Charleston Healthcare Center

Based on record review and staff interview, the facility failed to implement the care plan regarding the amount of feeding assistance needed as well as develop and implement impaired skin integrity interventions for Resident #153. This was true for one (1) of 18 residents reviewed during the survey process. Facility Census: 143.Findings Include:a1) Resident #153On 10/14/25 at 1:30 AM, a record review was completeid for Resident #153. The review found the care plan had not been implemented regarding feeding assistance. The resident was noted as totally dependent of staff x 1 (one) for eating. The documentation of assistance given during meals from 07/2025 through 09/2025 was reviewed. The following meals were not documented as dependent:--07/15/25 at breakfast, lunch--07/16/25 at dinner--0717/25 all meals--07/18/25 all meals--07/19/25 all meals--07/21/25 all meals--07/22/25 breakfast, lunch--07/23/25 all meals--07/24/25 all meals--07/25/25 all meals--07/27/25 all meals--07/28/25 all meals--07/29/25 all meals--07/30/25 all meals--07/31/25 all meals--08/01/25 all meals--08/02/25 all…

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 activities of daily living (ADLs) for a dependent resident, #153. The ADLs included feeding assistance as well as showers or baths. This was true for one (1) of 18 residents reviewed during the survey process. Resident Identifier: #153. Facility Census: 143. Findings Include:a1) Resident #153On 10/14/25 at 1:30 PM, a record review was completed for Resident #153. The review found the resident had not been provided feeding assistance as a dependent resident for meals. The documentation of assistance given during meals from 07/2025 through 09/2025 was reviewed. The following meals were not documented as dependent:--07/15/25 at breakfast, lunch--07/16/25 at dinner--0717/25 all meals--07/18/25 all meals--07/19/25 all meals--07/21/25 all meals--07/22/25 breakfast, lunch--07/23/25 all meals--07/24/25 all meals--07/25/25 all meals--07/27/25 all meals--07/28/25 all meals--07/29/25 all meals--07/30/25 all meals--07/31/25 all meals--08/01/25 all meals--08/02/25 all meals--08/03/25 all meals--08/04/25 breakfast,…

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 #152's recommendations from a hospital stay were followed up on with the attending physician. The discharge summary indicated the resident should have a BMP (Basic Metabolic Panel) and CBC (complete blood count) in one week from the date of discharge. This labs were not obtained nor was there evidence this was addressed with the attending physician to see if they wanted the lab work to be obtained or not. This was true for one (1) of residents reviewed during the complaint survey. Resident Identifier: #152. Facility Census: 143. Findings Included: a) Resident #152 A review of Resident #152's medical record found the resident was readmitted from the hospital on [DATE]. A review of the hospital discharge summary associated with this readmission found the following, Pending Labs and studies: BMP CBC in one (1) week. In the afternoon on 10/15/25 the Interim Director of Nursing (DON) was asked to provide the results of the BMP and CBC…

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 one (1) of three (3) residents reviewed for the care area of pressure ulcers, the wound nurse practitioner's note documented the wrong treatment being used. Resident Identifier: #152. Facility census: 143.Findings included:a) Resident #152Review of Resident #152's physician's orders showed an order written on 01/20/25 for skin prep to left great toe pressure injury. The order continued through the resident's discharge from the facility.The resident's medical records documented an allergy to betadine. Wound Nurse Practitioner (NP) #173 assessed the wound weekly and made treatment recommendations. On 01/23/25, 02/04/25, and 02/10/25, NP #173 indicated the resident's left great toe pressure ulcer was being treated with betadine. Beginning 02/19/25, NP #173 correctly indicated the pressure ulcer was being treated with skin prep. On 10/16/25 at 9:45 AM, the Director of Nursing (DON) confirmed NP #173's weekly treatment recommendations on 01/23/25, 02/04/25, and 02/10/25…

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 residents had care plans developed for as of area of concern. Resident #68 had suffered fluid volume depletion and did not have a care plan focus area for dehydration. Resident identifier: #68. Facility census: 145. Findings included: a) Resident # 68 During the initial interview on 10/28/24 at 12:47 PM, Resident #68 stated, I don't drink the water here. I drink coffee with each meal and I eat Ice chips. They don't always bring me my ice chips. They are getting a little better since I had that intravenous (IV) to get fluids. Further record review of Resident #68's diagnoses revealed that Resident #68 was diagnosed with a Urinary Tract Infection (UTI) on 09/06/24 that was resolved on 10/05/24. The Hydration risk evaluation dated 10/09/24 did not indicate that Resident #68 had a history of UTI, which would put her at a higher risk for dehydration. Further record review of Resident #68's diagnosis revealed a diagnosis of depression. The Hydration risk evaluation dated 10/09/24 does not indicate that Resident #68…

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 establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. These were random opportunities that had the potential to affect more than a limited number of residents. Resident identifiers: #132 and #130. Facility census: 145. Findings included: a) On 10/30/24 at 10:02 AM an inspection of the laundry room was made with the Assistant Executive Director accompanying the survey. In the dirty area of the laundry room, where dirty laundry was brought and sorted, five (5) mop heads were noted to hanging on hooks. Laundry room worker #176 stated the mop heads were clean. She stated they could not go into the dryer so they had been hung there to dry after washing. She stated she realized clean items should not be drying in the dirty laundry area, but that she did not have anywhere else to hang them. b) Resident #132 On 10/30/24 at 8:55 AM, an observation of Licensed Practical Nurse (LPN) #153 was made during medication…

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

Based on observations and staff interviews the facility failed to make sure call light was accessible to Resident #120. This was a random opportunity for discovery during the Long-Term Care survey. Facility census: 145. Resident identifier: #120 Findings included: a) Resident #120 During the initial facility tour on 10/28/24 around 11:45 AM the surveyor observed Resident #120 lying in bed with head elevated, the call light was not within reach of Resident #120. The call light was hanging between the headboard and the mattress. As the surveyor exited the room, the staff entered the room. Further observation on 10/28/24 around 12:15 PM of Resident #120 laying in the bed after staff left the room revealed the call light was still hanging on the headboard not within reach to Resident #20. An interview with Unit Manager Registered Nurse (UMRN)# 50 on 10/28/24 at approximately 12:20 PM confirmed the call light was not within reach for Resident #120. On 10/29/24 at approximately 9:00 AM the Administrator provided a copy of the facility policy. On page two (2) procedure one (1) Section C…

