility failed to notify the residents responsible party of a room change prior to moving the resident. This was a random opportunity for discovery during the compliant survey. Resident Identifier: #60. Facility Census: 58. Findings Include: a) Resident #60 During an interview with Resident #60's responsible party on 02/10/25 at 12:03 PM during a telephone interview , she stated, The last time they moved him they did not tell me. They just came in and packed up all his stuff and moved him. A review of the medical record on 02/10/25 in the afternoon found no indication the residents responsible party was notified of his room move. An interview with the Director of Nursing (DON) on the afternoon of 02/13/25 confirmed there was no evidence the residents responsible party was notified of his room move. She stated The social worker said she must have clicked the wrong button.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure all allegations of abuse and/or neglect was thoroughly investigated. This was true for Resident #59 and was a random opportunity of discovery during a complaint survey. This was determined to be past non-compliance because the facility had identified the failure and implemented an effective plan of correction to correct the non- compliance prior to the first day of the complaint survey. Resident Identifier: #59. Facility Census: 58. Findings Include: a) Resident #59 A review of the facility's reportable incidents on 02/10/25 found a reportable incident dated 02/15/24 pertaining to Resident #59. A review of the report found the following under the brief description of the incident: It is reported this afternoon (02/15/24) by (name of another state agency) worker that this resident allegedly received bruises and had multiple pressure ulcers of various stages upon returning home from (Name of facility). A review of the five day follow - up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident representative interview, staff interview, hospital staff interview, long term care ombudsman interview and record review the facility failed to ensure Resident #60 who was discharged from their facility and was expected to return was readmitted to the first available bed when medically stable. Resident #60 has remained in the hospital from [DATE] until the time of this survey. The facility has admitted other male residents instead of Resident #60 with claims they did not have suitable bed for him. Resident #60 has experienced actual psychosocial harm as a result of these failures. The resident has experienced anxiety, agitation, and feelings of despair thinking he has done something wrong to cause this. This was true for one (1) of three (3) facility residents whom were reviewed during this complaint survey. Resident Identifiers: #60. Facility Census: 58. Findings Include: a) Resident #60 On 01/28/25 the state survey agency received a complaint indicating Resident #60 was discharged 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 complete an accurate facility assessment related to the overall acuity of care needed for its population. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Extended Survey Process. Facility census 58. Findings Included: a) Facility Assessment (FA) A review on 01/14/24 at 11:30 AM of the Facility Assessment revealed the facility reviewed their FA on 10/24/24. Under over all acuity of residents the following calculations were determined: Assistance with Activities of Daily Living (ADL's) 20 % Mobility impairments 0% incontinence impairments 0% cognitive or behavioral impairment 18.18 % specialized care ( dialysis, vents, wound care) 0 % Other NA During an interview, on 01/14/25 at 2:00 PM, the Administrator stated, I missed a section evidently. I will fix it. He confirmed that he did not feel the overall acuity section out correctly. The Administrator later confirmed that the facility assessment was incorrect. A…

