River Oaks Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review the facility failed to ensure it had a complete and accurate medical record related to capturing correct Diagnosis upon admission. This failed practice was found true for (1) one of (2) two residents reviewed for correct diagnosis upon admit during the Long-Term Care Survey Process. Resident identifier # 78 . Facility Census 110.Finding Included: a) Resident # 78 During a facility walk through on 05/26/26 at 2:15 PM, the surveyor observed that Resident #78's room had signage for Enteric Precautions around her door. A record review on 05/26/26 at 3:30 PM, revealed that Resident #78's list of diagnosis did not coincide with the enteric precautions orders. Further record review revealed that Resident #78 was admitted to the facility on [DATE] and the hospital Discharge summary dated [DATE] listed the diagnosis of Clostridium difficile colitis.A review of Resident #78's list of diagnoses on 06/02/26 found that the diagnosis of Enterocolitis due to clostridium…

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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in the resident dining room. This was a random opportunity for discovery with the ability to effect a limited number of residents. Facility Census 110.Findings Included:a) The surveyor observed an issue on 06/01/26 at approximately 11:15 AM, in the resident dining room. The surveyor observed an approximate 3 inch round hole in the lower left doorfacing at the back exit door with sheet rock dust and chunks falling out and into the floor. This was easily accessible to all residents in the dining room. On 06/01/26 at approximately 11:25 AM, an interview with the dietician verified this finding. This finding was also acknowledged by the facilityadministrator on 06/03/26 at approximately 8:35 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of two (2) resident showers rooms located in the [NAME] Fort Hall. Facility Census: 113. Findings Included:a) On 03/16/26 at approximately 1:20 PM, Surveyor observed a damaged area of the wall in the central shower room on [NAME] Fort (300-400 Hall) that was covered up with black tape.b) On 03/16/26 at approximately 1:20 PM, Surveyor observed stained/discolored tile grout located in the shower stall of the central shower room on [NAME] Fort (300-400 Hall).c) On 03/16/26 at approximately 1:25 PM., an interview with the facility's Director of Plant Maintenance verified these findings. These findings were also acknowledged by the facility's Administrator at approximately 1:25 PM, and upon the exit conference on 03/17/26 at approximately 3:45 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F689Based upon Observations and Interviews the facility FAILED to ensure an environment that remains free from accident hazards as evidenced by A) Day room (end of hall room) of [NAME] court - Sani wipes (purple top) cleaners left on top of vending machines. B) Internet cafe/storage area with multiple equipment beds, lifts, pumps, chairs, and broken picture frame with sharp edges on counter. The area is open to residents and poses multiple hazards. C) Wiring exposed in a wall box without a cover outside RM [ROOM NUMBER]. This was a random opportunity of discovery with the ability to affect more than one person. Census 116 Findings include:A) In the day room at the end of hall room of [NAME] court there were Sani wipes (purple top) cleaners left on top of vending machines. Interview with employee #105 stated that no they should not be left on top of the machines, even if most residents are in wc and cant reach them. B) In the Internet cafe storage area was open to residents with multiple equipment beds, lifts,…

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 F880Based upon Observations and Interviews the facility FAILED to have a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. This is evidenced by A) Two open soda cans on a PPE cart outside a residents room. B) Three lift pads left on top of a clean linen cart; and C) PPE/EBP signs on multiple doors with out identifying the resident to whom the precaution applies to.These were all random opportunities for discovery, with the ability to affect more than a single person.Census: 116A) The PPE cart outside RM [ROOM NUMBER] had two soda cans sitting on it. (zero sugar shasta)B) Outside RM [ROOM NUMBER] there were three lift pads on top of the linen cart exposed and not covered. An interview w/employee #105 stated that they definitely should not be on top of that cart, they should be at least inside under the cover. Ill make sure they are taken care of.C) There were PPE/PBE signs throughout the building that are not marked with whom the precautions…

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, resident interview, and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Soiled briefs were being left in residential rooms following staff providing incontinence care. This was true for two (2) out of (2) residents reviewed. Resident identifiers: #92 and #78. Facility census: 115. Findings included: a) Resident #92 Record review completed on Monday, 04/07/25 at 1:30 PM revealed a resident grievance dated 01/16/25. Resident #92 alleged Nurse Aides do not pick up after themselves. Her roommate's soiled briefs are being left on the floor. The facility's Infection Preventionist and Social Service Designee #5 investigated the allegation and reported their findings to the Director of Nursing (DON). Nurse Aide #133 was re-educated, and the incident was logged as a teachable moment. Further review of Resident #92's electronic medical record revealed: -A physician determination of capacity, dated…

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 garbage and refuse in a proper manner. The dumpster area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 107. Findings included: a) Dumpster area An observation on 12/09/24 2:57 PM found the dumpster area was polluted with garbage and used medical supplies. On 12/09/24 at 3:16 PM during an Interview the Administrator verified the trash / medical supplies on the ground around the dumpster.

Based on record review and staff interview the facility failed to follow through with their plan of correction when a deficient practice was identified and investigated. This was true for ten (10) of ten (10 records reviewed. Resident Identifiers: #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258. Facility Census: 107 Findings Include: a) Resident #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258 On 12/04/24 at 11:23 AM a facility reported incident concerning a multi-resident medication error was reviewed. The incident report alleged Registered Nurse (RN) #404 failed to pass Physician ordered medications to ten (10) residents. This occurred on each night shift from 04/06/24 through 04/09/24. On 12/09/24 during an interview with the Director of Nursing (DON), she stated the error was identified when a random audit of the medication cart was performed by herself. It was found that the dated medication packets which come from the pharmacy were still in the medication cart, unopened. She then performed an audit of the Medication Administration Report (MAR) and found that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, the facility failed to incorporate an effective pest control program. This had the potential to affect all residents residing in the facility. Facility census: 107. Findings included: a) Gnats On 12/02/24 12:13 PM during the initial tour there were gnats all over the walls and ceiling in room [ROOM NUMBER]. The window was open, and a flying insect plug in was observed with multiple gnats trapped on the sticky pad. On 12/03/24 at 11:40 AM an observation and interview with the Central Supply Coordinator verified the gnats in the dining room and on resident trays. She stated they also have an issue with gnats in rooms where residents wet themselves On 12/03/24 at 12:11 PM during an interview with the exterminator, he stated he was never called to treat gnats in the facility prior to this date. He verified the gnats through the facility at this time. During an interview on 12/03/24 at approximately 12:45 AM, the Administrator verified they tried to exterminate the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, the facility failed to protect and promote a dignified dining experience and failed to answer a resident's call light on a timely basis. These were random opportunities for discovery. Resident identifiers: #24, #71, #37, #45, #68, #27, #42, and #51. Facility census: 107. Findings included: a) During an interview on 12/03/24 at 10:30 AM, Residents #24 and Resident #31 reported that they had gone to the dining room for their Thanksgiving meal. They reported that one of the more confused residents from the 400 hall, Resident #45, had a soiled brief in her lap as she wheeled into the dining room. Resident #45 reportedly lifted the soiled brief, spread it on the table in front of her, and started playing in the feces as though she was finger painting. Both residents reported two activity aides were in the room but failed to do anything to intervene. They reported that Resident #71 went to the [NAME] hallway to ask staff to address it, and was told, Hey,…

