Glasgow Hills Of Journey

Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for a resident with a newly evident or a possible serious disorder. This was true for one (1) out of 30 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifier: #35. Facility census: 101 Findings included: a) Resident #35 A record review, completed on 06/24/25 at 6:18 PM, record review revealed: -A physician order which read, Divalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium). Give one (1) tablet by mouth two times a day for seizures give with 500 mg tab to equal 750 mg two (2) times a day. -Question #30 Current Diagnosis (Check all that apply) on the Pre-admission Screening and Record Review (PASARR), dated 10/16/24, did not indicate an issue with seizures. During an interview on 06/25/25 at 10:45 AM, the facility Social Worker acknowledged a new PASARR had not been completed to capture the seizure disorder.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan that accurately reflected resident status and need for assistance. This deficient practice had the potential to affect two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifiers: #62 and #85. Facility census: 101. Findings included: a) Resident #62 Review of Resident #62's comprehensive care plan showed the following focus: - [Resident's name] has impaired cognitive function/dementia or impaired thought processes r/t [related to] poor recall. Psychotropic drug. BIMS [Brief Interview for Mental Status] >12. Date initiated: 05/13/23. Revision on: 08/24/24. The Brief Interview for Mental Status is a standardized assessment used to evaluate cognitive function. The BIMS is scored as follows: 13-15: Cognitively intact. 8-12: Moderate cognitive impairment. 0-7: Severe cognitive impairment. Resident #62's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/04/23 indicated the resident's BIMS score was 3. Resident #62's most…

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, record review, and staff interview, the facility failed to revise the comprehensive care plan to reflect the resident's choices and when a resident's medication dosages changed. This deficient practice had the potential to affect two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifier: #75 and Resident #101. Facility census: 101. Findings included: a) Resident #75 On 06/24/25 at 9:30 AM, Resident #75 was noted to have an indwelling urinary catheter. The urine collection bag was hanging from the resident's bed but did not have a privacy cover to prevent the urine in the bag being seen by others. On 06/24/25 at 10:02 AM, the Director of Nursing (DON) stated Resident #75 refused to have a privacy bag placed on the urine collection bag for his catheter. She stated this was reflected in the resident's comprehensive care plan. Review of Resident #75's comprehensive care plan showed the following focus, initiated on 05/16/23, [Resident's name] has a suprapubic Catheter d/t [due to] neurogenic bladder. Interventions…

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

Based on observation, staff interview and record review the facility failed to ensure Resident #85's care plan accurately reflected the level and type of assistance he needed for eating. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADL) during the long term care survey process. Resident Identifier: #85. Facility Census:101. Findings Include: a) Resident #85 An observation of the noontime meal on 06/24/25 found Resident #85 was feeding himself with his fingers. He was eating Turkey Tex Mex which contained rice, and bake beans. The resident was dropping food on his clothes. An additional observation of the noon time meal on 06/25/25 found the resident again feeding himself with his fingers. He ate a piece of pineapple upside down cake with his hands. He also had on his plate mashed potatoes , chopped broccoli and ground meatballs with gravy. He attempted to eat some mashed potatoes but had difficulty. An observation of his dining area found there was cake crumbs and bits of food scattered around the floor. He then left the…

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

Based on observation, record review, and staff interview, the facility failed to ensure the resident's oxygen flow rate was set according to the physician's orders. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of oxygen. Resident Identifier: #62. Facility census: 101. Findings included: a) Resident #62 On 06/24/25 at 11:18 AM, Resident #62 was observed to be using supplement oxygen therapy via nasal cannula at four (4) liters per minute. Review of Resident #62's physician's orders showed an order written on 12/30/24 for oxygen at two (2) liters via nasal cannula related to: COPD [chronic obstructive pulmonary disorder], respiratory disorder, as needed for short of breath. On 06/25/25 at 11:04 AM, Resident #62 was again observed to be using supplement oxygen therapy via nasal cannula at four (4) liters per minute. On 06/26/25 at 2:03 PM, Licensed Practical Nurse (LPN) #40 confirmed Resident #62's supplemental oxygen therapy was set to four (4) liters per minute. LPN #40 asked the resident if he had adjusted his oxygen…

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

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow Enhanced Barrier Precautions (EBP) for a resident with indwelling medical devices. This was a random opportunity for discovery. Resident Identifier: #59. Facility census: 101. Findings included: a) Resident #59 The facility's policy titled, Enhanced Barrier Precautions, with implementation date 03/20/25 and revision date 03/20/25, stated Enhanced Barrier Precautions (EBP) would be followed for residents with indwelling medical devices including tracheostomy/ventilator tubes and feeding tubes. The policy also stated personal protective equipment would be worn for high-contact resident care activities for residents in EBP. High-contact resident care activities included care of medical devices, including tracheostomy care and feeding tube care. The policy also stated that enhanced barrier precautions may be…

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

Based on record review and staff interview, the facility failed to ensure Resident #108 was free of chemical restraints. This was true for one (1) of six (6) residents reviewed under the care area of abuse. Resident Identifier: #108. Facility Census: 107. Findings Include: a1) Resident #108 On 05/19/25 at 12:30 PM, a record review was completed for Resident #108. The review found the resident had a physician's order for Ativan 0.5mg (milligram) by mouth every 12 hours as needed (PRN) on 05/18/24. The physician's order did not have a time limit. The monthly pharmacy review was completed on 05/23/24 with the recommendation to either discontinue the PRN Ativan or reorder with a specific number of days. The review was signed by the physician on 06/12/24. However, the physician's order was not changed until 07/06/24. At the time of the change, the PRN Ativan was ordered for 60 days. The review, also, found unacceptable reasons for two (2) doses of a PRN psychotropic medication. The first dose of PRN Ativan given on 06/12/24 noted the reason as Res (resident) refuses to stay in bed…

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 develop/implement the care plan for Resident #108 regarding non pharmacological interventions, restricted limb precautions for Resident #109, #15 and #91. This was true for four (4) of 13 residents reviewed during the survey process. Resident Identifiers: #108, #109, #15, and #91. Census: 107. Findings Include: a) Resident #108 On 05/19/25 at 12:30 PM, a record review was completed for Resident #108. The review found the resident did have a physician's order for Ativan 0.5mg (milligram) by mouth every 12 hours as needed (PRN). The care plan was reviewed and an intervention under the focus area of altered psychosocial needs r/t (related to) behaviors of resisting care, physical aggression and agitation exacerbated after family visits of provide non pharmacological interventions such as redirect with activity, offer food/fluid, offer reassurance/conversation, 1:1 (one on one). However, the review, also found the resident was administered 29 doses of PRN Ativan which did not include specific behaviors or non…

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 follow physician's orders regarding restricted limb precautions for Resident #109, #15 and #91. This was true for four (3) of 13 residents reviewed during the survey process. Resident Identifiers: #109, #15, and #91. Census: 107. Findings Include: a) Resident #109 On 05/19/24 at 9:30 AM, a record review was completed for Resident #109. The review found a physician's order dated 06/22/23 of do not take B/P (blood pressure on left arm and an additional physician's order dated 06/22/23 of location of dialysis fistula: left upper arm. Upon further review, the physician's order was not followed. The following dates indicate the blood pressure was taken in the left arm: --06/22/23 at 3:03 PM --06/23/23 at 3:44 AM --06/23/23 at 8:38 PM --06/24/23 at 10:42 PM --06/26/23 at 12:30 AM --06/26/23 at 2:59 PM --06/27/23 at 3:25 PM --06/30/23 at 12:51 AM --07/01/23 at 3:48 AM --07/02/23 at 1:29 PM --07/05/23 at 1:38 AM --07/05/23 at 2:07 PM --07/06/23 at 3:13 AM --07/06/23 at 11:55 AM --07/10/23 at 11:02 PM --07/14/23 at 10:03 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 Observation, staff and resident interview the facility failed to provide a homelike environment for resident # 78. Resident ' s privacy curtain had several stains. This was true for on (1) of five (5) residents reviewed for environment. Facility Census 107. Findings included: a) An observation on 05/21/25 at 10:30 AM, Resident #78 ' s privacy curtain had several large, red stains and a brown stain. Resident ' s roommate, resident #69 stated that the curtain had been stained for at least a couple of days. b) During an interview with Nurse Aide (NA) #28 acknowledged that the curtain was stained and in need of cleaning. She reported that when they notice the stains they will notify housekeeping who will change and clean the curtains.