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

Based on resident interview, medical record review, staff interview and Resident Council Meeting discussion, the facility failed to ensure the resident shower room was at a comfortable temperature for resident use. This failed practice had the potential to affect more than a limited number of residents. Resident Census: 58. Findings Included: a) Resident Shower Room During an interview with Resident #26 on 01/07/25 at 11:39 AM, he stated he refused a shower the day before because the shower room was too cold. He stated one shower room was being renovated, and the other room is always too cold. A review of Resident #13's medical record on 01/07/25 found a nurses note dated 01/04/25 at 2:51 AM which read, Resident refused shower states that it is too cold, and the shower room is cold resident asked again at a later time educated on importance of self-care, On 01/15/24 at 10:30 AM the maintenance director was asked to obtain the temperature in the shower room the temperature at this time was 63.8 degree Fahrenheit (F). The shower room was noted to have two (2) heaters on the wall. 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 interviews, the facility failed to revise care plan for Resident #40 for one (1) on one (1) activities and Resident #19 and Resident #29 for behaviors. This failed practice was found true for three (3) of 21 residents reviewed for the care planning care area. Resident identifiers: #40, #19, and #29. Facility census: 58. Findings included: a) Resident #40 Record review completed on 01/08/25 revealed resident #40 to be care planned to receive one (1) on one (1) visits from the Activity Department. Further record review on 01/08/25 shows no evidence Resident #40 received one (1) on one (1) visits from the activity department. During an interview with the Activity Director (AD) on 01/09/25 at approximately 2:00 PM, the AD stated We used to do one (1) on one (1) visits, however she (Resident #40) became more independent with activities of her (Resident #40) choice, I'll (AD) update the care plan. Confirming the care plan should have been updated when Resident #40 no longer required one (1) on one (1) visits. b) Resident #19 At approximately 10:00 AM 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 interviews, the facility failed to ensure residents were provided activities of interests that he/she was care planned for. This was found true for one (1) of six (6) residents reviewed for the activities care area. Resident identifier: #40. Facility census: 58. Findings included: a) Resident #40 Record review completed on 01/08/25 revealed Resident #40 was care planned to receive one (1) on one (1) visits from the Activity Department. Further record review on 01/08/25 shows no evidence for Resident #40 to receive one (1) on one (1) visits from the activity department. During an interview with the Activity Director (AD) on 01/09/25 at approximately 2:00 PM the AD stated, We used to do one (1) on one (1) visits, however she (Resident #40) became more independent with activities of her choice. I'll update the care plan. Confirming the care plan should have been updated when Resident #40 no longer required one (1) on one (1) visits.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice had the potential to affect four (4) of 21 residents in the long-term care survey sample. Physician's orders to obtain weights were not followed for Resident #26 and Resident #19. Insulin was held without physician orders or notification for Resident #32. Neurological checks were not completed after an unwitnessed fall for Resident #53. Resident identifiers: #26, #32, #53, and #19. Facility census: 58. Findings included: a) Resident #26 Resident #26 had an order written on 08/01/24 for monthly weights. The provider was to be notified if the resident's weight changed more than five (5) pounds. The resident's last weight was recorded on 10/01/24. Resident #26's treatment administration record (TAR) had an area for the nurses to indicate the resident's weight had been obtained. The resident's TAR for November 2024 indicated the resident's weight had been obtained. However, no weight was recorded in…

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

Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. A storage room containing hazardous items was found to be unlocked. This was a random opportunity for discovery that had the potential to affect any resident able to access the closet. Facility census: 58. Findings included: a) Storage room On 01/07/25 at 11:04 AM, a door with signage stating ''new linen room was found to be able to be opened by the surveyor. The door had a keypad on it. In addition to containing clean linens, the room had toiletries, including razor blades. On 01/07/25 at 11:06 AM, Licensed Practical Nurse (LPN) #31 confirmed the door was unlocked. She acknowledged the door should have been locked. It was found that the door did not close easily and remained unlocked unless the door was forcefully closed. When the door was forcefully closed, it did lock. LPN #31 stated she would have maintenance fix the door. No further information was provided through the completion of the survey.

Based on record review, staff interview and policy review, the facility failed to ensure a licensed pharmacist completed a monthly drug regimen review, reported any irregularities to the attending physician and the attending physician responded to any recommendations within the time frame established by the facility policy. This was true for three (3) of five (5) residents reviewed for the care area of unnecessary medications during the Long term care survey process. Resident Identifiers: #30, #53, and #32. Facility Census: 58. Findings Included: a) Resident #30 A review of Resident #30's medical record on the morning of 01/13/25 found no evidence that the pharmacist had reviewed Resident #30's drug regimen in the months of 08/2024, 09/2024, and 10/2024. In an interview with the Director of Nursing (DON) on 01/13/25 at 3:00 PM she confirmed she could not find any evidence to show the licensed pharmacist had reviewed Resident #30's drug regimen on the above mentioned months. b) Resident #53 At approximately 1:00 PM on 01/08/2024, during a review of Resident #53's medical record, it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, record review and staff interview, the facility failed to ensure food was served at a palatable temperature. This failed practice had the potential to affect more than an limited number of residents. Facility Census: 58. Findings Included: a) Grievance review A review of the grievances found the following grievances noted: Resident #13 and Resident #15, filed a grievance dated 03/22/24. The Residents stated the food is cool and they are not using the plate warmer. Resident #11 filed a grievance dated 08/21/24 and stated, when her tray is delivered it is cold almost every time at dinner time. Resident #1 filed a grievance dated 11/20/24 the resident indicated the pancakes were cold, not enough sausage, and the pancake was so hard she could not cut it. b) Resident Interviews On 01/07/25 at 11:38 AM, Resident #26 stated his food was often cold when served to him. On 01/07/25 at 2:26 PM, Resident #7 stated her food, especially soup, was often cold when served to her. During and interview…

