Meadowbrook Acres

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) notice was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #4 . Facility census: 54. Findings included: a) Resident #4 On 04/10/25 at 11:30 AM, a review was completed regarding the beneficiary protection notification liability notice given for the following resident who was discharged home following the last covered day of Medicare Part A services: -Resident #4's last covered day of Part A Services was on 01/08/25. -Resident #4 was discharged to home on [DATE]; however, the NOMNC was only issued 24 hours prior on 01/07/25 . The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be…

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 interviews, electronic medical record and policy review the facility failed to ensure they implemented their policy regarding the training of nurse aide staff following a substantiation of allegations of neglect. This is true of one (1) of six (6) residents reviewed for abuse and neglect. Resident identifier: #161. Facility census: 54. Findings included: a) Resident #161 A record review found an allegation from 05/07/24 where Nurse Aide NA #94 and NA #114 did not follow the plan of care and did not use the lift during a transfer causing a skin tear to Resident # 161's arm. A medical record review revealed the following care plan: Focus: (Name) has a ADL self-care performance deficit related to Dementia, blindness and limited functional mobility as well as generalized muscle weakness. Goal: Resident will maintain the current level of function in ADLs through the review date Interventions: Transfers: require two (2) staff assistance using a full body Hoyer lift and placing him in a Rock and Go Chair. A reportable was completed with action notes: NA's…

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

Based on record review, and staff interview. The facility failed to assist dependent residents with activities of daily living (ADL's) in accordance with the residents assessed needs for care. This was true for one (1) of one (1) residents reviewed for ADL care. Resident identifier:164. Facility census: 54. Findings included: a) Resident #164 A record review revealed Resident #164 was covered in feces on 11/17/24 and reported to the facility by her son. Statement from Nurse Aide #113 revealed Resident #164 was covered in dried feces from head to toe. Statements from Registered Nurse #87 confirmed that dried feces was all over the resident and the bed. Continued record review found the incident was reported to appropriate state and local authorities for neglect. The allegations were found substantiated by the facility and the NA assigned to Resident #164 was suspended and resigned at that time. An interview with the Director of Nursing on 04/14/25 at approximately 2:10 PM confirmed that Resident #164 did not get ADL care timely.

Based on record review and staff interview, the facility failed to ensure two (2) monthly pharmacy reviews were reviewed by the facility physician for Resident #35. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #35. Facility Census: 57. Findings Include: a) Resident #35 On 04/09/25 at 1:03 PM, a record review was completed for Resident #35. The review found two (2) monthly pharmacy reviews, 03/2024 and 01/2025, were not signed by the facility physician. The pharmacy reviews had no indication if the facility physician agreed or disagreed with the pharmacy recommendations. On 04/14/25 at 10:32 AM, the Administrator confirmed neither of the two (2) pharmacy reviews were signed by the facility physician.

Based on record review, and staff interview, facility failed to ensure residents was free from unnecessary medications in regard to psychotropic medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #23. Facility census: 54. Finding included: a) Resident #23 A review for Unnecessary Medication for Resident #23 on 04/14/25 found, Physician order for: Zoloft oral tablet 50MG (Sertraline HCI) Give one (1) tablet by mouth one time a day related to anxiety disorder. Continued review found no consent form for Zoloft in the medical record. During an interview on 04/14/25 at 4:15 PM the Director of Nursing (DON) stated that there was no signed consent form for Zoloft for Resident #23

Based on record review and staff interview, the facility failed to ensure an accurate and complete record for Resident #35. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #35. Facility Census: 57. Findings Included: a) Resident #35 On 04/09/25 at 10:00 AM, a record review was completed for Resident #35. The review found two (2) medications without diagnoses. The medication is as follows: --Eye Scrubs External Pad apply to eyes topically every day, which started on 11/07/24. --Metoprolol Tartrate 25mg (milligram) by mouth twice daily, which started on 03/08/25. On 04/09/25 at 4:00 PM, the Administrator and the Director of Nursing (DON) confirmed the medication did not have diagnoses.

Based on record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives for each resident related to resident's behaviors. This is true for two (2) of two (2) residents reviewed for behavioral care plans. Resident Identifiers: Resident #43 and Resident #6. Facility Census: 59 Findings Include: a)Resident #43 During a review of the reportable dated 04/08/24, Resident #43's incident was as follows: Reported to this nurse per restorative aide that resident was sitting in quiet lounge beside another resident (2935) touching her, when he put his hand in her face and she bit him on the pointer finger. Residents separated, small red bite mark to pointer finger on 2935 has since dissipated. (Physician name) made aware and verbalized understanding. POA( Power of Attorney) (name) contacted and verbalized understanding. Further review of the care plan with an initiated date 12/20/22 and revision date 01/11/13 no behavioral focus, goal or interventions were implemented after the 04/08/24 incident. 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.

