Brightwood Center

Based on record review, and interview, the facility failed to perform a thorough investigation and failed to take the necessary steps to correct the alleged violation. Resident identifier: #265. Facility Census: 111. Findings Include: a) Resident #265 A Facility Reported Incident (FRI) submitted on 10/21/24 at 3:15 Pm stated that Resident #265 had alleged that that she had to wait for three hours on 10/20/24 for incontinence care. The facility had performed an investigation and found the allegation unsubstantiated. Resident #265 was no longer at the facility. Record review on 05/22/25 at 10:00 AM revealed that Resident #265 had capacity and was classified as Dependent. Further review of records revealed a statement on 10/28/24 by Resident #74, the roommate of Resident #265, who stated that she had witnessed Resident #265 experience extended wait times for assistance on multiple occasions. Resident #74 also corroborated Resident #265's account of the night of 10/20/24. Record review also revealed that Resident #74 had capacity. Another statement by Physical Therapist #130 on 10/21/24…

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 record review and staff interview, the facility failed to implement the care plan for Resident #110 by failing to implement non-pharmacological interventions for pain and by failing to identify an acceptable level of pain. This was true for one (1) of 30 care plans reviewed during the survey process. Resident identifier: #110. Facility census: 111. a) Resident #110 During a review of Resident #110's care plan on 5/19/2025, the following was noted: Focus- (Resident #110's name) is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. Date initiated-05/02/25. Goal- (Resident #110's name) will improve current level of function in:bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting by next review as evidenced by improved ADL scores. Date initiated- 05/02/25. Interventions- Monitor for pain. Attempt non-pharmacological interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to revise a care plan for a resident with ordered adaptive equipment. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: #100. Facility Census: 111. Findings Included: a) On 05/19/25 at 05:44 PM, Resident #100 was given his drink during the dinner meal in a Sip-A-Mug cup. Resident #100's care plan stated to provide a [NAME] Cup. On 05/21/2025 at 03:00 PM, the Director of Nursing (DON) stated they changed the order yesterday for a Sip-A-Mug due to the straw used with a [NAME] Cup. The resident is currently ordered honey consistency thickened liquids. The DON confirmed the resident's care plan stated to provide a [NAME] Cup. b) The facility's policy and procedure for Assistive Devices stated, Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's/patient's ability to eat or drink…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interview, the facility failed to ensure dependent residents received required assistance with Activities of Daily Living (ADLs), by failing to ensure Resident #110 was assisted to bed and Resident #42 received assistance with toileting and incontinence care. This was true for two (2) of five (5) residents reviewed for ADL care during the survey process. Resident identifiers: #110, #42. Facility census: 111. Findings include: A) Resident #110 At approximately 2:50 PM on 5/19/25, Resident #110 was observed in his geri chair, facing the wall, between his and his roommate's beds. Resident #110 was attempting to sleep, curled up with his head resting on his left arm, on the left arm rest of his chair. At approximately 3:25 PM, multiple staff members had been witnessed walking by, and looking into, the resident's room, noticing him in the chair. At one point, staff walked in and pulled his roommate's curtain because he was asleep. At approximately 3:30 PM,…

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 interviews and record reviews, the facility failed to ensure that the environment over which it had control was free from accident hazards. Namely, the facility failed to identify risks and hazards related to the resident's beds and failed to perform preventive maintenance to ensure that the beds were safe and functional. In addition, the facility's preventive maintenance program failed to identify the risks posed by defective or broken bed wheels and failed to include inspection, assessment, and maintenance of the bed wheels in the facility's preventive maintenance policy. Resident Identifier: Resident #24. Facility Census: 111. Findings Include: a) Resident #24 A Facility Reported Incident (FRI) on 04/10/25 stated that Resident #24 was injured when the resident's bed moved while the nursing assistant was providing care. Resident struck his head against the stand on the left side of the bed. The resident sustained two lacerations to the top of his head. The resident was assessed, and neuro checks were implemented. Neuro checks were found to be within normal limits.…