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

Based on record review, resident interview, and staff interview the facility failed to honor Resident #68's choices in their preference to only have female caregivers. This failed practice was found true for (1) one of (9) nine residents reviewed for choices during the Long-Term Care Survey Process. Resident identifier: #68. Facility Census: 145. Findings include: a) Resident #68 During an interview on 10/29/24 at 1:00 PM, Resident #68 stated, I don't like it when the guys come in to take care of me, I won't let them. Record review on 10/29/24 at 2:15 PM, for Resident #68 revealed a care plan that reads as follows: Residents prefers female caregivers. A record review on 10/29/24 at 4:30 PM of the Daily Assignment sheets for EB2 indicated that Resident #68 had a male Nursing Assistant (NA) assigned to her on 10/08/24, 10/09/24, 10/15/24, and 10/23/24. During an interview on 10/29/24 at 4:40 PM, the Director of Nursing (DON) stated, She usually doesn't like male caregivers, but she will tolerate (NA #44 named). We do the assignments by seniority. So he typically gets the assignment…

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 a thorough investigation of a reported incident and identify an allegation of neglect. The facility did not follow physician's orders for Resident #122. This was true for 1(one) of 4 (four) residents reviewed for abuse and neglect. Resident identifier #122. Facility Census 145. Findings included: a) A review of the incident report, investigation and five day-follow-up that occurred on 06/16/24 for Resident #122 revealed the following: Resident # 122 was found in her room with chopped up fruit in her bed by a nurse aide. The resident's brother later reported to the nurse that he had Resident #122 laughing and spitting up chunks of fruit. There was a spoon and empty fruit cup on the floor beside her bed on 06/16/24. There were (3) three witness statements collected. Witness statements were collected from the nurse aide and Licensed Practical Nurse (LPN) #52 and the assistant cook. The Assistant [NAME] reported that a nurse called and asked for scrambled eggs for Resident #122 on 06/17/24 and she made them…

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 The facility failed to make a care plan revision in the area of advanced directives. This failed practice was found true for (1) one of (6) six residents reviewed for Advance Directives during the Long-Term Care Survey Process. Resident identifier: #66. Facility census: 145. Findings Include: a) Resident #66 A record review on [DATE] at 8:52 AM, revealed that Resident #66's was marked as a Do Not Resuscitate (DNR) on her post form dated [DATE]. Further record review of Resident #66's care plan reads as follows: Focus: Resident has a Cardiopulmonary Resuscitation (CPR) code status. Revised on [DATE] During an interview on [DATE] at 11:00 AM, the Director of Nursing (DON) confirmed that the code status for Resident #66 did not match.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure they provided emergency care in accordance with the resident's advanced directives. Resident #139 had a [NAME] Virginia Post Orders to Health Care (POST) form that specified the resident did not want cardiopulmonary resuscitation (CPR). The resident's care plan had not been updated to reflect this and indicated the resident was a full code. The resident received CPR when they had no pulse and were not breathing. Resident identifier: #139. Facility census: 145. Findings included: a) Resident #139 During a medical record rive for resident #139 on [DATE] at approximately 09:45 AM it is identified that the resident had capacity and had completed the [NAME] Virginia Post Orders to Health Care (POST) form on [DATE] which identifies the following: Section A) Cardiopulmonary Resuscitation Orders. Follow these orders if patient has no pulse and is not breathing. NO CPR: Do not attempt Resuscitation (May choose any option in Section B.…

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 the environment as free of accident hazards as possible. A used razor laying on Resident #53's bathroom sink. This was a random opportunity for discovery. Resident Identifier: #53. Facility Census: 145. Findings Include: a) Resident #53 On 10/28/24 at 11:18 AM, a used razor was observed laying on the bathroom sink in Resident #53's room. On 10/28/24 at 11:20 AM, the Facility Scheduler #19 confirmed the used razor was laying on the bathroom sink. The Facility Scheduler stated, I'll take care of it. On 10/29/24 at 8:58 AM, the Director of Nursing (DON) was notified and confirmed the used razor should not have been left on the bathroom sink.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and family interview the facility failed to recognize, evaluate, and address the needs of each resident at risk for and experiencing dehydration. This failed practice was found true for (1) of (3) residents reviewed for dehydration during the Long-Term Care Survey Process. Resident identifier #68. Facility Census 145. Findings Include: a) Resident identifier #68 During the initial interview on 10/28/24 at 12:47 PM, Resident #68 stated, I don't drink the water here. I drink coffee with each meal and I eat Ice chips. They don't always bring me my ice chips. They are getting a little better since I had that intravenous (IV) to get fluids. Further record review of Resident #68's diagnoses revealed that Resident #68 was diagnosed with a Urinary Tract Infection (UTI) on 09/06/24 that was resolved on 10/05/24. The Hydration risk evaluation dated 10/09/24 did not indicate that Resident #68 had a history of UTI, which would put her at a higher risk for dehydration. Further 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 resident interview, staff interview, observation and record review, the facility failed to promptly obtain needed dental services for damaged dentures for Resident #31. The was true for 1 (one) of 3 (three) reviewed for dental needs. Resident identifier #31. Facility census: 145. Finding included: a) Resident #31 An interview on 10/28/24 at 12:10 PM with resident #31 who reported that he had 2 (two) missing teeth from his upper, front dentures due to eating facility's tough meat. Resident's dentures were observed to have missing 2 (two) front teeth. He stated that the facility was aware that his dentures were broken for over a year and had not yet offered to make an appointment to have them repaired. He reported that he was not having difficulty eating but that he did not like the way they looked. b) On 10/29/24 an interview with Medical Records Coordinator #150 reported that nurses would give her a consult assessment when a resident was in need of a dental appointment, and she would follow up with business office for insurance options, schedule appointment and 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, staff interview and resident interview the facility failed to meet resident's nutritional needs by serving Resident #31 food he was allergic to. This is true for three (3) of 13 residents review for food preferences. Resident identifier: #31, #68, and #10. Facility census: 145. Findings included: a) Resident #31 On 10/28/24 at 12:10 PM an interview with Resident #31 who reported that he was allergic to lemon and the facility continues to serve him lemon products. He reported that some of his dietary cards reflect that he was allergic to lemon and other cards stated that he was allergic to only lemonade. Resident reported that when he consumes lemon products he would break out in hives. b) On 10/28/24 a review of resident's records revealed the following: Resident #31's care plan and medical records reveal that he was allergic to lemon. Resident # 31's dietary cards revealed the that the resident's card stated following and that he was served food containing lemon on these days: 08/19/23- Allergies: Lemon, Lemon Bar 09/13/23- Allergies: Lemonade, Lemon Bar…

