Summers Healthcare Center

Based on observation, record review, staff interview and resident interview, the facility failed to ensure food preparation/food service areas and resident rooms were free from visible signs of insects. This failed practice had the potential to affect more than a limited number of residents: Resident identifiers: #26 and #112. Facility Census:102 Findings included: On 08/14/25 at 9:45 AM, the administrator reported there was a Quality Assurance and Performance Improvement (QAPI) for flies with increased services added bi-weekly May-October. Three (3) large fly lights were installed at 2 exit doors to courtyard and main facility entrance. The Administrator reported there was no specific policy and procedure for pest control. On 08/13/25 at 9:55 AM, a fly was observed in the dishwasher area. At 12:25 PM, a fly was in the kitchen area around the food service area, near plates and food, and tray line. [NAME] #137 confirmed there was a fly in the area and stated, Yes, he targets me. On 08/20/25 at 11:36 AM, during the initial interview process, Resident #26 stated, I'm alright if the fly…

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 ensure the continuing competence of nurse aides by not providing at least twelve (12) hours of continuing education per year. This was found to be true for three (3) of five (5) nurse aide training records reviewed during the annual survey process. Nurse Aide (NA) identifiers: #5, #10, and #77. Facility census: 102. Findings included: a) Nurse Aide (NA) #5 Nurse Aide #5 was hired on 01/05/24. The facility provided a Relias transcript for the period of 08/01/24 through 07/31/25. A review of this transcript records 8.35 hours of education completed during this period including 1.5 hours of training related to Alzheimer's disease or dementia. b) Nurse Aide (NA) #10, Nurse Aide (NA) #10's date of hire was 05/19/20. The facility provided a Relias transcript for the period of 08/01/24 through 07/31/25. A review of this transcript records 9.1 hours of education completed during this period including 2.5 hours of training related to Alzheimer's disease or dementia. c) Nurse Aide (NA) #77 Nurse Aide #77 was hired 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 upon record review and staff interview, the facility failed to inform a resident's representative of the benefits and risks of psychotropic medication. This was found to be true for one (1) of five (5) residents reviewed during the annual survey process. Resident identifier: #6. Facility census: 102a) Resident #6A review of the Resident's medical record, Section entitled Orders, documented the following psychotropic medications being given: Zyprexa Oral Tablet 15 MG (Olanzapine)Give 15 mg by mouth at bedtime for schizoaffective disorder04/03/25The Resident did not have capacity to make her own Informed consents, so the representative signed and acknowledged consent specifying the benefits and risks affiliated with the following medications on 12/04/24 for Lorazepam, Zoloft, Haloperidol.There was no informed consent in the medical record for Zyprexa, so this was requested during the survey. The Director of Nursing (DON) verified on 08/13/25 at 10:35 AM that she could not locate a consent form for Zyprexa.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to honor residents' rights to establish directives regarding end-of-life care. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of advanced directives. Resident Identifier: #23. Facility census: 102. Findings included:a) Resident #23The facility's policy titled, Advance Directive (Resident's Right to Choose), with no implementation date or revision dates given, stated, Any decision making regarding the resident's choices in their medical order for life-sustaining treatment and/or advance directive will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.Review of Resident #23's electronic health record (EHR) showed a Physician's Determination of Capacity dated [DATE]. The physician determined the resident had the capacity to make medical decisions. Further review of Resident #23's EHR showed a [NAME]…

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 thoroughly investigate an allegation of resident to resident abuse for one(1) of nine (9) residents sampled during the facility's annual survey review . This failed practice had the potential to affect a limited number of residents. Resident identifier: #110. Facility Census: 102.Findings included:On 06/13/25 at 10:40 PM, an initial reporting of allegations was reported to the Office of Health Facility Licensure and Certification. The description of the allegation was as follows:Resident [#110] was coded by facility staff. CPR [cardiopulmonary resuscitation] and AED [automated external defibrillator] administered. EMS [emergency medical services] arrived at 8:45 PM to transport resident while still performing CPR. Call back from facility by paramedic at 9:18 PM to inform facility that resident has 2 quarter [NAME] [size] pieces of hamburger extracted from throat.The steps taken immediately to ensure the alleged victim was protected was to place…