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 resident and staff interview, the facility failed to control pain for Resident #110 by failing to implement non-pharmacological interventions for pain and by failing to identify an acceptable level of pain. This was true for one (1) of four (4) residents reviewed for pain during the survey process. Resident identifier: #110. Facility census: 111. Findings include: a) Resident #110 At approximately 3:30 PM, an interview was conducted with Resident #110 while he was in his chair, beside his bed. The resident stated he was in pain at the time, and would rate his pain at an eight (8) on a scale of one (1) to 10. The resident stated he would much rather be in his bed than the chair and stated he had asked staff to put him in his chair already, but was told they would be back to assist him. The resident stated he was in constant pain and did not feel like it was controlled. Review of the Resident's Minimum Data Set (MDS) dated [DATE], revealed the resident suffered frequent pain and it…

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

Based on record review and resident and staff interview, the facility failed to ensure Medically related social services were provided to Resident #51, related to a desired transfer to another facility. This is true for one (1) of one (1) residents reviewed for medically related social services during the survey process. Resident Identifier: #51. Facility census: 111. Findings include a) Resident #51 At approximately 2:40 PM on 05/19/25, an interview was conducted with Resident #51. During the interview, Resident #51 stated he would like to transfer to a facility in Maryland, but had trouble getting assistance from the facility. He states he reached out to his sister and she was looking but she doesn't know what to look for. Resident #51 states he told the social worker at the facility but she hasn't got back to me about it. During review of the resident's electronic health record, it was noted the facility has one note from September 2023 where they inquired with one facility about a transfer to Maryland. The note stated they were awaiting a response. No response or follow up notes…

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 interview the facility failed to honor resident preferences for meals or provide an alternative vegetable. This was a random opportunity for discovery. Resident Identifiers: #75 and #80. Facility Census: #111 Findings include: a) Resident #75 On 05/19/25 at 5:34 PM an observation was made of Nurse Aide (NA) #110 assisting Resident #75 with her meal. Resident #75 was heard to say, Do not give me any of these peas. Nurse Aide #110 replied, I know, I won't give you any. Resident #75 replied and don't get them mixed in my other food. When this surveyor ask Resident #75 don't you like peas? She stated, No and they know it. Observation of Resident #75's meal ticket did not have peas listed as being served. It listed the following: 4 Tbsp creamed peanut butter & jelly #10 scoop Ground meat butter crumb topped fish fillet with 1 Tbsp lemon mayonnaise 1/2 cup Au Gratin Potatoes 1 each ice cream variety 1 each frosted brownie 8 ox 2% milk 1 each dinner roll 1 each margarine It was confirmed with Nurse Aide#110 at that time that Resident #75 did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to provide adaptive devices during a meal. This was a random opportunity for discovery. Resident Identifiers: #89 and #100. Facility Census: #111 Findings Include: a) Resident #89 On 5/19/25 at 5:25 PM observation at the dinner meal found Resident #89 had a meal ticket that consisted of a sip a mug. She did not have a sip a mug provided with her meal. This was confirmed on 5/19/25 at 5:30 PM with Nurse Aide (NA) #110 at which time she commented I don't know if she still has an order for the sip mug. Review of her physicians orders reads: Regular/Liberalized diet Regular texture, standard thin liquids consistency, sip a mug per residents request. Her care plan read: Resident at increased nutritional risk d/t ETOH abuse, COPD, cerebral aneurysm may affect nutritional status/meal intake. Advanced age. significant weight loss from 2/7/25 - 3/7/25, decreased meal intake, She is forgetting to eat and needs cued. Patient will consume adequate…

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 accurately complete a smoking assessment for Resident #32. This was true for one (1) of five (5) residents reviewed for smoking. Resident identifier: #32. Facility census: 111. Findings include: a) Resident #32 During a review of Resident #32's electronic health record on 05/21/25, it was noted a smoking assessment was completed for the resident on 04/29/25. The last question of the smoking assessment had three (3) choices to choose from. Those choices were the resident was allowed to smoke independently, with assistance, or not at all. This question was left blank, with no determination made regarding the resident's smoking status. The incomplete assessment was acknowledged by the Director of Nursing (DON) at approximately 3:00 PM on 05/21/25.