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 and staff interview, the facility failed to ensure food was stored and an served in a safe and sanitary manner. There were multiple items in the walk-in cooler that was either out of date or not dated to indicate when they had been opened. Additionally two (2) vents in the kitchen ceiling had a collection of dust around the vents on the ceiling. The vent on the HVAC unit in the kitchen had a collection of dust on the outer metal grate covering the filter. The filter itself was also completely covered in dust. This failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Facility Census: 58. Findings Included: a) Walk in cooler: An initial tour of the kitchen with the Dietary Manager (DM) on 01/07/25 beginning at 10:47 AM found the following food storage issues in the walk in cooler: - 37 individual cups of assorted yogurt which all had a manufactures stamped expiration date of 01/06/25. - A prepackaged container of fruit salad…

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 follow proper infection control practices, by dropping cartons of milk on the floor and placing them back in the cart with clean cartons, by sending uncovered cups full of coffee out onto the floor from the kitchen, and by failing to ensure enhanced barrier precautions were followed and posted for Residents #20 and 58. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Resident identifiers: 20, 58. Facility census: 58. Findings included: a) Milk cartons At approximately 11:53 AM on 01/07/25 Nurse Aide (NA) #58 was observed, during lunch tray pass, dropping two cartons of milk on the floor. NA #58 picked up the two cartons and placed them back in the cart with the clean milk cartons. NA #58 acknowledged dropping the milk cartons on the floor and returning them to the cart with the clean milk cartons and stated I don't know why I did that, I just wasn't thinking. b) Coffee cups At approximately 11:59 AM on 01/07/25, during lunch tray pass, a tray of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to administer pneumococcal vaccines in accordance with Centers for Disease Control (CDC) guidelines. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #6 and #17. Facility census: 58. Findings included: a) Resident # 6 Review of Resident #6's medical records showed the resident signed a consent to have a PPSV23 vaccination administered on 12/06/24. The consent stated PCV20 may be used if PPSV23 was not available. The consent stated, The CDC recommends one pneumococcal vaccine PPSV23 for adults [AGE] years of age or older. If you are 65 or older and have not had a pneumonia vaccine, or received PCV13, PCV15 or PCV20 at least 1 year ago or PPSV23 at least 5 years ago (when under 65), you should receive one dose of PPSV23. On 12/11/24, Resident #6 received vaccination with PPSV23. b) Resident #17 Review of Resident #17's medical records showed the resident's representative signed a…

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

Based on resident interview, record review, and staff interview, the facility failed to allow residents to make choices important to them. This deficient practice had the potential to affect one (1) of 21 residents in the long-term care survey sample. The facility did not honor Resident #49's choice as to when to have his dressing changed. Resident identifier: #49. Facility census: 58. Findings included: a) Resident #49 Review of Resident #49's physician's orders showed an order written on 12/26/24 to Cleanse unstageable ulcer to outer right ankle with wound wash; allow to dry; apply Medihoney, cover with bordered foam, every night shift for wound healing until healed. Review of Resident #49's progress notes showed a nurse's note written on 1/4/2025 at 4:13 AM, which stated, Cleanse unstageable ulcer to outer right ankle with wound wash; allow to dry; apply Medihoney, cover with bordered foam, every night shift for wound healing until resolved. Resident refused TX [treatment] stating that if the nurse wanted to do his treatment, then she should have came into do it at a more…

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 complete and accurate bed hold notice was given to the resident representative when Resident #60 was transferred to the emergency room. This was true for one (1) of three (3) residents reviewed for the care area of hospitalizations during the long-term care survey process. Resident Identifier: #60. Facility Census: 58. Findings Included: a) Resident #60 A review of Resident #60's medical record on 01/08/25 found she was discharged to the emergency room on [DATE]. A copy of the resident's bed hold notice which was sent to the resident representative was requested on 01/09/24. The bed hold notice when provided was not complete. The notice contained the resident's name and medical record number and was signed by the nurse. The bed hold notice did not identify if Resident #60 had any behold days available to her from her insurance and the rate per day was not identified should the resident's representative want to pay privately to hold 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 Resident #60's and Resident #59's Minimum Data Set (MDS) were accurately completed. This was true for two (2) of 21 sample residents reviewed during the long term care survey process. Resident Identifiers: #59 and #60. Facility Census: 58. Findings Include: a) Resident #59 A review of Resident #59's medical record on 01/14/25 at 10:00 AM, found the resident was discharged home on [DATE]. The son had asked the facility to prepare for the discharge on [DATE]. The facility made all arrangements for the discharge including a referral for home health. The Discharge MDS with and Assessment Reference Date (ARD) of 12/05/24 found the MDS identified the residents discharge as unplanned, even though the discharge was planned. An interview with the Director of Nursing (DON) on 01/14/25 at 10:58 AM confirmed the MDS was not coded accurately. b) Resident #60 A review of Resident #60's medical record on the morning of 01/14/25 found a Weekly Wound…