Based on record review and staff interview the facility failed to establish and implement a grievance policy to ensure prompt resolution of grievances. The facility's policy indicated they would keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance was filed. The facility was unable to provide evidence of the prompt resolutions of grievances for the previous six (6) months. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 56. a) Policy Review A review of the facility's policy titled; Grievances found the following: .Documentation: The facility will keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance decision is issued. This policy was not dated. a) Grievances In the afternoon of 08/28/23 the grievances and concerns for the previous six months were requested from the Nursing Home Administrator (NHA). Upon leaving the building on 08/28/23 at approximately 4:00 PM the NHA was reminded we were still waiting for the…

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

Based on observation, record review, and staff interview, the facility failed to ensure a care plan was implemented for one (1) of three (3) residents reviewed for the care area of accidents. Resident identifier: #52. Facility census: 56. Findings included: a) Resident #52 Review of the medical record found the following: Review of the medical record found the current care plan: The care plan addressed the following: Resident is at risk of falls related to poor safety awareness related to dementia. The goal associated with the care plan: Resident will have no further falls through review date, revised on 8/8/23 Interventions included: Fall mat to left side of bed, dated 05/30/23 Observation at 12:25 PM on 08/29/23, with Registered Nurse #27, and Nurse Aides (NA) #67 and #49 found the fall mat was on the resident's right side of the bed. RN #27 said, well if you were standing at the foot of the bed the fall mat is on the left side of the bed. Both NA's stated they believed when an order says to place something on the right or left side, it is the Resident's right and left side, not…

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

Based on record review and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for accidents received adequate assistive devices to prevent accidents. Resident identifier: #54. Facility census: 56. Findings included: a) Resident #54 Record review found the Resident was care planned for: Additional falls related to a history of frequent falls, impaired cognition/poor safety awareness, impaired strength/balance/coordination, incontinence, adverse reaction of medications. Further review found the resident had the following falls since 05/01/23: 05/04/23 05/11/23 06/15/23 07/30/23 Review of the medical record found a nursing note dated 05/01/23: I walked into the resident's room to find (name of resident) sitting on the floor with her back against the wardrobe undressing. I had just been in and woke her for her 0600-medication administration. There did not seem to be incontinence at that time due to no smell being noted. The fall mat was down but she was between the mat and the bed. Legs were in front of her as she was taking off her depends, already…

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.

Deficiency Text Not Available

Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was reviewed at least once monthly by a licensed pharmacist or failed to ensure when the drug regimen was reviewed, and an irregularity was identified, the resident's physician responded with a rationale for the response made after review. This was true for four (4) of (5) residents reviewed for the unnecessary medication review care area during the Long-Term Survey Process (LTCSP). Resident identifiers: Resident #108, #4, #9 and #27. Census: 55. Findings included: a) Resident #108 A record review, for Resident #108, showed no evidence the licensed pharmacist had reviewed the resident's drug regimen on a monthly basis. Drug regimen reviews (DRRs) were reviewed from 04/2022 through 03/2023. This review found no evidence the resident's drug regimen had been reviewed by a licensed pharmacist for 04/2022, 08/2022, 09/2022, 10/2022, 11/2022, 12/2022, 01/2023, 2/2023 and 3/2023. An interview, with the Director of Nursing (DON), on 04/18/23 02:33 PM, confirmed no DRR had been completed…

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 store food in accordance with professional standards for food safety. The facility failed to label and date food items which were open and failed to dispose of expired food items. The facility also failed to keep an accurate refrigerator temperature log. The facility also failed to distribute and serve food and ice in a safe and sanitary manner. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen and ice from the B hall Ice chest. Facility Census: 55 Findings Included: a) Walk In Refrigerator During the initial tour of the kitchen with the Certified Dietary Manager (CDM) beginning on 04/17/23 at 10:30 AM, the following items were found in the walk-in refrigerator: -A pan of Chicken with the tin foil ripped exposing the chicken. -4 rolls of hamburger thawing on a rolling cart with no date as to when it was placed in the refrigerator for thawing. The Dietary Manager acknowledged the failure to label food items with a Date…