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's diet was followed per physician's orders for Resident #122. This is true for 1(one) of 13 residents reviewed for food. Resident identifier #122. Facility Census 145. Findings included: a) A review of incident report, investigation and five day-follow-up that occurred on 06/16/24 for resident #122 revealed the following: Resident # 122 was found in her room with chopped up fruit in her bed by Nurses Aide. The resident's brother later reported to the nurse that he had resident #122 laughing and spitting up chunks of fruit. There was a spoon and empty fruit cup in the floor beside her bed on 06/16/24. There were (3) three witness statements collected. That of the Nursed Aide and Licensed Practical Nurse #52 who found fruit and spoon but did not know how resident obtained it. The Assistant [NAME] was the last witness statement obtained and it was reported that a nurse called and asked for scrambled eggs for resident #122 on 06/17/24…

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 observatio and staff interview the facility failed to ensure they, prepared and served food under sanitary conditions. This has the potential to affect all residents of the facility who received an oral diet. Facility census:145. Findings included: a) During an observation of the lunch meal service in dining Room EB1 10/28/24, Resident # 90 had an egg sandwich. She took a bite and bit down onto a piece of foil which was inside the sandwich. During an interview with Dietary Director #20, he acknowledged the piece of foil and stated he would find out how it happened to be in her sandwich. During an observation of dining room EB2 lunch service on 10/29/24, there were three (3) beverage serving containers on a cart. These were being used to serve drinks to residents during the lunch service. These three containers were not labeled or dated for expiration. The outside of the containers did not appear to be clean. During an interview with Dietary Director #20, he identified the beverages as tea, fruit juice and punch. He acknowledged the containers should be labeled and dated.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to maintain a complete and accurate record regarding Resident #34's assistance for meals and Resident #75's diagnosis of anxiety. This was true for two (2) of 41 residents reviewed during the survey process. Resident identifiers: #34 and #75. Facility Census: 145. Findings Include: a) Resident #34 On [DATE] at 12:02 PM, a record review was completed for Resident #34. The review found the resident was ordered nothing by mouth (NPO) and received a tube feeding for nutrition which was Jevity 1.5 83ml (milliliters)/hr (hour) for 17 hours. The resident was noted to be dependent for all meal and fluid intake. The review, also, found documentation on the September, 2024 and October, 2024 medication administration record (MAR) indicating the resident was independent, set up only, one (1) person physical assistance and two (2) + ( plus) persons physical assist. The September, 2024 MAR indicated 28 times, the resident ranged from independent to 2+ persons…

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 discharge summary was completed by the physician for the basis for the discharge for one (1) of three (3) residents reviewed for a discharge to home. Resident identifier: #151. Facility Census: 148 Findings include: a) Resident #151 A medical record review was completed on 05/08/24 at 10:30 AM. The record review revealed Resident #151 was discharged to home on [DATE]. A discharge note (nurse note) dated 04/25/24 at 10:51 AM read as follows: piatient being discharged home today, this nurse did complete body audit on patient and no new skin issues noted, went over discharge instructions with patient and doughtier both verbalized understanding, order received to give patient 36 Norco 5-325, medications called in to mountaineer drug per patient request, patient leaving facility via wheelchair with family. The record did not reflect a physician discharge note was completed for the date of discharge. During an interview on 05/07/24 at 3:38…

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 a thorough investigations of Resident #75 allegations of abuse. The facility failed to maintain documentation that alleged violations were thoroughly investigated. This was true for one (1) of three (3) resdients reviewed for abuse. Resident Identifiers: Resident #75 Facility Census: 148. Findings include: a) Resident #75 A review of the facility reportable records log on 05/07/24 at 9:56 AM, revealed an alleged incident occurring on 03/06/24 involving Resient #75 was unsubstantiated. The reporting form dated 03/06/24 read as follows: Alleged Victim: ( Name of Resident #75) Alleged Perpetrator: (Name of Nurse Aide (NA) #57) Allegation: Date of Incident: unknown Time of incident: unknown Date this report completed: 03/16/24 Describe incident/injuries: An allegation of abuse was reported this date. A record review on 05/07/24 at 1:45 PM, found Resident #75 had a Brief Interview for Mental Status (BIMS) score of 00 on the quarterly Minimum Data Set (MDS) for ARD (assessment reference date) of 03/11/24. BIMS…

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 Daily Staffing Posting information was accurate and current and the facility failed to maintain the Daily Staffing Posting data for a minimum of 18 months. This was a random opportunity for discovery and had the potential to affect all resident currently residing at the facility. Facility Census 141 Findings included: a) Accurate and current data On 1/23/24 (01/23/24) at 10:00 AM, during a review of the facilities Daily Staffing Posting and the Daily Punches data for all direct care staff, the following discrepancies were identified with the total number of direct care hours being reported on the Daily Staffing Posting for 11/03/23, 11/16/23 and 1/19/24. -- 11/03/23 Daily Punches data for all direct care staff was 413.25 hours and the Daily Staffing Posting reported a total of direct care hours being 443.25, an inaccuracy of 30 hours. -- The 11/16/23 Daily Punches data for all direct care staff was 430.25 hours and the Daily Staffing Posting reported a total of direct care hours being 507.75 hours, 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.

