Putnam Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to provide a safe, clean, comfortable and homelike environment for the residents. This was a random opportunity for discovery. Resident Identifiers: Facility. Facility Census: 119Findings Included:a) Facility cleanlinessOn 09/18/25 at 12:25 PM observation found the floors in the facility to be cluttered with particles of paper, dust and spilled dried liquid in need of being swept and mopped. Trash cans were full and personal items were in the foor to the point of housekeeping not being able to sweep in some rooms. During a walk through with the Administrator he agreed, that in particular, the following rooms on that unit were the worst. room [ROOM NUMBER], 152, 153 and 154. On 09/18/25 at 12:45 PM he confirmed the faciity auto scrubber was down and the floors needed swept and mopped. b) Ceiling tilesOn 09/18/25 at 12:35 PM observation found that there were two (2) ceiling tiles outside the activity room that were dark in color as if something had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to offer sufficient fluid intake to maintain proper hydration and health. This was a random opportunity for discovery. Resident Identifiers: room [ROOM NUMBER]A, 150A, 155, 156A, 161, 162A. Facility Census: 119.Findings Include:a) Bedside water cupsOn 09/18/25 at 12:30 PM during a walk through at the facility it was observed that several residents on the 100 hallway did not have fresh, if any, water at bedside. Residents in rooms #148A, 150A, 155, 156A, 161 and 162 had no, or room temperature water at bedside. Observation on 09/18/25 at 12:38 PM found the resident in 150A had been at bedside eating his noon meal. He had just finished. He had no drink with his meal. There were two staff members at the door and told the Resident they were taking him for an appointment. The surveyor ask the facility van driver (as identified on his name tag) if the resident was not allowed to have a drink. He stated, he has one around here some where. He took a cup from…

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 follow Physicians orders by not placing heel boots on a resident to help prevent pressure ulcers to her heels. This was a random oportunity for discovery. Resident Identifier: #1 Facility Census: 119 Findings Include:a) Resident #1On 09/18/25 at 3:15 PM observation found that Resident #1 did not have her heel boots on as ordered from the Physician. On 09/18/25 at 3:25 PM Nurse Aide (NA) # 2 was asked if she could tell the surveyor why the resident did not have them on. NA #2 stated she did not know because she had just picked up that hall at noon. The surveyor ask NA #2 if she would please try and place the boots on the resident. When NA #2 obtained the boots from under the sink and ask Resident #1 if she wanted the boots on, the resident stated Yes, go ahead. On 09/18/25 at 3:30 PM it was confirmed with NA #2 and the Director of Nursing that Resident #1 did not have her heel boots on as ordered by the Physician.

Based on observation, resident interview, family interview, and staff interview the facility failed to maintain a clean, comfortable, homelike environment. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifiers #52, #24, #128. Facility census 114. Findings Include: a) Resident #52 An observation on 04/29/25 at 11:32 AM, found Resident #52's bathroom that adjoins next door to have 3 briefs that appeared to be soiled in the floor, along with 4 articles of clothing. On the floor and commode seat there was a brown, dried substance. During an interview on 04/29/25 at 11:32 AM, Resident #52 stated, I don't use that bathroom and my roommate doesn't either. It must be the people next door. There is always shit in there. During an interview and observation on 04/29/25 at 11:45 AM, The Infection Preventionist (IP) confirmed that the bathroom was dirty and needed to be cleaned. The IP further stated, That definitely needs to be cleaned. I will get it taken…

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

Based on resident interview, observation and staff interview, the facility failed to serve food that was palatable and at a safe appetizing temperature. This was found true for one(1) resident investigated for the care area of nutrition during the Long-Term Care Survey process. This failed practice had the potential to affect more than a minimal number of residents residing in the facility, Resident identifier: #54 Facility census: 114 Findings include: a) Resident #54 04/29/25 8:20 AM observed Resident #54 picking at their food, when asked, How is your breakfast this morning? Resident #54 stated, Honey it is cold, I just can't eat it. When asked if this happens often Resident #54 stated, Oh child breakfast and dinner is normally cold when we get it. The carts set out there before they come up from the desk to get it to do. 04/29/25 8:35 AM this surveyor requested the temperature to be taken on the last try to be delivered on the 100 hallways. The temperatures were recorded as follows: Oatmeal 112.00 degrees Fahrenheit (F) Fried Hash-browns 86.2 degrees (F) Gravy & Biscuits 105.5…

