Raleigh Center

Based on record review and staff interview, the facility failed to ensure a resident's Physician Orders for Scope of Treatment (POST) form was signed by the resident's Power of Attorney (POA). This was true for one (1) of three (3) residents reviewed for the care area of advance directives during the long term care survey process. Resident Identifier: #39. Facility Census: 65. Findings include: On 03/16/26 at 2:12 PM, during Resident's #39's electronic medical record review, the POST form was reviewed. A verbal consent was obtained by the POA on 01/19/26. A signed POST form was not in the electronic medical record. The state surveyor requested documentation or records to indicate the POST form had been mailed for the signature to be obtained. No documentation or records to indicate the form had been mailed to be signed or follow-up was attempted for signature until state surveyor intervention. On 03/16/26 at 3:20 PM, the Social Worker confirmed there was no signature on Resident #39's POST form. The Social Worker stated, I did follow-up and she said she would mail it. She has 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 maintain an accident and hazard free environment by leaving a medicine cart unlocked and unattended. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the Long-Term Care Facility. Facility census: 65. Findings include: a) During med pass observation, on 05/14/25 at 8:20 AM, LPN # 47 was observed preparing medicine on the cart, then turned and went into the resident's room leaving the medicine cart unlocked. During an interview on 05/14/25, at 8:26 am with LPN # 47, the LPN stated, I realized when I came out of the room and saw the cart that I left it unlocked. 05/14/25 9:00 AM the administrator confirmed the medication cart should have been locked if not in direct line of cite from the Nurse.

Based on observation and staff interview, the facility failed to ensure food was stored/prepared and served in a sanitary manner, due to items sitting on the floor, an oven not being cleaned, and stacking serving pans and bowls while still wet. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 65. Findings include: a) At approximately 9:30 AM on 5/13/2025 a case of oats and a case of grits were observed sitting on the floor in the dry stock room. Both items were dated for 05/06/25. This was confirmed by [NAME] #56. On 05/13/25 at 9:48 AM the following observations were observed, five (5) trays with blue serving bowls were sitting near the area where food is plated. The bowls were still wet. Further observations revealed the large, medium, and small pans that go on the steam table and holds the food being served were stacked on a shelf near the steam table; after pulling two pans from each stack, all pans pulled for observations was wet. When holding the pans up a steady…

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 the facility policy, the facility failed to ensure the residents had a comfortable, homelike environment. Meal tray service without removal of tray, and staff storing trash bags in residents room on residents hand towel rack. This was a random opportunity for discovery and had the ability to affect a limited number of residents. Resident identifier: Meal tray service without removal of tray and staff storing trash bags in residents room on residents hand towel rack. Facility census: 63. Findings include: a) Meal tray service without removal of tray. During an observation of the serving of the meal trays on 08/25/24 at approximately 11:50 AM the trays were being placed on the table for the residents and not being removed. During an interview with the Assistant Director of Nursing (ADON) on 08/25/24 at approximately 11:53 AM the ADON acknowledged the trays were not being removed from the table and agreed that the trays should have been removed. During an interview with the Administrator on 08/25/24 at approximately 12:00 PM, the administrator…

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 resident and staff interview, the facility failed to ensure residents of the facility were free from abuse and neglect due to a Nurse Aide (NA) neglecting their duties, not serving Resident #2 lunch in a timely manner, and ensuring other residents were free from abuse by Resident #16. These were random opportunities for discovery. Resident identifiers: #2, #6, #24, #16. Facility census: 63. Findings include: a) Nurse Aide (NA) #39 At approximately 11:30 PM on 08/26/24, NA #39 was observed sitting in the area labeled Resident Sitting Area on her cell phone while a call light in her assigned area was ringing. NA #39 continued to look down at her phone and not answer the call light until approximately 11:38 PM. At approximately 11:42 PM, NA #39 returned from the room to the Resident Sitting Area, set back down in the chair, and resumed usage of her cell phone. At approximately 11:58 PM, a call light was pressed in room [ROOM NUMBER], another assigned room for NA #39. The call light rang…