Based on observation and staff interview, the facility failed to ensure the resident environment remains as free of accident hazards as possible. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility census: 141 Findings included: a) During a tour of the facility on 1/23/24 at 1:24 PM the egress directly in front of the emergency exit door on unit EB2 off from the dining room and activity area was fully blocked by large dietary carts and a large trash can. During an interview with the Activities Director (AD) #19 on 1/23/24 at 1:27 PM, AD#19 acknowledged the emergency door exit was completely blocked and acknowledged this was not safe in the event of an emergency for evacuation. AD #19 immediately began moving the items away from the blocked emergency exit.

Based on observation and staff interview the facility failed to prepare food in accordance with professional standards for food service safety related to, sanitary conditions and the prevention of foodborne illness. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 141. Findings include: a) Kitchen Tour of the kitchen on 1/23/24 at 10:00 AM with the Dietary Manager found the steam table and lids and plate warmer was heavily soiled, with grease build up, and old food debris. Continued tour revealed 2 maintenance workers, working in the kitchen on the plate warmer without hair coverings. During an interview on 1/23/24 at 10:00 AM the Dietary Manager, confirmed the steam table with lids and plate warmer was heavily soiled, with grease build up, and old food debris. She also verified the Maintenance workers were working on the plate warmer in the food preparation area without hair coverings.

Based on observation 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. This failed practices was a random opportunity for discovery while observing medication pass. Resident identifiers: #120. Facility census 141. Findings include: a) Resident #120 On 01/23/23 at 8:40 AM Licensed Practical Nurse (LPN) #108 was pulling medication for Resident #120 and dropped a pill on the med-cart. There was not a barrier on the cart and LPN #108 picked up the pill without donning a glove and put the pill in the cup with the other medications. LPN #108 gave all of the pills in the cup to Resident #120. This is the list of medications given: Fexofenadine 180 mg Metoprolol 50 mg Myrbetrig 25 mg Valsartan 160 mg When asked, LPN #108 agreed she should have not picked the pill up with a bare hand.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on facility record review and staff interview the facility failed to offer the Pneumococcal vaccine when eligible. This was true for four (4) out of five (5) reviewed for immunizations. Resident identifiers: #143, #19, #100, and #120. Facility census: 141. Findings include: a) Pneumococcal vaccine Resident #143 was admitted on [DATE] and a review of the medical records found this resident received Pneumonia vaccine 23 on 10/12/12. Resident #19 was admitted on [DATE] and a review of the medical records revealed Resident #19 received the following Pneumococcal vaccines. The PREVNAR (PVC) 13 was given on 09/2016, Pneumococcal (PNX) on 12/2009, Pneumococcal Polysaccharide (PPSV 23) on 05/2015. Resident #100 was admitted on [DATE] and had nothing listed for pneumococcal vaccines. Resident #120 was admitted on [DATE] and did not have anything listed as past vaccinations. On 01/23/24 at 11:15 AM, the IP was asked about the four (4) residents mentioned above and their pneumococcal vaccines. It was pointed out…

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 the residents residing in room [ROOM NUMBER] was treated with respect and dignity when a housekeeper failed to obtain the residents permission before entering the room and talked on her cell phone the entire time, she was in the resident's room. This was a random opportunity for discovery. Resident Identifier: room [ROOM NUMBER]. Facility Census: #141 a) room [ROOM NUMBER] On 01/23/24 at 9:42 AM Housekeeper #170 was observed going into room [ROOM NUMBER] while talking on her teal-colored phone. This housekeeper opened the door and walked into the room without knocking. Housekeeper #170 was observed talking on her phone while in the room and remained on her phone when she exited the room. Housekeeper #170 was stopped upon exiting the room and was asked about knocking on doors before opening and walking in the room. Housekeeper #170 said, It does not matter if you knock or not most of these people here either can't hear or can't talk so it does…

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 to indicate skin issues were healed for Resident #73, #40 and #31. This is true for three (3) of five (5) residents reviewed under the care area of pressure ulcers. Resident identifiers: #73, #40 and #31. Facility Census: 141. Findings included: a) Resident #73 On 01/22/24 at 11:00 AM, a record review was completed for Resident #73. A review of the care plan indicated the resident had excoriation to the bilateral buttock. The weekly skin assessments were reviewed indicating the resident currently had no skin issues. On 01/22/24 at 3:00 PM, the Director of Nursing (DON) was interviewed and was asked, does the resident have any skin issues? The DON stated, the care plan is incorrect .the resident does not have any skin issues. b) Resident #40 On 01/22/24 at 11:25 AM, a record review was completed for Resident #40. A review of the care plan indicated the resident had open MASD (moisture-associated skin damage). The weekly skin assessments were reviewed indicating the resident had no skin issues…

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 facility record review and staff interview the facility failed to administer medication as prescribed by the physician, failing to offer the Respiratory syncytial virus (RSV) vaccine when available, failed to complete neuro checks, failed to notify physician of no bowel movement, failed to notify physician of resident requesting to go to the emergency room, no protocol for bowel regiment, failed to follow physicians' orders. These were random opportunities for discovery. Resident identifiers: #16, #14, #59, #75, #126, #147, #60, 18, and #145. Facility census 142. Findings included: a) Resident #147 Record review on 01/22/24 at 10:00 AM found that on 12/27/23 at 09:30 PM, according to a nurse progress note, Resident #147 had an elevated blood glucose level of 660. The nurse administered the ordered dose of insulin (18 units). There was no nurse note completed at that time of the Physician being notified. However, there is a progress note on 12/27/23 at 9:33 PM from Telehealth Physician which states:…

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

Based on medical record review and staff interview the facility failed to have a care plan addressing the provision of meals before, during and/or after dialysis treatments. This was true for one (1) of one (1) resident reviewed for dialysis treatment during a complaint survey. Resident identifier:#68. Facility census: 141. Findings included: a) Resident #68. Medical record review of Resident #68's medical record found a physician's order for: Dialysis every Tuesday, Thursday, and Saturday with chair time at 6:40 am. Continued review of the residents (resident's) dialysis care plan found there was no provision of meals before, during and/or after dialysis treatments. During an Interview with the Director of Nursing (DON) on 1/24/24 at 10:23 AM, she verified there was no dialysis meal plan for dialysis days in Resident #68's care plan.