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 identify medical diagnoses of Major Depressive disorder on the Preadmission Screening and Resident Review (PASARR). This was found true for one (2) of three (3) residents reviewed under PASARR care area. Resident identifiers: #40 and #30. Facility census 58. Findings included: a) Resident #40 On 01/07/25 at 3:21 PM record review found the following medical diagnosis: Schizoaffective Disorder, Bipolar type, and Major Depressive Disorder. Further record review on 01/07/25 of the PASARR revealed major depressive disorder was not identified on the form. An interview on 01/08/25 at 9:55 AM with the Director of Nursing (DON) who confirmed the PASARR was incorrect and did not contain major depressive disorder. b) Resident #30 A review of Resident #30's medical record on 01/14/25 found the resident's medical diagnosis list included the following: Unspecified Dementia, Bipolar Disease, and epilepsy. Further review of the record found a PASARR dated 07/07/24 did not identify the resident having a diagnosis of dementia, bipolar…

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 implement the care plan for Resident #19, by failing to identify triggers for behaviors. This was true for one (1) of twenty-one (21) resident care plans reviewed during the survey process. Resident identifier: #19. Facility census: 58. Findings included: a) Resident #19 At approximately 10:00 AM on 01/09/25, during a review of Resident #19's record, it was noted the care plan had a focus for behaviors. The care plan read as follows: Focus- BEHAVIORS: the resident has behaviors of delusions: fixed false beliefs despite evidence that they are untrue, hallucinations: visual, auditory or other, often makes false allegations, often talks about people wanting to have inappropriate behaviors with her. Date initiated: 11/28/2024 Revision on: 01/08/2025. Goal- The resident's behaviors will cause them less distress thru the review period. Date Initiated: 11/28/2024. Target Date: 04/06/2025. Interventions: -administer medications as ordered. Date initiated: 11/28/2024. -Approach with a calm quiet voice, divert attention, and…

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

Based on record review, observation, resident interview, and staff interview, the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (5) five residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifier #34. Facility Census 58. Findings Included: a) Resident #34 During the initial observation and interview on 01/07/25 at 2:15 PM, Resident #34's teeth were covered with a white substance with some black spots. Resident #34 stated, I can not tell you when the last time they brushed my teeth. I cannot do it myself. I do have a tooth brush in here, but I cannot tell you where it is. A record review on 01/08/25 at 1:30 PM, of Resident #34's Brief Interview for Mental Status (BIMS) score, dated 12/17/24 revealed a BIMS score of 14. Further record review revealed Resident #34's last dental consult was on 12/19/24, and included a hygiene note that reads as follows: Very heavy plaque, calculus and food debris. Recommend assistance with daily Oral Hygiene (OH). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to prevent, identify, assess, and treat pressure ulcers in accordance with professional standards of treatment. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident identifier: #6. Facility census: 58. Findings included: a) Resident #6 Review of Resident #6's medical records showed the resident returned to the facility on [DATE] after a hospital stay. A nursing note written on 12/26/24 at 2:56 PM stated the resident had a Pressure area to left buttock. A nursing note written on 12/26/24 at 3:10 PM stated the resident had an Open area to left buttock. The readmission Nursing Collection Tool dated 12/26/24 documented the resident had a pressure ulcer to the left buttock, measuring two (2) centimeters (cm) in length by two (2) cm in width. The depth and the stage were not documented. The Licensed Nurse Weekly Skin Observation dated 12/26/24 stated, Resident readmitted…

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 resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding. This was true for one (1) of two (2) residents reviewed for the care area of tube feeding during the long term care survey. Resident Identifier: #60. Facility Census: 58. Findings Included: a) Resident #60 1. Residual Order A review of Resident #60's medical record on the morning of 01/14/25 found the following physician order: Enteral Feed Order: every shift Check feeding tube residual every (provider please specify) Hold tube feeding if residual is greater than (provider to specify). This order had a start date of 01/08/25 and was the current order at the time of this review. An interview with the Director of Nursing at 10:58 AM on 01/14/25 confirmed the order to check the resident's residual of her feeding tube was incomplete. The provider failed to specify the number of times the residual should be checked or when the feeding should be held. 2. Amount of Feeding A review of…