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 establish and maintain an effective 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. The facility failed to ensure, residents with physician orders and care plan approaches for Enhanced Barrier Precautions, were implemented, placing all residents at risk for transmission of infections. In addition, the facility failed to ensure residents were provided hand hygiene prior to meals and failed to ensure the proper storage of linens to prevent the spread of infection. This practice had the potential to affect more than a limited number of residents. Resident Identifiers: Resident #31, # 108, #44, #29, #49, #19, and #53. Census: 55. Findings included: a) Resident #31 A record review, for Resident #31, showed a current physician's order for Enhanced Barrier Precaution related to MDRO: ESBL(Multi drug resistant organism: Extended Spectrum Beta Lactamase).…

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

Based on observation and staff interviews the facility failed to maintain equipment in safe operating conditions. The steam table drain was leaking around a shut off valve. The steamer was leaking water around the seal when opened. The walk-in freezer had ice build up on the shelving unit, on boxes of frozen food and on the floor. This failed practice had the potential to affect more than a limited number of residents currently receiving nutrition from the facility kitchen. Facility Census: 55 Findings Included: a) Steam table drain During the initial tour of the kitchen beginning on 04/17/23 at 10:30 AM with the Certified Dietary Manager (CDM) an observation of the steam table drain shut off valve had water dripping into a pan. During an immediate interview the CDM stated, Maintenance has tried to fix it, I think the whole thing needs replaced. During an interview on 04/17/23 at 1:40 PM the Maintenance helper #73 stated I did not know it was leaking, looks like someone just spilled water from the steam table. It's not leaking now. b) Steamer During the initial tour of the kitchen…

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 record review, the facility failed to ensure all residents were treated with dignity and respect. This was a random opportunity for discovery during the Long Term Care Survey Process, and was only true for Resident #37. Resident identifier #37. Census 55. Findings Included: a) Resident #37 Resident #37 was observed sitting outside of the conference room, in the hallway, with what appeared to be urine soaked pants on. A member of the survey team notified an unidentified staff member who stated she would take the resident to the nurses station and get someone to assist the resident with getting cleaned up. This occurred on 04/17/23 at approximately 2:30 PM. At 2:55 PM the same day, the resident was again observed in her scoot chair sitting at the nurses station. The resident was still wearing the same pants which were soaked with what appeared to be urine. There were numerous staff members at the nurses station. When the staff noticed the surveyor looking at the resident's clothing, Nursing Assistant (NA) #25 was instructed to take the…

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

Based on observation, record review, policy review and staff interview the facility failed to ensure each resident was free from physical restraints which are not required to treat the resident's medical symptoms. This was true for one (1) of one (1) residents reviewed for the care area of restraints during the long term care survey process. Resident Identifier: #21 Facility Census: 55 Findings included: a) Resident #21 A review of Resident #21's medical record on 04/17/23 at 1:20 PM shows a current order dated 03/29/23 which read Seat belt to WC (wheelchair) to minimize risk of unassisted ambulation/falls related to a history of falling. A Progress note on 03/10/23 at 2:10 PM reads: Was able to notify POA (Power of attorney) by telephone of residents fall without injuries. Spoke with her regarding a seatbelt potentially being placed on the WC for keeping her in her WC. After explaining how it would work and our policy for it she was in agreement and stated that she'd rather see the seatbelt then hear that the resident has fallen and gotten seriously injured. I stated I would notify…

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 interviews, the facility failed to notify the resident and/or the resident's representative, in writing, of the reason for the transfer/discharge to the hospital or to send a copy to the ombudsman for one (1) of four (4) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifier #55. Census 55. Findings Included: a) Resident #55 A review of Resident #55's medical record on 04/18/23 , found the resident was sent to the hospital on [DATE]. The transfer/discharge notice was requested from facility staff on multiple occasions for this transfer beginning at 11:15 am on 04/18/23. At 4:14 PM Medical Records #67 presented a copy of the resident's facesheet, medication administration record (MAR), and physician orders for scope of treatment (POST) which were sent with the resident when she went to the hospital. The notice of transfer/discharge was again requested. Medical Records #67 stated, she isn't sure they will have that but she…

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 interviews, the facility failed to notify the resident and/or the resident's representative of the facility policy for bed hold, including reserve bed payment for one (1) of four (4) residents reviewed for the category of hospitalization, during the long term care survey. Resident identifier #55. Census 55. Findings Included: a) Resident #55 A review of Resident #55's medical record on 04/18/23 , found the resident was sent to the hospital on [DATE]. Evidence of the bed hold policy being sent with the resident was requested from facility staff on multiple occasions for this transfer beginning at 11:15 am on 04/18/23. At 4:14 PM Medical Records #67 presented a copy of the resident's facesheet, medication administration record (MAR), and physician orders for scope of treatment (POST) which were sent with the resident when she went to the hospital. The bed hold policy was again requested. Medical Records #67 stated, she isn't sure they will have that but she will look for it. No…