Based on record review and resident and staff interview, the facility failed to deploy sufficient staff to meet resident care needs by failing to provide Activities of daily living (ADL) care for Residents #28, 24, and 81, while failing to meet state minimum staffing numbers on reviewed days. This has the potential to affect more than a limited number of residents. Resident identifiers: 28, 24, 81. Facility census: 109 Findings include: A) Resident #28 At approximately 12:55 PM on 04/23/24, an interview was conducted with Resident #28. Resident #28 stated he had requested to be shaved twice a week. Resident #28 stated he gets a shower one day a week and is supposed to be shaved during the shower,plus an additional day a week, however, Resident #28 states Sometimes they'll say they don't have time to shave me. Resident #28 had not been shaved at this time and stated they had not been shaved in at least a week. At approximately 11:20 AM on 04/24/24, an interview was conducted with Nurse Aide (NA) #103 concerning shaving Resident #28. NA #103 stated, We try to shave everyone 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 observation and staff interview, the facility failed to provide dignified dining experiences for residents eating in the dining room and their rooms. The facility failed to serve all residents seated at the same table at the same time. The facility also failed to sit down while feeding Resident #100 and #108. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: 100, 108. Facility census: 109. Findings include: a) Coral Dining Room At approximately 5:20 PM on 04/22/24, facility staff were observed in the Coral Dining Room serving dinner. During the dinner service, staff were observed serving residents at different tables instead of one table at a time, leaving residents to wait as long as ten (10) minutes for their tray, after the first resident was served at their table. The Director of Nursing (DON) was present in the dining room at the time of service and acknowledged witnessing the staff serving different tables. b) 300 Hall At approximately 5:46 PM on 04/22/24, dinner service was…

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

Based on record review and staff interview the facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner, complete neurological checks or accurately provide pain management. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Resident Identifier: #27 and #80. Facility census: 109. Findings include: a) RSV immunization During a review of the facility documents regarding immunizations, found zero (0) out of 109 residents have been provided educational information about the risk and benefits of receiving the RSV vaccination. On 04/25/24 at 11:09 AM, Infection Preventionist (IP) stated the facility has not started giving the information or offering the vaccine to anyone yet. b) The Centers for Disease Control and Prevention (CDC) Respiratory syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older…

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 complete temperature logs for food items being maintained on the steam table at meal service. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 109. Findings include: At approximately 1:25 PM on 04/22/24, during the initial tour of the kitchen, service line temperature logs were reviewed for the month of April. During this review, it was noted the service line temperature log for 04/15/24 was not completed for any meals that day, while the service line temperature log was not completed for dinner service on 04/16/24. The Dietary Manager (DM) confirmed the temperature logs were incomplete for the preceding dates and stated We ' re not perfect, we are going to miss some things.

Based on resident interview, resident council meeting, and anonymous staff interviews, the facility failed to offer residents a nourishing evening/bedtime snack. This failed practice had the potential to affect an unlimited number of residents. Resident identifiers: #80, #48, #28, #13, #40, #72, #66, #48, #63, #50, #105, #78, #53, #55, #68, #19, and #11. Facility census: 109. a) Evening/Bedtime Snack During an interview on 04/22/24 at 3:34 PM, Resident #80 reported she was not offered an evening snack. A subsequent review of Resident #80's Significant Change in Status minimum data set (MDS), with an assessment reference date (ARD) of 03/29/24, indicated resident's Brief Interview for Mental Status (BIMS) score was 15. This score signified the resident was cognitively intact. During a resident council meeting, on 04/23/24 at 10:40 AM, the 18 residents in attendance reported they were not offered evening/bedtime snacks but would like them if they were offered. One (1) resident stated she knew some residents had a physician order to receive a snack in the evening and those snacks were…

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

Based on observation and staff interview, the facility failed to store food in a safe and sanitary manner, and maintain sanitary equipment. This has the ability to affect more than a limited number of residents. Facility census: 109 Findings include: A) Salad At approximately 1:00 PM on 04/22/24, a tour was conducted of the kitchen in the facility. During the tour, three salads, in plastic bowls with lids, were found in the reach in refrigerator without dates on them. The Dietary Manager (DM) acknowledged and confirmed the salads had been prepared the previous week and had no date on them. B) Sauerkraut At approximately 1:02 PM on 04/22/24, during the tour of the facility's kitchen, a plastic container of sauerkraut was found in the walk in refrigerator without a date on it. The DM acknowledged and confirmed the sauerkraut had been prepared the previous week and had no date on it. C) Apple Sauce At approximately 1:12 PM on 04/22/24 during a tour of the nourishment rooms, a jar of opened apple sauce was found in the Nourishment Room A refrigerator with the date of 04/01/24 with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to maintain proper infection control practices by failing to ensure soiled specimen collection devices were not left in rooms, resident trays were not placed in nourishment room refrigerators, dirty linens were not left in the floor, linen carts were not uncovered, and that items that could contaminate clean linen were not placed on linen carts. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 109. Findings include: A) Nourishment Room A At approximately 1:12 PM on 04/22/24, during a tour of the nourishment room A, a resident's lunch tray from their room was found to be placed in the nourishment room refrigerator. The Dietary Manager (DM) was present during the tour and stated I don't know why that's in there. They know they are not supposed to put those in there because it causes an issue. B) room [ROOM NUMBER] At approximately 2:15 PM on 04/22/24, during a tour…

