Glenville Health & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and staff interview, the facility failed to perform a comprehensive assessment following significant change in a resident with weight loss of over 18% in less than three (3) months. This was found to be true for one (1) of one (1) residents reviewed during the long term care survey process. Resident identifier: #9. Facility census: 63. Findings included: a) Resident #9 Resident #9 was admitted to the facility on [DATE]. This resident does not have capacity to make own medical decisions. The resident is age [AGE]. Upon admission to the facility, the resident weighed 228.6 lbs. On 04/01/2026, the resident weighed 186.4 lbs which is a -18.46% weight loss. Resident #9's orders pertaining to diet were: -Regular diet, *Regular texture, *Regular/Thin consistencyfortified food at lunch Diet Active 1/27/2026 -Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals)Give 1 tablet by mouth one time a day for wound healingPharmacy Active 01/31/2026-Vitamin D3 Ultra Potency Oral Tablet 1250…

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 Minimum Data Set (MDS) was accurate regarding toileting schedule for Resident #48. This was true for one (1) of seven (7) residents sampled for accidents during the Long-Term Care Survey Process. Resident identifier: #48. Facility census: 63. Findings include: a) Resident #48 Resident #48's care plan reads, Toileting schedule: toilet resident upon rising, before and after meals and at bedtime. The significant change Minimum Data Set (MDS) dated [DATE] marked 'no' for both the urinary toileting program and the bowel toileting program. An interview with MDS coordinator #61 and the Director of Nursing (DON) at 11:45 AM on 04/15/26 confirmed that the care plan stated Resident #48 had a toileting schedule, but the MDS was marked as having no schedule.

Based on observation, record review, and staff interview, the facility failed to ensure Resident #6 received Oxygen therapy as ordered by physician. This was true for one (1) of two (2) residents sampled for Oxygen during the Long-Term Care Survey Process. Census: 63 Resident identifier: #6 Findings include: a) Resident #6 On 04/14/2026 at 2:00 PM, state surveyors observed Resident #6 in the therapy gym without oxygen. At 2:41 PM, Resident #6 was still in the therapy gym without oxygen. According to Resident #6's orders and care plan, the resident was to receive five (5) liters/minute at 28% humidification via tracheostomy mask. An interview with the Director of Nursing (DON) and Director of Rehab at 2:41 PM confirmed the resident was without oxygen and had been without oxygen during therapy. An interview with the DON at 4:00 PM confirmed the resident should have oxygen per current documented orders.

Based on Interview, and record review the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for one (1) of five (5) residents reviewed for pain during the long-term survey process. Resident Identifier: #42. Facility census: 63.Findings included: a) Resident #42During an interview on 04/13/26, at 1:18 PM, Resident #42 reported experiencing constant pain. She stated that she was only provided with Tylenol, which she felt was ineffective most of the time. Additionally, she mentioned that she remained awake and wandered throughout the night due to the severity of her discomfort. Medical record review revealed Resident #42's Physician orders for pain management:-Tylenol 8-hour Arthritis Pain Oral Tablet Extended Release 650 MG (Acetaminophen): Give 650 MG by mouth 3 times a day for mild to moderate pain. With supplemental documentation for the pain level. The start date was 07/07/2025. -Monitor for pain every shift. Start date 09/03/2025.A continued 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to work to identify a resident's past history of trauma, and/or triggers which may cause re-traumatization. This was found to be true for one (1) of two (2) residents reviewed for PTSD during the long term care survey process. Resident identifier: #25. Facility census: 63. Findings included: a) Resident #25 This [AGE] year old resident has the capacity to make own medical decisions. Resident was admitted to the facility on [DATE]. This surveyor attempted three times to interview the resident, but each time the resident was asleep. A review of the resident's medical record documented a trauma screening was performed on 01/14/26 by the Director of Social Services. To the question, Was care plan updated to reflect the resident's experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization. A response of yes was marked. From the care plan:the resident reported drauma during their trauma…

