Heritage Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon Observation and Staff interviews the facility failed to ensure use of proper infection control practices to prevent the potential spread of disease through improper/non use of PPE while in a Enhanced Barrier Protection room. This was observed on more than one occasion. Resident identifiers: #80, #9 and #14. Census: 157. a) Resident #80 During med pass LPN #38 did not use PPE while giving resident #80 her medications. Resident is currently on enhanced barrier precautions (EBP) and the sign is present on door with marking for who it applies to. The LPN did sanitize hands, but did not apply PPE per policy. She had direct contact with resident, LPN adjusted resident in bed as well as hugged resident before leaving room. When asked what they do if a room is marked with EBP sign LPN #189 stated that if they will have direct patient contact they need to put on PPE, gloves gown, mask ect . b) Resident #9On 09/24/25 8:45 AM a nurse and an aide were in in room [ROOM NUMBER]-A doing morning Activities of Daily…

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 the resident or resident's representative in advance, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This was found to be true for two (2) of five (5) residents reviewed for psychotropic medication use during the long-term care survey process. Resident identifiers: # 1, #10. Facility census: 157. Findings included:a) Resident #10The resident had the following pharmacy orders: Xanax Oral Tablet 1 MG (Alprazolam) Give 1 mg by mouth three times a day for Anxiety Disorder Pharmacy Active 9/9/2025 Quetiapine Fumarate ER Oral Tablet Extended Release 24 Hour 150 MG (Quetiapine Fumarate) (Brand name Seroquel)Give 1 tablet by mouth at bedtime for bipolar disorder with psychosisPharmacy Active: 09/09/25 Citalopram Hydrobromide Tablet 10 MG (brand name Celexa)Give 3 tablet by mouth one time a day for depression Give 30 mg PO daily. Pharmacy Active: 08/06/25 Upon review of the medical record, informed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide a Notice of Transfer/Discharge, and a written Bed Hold notice to a resident and/or the resident's legal representative when the resident was transferred to the hospital. This was true for one (1) of nine (9) residents reviewed for hospitalizations. Resident identifier: #177. Facility census. 157.Findings included: a) Resident #177 A record review, completed on 09/29/25 at 6:30 PM, revealed the following information: Resident #177 was sent out to the hospital on [DATE] at 2:06 PM. There was no evidence in the electronic medical record the facility had notified the resident or the resident's representative of the transfer/discharge and the reasons for the transfer in writing. Additionally, there was no evidence the facility provided a written notice which specified the duration of the bed-hold, if any, during which the resident would be permitted to return to the nursing home. During an interview, on 09/20/25 at approximately 12:45 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and staff interview, the facility failed to develop a person-centered comprehensive care plan, and implement the plan to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. This was found to be true for three (2) of thirty-four (34) residents reviewed during the long-term care survey process. Resident identifiers: #8, #100. Facility census: 157. Findings included: A) Resident #8 A personalized care plan was developed for this resident, but was not carried out. The Care Plan included a focus area pertaining to a risk for skin breakdown due to the resident's decreased activity, frail fragile skin, impaired cognitive function, impaired mobility. One intervention was to turn and position the resident every 2-3 hours. This intervention was developed on 05/15/24, and revised on 02/19/25. Among the resident's diagnoses were a facility-acquired Stage 3 pressure ulcer of other site diagnosed on [DATE], and a non-pressure chronic…

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 obtain lab services in a timely fashion for a resident. This was true for one (1) of five (5) residents reviewed for unnecessary medications throughout the Long-Term Care Survey Process. Resident identifier: #6. Facility census:157.Findings included: a) Resident #6 During a record review, completed on 09/29/2025 at 9:15 AM, there was no evidence in Resident #6's electronic medical record that blood work had been completed in the month of July 2025 as per a physician's order. The Director of Nursing (DON) was interviewed on 09/29/2025 at 12:00 PM. The DON confirmed there had been an active physician order stating, HGA1C (a blood test that provides an average of your blood sugar levels), CMP (Comprehensive Metabolic Panel) and CBC (Complete Blood Count) every 4 months - March, July, November. The DON reported the facility was unable to produce evidence that the lab work had been completed as ordered.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that were accurately documented. This was a random opportunity for discovery. Resident #6. Facility census: 157.Findings included: a) Resident #6 A medical record review, completed on 09/29/2025 at 9:15 AM, revealed the following details: - Resident #6 transferred to room [ROOM NUMBER]-B on 04/09/25.- On 04/20/25 there was an Encounter Note which incorrectly documented Resident #6 was in room [ROOM NUMBER]. - On 05/15/25 there was an Encounter Note which incorrectly documented Resident #6 was in room [ROOM NUMBER].- On 05/17/25 there was an Encounter Note which incorrectly documented Resident 36 was in room [ROOM NUMBER]. - Resident #6 transferred to room [ROOM NUMBER]-B on 06/26/25.- On 08/14/25 there was an Encounter Note which incorrectly documented Resident #6 was in room [ROOM NUMBER].- On 08/16/25 there was an Encounter Note which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide pneumococcal vaccinations in accordance with professional standards of practice. This deficient practice had to potential to affect one (1) of five (5) residents reviewed for the care area of vaccinations. Resident Identifier: #34. Facility Census: 157. a) Resident #34 The facility's policy titled Pneumococcal Vaccination with effective date 05/04/15 and revision date 09/15/25 stated pneumococcal vaccinations in adherence with current recommendations of the Advisory Committee on Immunizations Practices (ACIP) as set forth by the Centers for Disease Control and Prevention. The CDC publication titled Pneumococcal Vaccine Timing for Adults dated March 2025, which is available on-line, stated adults 50 years or older who have only received the pneumococcal conjugate vaccine (PCV) 13 should receive a single dose of PCV 21 or PCV 20 at least one year after the PCV 13 dose. Resident #34 was over [AGE] years old. Review of Resident #34's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure the quality assessment and assurance committee failed to identify quality deficiencies. In [DATE] Resident #150 was given cardiopulmonary resuscitation when his advanced directive indicated he wished to not be resuscitated. The facility quality assessment and assurance (QAA) committee addressed the issue of staff not identifying a resident's correct code status from [DATE] until [DATE]. After stopping the QAA code checks the facility developed another code status issue. Staff members were taking POST forms off the medical records for audits. The nursing staff stated the POST forms are where they would check for a resident's code status in an emergency. This practice had the potential to affect more than a limited number of residents. Facility census: 149. Findings included: a) Resident #150 Medical Record Review (MRR) revealed that on [DATE] a nurse contacted Resident #150's daughter at 12:31 PM and notified her that the facility staff had performed CPR on her father and that the…

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

Based on observation, record review, and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections. The facility failed to provide appropriate infection surveillance. This failed practice had the potential to affect every resident currently residing in the facility. Facility Census: 150. Findings Included: a) Infection Surveillance Record review of the facility's Infection control practices found the facility was unable to provide the required infection surveillance documentation of communicable illnesses. During an interview on 03/26/24 at 1:25 PM, Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated they were unable to locate the documentation of the infection control surveillance. She stated that the facility was trying to get ahold of the Infection Control Preventionist that was no longer employed with the facility. No other information was provided prior to the end of the survey on 03/26/24 at 5:30 PM.