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, and staff interview the facility failed to honor a Resident choice for bathing. This affected one of one reviewed for choices, during the long-term care survey. Resident identifiers #66. Census 109. Findings include: a) Resident #66 During an interview with Resident #66 on 04/23/23 at 12:21 PM, he stated he only receives one (1) shower a week. He stated, he would like to have at least two showers a week. Medical record review revealed, Resident #66's shower schedule is Monday and Thursdays and AS needed per Residents choice. A review of the Quarterly Minimum Data Set (MDS) from 03/07/24, found the resident's brief interview for mental status was fifteen (15). MDS Section E (Behaviors) also indicated Resident #66 does not reject care such as ADL Care, medications, or treatments. A continued review of Resident #66's ADL documentation found from 03/26/24 to 04/24/24: he only received five showers. On 04/24/24 at 4:45 PM the Director of Nursing verified Resident #66 did not receive his showers as scheduled.

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 two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident Identifiers: #48 and #216. Facility census: 109 Findings include a) Beneficiary Notice Review On 04/24/24 at 3:18 PM, a review was completed regarding the beneficiary protection notification liability notices given for the following two (2) residents who remained at the facility following their last covered day of Medicare Part A services: - Resident #24 began Medicare Part A skilled services on 01/17/24. The last covered day of Part A service was 02/17/24. Notice of Medicare Non-Coverage (NOMNC) was signed and dated on 02/15/24. There was no evidence a SNF ABN form had been provided and signed. - Resident #216 began Medicare Part A skilled service…

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 safeguard the privacy of Resident #88's medical record. This was true for one (1) of 12 residents reviewed during medication administration. Resident #88. Facility Census: 109. Findings Include: a) Resident #88 On 04/24/24 at 1:46 PM, an observation was made during medication administration on the B hall. Licensed Practical Nurse (LPN) #38 was standing at the medication cart. LPN #38 was preparing to administer medication to Resident #88. At this time, Resident #12 requested LPN #38 assist her to the bathroom. Upon walking away from the medication cart, LPN #38 left the computer screen visible to anyone within the vicinity of the medication cart. On 04/24/24 at 1:51 PM, LPN #38 returned to the medication cart. LPN #38 was advised the computer screen was visible while Resident #12 was being assisted. LPN #38 stated, I'm sorry I forgot to lock my computer screen. On 04/24/24 at approximately 5:00 PM, the Director of Nursing (DON) was notified of the incident during medication administration. The DON stated, thank you 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, the facility failed to provide an accurate Minimum Data Set (MDS) assessment for Resident #108. This was true for two (2) of 24 residents reviewed during the survey process. Resident Identifier: #108. Facility Census: 109. Findings Include: a) Resident #108 On 04/23/24 at 10:00 AM, the admission MDS dated [DATE] was reviewed. The review found Section O entitled Special Treatments, Procedures and Programs was incorrect regarding J1. Dialysis. Section J1 did not indicate the resident was receiving dialysis treatments. On 04/23/24 at 10:19 AM, Clinical Reimbursement Coordinator (CRC) #65 was notified. CRC #65 confirmed section J1 was incorrect. CRC #65 stated, we can send in a correction right away.