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 interviews, and staff interviews, the facility failed to ensure resident council grievances, issues, and concerns were acted upon promptly and provide a rational response. This had the potential to affect more than an isolated number of residents. Facility census: 107. Findings included: a) On 12/03/24 Resident Council minutes were received upon entry. It was noted that concerns and issues were brought up at the meetings but these previous grievances, concerns, and issues were not listed in the minutes. Review of the Resident Council minutes revealed the following: All Grievances, concerns, and issues are documented and given to the appropriate manager to complete and then they are given to the Administrator to file. During the resident council meeting with the resident council president and 3 others on 12/04/2024 at 10 AM, the council president stated the activities coordinator writes down the issues and concerns, but nothing is ever done and they do not get any feedback in future meetings. During an interview with the activities coordinator on…

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

Based on observation and staff interview, the facility failed to secure and keep confidential residents' medical information. The facility failed to safeguard private information that was placed in a clear acrylic wall file holder located outside of the medical records office. This was a random opportunity for discovery. Resident identifiers: #305, #155, #357, #30, #308, #28, and #100. Facility census: 107 Findings included: a) An observation on 12/02/24 at 11:40 AM revealed diagnosis sheets and mini nutritional assessments placed in an acrylic wall file holder outside the Medical Records office. There were diagnosis sheets for Resident #305, Resident #155, Resident #357, Resident #30, Resident #308, and Resident #28. Additionally, there were mini nutritional assessments for Resident #28 and Resident #100. All the forms had been printed by Minimum Data Set (MDS) RN #55. During an interview on 12/02/24 at 11:50 AM, the Medical Records Coordinator #17 confirmed the diagnosis sheets and mini nutritional assessments were accessible to any passerby and had confidential information on…

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

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. The facility failed to keep the dining room temperature at a comfortable temperature level. This was a random opportunity for discovery and had the potential to affect more than an isolated number of residents Residenti Identifiers: #45, #95, #37, and #8. Facility census: 107. Findings included: a) An Observation, on 12/03/24 at 11:30, identified the following: -Resident #45 shivered and stated she was cold. The Activities Director left the dining room to obtain a sweater for the resident. -Resident #95 stated, Wow, I'm cold. -Resident #37 was wearing a sweatshirt and a wrap around her shoulders. The resident also had a folded blanket on the back of her wheelchair. She smiled and stated, I came prepared. -Resident #8 had a blanket wrapped around her. Surveyor requested that a maintenance staff member come to the dining room to test the temperature to see if it met the minimum of 71 degrees Fahrenheit. The Maintenance Director took the temperature in 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 resident interview, record review, and staff interview, the facility failed to make prompt efforts to resolve verbal grievances. The facility failed to act on verbal grievances related to bringing back the Soup of the Day to the menu and failed to act on a verbal grievance regarding burnt food, gnats, and food not being removed from the resident's room for three (3) days. Additionally, the facility failed to act on a verbal grievance regarding a resident's missing personal property. Resident identifiers: #24, #71, #31, #37, #70, #80, #29, and #32. Facility census: 107. Findings included: a) Soup of the Day During an interview on 12/02/24 at 11:34 AM, Resident #24 stated that residents, including herself, requested that the Soup of the Day be put back on the menu at every resident council meeting but the residents never heard back about their request. She stated the only soup that was available to residents was tomato soup and many people were sick of having it. During a resident council meeting, on 12/03/24 at 10:00 AM, Residents #31, #37, #70, and #80 confirmed that 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 medical record review and staff interview, the facility failed to revise the comprehensive care plan in the area of showers, wound care and turning and repositioning. Resident identifiers: #20, #22, #58, #72 and #92. Facility census: 107. Findings include: a) Resident #20 On 12/03/24 at 11:11 AM Resident #20 states he prefers a shower over a bed bath but does not get his showers as ordered. According to the shower schedule provided by the facility Resident #20 should receive his showers on the evening shift every Wednesday and Saturday. On 12/05/24 at 1:00 PM review of the comprehensive care plan under the focus of Activities of Daily Living (ADL) is not resident specific in relation to specifying Resident #20's choice for a shower versus a bed bath. In addition, the care plan does not relay that Resident #20 has refusals for a shower in the past. Review of the task for showers/baths for the last thirty (30) days show Resident #20 has refused a shower three (3) times on 11/10/24, 12/01/24 and 12/05/24. On 12/05/24 at 2:10 PM Nurse Aide # 62 confirmed Resident #20 prefers…

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

Based on record review and staff interview the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences and professional standards of nursing practice for more than a limited number of residents. Resident Identifiers: #19, #25, #30, #43, #64, #69, #77, #255, #256, #258, #59, #89. Facility Census: 107 Findings Include: a) Resident #19, #25, #30, #43, #64, #69, #77, #255, #256, and #258 On 12/04/24 at 11:23 AM a facility reported incident concerning a multi-resident medication error was reviewed. The incident report alleged Registered Nurse (RN) #404 failed to pass Physician ordered medications to ten (10) residents. This occurred on each night shift from 04/06/24 through 04/09/24. On 12/09/24 at 9: 05 AM during an interview with the Director of Nursing (DON), she stated the error was identified when a random audit of the medication cart was performed by herself. It was found that the dated medication packets which come from pharmacy were still in the medication cart, unopened. She then performed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Three (3) medication carts and a treatment cart were unlocked and unattended. This was a random opportunity for discovery. This deficient practice had the potential to affect more than a limited number of residents. Facility Census: #107 Findings include: a) Medication carts On 12/04/24 at 4:50 AM it was observed at the nurses station on the 100/200 hallways there were two (2) medication carts that were unattended and unlocked. At 4:52 AM Licensed Practical Nurse (LPN) #87 returned to the medication cart and confirmed the medication cart she was responsible for on the 100 hallway was left unlocked and unattended. posing an accident threat to residents on the 100 and 200 hallways. At 4:57 AM LPN #70 returned to the medication cart and confirmed the medication cart she was responsible for on the 200 hallway was left unlocked and unattended. posing…