Based on record review, staff interview the facility failed to keep resident free from verbal abuse. This was true for one (1) of eleven (11) instances of alleged verbal abuse reviewed during this investigation. Facility census 107. Findings included: a) A review of Facility Reported Incident dated 5/13/25 revealed that Resident # 54 reported that laundry staff #124 was argumentative with her and rude and in regard to her laundry. The allegation was verified and the laundry service was notified that the facility did not wish for him to work at this facility. b) During an interview with with Director of Nursing on 05/20/25 at approximately 2:15 PM, it was acknowledged that the abuse did happen and that the staff member #124 was no longer employed at this facility and that all staff had since been re-educated by reviewing the facilities Freedom from Abuse and Neglect Policy, Identifying types of abuse and reporting. c) During a review facility ' s policy titled Abuse, Neglect and Exploitation, page one Policy: It is the policy of this facility to provide protections for the health,…

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 report an alleged incident of abuse to the appropriate agency. This is true for one (1) of six (6) residents reviewed. Facility Census 107. Findings included: a) During a review of hospital discharge plan dated for 2/18/25 that had updated into resident's electronic medical record, resident #78 reported facility staff had waterboarded her for 36 hours and threw her on the floor. She also reported she was subjected to weekly hour-long cold showers and which staff score water in her face and in her ear. b) Upon interview with Director of Nursing, Corporate Nurse, and Administrator, on 05/21/25 at approximately 12:44 AM, they acknowledged that it should have been reported and that it was not addressed after receiving the discharge information from the hospital. c) Interview with resident on 05/20/25 at approximately 3:30 PM who reported that she told unidentified staff she could not stand to be here in this facility anymore, that she can't take it and reported that unidentified staff called her a bitch and stated why…

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

Based on record review and staff interview the facility failed to complete an investigation and five-day follow-up for an alleged incident. This is true for one (1) of six (6) instances of alleged verbal abuse that was investigated during this survey. Facility Census 107. Findings included: a) Rreview of incident report dated 03/26/24 for Resident #110 alleging that resident's daughter heard while on the phone with the alleged victim, a staff member being argumentative with the victim, revealed there was no investigation and no five day follow-up attached. b) An interview with Director of Nursing (DON) on 05/19/25 at 1:44 PM who reported that the social worker is looking for five-day follow-up and investigation. c) During an interview with Regional [NAME] President of Clinical Services on 5/20/25 at approximately 12:45 PM, who reported we do not have a five-day follow-up for this incident. d) Review of the facility's Abuse, Neglect and Exploitation policy on page four (4), section V. Investigation of Alleged Abuse, Neglect and Exploitation stated the following: B. Written procedures…

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 four (4) residents reviewed under the care area of dialysis. Resident Identifier: #91. Facility Census: 107. Findings Include: a) Resident #91 On 05/19/25 at 11:00 AM, a record review was completed for Resident #91. The review did not find a physician's order to not take the blood pressure in the restricted limb. However, a physician's order dated 04/17/25 stated, dialysis: check thrill and bruit to fistula on left arm every shift. On the following dates the blood pressure was taken in the restricted limb: --04/19/25 at 1:55 AM --04/20/25 at 11:56 PM --04/22/25 at 6:03 AM --04/24/25 at 1:11 AM --04/25/25 at 1:31 AM --04/25/25 at 11:11 PM --04/27/25 at 12:42 AM --05/01/25 at 2:35 AM --05/07/25 at 7:12 AM --05/08/25 at 1:14 AM --05/08/25 at 5:16 PM --05/11/25 at 1:05 AM --05/13/25 at 2:27 AM --05/14/25 at 12:42 AM --05/15/25 at 6:45 AM --05/15/25 at 11:02 PM --05/18/25 at 4:17 AM On 05/22/24 at 10:00 AM, the DON 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 an accurate and complete record for Resident #109's skin assessment. This was true for one (1) of three (3) residents reviewed during the survey. Resident Identifier: #109. Facility Census: 107. Findings Include: a) Resident #109 On 05/20/25 at 2:00 PM, a record review was completed for Resident #109. The review of the physician's orders, care plan, weekly skin assessment and progress notes did not indicate the resident had any skin concerns. However, the facility provided a document entitled, Nursing Assistant Skin Inspection and Shower sheet dated 11/11/23 that indicated the resident did have a skin concern on the bilateral areas of the buttocks. On 05/20/25 at 3:30 PM, an interview was held with the Director of Nursing (DON) and the Corporate Registered Nurse (RN) #125 regarding the documentation of the skin issue. The DON and the Corporate RN #125 reviewed the entire medical record regarding any skin issues. The only skin issue documented was a skin tear on the right hand. The DON and the Corporate RN…

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 most recent survey was accessible to residents, family members, and legal representatives of residents. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 99. Findings included: a) Survey documentation On 04/22/24 at 3:35 PM, a review of the current Survey Documentation located in the lobby of the facility for public access revealed the survey book did not contain the most recent survey results for November 2023. An interview was conducted on 04/22/24 at 3:50 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) who acknowledged the most recent survey was not in the survey binder located in the front lobby for general access. ADON reported he could not locate the current survey results in the facility and stated the Administrator could email the survey results to him from outside of the office.

Based on record review and staff interviews the facility failed to ensure residents were free from neglect. Residents #13, #90 and #100 had physician orders for hourly checks for fall prevention. Due to the facility's failure to complete the hourly checks, resulting in the residents continuing to fall. Resident #2 was on 15-minute checks but was able to place himself in the room of a female resident and did not have pants on. Resident identifiers: #13, #90, #100. Facility Census: 99. Findings included: a) Policy Review A review of the facility policy titled Abuse Prevention Program with a revision date on 12/06 reads as follows: Neglect/Deprivation of Goods and Services by Staff (for further information, refer to Identifying Neglect policy) 1. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 2. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility…

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 an allegation of verbal abuse was reported to all the proper State Authorities. This was true for one (1) resident reviewed in the care area of verbal abuse during a complaint survey. Resident identifier: #10. Facility census: 99. Findings included: a) Policy Review A review of a facility policy titled Abuse Prevention Program with a revision date of 12/16 read as follows: 2. Verbal abuse may be considered to be type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. 3. Examples of mental and verbal abuse include, but are not limited to: a.harassing a resident b. mocking, insulting, ridiculing c. yelling or hovering over a resident, with the intent to intimidate; d. threatening residents, including but not limited to, depriving a resident of care or withholding a resident from contact with family and friends; and e. isolating a resident from social interaction or…

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 all residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. This failed practice was true for seven (7) out of seven (7) reviewed for sexual behavior which were ordered 15-minute monitoring checks without a duration or time frame to discontinue the checks. This was depriving the residents of sense of wellbeing for quality of life. Resident identifiers: #57, #2, #95, #99, #62, #37, and #60. Facility censuses 99. Findings include: a) Resident #57 A review of facility records found Resident # 57 was placed on 15-minute monitor check on 02/14/24 at 4:05 PM after this Resident was found in bed with another incapacitated resident without any pants on. Both residents reside in the memory unit. An interview with the Director of Nursing (DON) on 04/23/24 at 5:10 PM. The DON was asked how long the 15-minute monitoring checks were going to continue. The DON responded by saying she and the Administrator were talking about that and she believes they will do them for 90 days. 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 medical record review, and staff interview the facility failed to give medication as ordered by the physician, failed to complete 15-minute monitoring of a resident, failed to complete neuro checks after an unwitnessed fall. These failed practices were true for six (6) out of six (6) residents reviewed for late medications, and seven (7) out of seven (7) residents reviewed for 15-minute monitoring, and one (1) out of one (1) resident reviewed for neuro checks. Resident identifiers: #33, #62, #31, #7, #43, #20, #37, #60, and #90. Facility Census: Findings included: a) Resident #33 A review of the facility records titled; Medication Audit Report revealed the following order: Eliquis (an anticoagulant to prevent blood clots) One (1) tablet twice a day was ordered by the facility attending physician. On 03/15/24 this medication was scheduled to be administered at 9:00 PM and was not given until 11:06 PM by Licensed Practical Nurse (LPN) #1. There were not any nursing notes to indicate why or that the attending physician was notified. Resident #33 also had an order for Norvasc…