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

Based on observation and staff interviews, the facility failed to provide each resident the right to be treated with dignity and respect when passing meal trays. This was true for four (4) of thirty-three (33) residents observed in the dining room. Resident identifiers: #9, #28, #31 and #61. Facility census: 63 Findings include: a) On 10/23/24 at 12:05 PM during observation of the noon meal tray pass in the dining room there were five (5) residents observed at one table. Resident #5 received her lunch at 12:05 PM. The remaining four (4) residents were not served their tray and staff members continued to serve residents at the other three (3) tables. At 12:08 PM Resident #31 asked, Can we have our food now? The staff member walking past responded, We are getting it. At 12:12 PM staff members began serving the remaining residents sitting at this table. The last meal was served to Resident #61 at 12:16 PM. This left the four (4) residents sitting at the table for seven to eleven (7-11) minutes with Resident #5 while she ate her meal. On 10/23/24 at 12:17 PM Licensed Practical Nurse…

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 residents were able to examine the results of the most recent survey. This had the potential to affect more than an isolated number of residents. Facility census: 63. Findings included: a) An observation of the survey book in the facility revealed the last survey results that were in the survey book were from the annual inspection in November 2022. On 10/24/24 at 1:00 PM the administrator said one of the residents in the facility keeps getting papers out of the book. A review of the facility's survey history revealed complaints investigated in February 2023, September 2023 and February 2024 all had citations associated with them.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to provide a home like environment. This was true for four (4) of nine (9) rooms observed. Room identifiers: #104, #108, #110, #213. Facility Census: 63 Findings included: a) room [ROOM NUMBER] On 10/23/24 at 1:30 PM observation of nine (9) rooms in the facility found that four (4) rooms did not have a homelike environment. room [ROOM NUMBER] had two (2) residents residing in the room and there were no comforters or chairs provided for them. On 10/23/24 at 2:45 PM during an interview with the resident in (B bed), she was asked if she felt like her room was like her home prior to coming to the facility. She said it was not. b) room [ROOM NUMBER] room [ROOM NUMBER] had two (2) residents residing in the room and there were no comforters or chairs provided for them. On 10/23/24 at 3:00 PM during an interview with the resident in (B bed) he was asked if he felt like his room was like his home prior to coming to the facility. He said it was not. c) room…

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

Based on medical record review and interview, the facility failed to develop person-centered comprehensive care plans. The facility failed to develop care plans for a lap tray, dental issues, specialty mattress and failed to develop a resident centered care plan. This practice affected four (4) of (24) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #2, #61, and #64. Facility census: 63. Findings included: a) Resident #2 An observation on 10/21/24 12:45 PM Resident #2 had a lap tray in place in the dining room while eating lunch. A second observation on 10/22/24 at 845 AM Resident #2 had a lap tray in place when eating breakfast. A review of the current care plan showed there was no care plan addressing a lap tray during meals with interventions and goals. This showed it was not updated to reflect the residents' current status. A third observation on10/22/24 at 12:03 PM found the lap tray in place during lunch. On 10/22/24 at 12:14 PM during an interview the Administrator stated the tray was used for a table to eat only. During…

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

Based on observation and staff interview the facility failed to maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections by not providing hand hygiene prior to meals. Facility Census: #63 Findings include: On 10/23/24 at 11:55 PM during the noon meal pass it was observed that residents in the dining room were not provided hand hygiene prior to their meal. On 10/23/24 at 12:17 PM It was confirmed with Licensed Practical Nurse #26 that the residents are to be offered hand hygiene prior to their meal. She stated it is usually either a towelette or a pump of hand sanitizer (anti bacterial disinfectant), I am not sure why they did not offer it to the residents today.