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 deploy sufficient direct care staff to meet the care needs of all residents in the facility, based on the facility assessment. This has the potential to affect all residents residing in the facility. Facility census: 107. Findings include: A) Facility staffing At approximately 11:30 AM on 12/10/2024, a review was conducted of the facility assessment and staffing for the following days: 07/10/24, 08/13/24, 09/21/24, 11/30/24, 12/1/24. According to the facility assessment, the facility would deploy between ten (10) and twelve (12) Nurse Aides on day shift and between eight (8) and ten (10) on night shift to sufficiently meet the needs of the residents who reside at the facility. Punch in and out reports were conducted for above days, which showed every employee that clocked in and out of the facility for those days. The review of the punch in and out reports revealed the following: 7/10/24- Nine (9) Nurse Aides were in the facility on day shift. 8/13/24- Eight (8) Nurse Aides were in the facility for dash and four (4)…

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 ensure the medication regimens for Residents #307, #38,#22, and #64 were free from unnecessary medications. This was true for four (4) of six (6) residents reviewed for unnecessary medications during the survey process. Resident identifiers: #307, #38, #22, #64. Facility census: 107. Findings include: a) Resident #307 At approximately 3:30 PM on 12/03/2024, a review of Resident #307 ' s medical record was conducted during the review, the following orders were noted: Donepezil HCl Oral Tablet 5 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for dementia Active 11/27/2024 21:00 traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for depression Active 11/27/2024 21:00 The following diagnoses were noted on the resident's diagnosis list during the review: ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE CHRONIC OBSTRUCTIVE PULMONARY…

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 and staff interviews, the facility failed to ensure they were able to follow menus by not having the food items needed for the preperation of the meal. This had the potentital to affcet more than a limited number of residents. Facility census: 107. Findings included: a) Resident #88 During an Interview on 12/02/24 at 1:23 PM. Resident #88 stated the facility runs out of food all the time and must send us whatever they have. She stated that they, Haven't had milk for days. She continued to say that they sent her chocolate milk with her cold cereal this morning and they had ran out of bread also. She stated that she never gets what's on the menu. During an interview with the dietary manager on 12/02/24 at 230 PM he stated that if they do not have a menu item or run out of something, they just tell the Nurse Aides. When ask if they post changes in menus any where for the residents to see, he stated, No. A medical record review for Resident #88 revealed, a diet order for a regular diet. A review of the facility menu on 02/02/24 for lunch was kielbasa…

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 equipment manual review the facility failed to have a clean, sanitized kitchen, store food in the refrigerator, freezer, and dry storage in accordance with professional standards for food service safety. The facility also failed to keep the ice machine and dishwasher in safe operating condition. This has the ability to affect all residents that get their nutrition from the kitchen, and also attends food related activities. Facility Census: 107 Findings included: a) Initial Kitchen tour. During the initial kitchen tour with the Kitchen Account Manager on 12/02/24 at 11:54 AM, an observation found --Walk-in refrigerator - One container of cottage cheese, opened, not labeled, or dated. and 6 heads of lettuce brown / spoiled. -- Walk -in the freezer - Boxes of hamburger patties, waffles and french toast, open to air. -- Dry storage - 4 dented cans (peaches and soups) in circulation. --The microwave had dried food debris throughout the inside of it. -- The floors under the stove and sink area had food and debris. --The stove and outside of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, the facility failed to 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. Resident #45 was allowed to play in feces until other residents intervened, wound care for a resident under enhanced barrier precautions was provided without staff wearing the appropriate personal protective equipment (PPE), linens were on the floor and a linen barrel was overflowing. These were random opportunities for discovery. Resident identifiers: #45 and #56. Facility census: 107. Findings included: a) Resident #45 During an interview on 12/03/24 at 10:30 AM, Residents #24 and Resident #31 reported that they had gone to the dining room for their Thanksgiving meal. They reported that one of the more confused residents from the 400 hall, Resident #45, had a soiled brief in her lap as she wheeled into the dining…

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 a safe and homelike environment in regard to a black substance on packaged terminal air conditioner (PTAC) and ceiling vents. This had the potential to affect all residents living in the facility. Facility census: 107. Findings include: a) Dining Rooms An observation, on 12/03/24 at 12:55 PM, revealed a black substance around the packaged terminal air conditioner (PTAC) units. At an interview, on 12/03/24 at 12:58 PM, the Maintenance Director confirmed that the PTAC units had a black substance around them. b) Ceiling vents. An observation on 12/03/24 of the vents in the ceiling throughout the facility found a black substance and debris on and around the vents. On 12/03/24 at around 1:15 PM, the Maintenance Director also confirmed the presence of debris in the heating and cooling unit. He stated that cover/vents would be clear of debris and black substance today.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to honor the residents right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Resident identifier: #90 and #39. Facility census: 107. Findings included: a) Resident #39 A review of Resident #39's medical record found he was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 11/16/24. No written notice was given prior to the room move. b) Resident #90 A review of Resident #90's medical record found he was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 11/29/24. No written notice was given prior to the room move. During an interview on 12/5/24 at 11:20 AM the Social Worker confirmed no written notice was given to Resident #39 or #90 prior to them being transferred to different rooms.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interviews, the facility failed to ensure Resident #32 received showers in accordance with her preferences. This was true for one (1) of six (6) residents reviewed for Activities of Daily Living (ADLs) during the survey process. Resident identifier: 32. Facility census: 107. Findings include: a) Resident #32 At approximately 3:30 PM on 12/02/2024, an interview was conducted with Resident #32. During the interview, the resident stated Sometimes you have to [NAME] them before they will give you a shower, and even then, I don't get showers when I want them so, sometimes, I just tell them I don't want them. At approximately 10:00 AM on 12/04/2024, a review of Resident #32's record revealed she had refused showers on 11/20/2024 at 6:59 AM, 11/27/24 at 6:59 AM, 11/28/2024 at 10:16 PM, and 12/06/2024 at 6:59 AM, according to the bathing task sheet for the past thirty (30) days. A review of the progress notes for these days do not indicate a reason for refusals. At…

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

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 resident/resident's representative was provided with a written Notice of Transfer for an acute hospital transfer. This was true for two (2) out of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #71 and #89. Facility census: 107. Findings included: a) Resident #71 A record review, completed on 12/04/24 at 2:00 PM revealed Resident #71 was hospitalized on [DATE]. The electronic medical record did not have evidence that a Notice of Transfer / Discharge had been issued informing the resident of her right to appeal the decision if she so desired. During an interview on 12/04/24 at 9:55 AM, the Assistant Director of Nursing (ADON) reported the facility could not produce evidence that a Notice of Transfer / Discharge had been given. b) Resident #89 A record review, completed on 12/04/24 at 2:20 PM revealed Resident #89 was hospitalized on [DATE]. The electronic…

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 resident/resident's representative was provided with a written Bed Hold Notice for an acute hospital transfer. This was true for two (1) out of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #71. Facility census: 107. Findings included: a) Resident #71 A record review, completed on 12/04/24 at 2:00 PM revealed Resident #71 was hospitalized on [DATE]. The electronic medical record did not have evidence that a Bed Hold Notice had been issued. During an interview on 12/04/24 at 9:55 AM, the Assistant Director of Nursing (ADON) reported the facility could not produce evidence that a Bed Hold Notice had been given.