Based on medical record review and staff interview, the facility failed to update the care plan to reflect a change in activities of daily living (ADL) status for resident #80 and a change in Resident #108's need for assistance during meals. These were random opportunities for discovery. Resident identifiers: #80 and #108. Facility census: 109. Findings include: a) Resident #80 A medical record review was completed on 04/24/24 at 2:33 PM. Review of Resident #80's care plan revealed a discrepancy in the amount of assistance resident required for the following ADLs: -Toileting -Bed Mobility -Transfers The FOCUS section of resident's care plan stated resident required assistance/was dependent for the ADLS mentioned above. However, the INTERVENTIONS section of resident's care plan stated resident was independent in all three (3) areas. During an interview on 04/25/24 at 9:36 AM, the Director of Nursing (DON) reported Resident #80 was independent in the areas of toileting, bed mobility, and transfers. The DON acknowledged the FOCUS section had not been updated to reflect the resident's…

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

Based on observation, record review, and resident and staff interview, the facility failed to provide a resident who is unable to carry out activities of daily living (ADL)s the necessary services to maintain good grooming for Resident #28, by not shaving the resident twice a week, as requested by the resident, and by not providing nail care and assisting Resident #24 with meals. This was true for two (2) of four (4) residents reviewed for ADL care. Resident identifiers: 28, 24. Census 109. Findings include: A) Resident #28 At approximately 12:55 PM on 04/23/24 an interview was conducted with Resident #28. Resident #28 stated he had requested to be shaved twice a week. Resident #28 stated he gets a shower one day a week and is supposed to be shaved during the shower,plus an additional day a week, however, Resident #28 states Sometimes they'll say they don't have time to shave me. Resident #28 had not been shaved at this time and stated they had not been shaved in at least a week. At approximately 11:20 AM on 04/24/24, an interview was conducted with Nurse Aide (NA) #103 concerning…

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 maintain a safe and accident free environment as possible. This was a random opportunity for discovery. Resident Identifier: #58. Facility Census: 109. Findings Include: a) Resident #58 On 04/23/24 at 9:50 PM, a bottle of lubricating eye drops were found at Resident #58's bedside. The resident stated, I don't know how long they have been sitting there. On 04/23/24 at 9:52 PM, Licensed Practical Nurse (LPN) #92 was notified the eye drops were found at bedside. LPN #92 confirmed the eye drops should not have been left at bedside. On 04/24/24 at 9:20 AM, the Director of Nursing (DON) was notified of the incident regarding the eye drops found at bedside. The DON stated, medication should not be left at bedside.

Based on record review, resident interview and staff interview, the facility failed to manage Resident #5's chronic pain. This is true for one (1) of two (2) residents reviewed under the care area of pain. Resident Identifier: #5. Facility Census: 109. Findings Include: a) Resident #5 On 04/22/24 at 2:15 PM, an interview was conducted with Resident #5. The resident stated, I have had four (4) back surgeries .they won't give me pain medication .they say they are referring me to a pain clinic. On 04/22/24 at 5:00 PM, a record review was completed for Resident #5. The review found two (2) current physician's orders for the following: -- Tylenol Extra Strength 500mg (milligram) give two (2) tablets by mouth every 6 (six) hours as needed for general discomfort 1-4 (one to four) pain scale. Do not exceed 3 (three) gram within 24 hours. Code for non-pharm (pharmacological) intervention 0 (zero) nonpain 1 Reposition 2 massage 3 apply cold 4 apply heat 5 (five) Ambulate/movement 6 (six) limit movement 7 (seven) promote relaxation/calm environment 14 other-add to PN the description (Typed as…

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

, Based on record review and staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for one (1) of two (2) residents reviewed under the care area of dialysis. Resident Identifier: #108. Facility Census: 109. Findings Include: a) Resident #108 On 04/22/24 at 6:40 PM, a record review was completed for Resident #108. The review found the resident receives dialysis on Tuesday, Thursday and Fridays. The resident's chair time is 10:30 AM. A review of the Dialysis Communication forms was completed on 04/24/24 at 9:30 AM. The following Dialysis Communication form was found to be incomplete: --04/06/24 pre-dialysis facility nurse's signature was missing On 04/24/24 at 10:30 AM, the Director of Nursing (DON) was notified. The DON confirmed the Dialysis Communication forms should be filled out completely.