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 upon record review and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASARR) when a new diagnosis of a major mental disorder occurred. This was found to be true for one (1) of ten (10) residents reviewed during the annual survey process. Resident identifier: #6. Facility census: 102.Findings Included:A) Resident #6The Resident's PASARR was completed on 11/07/24 by the facility. At that time the resident had the following diagnoses Bipolar Disorder, unspecified and Generalized Anxiety Disorder. Section V of the PASARR is Supplemental Questions. Question 40 is Major Mental Illness or suspected MI, with a list of options to check. Checked on this question was:#F for Schizoaffective Disorder and#H for Other. Other was specified to be Bipolar disorder, unspecified and Generalized Anxiety Disorder. A Level II evaluation was not required. A review of the Resident's medical record, Section entitled Medical Diagnoses listed the following mental health diagnoses: BIPOLAR DISORDER, UNSPECIFIED 5/18/2022 DX #11 During StayGENERALIZED…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to implement Resident #33's care plan in regards to weights and Resident #85's care plan in regards to pain management. This was true for two (2) of 37 sampled residents reviewed during the long term care process. Resident Identifier: #33 and #85. Facility Census #102. Findings Include: a) Resident #33 A review of Resident 33's medical record on 08/11/25 found the following focus statement on the care plan: -- Resident with potential for altered nutrition status/nutrition related problems d/t diabetes obesity vitamin d deficiency, need for vitamin supplements, c/o heartburn w. nausea at times. He has the potential for weight fluctuations r/t kidney failur w/HD. Planned weight loss program r/t scheduled paracentesis. The goal associated with this practice statement read as follows: Resident will maintain adequate nutritional status through review dates as evidenced by consuming 75% of meals. The interventions related to this focus statement included:…

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 revise the comprehensive care plan when the resident's wishes for end-of-life treatment changed. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of advance directives. Resident Identifier: #23. Facility census: 102.Findings included:a) Resident #23 The facility's policy titled, Advance Directive (Resident's Right to Choose), with no implementation date or revision dates given, stated Any decision making regarding the resident's choices in their medical order for life-sustaining treatment and/or advance directive will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Review of Resident #23's electronic health record (EHR) showed a Physician's Determination of Capacity dated [DATE]. The physician determined the resident had the capacity to make medical decisions. Further review of Resident #23's EHR…

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 upon record review and staff interview, the facility failed to ensure the Resident's environment remained as free of accident hazards as possible. This was found to be true for one (1) of seven (7) residents reviewed during the annual survey process. Resident identifier: #10. Facility census: 102. Findings included: A) Resident #10 On 08/12/2025 at 9:45 AM, during a visit with this resident, a disposable razor was observed laying beside the resident's sink in the bathroom. The resident was in a private room. Resident #10 has diagnoses of Post Traumatic Stress Disorder (PTSD), Delusional Disorders, Anxiety, Anger, Irritability, Dementia, and Paranoid Personality Disorder. He does not have capacity to make his own medical decisions. Based upon these diagnoses and his mental capacity, the Resident could possibly use the razor to harm himself or harm others with the razor, making it a safety hazard. Once the interview with the Resident was concluded, the Nursing Home Administrator (NHA) was sought out by the surveyor. We returned to the room together. The Resident had left his…

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 ensure Resident #85 was provided with colostomy care in accordance with professional of care and to meet the needs of the resident. This was true for one (1) of one (1) residents reviewed for colostomy care during the long term care survey process. Resident Identifier: #85. Facility Census: 102. a) Resident #85 During an observation on the first day of the survey in the afternoon Resident #85 was observed leaving his room. Bowel movement was observed falling from the resident colostomy bag onto the floor. Resident #85 was assisted back to his room by a nurse at that time. A review of Resident #85's medical record found Resident #85 was admitted to the facility on [DATE]. Further review of the record found a hospital Discharge summary dated [DATE]. This discharge summary indicated the resident was to follow up with the surgeon in regards to his colostomy in 2-4 weeks after discharge. Upon further review of the record it was discovered…

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 store medications in accordance with professional standards of practice. A multi-use vial of insulin was not dated when first accessed. This was a random opportunity of discovery. Resident #107. Facility census: 102.Findings included:a) Resident #107 The facility's policy titled, Vials and Ampules of Injectable Medications, with no effective date or revision dates given, stated that when a medication vial was opened, the nurse should record the opened date on the vial. On 08/13/2025 at 8:20 AM, the D hallway medication cart was inspected with Licensed Practical Nurse (LPN) #78. In the cart was a multi-use vial of Tresiba insulin for Resident #107. The vial was delivered to the facility by the pharmacy on 08/08/25, according to the medication label. The vial had been opened but had not been dated when first accessed. According to the Tresiba insulin package insert, available on-line at the Food and Drug Administration Website, an opened multi-use vial could be used for 56 days. LPN #78 confirmed 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 follow physician's orders for laboratory testing. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of behavior/emotional. Resident Identifier: #43. Facility census: 102. Findings included: a) Resident #43 Review of Resident #43's physician's orders showed the resident was receiving the medication divalproex sodium, a form of valproic acid, 250 mg, three (3) times a day, for dementia with mood disturbance. The resident also had an order written on 10/25/25 for valproic acid level laboratory testing to be performed every (6) months or every 182 days. The resident's medical record showed a valproic acid level had been performed on 02/05/25 and was within normal limits. No valproic acid laboratory testing had been performed thus far in August. Valproic acid can accumulate in the body and cause symptoms such as drowsiness, confusion, tremor, or coma. Blood testing can monitor the level of the medication in the body. On 08/19/2025 at 5:25 PM, the Director of…