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

Based on observation and staff interview the facility failed to maintain an affective infection control program to prevent the spread of disease and infections. This was true for three (3) of thirty-one (31) residents observed during the long-term survey process and one (1) random opportunity for discovery. Resident identifiers: #69, #158, #264 and #25. Facility Census: 114 Findings include: a) Resident #69 On 04/29/25 at 8:20 AM during the initial interview of the long-term survey process, it was noted that Resident #69s' Continuous Positive Airway Pressure (C PAP) machine mask was not stored properly to prevent infections or the spread of disease. It was lying on the bedside table outside of the plastic storage bag that was supplied for storage. The resident stated that it is usually where they leave it. A follow up observation was performed on 04/29/25 at 1:23 PM and again on 04/29/25 at 4:22 PM and found the C PAP mask still on the bedside table outside of the plastic bag that was supplied for storage. On 04/29/25 at 4:27 PM it was confirmed with the Regional Resource Registered…

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 #264 was treated in a dignified manner due to being exposed, and in view of passersby and, by failing to knock before entering his room. This was a random opportunity for discovery. Resident identifier: #264. Facility census: 114. Findings include: a) Resident #264 At approximately 10:15 PM on 4/30/2025, Resident #264 was observed in his bed, uncovered, with his buttocks exposed and his catheter tubing visible coming from his groin area. Resident #264's door was open, and his curtain was not pulled, leaving him exposed to anyone that would pass by his room and look inside. The Infection Prevention (IP) Nurse was in the hallway at the time and confirmed the resident was exposed. The IP nurse then entered the room to check on the resident, however, she did not knock before entering. When she entered the room, she asked Resident #264 if he was cold, to which he stated ,Yes. The IP nurse then asked Resident #264 if he needed her help covering himself up, to which he stated, Yes. Upon exiting the room, 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, resident interview and staff interview the facility failed to provide residents a choice regarding bathing preferences. This was true for two (2) of eight (8) residents reviewed for Activities of Daily Living (ADL). Resident identifiers: #101 and #81. Facility Census: 114 Findings included: a) Resident #101 On 04/29/25 at 2:34 PM Resident #101 states she only gets one shower a week. She prefers a shower over a bed bath but does not always get that. On 04/30/25 at 11:48 AM the facility provided a North Unit Shower Schedule which indicates Resident #101 is scheduled for her showers on Tuesday and Friday, evening shift. On 04/30/25 at 12:10 PM a review of Resident #101's care plan indicates It is important for me to choose between a tub bath, shower, bed bath or sponge bath, I prefer a shower. On 4/30/25 at 11:50 AM a review of the GG Bathing task report for the last thirty (30) days, (04/01/25 through 04/30/25) documentation shows that Resident #101 received three (3) showers and seventeen (17) bed bath/sponge. On 05/05/25 at 3:30 PM it was confirmed with the…

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

Based on record review and staff interview, the facility failed to ensure Resident #87 was free from chemical restraints by failing to ensure a PRN (as needed) order for Ativan did not last longer than 14 days, and by failing to attempt non-pharmacological interventions before the administration of PRN Ativan. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: #87. Facility census: 114. Findings include: a) Resident #87 During a review of Resident #87's electronic health record on 05/01/25, it was noted he had been prescribed Ativan on an as needed basis, four (4) times since October 2025, with all four (4) orders being longer than 14 days. The orders are as follows: -Lorazepam oral tablet one (1) MG. Give one tablet by mouth every six (6) hours as needed for anxiety for three (3) months. Start date- 10/25/2024 10:00 AM. Discontinue date- 12/11/2024 10:45 PM. -Ativan injection solution 2MG/ML. Inject 0.5 ml intramuscularly every 24 hours as needed for acute anxiety for 30 days. Start date- 10/25/2024…

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

Based on record review and staff interview, the facility failed to implement the care plans for Resident #87 related to non-pharmacological interventions before administration of PRN Ativan, and the care plan related to activities for Resident #33. This was true for two (2) of 31 care plans reviewed during the survey process. Resident identifiers: #87, and #33. Facility census: 114. Findings include: a) Resident #87 During a review of Resident #87's electronic health record on 5/1/2025, it was noted he had been prescribed Ativan on an as needed basis, four (4) times since October 2025. The orders were as follows: -Lorazepam oral tablet one (1) MG. Give one tablet by mouth every six (6) hours as needed for anxiety for three (3) months. Start date- 10/25/2024 10:00 AM. Discontinue date- 12/11/2024 10:45 PM. -Ativan injection solution 2MG/ML. Inject 0.5 ml intramuscularly every 24 hours as needed for acute anxiety for 30 days. Start date- 10/25/2024 10:00 AM. This was discontinued on 11/24/2024. -Lorazepam oral tablet one (1) MG. Give one tablet by mouth every six (6) hours as needed…