Based on record review and staff interview, the facility failed to ensure medical records were accurate and complete. This is true for two (2) of three (3) residents reviewed under the care area of discharges. Resident Identifiers: #66 and #31. Facility Census: 141. Findings Include: a) Resident #66 On 01/23/24 at 11:00 AM, a record review was completed for Resident #66. The review found the resident had been transferred to an acute care facility on 01/23/24 at 9:20 AM. However, the transfer form indicates the resident was transferred on 12/19/23 at 9:27 AM. On 01/23/24 at 2:20 PM, the Director of Nursing was interviewed and was asked when the resident got transferred to the acute care facility. DON stated the transfer date on the form was incorrect. The DON stated, I have never noticed that before .the documentation is showing the last time the resident was sent out to the acute care facility. b) Resident #31 1) On 01/23/24 at 11:45 AM, a record review was completed for Resident #31. The review found the resident had been transferred to an acute care facility on 12/07/23 at 10:00…

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

Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #8. This was a random opportunity for discovery. Resident Identifier: #8. Facility Census:143. Findings Included: a) Resident #8 On 11/06/23 at 12:24 PM, multiple residents were being observed during the noon meal. Licensed Practical Nurse (LPN) #155 was observed standing while feeding Resident #8. On 11/06/23 at 12:35 PM, the Assistant Executive Director #76 was notified and confirmed no one should be standing while feeding a resident. No further information was obtained during the survey process. .

Based on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward a resolution. This was true for two (2) of four (4) grievances reviewed during the complaint survey. Resident identifiers: #1. Facility census: 143. Findings Included: a) Policy Review Record review of the facility's policy titled, Resident Grievance, showed: -The Grievance Official shall complete an investigation of the Resident Grievance. -The grievance review will be completed in a reasonable time frame consistent with the type of grievance. -The Grievance Official will meet with the resident and inform the resident of the result of the investigation and how the resident's grievance was resolved or will be resolved, if applicable. b) Hearing Aids During an interview on 11/06/23 at 12:55 pm, Resident #1 verified her Hearing Aids were missing. On 11/05/23 at 3:00 PM during an interview with Resident #1's Medical Power of Attorney stated that the facility lost her Hearing Aids in February 2023, and they have never…

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 remove the use of hearing aids for Resident #1 in the Minimum Data Set (MDS). This is true for one (1) of eight (8) residents reviewed during the survey process. Resident identifier: #1. Facility Census: 143. Findings included: a) Resident #1 On 11/07/23 at 12:00 PM, a record review was completed for Resident #1. The review found the MDS with the assessment reference date (ARD) of 10/16/23 was incorrect regarding hearing, speech, and vision in Section B. Section B stated the resident had moderate difficulty hearing and the use of hearing aids. However, the resident's hearing aids had not been used since February 2023 because they were lost at the facility. On 11/07/23 at 1:20 PM, the MDS Registered Nurse (RN) #126 confirmed the MDS with an ARD of 10/16/23 was incorrect. The MDS RN #126 stated, I thought the hearing aids had been replaced .she went out for an appointment. No further information was obtained during the survey process.

Based on record review, and staff interview, the facility failed to ensure a Resident had a person-centered comprehensive care plan developed and implemented to meet his / her preferences and goals and address the resident's physical needs. This practice had the potential to effect more than a limited number of Residents. Resident identifier: #1. Facility census 143. Findings Included: a) Resident #1 An observation during a complaint investigation about missing dentures on 11/06/23 revealed Resident #1 had top dentures in place. Medical record review on 11/07/23, showed a Long-Term Care Evaluation dated 10/01/22 Nutrition section: --Upper and Lower Dentures Further review of Resident #1's medical record revealed the care plan (an overview of resident care for nursing staff) did not contain an intervention for Dentures. During an interview, on 11/07/23 at 1:21 PM, the Minimum Data Set Nurse (MDS-N) #126, confirmed the facility failed to develop a care plan related to dental or denture care for Resident #1. She verified Resident #1's care plan was incomplete without dental or denture…

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 comprehensive care plan for Resident #1. This is true for one (1) of eight (8) residents reviewed during the survey process. Resident identifier: #1. Facility Census: 143. Findings Included: a) Resident #1 On 11/06/23 at 2:00 PM, a record review was completed for Resident #1. The review found the care plan listed a focus area of potential for communication problem due to patient having hearing problems. The interventions listed are as follows: --Change batteries to hearing aids as needed. --Ensure patient has hearing aids in (Bilateral) ears. However, the resident's hearing aids had been missing since February 2023. On 11/07/23 at 1:20 PM, the Minimum Data Set (MDS) Registered Nurse (RN) #126 confirmed the care plan had not been revised since the loss of the resident's hearing aids. The MDS RN #126 stated, I thought the hearing aides had been replaced .she went out for an appointment. No further information was obtained during the survey process.

Based on observation, resident interview, staff interview, and record review the facility failed to ensure proper treatment related to a hearing impairment for one (1) of two (2) resident in the care area of communication / sensory. Resident identifier: #1. Facility census: 143. Findings include: a) Resident #1 During an interview on 11/06/23 at 12:55 Pm, Resident #1 verified her Hearing Aids were missing. On 11/05/23 at 3:00 PM during an interview with Resident #1s Medical Power of Attorney stated, the facility lost her Hearing Aids in February 2023, and never replaced them. She stated she had reported the hearing aids missing multiple times to the Social Worker and Business office Manager. A record review of grievances found a grievance form filled out on 02/23/23 reporting Resident #1's missing hearing aids. The recommendation on the form revealed, Patient has insurance to cover replacement if not found, Center will facilitate as needed. The resolution was marked resolved, Facility will replace them. Continued review revealed an invoice sent from (A local Hearing Aide Provider)…