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

Based on observation, record review, and staff interview the facility failed to ensure residents were served food prepared in a form designed to meet their individual needs. Resident identifier: #82. Facility census: 102. Findings included:a) Resident #82On 08/14/25 during an observation of the noontime meal on the d-hall of the facility found Resident #82 was served regular spaghetti, regular sliced zucchini, and a regular slice of bread. Nurse Aide #82 stated she wanted to confirm with the kitchen that he had the right thing because he usually has pureed. Regional Dietary Manager #155 then presented to the hallway. He was asked to confirm the resident's diet was correct. He viewed the tray and stated it was okay to serve the resident the meal provided on his tray. The resident's diet order was for Dysphagia Mechanical Soft Texture.During an interview and observation on 08/14/25 with Resident #82 revealed an un- eaten tray containing spaghetti un-cut noodles with meat sauce over the top and a bowl of round zucchini, when asked how was his lunch he said Sh*t, I cant eat that They…

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 upon record review and staff interviews, the facility failed to ensure residents were served food in accordance to their preferences and intolerances. This was found to be true for three (3) of thirteen (13) residents reviewed during the annual survey process. Resident identifiers: #10, #83, #7. Facility census: 102. a) Resident #83 On 08/11/2025 at 01:13 PM, Resident #83 did not receive his Frozen Nutritional Supplement as printed on the resident's tray card in bold print. Nurse Aide (NA) #58 confirmed the resident did not receive his supplement that date. NA #58 went to the kitchen and got the supplement for the resident following state surveyor intervention. b) Resident #7 On 08/11/2025 at 11:42 AM, during the initial resident interview, Resident #7 reported she was allergic to fish and had asked for the alternate sandwich. The daily newsletter the resident's received this date stated: Lunch: Fish on a Bun was being served this date and Always Available items were: Ham & Cheese Sandwich, Turkey & Cheese Sandwich, Bologna & Cheese. The resident was told there was 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 record review, resident interview, and staff interview, the facility failed to provide reasonable accommodation of resident needs and preferences for Resident #25. This is true for one (1) of one (1) residents reviewed during the survey process. Resident Identifier: #25. Facility Census:111. Findings include: A) Resident #25 Record review on 10/24/23 at approximately 11:00 AM, indicated that Resident #25 had an order for a reacher to be always at the bedside. It was also indicated that a reacher was care planned to be within reach, always, due to the resident being a fall risk, attempting to lean out of their bed and wheelchair to reach for items. On 10/24/23 at approximately 11:38 AM, an interview with Nursing Aide (NA) #35 revealed Resident #25 was supposed to have a reacher in their room and that it was there. NA #35 said they did not know where it was due to Resident #25 putting things where she wants them. On 10/24/23 at approximately 11:40 AM, during an interview with Resident #25, the resident said they did not have a reacher due to it getting up and walking out 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, resident interview, family interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of activities of daily living. Resident identifier: #84 Facility census: 111. Findings included: a) Resident #84 During an interview on 10/23/23 at 2:04 PM, Resident #84's wife stated she did not think the resident received showers as scheduled. She stated she thought this because the resident's hair had been greasy on occasions. Review of facility's shower schedule showed the resident was scheduled to receive showers on Mondays and Thursdays. Resident #84's shower documentation for the past 30 days showed the resident did not receive a shower on Thursday, 10/12/23. The resident had received showers on Monday, 10/09/23, and Monday, 10/16/23. No bed baths were documented for the past 30 days. During an interview…

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 implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for four (4) of four (4) Residents reviewed for the Activity Care Area. Resident Identifiers: Resident #69, #86, #66, and #35. Facility Census:111. Findings included: a) Resident #69 During the initial tour of the facility on 10/23/23 at 12:25 PM, Resident #69 was sitting in a wheelchair in his room. An observation revealed Resident #69 was talking to something on the other side of the room. During the interview Resident #69 continued to look at the other side of the room, talking. He stated, You see that board right there? And continued to talk towards the other side of the room. This surveyor looked at the board he was pointing at It was his room mate's bedside table behind the privacy curtain. I informed him it was a bedside table 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. This deficient practice had the potential to affect more than an isolated number of residents residing in the building. Resident identifiers: #218, #96, #46, #101, #70, and #167. Facility census: 111. Findings included: a) Resident #218 Medical record review revealed Resident #218 had capacity with a determination form dated 09/01/23. On 10/23/23 at 2:00 PM Resident #218 was observed eating his lunch in his room. He was sitting in a wheelchair and had a clear plastic bag partially under his shirt. There was a foul odor of bowel movement in his room. Resident #218 was asked about the care he receives. He said, well it is not so good. He lifted the plastic bag away from his body.…