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

Based on record review and staff interview, the facility failed to implement non-pharmacological interventions for behaviors exhibited by Resident #19. This was true for one (1) of one (1) residents reviewed for behaviors during the survey process. Resident identifier: 19. Facility census: 58. Findings included: a) Resident #19 During a review of Resident #19's record on 01/09/25, multiple episodes of psychosis were noted.The facility documented behaviors in the progress notes section of the resident's record. Upon review of those behavior notes, it was determined the facility staff was attempting to redirect the resident and, if that did not work, no other non-pharmacological interventions were attempted. During a review of Resident #19's orders, it was noted the resident had an order, beginning on 12/30/24, for behavior monitoring and, included in the order, were eight (8) non-pharmacological interventions. The interventions are as follows: (1) Redirect (2) 1:1 (3) activities (4) toilet (5) give food or fluids (6) reposition (7) back rub (8) other-chart in progress notes. 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 monitor Resident #53 for psychotropic medication side effects in November of 2024, during which time, the resident had an unwitnessed fall. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: 53. Facility census: 58. Findings included: a) Resident #53 Resident #53's medical record review revealed she received Remeron and Zyprexa. Resident #53 discovered the resident suffered an unwitnessed fall on 11/01/24. The following note for the fall is typed as written in the progress notes in the resident's medical record: 11/1/2024 16:39 *Nursing Note Note Text: This nurse was walking by in the hallway and observed resident sitting in the floor on her buttocks beside her bed with WC behind her. Appears that resident was trying to self transfer into bed. Residents roommate was standing beside her. When nurse asked resident she stated I don't know what I did. Resident was assisted up and back to WC per her request by 2x staff members. Body…

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 and staff interview, the facility failed to accommodate Resident #36's food preferences by serving her eggs. This was a random opportunity for discovery. Resident identifier: #36. Facility census: 58. Findings included: a) Resident #36 At approximately 2:15 PM on 01/07/25, during an interview with Resident #36, she stated They send me eggs every morning and I can't eat them because I'm allergic to them. The resident reiterated she did not like eggs. At approximately 2:00 PM on 01/08/25, during review of Resident #36's dietary profile dated 12/27/2024, it was noted, under the food allergy section of the assessment, the resident was allergic to eggs. At approximately 8:00 AM on 01/09/25, during observation of the breakfast tray pass, Resident #36 was served a breakfast casserole. At approximately 8:05 AM on 01/09/25, the Dietary Manager (DM) confirmed the breakfast casserole contained eggs. At approximately 8:15 AM the Director of Nursing (DON) confirmed the resident had received breakfast casserole. At approximately 12:00 PM 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 ensure complete and accurate medical records for two (4) of 21 residents in the long-term care survey sample. Resident #49 had an incomplete Physician Orders for Scope of Treatment (POST) form. Resident #6 had an inaccurate medication order and care plan. Resident identifiers: #49, and #6. Facility census: 58. Findings included: a) Resident #49 Review of Resident #49's medical records showed a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form completed on 05/24/24. The portion of the POST form regarding medically assisted nutrition was blank. This section contained the following four (4) options: - Provide feeding through new or existing surgically-placed tubes. - Time-limited trial of ____ days but no surgically-placed tubes. - No artificial means of nutrition desired. - Discussed but no decision made (provide standard of care). On 01/08/25 at 12:06 PM, the Director of Nursing (DON) stated medically assisted nutrition was discussed with the resident representative who was unable to make a decision…

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 interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the water management program to reduce Legionella growth and spread in the facility. This practice had the potential to affect all residents that reside in the facility. Facility census: 52. Findings included: a) Water Management Program Review of the facility's water management program found documentation was not maintained to reduce the building's risk for growing and spreading Legionella. The flow diagram did not identify the building's water systems for which Legionella control measures are needed. No documentation was provided describing the building water systems using text and flow diagrams, and no documentation was provided to identify areas where Legionella could grow and spread. No documentation was made on where control measures should be applied and how the control…