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 interviews, staff interview, and record review, the facility failed to allow residents to be involved in developing their care plan and making decisions about his or her care for two (2) of 24 residents reviewed for the category of care planning, during the long term care survey. Resident identifiers #45 and #7. Census 55. Findings Included: a) Resident #7 An interview with Resident #7 on 04/17/23 at 11:32 AM, resulted in the resident stating he has never heard of a care plan meeting nor has he ever been invited to his care plan meeting. On 04/18/23 at 10:56 AM, a staff interview was conducted with social worker (SW) #56. SW #56 stated resident #7 has been invited to his care plan meetings in the past but it's probably been a long time since he has been invited. This is because he usually cusses the staff and wants his wife to do everything. SW #56 does agree that he could participate in his care plan meetings. On 04/18/23 a record review found, the resident's care plan notes were void of any documentation showing the resident was invited to participate in his care…

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

Based on observation, record review and staff interview the facility failed to follow physician orders for heel protectors. This was true for one (1) of three (3) residents reviewed for the care area of pressure ulcers during the long term care survey process. Resident Identifier: #2 Facility Census: 55 Findings Included: a) Resident #2 On 04/18/23 at 9:10 AM, 12:40 PM and 3:58 PM Resident #2 was observed with no heel protectors on. Record review found an order dated 03/02/23 which reads Resident to have bilateral heel protectors in place (may remove for personal hygiene) every shift for skin breakdown prevention. At 3:58 pm on 04/18/23 the Director of Nursing (DON) confirmed Resident #2's heel protectors were not on as ordered by the physician. .

Based on Medical record review 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 quarterly smoking assessment was not completed for Resident #9 who is the facility's only smoker. This was true for one (1) of one (1) residents reviewed for the care area of smoking during the long term care survey process. Resident Identifiers: # 9. Facility census: 55. Findings Included: a) Policy Review Record review of the facility's policy titled, Resident Smoking, showed: -All Residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. --Residents that smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if Resident is safe to smoke at all. --A safe smoking assessment will be completed on all residents using e-cigarettes. b) Resident #9 An observation on 04/17/23 at 12:14 PM found Resident #9 smoking a Vape cigarette (e cigarette)…

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, staff interview, and record review, the facility failed to provide hydration care and services for one (1) of 24 residents reviewed for hydration, during the long term care survey. Resident identifier #7. Census 55. Findings Included: a) Resident #7 Observation on 04/17/23 at 11:32 AM, found the resident did not have a water pitcher or cup at bedside. A resident interview on 04/17/23 at 11:32 AM, confirmed he did not have anything to drink. He stated, I normally has a pitcher of water. Staff interview on 04/17/23 at 11:40 AM, with Licensed Practicing Nurse (LPN) #24, confirmed the resident did not have any water at bedside. LPN #24 said the resident recently changed to thickened liquids and the staff must have taken his cup away with his breakfast tray. LPN #24 stated the resident is supposed to have a pitcher and a cup with a handle, with thickened liquids at bedside. Record review of Resident #7's care plan indicates the resident is to have nectar thick liquid, and a blue cup with spout to be used for water/fluids at bedside. .

Based on observation, policy review and staff interview the facility failed to follow their policy to store the nebulizer mask in a sanitary manner. This was true for one (1) of one (1) resident reviewed for the oxygen care area during the long term care survey process. Resident Identifier: #44 Facility Census: 55 Findings Included: a) Resident #44 An observation on 04/17/23 at 11:35 AM, found Resident #44's nebulizer mask was on the bedside table and not stored in a sanitary manner. This was confirmed with Licensed Practical Nurse #16 on 04/17/23 at 11:40 AM. The Oxygen Administration Policy (not dated) states under the Policy Explanation and Compliance Guidelines: #5 Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: (e) Keep delivery devices covered in plastic bag when not in use. This was confirmed with Licensed Practical Nurse #16 on 04/17/23 at 11:40 AM. .