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

Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. Unsanitary and unclean areas were discovered. The facility failed to store utensils and serve drinks in a sanitary manner. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen and the resident's refrigerator. Facility Census:111 Findings Included: A review of the facility policy titled: Storage of Resident Food with a effective date of 01/19/21 read as follows: Procedure: .II .E. Staff will date the container when food or beverages are brought into the facility and discard food when non-safe. F. Frozen foods must be stored and keep frozen III. The dietary staff will monitor refrigerator for food safety and reserve the right to dispose of expired, unsafe foods. .D. The dietary staff will monitor refrigerator storage areas for Resident's food monitoring for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview, the facility failed to inaccurate establish and maintain complete and accurate surveillance and line listing. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Resident identifiers: #67, #167, and #70. Facility census 111. Findings included: a) Resident #67 A review of the line listing provided of the facility's Infection Preventionist (IP) found Resident #67 was admitted on [DATE] with a diagnosis of (ESBL) stands for Extended Spectrum Beta-Lactamase. Beta-lactamases in the urine and receiving Merrem (an antibiotic used for infections) Intravenously (IV) treatment for the Multidrug-resistant organisms (MDRO) infection. On the line listing provided it was marked type of isolation: No isolation required. A review of the active orders for Resident #67 found an order for Contact precautions for ESBL on 10/21/23. Interview with IP on 10/27/23 at 10:15 AM, agreed it was inaccurate and states…

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 maintain equipment in safe operating conditions. The ice machine did not have a one-inch air gap for drainage. This failed practice had the potential to affect all residents currently receiving nutrition from the facility kitchen. Facility Census: 111. Findings included: a) Ice Machine A tour of the kitchen, on 10/24/23 beginning at 11:34 AM, with the Culinary Director (CD) revealed the ice machine water drain was touching the floor drain without a one (1) inch gap allowing for the potential for contaminants to enter the line and travel to the ice machine. During an immediate interview, the CD acknowledged the water drain was touching the floor drain without a one (1) inch gap. During an interview, on 10/24/23 at 1:38 PM, with Director of Plant Maintenance #76, he stated the company that installed the new ice machine last year was supposed to leave the one (1) inch air gap. The Director of Plant Maintenance said, I don't guess they did. It will be fixed in about two minutes.

Based on observation and staff interviews the facility failed to maintain an environment free from flies. This practice had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 111. Findings included: a) Flies in Kitchen An initial tour of the kitchen, with the Culinary Director (CD), beginning on 10/23/23 at 11:23 AM observation of flies in the kitchen. During an immediate interview [NAME] #101 stated the flies were not as bad as they were before. During the tour on 10/23/23 steam table food temperatures were being obtained by the CD. A fly landed on a pan of biscuits being served with the noon meal. The CD acknowledged the fly landing on the pan of biscuits. The CD also indicated the biscuits needed to be discarded. During an interview, on 10/24/23 at 1:51 PM, the Corporate Dietary Manager stated, there is a fly issue, they have been pouring chemicals down the drains at night. We have a pest specialist monthly. During an interview, on 10/25/23 at 9:56 AM, the Administrator stated, We have ordered the bug lights, but they are on…

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

Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #70. This was a random opportunity for discovery. Resident identifier: #70. Facility census: 111. Findings included: a) Resident #70 On 10/25/23 at 12:04 PM, Resident #88 was served lunch in her room. Her roommate, Resident #70, was in the room but was not served lunch at that time. On 10/25/23 at 12:29 PM, the tray pass for the hallway had been completed. Resident #70 had not been served lunch. During an interview, on 10/25/23 at 12:29 PM, Nursing Assistant (NA) #40 stated after passing trays, she checked the rooms to make sure everyone was served and then obtains additional trays as needed. She stated Resident #70's tray had been delivered to the dining room because she usually ate there. She stated she would obtain a lunch tray for the resident. Resident #70 was served lunch in her room on 10/25/25 at 12:37 PM. Her roommate, Resident #88, had finished eating lunch by this time.

Based on Resident interview, staff interview and record review. The facility failed to honor the choices of the residents in the care area of showers and/or baths. This failed practice was true for one (1) out of three residents (3) reviewed for choices. Resident identifier: # 36. Facility census: 111. Findings included: a) Resident #36 On 10/23/23 at 1:04 PM, Resident # 36 said if she was not feeling good or not ready for a shower when the aides want to give her a shower, she did not get one later when she asks for one. Resident #36 said they told her they are too busy. Resident #36 stated she prefers to shower in the evenings. A review of the facility documents found Resident #36's was scheduled for showers on Monday and Thursday nights. On 10/24/23 at 3:26 PM, the Director of Nursing (DON) provided a facility form called the, POC Responses History. Review of this form showed that in the last 30 days, Resident #36 had one (1) shower on 10/04/23 at 1:17 PM and two (2) bed baths on 10/05/23 and 10/09/23. On 10/24/23 at 3:45 PM, DON agreed that Resident #36 was not receiving showers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN 9CMS-10055) to beneficiaries and/or beneficiary's representatives. This failed practice was true for one (1) of three (3) residents reviewed. Resident identifiers: Resident #318. Facility Census: 111. Findings included: a) Resident #318 Record review on 10/24/23 at 3:30 PM for Resident #318 revealed the resident was admitted to the facility on [DATE]. Resident #318 was receiving skilled services for therapy and the payor source was Medicare. Further record review revealed Medicare Part A Skilled Services Episode start date was 04/14/23. The last covered day of Part A services was 06/14/23. During an interview, on 10/24/23 at 4:24 PM, the Administrator stated the notice of Medicare Non-coverage was not initiated. She acknowledged the forms should have been provided to the beneficiary and/or the representative.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. Room C6 privacy curtain was soiled, and Resident #79's personal fan needed to be cleaned. Resident identifier: Resident #79. Facility Census: 111 Findings included: a) Room C-6 Privacy Curtain The initial tour, on 10/23/23 at 12:40 PM, revealed the privacy curtain in Room #C-6 was soiled. During another observation, on 10/24/23 at 2:08 PM, the privacy curtain in Room #C-6 was still soiled. During another observation on 10/25/23 at 8:37 AM, the privacy curtain in Room #C-6 was still soiled. During an interview on 10/25/23 at 3:46 PM, Director of Plant Maintenance #76 acknowledged the curtain was soiled and needed to be changed. b) Resident #79 During the initial tour of facility on 10/23/23 at 12:58 PM, Resident #79's fan was impacted with dirt and dust build up. During another observation on 10/24/23 2:09 PM, Resident #79's fan was still not cleaned. During an observation on 10/25/23 at 8:41 AM, Resident #79's continued to be impacted with dust build up.…