The facility failed to honor resident choices regarding the things that are important in her life regarding making her bed early in the morning. This is true for one (1) of (1) residents reviewed for choices. Resident Identifier #25. Facility census: 63. Findings included: a) Resident #25 During an observation with Resident #25, on 10/21/20 at 9:02 AM, she was upset about the staff not making her bed. On 10/22/24 at 08:57 AM during an interview, Resident #25 became upset and tearful about her bed not being made. She stated, They don't help me get my bed made in the mornings. She continued to say that she had to ask staff to come and make the bed all the time. On 10/22/24 at 3:36 PM during an interview the Social Services director revealed she was aware that Resident #25 liked her bed made early and got upset when it was not made. During an interview, on 10/23/24 at 1:15 PM, the Physical Therapy director stated that Resident #25 did get upset when staff did not make her bed and would refuse therapy treatment. No further information was provided prior to the end of the survey 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family interview, and staff interview, the facility failed to provide appropriate notice of transfers or discharge for one (1) of two (2) residents reviewed for the care area of discharge. The facility failed to provide a facility-initiated discharge notice at least 30 days before the resident was discharged . For one (1) of five (5) residents reviewed for the care area of hospitalizations, the facility failed to notify the resident's representative of a hospital transfer and the reasons for the move in writing. Resident identifiers: #168, #47. Facility census: 63. Findings included: a) Resident #168 The Director of Nursing (DON) and Administrator were interviewed on 10/24/24 at 11:15 AM regarding an anonymous complaint regarding a resident elopement. The resident had not been identified in the complaint. The DON and Administrator identified Resident #168 as a resident who was exit seeking and walked around the facility's campus and surrounding area with staff, but never actually eloped.…

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, family interview, and staff interview, the facility failed to provide a written bed hold notice to the Medical Power of Attorney (MPOA) for one (1) of five (5) residents reviewed for the care area of hospitalizations. Resident identifier: #47. Facility census: 63. Findings included: a) Resident #47 Review of Resident #47's medical records showed the resident was transferred to the hospital on [DATE] due to fever and increased secretions. The resident did not have capacity to make medical decisions. The resident returned to the facility 04/14/24. Further review of Resident #47's medical records showed a Bed Hold Notice of Policy and Authorization. The notice had been signed by a Licensed Practical Nurse, as the representative for the Center. However, the notice was not signed by the Resident Representative. On 10/23/24 at 4:25 PM, the Director of Nursing (DON) stated Resident #47's representative was called and informed of the bed hold policy. She stated the Bed Hold Notice of Policy and…

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

Based on resident interview, medical record review and staff interview the facility failed to ensure they facilitated a resident's involvement and invited him in advance to his care plan meeting. Resident identifier: #54. Facility census: 63. Findings included: a) Resident #54 During an interview with Resident #54 on 10/22/24 at 11:59 AM he commented that he did not know anything about care plan meetings. Review of the medical record did not reveal any documentation regarding the facility's invitation to Resident #54 for care plan meetings or their facilitation to involve him in these meetings. During an interview with the social worker on 10/23/24 at 9:00 AM she said she goes around the day of the care plan and talks to the resident and asks him if he wants to attend the meeting. The medical record review revealed an invitation to the care conference scheduled for 10/24/24. The social worker said this invitation was mailed to the legal representative. Care plan conference sign in sheets for meetings held on 05/09/24, 02/08/24, 11/08/23, and 08/16/23 did not reveal the resident 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 record review, observation, resident interview, and staff interview the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of each resident. This had the potential to affect a limited number of residents residing at the facility. Resident identifiers: #34 and #12. Facility census: 63. Findings included: a) Resident #34 During multiple observations of Resident #34 on 10/21/24, 10/22/24 and 10/23/24, the resident was lying in bed with no activities being provided. Record review revealed an activities participation sheet. The activities assessments revealed one (1) on one (1) activities were required. During an interview on 10/23/22 at 12:48 PM with the facility Activities Director (AD) she stated that there was not any documentation of one (1) on one (1) activities being provided. She stated she only had one other staff member to provide activities seven (7) days a week. b) Resident #12 On 10/21/24 at 3:19 PM Resident #12 stated she liked…