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 a program of activities to meet the needs and interest of the residents. This failed practice was found true for (1) one of (4) four residents reviewed for activities during the Long-Term Care Survey Process. Resident identifier #33. Facility Census 114. Findings Include: a) Resident #33 Resident #33 During the initial observation on 04/29/25 at 12:41 PM, revealed Resident #33 lying in bed, still in her nightgown with the lights off. No television (TV) or radio was playing. Resident #33 was talking out loud to herself. Further observation of Resident #33 on 04/29/25 at 3:10 PM, revealed Resident #33 lying in bed, continues to be in her nightgown. No TV or radio was playing. Resident #33 was holding and rubbing the sides of a cup. An observation on 05/05/25 at 11:30 AM revealed Resident #33 lying in her bed. No TV or radio was on in the room and the room was dark. A record review on 05/05/25 at 12:31 PM, of Resident #33's Activity care plan dated 03/17/25 reads as follows: Focus: Prefers to 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, resident interview and staff interview the facility to follow the Physicians orders relating to administering medications in a timely manner, obtaining blood lab orders and following the hypoglycemia protocol as written. Resident Identifiers: #12, #24 and #101. Facility Census: 114 Findings Include: a) Resident #12 On 05/01/25 at 12:20 PM record review of laboratory results for Resident #12 shows an Ammonia level drawn on 03/07/25 at 5:53 AM had abnormal results indicating an elevated Ammonia level. This was addressed by the Unit Manager with a Physicians order to increase Lactulose to 15 ml twice a day and repeat the ammonia level in one week. Review of the following laboratory results for the rest of March, 2025 found no repeat ammonia level was completed. On 05/05/25 at 8:30 AM the above information was discussed with the Administrator who confirmed that the repeat Ammonia level was not completed as ordered. b) Resident #24 On 05/05/25 at 12:58 PM record review of the Medication Administration Record shows that Resident #24 had a documented blood glucose…

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, record review and staff interview the facility failed to ensure residents received the correct prescription of reading glasses as ordered by the Ophthalmologist. This failed practice was found true for (1) of (1) residents reviewed for vision services during the Long-Term Care Survey Process. Resident identifier #52. Facility Census 114. Findings Include: a) Resident #52 During the initial interview on 04/29/25 at 11:28 AM, Resident #52 stated, The eye doctor checked my eyes six months ago and ordered me glasses and I still have not gotten them. They gave me these, but I can't see good out of them. A record review revealed Resident #52's last Ophthalmologist appointment was dated 01/16/24. Final Spectacles Prescription read as follows: SPH CYL Axis ADD OD +.50 -0.50 090 +3.00 OS +.50 -0.50 090 +3.00 During an interview on 04/30/25 at 12:57 PM, The Administrator stated, I feel like that is a prescription for reading glasses. Let me go talk to her and I will check on it. The Administrator further stated, I went back there, and she had +1.75. I went and got…

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

Based on observation and staff interview, the facility failed to ensure the resident environment, over which it had control, was as free of accident hazards as possible. A mattress was left lying on the floor in the hallway. This was a random opportunity for discovery. Facility census: 117. Findings include: A) Mattress observation At approximately 7:30 AM on 04/29/25 a mattress was observed lying on the floor in the north hallway, in a resident area, in front of the mechanical room and the entrance to the kitchen/service hall. Nurse Aide (NA) #66 and Registered Nurse (RN) #30 acknowledged the mattress in the floor and stated it should not have been left there. Both acknowledged the mattress was a hazard and a resident could have fallen over it.