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 interviews the facility failed to correctly code resident discharge in the Minimum Data Sets (MDS) for one (1) of three (3) sampled residents reviewed for closed records. Resident #115's MDS was inaccurate in discharge status. Resident identifier: #115. Facility census: 111 Findings included: a) Resident #115 A medical record review on 10/24/23 at 10:33 AM for Resident #115 revealed a discharge MDS had been coded as an acute care hospital discharge for Resident # 115, who was discharged to home on 9/01/23. Further review of the discharge summary recapitulation of stay WV-V9 section B. Social Services 2. Discharge location/address: Daughters Residents/Daughters name Medical Power of Attorney (MPOA) and address listed. Further review of Minimum Data Set (MDS) revealed a MDS with ARD date of 09/01/23 Section A titled Identification Information, Section A2100 titled discharged Status was coded 03 Acute Hospital. During an interview, on 10/24/23 02:35 PM, the Administrator stated Resident # 115's discharge plan was to go home upon admission. The…

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

Based on resident interview, observation, record review, and staff interview. The facility failed to ensure resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Resident identifier: #218. Facility census 111. Findings included: a) Resident #218 Medical Record review revealed Resident #218 had capacity determination dated 09/01/23. The resident was deemed to have capacity. On 10/23/23 at 2:00 PM Resident #218 was observed eating his lunch in his room. He was sitting in a wheelchair and had a clear plastic bag partially under his shirt. There was a foul odor of bowel movement in his room. Resident #218 was asked about the care he receives. He said, well it is not so good. He lifted the plastic bag away from his body. Which revealed a large amount of brown smashed and partly dyed feces covering his abdomen. He stated he had been waiting for someone to clean him for two (2) to three (3) hours. He went on to say he was also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of 24 residents in the long-term care survey sample. The facility failed to monitor Resident #96's blood pressure. Resident identifier: #96. Facility census: 111. Findings included: a) Resident #96 Review of Resident #96's medical records showed the resident was transferred to the hospital on [DATE] for altered mental status. The resident's blood pressure was noted to be 204/100 prior to the hospital transfer. Resident #96's diagnoses at the hospital included hypertensive emergency. Review of Resident #96's medications at time of the hospital transfer on 08/08/23 showed the hospital was receiving the following antihypertensive medications: - Cozaar (losartan potassium) 50 mg, one (1) time a day. The resident had been receiving this medication since 10/29/22. - Metoprolol…

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

Based on observation, resident interview and staff interview the facility failed to ensure the resident environment remains as free of accident hazards as is possible. This failed practice was a random opportunity for discovery, medication in residents' room. This had the potential to affect a limited number of residents that currently reside at the facility. Resident identified: #218. Facility census 111. Findings included: a) Resident #218 On 10/23/23 at approximately 2:00 PM Resident #218 showed this surveyor a tube of prescription medication, that was laying on his bed. He said he received it from a hospital he was in. He said the cream was for his legs and toe. The The name on the tube of medication was Mupirocin topical cream (used for infected traumatic skin lesions due to specific bacteria). The medication was observed laying on his bed with the supplies for his colostomy. On 10/23/23 at 3:58 PM, it was noted Resident #218 was not in his room and the door was open, which revealed the tube of medication still laying on the bottom of his bed. Registered Nurse (RN) #69 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 and staff interview the facility failed to ensure residents received catheter care at a professional standard of practice. This was a random opportunity for discovery, and had the potential to affect one resident. Resident identifier: #46. Facility census 111. Findings included: a) Resident #46 Resident #46 was observed on 10/23/23 at 1:45 PM laying in the bed under a blanket and her indwelling foley catheter was hanging under her wheelchair approximately two feet from the bed. On 10/23/23 at 1:47 PM, Nurse Aide #116 was asked about the catheter being left on the wheelchair. NA #116 said, Resident #46 probably transferred herself and done that. At this same time NA #18 said, No, I put Resident #46 back to bed and I forgot to move her foley catheter bag to the bed. Director of Nursing (DON) was informed of the above findings on 10/23/23 at 4:00 PM. The DON stated she had re-educated NA #18.