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

Based on observation and staff interview the facility failed to ensure the resident environment over which it had control and remained as free of accident hazards as was possible. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents who reside at the facility. Facility census: 99. Findings included: a) Medication room On 04/24/24 at 1:04 PM the medication room door was observed propped open and unattended. This was witnessed by Licensed Practical Nurse (LPN) #56. LPN #56 stated the Pharmacy tech was the person that did it. On 04/24/24 at 1:09 PM the Pharmacy Tech returned to the medication room from a room beside the Medication room and closed the door. b) Electrical box On 04/24/24 at 1:10 PM at the west nurse's station there was an electrical box on the wall that had a padlock on the door, but the padlock was unlocked. This was pointed out to LPN #56. LPN #56 locked the padlock. The above observations were reported to the Administrator at 1:15 PM. No comments were made.

Based on facility documents and staff interviews the facility failed to meet the requirements of the staff posting by failing to reflect the actual number of staff who worked and the actual number of hours they worked. This failed practice had the potential to affect a limited number of residents. Facility census: 99. Findings included: a) Staff Posting On 04/22/24 at 3:23 PM, the Administrator provided the staff postings for the last two (2) weeks. A review of these documents revealed the posting sheets were not a working sheet to reflect a call-out. The Administrator was asked if the facility had any callouts in that time frame. After a review of the direct care staff time punch card for the last two (2) weeks it was found the facility had 13 callouts in that time frame. On 04/24/24 at 9:10 AM the Administrator agreed the staff postings had not been corrected and/or updated the reflection of the actual number of staff that worked.

Based on observation and staff interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. This was a random opportunity for discovery and had the potential to affect a limited number of residents who reside at the facility. Facility census: 99. Findings included: a) Low temperature On 04/24/24 at 12:45 PM an observation of the residents sitting at the nurses with a blanket on. The area felt very cool. Called for Maintenance Assistant #6 to please check the temperature at chair level with an ambient thermometer. On 04/24/24 at 12:49 PM Maintenance Assistant #6 had an ambient thermometer and the temperature at chair level was 61 degrees and the wall thermometer was set on 69. Maintenance Assistant #6 changed it to 74 degrees. Maintenance Assistant #6 went on to say he had to change the thermostat back up all the time.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, record review and staff interview the facility failed to promote and facilitate resident self-determination through support of resident choice, and to ensure residents rights for self-determination was encouraged. This was true for two (2) residents and was a random opportunity for discovery. Resident identifiers: # 95 and #99. Facility 99. Findings include: a) Resident #95 Resident #95 is a [AGE] year-old male, who has capacity and is a Paraplegic. While reviewing a report it was discovered Resident #95 had kissed Resident #99 at the nurses' station on the mouth. The nursing notes stated Residents were separated and educated on inappropriate behavior. DON (Director of Nursing), administrator, and management on call notified. This note was written at 8:53 PM on 03/30/24. The reportable note stated, Nurse separated both easily redirected and placed on 15-minute checks and skin assessments and both residents stated they consented for the kiss, however, the other resident lacks…

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 review of facility documents, staff interview, and interview via phone with the [NAME] Virginia licensing board of nursing. The facility failed to report nurses who had a disciplinary action in effect taken and/or released from their employment at the facility due to unaccounted for or missing controlled medications and not administering medications as ordered, along with falsified documentation about marking a medication as given when it was not given. Resident Identifier: # 101. Facility census: 99. Findings include: a) Resident #101 During a review of the facility reportable for an incident which took place on 12/25/23 or 12/26/23, the brief description of the incident was: Narcotic count off. Discrepancy of (liquid) Morphine amount on 12/25/23 at 3:00 PM and discrepancy of Neurontin on 12/26/23 at 3:20 PM. Immediate action taken to protect residents: Count Corrected, Perpetrator suspended pending investigation. This incident was not reported until 12/26/23 at 3:27 PM, even though the first discrepancy occurred on 12/25/23. On 12/25/23 Licensed Practical Nurse #115 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 medical record review and staff interview the facility failed to ensure all handwritten skin assessments were clear and accurate and contained enough information to accurately identify the resident. This failed practice had the potential to effect more than a limited number of residents. Facility census: 99. Findings include: a) Skin assessment While reviewing the medical records of residents that have had skin assessments because of a sexual behavior allegation of another resident. 12 forms were found where the name of the resident was unidentifiable or was missing altogether. On 04/23/24 at 1:10 PM the Director of Nursing (DON) was shown the skin assessment forms and agreed that six (6) had unidentifiable names and six (6) had no names. It was also pointed out that the forms did not have a date or shift on the form. The DON confirmed all 12 pages had the signature of the Assistant Director of Nursing.

Based on observation and staff interview the facility failed to ensure they maintained a clean and sanitary environment for all residents. Observations were made of torn pillows and a room with an foul odor. These were random opportunities for discovery. Resident identifiers: #67 and #75. Census: 94. Findings included: a) Resident #67 On 02/14/24 at 1:00 PM an observation of Resident #67's yellow pillow revealed it was torn in several places. On 02/15/24 at 9:30 AM an observation revealed Resident #75's yellow pillow was torn in several places. Resident #75's pillow was shown to Social Worker #79 on 02/15/24 at 9:40 AM. On 02/15/24 at 12:45 PM the director of nurses (DoN) said she saw the pillow and replaced it after the surveyor observed it on 02/14/24. b) Resident #75 An observation of Resident #75's room, on 02/14/24 at 11:00 AM, revealed a strong odor coming from the room. A half full urinal was observed sitting in the window seal. Nurse Aide #32 said the odor was from Resident #75. Nurse Aide #32 said the resident was a heavy wetter and the mattress was where the odor 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 observation, record review and staff interview the facility failed to ensure three (3) residents who were random opportunities of discovery had Activities of Daily living (ADL) provided for them in the form of grooming (nail care). Resident identifiers: #29, #41, and #76. Facility census: 94. Findings included: a) Resident #29 An observation of Resident #29's finger nails on 02/14/24 at 12:50 PM revealed the resident's nails were long and jagged with debris underneath them. Resident #29 said he would not mind to have his nails trimmed. The resident's care plan revealed he was dependent for ADLs. b) Resident #41 An observation of Resident #41's hands on 02/14/24 at 11:00 AM revealed the resident had long jagged fingernails. Resident #41 said she he would let a facility staff member trim/cut his finger nails. Care plan review revealed the resident was dependent for ADLs. c) Resident #76 An observation of Resident #76's hands on 02/15/24 at 11:30 AM revealed the resident had long fingernails with debris underneath them. The care plan review revealed the resident was dependent…

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 have Quality Assurance Assessment (QAA) Committee meetings that consist of the Infection Preventionist (IP) attendance. This had the potential to affect all residents currently residing in the facility. Facility Census: 93. Findings included: a) QAA meeting During a review of the facility QAA meeting sign in sheet on 12/11/23 at 3:30 PM, revealed the QAA meetings were held monthly with no IP attending within the third quarter of the QA meetings. During an interview 12/12/23 at 8:17 AM, the Administrator acknowledged the IP was not in attendance for any of the third quarter QA meetings.

Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the laundry room and water management. This practice had the potential to affect all residents that resided in the facility. Facility census: 93. Findings included: a) Laundry Room During a tour of the laundry room on 12/05/23 at 3:45 PM with the Maintenance Director #120 found: --The door closure was removed to keep the door open, that maintained a separation between the clean and soiled area of the laundry room to prevent contamination of airflow. --The ventilation was not on/ working to pull air from the clean to the soiled area. --There was a black substance on the walls at the side and behind the washer. -- There was dirt and debris around the washer area. -- The hand sink was not hooked up in the laundry room. Staff had to go across the hall, for hand hygiene. -- There 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 medical record review, policy review and staff interview the facility failed to notify the physician and/or resident representative in a timely manner when a resident had a change in condition. Resident #73 perpetrated sexual abuse on Resident #47, #60, and #17 on several occasions. The facility staff failed to notify the physician and/or responsible parties of these incidents. Resident identifiers: #74, #47, #60 and #17. Facility Census: 93 Findings included: A review of the facility policy titled Freedom from Abuse and Neglect Policy read as follows. .Investigation: .3. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions. The investigation will include, but is not limited to the following: a. Notification of physician and representative; . a) Resident #74 During a review of the facility mandatory reportable forms on 12/04/23 at 2:00 PM, A resident to resident encounter of sexual nature which occurred on 11/23/23 and 09/06/23 by Resident #74. During a record review on 12/05/23 at 8:49 AM, Resident # 74's medical…

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 their abuse prohibition policy regarding reporting of allegations of sexual abuse. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: Resident #47 and #60 . Facility Census: 93. Findings Included: During a review of the facility policy titled Freedom from Abuse and Neglect Policy not dated read as follows. .Identification: 1. Staff will immediately report any suspicious event or injury that may constitute abuse, neglect, exploitation, or misappropriation to the Executive Director. .3. The facility will report the allegation to the State Agency in accordance with state law. a) Resident #47 During a record review on 12/04/23 at 12:56 PM, Resident #10's medical records revealed the following notes: -11/09/23 at 11:00 AM, Resident to Resident encounter of verbal sexual abuse to Resident #47. -11/09/23 at 3:55 PM, Resident to Resident encounter verbal sexual abuse to Resident #47. -11/12/23 at 11:39 AM, 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 ensure an allegation of abuse was reported to all the proper State Authorities. This was true for two (2) of three (3) resident reviewed in the care area of Abuse during the Long Term Care Survey Process . Resident identifier: Resident #47, and Resident #60. Facility Census: 93. Findings Included: a) Resident #47 During a record review on 12/04/23 at 12:56 PM, Resident #74's medical record found the following notes: -11/09/23 at 11:00 AM Resident to Resident encounter of verbal sexual abuse to Resident #47. -11/09/23 at 3:55 PM Resident to Resident encounter of verbal sexual abuse to Resident #47. -11/12/23 at 11:39 AM Resident to Resident encounter of verbal sexual abuse to Resident #47. b) Resident #60 During a record review on 12/04/23 at 12:56 PM, Resident #74's medical records revealed a note dated on 11/23/23 at 11:04 AM pertaining to a resident to resident encounter of sexual nature with Resident #60. During an interview on 12/05/23 at 8:25 AM, the Administrator stated, (Resident #74's name) has had sexual…

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

Based on record review and staff interview the facility failed to revise the person-centered care plan, after a change in the resident's care or preference for care, for three (3) of 20 residents reviewed during the Long-term Care Survey Process (LTSP). Resident identifiers: Resident # 44, #26, and #46. Census: 93. Findings included: a) Resident #44 A record review, on 12/7/23, showed a progress note, dated 10/31/23 , indicating Resident #44 experienced the death of a sister. It was also noted the resident was in agreement to grief counseling. An assessment was conducted on 11/16/23, which assessed the resident as having grief. Recommendations were made to encourage resident to participate in activities such as massage and aromatherapy and psychotherapy as indicated. Follow up within 3-6 months or sooner as indicated, address concerns and questions. A review of the current care plan , updated 11/28/23 failed to contain a focus area of grief or bereavement , when the resident had consented to grief counseling after the loss of a family member. An interview, with Social Worker #74, 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 record review, resident interviews and staff interviews the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of the Residents. This was true for four (4) of five (5) Residents reviewed in care area of Activities during the Long-Term Care Survey Process (LTCSP). Resident Identifiers: Resident #74, Resident #65, Resident #35 and Resident #82. Facility Census: 93. Findings Included: a) Resident #74 During a record review on 12/06/23 at 10:51 AM, Resident # 74's medical record revealed monthly activity participation record. The participation records were void documentation of any involvement in group or individual activities. During a record review on 12/06/23 08:05 PM, Resident # 74's daily activity participation record revealed the following days void of any activity participation: -11/01/23 to 11/05/23 -11/07/23 to 11/12/23 -11/14/23 to 11/17/23 -11/22/23 to 11/30/23 -12/01/23 -12/03/23 -12/05/23 -12/06/23 During an interview on 12/07/23 at 10:01 AM the…

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

Based on record review, and staff interview the facility failed to follow Physician orders for Resident #46. Resident #46 was not getting his morning time medications as ordered by the physician on days he went to dialysis. Resident #46 also was not served food in the correct form to meet his needs and as ordered by the physician. This was true for one (1) of 20 sampled residents. Resident Identifier: #46. Facility Census: 93. Findings Include: a-1) Resident #46's meal service On 12/11/23 at 10:58 AM, a review of Resident #46's medical record found a physician order for a Dysphagia Advanced diet, with thin liquids. and a peanut butter and jelly sandwich with each meal. An observation of the noontime meal on 12/11/23 beginning at 12:10 PM, revealed Certified Nursing Assistant (NA) #13 delivered Resident #46 his roommates tray. When Nurse Aide #82 entered the room with Resident #46's tray NA #13 was overheard saying, I screwed up. Upon entering the room, NA #82 delivered Resident #46's tray to his roommate since Resident #46 all ready had the roommates tray on his over the bed table…

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 performance reviews of Nurse Aide (NA) at least once every 12 months. This was true for two (2) of five (5) employee files reviewed for the Sufficient Nurse Staff care area. This had the potential to affect more than a limited number of residents currently residing in the facility. Employee identifiers: #23, and #46. Facility census: 93. Findings included: a) Nurse Aide #23 During the staff record review, on 12/11/23 at 10:00 AM, personnel files were reviewed to ensure the performance reviews were completed at least once every 12 months. During the review of NA #23's file it was revealed the NA was hired on 02/01/22. The personnel file was void of the performance reviews needed every 12 months. During an interview, on 12/11/23 at 12:56 PM, the Director of Nursing (DON) acknowledged there were no performance reviews completed for NA #23. b) Nurse Aide #46 During the staff record review, on 12/11/23 at 10:00 AM, personnel files were reviewed to ensure the performance reviews were completed at least once every 12…

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 have a pharmacist review each resident's medication regimen monthly to identify irregularities and maintain record of the identified irregularities. This was true for three (3) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #70, #66 and #46. Facility census: 93. Findings included: a) Resident #70 A review for Unnecessary Medication for Resident #70 on 12/06/23 found the record did not contain medication regimen reviews or gradual dose reductions for December 2022, January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, or July 2023. During an interview on 12/07/23 at 8:35 AM the Director of Nursing (DON) verified the facility was unable to find documentation that pharmacy reviews were completed. b) Resident #66 On 12/06/23 at approximately 3:00 PM, a review of Resident #66's electronic record was conducted. During this record review, there was no indication of any Medication Regimen Review (MRR) or Gradual Dose Reduction (GDR) documentation for Resident #66. 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 keep the nourishment room on the dementia unit clean and sanitary. This failed practice had the potential to affect more than isolated number of residents. Facility Census: 93. Findings included: a) Nourishment Room Tour of the dementia care unit on the morning of 12/05/23 found the refrigerator in the activities room were the resident food was stored was rusted on the outside and the inside had a build up of debris and needed cleaned. The dementia care unit also had a small nourishment room which contained a microwave and a coffee pot. The coffee pot was observed to be dirty and was covered with dry brown stains. In the cabinets in the nourishment room was spilt coffee and other crumbs. In one cabinet was a tub of peanut butter which had a use by date of 09/14/23. The certified dietary manager was present during these observations and confirmed the findings. He stated, I didn't even know this nourishment room was here. Licensed Practical Nurse (LPN) #46 was interviewed at the conclusion of the tour. She was asked if…