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 two (2) residents had received care and treatment in accordance with professional standards of practice, and the comprehensive care plan. For Resident #61 they failed to follow a physician's order for wound care and failed to provide. For Resident #33 they failed to follow the care plan for the use of a palm protector. Resident identifiers: #61, #33. Facility census: 63. Findings included: a) Resident #33 An observation on 10/21/24 at 2:57 PM revealed Resident #33 had a contracture to his left hand. The resident said she had suffered a stroke. The resident's medical record revealed she had a left hand contracture. Observations throughout the day on 10/21/24 and 10/22/24 revealed the resident's palm protector was not in place. On 10/24/24 at 11:15 AM during an interview with Certified Occupational Therapy Assistant (COTA) #66 he stated he had recommended the palm protector when he worked with Resident #33. A palm protector can help with hand contractures by preventing skin breakdown and keeping…

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 monitor weights as ordered by the physician for a resident at risk for weight loss. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of nutrition. Resident identifier: #64. Facility census: 63. Findings included: a) Resident #64 Review of Resident #64's comprehensive care plan showed the following focus initiated on 09/04/24, The resident has nutritional problem or potential nutritional problem r/t [related to] poor po [oral] intakes, need for mechanically altered diet, T2DM [type II diabetes mellitus], anxiety, PCM [protein calorie malnutrition], dementia, depression, Alzheimer's, underweight, presence of wound increasing needs. Review of Resident #64's physicians' orders showed an order written on 08/31/24 for the resident to be weighed daily for three (3) days, weekly for four (4) weeks, then monthly. Resident #64's documented weights were as follows: - 08/31/24: 128.2 pounds (lbs) - 09/01/24: 128.2 lbs - 09/23/24: 122.2 lbs - 10/01/24: 121.8 lbs Resident…

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 laboratory reports filed in the resident 's clinical record. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #64. Facility census: 63. Findings included: a) Resident #64 Review of Resident #64's physicians' orders showed an order for laboratory testing written on 09/03/24. The laboratory testing to be performed was complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), and Hemoglobin A1c (HgA1c). Resident #64's medical records contained the results for a CBC and HgA1c obtained on 09/05/24. The results contained the notation that the records were reviewed by [physician's initials] on 09/06/24. On 10/23/24, the Director of Nursing (DON) brought the CMP and TSH results to the surveyor. She stated she had obtained the results from the hospital laboratory who had tested the blood sample. The DON stated she didn't know why these results were not in the resident's…

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

Based on observation and staff interviews, the facility failed to store a resident's beverages in accordance with professional standards for food service safety related to storage. This has the ability to affect more than a limited number of Residents. Facility census: 63. Findings included: a) Nutrition pantry During the initial kitchen tour on 10/21/24 at 11:30 AM an observation of the nutrition pantry found a Residents 12 pack of Coke cans and two (2) six (6) packs of bottled Dr Pepper, and a coffee pot stored under the sink by the sewer/waste disposal pipe. On 10/21/24 at11:35 AM during an interview with the Dietary Manager (DM) verified that resident's soda or coffee pot should not be stored under any sink. The soda and the coffee pot were removed at this time.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the Electronic Medical Record (EMR) and staff interview, the facility failed to maintain an accurate medical record for Resident #6. This was true for one (1) of three (3) residents reviewed for pressure ulcers. This had the potential to affect a limited number of residents. Resident identifier: #6. Facility census: 62. Findings included: a) Resident #6 A review of the EMR on 12/18/24 at approximately 2:15 PM found pressure ulcer measurements for Resident #6 on 11/26/24, 11/29/24, 12/06/24, 12/13/24, and 12/17/24. The resident was in the hospital from [DATE] through 12/08/24 when the Resident returned to the facility. At approximately 3:00 PM on 12/18/24, the Director of Nursing (DON) stated that she had made a mistake and there were no measurements during the time in which Resident #6 was in the hospital. In addition the DON stated that the measurements on 12/13/24 and 12/17/24 were correct and that the measurements on 11/26/24, 11/29/24, 12/06/24 had been struck out.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure alleged violations involving resident abuse were reported, not later than 2 hours after the events / allegations were brought to the facility's attention, to appropriate state agencies as required. This was a random opportunity for discovery during a complaint survey. Resident identifier: #29. Facility census: 61. Findings iincluded: a) Resident #29 On 02/20/24 at 12:25 PM, a review of facility reportables from September 2023 - Present was completed. There was an abuse reportable, dated 02/05/24, which revealed the following details: -An allegation of abuse was made against Licensed Practical Nurse (LPN) #70. -The victim of abuse was Resident #29. Resident #29 was an [AGE] year-old white female who was admitted as a long-term care resident on 04/04/22. Resident #29 had a diagnosis of Alzheimer's/Dementia and lacked capacity to make decisions for herself. -LPN #3 witnessed the incident between LPN #70 and Resident #29. LPN #3's gave the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to develop or implement a comprehensive person-centered care plan with measurable objectives for behaviors. This was true for one (1) of three (3) residents reviewed during the Complaint Survey Process. Resident Identifiers: Resident #63 Facility Census 61. Findings Included: a) Resident #63 On 02/20/24 at 12:05 PM, a brief medical record review found Resident #63 was admitted to the facility on [DATE] with a Brief Interview of mental status (BIMS) of 3 and lacking capacity. Further review of the medical record found the following physician order: behaviors - monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression and refusing care. A review of Resident #63's care plan found no goals, focus statements or interventions related to Resident #63's behaviors or behavior…