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 promote dignity during dining. Residents were not served lunch trays at the same time as roommates for dining within the residents' room. This was a random opportunity for discovery and had the potential to affect only a limited number of residents. Resident identifiers: #14, #45. Facility census: 55. Findings included: a) On 01/09/24 at 12:08 PM Resident #45 was served a lunch tray in her room and began eating. At 12:14 PM Resident #14 (Resident #45's roommate) was observed ambulating out of the room and grabbed a tray off the tray cart and returned to her room with the lunch tray. Resident #14 set the tray on her bed, removed the plate cover, and began to eat. The surveyor informed Certified Nurse Aide (CNA) #25 the resident had obtained a tray from the tray cart and was eating it. CNA #25 went into Resident #14's room, looked at the meal ticket and removed the tray. CNA #25 stated, That's not even her tray its [Resident #41's first name]. I will get him a new tray. At 12:16 PM, CNA #25 located Resident #14's 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 and staff interview the facility failed to serve food and drink that was palatable and at a safe and appetizing temperature for Resident # 54. This was a random opportunity for discovery. Resident identifier: 54. Facility census: 55. Findings included: a) On 01/09/24 at 12:02 PM, meal trays were transported to the hallway on open food delivery carts. Dietary Manager (DM) manager stated they had enclosed tray carts; however, they were upstairs, and they cannot get them downstairs due to the elevator being currently down. On 01/09/24 at 12.25 pm temperatures were obtained on the lunch meal tray for Resident #54 at the time of service. The following temperatures were obtained by the DM using her thermometer. -- Mashed potatoes with gravy: 125 degrees Fahrenheit (F) - Ham: 122 degrees F --Broccoli: 110 degrees F --Milk: 39 degrees F -Milkshake: 39 degrees F On 01/09/24 at 3:02 PM enclosed tray carts were noted to be available for staff use by the kitchen hallway. On 01/9/24 at 3:06 PM DM stated the carts will be used for the next meal at dinner . On 01/09/24 at 3:30…

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 Residents on the second floor with a dignified dining experience. Residents were not served meals in the traditional dinnerware. This was a random opportunity for discovery and had the potential to affect all 11 Residents residing on the second floor. Facility Census: 49. Findings Included: a) Observation of Second Floor dining During an Second floor observation on 08/28/23 at 1:02 PM, Nurse Aide (NA) #16 was carrying a tray with a Resident's noon meal. The meal was in a Styrofoam tray, NA #16 stated their meals come in styrofoam along with their drinks and plastic silverware. All the Residents on the second floor that receive meals have them served in styrofoam since the flood on Memorial Day. During an interview on 08/28/23 at 1:25 PM, the Certified Dietary Manager (CDM) stated it was a request of the building for dietary to serve the meals in styrofoam for the second floor residents. The elevator is not working, the staff are carrying the food up the steps. During an interview on 08/28/23 at 3:37 PM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview and staff interview, the facility failed to provide a clean and sanitary environment. This failed practice had the potential to affect all the Residents that receive nourishment from the facility kitchen. The facility also failed to maintain Rooms 129, 130, 131, 132 and the Long Hall in a sanitary condition. Facility Census: 49 Findings Included: a) An in the Kitchen During an initial tour of the kitchen on 08/28/23 at 10:41 AM, with the Certified Dietary Manager (CDM) an observation of an industrial size floor fan was revealed. The fan had an accumulation of dust on the fan blades and a thick layer of a light brown substance around the inside of the fan. The base of the fan had a build up of food particles. During an immediate interview the CDM stated the air conditioner is broken. They are here repairing it today. The CDM was asked, who is responsible for the cleaning of the fan? The CDM stated the Maintenance Department. During an interview on 08/28/23 at 11:15 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, the facility failed to ensure residents had access to water that was a comfortable temperature desired by the resident. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifiers: #14. Facility census 49. Findings included: a) Resident #14 On 08/28/23 at 10:35 AM, Resident #14 said she has been at this facility for three (3) years and has not had hot water in her sink the whole time. She went on to say, she gets warm showers but on the days she does not she has to wash up with cold water or wait until one (1) of the Nurse Aides (NA) has time to bring me a pan of warm water. She also said that she would love to wash her hands in warm water and the NA's must use hand sanitizer because of no hot water. On 08/28/23 at 12:00 PM, Maintenance Staff #56 came to check the hot water temperature in room [ROOM NUMBER]. E#56 turned on the hot water in the sink at 12:07 PM, and ran the water…