Based on record review and staff interview, the facility failed to ensure narcotic medications for Resident #91 were not misappropriated by failing to properly reconcile the narcotic medication count. This was true for one (1) of one (1) for pharmacy records during the survey process. Resident identifier: 91. Facility census: 91. Findings include: A) Incident At approximately 6:00 AM on 04/06/24, Registered Nurse (RN) #5 noticed a bottle of liquid morphine was empty, indicating a discrepancy in the narcotic medication count. RN #5 signed the narcotic medication count sheet, indicating the count was correct, however it was not. When the Registered Nurse Supervisor (RNS) #106 reported to work that day at 8:00 AM, RN #5 reported the discrepancy, failing to follow facility policy on reporting discrepancies in narcotic medication counts immediately. B) Investigation RNS #106 was made aware of the discrepancy for Resident #91's liquid morphine on the narcotic medication count sheet. RNS #106 went to verify the count with Licensed Practical Nurse (LPN) #51, confirming the bottle of liquid…

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

Based on observation and staff interviews, the facility failed to post accurate menus prior to meal times. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 109. Findings include: At approximately 1:38 PM on 04/22/24, it was noted the menus for 04/21/24 were still displayed outside of the Fiesta Dining Room. The Housekeeping Manager (HM) was standing outside the dining room at the time and confirmed the menus from 04/21/24 were still up after lunch service had taken place on 04/23/24. The HM was asked to accompany this surveyor across the facility to check for other places that accurate menus were not placed. Menus for 04/21/24 were found to still be displayed at the A Nurses Station and the B Nurses Station. At approximately 1:44 PM on 04/22/24, an interview was conducted with the Dietary Manager (DM) regarding the menus. The DM stated I had to make new menus because my truck didn't come. I just forgot to hang them up.

Based on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #22. This was true for one (1) of 24 residents reviewed during the survey process. Resident Identifier: #22. Facility Census: 109. Findings Include: a) Resident #22 On 04/22/24 at 5:18 PM, a record review was completed for Resident #22. The review found the Physician's Scope of Orders for Treatment (POST) form was not complete. The POST form was not signed or dated by the resident or the resident representative. On 04/22/24 at 6:41 PM, the Director of Nursing (DON) was notified of the incomplete POST form. The DON confirmed the form was missing the signature of the resident or the resident representative as well as the date. No further information was obtained during the survey process.

Based on policy review, record review, and staff interview, the facility failed to ensure the resident environment over which it has control is as free from accident hazards as possible. The facility failed to correct the identified issue of nurses placing resident medication in medicine cups, placing the medicine cups on the bedside table or over-bed tray, and walking away without waiting to see if the medication was taken. Resident identifiers: #13, #84, #15, #92, and #26. Facility Census: 114 a) General Dose Preparation and Medication Administration Policy Section 5 of the facility's General Dose Preparation and Medication Administration Policy reads, During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: - 5.10 Observe the resident's consumption of the medication(s). b) Resident #13's Grievance Resident #13 filed a grievance on 07/19/23 reporting, Meds (medications) are being left on bedside table. The Director of Nursing (DON) was designated to act on the concern.…

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 each resident had the right to personal privacy and confidentiality of his or her personal and medical information. Staff failed to secure medical information from those who did not have a need to know, by leaving reports on the medication carts unattended, which contained personal and medical information for resident's care. The information was in plain sight of anyone passing by in the hallway. This deficient practice was identified through a random opportunity for discovery and had the potential to affect more than a limited number of residents. Census: 108 Findings included: An observation, on 08/23/22 at 07:48 AM, revealed a 24-hour shift report laying on the A/B medication cart. The report contained residents names, with information regarding the residents' diagnoses, code status, vital signs, special instructions for care that could be seen by anyone passing down the hallway. An interview, with Licensed Practical Nurse (LPN # 49), on 08/23/22 at 07:48 AM, verified the 24-hour report was visible to those…

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

Based on observation, resident interview, staff interview and policy review the facility failed to serve all Residents residing in the same room at the same time. This was a random opportunity for discovery. Resident #34 was not afforded a dignified dining experience. Resident identifier: #34. Facility census: 108. Findings included: Record review of the facility's policy titled Meal Service, revised on 10/27/19, showed Trays are labeled with a tray card and are assembled by each employee contributing assigned service ware items. a) Resident #34 An observation on 08/22/22 12:40 PM, showed a lunch tray was delivered to Resident #34's roommate but not to Resident # 34. An observation on 08/22/22 at 12:45 PM, showed Resident #34 was sitting on bed with bedside table prepared for lunch tray delivery and watched roommate already eating lunch. During an interview on 08/22/22 at 12:47 PM, Resident #34 stated that I think they forgot me. During an interview on 08/22/22 at 12:49 PM, Nurse Aide (NA) #79 stated usually staff deliver food trays to roommates together however there was a tray…