Based on Resident interview, observation, record review, and staff interview, the facility failed to provide colostomy care with the current professional standards of care. This was true for one (1) out of one (1) reviewed for colostomy care. Resident identifier: Resident #218. Facility census 111. Findings included: a) Resident #218 Record review revealed Resident #218 had been deemed to have capacity as of 09/01/23. On 10/23/23 at 2:00 PM Resident #218 was observed eating his lunch in his room. He was sitting in a wheelchair and had a clear plastic bag partially under his shirt. There was a foul odor of bowel movement in his room. Resident #218 was asked about the care he receives. He said, well it is not so good. He lifted the plastic bag away from his body. Which revealed a large amount of brown smashed and partly dyed feces covering his abdomen. He stated he had been waiting for someone to clean him for two (2) to three (3) hours. He went on to say he was also hungry, so he was trying to eat also, so that is why he put a plastic bag over it. Resident #218 stated that since noon…

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, medical record review and staff interview the facility failed to provide necessary respiratory care and services. This is true for one (1) of one (1) residents reviewed for the respiratory care area. Resident #85 was not receiving his oxygen therapy at the prescribed rate. Resident identifier: #85. Facility Census: 111 Findings included: a) Resident #85 During an observation on 10/23/23 at 12:40 PM, Resident #85's oxygen flow rate was between two (2) and two and half (2.5) liter/minute (l/m) via nasal cannula. During an observation, on 10/23/23 at 3:15 PM, Resident #85 was seen standing in his doorway. Resident #85 could be heard from the hallway by two Surveyors gasping for breath and wheezing. During an interview, on 10/23/23 at 3:21 PM, Licensed Practical Nurse (LPN) #98 stated Resident #85's name gets up often and the resident does wheeze often due to not wearing his oxygen. This surveyor asked LPN #98, Have you seen Resident #85 with his oxygen off today. No response was given. LPN #98 kept telling the Resident to breathe through his nose. LPN #98 stated…

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 medical record review the facility failed to provide a two (2) handled spouted cup for a resident at meal time. This was a random opportunity for discovery. Resident identifier: Resident #101. Facility Census: 111. Findings included: a) Resident #101 During a Main Dining room observation beginning on 10/24/23 at 12:20 PM, Resident #101 was drinking red colored liquid from a regular plastic glass. Further observation at 12:37 PM, the resident's lunch meal tray was served to Resident #101, which had a two (2) handled spouted cup for the liquids. Further observation at 12:48 PM, Nurse Aide (NA) #116 was assisting Resident #101 with her liquids from a regular cup. During a interview at 12:50 PM, NA #116 acknowledged Resident #101 drinks was to be a two handled spouted cup. During a medical review, on 10/24/23 at 1:34 PM, Resident #101's medical records revealed a physician order dated 08/09/23 Regular diet, Regular texture, regular Consistency, 2 (two) handled cup with lid on all meal trays. During an interview on 10/25/23 at 11:04 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY c) Resident #168 Review of Resident #168's medical records showed an order written on 10/19/23 for lamotrigine (Lamictal), 25 milligrams (mg), orally, one (1) time a day for health maintenance. During an interview on 10/24/23 at 2:25 PM, the Director of Nursing (DON) was informed health maintenance was not an appropriate indication for this medication. During an interview on 10/25/23 at 3:41 PM, the DON stated Resident #168 was receiving lamotrigine for depression, and the order was revised to reflect this. Based on observation, record review, resident interview and staff interviews the facility failed to ensure accurate and complete identifying information on a medical record. This was true for three (3) of 24 in reviewed for the Long-Term Care Survey Process (LTCSP) and one (1) of three (3) reviewed for closed record. Resident identifiers: #101, #168 and #116. Facility Census: 111. Findings included: a) Resident #101 During a dining room observation, on 10/24/23 12:46 PM, Resident #101's noon meal tray 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 observations, record review and staff interviews, the facility failed to store medications in accordance with currently accepted principles. Two (2) of three (3) refrigerators containing medications did not have temperatures recorded twice a day. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 110. Findings included: a) Medication room for hallway CD On 08/30/23 at 12:07PM an observation of the medication room for Hallway CD was made with Licensed Practical Nurse (LPN) #109. The medication room had two refrigerators to store medications. Posted on the refrigerator doors was a log to record temperatures twice daily. According to the log, temperatures have not been recorded for the following dates and times: -08/17/23 morning -08/21/23 evening -08/22/23 morning -08/25/23 evening -08/26/23 morning -08/27/23 morning LPN #109 acknowledged refrigerator temperatures were not recorded for the above referenced dates and times. b) Medication room for hallway AB On 08/30/23 at 12:10PM an observation of the medication 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 observations and staff interview, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This was a random opportunity for discovery that had the potential to affect all residents residing in the facility. Facility census: 110. Findings included: a) Kitchen During a tour of the kitchen on 8/30/23 at 11:59 AM with Maintenance Technician #23, a cart full of dirty dishes was observed located by the door going into the kitchen. The were numerous flies around this cart. On 08/30/23 Maintenance Technician #23 acknowledged the presence of flies in that area. .