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 three (3) of 20 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per direction and one (1) of 20 residents Physician 0rders were accurate. Resident identifiers: #72, #40, #74 and #99. Facility census: 93. Findings Included: a) Resident #72 Record review on 12/06/23 at 9:43 AM found, a POST form on Resident #72's chart was unsigned by the Resident or Medical Power of Attorney (MPOA). The POST form was dated 06/09/22. During an interview on 12/06/23 at 2:04 PM with the Director of Nursing, she confirmed Resident #72's POST form was incomplete without a Resident or MPOA signature. b) Resident #40 Record review on 12/05/23 at 2:30 PM found, a POST form on Resident #40's chart was unsigned by the Resident or MPOA. The POST form was dated 06/27/22. During an interview on 12/06/23 at 2:04 PM with the Director of Nursing, she confirmed Resident #40's POST form was incomplete without a Resident or MPOA signature. c) Resident #74 During 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 and staff interview, the facility failed to treat each resident with dignity and respect. This was true for one (1) of one (1) resident reviewed for the dignity care area and one (1) random opportunity for discovery . Resident Identifiers: #66, #74. Facility Census: 93. Findings included: a) Resident #66 On 12/6/23 at approximately 12:27 PM, during a tour of the facility, Resident #66 was observed sitting up in their bed while Nurse Aide (NA) #42 stood over top of them while feeding the resident their noon time meal. On 12/6/23 at approximately 12:27 PM, NA #42 stated in an interview they knew they were supposed to be sitting down, next to Resident #66 while providing feeding assistance and they were sorry. NA# 42 then stated, Resident #66 is finished eating anyway. b) Resident #74 A review of the facility policy titled Dignity with a revision date on 02/21 read as follows. Policy Interpretation and Implementation .11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment…

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 interview, the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences, by failing to ensure residents were provided with the proper sized undergarments. This was true for one (1) of one (1) resident reviewed for the accommodation of needs care area. Resident identifiers: 43. Facility Census: 93. Findings Include: a) On 12/5/2023 at approximately 12:54 PM, during an interview, Resident #22 stated the facility will frequently run out of bariatric incontinence supplies and the Nurse Aides will have to put them in a smaller size, which cuts into their sides. On 12/11/23 at approximately 10:30 AM, during an interview with Central Supply Clerk (CSC) #2 the employee said the facility did run out of bariatric incontinence supplies and the staff would have to put smaller sizes on the residents until they received a shipment of new ones, or they can borrow some from another facility. On 12/11/23 at approximately 11:02 AM, an interview was conducted with Nurse Aide (NA) # 82. NA #82 stated, The only…

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 interviews the facility failed to provide the resident and/or representative with the bed hold policy at the time of discharge. This was true for one (1) of two (2) residents reviewed for the care area of hospitalizations during the long term care survey process. Resident Identifiers: #46. Facility Census: 93. Findings Included: a) Resident #46 On 12/11/23 at 11:00 AM, during a record review of Resident #46 for hospitalizations, one (1) of four (4) bedhold notifications was not available. During an interview on 12/11/23 at 11:30 AM, Staff # 68 was unable to provide the requested behold notification dated 6/23/23. Staff #75 followed up on 12/11/23 at 2:40 PM to confirm the behold document was not found. Staff #75 stated they could not speak to why but they would do better next time. .

Based on medical record review and staff interview the facility failed to ensure a new Pre admission Screening and Resident Review (PASARR) was completed to reflect the residents new diagnosis bipolar disorder and major depression. This was true for one (1) of two (2) residents reviewed in the PASARR care area. Resident Identifiers: Resident #45. Facility Census: 93. Findings Included: a) Resident #45 During a record review on 12/06/23 09:42 AM, Resident # 45's PASARR dated 09/07/21 was void of the diagnosis of affective bipolar disorder and Major depression. Further record review revealed the following diagnosis included: -Schizoaffective Disorder 06/04/21 -Affective Bipolar Disorder 06/04/21 -Major Depression 03/15/23 During an interview on 12/07/23 at 8:43, AM the Social Worker (SW) stated I was unaware we needed to do a new PASARR with a new diagnosis. I have worked in long term care for years, and never knew that. The SW acknowledged a new PASARR should have been completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interviews, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) resident reviewed for the category of PASARR, during the long-term care survey. Resident identifier #40. Census 93. Findings Included: a) Resident #40 On 12/07/23, a record review of the resident's electronic medical record (EMR), the resident's most recent PAS, dated 08/11/22, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated No current diagnosis. The record also revealed indicated the resident had a psych diagnosis of Major Depression on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed. On 12/07/23 at 2:23 PM the Director of Nursing verified, Resident #40's PAS did not reveal his diagnosis of Major Depression. She confirmed a new PAS was not completed.

Based on medical record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives for Resident #47 and Resident #40. This was true for two (2) of 20 residents sampled during the Long-Term Care Survey Process (LTCSP). Resident Identifiers: Resident #47 and Resident #40. Facility Census: 93. Findings included: a) Resident #47 During a record review on 12/07/23 at 9:30 AM, Resident # 47's medical record revealed a care plan with an initiated date of 10/11/23 was void any focus, goals, and interventions for the resident-to-resident sexual encounter of nature. During an interview on 12/11/23 at 10:03 AM, the Director of Nursing (DON) acknowledged the care plans did not reflect any plans for the resident-to-resident sexual encounter of nature. b) Resident #40 On 12/05/23 at 12:05 PM during an interview Resident #40 stated that all he does is lay in bed or watch tv. He stated that there is nothing to do. A review of the current care plan with the initiated date of 08/01/22 showed there was no care plan…

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, family interview, staff interview and medical record review the facility failed to ensure Resident #66 maintained acceptable parameters of hydration status. This was true for one (1) of one (1) resident reviewed for the Nutrition/Hydration Status area of care. Resident Identifiers: 66. Facility Census: 93. Findings Include: a) Resident #66 On 12/05/23 at approximately 12:34 PM, during a tour of the facility, it was observed that no water was placed within reach of Resident #66. Upon further observation, it was discovered there was no water in Resident #66's room. On 12/06/23 at approximately 2:20 PM, a family interview was conducted in Resident #66's room. The family member stated Resident #66 is not able to reach for or hold things up well enough to eat or drink. The family member stated Resident #66 is often thirsty when I visit and I am worried [they] are not getting enough to drink. A full glass of thickened water was observed sitting out of reach of Resident #66 on the nightstand, during the family interview. On 12/06/23 at approximately 2:23 PM, 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 medically-related social services were maintained to ensure the highest practicable well-being of one (1) of 20 residents reviewed during the Long-term Care Survey Process (LTCSP). Resident #44 was identified as having grief and there was lack of evidence the resident was monitored and or interventions implemented during the grief process. Resident identifier: Resident #44. Census: 93. Findings included: a) Resident #44 A record review on 12/7/23, showed a progress note, dated 10/31/23, in which Resident #44 was informed of the death of a sister. It was also noted that the resident agreed to have grief counseling. An assessment was conducted on 11/16/23 noting the assessor documented areas were not assessed due to a language barrier. For example, past history was unknown due to language barrier, suicidal ideation's, homicidal ideations and notes indicated unable to score to language barriers. However, the resident was assessed as having grief with recommendations to encourage resident to participate in…

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 drugs and biologicals, used in the facility, were stored, and labeled in accordance with current accepted professional practices. This was true for medications stored in one (1) of two (2) medication carts inspected. The facility failed to ensure medications were dated when opened and put in to use or was found to be expired and still being stored for use. This practice had the potential to effect more than a limited number of residents. Resident identifiers: Resident #7, and Resident #50. Facility census: 93 Findings included: a) An observation of the East Front Medication Cart, on [DATE] at 10:17 AM, revealed a vial of Levimir insulin for Resident #50, that was opened but had no date of when the vial of insulin was opened for use. Licensed Practical Nurse (LPN) #4 was questioned about the undated opened vial of insulin during this time. LPN #4 verified the vial of Levimir insulin was opened and being used for Resident #50, but 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.