Based on record review and staff interview, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses. This was true for one (1) out of two (2) residents reviewed for the category of PASARR (Pre-admission Screening and Record Review, during the Long-Term Care Survey Process. Resident identifier #52. Facility census: 107. Findings included: a) Resident #52 A medical record review, completed on 12/04/24 at 8:48 AM, revealed Resident #52 had the following diagnoses: -A Major Depression Disorder diagnosis -An Epilepsy diagnosis A PAS, completed on 05/20/21, marked NONE under Section III Question 30 entitled, Current Diagnosis (Check all that apply). Addionally, Section V Question 40 entitled, Major Mental Illness (MI) or Suspected MI only listed major depression. During an interview on 12/04/24 at 9:15 AM, the Director of Social Services reported that resident's Epilepsy diagnosis had not been captured on the PAS.

b) Resident #33 A record review completed on 12/10/24 at 9:44 AM, revealed the following details regarding a resident-to-resident altercation: -The resident-to-resident incident occurred on 11/07/24 at 7:00 AM. -The incident occurred in the resident's room. -Description of incident: Resident #33 was seen grabbing a foot rest from a wheelchair and hitting her roommate (Resident #16) in the left arm. Resident #16 had a bruise to the left wrist and outer left forearm. -Review of Resident #33's care plan did not reflect a history of resident-to-resident physically aggressive behaviors. During an interview on 12/10/24 at 10:40 AM, the Director of Nursing confirmed that Resident #33's care plan had not been updated to include a history of physically aggressive behaviors toward other residents. Based on record review and staff interview, the facility failed to follow the care plan of Resident #66 by failing to monitor for behaviors, and to include Resident #33 's history of physical aggression with other residents into her care plan. This was true for three (3) of 54 care plans reviewed…

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 and staff interviews and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living (showers) to maintain good grooming, and personal hygiene. This was true for two (2) of four (4) records reviewed for showers. Resident Identifiers: #58 and #92. Facility Census: 107. Findings Include: a) Resident #58 On 12/03/24 at 10:01 AM Resident #58 states he prefers a shower over a bed bath but does not get his showers as ordered. According to the shower schedule provided by the facility Resident #58 should receive his showers on day shift every Monday and Friday. On 12/05/24 at 1:10 PM record review of showers given for the last thirty (30) days shows Resident #58 had eight (8) opportunities for a shower. He received five (5) of the eight (8) showers. There were no refusals documented. The care plan was reviewed and Resident #58 is not care planned for a history of refusing showers. According to the schedule he was scheduled a shower on the following dates: 11/11/24 11/15/24 11/18/24 11/22/24…

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 observation, record review and staff interview the facility failed to turn and reposition an immobile resident according to standard practice of nursing care to prevent new or worsening pressure ulcers. Resident Identifier: #72 Facility Census: #107 Findings Include: a) Resident #72 On 12/05/24 at 2:18 PM observation and record review identified Resident #72 has a stage III pressure ulcer to her left back. Record review and Licensed Practical Nurse #26 confirmed the wound was first identified 08/29/24. Current orders for wound care to her back are: 1) WOUND CARE: Monitor Stage 3 pressure injury to thoracic spine. Notify medical provider if presence of complications (e.g. increased redness, swelling, drainage, abnormal odor, new or worsening pain/discomfort. WOUND CARE: Cleanse Stage 3 pressure injury to left back with wound cleanser, apply hydrogel with silver to wound bed, cover with bordered gauze. On 12/05/24 at 3:10 PM record review of Resident #72's care plan and current orders show there are no interventions or tasks for turning and repositioning the resident to…

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

Based on record review and staff interview the facility failed to maintain adequate nutritional status, to the extent possible, to ensure the resident is able to maintain the highest practicable level of well-being. This was true for one (1) of three (3) records reviewed for weight loss. Resident identifier: #59 Facility Census: #107. Findings Include: a) Resident #59 On 12/03/24 at 9:15 AM record review of weights for Resident #59 found there had been a significant weight loss of 10.3% in one month. Documentation showed Resident #59 weighed 208 pounds on 10/11/24 and dropped to 186.6 pounds on 11/11/24. This reflects a weight loss of 10.3% of her weight in 30 days. A significant weight loss is defined as: 5% change in weight in 1 month (30 days) 7.5% change in weight in 3 months (90 days) 10% change in weight in 6 months (180 days) Resident #59 has the following active orders: Regular diet Regular texture, Regular consistency, Diabetic Condiments No Salt Packet and Weight times 4 weeks upon admission on e time a day every Sun for Baseline Weight for 4 Weeks AND every day shift…