Based on staff interview and record review the facility failed to capture information and accurately enter it into the Minimum Data Set (MDS). This failed practice was true for one (1) out of three (3) residents reviewed for MDS accuracy. Resident identifier: #32. Facility census 110. Findings included: a) Resident #32 A document titled, Internal Med History and Physical dated 10/19/22, from a local hospital, which was sent with the resident on admission. Revealed the following information: Social history: Resident #32 admits to physical and emotional abuse by her mother, record reports a history of sexual abuse and was raped at the age of 16. Quit school at the age of 16. A review of the MDS found no one had documented Post Traumatic Stress Disorder (PTSD). On a reentry MDS completed on 06/26/23 in section I Psychiatric/Mood disorder I5700 was checked for Anxiety. I5800 was checked for Depression. I6100 for PTSD was not checked. The statement below is written as recorded by Registered Nurse #104, on 08/04/23: (Called resident #32 by last name) asked me to come speak with her 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.

Based on record review and staff interview, the facility failed to develop an accurate and resident-centered care plan in the area of dialysis for one (1) of three (3) residents reviewed for the care area of dialysis. in addition the facility failed to ensure Resident # 43's and Resident #109's care plan regarding an indwelling catheter was implemented. This was true for two (2) of three (3) residents reviewed for wound care during the complaint survey. Resident identifier: #53, #43 and #109. Facility census: 110. Findings included: a) Resident #53 Review of Resident #53's medical records showed the resident received dialysis treatment through an arteriovenous (AV) fistula located in her left upper arm. The resident had an order for no intravenous needle sticks or blood pressures to be obtained in her left arm. Resident #53's comprehensive care plan had the following interventions for the focus of dialysis treatments: - Hemodialysis - AV fistula: Do not complete blood draws / blood pressure in same arm as AV fistula. (Blood draws / Blood Pressure should be taken in Left upper arm.)…

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 provide care for an indwelling foley catheter to meet the professional standards of care. This failed practice was true for two (2) out three (3) residents reviewed for wound care. Resident Identifiers: #43 and #109. Facility census 110. Findings included: a) Resident #43 On 08/31/23 at 8:43 AM, an observation of wound care with Registered Nurse #133, found there was not a secure device being used (a secure device is used to prevent the indwelling foley catheter from being accidentally removed and causing tissue damage). RN #133 verified there was not a secure device. b) Resident #109 During an observation of wound care on 08/31/23 at 8:55 AM. It was noticed Resident #109 had an indwelling foley catheter. RN #133 agreed the secure device was not applied in the correct manner and could not prevent accidental removal or tension on the catheter. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to provide dialysis services in accordance with professional standards of practice. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of dialysis. Resident identifiers: #28 and #101. Facility census: 110. Findings included: a1) Resident #28 - post-dialysis assessment Review of Resident #28's medical records showed he received dialysis treatments on Tuesdays, Thursdays, and Fridays. When the resident returned to the facility from dialysis, a post-dialysis assessment form was completed by a facility nurse. The post-dialysis assessment form contained an assessment of the resident's vital signs and the resident's dialysis access device. No post-dialysis assessment could be located in the Resident #28's medical records for 08/26/23. During an interview on 08/31/23 at 10:15 AM, the Director of Nursing acknowledged that Resident #28 did not have a post-dialysis form completed upon return to the…

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

Based on Resident Council interview, observations and staff interview, the facility failed to display the most recent State inspection in a readily accessible area frequented by residents. It was discovered the State inspections were placed in an area too high for residents to reach. This had the potential to affect more than a limited number of residents. Facility census: 82 Findings included: a) State inspection postings During the Resident Council meeting on 04/13/22 at 9:30 AM, it was reported the State inspection survey results were located on the B hallway. An observation on 04/13/22 at 9:50 AM, revealed the State survey results were in wall pockets at two (2) locations on the B hallway, one (1) at the Director of Nursing office and the other at the Social Services office. Both locations were observed to have the State inspection survey results placed too high on the walls for residents in a wheelchair to reach. In an interview with the Nursing Home Administrator on 04/13/22 at 10:45 AM, verified the State survey results were placed too high on the walls, and were 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 observation and staff interview, the facility failed to provide Resident #74 with a dignified dining experience. Resident #74 was not served his meals in the traditional dinnerware that was provided to all other residents in the facility. This was a random opportunity for discovery and had the potential to affect a limited number of residents that currently reside at the facility. Resident identifiers: Resident #74. Facility census: 82. Findings included: a) Resident #74 During the initial tour of the facility on 04/11/22 at 12:05 PM, Resident #74 was provided his lunch meal in a Styrofoam container, all other resident's on C hall was provided traditional dinnerware. During an interview on 04/11/22 at 12:08 PM with Dietary Service Supervisor(DSS) #54 stated I am not sure why he receives a Styrofoam tray I will look at his orders and care plans. During an interview on 04/11/22 at 12:54 PM, Certified Nursing Assistant #19 stated he always gets the Styrofoam tray for all his meals. During an interview on 04/11/22 at 1:04 PM DSS #54 stated there is no orders or care plan for…