Based on record review and interview the facility failed to implement its protocol for antibiotic use and failed to monitor actual antibiotic use reviewed for antibiotic stewardship. This has the potential to affect all residents in the facility. Facility Census: 150. Findings included: a) Antibiotic Stewardship Record review of the facility's documentation of Infection control practices found the facility was unable to provide the required Infection surveillance and antibiotic stewardship documentation. During an interview, on 03/26/24 at 1:25 PM, Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated they were unable to locate the documentation of the infection control surveillance or antibiotic stewardship. She stated that the facility was trying to get ahold of the Infection Control Preventionist that was no longer employed with the facility to find out where to find all the documentation. No other information was provided prior to the end of the survey on 03/26/24 at 5:30 PM.

Based on facility documentation and staff interview the facility failed to have a designated certified Infection Preventionist (IP). This failed practice had the potential to affect all residents residing at the facility. Facility Census: 150. Findings Included: Record review of the facility's documentation of Infection control practices found the facility was unable to provide the required Infection surveillance and antibiotic stewardship documentation. During a facility record review found a certificate for Nursing Home Infection Preventionist with the Assistant Director of Nursing (ADON). During an interview on 03/26/24 at 11:43 the Corporate Administrator stated that the facility has not dedicated an IP, since the previous IP quit. She stated that the ADON and Director of Nursing (DON) has been working on Infection control. During an interview on 03/26/24 at 1:25 PM, Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated that the previous IP quit in October or November 2023. The ADON stated that she took the course after the previous IP left. During the…

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

Based on observation, family interview, policy review and staff interview, the facility failed to honor the right of the resident to file grievances anonymously as the residents did not have access to the grievance forms. This has the potential to affect more than a limited number of residents. Resident Identifier: #71. Census: 150. Findings included: a) Resident #71 On 03/18/24 at approximately 12:55 PM during an interview with Resident #71's family member, stated that when expressing concerns for Resident #71 was told to speak with the Guest Services Director (GSD) #07 to file a grievance. He further stated he had never been made aware that he could file a grievance himself. He then stated he was not aware of what an anonymous grievance was. He stated he had never seen an actual grievance form and did not know where to get one. On 03/20/24 at 2:38 PM during an interview with GSD #07, she stated that the residents and families are educated in person during the residents admission meeting to take any nursing concerns to the nurse in charge and anything else that may be a concern is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure residents with newly evident or possible serious mental disorder were referred for Level II resident review. This failed practice had the potential to affect seven (7) of eight (8) residents reviewed for the care area of Preadmission Screening and Resident Review. Resident identifiers: #23, #15, #74, #29, #66, #17, #33. Facility census: 150. Findings included: a) Resident #23 Review of Resident #23's medical records showed the resident was admitted on [DATE]. Resident #23's Preadmission Screening and Resident Review (PASRR) completed on 07/11/23 stated Level II PASRR resident review was not required. Level II evaluation determines whether a resident with mental illness or intellectual disability requires specialized services. On 10/20/23, Resident #23 received a new diagnosis of major depressive disorder, recurrent. The resident was not referred for Level II evaluation. On 03/19/24 at 2:44 PM, the Corporate Administrator 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the Centers for Disease Control and Prevention (CDC) in a timely manner and failed to follow physician's orders, notify residents physician, collaborate with Hospices services, or do pacemaker checks. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Resident Identifier: #73, #79, #23, and #19. Facility Census: 150. Findings included: a) RSV Immunization During a review of the facility documents regarding immunization, found zero out of 150 residents had been provided educational information about the risk and benefits of receiving the RSV vaccination. On 03/26/24 at 1:25 PM, Assistant Director of Nursing ADON stated she had not offered…

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 nurse aides (NAs) completed the competencies and skill sets for the residents needs, safety and in a manner that promotes each residents rights, physical, mental and psychosocial well-being. This was true for three (3) of five (5) staff competency records reviewed during the survey process. This has the potential to affect a limited number of residents residing in the facility. Staff identifiers: #92, #129 and #164. Facility census: 150. a) NA #92 During a review of the Nursing Assistant competencies on 03/26/24 at approximately 4:10 PM the following NA competencies were identified as not completed: * Hand Hygiene * Donning/Doffing PPE * Lift/ Transfer Equipment * Weights/Heights b) NA #129 During a review of the Certified Nursing Assistant competencies on 3/26/24 at approximately 04:10 PM the following NA competencies were identified as not completed: * Hand Hygiene * Donning/Doffing PPE * Weights/Heights c) NA #164 During a review of the Certified Nursing Assistant competencies on 03/26/24 at approximately…

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

Based on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current and the facility failed to maintain the Daily Staffing Posting data for a minimum of 18 months. This was a random opportunity for discovery and had the potential to affect all residents. Facility Census 150 a) Accurate and Current Data On 03/25/24 at 11:00 AM, during a review of the facility daily time detail by department for Nursing- Direct Care and the Daily Nurse Staffing Posting Form, it was identified that on the following follow days the nursing administrative staff hours were calculated in with the Nursing Direct Care hours. * 03/01/24 - Clinical Reimbursement Coordinator (CRC) #144 - CRC #170 - CRC #49 - Registered Nurse Unit Manager Director (RN UMD) #128 - Assistant Director of Nursing (ADON) #26 - RN UMD #38 *03/03/24 - RN UMD #38 *03/15/24 - RN UMD #128 - CRC #144 - CRC #49 - CRC #170 - ADON #26 - RN UMD #38 On 03/25/24 at approximately 11:50 AM during an interview with the Corporate Administrator (CA) #182 in requesting the…