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 the environment was free of accident hazards. Residents fall mats were preventing a resident to safely make it to his bed in his wheelchair, oxygen was stored in resident sitting area with no signage, and medications were not stored in a safe manner. These were random opportunities for discovery during the long term care survey process and had the ability to affect a more than a limited number of residents currently resding in the facility. Identifier: Resident #26. Facility Census.: 63. Findings include: a) Resident #26 fall mats. During a tour of the facility on 08/25/24 at approximately 2:15 PM, Resident #26 was observed attempting to wheel himself in his wheelchair to his side of the room by the window. The resident stated, he was unable to safely go to his side because he can't get over the fall mats with his wheelchair. During this observation, fall mats were identified on the left and right side of the first bed entering the room and this resident was sitting in his wheel chair to 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 resident and staff interviews, the facility failed to offer snacks to residents who wished to revieve a snack at night time, and failed to ensure all ordered snacks were delivered to residents at night time. This was a random opportunity for discovery. Resident identifiers: #24, #28, #33, #51, #52, #22, #58. Facility census: 63. Findings included: a) Resident #24 At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, a sandwich was found in the refrigerator with a label dated 08/24/24 S3 (third shift, night shift), with the resident's name on it. A review of the task sheet for snacks offered for Resident #24 indicated Not Applicable was selected under question 2, titled Snack Accepted. At approximately 10:45 AM, an interview with the District Dietary Manager (DDM) confirmed the resident was ordered the snack, the S3 on the label meant third shift, or night shift, and they were not passed. At approximately 11:00 AM on 08/25/24, an interview was conducted with the Dietary Manager (DM) regarding snacks. The DM stated 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 food was stored, prepared, and served in a sanitary manner. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 63. Findings include: a) Kitchen Tour At approximately 9:45 AM on 08/25/24, during the initial tour of the kitchen, a jar of apple sauce was discovered in the reach-in refrigerator. The apple sauce had a discard date of 7/19/24 on it and was still in use. [NAME] #82 acknowledged the apple sauce, discard date, and that it was still in use. At approximately 11:00 AM, an interview was conducted with the Dietary Manager (DM) regarding the apple sauce. During the interview, the apple sauce was still in the refrigerator and acknowledged by the DM. b) Dining Observation On 08/25/24 at 12:00 PM, the Assistant Director of Nursing (ADON) #55 was observed assisting a resident with her fork, food and drink while the resident was eating. The ADON then turned and picked up a clean tray to serve another…

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 ensure each resident was treated with dignity. This was a random opportunity for discovery. Resident identifier: #12. Facility Census: 63. Findings include: a) Resident #12 On 08/25/24 at 11:40 AM, during an interview with Resident #12, she reported when she pressed her call light it often took staff up to 20 minutes to answer. Resident #12 had a privately paid care giver in the room with her who agreed with the statement of the resident. Resident #12 reported, if she asked to go to the bathroom, she required the use of a lift to put her in the bed to use the bedpan, and staff would make her go to bed for the remainder of the day and would not let her get back up until the following day. On 08/27/24 at 2:00 PM, observed Nurse Aide (NA) #51 exit Resident #12's room with a lift. She reported she had just put the resident on the bedpan. She stated, Resident #12 has a private sitter due to blindness. She stated the resident gets up out of bed around 10:30 AM, will do her therapy and eat. She then…