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 assist with replacing a Resident's missing Lower dentures in a timely manner. This is true for one (1) of two (2) reviewed for missing dentures. Resident identifier: #1. Facility census 143. Findings included: a) Resident #1 An observation during a complaint investigation about missing dentures on 11/06/23 found Resident #1 had top dentures in place with no lower dentures. Resident #1 verified her lower dentures were missing. On 11/05/23 at 3:00 PM, during an interview Resident #1's Medical Power of Attorney stated, the facility lost her lower dentures about a year ago, and they had never replaced them. She stated she had reported the dentures missing multiple times to the Social Worker and Business office Manager. Medical record review on 11/07/23, showed a Long-Term Care Evaluation dated 10/01/22 Nutrition section confirmed, Resident #1 had Upper and Lower Dentures. During an interview on 11/06/23, at 3:38 PM the Business Office Manager stated, she was aware Resident #1 was missing her bottom dentures for about 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 facility documentation and staff interview the facility failed to have a certified Infection Preventionist (IP) that worked at least part time in the facility. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 141. Findings included: a) Infection Preventionist Record review of the facility's documentation of Infection control practices found the facility was unable to provide an Infection Control Preventionist Certification or documentation for an IP that worked at least part time in the facility. During an Interview 09/06/23 at 1:38 PM Director of Nursing (DON) Stated that she and the assistant Director of Nursing (ADON) document all infections for residents in the facility, neither are IP certified. She continued to say that the facility has not had an IP since May 2023, she stated that the corporate consultant is available if they need her, she works at the corporate office. No other information was provided prior to the end of the survey on 09/07/23.

Based on observation and interview the facility failed to maintain compliance with an effective pest control program that would ensure that the facility is free of pests and rodents for one (1) out of three (3) medication supply rooms. This failed practice has the potential to affect more than an isolated number of residents within the facility. Facility census: 141. Findings included: a) Medication Supply Room Observation An observation was conducted on 09/06/23 at 8:46 a.m. on Complex Transitional Care Unit #1 (CTC1) of the medication supply room. Staff #118 was present during the observation. The medication supply room was dirty, and trash was overflowing in the garbage can. The counter tops were dirty with dust and stains on them. The floor had spills and stains on it. There was a dead spider on the floor and spider droppings, cobwebs, and spider eggs behind the door. When asked how often the room was cleaned Staff #118 stated at least once a week or more if needed. There were three (3) large boxes of outdated medications sitting in the room with an open lid. When ask how often…

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

Based on interview and record review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for one (2) of three (3) reviewed during a complaint Survey. Resident identifier: #70. Facility census: 141. Findings included: a) Resident #70 During an interview with Resident #70 on 09/05/23 at 2:20 PM she revealed she did not get his showers as they were scheduled. She stated that most of the time her family must call and complain before she receives showers. She stated her son had to call today because she had not received her shower today. At 2:29 PM during this interview two (2) Nurse Aids entered the room and told Resident #70 they were there to take her to the shower. Medical record review revealed, Resident #70's shower schedule and preference was two (2) times weekly. A continued record review of Resident #70's Quarterly 06/09/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status)…

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 operation policy the facility failed to report alleged violation related to, neglect and report the results of all investigation to the proper authorities within a prescribed time frame. This is true for one (1) of three (3) allegations of abuse. Resident identifier: #70. Facility census: 141 Findings included: a) Resident #70 Record review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, showed: Neglect: Neglect is the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional destress . -Investigation of an incident: -An event may not be perceived by staff to constitute resident abuse, neglect, or misappropriation of resident property; however. If a resident, family member or visitor perceives an event to be abuse, neglect, or misappropriation, the facility must report the event. -The Executive Director / Designee will report appropriate incidents to Adult…

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, staff interview, and operation policy the facility failed to investigate an alleged violation related to, neglect, report the results of all investigation to the proper authorities within a prescribed time frames. This is true for one (1) of three (3) allegations of abuse. Resident identifier: #70. Facility census: 141. Findings Included: Record review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, showed: Neglect: Neglect is the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional destress. -Investigation of an incident: -An event may not be perceived by staff to constitute resident abuse, neglect, or misappropriation of resident property; however. If a resident, family member or visitor perceives an event to be abuse, neglect, or misappropriation, the facility must report the event. -The Executive Director / Designee will report appropriate incidents to Adult…

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 and staff interview, the facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the Residents assessed needs for care. This was true for two (2) of three (3) residents reviewed for ADL care. Resident identifiers: #70 and #124. Facility census: 141. Findings Included: a) Resident #70 During an interview with Resident #70 on 09/05/23 at 2:20 PM she revealed that she does not get his showers per scheduled. She stated that most of the time her family must call and complain before she receives showers. She stated that her son had to call today, because she had not received her shower today. At 2:29 PM during this interview two (2) Nurse Aids entered the room and told Resident #70 they were there to take her to the shower. Medical record review revealed, Resident #70's shower schedule and preference is two (2) times weekly. A continued record review of Resident #70's Quarterly 06/09/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest…

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, staff and resident interview, and record review, the facility failed to provide care and treatment in accordance with physician's orders for one (1) of seven (7) residents reviewed. Resident #85 experienced a delay in diagnostic testing and the facility failed to ensure the physician had knowledge of the delay in services. Resident identifier: #85. Census: 141. Findings included: a) Resident #85 An interview, with Resident #85, on 09/05/23 at 11:45 AM, revealed the resident had fallen in the facility in July 2023 and sustained an ankle fracture. Resident #85, was noted to have a brief Interview for Mental Status (BIMS of 15, identified on the 02/03/23 comprehensive assessment). A BIMS of 15 noted the resident was cognitively intact. Further interview, with Resident #85, revealed there was a long period of time from when the fall occurred until the ankle was X-rayed. A record review showed, Resident #85 had a witnessed fall on 07/03/23 at 22:00 hours (10:00 PM). At this time 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.

Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, shower documentation. This practice affected one (1) of three (3). Resident identifier #70. Facility census: # 141. Findings included: a) Resident #70 During an Interview with Resident #70 on 09/05/23 at 2:20 PM she revealed that she did not get showers as scheduled. She stated most of the time her family must call and complain before she received a shower. She stated her son had to call today, because she had not received her shower. At 2:29 PM during the interview two (2) Nurse Aides entered the room and told Resident #70 they were there to take her to the shower. Medical record review revealed, Resident #70's shower schedule and preference was two (2) times weekly. A continued record review of Resident #70's Quarterly 06/09/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status) indicates Total Dependence with bathing. MDS Section E…

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 facility documentation and staff interview the facility failed to have a certified Infection Preventionist (IP) attend and participate in the Quality Assessment and Assurance (QAA) meetings that worked at least part time in the facility. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 141. Findings included: a) QAA Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no IP attended the meeting since May 2023. During an Interview 09/06/23 at 1:38 PM Director of Nursing (DON) Stated that she and the assistant Director of Nursing (ADON) document all infections for residents in the facility, neither are IP certified. She continued to say that the facility has not had an IP since May 2023, she stated that the corporate consultant is available if they need her, she works at the corporate office. No other information was provided prior to the end of the survey on 09/07/23.

Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of notification of changes was informed in advance of outpatient appointments. Resident identifier: #5. Facility census: 144. Findings included: a) Resident #5 On 11/14/22 at 9:50 AM, the resident said, I never know when my appointments are. One day not too long ago they came in, woke me up from a sleep, and said you are going to the doctor now. I said what Doctor am I going to? I wish they would tell me these things before it's time to go. If they would tell me, I would keep track of the appointments. The resident said this has happened before. Review of the medical record found the physician determined the resident has capacity to make decisions on 04/06/20 and again on 05/04/22. The residents most recent minimum data set (MDS) with an assessment reference date (ARD) of 08/17/22 indicated the resident was cognitively intact with a brief interview for mental status (BIMS) of 15. Review of the electronic medical record found 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 appropriate information was communicated to the receiving hospital to ensure a safe and effective transition of care. 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: Resident #493. Facility census: 144. Findings included: A facility policy titled Transfer and discharge (including AMA) with a revision date of 05/03/21 found the following. .7. Emergency Transfers/Discharges .d. Completed and send with the patient a Transfer Form which documents: i.Patients status, including baseline current mental behavioral and functional status and recent vital signs ii. Current diagnosis, allergies and reason for transfer/discharge. iii. Contact information of the practioner responsible for the care of the patient iv. Patient representative information including contact information v. Current medication medication (including when last…

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 medical record review and staff interview, the facility failed to provide evidence a copy of the Notice of Transfer was sent to the Office of the State Long-Term Care Ombudsman. This was true for one (1) of three (3) reviewed for the care area of hospitalization during the long-term care process. Resident Identifier: Resident #493. Facility Census: 144. Findings Included: A facility policy titled Transfer and Discharge (including AMA) with a revision date 05/03/21 found the following. .7. Emergency Transfers/Discharges .k. Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. a) Resident #493 During a review of Resident #493's medical record on 11/15/22 at 12:07 PM, revealed she was transferred to a local hospital on the following dates: -07/29/22 -07/07/22 -06/21/22 A further review of the medical record revealed Resident #493 was provided Bed hold policy on the following dates: -07/29/22 -07/07/22 -06/21/22…

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 two (2) of twenty-nine (29) minimum data sets (MDS) reviewed during the Long-term Care Survey Process (LTCSP) were accurately coded. For Resident #75, the MDS were inaccurate in area of medication. For Resident # 104 the MDS inaccurately coded her siderails as a physical restraint. Resident identifiers: #75 and #104. Facility census: 144. Findings include: a) Resident #75 Review of Resident #75's medical records revealed Resident #75 was re-admitted to the facility on [DATE]. Review of Resident #75's 5 day-admission MDS with assessment reference date (ARD) of 10/09/22, found under section N -Medications; the MDS was coded the resident's use of an anticoagulant. Resident #75's physicians orders reviewed found an order for, Plavix-(Clopidogrel) 75 milligrams (mg) daily Review of the Center for Medicare and Medication Services (CMS), Resident Assessment Instrument (RAI) Version 3.0 Manual CH 3: MDS Items [P] Page N-7. N0410E, Anticoagulant…

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, observation and record review the facility failed to develop and implement a care plan for two (2) of 27 records reviewed during the long term care survey. Resident identifiers: #5 and #19. Facility census: 144. Findings included: a) Resident #5 On 11/14/22 at 8:36 AM, the resident said her hearing aids were broken. She said I am afraid I will have an appointment with the neurologist and I won't be able to understand what he is saying. It is very important that I hear him because I need to know what's happening to me. The surveyor had to adjust the voice tone and stand at the resident's left side for the resident to hear. The resident said one hearing aid is broken and the other one isn't working. They told me those need cleaned but I can't clean them myself. The resident said she was unsure of the exact time frame when each hearing aid quit working. She said it was less than a month. One broke probably 3 weeks ago. Then the other one quit, working about a week ago. Review of the medical record found the physician determined the resident has capacity 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, observation and staff interview, the facility failed to follow a physician's order for the application of hipsters for a resident with a history of multiple falls. This was true for one (1) of four (4) residents reviewed under the care area of falls. Resident Identifier: #33. Facility Census: 144. Findings Included: a) Resident #33 On 11/15/22 at 11:30 AM, a record review was completed for Resident #33. A physician's order dated 08/02/22 stated the following: hipsters at all times may remove for bathing, hygiene, and skin checks every day and every night shift. The care plan also listed hipsters at all times as an intervention under the focus area of actual falls with potential injuries . On 11/15/22 at 1:35 PM, the resident was found with no hipsters in place. Nurse Aid (NA) #88 verified the resident was not wearing the hipsters per the physician's order. On 11/15/22 at 2:17 PM, the Administrator was notified and confirmed the resident should be wearing hipsters per the physician's order and care plan intervention. No further information was obtained during…