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

Based on observation, staff interview, and policy review the facility failed to ensure food was prepared and stored in a safe sanitary manor. Sliced ham was not dated in the walk-in refrigerator and the flat top grill was dirty. This failed practice had the potential to affect more than a limited number of residents. Facility census 150. a) Storage of ham Initial tour of the kitchen on 03/18/24 at 11:32 AM, revealed there was ham stored in the walk in refrigerator in a clear container with no date. During an interview on 03/18/24 at 11:34 AM, the Dietary Manager (DM), confirmed that everything in the walk-in should be dated. A review on the facilities policy on 03/18/24 at 2:00 PM, titled {Refrigerated/Frozen Storage} reads under Process, Number (1) one Refrigeration, Number 1.4 as follows: All foods are labeled with name of product and the date received and 'use by' date once opened. Manufacturer 'use by' dates are used until opened. b) Dirty stove top The initial tour of the kitchen, on 03/18/24 at 11:45 AM, revealed that the flat top stove was covered in black build-up and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician's Orders for Scope and Treatment (POST) forms were not complete for four (4) of 16 residents reviewed for the care area of advance directives. Meal intakes were not completely recorded for one (1) of (1) residents reviewed for the care area of tube feeding. Resident identifiers: #14, #23, #15, #141. Facility census: 150. Findings included: a) Resident #14 Review of Resident #14's medical records showed the Physician's Orders for Scope and Treatment (POST) form was completed on [DATE], using the form developed in 2021. A POST form indicates the resident's wishes for end-of-life treatment. If the resident is not competent to make medical decisions, the POST form is completed by the resident's representative. The form indicated verbal consent was obtained from Resident #14's representative for cardiopulmonary resuscitation (CPR), full treatments, and tube feeding if needed. The form was signed…

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 all of the call system functioning. This failed practice had the potential to affect every resident currently residing in the facility. Facility Census: 150. Findings included: During observation tour on 03/19/24 at 11:04 AM 2nd floor, found the call light system turned down at the nurse's station to a volume too low to be heard throughout the unit. During an interview on 03/19/24 at 11:08 AM, Nurse Aide #119 verified he was unable to hear an audible sound from the call system in his section, he stated he just has to look for the light above the resident's doors. During an interview on 03/19/24 at 11:10 AM, the Maintenance Director confirmed that the call system was visual and audible. He stated that all the call systems in the building are turned down because that is how the staff like them. During observation tour on 03/26/24 at 9:24 AM on the transitional care unit, found the call light system turned down at the nurse's station to a volume too low to be heard. During an interview on 03/26/24 at 9:28 AM, the…

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

Based on observation, record review, staff interview, and resident interview, the facility failed to provide reasonable accommodations of needs, by not providing Resident #17 a readily accessible wheelchair. This failed practice was found true for (1) one of (3) three residents reviewed for environment during the Long-Term Care Survey Process. Resident identifier #17. Facility Census 150. Findings Included: a) Resident #17 An observation on 03/18/24 at 3:52 PM revealed that Resident #17 was non-verbal and uses an alphabet board to communicate, by pointing out the letters to spell words. During an interview on 03/18/24 at 3:52 PM with Resident #17 he communicated, They will not get me up. They say they don't have a wheelchair for me. During an interview on 03/19/24 at 12:10 PM with the Assistant Nursing Director, (AND) she stated , He is in a Geri chair. He does not have one up here. He refuses to get up. The Therapy department has some in their room on the first floor if we need it, if there was an emergency we would do the sheet drag on him. An observation, on 03/19/24 at 12:15 PM,…

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

Based on observation, record review, staff interview, and resident interview, the facility failed to give Resident #17 a choice regarding daily routine by not providing him with a readily accessible wheelchair to be gotten up in when he chooses. This failed practice was found true for (1) one of (7) seven residents reviewed for choices during the Long-Term Care Survey Process. Resident identifier #17. Facility Census 150. Findings Included: a) Resident #17 An observation on 03/18/24 at 3:52 PM revealed that Resident #17 is non-verbal and uses an alphabet board to communicate, by pointing out the letters to spell words. During an interview on 03/18/24 at 3:52 PM with Resident #17 he communicated, They will not get me up. They say they don't have a wheelchair for me. During an interview on 03/19/24 at 12:10 PM with Assistant Nursing Director (AND) she stated , He is in a Geri chair. He does not have one up here. He refuses to get up. The Therapy department has some in their room on the first floor if we need it, if there was an emergency we would do the sheet drag on him. An…