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

Based on record review and staff interview, the facility failed to ensure one (1) of 28 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed correctly per directions specified by the [NAME] Virginia Center for End-of-Life Care. Resident identifier: #11. Facility census: 108. Findings included: a) Resident #11 An electronic medical record review was completed on 08/22/22 at 2:58 PM. There was a 2021 Edition of the POST form in Resident #12's medical record. The Patient or Patient Representative signature line on the POST form was dated 05/31/22. Verbal consent from resident's Health Care Surrogate (HCS) had been accepted via phone by LPN #41 and LPN #49 on this date. Review of all progress notes in the electronic medical record did not reveal documentation related to the completion of the POST form or that the HCS had been asked to sign form at their earliest convenience. Review of the Using the POST Form Guidance for Health Care Professionals, 2021 Edition, revealed the following guidance for completing…

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 that a copy of a resident's Notice of Transfer/Discharge was sent to the Long-Term Care Ombudsman. This was true for one (1) of three (3) sampled residents reviewed for hospitalizations. Resident identifier: #64. Facility census: 108. Findings Included: a) Resident #64 A medical record review was completed on 08/23/22 at 2:33 PM. The record review revealed Resident #64 was transferred to the hospital on [DATE]. The record did not reflect the Notice of Transfer was sent to the Ombudsman. During an interview on 08/24/22 at 8:36 AM, the Administrator stated the facility had no evidence a Notice of Transfer had been provided to the Ombudsman. .

Based on record review and staff interview, the facility failed to provide resident-centered care and services, in accordance with professional standards of practice to meet each resident's needs. The facility failed to follow physician orders for the administration of insulin. This was true for two (2) of seven (7) residents reviewed for medications during the Long-term Survey Process Survey Process. Resident identifiers: #64 and #85. Facility census: 108. Findings included: a) Resident #64 A medical record review, on 08/23/22 at 2:41 PM, found the following sliding scale order for insulin on Resident #64's chart: ORDER: NovoLOG (Insulin Aspart) Inject as per sliding scale: if 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units, subcutaneously before meals and at bedtime for DM [Diabetes Mellitus] II If BG [Blood Glucose] is below 70 or greater than 400 notify MD [Medical Doctor]. Subsequent reviews of the Medical Administration Records (MARS) for the months of June, July, and August 2022 found the following: - On 08/03/22 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 resident interview, observation, and staff interview, the facility failed to serve food that was palatable and at an appetizing temperature. This failed practice had the potential to affect a limited number of residents currently receiving nutrition from the facility's kitchen. Resident Identifiers: #1 and #79. Facility Census: 108. Findings Included: A) Resident #1 During an interview 08/22/22 at 11:45 AM, Resident #1 stated she ate in her room for meals and that the food is cold. On 08/23/22 at 12:51 PM, temperatures were obtained on the lunch meal tray for Resident #79. (Resident #79's tray was selected because it was the last tray to be served on the same hall as Resident #1. The following temperatures were obtained by the Dietary Manager using his thermometer: -Mixed vegetables 140.2 degrees Fahrenheit (F) -Fish - 155.0 degrees F -Diced Potatoes - 122.0 degrees F During an interview on 08/22/22 at 12:53 PM, the Dietary Manager stated, The potatoes aren't climbing to the desired temperature. When asked what the desired temperature would be, the Dietary Manager replied,…

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

Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that were opened. This failed practice had the potential to affect a limited number of residents who are served food from the kitchen. Facility census: 108. Findings included: a) Initial Tour of Kitchen Observations during the initial tour of the kitchen, on 08/220/22 at 10:45 AM, revealed: -One (1) gallon plastic container of vanilla ice cream. Approximately 3/4 of the ice cream had been consumed. There was no opened date on the container. -One (1) ten pound opened bag of pasta. Approximately 1/5 of the pasta had been consumed. There was no opened date on the container. During an interview on 08/22/22 at 10:55 PM, [NAME] #26 acknowledged this practice did not follow facility protocol of labeling and dating all opened food items in the kitchen and did not allow the staff to ensure the food is still safe for consumption. .