Based on medical record review and staff interview the facility failed to provide a COVID-19 booster vaccination for one (1) of five (5) residents reviewed for compliance with Covid -19 vaccinations. Resident identifier: #72. Facility Census: 93. Findings included: a) Resident #72 Medical record review, on 12/12/23, for Resident #72 revealed he did not receive a Covid-19 vaccination booster. Continued review found Resident #72's could have received the Covid-19 booster on 03/27/22. On 12/12/23 at 10:28 AM during an Interview, the Infection Preventionist verified Resident #72 did not receive the Covid-19 booster when eligible and the facility did not follow up on the missed dose.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident interview, and staff interview, the facility failed to make information on how to file a grievance or complaint available to the resident, and to establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights . This has the potential to affect more than a limited number of residents . Resident Identifiers: Resident Council, 22, 28. Room numbers: #117, #126, #129, #130, #131, #133, #201. Facility Census: 91. Findings included: a) Resident #22 On 12/05/23 at approximately 12:54 PM, Resident #22 reported they were missing 15 pairs of socks, 2 gowns, and a shirt. Resident #22 stated they had reported the missing items to housekeeping, CNAs, and Nurses. Resident #22 reported they were never given a grievance form to fill out and the facility never followed up on the missing items, nor had they been found. On 12/5/23 at approximately 3:26 PM, an interview with Senior Executive Director (SED) #50 confirmed they were aware Resident #22 had…

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, comfortable, and homelike This has the potential to affect more than a limited number of residents . Resident identifiers: #45, #48, #86, and #92. Room numbers: #117, #126, #129, #130, #131, #133, #201, #302, #304, #312, #311, #31, and #303. Facility Census: 91. Findings Include: a) Hallways On 12/04/23 at approximately 10:34 AM, Excessive debris in the floor in front of the storage closet on the East Front hallway was observed. On 12/04/23 at approximately 10:39 AM, observation of the floors in the East Back hallway found excessive debris in the floor, in front of resident rooms, and thick layers of dirt and debris in the corners of the hallway. On 12/04/23 at approximately 10:44 AM, Environmental Services Manager (EVSM) #118, witnessed the condition of the hallways. b) room [ROOM NUMBER] On 12/04/23 at approximately 10:35 AM, popcorn and excessive debris was observed on the floor in room [ROOM NUMBER].…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice of staff failing to properly don Personal Protection Equipment (PPE) when indicated by signage on door and had the potential to affect all residents who currently reside at the facility. Facility census 96. Findings included: The Facility was in a COVID outbreak with positive staff a) room [ROOM NUMBER] On 09/18/23 at 9:51 AM, it was observed that Housekeeper (HK) #105 was in room [ROOM NUMBER] cleaning. There was a sign on the door bright yellow and orange in color the stated this room is in Contact Precaution. The sign said, STOP you must wear mask, gown, and gloves before entering the room. HK #105 did not have a gown or gloves, and her mask was under her chin. HK #105 was asked about wearing the PPE 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 interview the facility failed to provide pharmaceutical services , including procedures that assure the accurate dispensing and administering of all drugs. This was found for five (5) of five (5) resident records reviewed. Resident Identifiers: Resident #25, #38, #44, #52 and #85. Facility Census 96. Findings Include: a) Medication administration - interviews On 09/18/23 at 1:00 PM, the surveyor spoke with Assistant Director of Nursing (ADON) regarding reconciliation of narcotics. He said he runs a daily report and compares what was removed from the Pixis (automated drug dispenser), compared to the Medication Administration Record (MAR). He said there are often minor discrepancies and he gets the nurse that dispensed the medication to fix it on the MAR. He said it is usually just a matter of changing the date or the time. On 09/19/23 at 11:00 AM, the ADON who said he had gotten yesterdays medication discrepancies corrected; all but one. As of this morning he has six (6) awaiting correction. 09/19/23 at 12:00, the ADON said reconciliation of medication is…

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 interview the facility failed to serve food within professional standards for food safety. This failed practice had the potential to affect more than a limited number of residents and was a random opportunity for discovery. Facility census: 96. Findings include: a) Kitchen observations On 09/18/23 at 10:00 AM, a tour of the kitchen was conducted with the Dietary Account Manager (DAM). The panty door was propped open with a can of food. When asked why, the DAM said the magnet was broken and that was the only way to keep the door open. Behind the door revealed a hole in the wall where the wall part of the magnetic closure was caved in and would not make contact. The floor behind the door was dirty and had a dead insect in the dust. When the DAM pulled out several of the metal shelves, all had dust, dirt and debris behind and under them. The dishwashing room also had dirt and debris behind and under the tables. The Prep table had dirt and debris under it as well. The ovens had a hard build up of dried food on the bottom of the oven. The trash can, beside the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Record review and staff interview the facility failed to ensure all medical records were accurate. This was a random opportunity for discovery and the potential to affect a limited number of residents. Resident identifiers: #37, #24, and #83. Facility census 96. Findings included: a) Research of licenser While investigating an allegation that stated a Licensed Practical Nurse (LPN) #35 was portraying themselves as a Registered Nurse (RN) #35, the Assistant Director of Nursing (ADON) #35 was asked when he became a RN. ADON #35 said a couple of months ago. License research found that ADON #35 received a temporary RN license on [DATE] and this license expired on [DATE]. After [DATE], RN #35 was a LPN until he passed the testing for a RN on [DATE]. b) Record review findings While reviewing medical records it was discovered that on [DATE] and [DATE] the current ADON #35 signed a nursing note on Resident #37, that stated his position was an RN. However, from [DATE] until [DATE] the current RN #35 was a LPN…

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, functional, sanitary, and comfortable environment for residents. Window curtains were not present or did not close properly to allow for privacy. Vents in the ceiling were covered with dust and the ceiling on 300 hallway was in need of repair. This was a random opportunity for discovery and had the potential to affect more than a limited number of Residents at the facility. Facility census: 96. a) Observations of curtains At 10:15 AM on 09/18/23, a tour of the facility with the housekeeping supervisor #88 found the following rooms had no window curtains and no blinds allowing resident care to be visible from outside the facility. Rooms 214, 216, 313, 301, 113, 133, 105, and 106. For rooms 105, 107, 109, 106, 110, 112, 115, 112, 125, 124, 126, and 128, the hooks for the curtains were missing on both the left and right sides of each pair of curtains where the curtains meet in the middle of the window. This would also allow for care to be observed from outside the facility. The Housekeeping Supervisor said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure a baseline care plan was developed within 48 hours of admission for one (1) of three (3) residents reviewed for the care area of falls. Resident identifier: #97. Facility census: 96. Findings include: a) Resident #97 The resident was admitted to the facility from the hospital with a diagnosis of closed fracture of the right pelvis on 11/03/22. The Resident was discharged to home on [DATE]. A nurses note dated 11/03/22: .She has been admitted to us with a fractured pelvis, history of falls, shoulder pain, knee pain, inability to walk . The Resident's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/08/22 found the resident was coded as having falls prior to being admitted to the nursing home. Review of the Residents care plan for falls found the following focus: Is at risk for falls r/t (related to) new environment, psychotropic medication use, history of falls, Deconditioning and Gait/balance problems.…

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, observation and staff interview the facility failed to implement the care plan for two (2) of three (3) residents reviewed for the care area of falls. Resident identifiers: # 58 and #3. Facility census: Facility census: 96. Findings included: a) Resident #58 Record review found the Resident had four (4) falls since 05/03/23. Review of the current care plan found the following focus: At risk of falls related to deconditioning, gait/balance problems, muscle atrophy, incontinence and history of falls. revised on 05/22/23 The goal associated with the focus: Will not sustain serious injury through the review date. Resident will not attempt to pick up objects off the floor and will request staff assistance. Revised on 08/28/23. Interventions included: Non skid strips to foot of bed initiated on 10/25/22. Observation of the Resident at 3:40 PM on 09/18/23, found the resident was sleeping in his bed. The non skid strips were not present at the foot of the bed. At 3:40 PM on 09/18/23, the Licensed…