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 ensure that the physician or delegate responded to a new onset of symptoms, in a resident's condition, in a timely manner. This failed practice had the potential to cause more than minimal harm. Resident Identifier: #103. Facility Census:107. Findings included: a) Resident #103 During a closed record review on 12/03/24 at approximately 2:15 PM, a nursing note entered by Licensed Practical Nurse (LPN) #117 on 11/06/24 at 4:29 AM revealed the following: Nursing Assistant (NA) informed this nurse that there was blood in residents catheter bag. This nurse assessed residents' catheter and found no abnormalities. Resident has no c/o pain or discomfort with catheter. Secure messaged Nurse Practitioner (NP) #120, and Medical Director (MD) #121. And attempted to reach Medical Power of Attorney (MPOA). No concerns at this time, will continue to monitor this shift. Further record review on 12/03/24 at 2:25 PM revealed that neither MD #121, nor NP #120, had responded to the LPN's message. 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 ensure a physician responded to recommendations made by a licensed pharmacist for Resident #66, and to ensure the physician provided a rationale for the use of a medication Resident #38 had a documented allergy to. This was true for two (2) of six (6) residents reviewed for unnecessary medications during the survey process. Resident identifiers: #66, #38. Facility census: 107. Findings include: a) Resident #66 At approximately 12:30 PM on 12/04/2024, a review of the physician ' s responses to pharmacy recommendations was conducted with the Assistant Director of Nursing (ADON). During the review, the following recommendations were noted: 05/28/2024- Reassess the PRN order for Lorazepam 05/28/2024- Possible duplicate orders for Tramadol 50 mg and Ativan 0.5 mg 06/06/2024- Reassess the PRN order for Lorazepam There are no options marked for agree, disagree, or other. There was no rationale provided for any decision made. There was no physician's signature or date to indicate the physician ever acknowledged 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 offer the opportunity to receive a substitute when residents refused food items during the morning meal. This was a random opportunity for discovery. Resident identifiers: #7 and #61. Facility census: 107 Findings included: a) During observation of the 400 Hall breakfast meal delivery on, 12/04/24 at 7:20 AM, Resident #7 and Resident #61 refused their breakfast trays by stating, No thanks. CNA #71 removed the meals from their room but did not offer an alternative. When questioned as to how CNAs are trained to serve meals, CNA #71 reported, I didn't offer an alternative because we know she (Resident #7) only likes sweets for breakfast. If it had been something like a cinnamon roll, she would have said yes. During an interview with the Director of Nursing on 12/04/24 at 8:12 AM, she stated that all aides are trained to offer residents the opportunity to receive a substitute if they are unhappy with the meal served.

Based on record review and staff interview, the facility failed to maintain an accurate medical record for three (3) out of four (4) records reviewed for accurate POST forms. Resident identifiers: #16, #29, and #33. Facility census: 107 Findings included: a) Resident #16 An electronic medical review, completed on 12/03/24 at 11:17 AM, found a scanned Physician Orders for Treatment (POST) form in Resident #16's electronic chart that left Section F completely blank. Section F should have the Physician's signature, phone number and license number. On 12/03/24 at 2:40 PM, a review of the Residents' POST Binder which is kept at the nurses' station, found the original POST form did not have the physician's signature, phone number, and license number. During 12/03/24 at 3:30 PM, the Director of Social Services confirmed without the physician's signature, phone number and license number, the form could not be considered a valid POST. b) Resident #29 An electronic medical review, completed on 12/03/24 at 2:32 PM, found a scanned POST form in Resident #29's electronic chart that did not have…

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

Based on record review and staff interview, the facility failed to ensure a serious bodily injury was reported timely for Resident #109. Allegations of misappropriation of Resident funds for Residents #23 and #82 was not reported to State authorities. For Resident #67 an allegation of abuse was not reported. For Resident #101 an allegation of abuse was not reported to all the required State agencies. Resident identifiers: #109, #23, #82, #67 and #101. Facility census: 106. Findings included: a) Resident #109 Record review found the following progress notes: 08/09/23 at 9:00 PM: Late Entry: Note Text: Resident had fist fight with one of the confused resident. No apparent injury noted. resident's wife (Name of wife and facility physician) made aware. C/o (complained of) pain on left pinky, Tylenol given as ordered. Remained in bed. 08/10/23 at 09:07 AM IDT (interdisciplinary team) Follow Up Late Entry: Date of review:: 8/10/23 Type of incident:: Fall What was happening at the time:: Resident attempting to redirect another resident out of his room and lost his balance. Root cause of…

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

Based on record review, staff interview and policy review the facility failed to follow policy to re-weigh a resident when there was a five (5) pound difference in weight, to obtain a physician's order for the use of Styrofoam dinnerware, to coordinate with Hospice, to produce evidence physician orders were followed for enhanced barrier precautions and that medications were administered. Resident identifiers: #25, #106, #67, #63 Facility Census: 106 Findings Include: a) Resident #25 On 12/12/23 at 11:11 AM record review shows there were no re-weights obtained when the current weight reflected a five (5) pound difference in weight. Facility Policy #NS 1320-02 Resident Height and Weight states . 9) Re-weight Parameters: a) A plus/minus of 5 pounds of weight in one week will result in: i) Re-weigh within 24 hours Record review shows the following weights with a +/- of five (5) pounds of weight difference that required to be re-weighed which was not performed as policy states. 05/19/23 weight 246.6 pounds 06/08/23 weight 239.4 pounds reflecting a 7.2 pound weight difference 08/27/23…

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

Based on observations and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered a heavily soiled floor in the storage room, several damaged floor tiles in the serving area and dish room, a trash can was parked directly in front of the hand washing sink, and dirty shelving units. This failed practice had the potential to affect all residents receiving nourishment from the kitchen. Facility census: 106 Findings included: a) Kitchen tour During the kitchen tour on 12/10/23 at 11:23 AM, it was discovered several damaged and missing floor tiles in the serving area and the dish room. The floor in the storage room was heavily soiled with a brown substance. The handwahing sink was blocked by a 30 gallon trash can used to collect debris from dirty dishes. There was an accumulation of dust on the shelving units used to house the mixing bowls and serving trays for the steam table. An interview with the Dietary Manager on 12/10/23 at 12:35 PM, verified the floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to provide hand hygiene in order to prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Resident Identifiers: #8, #27, #38, #40, #68, #71, #97 and #101. Facility Census: 106 Findings Included: a) On 12/10/23 at 12:11 PM it was observed that staff were passing the lunch meal trays on the [NAME] Fort Court hallway without providing hand hygiene for the residents. It was observed in Rooms 400, 401, 417 and 419 (each a semi-private room) received their meals without hand hygiene being offered or performed. The Residents affected were Resident numbers #8, #27, #38, #40, #68, #71, #97 and #101. On 12/10/23 at 12:14 PM this was confirmed with Certified Nurse Aide #34 who stated they usually give the Residents sanitizer wipes to wipe their own hands. There were no wipes provided to the above Residents. This was further confirmed with the Director of Nursing on 12/10/23 at 4:10 PM who…

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 administer seasonal influenza vaccines in accordance to the Centers for Disease Control and Prevention (CDC) guidelines for the 2023-2024 influenza season. Facility: Facility Facility Census 106 Findings Included: a) On 12/12/23 at 11:34 AM record review of facility influenza vaccines shows sixty six (66) of the 106 Residents residing in this facility have not been vaccinated for the 2023-2024 influenza season. Facility Census: 106 Influenza vaccines administered as of 12/12/23 for the 2023-2024 influenza season: 40 Consents obtained in October and on 11/01/23 for the influenza vaccine but have not been administered as of 12/12/23: 16 Residents that have been entered in Point Click Care as vaccine requested but no consent obtained as of 12/12/23: 13 Residents that no action has been taken towards receiving the influenza vaccine consents or the vaccine itself this season: 17 Residents that have refused the vaccine: 10 According the the CDC vaccination should be offered during September or October During an interview on…