Based on record review and staff interview the facility failed to evaluate residents for an acceptable diagnosis for the use of psychotropic medications. This was true for two (2) of five (5) residents reviewed for the care area of unnecessary medications during the long term care survey process. Resident identifier: #9 and #36. Facility census: 55. Findings included: a) Resident #9 A review of Resident #9's medical record on 04/18/23 found the following pharmacist recommendations: -- Review dated 01/19/23 Resperidone not in new guidelines to be given for bipolar. -- Review dated 02/06/23 Resperidone not recommended for bipolar. The physician had signed this recommendation but no rational for using bipolar a diagnosis was provided. A further review of the medical record found a current order for Resperidone for a diagnosis of bipolar. During an interview on 04/18/23 at 11:20 AM the Director of Nursing (DON) verified these pharmacy recommendations there is no documentation for Physician responses from the pharmacy reviews and the resident still had the diagnosis of bipolar for 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, recipe review and staff interview the facility failed to provide food prepared by methods that conserve the nutritive value and the appearance of the food. This practice had the potential to affect an isolated number of residents who receive their nutrition from the kitchen. Facility census 55. Findings Included: a) Brussels Sprouts During a tour of the kitchen on 04/17/23 at 11:45 AM, while obtaining the temperatures on the steam table there was a roundish, shriveled up vegetable which was brown in color. This surveyor asked Is that mushrooms, to clarify what the vegetable was. The Certified Dietary Manager (CDM) stated, no that is our substitute vegetable, Brussels sprouts. This surveyor then stated, but they are brown not green. The CDM stated She [NAME] them in the oven, that is probably why. The CDM acknowledged the Brussels sprouts were not appealing in appearance and probably had no nutritive value. On 04/17/23 the CDM provided the Brussels sprouts recipe, the recipe was as…

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 provide a spouted cup for Resident #25 at meal time. This was a random opportunity for discovery during the observation of the noon time meal on 04/17/23. Resident Identifier: Resident # 25. Facility Census: 55 Findings Included: a) Resident #25 During a dining observation on 04/17/23 at 12:35 PM. Resident #25's lunch meal tray ticket was reviewed. This review revealed the following: .Texture: Regular 4 Adaptive Equipment: Spouted Cup. Resident #25 had his meal tray in front of him and there was no spouted cup on the tray. During an interview on 04/18/23 at 12:36 PM Nurse Aide (NA) #1 acknowledged the spouted cup was not on the lunch meal tray and should have been. During an interview on 04/18/23 at 12:37 PM Licensed Practical Nurse (LPN) #5 stated its dietary's responsibility to provide the assistive equipment for meals on the trays. During a record review on 04/17/23 at 2:30 PM, Resident #25's medical record revealed a physician diet order dated 10/04/22 regular texture, thin consistency,…

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

Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1) of 24 sampled residents during the Long-Term Care Survey Process. Specifically, the facility failed to accurately accept verbal consent on a Physician Orders for Scope of Treatment (POST) form by not having a witness to the consent. Resident identifiers: #19. Facility census: 55. Findings included: a) Resident #19 A medical record review, completed on 04/03/23 at 1:52 PM, revealed the following details: -There was a Physician Orders for Scope of Treatment (POST) form on file for Resident #19. -A verbal consent from Resident #19's Health Care Surrogate (HCS). The verbal consent was accepted on 04/23/21. No witness to the verbal consent and no follow-up signature was obtained. Review of instructions on how to complete the POST form from Using the POST Form: Guidance for Healthcare Professionals 2021 Edition, page 20, outlined: If the incapacitated patient's MPOA [Medical Power of Attorney] representative or Health Care Surrogate [HCS] is unavailable at the…

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

Based on observation and staff interview the facility failed to employ a clinically qualified nutrition professional on a full time basis to manage the daily function of the kitchen. This had the potential to affect all the residents that receive nutrition from the kitchen. Facility Census: 54 Findings Included: During an interview on 03/14/22 on 12:50 PM, the Dietary supervisor (DS) #1, which was hired on 03/15/21, stated he was not a Certified Dietary Manager (CDM). He indicated he took the CDM class in 2015 and was supposed to test the day COVID hit. He further confirmed he has not rescheduled to take the test yet. During an interview on 03/15/22 at 9:32 AM DS #1 was asked how often the Registered Dietician visits the facility. DS #1 replied the RD #21 visits on Wednesday and Fridays. During an interview on 03/15/22 at 12:05 PM the Administrator stated the RD works 16-20 hours a week. She is not sure why DS #1 has not taken his test, we will get it scheduled. He has worked in several other facilities before coming to this one. .