Based on observation, resident interview and staff interview the facility failed to offer sufficient fluid intake to maintain proper hydration and health. This was true for two (2) of thirty one (31) residents reviewed for hydration during the Long Term Care Survey Process. Resident Identifiers: #23 and #36. Facility Census: 114 Findings Include: a) Resident #23 On 04/29/25 at 8:30 AM Resident #23 states it is hard to get water at around here. Observation at that time finds a disposable cup on the over the bed table dated 04/28/25 to be empty. Further observations on 04/29/25 at 1:20 PM and 04/29/25 at 4:20 PM found a disposable cup on the over the bed table dated 04/28/25 to be empty. It was confirmed with the Administrator on 04/29/25 at 4:30 PM that this resident has not had proper hydration on 04/29/25. She agreed. b) Resident #36 On 04/29/25 at 8:15 AM Resident #36 states staff won't always give me water, they tell me I don't need it. Observation at that time finds a disposable cup on the over the bed table dated 04/28/25 to be empty. Further observations on 04/29/25 at 1:21 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 record review, resident interview, and staff interview the facility failed to provide routine dental services to Medicaid funded residents. This failed practice was found true for (1) one of (1) one residents reviewed for dental services during the Long-Term Care Survey Process. Facility Census 114. Resident identifier: #52. Findings included: a) Resident #52 During the initial interview on 04/29/25 at 11:29 AM, Resident #52 stated, I have 3 teeth. One on the top and 2 on the bottom. This top one hurts sometimes so it's hard for me to chew. I have not seen a dentist since I have been here. A record review on 04/30/25 at 1:00 PM, revealed a dental care plan for Resident #52 created on 10/14/23 that reads as follows: Focus: Resident is at risk for oral health problems R/T poor dentition. Has 1 upper tooth and 2 bottom teeth with obvious caries noted. Currently denies oral pain or discomfort but states the upper tooth scratches her inner lip at times. Goals: The resident will maintain intact oral mucous membranes as evidenced by the absence of discomfort, gum…

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 A review of the electronic health record was conducted on 04/29/25. During the review it was noted Resident #72 was admitted [DATE] and had suffered seven (7) falls during this time. The falls were on the following dates: 04/14/25, 04/19/25 04/20/25 04/23/25 04/27/25- three (3) times During a review of, on 04/30/25, of the post fall neurological assessments completed by the facility, it was determined that one that was scanned into the resident's health record did not have correct dates and was not signed, in eight (8) instances, by the nurse completing the assessments. A neurological assessment was performed for a fall suffered by Resident #72 on 4/23/2025 at 6:00 PM. The directions for the assessment were to evaluate the resident every 15 minutes for the first two (2) hours after the initial evaluation following the fall, then evaluate the resident every 30 minutes for two (2) hours, evaluate the resident every hour for four (4) hours, and lastly, evaluate the resident every eight (8) hours for at least 64…

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 provide reasonable accommodations of needs by not ensuring residents could turn the over-bed light on and off by their own free will. This failed practice was a random opportunity for discovery and the potential to affect a limited number of residents. Resident identifier #1. Facility census: 114. Findings Include a) Resident #1 During the initial interview and observation on 04/29/25 at 10:55 AM, Resident #1 stated, Last night I had to sleep with this light on above my bed, because the light switch is not long enough for me to reach. During the interview an observation of the light string above the bed showed that the string was about an inch long and that the resident could not reach it to turn it off and on. During an interview and observation, on 04/29/25 at 11:30 AM, the Director of Nursing (DON), confirmed that he could not reach the light string. During an interview, on 04/30/25 at 3:15 PM, the administrator stated, We fixed his lights and did an audit and fixed the rest that were not long…

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 a care plan regarding fall preventions for Resident #13, #32, #120 and regarding food restrictions for Resident #27. This was true for four (4) of 13 residents reviewed during the survey process. Resident Identifiers: #13. #32, #120 and #27. Facility Census: 114. Findings Include: a) Resident #13 On 01/22/25 at 1:00 PM, a record review was completed for Resident #13. The review found the care plan had not been revised regarding fall interventions put in place. The care plan did not include call light within reach. On 01/22/25 at 2:00 PM, the Administrator confirmed the fall intervention should have been listed in the care plan. The Administrator stated, we have started a house-wide audit regarding fall interventions. b) Resident #32 On 01/22/25 at 1:15 PM, a record review was completed for Resident #32. The review found the care plan had not been revised regarding fall interventions put in place. The care plan did not include non-skid strips to the right side of the bed or dumped wheelchair. On 01/22/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that Resident # 106 was free from physical abuse from Resident #118. Resident #106 was physically abused by Resident #118. Resident #106 was a nonverbal resident who was hit on the left side of the face by Resident #118. This is true for one (1) of three (3) residents reviewed for resident to resident abuse. Resident identifiers: #106 and #118. Facility Census: 114. Findings included: a) Resident #118 A facility reported incident dated 01/06/25 explained the following: Resident #118 was witnessed hitting Resident #106 multiple times in the face on the left side. The power of attorney was called for both perpetrator and victim. Resident #106 was sent for a medical evaluation and Resident #118 was sent for a psychiatric evaluation. The medical record review revealed Resident #118 was immediately separated from Resident #106 by staff. Resident #118 was redirected to his room and staff ensured residents remained separated while conducting…