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

Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident's #106 and #61. These were random opportunities for discovery. Resident Identifiers: #106 & #61. Facility Census: 106. Findings Included: a) Resident #106 On 12/10/23 at 12:30 PM, while observing the noon meal, Resident #106 was served his lunch on styrofoam dinnerware with plastic utensils. At this time, Licensed Practical Nurse (LPN) #87 was interviewed and asked why Resident #106 was served lunch on styrofoam? LPN #87 stated, I think it's because of his behaviors .he throws things. On 12/11/23 at 10:20 AM, the Director of Nursing in Training (DON) was notified of the resident receiving meals on styrofoam. The DON stated, I think it's because he was throwing knives at the staff and behaviors. On 12/11/23 at 10:45 AM, the DON confirmed there was no physician's order for meal service on styrofoam and the care plan had not been revised to reflect the behaviors and meal service on styrofoam. However, the dietary department had printed a meal ticket stating, styro box and…

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

Based on medical record review and staff interview, the facility failed to ensure the physician was notified of changes regarding the resident's physical status. This was true for one (1) of 28 sample residents. The physician was not notified of a significant weight loss for Resident #40. Resident identifier: #40. Facility census: 106. Findings included: a) Resident #40 A medical record review on 12/11/23, revealed Resident #40 weighed 208 pounds on 10/06/23 and on 11/18/23 she weighed 183. There was no evidence the physician was notified of the significant weight loss of 25 pounds. During an interview with the Director of Nursing (DON) on 12/11/23 at 2:05 PM, she could not provide any evidence the physician had been notified of the weight loss of 25 pounds between 10/06/23 and 11/18/23. The DON agreed the physician should have been notified of Resident #40's change in condition.

Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed Resident #212 at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident Identifier: #212. Facility census: 106. Findings included: a) Beneficiary Notice Review The facility provided a list of residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months. On 12/11/23 at 10:14 AM, a review was completed regarding the beneficiary protection notification liability notices given for Resident #212 who remained at the facility following her discharge from a Medicare covered Part A stay with benefit days remaining. - Resident #212's last covered day of Part A service was 07/29/23. A Notice of Medicare Non-Coverage (NOMNC) was issued by the facility on 07/27/23. No Skilled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview and staff interview, the facility failed to provide a safe, clean and homelike environment for room [ROOM NUMBER] which had dirty, stained sheet rock, room [ROOM NUMBER] was noted with a heavily soiled bed curtain and holes in the blinds, and room [ROOM NUMBER] was noted with holes in the bathroom door and missing sheet rock in the bathroom . These were random opportunities of discovery. Facility Census: 106. Findings Included: a) room [ROOM NUMBER] On 12/12/23 at 8:20 AM, upon observing medication administration in room [ROOM NUMBER], an observation was made of the sheet rock of the wall by the window. The sheet rock appeared to be dirty with brown, black and red stains. The top of the packaged terminal air conditioner (PTAC) was noted with a dry black substance. On 12/12/23 at 8:30 AM, the Clinical Manager #125 was notified and stated, let me get Maintanence. On 12/12/23 at 8:35 AM, the Director of Maintenance (DOM) #78 confirmed the sheet rock was dirty with multiple…

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 information was provided to the receiving provider to ensure continuity of care when the resident was transferred to the hospital. This was found for one (1) of three (3) discharged residents reviewed. Resident identifier: #108. Facility census: 106. Findings included: a) Resident #108 Record review found a nursing note dated 10/02/23 at 9:31 AM, which noted the resident was having increased congestion and mild edema to extremities. New orders were obtained for a chest x-ray and laboratory values to be obtained. When the medical power of attorney (MPOA) was contacted about the Resident's change in condition, the MPOA wanted the resident sent to the hospital. The facility complied with the MPOA wishes and sent the Resident to the hospital. On 12/12/23 at 9:05 AM, the Director of Nursing (DON) in training Registered Nurse (RN) #118 reviewed the Hospital Transfer Form, dated 10/02/23. RN #118 confirmed this form accompanied the Resident to the hospital. RN #118 was unable to provide evidence the receiving…

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

Based on record review and staff interview, the facility failed to ensure the ombudsman was notified of the transfer to the hospital for one (1) of three (3) Resident's reviewed for transfer/discharge from the facility. Resident identifier: #108. Facility census: 106. Findings included: a) Resident #108 Record review found a nursing note dated 10/02/23 at 9:31 AM which noted the resident was having increased congestion and mild edema to extremities. New orders were obtained for a chest x-ray and laboratory values to be obtained. When the medical power of attorney (MPOA) was contacted about the Resident's change in condition, the MPOA wanted the resident sent to the hospital. The facility complied with the MPOA wishes and transferred the resident to the hospital. The Resident has not returned to the facility. On 12/12/23 at 9:43 AM, Medical Records Coordinator (MRC) #18 and the Director of Nursing (DON) in training #118 were asked for verification to confirm the ombudsman was notified of Resident #108's transfer to the hospital. MRC #18 said she faxes a list of all the Residents…

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

Based on record review and staff interview, the facility failed to ensure a copy of the bed hold notice was provided to the Resident/Medical Power of Attorney (MPOA) upon transfer to the hospital for one (1) of two (2) residents reviewed for hospitalization. Resident identifier: #108. Facility census: 106. Findings included: a) Resident #108 Record review found a nursing note dated 10/02/23 at 9:31 AM, which noted the resident was having increased congestion and mild edema to extremities. New orders were obtained for a chest x-ray and laboratory values to be obtained. When the MPOA was contacted about the Resident's change in condition, the MPOA wanted the resident sent to the hospital. The facility complied with the MPOA wishes and sent the Resident to the hospital. On 12/12/23 at 9:05 AM, the Director of Nursing (DON) in training Registered Nurse (RN) #118 reviewed the Hospital Transfer Form, dated 10/02/23. RN #118 confirmed this form accompanied the Resident to the hospital but no information regarding the bed hold was referenced. RN #118 was unable to provide evidence a copy of…