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

Based on Resident Council meeting responses, and staff interviews, the facility failed to ensure Resident Council minutes had been reviewed and resident concerns/grievances were addressed. This failed practice had the potential to affect a limited number of residents. Facility census: 150. Findings included: a) Resident Council Meeting Prior to the 03/19/24 at 1:00 PM meeting, minutes from the 10/24/23,11/29/23, 12/26/23, 1/30/24, 2/27/24 were reviewed with permission from the President. The following Resident Council minutes were as follows: -10/24/23 The meeting was facilitated by the Guest Services Director (GSD). There were 16 residents in attendance but list of names was not noted. NonCouncil Member attending were the Dietary Manager, Assistant Administrator and Ombudsman. Prior meeting minutes reviewed was marked as accepted as written. Discussion of Old/Unfinished Business Mail Delivery, location of Ombudsman and State contact information. Location of Survey results. The location of after hours money (2nd Floor med cart Blvd.) Visiting hours. There were no signatures on 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 electronically transmit accurate Minimum Data Set (MDS) data. This was true for two (2) of two (2) residents that the Minimum Data Sets (MDS's) were reviewed for discharges. Resident identifiers: #148 and #149. Facility census: 150. Findings included: a) #148 On 03/19/24 at 11:41 AM during a medical record review for Resident #148 , a nurse note dated 01/01/24 stated the resident was being admitted to the other hospital telemetry unit for congestive heart failure. A review of the residents electronically submitted MDS Assessment Reference Date (ARD) dated 01/01/24, in Section A- Identification Information under A2105 Discharge Status, the code submitted for this discharge was 01- Home/Community. On 03/19/24 at 01:07 PM during an interview with the MDS Coordinator #170, she agreed that the coding was in error and felt it was due to her doing so many other things and being short staffed. b) #149 On 03/19/24 at 12:11 PM medical record review for Resident #149 revealed the nurses note prior to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure complete and accurate pre-admission screening had been performed for residents with serious mental disorders prior to their admission. This failed practice had the potential to affect one (1) of eight (8) residents reviewed for the care area of Preadmission Screening and Resident Review. Resident identifier: #23. Facility census: 150. Findings included: a) #23 Review of Resident #23's medical records showed the resident was admitted on [DATE]. She had also been a resident in the facility in 2021. Further review of the medical records showed a diagnosis report showing a diagnosis of schizophrenia from 12/09/21 to 10/27/23 and a diagnosis of epilepsy from 07/12/23 to the present. On 10/20/23, Resident #23 received a diagnosis of paranoid schizophrenia. Resident #23's history and physical from the hospital on [DATE] indicated the resident had a history of schizophrenia and grand mal seizures. Resident #23's Preadmission Screening and 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 revise care plans in a timely manner related to behaviors, and smoking. This failed practice was found true for (2) two of 30 residents reviewed for care plans during the Long-Term Care Survey Process. Resident identifiers: #14 and #24. Facility census: 150. Findings included: a) Resident #24 An observation on 03/19/24 at 9:00 AM revealed Resident #24 was smoking in the front parking lot designated smoking area. During an interview on 03/19/24 at 2:54 PM, with Corporate Administrator#182 , she stated, Yes that smoking area is on the facility property. A record review on 03/19/24 at 2:55 PM, of Resident #24's care plan read as follows: Patient may not smoke on property per smoking assessment d/t (due/to) not following facility smoking rules, resident goes off the property to smoke. Patient will not smoke on property through the next review period. During an interview, on 03/21/24 at 10:30 AM, with Corporate Administrator #182, she stated, He is safe to smoke according to his smoking assessment. That is the old smoking…

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

Based on record review, staff interview, and resident interview the facility failed to provide an activity program to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Resident #17 was not provided with a wheelchair to attend activities of his choice and Resident #29 was not provided with scheduled one to one visits. This failed practice was found true for (2) two of (4) four residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers: #17, and #29. Facility census: 150. Findings Include: a) Resident #17 An observation on 03/18/24 at 3:52 PM revealed that Resident #17 was non-verbal and used an alphabet board to communicate, by pointing out the letters to spell words. During an interview, on 03/18/24 at 3:52 PM, with Resident #17 he communicated, I do not go to activities, because I do not have a wheelchair. A record review, on 03/20/24 at 9:47 AM, of Resident #17's Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 06/27/23 revealed that section F, question FO500, Letter E, 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, resident interviews and staff interviews, the facility failed to ensure the residents environment remained free of accident hazards and that each resident received adequate supervision. Resident #29's landline telephone was sitting directly above the residents head on the edge of the over the bed light fixture. Resident #15 was observed taking medication out of a medicine cup without a nurse present. This was random opportunities for discovery and had the potential to affect a limited number of residents. Resident identifiers: #29 and #15. Facility Census: 150. Findings included: a) Resident #29 On 03/18/24 at 11:15 AM during an interview with Resident #29, the facility room telephone designated for her was sitting directly above her head on the corner edge of the over the bed light fixture. The resident stated she did not know why it was there. During an interview with Licensed Practical Nurse (LPN) #163 at approximately 11:20 AM on 03/18/24 LPN #163 stated she did not know who put the telephone there and stated it was dangerous to be there. b) Resident #15…

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 care for residents' catheters in accordance with professional standards of care. The urine collection bag was observed lying on the floor for one (1) of two (2) residents reviewed for the care area of urinary catheter. Resident identifier: #49. Facility census: 150. Findings included: a) Resident #49 The facility's procedure titled Catheter Indwelling Urinary - Care of with effective date 06/01/96 and revision date 02/01/23 stated the drainage bag was to be kept below the level of the patient's bladder and off the floor. During an interview on 03/18/24 at 12:32 PM, Resident #49 stated she had a urostomy. The urine collection bag was noted to be lying on the floor, under the resident's bed. During an observation on 03/19/24 at 12:25 PM, Resident #49's urostomy urine collection bag was still lying on the floor, under the resident's bed. On 03/20/24 at 10:31 AM, Resident #49's urostomy urine collection bag was again observed lying on the floor, under the resident's bed. On 03/20/24 at 10:35 AM, Licensed…

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

Based on observation, staff interview and policy review the facility failed to store oxygen tanks in a safe manner consistent with professional standards of practice. This failed practice was a random opportunity for discovery. Facility Census 150. a) Facility An observation on 03/19/24 at 1:59 PM, of the facilities courtyard, there was found to be an empty oxygen tank stored in the seat of a wheelchair. During an interview on 03/19/24 at 2:00 PM, with the Corporate Administrator #182, she stated, No, that is not the proper way to store tanks full or empty. A review on 03/20/24 at 9:00 AM, of the facilities policy titled, SH500 Compressed Gases'', under process number (3) three, 3.3 reads: {Cylinders must be stored in and approved cabinet, holder, or secured by cylinder brackets or chains. The restraining mechanism must be above the midpoint of the cylinder.}

Based on resident interview, record review and staff interview the facility failed to assist a resident in obtaining dental care. This was true for one (1) of one (1) residents reviewed for dental care. Resident identifier: #120. Facility Census: 150. Findings included: a) Resident #120 On 03/18/24 at 03:41 PM during an interview with Resident #120, the resident stated he wanted his dentures. He further stated they did an impression for them over three (3) months ago. On 03/20/24 at 11:45 AM during a medical record review, it identified there were no follow up notes in his record for his dental care after he was seen by the dentist on 11/22/23. On 03/20/24 at approximately 11:55 AM during an interview with the Administrator, she stated that the resident was seen in November 2023 for an impression of dentures and she would check to see when the return appointment was. On 03/20/24 at 12:30 PM the Administrator returned and stated that the return appointment never was scheduled because there were issues with getting payment from the insurance company. She further stated that they (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 facility documentation and staff interviews, the facility failed to identify the Certified Nursing Assistant (CNA) staff competencies that were necessary to provide the level and types of care needed for the resident population in the Facility Assessment. This had the potential to affect more than a limited number of residents in the facility. Facility census: 150. a) Facility Assessment. On 03/26/24 at approximately 3:15 PM during a review of the Facility Assessment, the NA competencies that were required to be completed based on the level and types of care needed for the resident population in the Facility Assessment could not be identified. In reviewing each category under Section II. Staffing, Training, Services & Personnel sub section A). Function, Mobility, & Physical Disabilities it was identified that the Sufficiency Analysis Categories included but was not limited to the following: Activities of daily living Daily Care (excluding bath) Bed mobility Transfer Walk in Room Toilet Use Eating Bathing Dressing Hygiene/grooming Ambulation With Contractures Physically…