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

Based on observation, staff interview and resident interview, the facility to ensure call light was placed in a position which would allow the resident to use it if she needed to call for help. This is true for one (1) of 22 sampled residents reviewed during the long term care survey process. Resident Identifier: Resident #35. Facility Census: 63. Findings include: a) On 08/26/24 at 10:55 AM, an observation found Resident #35 resting in her bed. Her call light button was clipped to the left side of her bed and was hanging down toward the floor. Resident #35 reported she was not able to use her left hand at all and was not able to use the call bell when it is clipped to the left side of her bed. On 08/26/24 at 11:00 AM, when Licensed Practical Nurse (LPN) #17 came into the room, she acknowledged the light was clipped to the non dominant side of the resident and moved it to the right side of the bed and placed it in HER dominant hand. She stated, resident had been working with physical therapy to try to strengthen the left hand. On 08/29/24 at 12:55 PM, The Director of Nursing (DON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to implement the policy and procedure entitled, Abuse Prohibition. This was a random opportunity for discovery. Resident identifiers: Resident #16, #6 and #24. Facility census 63. Findings include: c) Resident #16 On 08/27/24 at approximately 12:00 PM, a record review was conducted for Resident #16. During the record review, Resident #16 was noted to have the following diagnoses: Anxiety disorder, unspecified, date 02/10/17 Insomnia, unspecified, date 03/25/17 Major depressive disorder, unspecified, date 02/10/17 Schizoaffective disorder, bipolar type, date 05/17/24 Psychotic disorder with hallucinations, date 12/15/23 Unspecified dementia, unspecified severity, date 02/10/27 Alzheimer's disease, unspecified, date 12/31.20 Vascular dementia with behavioral disturbance, date 12/31/20 Resident #16 was also noted to be receiving the following medications: Clonazepam 0.5 milligram (MG) 1 (one) tablet by mouth three times a day Cymbalta 60 MG 1 (one)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to report an allegation of abuse. This was a random opportunity for discovery. Resident identifiers: #16, #6, #24. Facility census: 63. Findings included: a) Resident #16 On 08/27/24 at approximately 12:00 PM, a record review was conducted for Resident #16. During the record review, Resident #16 was noted to have the following diagnoses: Anxiety disorder, unspecified, date 02/10/17 Insomnia, unspecified, date 03/25/17 Major depressive disorder, unspecified, date 02/10/17 Schizoaffective disorder, bipolar type, date 05/17/24 Psychotic disorder with hallucinations, date 12/15/23 Unspecified dementia, unspecified severity, date 02/10/17 Alzheimer's disease, unspecified, date 12/31/20 Vascular dementia with behavioral disturbance, date 12/31/20 Resident #16 was also noted to be receiving the following medications: Clonazepam 0.5 milligram (MG) 1 (one) tablet by mouth three times a day Cymbalta 60 MG 1 (one) capsule by mouth one time a day Nuplaid 34 MG 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, staff interview and the facility policy and procedure review, the facility failed to provide evidence that all alleged violations were thoroughly investigated, and that corrective action was taken. Residents level of care was not reviewed for possible discrepancies and statements were not obtain from all relevant staff members. This was true for one (1) of five (5) residents reviewed for abuse during the long terms survey process. Resident identifier: #4. Facility census: 63. Findings Include: a) Resident #4 On 08/29/24 at approximately 2:40 PM during the review of the facility investigation completed for the incident which occurred on 06/01/24 it was identified that statements from all staff who had cared for the resident during this time had not been obtained. It was further identified Resident #4's radiology report results states Resident #4 had a moderately displaced impaction fracture of the distal femur metaphysis. The facility did follow up with the medical treatment 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 medical record review and staff interview the facility failed to accurately complete a Minimum Data Set (MDS) when Resident #61 was discharged home. This was true for one (1) of 22 residents reviewed during the long term care survey process. Resident Identifier: Resident #61. Facility census: 63. Findings include: a) Resident #61 During a medical record review on 08/26/24 at 1:49 PM a review of a nursing note revealed the following [typed as written] Resident discharging home, discharge transition packet and medications discussed. Belongings packed up and sent with resident. All questions answered satisfactorily, medications called in to (Name of Local Pharmacy). Son at bedside to transport. During a further review the facility discharge plan documentation's also identified the resident discharged to home. During a medical record review of the MDS dated [DATE] it is identified in Section A. 2105 that the resident discharged to a short-term General Hospital. During 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 medical record review and staff interview the facility failed to develop and implement the individualized comprehensive care plan for depression. This was true for one (1) of 22 residents reviewed during the long term care survey process. Resident identifier: #26. Facility census: 63. Findings include: a) Resident #26 During a medical record review for Resident #26 on 08/27/24 at 12:40 PM it was identified the Resident had a physician order for Escitalopram Oxalate Tablet 20 MG to be given one (1) tablet by mouth for a diagnosis of depression. A review of Resident #26's care plan found it did not include a individualized comprehensive care plan that addressed the diagnosis of depression. During an interview with the Director of Nursing (DON), on 08/27/24 at 1:54 PM, the DON agreed the individual comprehensive care plan for the diagnosis of depression had not be developed for Resident #26.