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 they maintained housekeeping and maintenance necessary to maintain a sanitary, orderly and comfortable interior. Environmental issues were found on both of the facility's hallways. These observations were random opportunities for discovery. Facility census: 58. Findings included: a) On 09/13/23 at 10:15 AM the environmental supervisor and later the housekeeping supervisor accompanied the surveyor to the rooms with concerns. room [ROOM NUMBER], #115, #202, and #214 had been identified on 09/11/23 as having issues that needed addressed. The following was observed in room [ROOM NUMBER]: holes in the wall near the bed, chipped Formica in the window seal. The following was observed in room [ROOM NUMBER]: Cracked floor tile near the air conditioning unit, cracked Formica on the window seal and dirt and debris inside the heating/air conditioning unit. The following was observed in room [ROOM NUMBER]: Splashes on the wall underneath the sink. 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 ensure when (1) of three (3) residents reviewed had a change in medication and issues with sexually inappropriate behaviors the medical power of attorney was notified. Resident #59. Facility census: 58. Findings included: a) Resident #59 A review of Resident #59's medical record revealed an order dated 03/06/23 for Cimetidine Oral Tablet 200 milligram (mg). The medication was ordered to be given as follows: One (1) tablet by mouth two (2) times a day for sexually inappropriate behaviors. Medication Administration Record (MAR) for March 2023 revealed Resident #59 received Cimetidine as ordered on 03/07/23, 03/08/23, 03/09/23, 03/10/23, 03/11/23, 03/12/23, 03/13/23, 03/14/23 and once on 03/15/23. Further medical record review revealed Cimetidine was discontinued on 03/15/23 per family request. A review of Resident #59's progress notes, and care plan did not reveal any sexually inappropriate behaviors. The minimum data set (MDS) review included a review of the admission assessment and quarterly MDS review.…

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, observations and staff interview the facility failed to ensure three (3) randomly observed residents received the assistance needed to promote adequate grooming. Residents were observed with long, dirty fingernails. Resident identifiers: #23, #51, and #47. Facility census: 58. Findings included: a) Resident #23 An observation of Resident #23 on 09/11/23 at 4:17 PM, revealed the resident had long fingernails. He said he would like to have them cut shorter. A Minimum Data Set (MDS) review revealed a quarterly assessment with an Assessment Reference Date (ARD) of 07/03/23. Under Section E which assesses a residents need for assistance with activities of daily living the resident was assessed as needing extensive assistance with personal hygiene. b) Resident #51 The resident was observed on 09/11/23 at 1:40 PM. He was observed to have long fingernails. He was interviewed and said he would like to have them cut. He said sometimes his family would cut them for him. His MDS with an ARD of 06/30/23 revealed he was extensive assist with personal hygiene. C)…