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 ombudsman interview, resident interview, record review and staff interview, the facility failed to ensure activities of daily living were performed for dependent residents. This failed practice had the potential to affect four (4) of five (5) residents reviewed for the care area of activities of daily living. Resident identifiers: #118, #122, #84, #143. Facility census: 152. Findings included: a) During an interview on 01/23/24 at 11:00 AM, the long-term care Ombudsman stated residents and resident family members had expressed concerns that residents were not receiving scheduled showers. b) Resident #118 Review of Resident #118's comprehensive care plan showed the resident required extensive assistance for bathing. The care plan also stated the resident preferred to receive showers. The facility's shower schedule showed the resident was scheduled to receive showers on Mondays and Thursdays. Review of the Nurse Aid (NA) task report for bathing activities from 12/27/23 through 01/23/22 showed the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review, and staff interview, the facility failed to ensure the use of bed rails was in accordance with professional standards of practice. This deficient practice had the potential to affect four (4) of five (5) residents reviewed for the care area of bed rails. Resident identifiers: #155, #112, #118, #99. Facility census: 152. Findings included: a) Policy review The facility's policy titled Bed rails with effective date [DATE] and revision date [DATE] gave the following procedures: - Complete the Bed Rail Evaluation to determine the need for bed rails. - If the Bed Rail Evaluation determines that the patient would benefit from bed rails: - Review the risks and benefits of bed rails with the patient or, if applicable, the patient representative - Obtain informed consent from the patient or, if applicable, patient representative, prior to installation using the Consent for Use of Bed Rails form that is part of the Bed Rail Evaluation - Obtain physician or advanced practice provider…

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, family, and staff interviews, the facility failed to ensure palatable food. Hot and cold food were outside the palatable temperatures at the time of service. This had the potential to affect all residents receiving nutrition from the kitchen. Resident identifiers: #84, and #21 Facility Census: 152. Findings include: a)Resident #84 At approximately 11:30 AM on 01/22/24, an interview was conducted with Resident #84. During the interview, Resident #84 stated their food was often cold when it arrived to their rooms during meal times. b) Resident #21 During an interview on 01/22/24 at 1:45 PM, Resident #21's family member stated they visited the resident frequently. They stated Resident #21's food was sometimes cold when they received it. c) Temperatures At approximately 1:36 PM on 01/23/24, an observation was made of Dietary Manager (DM) #74 taking the food temperatures of a tray delivered to the floor. The food being served was Tomato Soup and Mandarin Oranges. The temperature obtained by DM#74 of the tomato soup was 115 degrees Fahrenheit. The…

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

Based on record review and staff interviews, the facility failed to ensure Resident #21's medical record was complete and accurate. The meal percentages documented by nurse aides in the task report and by nurses on the medication administration record (MAR) did not match. This was true for one (1) of twelve (12) residents reviewed in the complaint sample. Resident identifier: #21 Facility census: 152. Findings included: a) Resident #21 At approximately 3:00 PM on 01/22/24, a review of Resident #21's medical record revealed, meal percentages documented by nurse aides on the task reports did not match the percentages documented by nurses in the MAR, when documenting for the order pertaining to meals. The following days and times have discrepancies between the task report and the MAR: 01/01/24: MAR- 75% eaten at 8:00 AM and no documentation for the following two meals. Task report- 25% eaten at 12:24 PM x2. 01/02/24: MAR- 50% eaten at 8:00 AM, 12:00 PM, and 5:00 PM. Task report- 75% eaten at 12:48 PM x2. No documentation of a third meal. 01/03/24: MAR- 50% eaten at 8:00 AM, 12:00 PM,…

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

Based on observation and staff interview, the facility failed to ensure Resident #97 was treated with dignity and respect. This was a random opportunity for discovery. Resident identifier: #97 Facility Census: 152. Findings included: A) Resident #97 At approximately 11:48 AM on 01/22/24, an observation was made of Resident #97's room. From the hallway, there was a sign visible to employees, other residents, and visitors that read Please wipe face with wet cloth after feeding. At approximately 12:38 PM on 01/22/24, an interview was conducted with Unit Manager Director (UMD) RN #100. UMD RN #100 acknowledged the sign did not protect the dignity of Resident #97.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment. This was a random opportunity for discovery. Room identifiers: #313 and #314 Facility census: 152. Findings include: a) room [ROOM NUMBER] At approximately 11:28 AM on 01/22/24, an observation was made in room [ROOM NUMBER]. Two clear, slick, wet spots were observed in the floor between the door and the A bed. There was a used medical glove and multiple plastic wrappers laying on the floor underneath the B bed. At approximately 11:33 AM on 01/22/24, Assistant Administrator (AA) #109 acknowledged the condition of the room. b) room [ROOM NUMBER] At approximately 11:36 AM on 01/22/24, an observation was made of room [ROOM NUMBER]. There was a broken feeding pump which had not been cleaned, laying on the air conditioning unit. A cap for the formula and a used piston syringe were observed laying in the windowsill. Observed sitting on the nightstand was a wrapper and a cap for the used piston…

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 alleged violations of neglect were reported to all state agencies in a timely manner. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for the care area of neglect. Resident identifier: #155. Facility census: 152. Findings include: a) Resident #155 The following information was received by the Office of Health Facilities Licensure and Certification (OHFLAC) on [DATE] at 2:37 PM On the evening of [DATE] at approximately 5:30 PM, resident [Resident #155's name redacted] was observed by nurse on unit to be absent of vital signs and CPR [cardio-pulmonary] resuscitation was initiated. EMS [Emergency Medical Services] arrived at the facility at approximately 5:57 PM and resumed CPR. Resident was transported [hospital name redacted] at that time. An investigation has been initiated due to potential entrapment of resident based on review of conflicting nursing documentation. Bed rail evaluations will be…