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, staff interview and record review, the facility failed to maintain appropriate infection control standards for linen storage and ice storage. These were random opportunities for discovery. Facility Census: 114. Findings Included: a) Linen carts On 09/11/23 at 9:09 PM, an observation on the South unit was made noting one (1) linen cart sitting between rooms [ROOM NUMBERS] with the cover flipped over the top, and an additional linen cart sitting by room [ROOM NUMBER] with the cover flipped over the top and a bath basin with water, soap and wash cloths sitting on top of the linen cart. On 09/11/23 at 9:11 PM, Nurse Aide (NA) #56 and NA #32 acknowledged the linen carts were uncovered and the bath basin should not be sitting on top of the linen cart. On 09/11/23 at 9:15 PM, Registered Nurse (RN) #2 was notified of the uncovered linen carts and the bath basin sitting on top of the linen cart by room [ROOM NUMBER]. On 09/12/23 at 8:30 AM, the policy entitled Linen Handling, section 1.1 states keep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain safe operating equipment kept in a resident area. This was a random opportunity for discovery. Facility Census: 114. Findings Included: a) Scoot chair On 09/12/23 at 12:13 PM, a leaning scoot chair missing a wheel was observed in the walk way at the foot of the beds in room [ROOM NUMBER]. Licensed Practical Nurse (LPN) #64 and Maintenance Director #46 were alerted to the broken chair. LPN #64 and Maintenance Director #46 entered the room and pulled the scoot chair into the hall. The missing wheel was found under bed A. The Maintenance Director #46 stated, the wheel is missing .all the bolts are loose while turning the bolts of the chair. The scoot chair was removed from the hallway and taken out of service. No work order had been placed prior to discovery. On 09/12/23 at 12:29 PM, the Director of Nursing (DON) could not identify which resident uses the scoot chair. On 09/12/23 at 12:50 PM, the Administrator stated, the work order has been…

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 reconcile the narcotic reconciliation sheets on two (2) of three (3) medication cart narcotic books reviewed. This failed practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility Facility Census: 117 Findings included: a) North Hall Narcotic Books On 05/09/23 at 9:05 AM upon review of North front and back hall hall narcotic book it was found to be incomplete as per the facility Routine Reconciliation of Controlled Substances Policy dated 01/01/22. Review dates of the narcotic reconciliation books were from 04/01/23 through 05/07/23 for a total of 37 days. Normally there are two (2) entries per day as the nurses work twelve (12) hour shifts and reconcile the narcotic book each shift change (7 AM and 7 PM). This gives them 74 entry possibilities during the time frame reviewed. The North front hall missed thirty eight (38) entries and the North back hall missed twenty three (23) entries. The following entries were missing or incomplete…

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, staff interview and policy review the facility failed to ensure supplies in the medication storage room were within the expiration date in accordance with currently accepted professional principles. This failed practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility Census: #117 Findings included: a) On [DATE] at 4:04 PM during an audit review of the South Medication Room with Licensed Practical Nurse (LPN) #18, there were numerous medical supply items in the storage room that had expired. According to the facility Storage and Expiration Dating of Medications, Biological's, Syringes, and Needles dated [DATE] revision date, the Facility should ensure medications, biological's and supplies that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed…

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

Based on record review and staff interview the facility failed to maintain complete and accurate medical records for seven (7) of 27 sampled residents reviewed during the long term care survey process. Resident identifiers: #77, #106, #58, #86, #85, #53, and #11 Facility Census: #117. Findings included: On 05/09/23 at 1:15 PM a review of documentation for a thirty (30) day period from 04/10/23 through 05/09/23 showed incomplete or missing documentation for meal intakes for the four (4) residents presented below. For this time period, with three (3) meals per day, there were ninety (90) opportunities for documentation. a) Resident #77 On 05/09/23 a review of Resident #77's medical record found documentation for a thirty (30) day period from 04/10/23 through 05/09/23 showed incomplete or missing documentation for meal intakes. For this time period, with three (3) meals per day, there were ninety (90) opportunities for documentation. The following are the dates and entries missed for Resident #77: 04/10/23 missing two (2) entries 04/11/23 missing one (1) entry 04/13/23 missing one (1)…

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 staff interview and resident interviews, the facility failed to accurately explain the arbitration agreement to residents and/or their representatives. This failed practice has the potential to affect more than an isolated number of residents currently residing in the facility. Census 117. a) Staff Interview On 05/10/23 at 11:05 AM, the Admissions Director (AD) #88 was asked to state to the survey team how she explained the arbitration agreement to new residents and/or their representatives. AD #88 stated, she most importantly explained to the residents the arbitration agreement was voluntary, meaning they do not have to sign it. AD #88 also stated she explained to the resident if they sign the agreement, they would have a third party arbitrator to help them settle the dispute, but if they could not settle this way, then they could have a judge and jury; an arbitrator was their first step before court. Surveyors explained when a resident signed the arbitration agreement they are waiving their right to have a judge and jury. AD #88 stated that was how she was taught to…