Based on observation, record review and staff interview the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to provide care according to physicians orders. This was a random opportunity for discovery during the Long Term Care Survey Process. Resident identifiers: Resident #15 and Resident #25. Facility census: 63. Findings include: a) Resident #15 On 08/26/24 at approximately 9:00 AM, a record review was conducted for Resident #15 revealing the following diagnoses: Hemiplegia and heiparesis following unspecified cardiovascular disease affecting non-dominate side dated as admitting diagnosis. Epilepsy, unspecified, date 05/18/18 Cerebral palsy, date 05/07/18 Nontraumatic subdural hemorrhage, unspecified, date 05/07/18 Personal history of traumatic brain injury, date 05/07/18 Unspecified convulsions, date 05/07/18 In addition, Resident #15 had a physicians order to wear a helmet when out of bed and an optifoam to head for breakdown prevention. At that time, the following care plan was noted in reference 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 timely act upon a Medication Regimen Review (MRR) of a high-risk medication. This was true for 1 (one) of 5 (five) residents reviewed for the care area of unnecessary medications during the Long-Term Care Survey Process. Resident identifier: Resident #16. Facility census 63. Findings include: a) Resident #16 On 08/27/24 at approximately 12:00 PM, a record review was conducted for Resident #16. During the record review, Resident #16 was noted to have the following diagnoses: Anxiety disorder, unspecified, date 02/10/17 Insomnia, unspecified, date 03/25/17 Major depressive disorder, unspecified, date 02/10/17 Schizoaffective disorder, bipolar type, date 05/17/24 Psychotic disorder with hallucinations, date 12/15/23 Unspecified dementia, unspecified severity, date 02/10/17 Alzheimer ' s disease, unspecified, date 12/31/20 Vascular dementia with behavioral disturbance, date 12/31/20 Resident #16 was also noted to be receiving the following medications: Clonazepam 0.5 milligram (MG) 1 (one) tablet by mouth three times a…

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

Based on observation, record review, and staff interview, the facility failed to ensure Resident #24 and #28 were served the correct diet to meet their needs. This was a random opportunity for discovery. Resident identifiers: #24, #28. Facility census: 63. Findings included: a) Nourishment Room At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, two (2) bologna sandwiches, with labels for snacks from the previous night shift, were discovered with the names of Resident #24 and #28 on them. Upon further inspection, the labels for both sandwiches read Peanut Butter and Jelly and listed both residents' diets as advanced. At approximately 10:45 AM, an interview was conducted with the Dietary District Manager (DDM) concerning the diets listed on the sandwiches, the type of sandwich indicated by the labels, and the actual sandwich that was served. The DDM confirmed the labels for both Residents #24 and #28 stated Peanut Butter and Jelly and listed both diets as advanced. The DDM stated neither Resident #24 nor #28 should have received a bologna…

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 garbage and refuse was disposed of properly. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents residing in the facility. Facility census: 63. Findings included: a) At approximately 10:00 AM on 08/25/24, during a tour of the facility, the dumpster was observed with the lid and door open with debris (food particles and trash) laying all around it, on the ground. Gloves and masks were observed laying on the ground around the dumpster as well. Housekeeper #88 acknowledged the state of the dumpster and the ground around it. The Director of Nursing (DON) arrived at the facility during this time and also acknowledged the dumpster.