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

Based on record review and staff interview the facility failed to follow Resident #21's physician orders when the resident refused meals. This was a random opportunity for discovery and was true for Resident #21. Resident Identifier: #21. Facility Census: 152. Findings included: a) Resident #21 At approximately 3:00 PM on 01/22/23, a review of Resident #21's medical record revealed an order which indicated Resident #21 was to receive assistance on all meals and the resident's family member was to be notified each time a meal was refused. At approximately 12:20 PM on 01/23/24, an interview with Unit Manager Director (UDM) RN #100. UDM - RN #100 confirmed Resident #21 had a physician's order to call the family in the event they refuse their meals. At Approximately 12:50 PM on 01/23/24, a further review of Resident #21's medical record found Resident #21 had refused meals at 11:02 AM and 2:55 PM on 01/07/24. Upon further review, there was no documentation to indicate the facility had notified Resident #21's family as directed by the physician's order. At approximately 1:00 PM on…

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

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Pain medication was administered outside the prescribed time period for one (1) of three (3) residents receiving scheduled pain medications who were reviewed during the complaint investigation. Resident identifier: #44. Facility census: 150. Findings included: a) Resident #44 The facility's policy titled, Medication: Administration: General, with effective date 01/01/04 and revision date 06/01/21 stated medication doses will be administered within one (1) hour of the prescribed time unless otherwise indicated by the prescriber. Review of Resident #44's physician's orders showed an order for oxycodone-acetaminophen (Norco) 5-325 milligrams (mg), twice a day for wound pain, at 9:00 AM and 9:00 PM. The resident's Medication Administration Audit Report showing when medications were administered was reviewed for the past week. According to the Medication Administration Audit Report, the resident's Norco scheduled at 9:00 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days or, if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, the rationale was documented in the resident's medical record and the duration for the PRN order was indicated. This was a random opportunity for discovery during the complaint investigation process. Resident identifier: #150. Facility census: 150. Findings included: a) Resident #150 Review of Resident #150's physician's orders showed an order written on 08/06/23 for diazepam (Valium) 7.5 mg, every eight (8) hours as needed for anxiety. The medication continued until the resident's discharge on [DATE]. Review of Resident #150's Medication Administration Record (MAR) for September 2023 showed the resident took diazepam once a day on 09/01/23 through 09/6/23 and on 09/08/23. The resident took diazepam twice a day on 09/06/23 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 observation, staff interview and policy review the facility failed to respect the Residents right to be treated with respect and dignity. This was a random opportunity for discovery. Resident Identifier: #75. Facility Census: #149 Findings included: a) Resident #75 On 09/11/23 at 11:55 AM, observation was made by this surveyor as Certified Nurse Aid (CNA) #184 was assisting Resident #75 with him noon meal and was standing while feeding him. This was confirmed with the CNA and she stated I didn't know that, at which time the Surveyor explained to her that she must get a chair and sit to assist residents with feeding. Facility Policy for Feeding a Patient/Resident, revision date of 06/01/21 states . 6. Sit in chair at eye level with the patient . This was confirmed with Nurse-Unit Manager Director Registered Nurse #33 on 09/11/23 at 11:59 AM.

Based on medical record reviews and staff interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was true for two (2) of four (4) residents reviewed for a complaint survey. The physician's orders were not followed for Resident #146 and Resident #4 had a delay in treatment. Resident identifiers: #146 and #4. Facility census: 150. Findings included: a) Resident #146 During a medical record review on 09/11/23 for Resident #4, it was discovered there was an order on 08/27/23 to obtain an appointment with the wound care clinic. If the wound clinic did not contact the facility within three (3) days, the facility was to contact the wound clinic to obtain an appointment. On 09/11/23 there had been no appointment scheduled at the wound clinic for Resident #146. In an interview with the Director of Nursing (DON) on 09/11/23 at 2:10 PM, verified the appointment had not been scheduled at the wound clinic for Resident #146. b) Resident #4 On 09/11/23 at 1:54 PM record review shows Resident #4 fell and was found…

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

Based on observation and staff interview the facility failed to provide a safe, clean, comfortable and homelike environment for each resident. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility areas: Second (2nd) Floor and Main dining room Facility Census: 144 Findings Included: a) Second Floor rooms 201-218 On 8/08/22 at 9:44 AM during the initial interview process of the survey it was observed that the walls in several of the Residents rooms on the second (2nd) floor were in need of repairs. Many of them have holes, anchor wall plugs left in the wall where nothing is hanging, entire lengths of corner trim missing and scrapes and discoloration of the walls. Of the rooms observed from 201-218 the following rooms are in need of repairs to ensure a homelike environment. Room numbers 201 through 205, 208, 209, 214, 215, 218. This was confirmed with the Nurse Unit Manager Director Registered Nurse #94 on 8/08/22 at 9:50 AM and no further information was provided. b) Main Dining Room An observation 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 and staff interview, the facility failed to send a copy of the notice of transfer to the representative of the Office of the State Long-Term Ombudsman. This was true for six (6) of seven (7) residents reviewed during the survey process. Resident Identifiers: #42, #48, #96, #202, #152 and #153. Facility Census: 144. Findings Included: a) Resident #42 A review of Resident #42's medical record on 08/09/22 found on 05/22/22, the resident was sent to an acute care facility due to lethargy. The resident returned to the facility on [DATE] with the following diagnoses: --Lethargy --Asymptomatic bacteruria On 08/09/22 9:31 AM, the Director of Nursing (DON) stated, we do not have the notification to the Ombudsman. b) Resident #48 A review of Resident #48's medical record on 08/08/22 found on 07/18/22, the resident was sent to an acute care facility due to increased confusion, fever and intermittent non-responsiveness. The resident returned to the facility on [DATE] with the following diagnoses:…

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 residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure laboratory testing for Resident #76 was performed as ordered by the physician. The facility also failed to initiate treatment for Resident #108's Urinary Tract Infection (UTI) timely after the culture and sensitivity was received to determine what antibiotic the infection was sensitive to. Finally, the facility also failed to ensure bleeding experienced by Resident #85 was thoroughly investigated and reported to the physician. This deficient practice had the potential to affect three (3) of 38 residents reviewed in the long-term care survey sample. Resident identifiers: #76, #108 and #85. Facility census: 144. Findings included: a) Resident #76 Review of Resident #76's physician's orders showed an order written on 04/20/22 for HgA1c testing for diabetes to be performed every three (3) months in April, July, October, and January. No HgA1c testing for Resident #76 in July 2022 was not…