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

Based on record reviews and staff interviews the facility failed to implement the comprehensive person-centered care plan for an altered nutritional status for Resident #40. For Resident #67 the care plan was not developed for coordination of hospice services. This deficient practice was true for two (2) of 28 sample resident care plans reviewed during the Long-Term Care Survey Process. Resident identifiers: #40 and #67. Facility census: 106 Findings included: a) Resident #40 A medical record review on 12/11/23, revealed Resident #40 weighed 208 pounds on 10/06/23 and on 11/18/23 she weighed 183. There was no evidence the physician was notified of the significant weight loss of 25 pounds. During a medical record review on 12/11/23 for Resident #40's care plan was not implemented for the nutritional intervention to notify the medical provider of any unplanned weight changes. During an interview with the Director of Nursing (DON) on 12/11/23 at 2:05 PM, she could not provide any evidence the physician had been notified of the unplanned weight loss. b) Resident #67 Record review found…

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 revise the care plan regarding behaviors and the use of styrofoam dinnerware and plastic utensils. This was a random opportunity for discovery. Resident Identifier: Resident #106. Facility Census: 106. Findings Included: a) Resident #106 On 12/10/23 at 12:30 PM, while observing the noon meal, Resident #106 was served his lunch on styrofoam dinnerware with plastic utensils. At this time, Licensed Practical Nurse (LPN) #87 was interviewed why is Resident #106 being served lunch on styrofoam? LPN #87 stated, I think it's because of his behaviors .he throws things. On 12/11/23 at 10:20 AM, the Director of Nursing in Training was notified of the resident receiving meals on styrofoam. The DON stated, I think it's because he was throwing knives at the staff and behaviors. On 12/11/23 at 10:45 AM, the DON confirmed there was no physician's order for meal service on styrofoam and the care plan had not been revised to reflect the behaviors and meal service on styrofoam. However, the dietary department had printed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain a safe and as free from accidents as possible. These were random opportunities for discovery. Facility Census: 106. Findings Included: a) room [ROOM NUMBER] On 12/10/23 at 12:17 PM, upon initial observation of room [ROOM NUMBER], three (3) medication cups with a thick, white substance were noted sitting on the over the bed table which was pushed against the wall. Licensed Practical Nurse (LPN) #87 was notified and confirmed the thick, white substance in the medication cups was zinc oxide cream, which is used to prevent skin irritation during incontinence episodes. On 12/10/23 at 12:19 PM, LPN #87 stated, that shouldn't be sitting there. LPN #87 removed the three (3) medication cups from the room. On 12/10/23 at approximately 1:00 PM, the Director of Nursing (DON) was notified of the above issue. The DON stated, that shouldn't be at bedside. No further information was obtained during the survey process. b) Medication Cart On 12/12/23 at…

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

Based on observation, resident interview and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportunities of discovery. Resident Identifier: #61 and #93. Facility Census: 106. Findings Included: a) Resident #61 On 12/12/23 at 8:32 AM, an observation was made during Resident #61's medication administration. The resident was ordered a breathing treatment of Albuterol Sulfate. Upon entering the room, the nebulizer was observed laying in the floor with the respiratory tubing wrapped around a chair arm near the resident's bed. The respiratory tubing was not stored in a respiratory bag. On 12/12/23 at 8:33 AM, Licensed Practical Nurse (LPN) #121 confirmed the nebulizer was laying in the floor and the respiratory tubing was not stored correctly. LPN #121 stated, we will get you some new tubing. On 12/12/23 at 8:35 AM, the Clinical Manager (CM) #125 was notified and confirmed the nebulizer and respiratory tubing were not stored correctly. On 12/12/23 at 8:40 AM, the Administrator was also…

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

Based on record review and staff interview, the facility failed to assess and monitor pain every shift per the physician orders for Resident #106, #93 and #67. This was true for three (3) of three (3) residents reviewed under the care area of pain management. Resident Identifiers: #106, #93, and #67. Facility Census: 106. Findings Included: a) Resident #106 On 12/12/23 at 1:30 PM, a physician's order dated 04/03/23 for monitor pain every shift was noted. Upon reviewing the December, 2023, medication administration record (MAR), the notations for each shift were check marks. However, the notations did not include if the resident was having pain, a pain rating or the location of pain. On 12/12/23 at 2:07 PM, the Director of Nursing in Training (DONIT) was notified of the finding and confirmed the notations did not include if the resident was having pain, a pain rating or the location of pain. b) Resident #93 On 12/12/23 at 1:30 PM, a physician's order dated 10/18/23 for monitor pain every shift was noted. Upon reviewing the December, 2023, medication administration record (MAR), 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 employee record reviews and staff interviews the facility failed to ensure nurse aides had annual performance evaluations completed. This was true for three (3) of five (5) employees reviewed for the facility task of sufficient and competent nurse staffing. Employee identifiers: #1, #96, and #36. Facility census: 106. Findings included: a) Annual performance evaluations During a review of the employee records on 12/12/23, it was discovered Nurse Aide (NA) #1 had an annual performance evaluation due on or before 08/15/23, NA #96 was due by 08/15/23, and NA #36 was due by 08/10/23. There was no evidence presented the three (3) employee annual performance evaluations had been completed. An interview with the Human Resource Manager on 12/12/23 at 2:35 PM, reported he was unable to locate any annual performance evaluations completed for NA #1, #96, and #36.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to monitor the medication refrigerator temperatures, store a schedule IV medication in a double lock system, remove personal food and drinks from the medication refrigerator and maintain a clean medication refrigerator on the [NAME] Court unit. These were random opportunities for discovery. Facility Census: 106. a) Temperature Logs On 12/12/23 at approximately 10:00 AM, a tour of the medication room on [NAME] Court was completed. The tour of the medication room found the medication refrigerator temperature logs had not been completed for the months of October, 2023, November, 2023 and December, 2023. The following is a list of the missing temperatures and dates for each month: October, 2023 --10/01/23 PM --10/02/23 PM --10/09/23 PM --10/10/23 PM --10/12/23 PM --10/13/23 PM --10/14/23 PM --10/15/23 PM --10/20/23 PM --10/22/23 AM & PM --10/23/23 AM & PM --10/24/23 AM & PM --10/25/23 AM & PM --10/26/23 AM & PM --10/27/23 AM & PM --10/28/23…