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

Based on resident interview, observation, and record review, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of communication/sensory during the long-term care survey had hearing aids in good repair. Resident identifier: 5. Facility census: 144. Findings included: a) Resident #5 On 11/14/22 at 8:36 AM, the resident said her hearing aids were broken. She said, I am afraid I will have an appointment with the neurologist and I won't be able to understand what he is saying. It is very important that I hear him because I need to know what's happening to me. The surveyor had to adjust the voice tone and stand at the resident's left side for the resident to hear. The resident said one hearing aid is broken and the other one isn't working. They told me those need cleaned but I can't clean them myself. The resident said she was unsure of the exact time frame when each hearing aid quit working. She said it was less than a month. One broke probably 3 weeks ago. Then the other one quit working about a week ago. Review of the medical record found 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 resident interview, observation, medical record review and staff interview, the facility failed to provide foot care to a diabetic resident consistent with professional standards of practice. Arrangements were not made for routine podiatry services to prevent foot complications and maintain comfort in a resident with diabetes. This was a random opportunity for discovery. Resident identifier: 10. Facility census: 144. Findings include: a) Resident (R) #10 During an interview on 11/14/22 at 8:58 AM, R#10 reported foot discomfort and stated she needed her toe nails trimmed. An observation during this interview found her toe nails to be long with overlapping toes. Review of the medical record on 11/15/22 revealed R#10 was admitted to the facility on [DATE] with multiple diagnoses including diabetes. The physician orders include an order for a podiatrist consult written 03/22/22. The care plan states see podiatrist as needed for diabetic foot care. The record lacks any information regarding podiatry…

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.

b) Resident #47 On 11/14/2022 at 10:57 AM, the resident said she is supposed to have palm guards for her hands, and staff are not putting them on. Observation found no palm guards were in place. Resident #47 states that she believes they must have thrown it away as she said she has not seen it in a long time. On 11/14/2022 at 1:55 PM, staff observed that resident #47 did not have palm guards in place as directed by the care plan which says, CNA (certified nursing assistant) to apply left palm guard in the AM after skin care. CNA to remove in the PM, dated 06/20/2022. On 06/22/22, the physician wrote an order for: CNA to apply left palm guard in the AM after skin care. CNA to remove in the PM, order dated 06/22/2022. On 11/14/2022 at 2:00 PM, Registered Nurse (RN) #14 stated that applying the palm guard was a task assigned to the nursing assistants and she was unsure if they are currently applying the palm guard to resident. On 11/15/2022 at 9:00 AM, Resident #47 was again observed by staff without palm guard. On 11/15/2022 at 9:10 AM, the Assistant Director of Nursing (ADON) #5…

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

Based on medical record review, observation and staff interview the facility failed to provide hemodialysis services consistent with professional standards of practice. This was discovered for one (1) of one (1) resident reviewed for dialysis services during the Long Term Care Service Process. Resident identifier: #96. Facility census: 144. Findings included: a) Resident #96 During a medical record review for Resident #96 on 11/15/22 a physician's order indicated hemostats were to be readily available for Resident #96's perma catheter. On 11/16/22 at 8:42 AM, the Unit Charge Nurse #145 was unable to locate any hemostats in Resident #96's room. The UCN #145 reported the hemostats were not readily accessible at bedside for the perma catheter for Resident #96. .

Based on record review and staff interview the facility failed to ensure the physician provided a rationale for disagreeing to discontinue an unnecessary medication, recommended by the facility pharmacist. This was true for one (1) out of five (5) residents reviewed for unnecessary medications. Resident identifiers: # 114. Facility census 144. Findings included: a) Resident #114 Medical record review found on 10/21/22, the facility pharmacist recommended the medication, Methenamine Hippurate 1 gram to be discontinued. Methenamine Hippurate is used to prevent urinary tract infections (UTI). The facility attending physician did not provide a rationale for disagreeing with the pharmacist. The physician marked the disagree box, signed, and dated the recommendation. During an interview on 11/15/22 at 2:00 PM, the Administrator agreed there was no rationale provided for not accepting the Gradual Drug Reduction (GDR) recommended by the pharmacist. On 11/15/22 at 2:12 PM, the Director of Nursing (DON) verified the physician provided no rationale for disagreeing with the pharmacist. .

Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered food had not been dated after opening and the ice machine needed to be cleaned. These practices had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 144. Findings included: a) Kitchen tour During the kitchen tour on 11/14/22 at 10:56 AM, it was discovered a package of parmesan cheese was not dated after opening and the ice machine was dirty with corrosion build up around the lid area. On 11/14/22 at 11:05 AM, the Dietary Manager verified the parmesan cheese had not been dated after opening and the ice machine needed to be cleaned. .

Based on record review, observation and staff interview, the facility failed to ensure the residents medical record was complete and accurate for two (2) of four (4) residents reviewed for position and mobility. Resident identifier: #117 and #19. Facility census: 144. Findings included: a) Resident #117 Review of the physician's orders found the following order on the medication administration record (MAR): Seat belt placement checks and repositioning while up in wheelchair Q (every) 2 hours -Start Date: 08/04/22. Review of the MAR for November 2022 with Registered Nurse (RN) unit manager #101 on 11/15/22 at 10:49 AM, found the MAR was initialed by the residents nurse every 2 hours on the following days: 11/03/22 11/06/22 11/08/22 11/09/22 11/10/22 11/11/22 11/12/22 11/13/22 RN #101 confirmed initialing the MAR every 2 hours for 24 hours would indicate the resident was up in his wheelchair all day for 24 hours a day on the above dates, which RN #101 said was not true. RN #101 said the order needed to be rewritten because it is confusing. b) Resident #19 Observation of the 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.

b) Facility: Administration of medication A facility policy titled Medication Administration with a date of 06/21/17 found the following. .Never touch any of the medication with fingers. An observation on EB-1 Hall on 11/15/22 at 9:45 AM, found Licensed Practical Nurse (LPN) #64 dropped a pill on the floor. LPN #64 stated, does this apply to the five (5) second rule and laughed. LPN #64 picked up the pill with her bare fingers off the floor, placed it in the medication cup with other medication that was already in the cup. LPN #64 continued to get another medication out of a package, thinking she dropped it on the floor. Several staff members and this surveyor looked for the medication on the floor. LPN #64 stated, Oh look it's in my pocket. LPN #64 reached in her pocket, and placed the medication in the medication cup with other pills. LPN #64 acknowledged one pill was in the floor and the other pill was in her pocket, and continued to place other medication in the cup. Registered Nurse (RN) #145 acknowledged LPN #64 putting the pill from her pocket in the medication cup with all…

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.