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

Based on medical record review and staff interview the facility failed to ensure meal percentages were documented for residents with fluctuating weight. This was true for three (3) of seven (7) residents reviewed for the care area of nutrition during the Long Term Care Survey Process (LTCSP). Resident identifiers: #43, #77 and #87. Facility census: 144 Findings included: a) Resident #43 A medical record review on 08/10/22 revealed the daily meal percentages reviewed from 07/24/22 to 08/08/22 had several missing meal consumption percentages for the following dates: 07/29/22 only two (2) meal consumptions were documented 07/30/22 only two (2) meal consumptions were documented 08/03/22 only one (1) meal consumption was documented 08/04/22 only two (2) meal consumptions were documented 08/05/22 only two (2) meal consumptions were documented 08/07/22 only two (2) meal consumptions were documented An interview with the Director of Nursing (DON) on 08/10/22 at 11:46 AM, verified the missing meal percentages were not documented for the above dates for Resident #43. b) Resident #77 Review of…

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

Based on observation and staff interview the facility failed to maintain a sanitary condition at the outside garbage receptacle to prevent the harborage and feeding of pests. This deficient practice has the potential to affect more than a limited number of residents that reside in the facility. Facility Census: 144. Findings Included: a) Outside garbage receptacle Observation made during the outside tour at 12:30 PM on 08/08/22 revealed the garbage receptacle and the area around the facility had trash scattered about on the ground which included: used gloves, used masks, plastic silverware, multiple used cigarettes butts, toothbrushes, straws, straw paper, empty pop bottle, food/cup lids and other trash items. During an interview on 08/08/22 at 12:40 PM the Administrator stated we will get it cleaned up right away, cigarette butts have always been a problem, but not all this. .

Based on record review and staff interview, the facility failed to ensure medical records were accurate and complete. This was true for three (3) of 38 residents reviewed during the long-term survey process. Resident Identifiers: #96, #48 and #76. Facility Census: 144. Findings Included: a) Resident #96 A review of the medical record was completed on 08/09/22. A Facility To Hospital Transfer Form was reviewed. Resident #96 was transferred to an acute care facility on 05/21/22. However, the date of transfer on the form was listed as 04/20/21. On 08/09/22 at 10:38 AM, the Director of Nursing (DON) confirmed the transfer form had the incorrect date of transfer listed. b) Resident #48 A review of Resident #48's medical record completed on 08/09/22 found Resident #48 was transferred to an acute care facility on 07/18/22. However, the date on the form was listed as 10/21/15 to an acute psychiatric facility. On 08/09/22 at 10:40 AM, the DON confirmed the transfer form had the incorrect date and facility of transfer listed. c) Resident #76 Review of Resident #76's physician's orders showed…

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

Based on record review, staff interview, and policy review the Quality Assessment and Assurance (QAA) committee failed to identify and/or correct quality deficiencies of which it was aware of or should have been aware. The facility failed to develop a policy to ensure lab services were btained and processed as physician's orders. The facility failed to ensure meal percentage were recorded for three (3) meals a day for all residents. The facility failed to ensure when residents were transferred and/or discharged from the facility that the transfer form was communicated to the Ombudsman as directed. Finally, the facility failed to have a pressure ulcer system to identify, assess and treat pressure ulcers in an effective manner. These failed practices had the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 144. Findings included: a) Cross Reference F623. b) Cross Reference F684. c) Cross Reference F686. d) Cross Reference F692. An interview with the facility's Administrator was conducted on 08/10/22 at 1:31 p.m.…

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 Physician orders for scope of treatment (POST) forms were fully completed and accurately represented the resident and/or responsible party's wishes. This was true for Two (2) of Two Residents reviewed for the care area of advance directives. Resident Identifiers: #72 and #48 Facility Census: 144 Findings included: a) Resident #72 On [DATE] at 2:33 PM while reviewing advanced directives, it was noted that the Physicians Orders for Scope of Treatment form (POST) for Resident #72 was not completed correctly. The Post reflects the Resident is to have Cardiopulmonary Resuscitation (CPR), full interventions, feeding tube long term and Intravenous Fluids (IVF) for a trial period of no longer than _______ (no time period entered). In Section C, Medically Administered Fluids and Nutrition the trial period for IVF was left blank. The POST was consented by the Residents' surrogate by telephone which requires confirmation and signature by two…

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 the Minimum Data Set (MDS) was accurate in skin condition status for Resident #19. This was true for one (1) of 38 sampled residents. Resident Identifier: #19. Facility Census: 144. Findings Included: a) Resident #19 Review of Resident #19s medical record review found skin and wound evaluations dated 05/10/2022 which indicated the resident had the following skin conditions: --One (1) unstageable pressure ulcer on the left lateral malleolus. --Two (2) DTI ( Deep Tissue Injury) areas located on the right and left heel. --One (1) venous and arterial ulcer on the left dorsal foot. Further review of the medical record found a MDS with an assessment reference date (ARD) of 05/23/22. Review of this MDS found section M skin conditions indicated Resident #19 only listed one (1) DTI wound present. On 08/10/22 at 12:45 pm the Center Nurse Executive (CNE) reviewed the MDS with ARD of 05/23/22 for Resident #19. She confirmed the MDS was not coded correctly. It should have been coded for two (2) DTI wounds. .

Based on record review and staff interview, the facility failed to develop an accurate care plan for pressure ulcer treatment for one (1) of six (6) residents reviewed for pressure ulcers. Resident identifier: #152. Facility census: 144. Findings included: a) Resident #152 The care plan was reviewed with the Director of Nursing (DON) on 08/10/22 at 9:05 AM. The care plan focus/problem, dated 04/16/22 and revised on 05/10/22, noted the following: Resident has stage 4 to left buttock, DTI (Deep Tissue Injury) to left buttock and coccyx and a pressure ulcer, stage 1 to left trochanter. The DON confirmed the resident was admitted with 3 pressure areas: the DTI to the coccyx, the Stage four (4) to the left buttocks and a Stage 1 pressure ulcer to the trochanter, not four (4) pressure areas as stated in the care plan. .