According to record review and resident and staff interviews, the facility failed to accurately complete medical records pertaining to blood pressures for Resident #45 and a diagnosis of depression for Resident #26. This was a random opportunity for discovery. Resident identifiers: #45, #26. Facility 63. Findings include: A) Resident #45 At approximately 10:30 AM on 08/29/24, during record review pertaining to Resident #45's dialysis, it was discovered the facility was documenting blood pressures in the resident's left arm, which she has orders not to, due to having a fistula in her left arm. The following dates were documented as times the resident's blood pressure was taken in her left arm: 10/07/2023- Three (3) times 10/10/2023 10/14/2023 10/28/2023 11/22/2023- Three (3) times 11/29/2023 11/30/2023 12/06/2023 12/09/2023 12/12/2023 12/20/2023 01/18/2024 01/25/2024 02/08/2024 02/18/2024 02/21/2024 03/13/2024 05/13/2024 05/14/2024 05/20/2024 05/22/2024 06/17/2024 06/27/2024 06/29/2024 At approximately 10:45 AM an interview was conducted with the Director of Nursing (DON) regarding…

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 store respiratory equipment at bedside in a sanitary manner according to professional standards of care. This was a random opportunities for discovery. Resident Identifier: #219, #3, #27 Facility Census: 63 Findings included: a) Resident #219 During the initial interview process of the survey it was discovered that Resident #219 had a Bi-Pap at bed side that was not stored in a sanitary manner. The machine was on the bedside table with the tubing draped across the bedside table. There was nothing covering the Bi-Pap machine or tubing. The appropriate plastic storage bag was on the floor. This was confirmed with Licensed Practical Nurse # 9. b) Resident #3 During the initial interview process of the survey it was discovered that Resident #3 had a nebulizer machine at bed side that was not stored in a sanitary manner. The machine was on the bedside table with the tubing draped across the machine. There was nothing covering them for protection. There…

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 interview the facility failed to ensure a complete and accurate medical record. 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 was true for three (3) of 17 residents reviewed for the Long-Term Care Survey Process. Resident Identifiers: #44, #66, and #8. Facility Census: 63. Findings included: a) Resident #44 A medical record review on 03/06/23 at 1:47 PM, revealed the POST form for Resident #44 noted no medically assisted nutritional status and no signature of the person participating or assisting the resident with the completion of the POST form. An interview with the Licensed Social Worker on 03/07/23 at 10:19 AM, verified the resident's wishes for any medically assisted nutrition was not addressed and there was no signature for the person participating or assisting with the completion of the POST form. b) Resident #8 Review of Resident #8's medical records showed a Physician Orders for Scope of Treatment (POST)…

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

Based on record review, resident interview, and staff interview, the facility failed to develop and/or implement the comprehensive care plan. Resident #40's comprehensive care plan was not developed in the area of shoulder pain. Resident #8's care plan was not implemented in the area of nutrition. This deficient practice had the potential to affect two (2) of 17 residents reviewed in the long-term care survey sample. Resident identifiers: #40, #8. Facility census: 63. a) Resident #40 During an interview on 03/06/23 at 12:41 PM, Resident #40 reported bilateral shoulder pain. She stated she was receiving pain medication but still had shoulder pain, particularly in the morning when her clothing was changed. Review of Resident #40's medical records revealed she had a diagnosis of osteoarthritis and a history of right humerus fracture. The resident had received bilateral shoulder steroid injections at an orthopedic office on 11/9/22, 12/14/22, and 2/15/23. Review of Resident #40's comprehensive care plan showed the following focus related to pain, Resident exhibits or is at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview and policy procedures the facility failed to provide treatment and care in accordance with professional standards of practice. This was true for two (2) of three (3) records reviewed for accidents. Findings Included: Resident #28 a) On 3/6/23 at 1:04 PM record review shows that Resident #28 had a fall on 2/25/23. The fall was unwitnessed and he presented with a swollen right hand that required an x-ray (negative). According to the facility Falls Management Policy dated 9/15/01, Revision date 6/15/22 Any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neuro check, per policy According to the Director of Nursing (DON) on 3/6/23 at 3:25 PM, the neurological checks are to be done in the following sequence. Every fifteen (15) minutes X's two (2) hours, Every thrifty (30) minutes X's two (2) hours. Every hour X's four (4) hours and every eight (8) hours X sixty-four (64)…