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 residents were offered the pneumococcal immunization recommended by The Centers for Disease Control (CDC). This was true for two (2) of five (5) residents reviewed for the care area of immunizations. Resident identifiers: #6, #9. Facility census: 49. Findings included: a) Policy Review The facility's policy titled Pneumococcal Vaccine dated 2001 with revision date 2016 stated that administration of pneumococcal vaccination or revaccinations would be made in accordance with current CDC recommendations at the time of the vaccination. b) Resident #6 Review of Resident #6's medical records showed Resident #6's Medical Power of Attorney (MPOA) was offered the Pneumococcal Polysaccharide Vaccine (PPSV23) vaccination for the resident upon admission [DATE]. The MPOA declined the vaccination. The CDC's publication titled Pneumococcal Vaccine Timing for Adults with implementation date 03/15/23, available on-line, recommended non-vaccinated adults…

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 complete infection surveillance for residents who are actively being treated for Multidrug-resistant organisms (MDRO.) In addition, the facility failed to track and trend other infections. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Facility census 48. Findings included: a) Infection surveillance Facility Policy titled, Infection Reporting no date was on the policy. --New orders for antibiotics or new lab orders, such as to obtain cultures, will be noted in the 24-hour shift report. --The nurse noting orders for transmission-based precautions will communicate the type of precautions (e.g., contact, droplet, airborne) ordered for resident, room number, to all departments, the Director of Nursing, Administrator, and the Infection Preventionist via the in-house communication form. --Transmission-based precautions will be noted with a sign on the residents door for the duration the resident is on transmission-based precautions. During an…

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 interview, the facility failed to ensure resident privacy was available during the delivery of personal care. Windows were not covered and a resident's room door was not closed during care. These findings were random opportunities for discovery. Resident identifiers: #107, #21, #50 and room [ROOM NUMBER]. Facility census 48. Findings included: a) Resident #107 During an interview with Resident #107 on 04/24/23 at 2:48 PM, Resident #107 said her window blinds don't close all the way. The resident had her privacy curtain pinned across the window. The facility parking lot is just outside the window. a 1) Resident #107 On 04/25/23 at 1:00 PM, Registered Nurse #57 was providing care for Resident #107 and did not close the door. It was noted that a male resident was in the hall looking in the room at Resident #107 while she was uncovered and exposed. RN #57 was asked to close the door. RN #57 said she cannot close the door because she must keep her eye on 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 Observation, record review and staff interview the facility failed to develop a comprehensive person-centered care plan in the care area of pressure injury preventions, privacy cover on a Foley catheter collection bag, and having a resident placed in contact isolation. This was true for three (3) out of 16 residents reviewed for care plans. Facility census 48. Findings included: a) Resident #107 (treatment and prevention of pressure ulcers) During an observation of pressure ulcer care on 04/25/23 at 1:00 PM, Resident #107 had a Deep Tissue Injury (DTI) on the left heel extending to the outer lateral foot. The wound was deep purple in color, approximately 5.5 cm in length and 4 cm in width. Before the care was provided it was noted that there was no type of pillow or boot being used to keep pressure off the left heel. After the care was completed again the left foot was left lying directly on the mattress. On 04/25/23 at 2:10 PM, Registered Nurse #57 was asked if any interventions were in place to off load the pressure on the left heel to prevent further damage. RN #57…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, staff interview and resident interview, the facility failed to hold a care plan meeting and involve R #17 in his individual care planning process. This was true for one (1) of 16 Residents reviewed for care plans. Resident identifier: #17. Facility census: 48. Findings included: a) Resident #17 On 04/24/23 at 12:12 PM, Resident #17 asked the surveyor to find out his plan and how long he was going to have to stay here. The resident stated he has never been to any meetings and had never heard of a care plan meeting. Resident #17 was admitted [DATE]. Record review of progress notes found no mention of a care plan meeting ever being held for Resident #17. During an interview on 04/26/23 at 10:28 AM, the Director of Nursing (DON) stated, I can't say we had a care plan meeting. The DON further explained the social worker left the faciity on 4/12/23, and a letter had been sent out 03/27/23 for a care plan meeting that was to be scheduled on 04/20/23. The DON stated, I have no idea if that…