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

Based on record review and staff interview the facility failed to maintain an ongoing Quality assurance and performance improvement (QAPI) program. This failed practice had the potential to affect all residents residing at the facility. Facility census: 117. Findings included: On 05/10/23 at 4:30 PM, the Administrator stated, QA [quality assurance] was not done last year, we didn't have any meetings. I just had the first one since I have been here last week. The Administrator provided a copy of the QA sign in sheet with a meeting date of 05/03/23. Record review showed no documentation of QAPI meetings for the past year other than the meeting held 05/03/23. Record review of the facility's policy titled, Center Quality Assurance Performance Improvement Process, revised 10/24/22, showed the Quality Assessment and Assurance committee meets at least quarterly. .

Based on observation, record review and staff interview the facility failed to maintain a quality assessment and assurance committee (QAPI) consisting of the minimum required members. The infection preventionist failed to attend the monthly QAPI meeting. This failed practice had the potential to affect all residents currently residing at the facility. Facility census: 117. Findings included: a) On 05/10/23 at 4:30 PM, the Administrator stated, QA [quality assurance] was not done last year, we didn't have any meetings. I just had the first one since I have been here last week. The Administrator provided surveyor with a copy of the QA sign in sheet with meeting date of 05/03/23. The Infection Preventionist (IP) did not attend the 05/03/23 meeting, as verified by the Administrator. The Administrator stated the IP was on vacation during the time of the meeting. Record review of the QA sign in sheets showed all required members were at the 05/03/23 meeting with the exception of the facility's IP. Record review of the facility's policy titled, Center Quality Assurance Performance…

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 dignity during care for Resident #50. This failed practice was a random opportunity for discovery and was true for only Resident #50. Resident identifier: #50. Facility census: 117. Findings included: a) Resident #50 On 05/10/23 at 9:00 AM, surveyor and Director of Nursing (DON) entered Resident #50's room. Nurse Aide (NA) #74 and NA #130 were giving Resident #50 a bed bath. The window blinds were open, and the resident was laying in bed completely nude, exposed to anything outside the window or adjacent rooms. The DON immediately stepped over and closed the blinds. As the Surveyor and DON left the room at 9:05 AM on 05/10/23, the DON was asked if dignity was provided while providing care to Resident #50? The DON replied, No it wasn't that is why I jumped over there and jerked the blinds closed.

Based on observation, resident interview, and staff interview, the facility failed to ensure one (1)resident was provided a clean, sanitary homelike environment. The resident had dirty sheets his bed. This was a random opportunity for discovery during the long term care survey. Resident identifier #11. Census 117. Findings included: a) Resident #11 On 05/08/23 at 11:10 AM, the surveyor observed Resident #11 sitting in his wheelchair in his room. The surveyor also observed the sheets on the resident's bed were covered in, what appeared to be, black dirt. The surveyor asked the resident if he was given showers on a regular basis and the resident responded yes, he gives himself a shower. The surveyor asked the resident if he changed his own bed linens too. The resident responded, no and said he had to have help. The surveyor asked how long it had been since they were changed. He said he was not sure but he would have them help change them sometime today. On 05/09/23 at 11:30 AM, the surveyor entered Resident #11's room and observed the same dirty sheets were still on the resident's…

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

Based on record review and staff interview the facility failed to have an accurate MDS (Minimum Data Set) discharge for Resident #116. This was true for one (1) out of four (4) reviewed for the care area of discharges during the Long Term Care Survey Process. Facility census 117. Findings included: a) Resident # 116 A review of the nursing documentation found; Resident # 116 was discharged to home with family. The facility MDS states Resident # 116 was sent to an acute hospital. Further review of the record found the following nursing note dated 04/21/23: Note: resident discharged home via family car. Discharge paperwork, bed hold policy and mediations send with resident. All personal belongings sent with resident. On 05/10/23 at 10:38 AM, the Director of Nursing reviewed the Nursing note dated 04/21/23 and the MDS section A 1800. and agreed the MDS was coded wrong. I