Based on record review and staff interview, the facility failed to revise the care plan for Resident #42 in the care area of diagnosis for a foley catheter and skin conditions for Resident #77.This was true for two (2) of 38 residents reviewed during the long-term survey process. Resident Identifiers: #42 and #77. Facility Census: 144. Findings Included: a) Resident #42 On 08/08/22 at 1:27 PM, a review of Resident #42's care plan was completed. The review did not find a diagnosis for the use of the foley catheter. A progress note dated 05/31/22 at 1:45 PM states, Resident has had a decrease in urine output. Foley catheter placed per verbal order from (Name of facility Nurse Practitioner). 600 ml (milliliters) emptied from drainage bag. No complaints of pain. (Typed as written.) A review of the current physician's orders were completed on 08/09/22. A physician's order dated 05/31/22 states, Foley catheter 16 FR (french size of the foley catheter) with 10 cc (cubic centimeters) balloon to bedside straight drainage. (Typed as written.) On 08/09/22 at 1:27 PM the Director of Nursing…

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 ensure activities of daily living (ADL) care was provided to residents who were unable to carry out these activities on their own. This deficient practice was true for one (1) of five (5) residents reviewed for activities of daily living. Resident identifier: #77. Facility census: 144. Findings included: a) Resident #77 Resident #77's comprehensive care plan stated the resident prefered showers but some times refused showers. Resident #77's bathing task report documented the resident had received only one (1) shower in the last thirty days. This shower was documented on 07/15/22. No shower refusals were documented on the bathing task report in the last 30 days. During an interview on 08/09/22 at 12:11 PM, Resident #77 stated she would like to receive more showers but stated she thought it was easier for the staff to give her bed baths. She was unable to recall how often she had received showers or when her last shower was given. Review of the shower schedule showed Resident #77 was scheduled to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure two (2) of six (6) residents reviewed for the care area of pressure ulcers received care, consistent with professional standards of practice for assessing and treating pressure ulcers. Resident identifiers: #152 and #45. Census: 144. Findings included: a) Resident #152 Record review found the resident was admitted to the facility on [DATE]. The resident did not have any pressure areas at the time of this admission. On 11/29/22 the resident was discharged to the hospital. On 12/01/22 the resident returned to the facility from a hospital stay. A nurses note written on 12/02/21 at 3:55 PM found the resident was assessed to have a DTI (Deep Tissue Injury) to the left thigh, the pressure ulcer was listed as present upon admission. A nursing note dated 12/02/21 at 3:55 PM: New admission skin assessment: resident is alert and in bed, requires assistance with turning and repositioning in bed. Skin assessment showed resident to have a sm (small)…

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

Based on medical record review and staff interview the facility failed to provide respiratory services in accordance to professional standards of practice. This was true for one (1) of two (2) residents reviewed for respiratory services. Resident identifier: #106 Facility census: 144 Findings included: a) Resident #106 During an observation on 08/08/22 at 10:30 AM. it was discovered Resident#106's continuous positive airway pressure (CPAP) tubing had been disconnected from the face mask and was draped over the oxygen concentrator allowing the tubing to touch the floor. In an interview with Licensed Practical Nurse (LPN) #69 on 08/08/22 at 10:35 AM, verified the CPAP tubing had not been stored properly when it had been disconnected from the face mask. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to ensure they established and implemented a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The facility failed to ensure that two (2) licensed professionals were present when controlled substances were destroyed as required by law and the facility policy. These were random opportunities for discovery and was true for Resident #552 and Resident #153. Resident Identifier: #552 and #153. Facility Census: 144. Findings Included: a) Resident #552 A review of Resident #552 medical record on [DATE] found she had expired at the facility on [DATE]. At the time of her death she had the following controlled substances remaining: -- Hydrocodone 5- 325 milligram (MG) - 5 pills remaining. -- Hydrocodone 5- 325 mg - 30 pills remaining. -- Morphine Sulfate 20 mg per 1 milliliter (ML) - 29.50 mls remaining, and -- Lorazepam 1 mg - 6 pills remaining. Further review of the controlled…

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, observation and staff interview, the facility failed to date a Novolog Flex-pen when opened for insulin administration. This was true for one (1) of three (3) residents reviewed during medication administration. Resident Identifier: #44. Facility Census: 144. Findings Included: a) Resident #44 On 08/10/22 at approximately 9:25 AM, the medication cart was reviewed. A Novolog Flex-Pen was labeled with Resident #44's name. However, there was no open date noted on the Novolog Flex-Pen or the plastic bag in which it was stored. On 08/10/22 at 9:30 AM, the Unit Manager (UM) #114 was notified of the undated insulin pen. UM #114 confirmed the insulin pen was not dated when opened. The UM #114 stated, we will get rid of it and get a new one .we don't know when it was opened. The facility policy entitled Medication Administration: Injectable section 2.4 Medications labeled for multi-dose states the following: --2.4.1 Dedicate to a single patient whenever possible; --2.4.2 Date and initial when opened; --2.4.3 Discard within 28 days unless manufacturer specifies a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident council meeting minutes, policy review, resident interview, and staff interview the facility failed to serve food that was palatable and at a preferable temperature. This failed practice had the potential to affect more than an isolated number of residents. Facility census 144. Finding Included: a) Cold Food A review of a facility policy titled 4.7 Food Handling with an effective date of 07/01/98 and revision date of 06/15/18 stated: .16. All Time/Temperature Control for Safety Food must maintain an internal temperature of 41 degree F of lower, or 135 degree F or higher while being held for service. During an interview on 08/08/22 at 10:04 AM Resident #78 stated The food is always served cold. On 08/09/22 at 1:00 PM temperatures were obtained on the lunch tray for Resident #32 at the time of service. The following temperatures were obtained by the Dietary District Manager #193 using her thermometer: --a bowl of Broccoli Soup: 147 degrees Fahrenheit (F) --Sloppy [NAME] Sandwich 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 correctly document the cook dish sink temperatures. This deficient practice has the potential to affect a limited number of residents. Facility Census: 144. Findings Included: a) [NAME] Dish Sink Temperature Log The initial tour of the kitchen with Dietary Manager in Training(DMIT) #173 at 9:15 AM on 08/08/22 revealed the cook dish sink temperature log was completed for the lunch section with the following temperatures. Lunch: Wash: 170 Rinse: 180 Initials: RO During an interview on 08/08/22 the DMIT #173 and Dietary District Manager #193 acknowledged the cook dish sink temperature log was completed for the lunch section at 9:18 AM and should not have been completed until lunch time. .