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

Based on record review, staff interview and resident interview, the facility failed to provide appropriate care for elevated blood glucose levels for one (1) of one (1) Resident reviewed for unnecessary medications. Resident identifier: #21. Facility census: 48. Findings included: a) Resident #48 During an interview on 04/24/23 at 12:49 PM, Resident #21 stated his blood sugars had been running high. Record review showed the following blood glucose levels to be extremely elevated in April with no documentation of interventions or provider notification: 04/03/23 518 mg/dL at 7:00 AM 04/03/23 518 mg/dL at 5:00 PM 04/07/23 443 mg/dL at 7:00 AM 04/12/23 600 mg/dL at 11:00 AM 04/17/23 501 mg/dL at 7:00 AM 04/17/23 501 mg/dL at 5:00 PM Record review showed the following orders for treatment: Humalog U-100 Insulin (insulin lispro) cartridge; 100 unit/mL; amount: 15 units; subcutaneous Special Instructions: Hold if BS < 160. Once A Day at 11:00 AM. Humalog U-100 Insulin (insulin lispro) cartridge; 100 unit/mL; amount: 5 units; subcutaneous Special Instructions: Hold if blood sugar is less…

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 ensure residents receive care, consistent with professional standards of practice, for care of pressure ulcers. This was true for one (1) of one (1) resident reviewed for pressure ulcer care. Resident identifiers: Resident identifier: # 107. Facility census 48. Findings included: a) Resident #107 A review of the medical records revealed Resident # 107 was admitted to the facility on [DATE]. Resident # 107 was noted to have pressure injuries on the left heel, left and right thigh, sacrum, and left buttock. An observation of pressure ulcer care on 04/25/23 at 1:00 PM, with Registered Nurse #57, found the following: RN #57 failed to clear, disinfect and use a side table to place the supplies on for the pressure ulcer care. RN #57 used a single paper towel and placed it on the foot of the bed, she then put the supplies on the paper towel. The sheets on the bed had red blood smears and visible brown debris on them. RN #57 carried the can of wound…

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

Based on observation, record review and staff interview the facility failed to ensure the environment is free from accident hazards. This was true for one (1) of one (1) resident reviewed for the care area of accidents related to smoking and one (1) was a random act of discovery. Resident identifiers: #11 and #3. Facility Census: #48 Findings Included: a) Resident #11 On 04/24/23 at 2:55 PM records revealed Resident #11 is a smoker. Further record review found the following: 06/15/22 Quarterly Tobacco Use Observation assessment, Description: Annual Assessment 10/11/22 Quarterly Tobacco Use Observation assessment, Description: Quarterly Assessment 11/22/22 Quarterly Tobacco Use Observation assessment, Description: Quarterly Assessment The next Quarterly Tobacco Use Observation assessment was due 02/22/23 and had not performed. The care plan reflects the following: Approach: Safe smoking assessment completed on admission, quarterly and as needed. Start Date 07/03/2021 On 04/25/23 at 8:30 AM and 12:30 PM, Resident #11 was observed smoking in the designated smoking area with staff…

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, and staff interview the facility failed to follow physicians' orders for ensuring the Foley Catheter collection bag was covered at all times. This was true for one (1) of one (1) resident reviewed for catheter care. Resident identifier: #107. Facility census 48. Findings included: a) Resident #107 Medical record review found the facility Physician ordered a urinary catheter bag cover to be used at all times on 04/19/23. During an observation on 04/24/23 at 2:46 PM, it was noted there was no privacy cover over the Foley catheter collection bag. On 04/24/23 at 2:47 PM Licensed Practical Nurse #53 said she would put a privacy cover on the urinary bag. .

Based on record review and staff interviews the facility failed to offer pneumococcal immunizations to all residents. This was true for two (2) out of five (5) reviewed for immunizations. Resident Identifiers: #107, and #41. Facility census 48. Findings included: a) Resident #107 A review of the medical records for Resident #107 found no evidence the Resident received a pneumococcal vaccine. On 04/25/23 at 12:00 PM, the Infection Preventionist (IP) was asked if Resident #107 was offered the vaccine. The IP stated it was her understanding Resident #107 did not want the vaccine. At 1:45 PM on 04/26/23, the IP provided the Pneumococcal vaccination declination. Record review found Resident #107 has capacity; however, Registered Nurse (RN) #53 signed the forms instead of the Resident. There was no evidence to support that Resident #107 was offered and declined the vaccine. b) Resident #41 Resident #41 has been in the facility since 05/13/22. A review of the medical record found Resident #41 was not offered a pneumococcal vaccine. At 1:45 PM on 04/26/23, the IP stated she called the MPOA…

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.