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

Based on record review and staff interview, the facility failed to revise the resident's care plan when a change occurred. This deficient practice had the potential to affect one (1) of 20 residents reviewed during the long-term care survey process. Resident identifier: #39. Facility census: 82. Findings included: a) Resident #39 Review of Resident #39's medical records showed on 10/03/21, the resident weighed 134 lbs. On 04/03/22, the resident weighed 109 pounds. This was a 19% weight loss in 6 months. Further review of the resident's records showed the weight loss had occurred while the resident was in the hospital. A nutritional assessment performed on 2/23/22 stated the resident's ideal body weight was 127-153 pounds. Resident #39's comprehensive care plan had a focus related to potential nutritional problems. On 11/07/21, the following goal was initiated: Patient will comply with recommended diet for weight reduction daily through review date. The goal was revised on 04/05/22. During an interview on 04/12/22 at 1:24 PM, Registered Nurse (RN) #118 agreed a goal of weight loss…

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, observation, and staff interview the facility failed to ensure appropriate treatment and care for a urinary catheter drainage bag. This was discovered for one (1) of one (1) residents reviewed for the care area of urinary catheters during the Long Term Care Survey Process. The bedside urinary catheter drainage bag for Resident #18 was not positioned properly under her wheelchair, which allowed the catheter drainage bag to come in contact with the floor. Resident identifier: #18 Facility census: 82 Findings included: a) Resident #18 During an observation on 4/12/22 at 12:20 PM, it was discovered Resident #18's bedside urinary catheter drainage bag was not attached properly to her wheelchair, which allowed for the catheter bag to touch the floor. An observation by the Nursing Coordinator on 04/12/22 at 12:27 PM, verified the urinary catheter drainage bag, under Resident #18's wheelchair was touching the floor. .

Based on observation and staff interview the facility failed to ensure residents who require dialysis receive services, consistent with professional standards of practice. The facility failed to have a dialysis emergency kit available at bedside. This was discovered for one (1) of (1) one resident reviewed for the care area of dialysis during the Long Term Care Survey Process Resident Identifier # 50. Facility Census: 82 Findings Included: a) Resident # 50 On 04/12/22 at 9:10 AM, observations found no emergency equipment at Resident # 50's bedside who uses a Peracath for dialysis access. On 04/12/22 at 9:16 AM, Licensed Practical Nurse (LPN) # 101 confirmed Resident # 50 uses a Permacath for dialysis. LPN # 101 also confirmed no emergency kit was available at the bedside of Resident # 50. LPN #101 stated No, there are no clamps at bedside. On 04/12/22 at 9:21 AM, the Director of Nursing (DON) and Administrator acknowledged there was not an emergency kit or a set of clamps at the bedside of Resident #50. The DON stated she would call the dialysis facility and get hemodialysis clamps…

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

Based on observation, staff interview and resident interview, the facility failed to serve food that was palatable and at a safe and appetizing temperature. The failed practice had the potential to affect a limited number of residents currently receiving nutrition from the facility's kitchen. Resident Identifier: Resident # 8. Facility Census: 82 Findings Included: A) Resident #8 During an interview 04/12/22 at 8:30 AM Resident #8 stated the food is always cold. On 04/12/22 at 12:06 PM, temperatures were obtained on the lunch meal tray for Resident #4 (Resident #4's tray was selected because it was the last tray to be served) at the time of service. The following temperatures were obtained by the Dietary Services Supervisor (DSS) #54 using his thermometer: --Brown Beans: 146 degrees Fahrenheit (F) --Green Beans: 123 degrees F --Ham with gravy: 113 degrees F --Diced Potatoes: 115.5 degrees F --Peaches: 28.8 degree F During an interview on 04/12/22 at 12:07 DSS #54 stated the hot food temperatures are suppose to be 120 degrees or greater and the cold food should be less than 50…

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 a resident's care plan included a description of the care and services to be provided by hospice and the facility. This was discovered for one (1) of one (1) residents reviewed for the care area of hospice services during the Long Term Care Survey Process. The care plan for Resident #2 did not specify care and services to be provided by hospice or the facility. Resident identifier: #2 Facility census: 82 Findings included: a) Resident #2 During a medical record review on 04/12/22 for Resident #2, it revealed the care plan did not include care or services to be provided by hospice and the facility. In an interview with the Director of Nursing (DON) on 04/12/22 at 10:45 AM, she verified the care plan for Resident #2 did not specify care and services to be provided by hospice or facility staff. .