Based on record review and staff interview, the facility failed to employee an Infection Preventionist (IP)who met all required qualifications. This failed practice has the potential to affect all residents currently residing in the facility. Findings Included: During record review it was determined the IP, RN #6 did not have the required certification on file. During an interview with RN #6 on 03/16/22 at 02:59 PM she states she has been in the IP position since 02/18/22 but is not yet been certified. She registered on 03/15/22 for the class and will be fulfilling the qualifications soon. .

Based on medical record review and staff interview the facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End of Life Care. This is true for seven (7) of seven (7) residents reviewed during the Long Term Care Survey Process. Resident Identifiers: Resident # 39, #35, #2, #54, #17, #25 and #45. Facility Census: 54. Findings Included: a) #39 On 03/14/22 at 4:20 PM the POST form for Resident #39 was reviewed. The POST form was signed and dated by the physician on 08/05/21. The POST form was missing the physician's printed full name and telephone number which were left blank. During an interview on 03/16/22 at 11:41 AM Social Worker (SW) #23 acknowledged the POST form was incomplete. SW #23 stated I will definitely work on the POST forms. b) #35 On 03/14/22 at 4:31 PM the POST form for Resident #35 was reviewed. The POST form was signed and dated by the physician on 02/20/22. The POST form was missing the physician's printed full name and telephone number which were left blank.…

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 report falls with serious bodily injury to state and other appropriate agencies as required within two (2) hours of discovering the serious bodily injury. This was true for four (4) of four (4) records reviewed during the Long Term Care Survey. Resident Identifiers: # 46, #205, #25, and #34. Facility Census: 54 a) Resident # 46 According to a record review, Resident #46 had two (2) unwitnessed falls on 07/27/21. The Resident fell on [DATE] and on 08/02/21 Licensed Practical Nurse (LPN) #71 notified the Physician of swelling to the right knee and a new order for an X-ray of the right knee was obtained. On 03/16/22 at 02:20 PM this was confirmed with LPN #71. On 08/03/21 when the Physician assessed the Resident and upon observing the right knee being swollen, the Resident was transferred to a local hospital emergency room on [DATE] at approximately 10:45 AM according to hospital records. Based on record review from the hospital 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 medical record review and staff interview the facility failed to thoroughly investigate falls with serious bodily injury as required. This was true for four (4) of four (4) records reviewed. Resident Identifiers: # 46, #205, #25, and #34. Facility Census: 54 a) Resident # 46 According to record review, Resident #46 had two (2) unwitnessed falls on 07/27/21. The Resident fell on [DATE] and on 08/02/21 Licensed Practical Nurse (LPN) #71 notified the Physician of swelling of the right knee and a new order for an X-ray of the right knee was obtained. On 08/03/21 when the Physician assessed the Resident and upon observing the right knee being swollen, the Resident was transferred to a local hospital emergency room on [DATE] at approximately 10:45 AM according to hospital records. Based on record review from the hospital the Residents right knee was swollen and she could not straighten her leg out. The Physician determined from their right femur x-rays, the Resident had an acute displaced fracture involving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review and staff interview the facility failed to provide care and services according to professional standards of care and the resident's plan of care. This is true for five (5) of 25 residents reviewed during the long term care survey process. Resident Identifiers #54, #205, #46, #44, and #35. Facility census 54. Findings Included: a) Resident #54 An observation of the medication pass on the A hallway at 9:20 am on 03/16/2022 found Licensed Practical Nurse (LPN ) # 56 administered a Symbicort (a steroid inhaler) to Resident #54. After administration of the steroid inhaler Resident #54 was not asked to rinse her mouth. Review of the facility policy Medication Administration failed to advise to have the resident to rinse their mouth after administering a steroid inhaler. According to the Symbicort manufacturers guideline: After using your SYMBICORT inhaler: Put the cover back on, Rinse your mouth with water and spit it out, Don't swallow the water. An interview with the Director 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 observation, record review and staff interview, the facility failed to complete an accurate and complete record of controlled substances in the narcotic count book. This was a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 54. a) Narcotic Count Book The Controlled Substance Administration and Accountability Policy was reviewed and states in section 3 (three) ordering and receiving controlled substances in subsection e, The medications delivered are immediately recorded on the appropriate drug disposition record . On 03/16/22 at 9:12 AM, Licensed Practical Nurse (LPN) #71 confirmed the index of the Narcotic Count Book was blank. The Index did not list the name of the residents, medications, dosages and page number for each controlled substance. On 03/16/22 at 9:15 AM, the the Director of Nursing (DON) confirmed the index of the Narcotic Count Book was blank. The Index did not list the name of the residents, medications, dosages, and page numbers for each controlled substance. .