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 one (1) of three (3) resident's drug regimen was free from unnecessary drugs. Resident #59 had been prescribed a medication without indication for use. Resident identifier: #59. Census: 58. Findings included: A review of Resident #59's medical record revealed an order dated 03/06/23 for Cimetidine Oral Tablet 200 milligram (mg). The medication was ordered to be given as follows: One (1) tablet by mouth two (2) times a day for sexually inappropriate behaviors. The Medication Administration Record (MAR) for March 2023 revealed Resident #59 received Cimetidine as ordered on 03/07/23, 03/08/23, 03/09/23, 03/10/23, 03/11/23, 03/12/23, 03/13/23, 03/14/23 and once on 03/15/23. Further medical record review revealed Cimetidine was discontinued on 03/15/23 per family request. A review of Resident #59's progress notes, and care plan did not reveal any sexually inappropriate behaviors. The minimum data set (MDS) review included a review of the admission assessment and quarterly MDS review. Section E which assessed…

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 the Minimum Data Set (MDS) for Resident #13, #5 and #20 was coded to accurately reflect the residents status. This was true for three (3) of 21 sampled residents during the long term care survey process. Resident Identifiers: #13, #5 and #20. Facility Census: 57. Findings Included: a) Resident #13 A review of Resident #13's medical record on 11/28/22 found the resident was sent to an acute care hospital on [DATE]. Further review of the record found a Minimum Data Set (MDS) with an Assessment Reference Date of 08/06/22. This MDS was coded under section A0310. Type of Assessment F. Entry/discharge reporting with a number 10 indicating the resident was discharged with a return not anticipated. An interview with the Director of Nursing (DON) on 11/30/22 at 10:06 am confirmed the MDS should have been coded Discharge Return Anticipated because the resident was sent to the hospital for an acute illness and was expected to return once her…

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 nurse aides had an employee performance review completed at least annually. This was true for five (5) of five (5) Nurse Aides reviewed. This failed practice had the potential to effect more than an isolated number of residents. Employee Identifiers: Nurse Aide (NA) # 49, NA # 53, NA #54, NA #30 and NA #40. Facility Census: 57. Findings Included: a) Employee Performance Reviews On 11/29/22 the Nursing Home Administrator (NHA) was asked to provide the current nurse aide performance reviews for Nurse Aide (NA) #49, NA #53, NA #54, NA #30, and NA #40. On 11/30/22 at 8:20 am the NHA was asked if she had the requested NA performance reviews. She stated, We have not done those within the last year. When asked when the last one was completed she stated, The last one was done before COVID. .

Based on record review and staff interview the facility failed to ensure the nurse staffing information posted daily contained the correct number of staff working including the actual hours worked for each licensed and unlicensed staff directly responsible for resident care per shift. This failed practice had the potential to more than a limited number of residents currently residing in the facility. Facility Census: 57. Findings included: a) Nurse Staff Postings A record review of the Nurse Staff Postings maintained by the facility as well as the facility's Hours Per Patient Day (HPPD) report for the time frame of 04/01/22 to 06/30/22, found on the following occasions the nurse staff posting hours were more than the actual hours worked on the HPPD report which is generated from the time clock hours when the staff punch in and out for their shift. The HPPD report contains the acutal number of hours worked by those providing direct care to the residents. -- 04/01/22 the staff posting indicated a total of 167 hours of direct care, but the HPPD report indicated a total of 143.75 total…