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

Based on observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #48 did not have fall mats to her floor as ordered by the physician. This was a random opportunity for discovery. Resident identifier: #48. Facility census: 63. Findings included: a) Resident #48 On 03/06/23 at 12:35 PM, Resident #48 was observed lying in bed with fall mats on the floor on both sides of her bad. On 03/08/23 at 8:45 AM, Resident #48 was observed lying in bed. The fall mats were propped up against the wall and not on the floor. Review of Resident #48's physician's orders showed an order written on 06/11/21 for bilateral mats to bedside while the resident was in bed. Review of Resident #48's medical records showed the resident's most recent fall had occurred on 01/03/23. On 03/08/23 at 9:10 AM, Nursing Assistant (NA) #35 confirmed Resident #48's floor mats were not properly placed on the floor. No further information was provided through the completion of the survey process. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the pharmacist failed to report a medication irregularity for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #8. Facility census: 63. Findings included: a) Resident #8 Review of Resident #8's medical records showed the resident was admitted from the hospital on [DATE]. The resident's hospital discharge instructions included an order for the medication Buspar (buspirone hydrochloride) 10 mg twice a day for anxiety. The resident had a diagnosis of end stage renal disease and was receiving dialysis treatments. Further review of Resident #8's medical records showed a pharmacy medication review was performed on 08/08/23. The medication review stated, Clinically urgent recommendation: prompt response requested. [Resident's name] receives Buspar 10 mg twice daily for anxiety and requires dialysis. The use of buspirone hydrochloride is contraindicated in individuals receiving dialysis. Recommendation: Please evaluate…

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 controlled substance count was completed and documented by two (2) licensed nurses during shift change. This was a random opportunity for discovery. Facility Census: 63. Findings Included: a) Medication Administration On 03/07/23 at 8:15 AM, a review of the controlled substances count was completed. The following dates were not signed by two (2) nurses during shift change and the narcotic count was not completed: --02/07/23 off going nurse 7:00 AM --02/08/23 off going nurse 7:00 AM --02/09/23 on coming nurse 7:00 AM --02/11/23 on coming nurse 7:00 AM --02/11/23 off going nurse 7:00 PM --02/17/23 on coming nurse 7:00 AM --02/17/23 off going nurse 7:00 PM --02/23/23 on coming nurse 7:00 PM On 03/07/23 at 8:20 AM, licensed practical nurse (LPN) #60 confirmed the above dates were not signed by two (2) nurses at the end of each shift. On 03/07/23 at 8:25 AM, Assistant Director of Nursing (ADON) #61 was notified and confirmed the dates were not signed by two (2) nurses and the pages were not complete. b) Policy…

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 kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the freezer floor needed to be cleaned and the beverage dispenser was not draining properly. This had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 63. Findings included: a) Kitchen tour During the kitchen tour on 03/06/23 at 10:50 AM, it was discovered the walk-in freezer had six (6) individual cups of ice cream on the floor and also the floor needed to be cleaned. The tubing for the beverage dispenser wand was draining into the hand washing sink. On 03/06/23 at 11:20 AM, the Dietary Manager on verified the floor to the walk-in freezer needed to be cleaned and the beverage dispenser machine should not have tubing draining into the hand washing sink. .