Based on observation, policy review and staff interview the facility failed to store, label and date food in a sanitary manner in accordance with professional standards for food service safety. The facility also failed to correctly document dishwasher temperatures. This deficient practice has the potential to affect a limited number of residents who receive nutrients from the kitchen. Facility Census: 54 Findings Included: a) Initial Tour of the kitchen An initial tour of the kitchen with the Dietary Supervisor(DS) #1 on 03/14/22 at 12:50 PM revealed the following failed practices: The Walk in Freezer: --Pork Chops box lid was opened and exposing the meat to the elements --Raisin Bread was opened and not labeled with a date --5 Hamburger patties with no open date or use by date The DS indicated the pork chops, raisin bread and hamburger patties needed to be discarded. The Walk in Refrigerator: --a bag of liquid scrambled eggs which was open with no date to indicate when they were opened or needed to be discarded. The DS indicated the eggs needed to be discarded. Spice Rack: --Ground…

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 record review, the facility failed to maintain appropriate infection control standards during medication administration by using a barrier with the inhaler for Resident #27, popping a pill into bare hands for Resident #33, not providing hand hygiene to residents prior to a meal and not bagging an inhaler in the drawer of the medication cart for Resident #54. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Resident identifiers: #27, #33 and #54. Facility Census: 54. Findings Included: a) Resident #27 On 03/16/22 at 8:45 AM, Licensed Practical Nurse (LPN) #71 was observed during medication administration. LPN #71 did not use a barrier between Resident #27's nasal spray and the sink. On 03/16/22 at 9:05 AM, LPN #71 stated I'm sorry I was nervous. On 03/16/22 at 10:20 AM, the Director of Nursing (DON) confirmed using a barrier between the medication and the furniture in a resident's room was a professional standard of care for the prevention of infections. The DON confirmed…

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 care for a resident in a respectful manner to protect their dignity. Resident #2's urinary catheter drain bag was laying uncovered on the fall and visible from the hallway. This was a random opportunity of discovery. Resident identifiers: # 2. Facility census: 54. Findings Included: a) Resident #2 An observation on 03/15/22 at 2:15 PM found Resident # 2's urinary catheter drain bag was not in a privacy cover and was laying in the floor. During an interview on 03/15/22 at 2:16 PM Licensed Practical Nurse (LPN) #30 acknowledged the urinary catheter bag was uncovered and laying in the floor. On 03/15/22 at 2:37 PM the Director of Nursing (DON) was notified of the urinary catheter bag was not in a privacy cover and the catheter bag was laying on the floor, no further information was provided. .

Based on record review and staff interview the facility failed to notify the Physician and the Resident's Medical Power of Attorney (MPOA) timely of a change in the resident's condition for one (1) of one (1) resident reviewed for a change in condition. Resident Identifier #205. Facility census 54. Findings included: a) Resident #205 A review of the medical record found Resident #205 developed a fever on 09/04/21 at 11:16 PM. Resident coughing and running a temperature of 102.1 temporal (non-touch). The facility failed to notify Resident # 205's Physician regarding the change in condition until 09/07/21 at 5:41 PM . The facility failed to notify Resident #205's MPOA regarding the change in condition until 09/07/21 at 6:05 PM. The facility was not able to provide a policy regarding Resident Change in Condition documentation or notification. An interview at 10:15 AM on 03/17/22, with the Director of Nursing (DON), confirmed the Resident's Physician and MPOA should have been notified at the time the change in condition occurred. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) was complete and accurate. This was true for one (1) of 25 residents reviewed during the survey process. Resident Identifier: #52. Facility Census: 54. Findings Included: a) Resident #52 On 03/16/22 at 11:55 AM, the MDS dated [DATE] section L Oral/Dental Status was reviewed. The section was was coded indicating there were no dental issues. A consultation dated 11/16/21 from a local denture company stated recommend extracting teeth 23, 24, 25, 26 and roots 28 and 29 with an oral surgeon. After a review of the medical record and resident interview on 03/16/22, the resident's teeth and roots had not been extracted as recommended. The resident stated I really want them out . On 03/16/22 at 11:43 AM, Social Worker (SW) #23 confirmed the resident's teeth and roots had not been extracted as recommended and section L of the MDS was incorrect. We are waiting on a pre-authorization before she [the resident] can…