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 staff interview the facility failed to accommodate a Residents' food allergy. This was true for one (1) of seven (7) residents reviewed for food during the long term survey process. Resident Identifiers: #103 Facility Census: 106 Findings Included: a) Resident #103 On 12/10/23 at 12:19 PM it was observed that Resident #103 had baked apples on his lunch tray. He stated he is allergic to cinnamon as he smells the cinnamon on the apples. He also states he continues to get food with cinnamon on it even after he has told dietary staff that he is allergic to it. On 12/11/23 at 08:23 AM record review shows his allergies are documented as cinnamon being one of his two allergies. Review of his meal ticket for 12/10/23 shows as follows: Rosemary Roast Beef Au Jus, Baked Potato, Margarine, Sour Cream, Sliced Parsley Carrots, Dinner roll, Margarine. It also has Allergies: Cinnamon. The menu posted for 12/10/23 shows the following: Rosemary Roast Beef Au Jus, Baked Potato, Margarine, Sour Cream, Sliced Parsley Carrots, Dinner roll, Margarine, Harvest…

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 obtain daily temperature checks on residents' personal refrigerators. This was true for three (3) of three (3) personal refrigerators observed during the Long Term Care Process . Resident Identifiers: #34, #35, #23. Facility Census: 106 Findings Included: a) Resident #34 On 12/10/23 at 12:45 PM it was observed that Resident #34 has a personal refrigerator in his room that had no temperature log located at the refrigerator. According to the facility Policy #IC 1021-02 states Procedure: daily refrigerator temperature checks must be performed: d. Record and Log temperatures daily on a log kept at the refrigerator. On 12/10/23 at 1:58 PM, this was confirmed with the Director of Nursing #118 who stated they did not have any logs due to new maintenance personnel. No further information was obtained during the long term survey process. b) Resident #35 On 12/10/23 at 12:52 PM it was observed that Resident #35 has a personal refrigerator in her room. Further observation found there was no temperature log located…

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 garbage and refuse container in good condition. During a random opportunity for discovery, it was noticed one (1) of the two (2) dumpsters had only a partial covering. This practice did not allow for garbage and refuse to be disposed of properly. Facility census: 106 Findings included: a) Damaged dumpster During a random opportunity for discovery on 12/12/23 at 3:00 PM, a dumpster was not covered properly due to a broken lid, there was only a partial covering over the container. An interview with the Housekeeping Supervisor on 12/12/23 at 3:03 PM, verified half of the lid for the dumpster was missing and agreed the lid needed to be replaced.

Based on record review and staff interview, the facility failed to provide evidence Quality Assessment and Assurance (QAA) meetings were held and required members were in attendance for the first and second quarter of 2023. This had the potential to affect all residents that resided at the facility. Facility census: 106. Findings included: a) QAA Meetings During an interview on 12/12/23 at 9:12 AM, the Administrator reported the facility could not produce the QAA sign-in sheets for the first two quarters of 2023. The Administrator explained she started her position in June 2023. It was also noted the facility had reached out to the previous Administrator for help in locating the sign-in sheets for the first two quarters of 2023 and had received no response.

Based on employee record review and staff interview, the facility failed to ensure nurse aides received the requied annual in-service training to include dementia management and abuse pervention training. This was true for one (1) of five (5) employees records reviewed for sufficient and competent nurse staffing. Resident identifier: #96. Facility census: 106. Findings included: a) Required in-service training During a review of the employee record for Nurse Aide (NA) #96, there was no evidence he had completed the required 12 hour in-services to include dementia management and abuse prevention training. During an intrview with the Human Resource Manager on 12/12/23 at 2:37 PM, he reported he was unable to locate any dementia management and abuse prevention training for NA #96.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and resident 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. Staff failed to don appropriate Personal Protection Equipment (PPE) when providing care for residents placed in Droplet Precautions. These failed practices had the potential to affect more than a limited number of residents who currently reside at the facility. Facility census: 112. Findings included: a) Donning Appropriate Personal Protection Equipment (PPE) A brief general observation tour was conducted on 09/25/23 at 12:05 PM. The following resident rooms were under droplet precautions: -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure residents receiving a shower in the Long Hall Shower Room on [NAME] Court were afforded full visual privacy. The shower curtain was torn in multiple areas and half of the shower curtain was hanging down from the ceiling track. This was a random opportunity for discovery. Facility census: 112. Findings included: a) Shower Curtain Observation on 09/26/23 at 12:00 PM in the Long Hall Shower Room on [NAME] Court found the shower curtain to be torn in multiple areas and half of the shower curtain hanging down from the ceiling track. The Interim Director of Nursing (DON) acknowledged this did not allow a resident receiving a shower to have full visual privacy and stated she would have the issue addressed. The Interim DON stated to her knowledge the Maintenance Staff had not been notified of this issue prior to this observation. During an interview on 09/26/23 at 1:50 PM, the Administrator reported the facility had no documentation that the ripped…

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 upon record review and staff interview, the facility failed to document accurately in the resident's medical record. Resident #102. Facility census 113. Findings include: a) Resident #102 On 09/25/23 a review of Resident #102's skin assessment dated [DATE] at 11:18 a.m., revealed the resident did not have any skin areas noted. However, the resident had documented larva in a wound on 09/11/23. Interview with the Interim Director of Nursing verified the finding and the finding was acknowledged by the Administrator upon exit on 09/26/23 at 5:00 p.m.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for the residents. Fecal matter was not cleaned from the shower room floor following resident showers. This had the potential to affect a limited number of residents. Facility census: 112. Findings included: a) Fecal Matter on the Floor in Shower Room When entering the Short Hall Shower Room on [NAME] Fort Court on 09/26/23 at 12:10 PM, the Interim Director of Nursing (DON) stated, I am sorry. It seems to really smell in here today as she moved two (2) rolling bins with lids to the right to afford entry into the shower room itself. Surveyor and Interim DON then observed fecal matter which had been left on the floor following a resident's shower. The Interim DON stated, Well, that would be why it smells so bad. The Interim DON acknowledged the fecal matter as an infection prevention and immediately went to the Nurses Station to question the staff present if they knew had used 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 ensure the daily posting of nursing staff working was completed and placed in an area accessible to residents and visitors. This had the potential to affect more than a limited number of residents. Facility census: 112. Findings include: a) Staff Posting Observation of the staff posting with the Director of Nursing (DON) at 2:50 PM on 09/12/23 found the staff posting was dated 09/11/23. The DON said she would post current information.

Based on record review and staff interview the facility failed to ensure medical records were complete. Resident #113's medical record did not contain information from psychiatric visits. This was a random opportunity for discovery. Facility census: 112. Findings include: a) Resident #113 At 10:54 AM on 09/13/23, the Director of Nursing confirmed the Resident had tele-med visits with a psychiatrist and the information from the visits were not in the Resident's medical record. The DON provided printed progress notes from visits to the psychiatrist occurring on 10/05/22, 03/27/23 and 06/27/23. There was no indication until today, 09/13/23 that the notes from the visits were obtained prior to surveyor intervention by the facility and provided to the physician for review.