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 observations and staff interview the facility failed to ensure the Resident's environment was clean, safe, sanitary, and homelike. A privacy curtain in Resident room [ROOM NUMBER] was visibly soiled. Resident room [ROOM NUMBER] and 303 had doors which were in poor repair, and the wardrobe door was broken off lying in the floor of resident room [ROOM NUMBER]. These findings were random opportunities for discovery. Resident identifier: R #35. Room Numbers: 108, 302, 303, and 305. Facility census: 90. Finding included: a) room [ROOM NUMBER] soiled privacy curtain An observation on 11/14/22 at 12:14 PM showed the privacy curtain in room [ROOM NUMBER] between beds to be visibly soiled with large amounts of pink substance running down the curtain. This finding was verified by Licensed Practical Nurse (LPN) #66. LPN #66 stated, Yea that needs changed, I'm not sure what that [pink substance] is. Resident #35 stated he liked to keep that curtain pulled so it would block out the light coming in from the outside…

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 representative from the Office of the State Long-Term Care Ombudsman was notified of transfers and/or discharges as required. This was true for two (2) of three (3) residents reviewed for the care area of hospitalizations and true for one (1) of two (2) residents reviewed for discharge during the long term care survey process (LTCSP). Resident Identifiers: Residents #442, #342 and #42. Census: 90. Findings included: a) Resident #442 A record review showed Resident #442 had been transferred to the hospital after a fall on 04/22/22. Further review of the record showed no evidence the State Ombudsman had been notified of the transfer as required. An interview, with the facility's Administrator, on 11/15/22 at 3:31 PM, verified the facility had failed to notify the State Ombudsman of Resident #442's transfer to the hospital, occurring on 04/22/22. b) Resident #342 A record review showed Resident #342 had been discharged on 9/15/22 with a return not anticipated. Further review of the medical record showed no…

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

Based on observation and staff interview the facility failed to ensure the resident environment over which it had control was as free of accident hazards as possible. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility census: 90. Findings Included: a) Unlocked Nourishment Room During the initial tour on 11/14/22 at 11:50 AM an observation found the nourishment room door was unlocked on the Life Engagement Alzheimer's Unit (ACU). The nourishment room contained a coffee maker with a hot pot of coffee on the counter, accessible to residents living on the ACU. On 11/14/22 at 11:50 AM the Director of Nursing (DON) verified the door was sticking and not closing all the way and there was a coffee maker with a hot pot of coffee in reach of residents. She stated the nourishment room should always be locked. The DON called maintenance to get the door fixed at this time. b) The ACU kitchen. On 11/14/22 at 12:02 PM an observation the Life Engagement Alzheimer's Unit (ACU) of the Resident Kitchen found three (3)…

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 held prior to food service at appropriate temperatures, cold food should be held at 41 degrees or below. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 90 Findings included: a) Kitchen Tour Observation on 11/14/22 at 11:14 AM during the kitchen tour found, the chopped tossed garden salad in the steam table. During an Interview and temperature check on 11/14/22 at 11:20 AM with Dietary aide #48 revealed the chopped tossed salad was being held at 94 degrees. On 11/14/22 at 11:40 AM the dietary Manager in training verified cold food should be held at 41 degrees on below and the chopped tossed garden salad was not. .

Based on observations, staff interview, and record review, the facility failed to provide each resident food and / or drink that was palatable, attractive, and at a safe and appetizing temperature. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility Census: 90 Findings Included: a) Dining Observation On 11/15/22 at 12:06 PM an observation of tray pass on the 100-hall found, the holding tray cart open on both sides throughout the tray pass. On 11/15/22 at 12:19 PM the Dietary Manager in Training took temperatures of the last resident tray on the 100-hall cart the following temperatures were obtained: --Ham - 95 degrees Fahrenheit (F) --Glazed Carrots -107 degrees F. --Egg Noodles - 96 degrees F. --Spiced Peaches -54 degrees F. On 11/15/22 at 12:22 AM during an Interview the Dietary Manager in Training verified the lunch trays were not being served at a palatable safe and appetizing temperature. .

Based on observation, policy review and staff interview the facility failed to complete labeling and date stored food items in the refrigerator and freezer on the Life Engagement Alzheimer's Unit (ACU) resident kitchen. The facility also failed to the monitor the temperature of Resident #85's personal refrigerator in his resident room. This has the ability to affect more than a limited number of residents that reside on the ACU. In addition to Resident #85 who was a random opportunity for discovery. Resident Identifiers: #85. Facility Census: 90. Findings Included: a) ACU Resident Kitchen A review of the facility's policy titled Food Receiving and Storage, with revised date October 2017, revealed the following: Food items and snacks kept on the nursing units be maintained as indicated below. --All food items to be kept below 41 degrees, must be placed in the refrigerator and labeled with use by date. Observation during the ACU kitchen tour on 11/16/22 11:59 AM found: -- Refrigerator -two (2) packs of open cheese with no labeling or dates. -- Freezer- One (1) open gallon of vanilla…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to ensure each medical record was complete and accurate this was true for 12 of 27 sampled residents during the Long Term Care Survey Process. Resident Identifiers: #62, #33, #56, #84, #89, #22, #91, #35, #342, # 55, #66, and #54. Facility Census: 90. Findings Included: a) Resident #33 A review of Resident #33's shower/bed bath documentation from the point of care system in the medical record indicated Resident #33 received the following showers and/or bed baths. -- [DATE] - Bed Bath at 6:59 pm. -- [DATE] - a shower at 5:58 pm. -- [DATE] - a shower at 9:03 am. -- [DATE] - a bed bath at 6:59 pm. Further review of the shower sheets provided by the facility found the following conflicts in regards to the documentation in the Point of Care System: -- [DATE] the shower sheet indicated Resident #33 received a bed bath. This was not documented in POC in the medical record. -- [DATE] the shower sheet indicated Resident #33 received a shower. This was 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 record review and staff interview, the facility failed to ensure documentation in the residents medical record of the information/education provided regarding the benefits and risks of immunizations and the administration or the refusal of /or medical contraindications to the vaccines. This was true for three (3) of five (5) residents reviewed for immunizations during the Long- Term Care Survey Process (LTCSP). This failed practice had the potential to affect all residents residing in the facility eligible for immunizations. Resident identifiers: Residents #47, #33 and #44. Census: 90 Findings included: a.) Policy Review A review of the Policy, titled: Vaccination of Residents, dated with a revision date of October 2019, showed prior to receiving vaccinations, the resident or legal representative [NAME] be provided information and education regarding the benefits and potential side effects of the vaccinations and this education would be documented in the resident's medical record. If vaccinations 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, resident interview, and record review the facility failed to ensure Resident #18's call light was always within reach. This was a random opportunity for discovery. Resident identifier: #18. Facility census: 90. Findings included: Observation on 11/14/22 at 12:01 PM found Resident #18's call light was not within reach. The call light was hanging on the back of the privacy curtain against wall. Nurse Aide (NA) #28 verified the call light was not in reach for the resident, and stated Well where is it? NA #28 then traced the cord from the wall and found the light was above the residents reach clipped into the folds of the privacy curtain. The Resident stated, I don't see well, do I have a call light? NA #28 then provided the call light to the Resident and instructed her how to use it. Record review of Resident #18's care plan showed the Resident is risk for falls related to being legally blind, non-ambulatory, seizures, psychotropic medication use and has dementia. Intervention stated to be sure Resident's call light is within reach and encourage Resident #18 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 resident interview, resident observation, record review and staff interview the facility failed to allow the resident the right to choose his preference in relation to his personal care. This was true for one (1) of two (2) residents reviewed for the care area of choices. Resident #77. Facility Census: 90 Findings Included: a) Resident #77 On 11/14/22 at 1:06 PM Resident #77's appearance was disheveled. He needed to be shaved, his hair was long and unkept and his finger nails were visibly dirty. He stated he is not getting his showers as he should be. He expressed his desire to take showers rather than bed baths and he hasn't had a shower in over a week. He would like a hair cut and shaved. This was confirmed on 11/14/22 at 1:15 PM with Licensed Practical Nurse # 89. Record review shows Resident #77 is scheduled for a shower twice a week on Wednesday and Saturday 7:00 AM - 7:00 PM shift. According to documentation in Point Click Care (PCC) for the last 30 days, he received a shower on 11/02/22. Since 10/19/22 he received one (1) shower, 10 bed baths and four (4) days 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to ensure a notice of the behold policy was given to each resident and/or representative upon discharge from the facility. This was true for two (2) of three (3) residents reviewed for the care area of hospitalizations during the Long-Term Care Survey Process (LTCSP). Resident Identifiers: Residents #342 and #42. Census: 90. Findings included: a) Resident #342 A record review, for Resident #342, showed the resident had been transferred to the emergency department, on 11/04/22, because of a change of condition. Further review of the record, showed no evidence a written notice of the transfer, including readmission rights and the policy of the bed hold period was provided to the resident or resident's representative. An interview, with the facility Administrator, on 11/15/22 at 1:28 PM, verified the facilty failed to send the required written information of the bed hold policy or re-admission rights when Resident #342 was transferred to the hospital.…