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 #49's drug regimen was free from unnecessary psychotropic medications. Resident #49's physician agreed to decrease Resident #49's antipsychotic medication on 06/20/22. This medication was not decreased until 07/18/22 which was 28 days after the physician agreed to discontinue the medication. In addition nursing staff was identifying on the Medication Administration Record (MAR) that Resident #49 had side effects related to psychotherapeutic medications, but failed to identify what the side effect was and/or to implement an alternative plan of care without side effects. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident Identifier: #49. Facility Census: 57. Findings Included: a) Resident #49 1. Gradual Dose Reduction of Seroquel A review of Resident #49's medical record found a Consultation Report issued by the pharmacist containing a recommendation date 07/18/22. The comment on the recommendation…

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.

c) Resident (R) #20 Review of the medical record on 11/30/22 revealed R #20's hospital after visit summary notes he takes Buspirone (antianxiety medication) twice a day for repeated episodes of anxiety. The physician's history and physical dated 08/05/2022 states past medical history: As above, and see hospital records and no change in condition under the psychiatric system. The physician admission orders include Buspirone hydrochloride 10 milligrams (mg) twice a day for anxiety. The diagnosis section of the medical record and the admission minimal data set (MDS) assessment with an assessment reference date of 08/15/20 are silent for the diagnosis of anxiety. During an interview on 11/30/22 at 09:24 AM, the Director of Nursing (DON) confirmed R#20's active diagnosis of anxiety is not listed in the diagnosis section of the medical record or in the admission MDS assessment. Based on medical record reviews and staff interviews the facility failed to provide complete and accurate medical records. Resident #34 had incomplete hospice interventions on the care plan and Resident #20 had 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, resident interview 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. Staff were unaware of the correct procedures to follow for residents in isolation, isolation carts for soiled gowns were not hands free, and medications were not administered safely in an isolation room. This practice has the potential to affect more than a limited number of residents currently residing in the facility. Facility census: 57. Findings include: a) Staff isolation practices A random observation on 11/28/22 revealed a resident room marked with a stop sign stating Standard plus Contact precautions to prevent the spread of infection. Please see the nurse before entering the room. When asked, Licensed Practical Nurse (LPN) #29 reported the isolation was for Resident (R) #159's foot wound which contains Vancomycin Resistant Enterococci (VRE). LPN #29 reported anyone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to complete a baseline care plan in a timely manner. This was true for one (1) of ten (10) new admissions reviewed. Resident identifier #258. Facility Census: 57. Findings Included: a) Resident #258 A review of Resident #258's medical record found the resident was admitted on [DATE] with a femur fracture and urinary tract infection (UTI) as well as Alzheimer's disease, a history of falls, hypertension, coronary artery disease, muscle weakness and difficulty walking. Further review of the medical record on 11/30/22 found no baseline care plan for Resident #258. An interview with the Administrator on 11/30/22 at 1:00 pm confirmed Resident #258 did not have a baseline care plan and should have. .

Based on record review and staff interview, the facility failed to develop a comprehensive care plan to meet Resident #20's mental and psychosocial needs. This is true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the long term survey process. Resident identifier: #20. Facility census: 57. Findings included: a) Resident #20 Review of the medical record on 11/30/22 revealed Resident #20's hospital after visit summary notes he takes Buspirone (antianxiety medication) twice a day for repeated episodes of anxiety. The physician admission orders include Buspirone hydrochloride 10 milligrams (mg) twice a day for anxiety. The care plan identifies a focus of limited engagement related to a diagnosis of depression, but lacks any goals or interventions. In addition, the care plan is silent for Residnet #20's diagnosis of anxiety and the administration of his psychotropic medications. During an interview on 11/30/22 at 09:24 AM, the Director of Nursing (DON) confirmed Resident #20 has diagnoses of anxiety and depression. The DON acknowledged the…