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening (PAS) for one (1) of three (3) residents reviewed for the category of PASARR (pre admission screening and resident review), during the long term care survey process. Resident identifier #85. Census 117. Findings Included: a) Resident #85 On 05/08/23 at 2:14 PM, a record review of Resident #85's electronic medical record (EMR), found the resident's most recent PAS, dated 03/29/21, indicated no level II was needed. It was also noted on this PAS the resident did not have any behaviors. This PAS was completed by a home health agency for his admission to the facility. The resident was admitted to the facility on [DATE]. At the time of admission he had a diagnosis of Other Schizophrenia, Bipolar Disorder Unspecified, and Mild Intellectual Disabilities, none of which were indicated on section III, number 30 of the PAS dated 03/29/21. On 05/09/23 a copy of this PAS was provided to the surveyor by Corporate Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to implement the care plan for monitoring behaviors for Resident # 117 and failed to develop a care plan for Resident #41's bipolar disorder. This was true for two (2) out of 27 residents reviewed for care plans. Facility census 117. Findings included: a) Resident #117 A review of the medical record for Resident #117 found the staff failed to implement the care plan to monitor behaviors for Resident #117. On the TAR (task administration record) the staff wrote yes for having a behavior. There were no other nurses notes describing the behavior observed. The care plan states the following: Focus: Resident is at risk for complications related to the use of psychotropic drugs. Goal: Residents will have the smallest most effective dose without side effects by next review. Interventions: Monitor changes in mental status and functional level and report to MD as indicated. Monitor for continued need of medication as related to behavior and mood. 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 resident interviews, the facility failed to revise care plans to reflect the resident's preferences and meet the resident's needs for three (3) of three (3) residents reviewed for the category of activities, during the long term care survey. Resident identifiers #11, #100, and #84. Census 117. Findings Included: a) Resident #11 On 05/08/23 during a resident interview the resident stated he doesn't go to activities because he doesn't like BINGO. A record review was conducted on 05/09/23 of the resident's Recreation Quarterly assessment dated [DATE]. It included, .List independent leisure pursuits: watching TV/movies independently and/or with other residents, resting, reading newspaper/daily chronicle, talking/visiting with office staff and other residents, going outside, smoking, collecting recipes .List the most frequently attended group programs: outings, music related programs, movies . Record review of the resident's activities care plan does not reflect the resident's preferences…

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, resident observation and staff interview the facility failed to ensure residents who are dependent on staff for carrying out thier Activities of Daily Living (ADL) recieve the necessary services to maintain good nutrtion, grooming, and personal hygiene. The was true for three (3) of three (3) residents reviewed for the care area of ADL care during the long term care survey process. Resident Identifiers: #424, #217, and #70. Facility Census: 117. Findings included: a) Resident #424 An observation of Resident #424 on 05/08/23 at 11:44 AM, found her hair was dishelved with part of it pulled up with a hair band on top of her head. The hair was coming out of the hair band and sticking up. It appeared her hair had not been combed recently. The resident was wearing an oversized sweat shirt which was dark blue at the bottom and light blue at the top. She was wearing a pair of dark pants. On 05/09/23 multiple observations of Resident #424 during the day beginning at 9:00 am and concluding at…

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

Based on observation, record review and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. An accurate skin assessment was not completed for Resident #4. Appropriate action was not taken in a timely manner for an incident involving injury for Resident #50. These failed practices were a random opportunity for discovery and was true for Resident #4 and Resident #50. Resident identifiers: #4, and #50. Facility census: 117. Findings included: a) Resident #4 On 05/08/23 at 11:38 AM, Resident #4 was noted to have open skin areas with partial scabbing to her left forehead area. The Resident stated she told her daughter about it, and they probably should be putting something on it because they won't heal. Record review showed on 05/08/23 at 1:58 PM, a skin check was performed. No skin injury/wound(s) were noted on the Skin assessment done by Licensed Practical Nurse (LPN) #18. Record review showed on 05/01/23 at 6:17 AM a skin check was performed, and no skin injury/wound(s) were noted on the skin…