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, observation and staff interview the facility failed to ensure three (3) of 27 residents Minimum Data Set (MDS) assessments were coded to accurately reflect the resident's status. Resident identifiers: #18, #35, and #22. Facility census: 90. a) Resident #18 Record review of the Resident's MDS with and ARD target date of 10/22/22 indicated seven (7) days of antibiotic use. Review of the Resident's orders and Medication Administration Record showed no record of antibiotics being ordered or administered in the month of October 2022. During an interview on 11/15/22 at 2:30 PM the Director of Nursing (DON) stated, I have looked everywhere and asked all the departments, we can't find where she got any antibiotics in October, so it must be coded wrong. b) Resident #35 During an interview on 11/14/22 at 12:20 PM Resident #35 stated, I can't chew the meat, it's too tough I don't have any teeth. I look at the tray and if I don't think I can eat it I ask for something else. Record review of the…

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

Based on record review, staff interview and resident interview the facility failed to provide Resident #4 with advance notice of care planning conferences to enable resident's participation. This was true for one (1) of 27 Residents reviewed in the sample. Resident identifier #4. Facility census: 90. Findings included: During an interview on 11/14/22 at 2:00 PM, Resident #4 stated, I just wish they would they [facility staff] would let me know about my transfer. Resident was asked if she was given the opportunity to attend her care plan meetings to discuss discharge planning and she stated she did not know what that was? The Resident further stated [Ombudsman's first and last name] came and met with her in her room recently but that was it. A record review showed no progress notes or recent care plan meeting notes within the medical record. During an interview on 11/16/22 at 12:15 PM the facility's Licensed Social Worker (LSW) stated she does not take care of the care plan meeting or invites. The LSW stated she just started working there in October 2022 and [Registered Nurse #90'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliations of all pre- and post - discharge medications. Also, the facility failed to ensure the discharge instructions were signed by the staff member completing the discharge and by the resident or the resident's representative. This was true for one (1) of one (1) residents reviewed for the care area of discharge. Resident identifier: #90. Facility census: 90. Findings included: a) Resident #90 Review of Resident #90's medical records showed the resident was discharged to home on [DATE]. Review of Resident #90's Discharge Instruction Form showed the section for discharge medications was blank. The section contained areas to list medication names, medication actions, dosages, and how and when to take the medications. None of these areas had been completed. The form also contained an area to indicate if 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, resident interview, and record review the facility failed to ensure that residents who are dependent for Activities of Daily Living (ADL) care receives necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was true for two (2) of three (3) residents reviewed for the care area of ADL care. Resident Identifiers: #77 and #89. Facility Census: 90. Findings Included: a) Resident #77 On 11/14/22 at 1:06 PM Resident #77's appearance was disheveled. He needed shaved, his hair was long and unkept and his finger nails were visibly dirty. He stated he is not getting his showers as he should be. He expressed his desire to take showers rather than bed baths and reported he had not had a shower in over a week. He also indicated he would like a hair cut and shave. This was confirmed on 11/14/22 at 1:15 PM with Licensed Practical Nurse # 89. A Record review found Resident #77 is scheduled for a shower twice a week on Wednesday and Saturday 7:00 AM - 7:00 PM 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.

Based on observation, resident interview, medical record review and staff interview the facility failed to follow the Physician's orders as written. This was true for two (2) of twenty-seven (27) sampled residents. Resident Identifier: #55 and #85. Facility Census: 90 Findings Included: a) Resident #55 On 11/14/22 at 1:51 PM it was observed that Resident #55 had an oxygen concentrator at bedside. He was not wearing oxygen at this time. He stated he is suppose to have it on, but since he was moved to his current room on 10/17/22, the staff has not set it up nor put it on him. It was confirmed with Licensed Practical Nurse #89 on 11/14/22 at 2:04 PM that Resident #55 had been without his oxygen for twenty-eight (28) days. A review of the medical record found a current order dated 9/04/22 for two (2) Liters of oxygen via nasal cannula. According to the current care plan he is to have Oxygen (02) via nasal canula @ 2 Liters per order for shortness of breath. b) Resident #85 1) Computed Tomography Scan On 11/14/22 at 12:30 PM, Resident #85 complained of having kidney stones. A review of…

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

Based on observation, record review, and staff interview, the facility failed to ensure an indwelling urinary catheter was maintained within professional standards of practice. The facility failed to ensure the catheter was anchored. The facility also failed to clarify and initiate bladder training ordered by the physician. The facility also failed to provide appropriate catheter care. This was true for one (1) of two (2) residents reviewed for catheter care. Resident identifier: #22. Facility census: 90. Findings included: a) Resident #22 Review of Resident #84's medical records showed the resident had an indwelling urinary catheter inserted on 11/04/22 when the resident was unable to urinate. On 11/15/22 at 9:19 AM, observation of Resident #84's catheter care was made. The catheter did not have an anchor to secure the catheter to the resident's thigh to prevent excessive tension on the catheter, which can lead to discomfort, urethral tears or dislodging of the catheter. Nurse Aid (NA) #84, who was performing the catheter care, confirmed the catheter was not anchored. Licensed…

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 monitor meal intakes for a resident with significant weight loss. This was true for one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #75. Facility census: 90. Findings included: a) Resident #75 Review of Resident #75's medical records showed on 05/12/22, the resident weighed 195 lbs. On 11/10/22, the resident weighed 171 pounds, which was a 12% loss in 6 months. Review of Resident #75's meal intake documentation for the last 30 days showed on eight (8) days the percentage of the meal eaten had not been recorded for every meal. - On 10/22/22, only one (1) meal intake had been recorded. - On 10/29/22, only two (2) meal intakes had been recorded. - On 10/30/22, only two (2) meal intakes had been recorded. - On 11/02/22, only two (2) meal intakes had been recorded. - On 11/03/22, only two (2) meal intakes had been recorded. - On 11/04/22, only two (2) meal intakes had been recorded. - On 11/06/22, only two (2) meal intakes had been recorded. - On 11/07/22, only two (2)…

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 medications were stored in accordance with currently accepted professional principles. A multi-use medication vial stored in the medication preparation room had not been discarded in the time frame recommended by the manufacturer after opening . Additionally, two (2) bags of intravenous fluids were past the manufacturer's expiration date. These were discoveries made during the facility task of medication storage. Facility census: 90. Findings included: a) East medication preparation room During investigation of the medication preparation room on [DATE] at 10:25 AM, a multi-dose vial of Mantoux tuberculin purified protein derivative (PPD) stored in the room refrigerator was noted to have an opening date of [DATE]. (Tuberculin purified protein derivative is given by injection to aid in the diagnosis of tuberculosis.) The vial's box stated the medication was supposed to be discarded 30 days after opening. Additionally, two (2) bags of .45%…

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 to ensure the residents care plan contained descriptions of care and services provided by hospice. This was true for one (1) of one (1) residents reviewed for the care area of hospice services. Resident identifier: 13. Facility census: 90. Findings included: a) Resident #13 Review of Resident #13's medical record on 11/15/22, showed a physician order: Hospice care services as of 08/10/22. Continued review found the care plan did not contain the required descriptions of care and services provided by hospice. On 11/16/22 at 11:50 AM the Director of Nursing (DON) confirmed neither the order, nor the care plan contained specific Hospice care information. .