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

Based on record review and staff interview, the facility failed to revise the care plan with new interventions after Resident #25 and #205 had additional falls. This was true for two (2) of two (2) residents reviewed during the long-term care survey. Resident identifier #25 and #205. Facility Census: 54. Findings Included: a) Resident #205 A record review found Resident #205 was admitted to the facility 08/20/19. A care plan for risk for falls ., and risk of fracture during falls ., was initiated 08/22/2019, and canceled on 09/23/21 (upon discharge). A review of August 2021 and September 2021 incident reports for Resident #205 found she fell six (6) times (08/02/21, 08/08/21, 08/27/21, 09/01/21, 09/15/21, 09/19/21). The only revision to interventions for the .risk for falls . care plan for Resident #205 during August 2021-September 2021 (other than canceling the interventions upon discharge) was resolving RNP scheduled toileting program as ordered on 09/15/21. An interview with both the Director of Nursing (DON) and Administrator on 03/16/22 at 12:30 PM confirmed Resident #205's…

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

Based on record review and staff interview the facility failed to provide adequate supervision and interventions to prevent accidents. Resident #205 sustained two (2) falls which resulted in injuries to her head and no interventions were put into place after each fall. This is true for one (1) of 1 resident reviewed for the care area of accidents during the long term care survey process. Resident identifier #205. Facility census 54. Findings Included: A) Resident #205 A review of Resident #205's medical record found she sustained a fall on 08/27/21 at 2:45 am. Resident #205 fell out of bed and sustained a wound to her left forehead that required medical intervention and was transferred to a local hospital for treatment. Resident #205 required sutures to her left forehead and developed a hemotoma. A review of Resident #205's medical record and the incident report for her fall on 08/27/21 found no interventions were put in place after this fall to prevent further injury should another fall occur. Further review of Resident # 205's medical record found she was found on the floor beside…

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 provide necessary respiratory care consistent with professional standards of practice. This was true for one (1) of one (1) residents reviewed for respiratory services during the Long Term Care Survey Process. Resident identifier: #54. Facility Census: 54 Findings Included: a) Resident #54 An observation on 03/14/22 at 4:00 PM, found Resident #54's portable oxygen was set on 2 liters per minute, Activity Supervisor #67 acknowledged it was set on 2 liters per minute. An observation on 03/15/22 at 10:00 AM, Resident #54 oxygen concentrator was not turned on with no oxygen flowing. During an interview on 03/15/22 at 10:00 AM LPN #72 acknowledged the oxygen concentrator was not turned on. On 03/15/22 at 10:03 AM LPN #72 monitored her oxygen saturation at 83. On 03/15/22 at 10:04 AM stated (Resident's name's) oxygen saturation are usually between 96-98, I am unsure how long the oxygen has been off. On 03/15/22 at 10:05 AM LPN #72 monitored her oxygen saturation was between 90-91. On 03/15/22 at 10:07…

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, policy review and staff interview the facility failed to ensure medication were labeled in accordance with accepted professional principles. The facility failed to label a bag of intravenous(IV) fluid of Normal Saline and intravenous tubing when it was put into use for Resident #35. This was a random opportunity for discovery. Resident Identifiers: #35. Facility Census: 54. Findings Included: a) Resident #35 An observation on 03/14/22 at 2:50 PM , found a bag of IV fluids was being administered to Resident #35 with no date or order information on the bag or no date on the IV tubing. An interview on 03/14/22 at 2:55 PM, with Licensed Practical Nurse (LPN) # 30, comfirmed (LPN #72's name) is her nurse today she is on lunch. I know that 2 bags of fluids was to be given per report. During an interview on 03/14/22 at 2:55 PM LPN #30 confirmed no label on the normal saline or IV tubing. During an interview on 03/14/22 at 3:00 PM the Director of Nursing (DON) acknowledged there was no date on tubing and no date or information on IV fluids of normal saline being…

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 keep an accurate medical record for Resident #205 and #37. This is true for two (2) of 25 sampled residents reviewed during the long term care survey process. Resident identifiers #205 and #37. Facility Census 54. Findings Included: a) Resident #205 A review of the medical record found a Progress Note written 09/05/21 at 12:07 am {typed as written} Staff reported that resident was coughing and had a temperature of 102.1 Resident was given a PRN Covid test. Results of test are negative. Gave resident Tylenol 325mg x2 tabs and temperature is now 99. Lung sounds are clear. Will continue to observe resident and report these findings to morning nurse. Resident appears to have yellow drainage from left eye. No redness or swelling to forehead. Stitches are dry and intact. A record review of the Medication Administration Record (MAR) for September 2021 found no Tylenol (Acetaminophen) administered to Resident #205 on 09/05/21. An interview at 10:15 am on 03/17/22 with the Director of Nursing (DON) verified if a medication was…

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