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

Based on medical record review and staff interview the facility failed to review and revise the care plan in relation to the Resident's nutrition assessment orders. This was true for One (1) of 21 sampled residents reviewed during the long term care process. Resident Identifier: #41 Facility Census: 57 Findings Included: a) Resident #41 A review of Resident #41's medical record found the following current physician orders: -- House Supplement two times a day house shake 2 time/day at 10 AM and evening snack providing 400 calories/12 gm protein r/t (related to) weight loss. Order date 7/26/22 -- Regular diet Regular Texture texture. Order date 10/28/22 -- Obtain Monthly weight every day shift every 1 month(s) starting on the 10th for 1 day(s). Order date 11/01/22 Resident #41's current care plan (created on 6/28/22) read as follows: Focus: Resident is at nutritional risk related to dementia with new environment, hx (history) of significant weight loss. Goal: Resident will receive and tolerate diet as ordered without s/s (signs or symptoms) aspiration or dysphagia and will consume…

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 follow their own policies, or state law as related to discharges which are Against Medical Advice (AMA) for Resident # 55. These practices affected one (1) of two (2) resident's reviewed for the care area of discharges during the Long-Term Care Survey Process (LTCSP). Resident Identifier #55. Facility census 57. a) Resident #55 A review of Resident #55's medical record on 11/29/22 found Resident #55 was discharged from the facility on 11/12/22. Contained in the medical record was a Voluntary Discharge Against Medical Advice form that was signed by Resident #55 dated 11/12/22. A review of the facility's policy titled, Discharge Against Medical Advice (AMA) with an effective date 06/01/96, found the following: . Documenting the AMA : . 7. The discharge transition plan will be provided to the patient or resident representative. Efforts will be made to make referrals to community resources and agencies to the extent possible. The Nursing Home…

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 obtain a re-weight after the Resident experienced a significant weight loss. This was true for one (1) of four (4) residents reviewed for weight loss. Resident Identifier: #41 Facility Census: 57 Findings Included: a) Resident #41 Resident #41 has current orders for: -- House Supplement two times a day house shake 2 time/day at 10 AM and evening snack providing 400 calories/12 gm protein r/t weight loss. Order date: 07/26/22 -- Regular diet Regular Texture texture. Order date: 10/28/22 -- Obtain Monthly weight every day shift every 1 month(s) starting on the 10th for 1 day(s). Order date 11/01/22 The medical record contained the following weights: 11/10/22 at 4:55 pm 149.0 Pounds(Lbs) 11/1/22 at 5:00 pm 147.6 Lbs 10/10/22 at 09:04 am 147.6 Lbs 10/3/22 at 6:07 pm 147.0 Lbs 09/26/22 at 10:21 am 146.0 Lbs 09/19/22 at 11:23 am 146.0 Lbs 09/12/22 at 4:27 pm 145.6 Lbs 09/5/22 at 09:08 am 145.8 Lbs 08/29/22 at 09:24 am 146.2 Lbs 08/22/22 at 10:19 am 144.0 Lbs 08/15/22 at 07:52 am 144.4 Lbs 08/08/22 at 4:37 pm 143.2…

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.

Based on observation and staff interview the facility failed to serve food in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered dietary staff had not used proper hand sanitation. This failed practice had the potential to affect a limited number of residents. Facility census: 57. Findings included: a) Kitchen tour During the kitchen tour an observation on 11/28/22 at 12:01 PM, revealed Dietary Aide (DA) #5 had picked up mustard packets, that had fallen to the floor. DA #5 did not wash her hands before returning to the beverage and dessert area of the tray service line, and began serving food and/or beverages. An interview with DA #5 on 11/28/22 at 12:02 PM, verified she picked up the mustard packets from the floor and did not wash her hands before resuming the service of food. .

Based on medical record review and staff interview, the facility failed to collaborate with hospice services to develop a coordinated care plan for one (1) of one (1) residents reviewed for the care area of hospice during the Long Term Care Survey Process. The care plan for Resident #34 did not specify when and what services were to be provided by the hospice staff. Resident identifier: #34. Facility census: 57. Findings included: a) Resident #34 A medical record review on 11/30/22 for Resident #34, revealed the care plan did not include any information regarding when the hospice nurse aides and nurses would visit and what specific services they would provide. An interview with the Nursing Home Administrator (NHA) on 11/30/22 at 12:29 PM, verified the care plan for Resident #34 did not specify care and services to be provided by the hospice staff. .