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 the resident weights were confirmed by a reweight when there was a 5 pound difference from the previously obtained weight. Failure to confirm the weights made it difficult for the dietician and other healthcare professionals to monitor Resident #82's nutritional status. This was true for one (1) of two (2) residents reviewed for the care area of nutritional status during the Long Term Care survey process . Resident Identifier: #82. Facility Census: 117. Findings included: a) Resident #82 A review of Residents #82's medical record on 05/08/23 found the following weights recorded: -- 04/13/23 95 pounds (Date of admission to facility) -- 04/18/23 98 pounds -- 04/26/23 109 pound this was an 11 pound gain -- 05/04/23 90 pounds this was a 19 pound loss. -- 05/09/23 99 pounds this was a 9 pound gain. During and interview with the Director of Nursing (DON) on 05/10/23 at 6:07 PM, she confirmed if there is a 5 pound difference from the previous weight the staff should reweigh the resident to confirm the loss/or gain 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 record review, policy review, and staff interview, the facility failed to ensure the physician responded timely to monthly drug regimen reviews. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #84. Facility census: 117. Findings included: a) Resident #84 Record review of the facility's policy titled, Medication Regimen Review, showed: --The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident. a) Resident #84 A medical record review for Resident #84 revealed monthly drug regimen reviews were not responded to by the physician timely. -02/15/23 Recommendation to evaluate continued use of a long-acting Potassium Chloride product, Potassium Chloride ER 10meg and Benztropine Mesylate 1 mg. This recommendation was not responded to until 03/29/23. -02/15/23 Recommendation to increase Atorvastatin or adding icosapent ethyl capsules 2 grams twice daily with food. This recommendation was not responded to…

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

Based on record review and staff interview the facility failed to ensure a residents drug regimen was free from unnecessary drugs. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident identified: #117 Facility census 117. Findings included: a) Resident #117 A review of medical records for Resident #117 revealed the resident was ordered to receive Macrobid (antibiotic) one (1) tablet once a day for Prophylaxis. The order did not state what they were trying to prevent with this prophylactic medication. On 05/09/23 at 2:15 PM the Director of Nursing (DON) was asked about the order. (Macrobid) Antibiotic used for Prophylaxis. The DON agreed the order should have included a Urinary Tract Infection. .

Based on record review and staff interview the facility failed to ensure a resident did not receive unnecessary psychotropic medications (a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior.) This was true for One (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: #117. Facility census 117. Findings included: a) Resident #117 A review of Resident #117's medical record on 05/10/23 found the resident was ordered to receive the psychotropic medication of Seroquel for hallucinations. During an interview on 05/10/23 at 10:20 AM, the Director of Nursing (DON) agreed hallucinations were a symptoms of a disease and not a diagnosis of an illness. All psychotropic medications were required to have an appropriate diagnosis for their use. .

Based on record review and staff interview, the facility failed to employ a qualified dietitian and/or a certified dietary manager on a full-time basis. This failed practice had the potential to affect all residents currently residing in the facility. Facility census: 118. Findings include: Initial kitchen rounds were completed on 02/07/22 at 11:30 am, accompanied by Employee #126 who was introduced as the dietary manager. On 02/10/22 at 11:00 am, the facilities dietician, Employee #125 and Employee #127, Corporate Dietary Manager came to the room and informed this surveyor that Employee #126 is not a certified dietary manager and was not enrolled in a dietary manager program. Employee #126 was hired at the facility on 06/06/17. The dietician (#125) stated she was full time at the facility, and she stated, yes, I work 24 hours a week. This surveyor referred to the regulation which indicates, Full-time means working 35 or more hours a week. No further information was provided. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to ensure [NAME] Virginia Physician Orders for Scope of Treatment (POST) forms were completed correctly for three (3) of six (6) residents in the long-term care survey sample. Resident identifier #51, #68 and #63. Facility Census 118 Findings included: a) Resident #51 A record review found the POST form dated [DATE] directed no CPR (cardiopulmonary resuscitation) - Do not attempt resuscitation with limited additional interventions was not completed appropriately On [DATE] at 10:15 AM an interview with Social Worker (SW) #69 confirmed the POST form was not completed correctly due to missing information relating to the residents address, date of birth and social security number and the Guardian had not signed the POST form. The POST form contained only a verbal consent from the Guardian. On [DATE] at 12:10 PM a review of the Physician Determination of Capacity form dated [DATE] indicated the Resident does not have capacity. The Guardian court order…

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

Based on record review and staff interview the facility failed to implement there abuse prohibition policy in regards to reporting and the investigation of serious bodily injury. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident Identifier: #55. Facility Census: 118. Findings Included: a) Policy Review A review of the facility's Abuse Prohibition policy with an effective date of 06/01/96 and a review and revision date of 04/09/21 on 02/09/22 found the following: --7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the CED (Center Executive Director) or designee will perform the following. --7.3 Report allegations to the appropriate state and local authority (s) involving neglect, exploitation or mistreatment (Including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two (2) hours after the allegation is made if the event results in serious bodily injury. Serious bodily…

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 that nurse aides we competent to carry out the duties of their job. The facility had a total of 42 nursing assistants working at the facility. Of those 42 only four (4) had competency evaluations completed in the last year. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Staff Identifiers (All Nurse Aides): #44, # 23, #19, #84, #65, #98, #122 , #42, #33, #15, #46, #9, #39, #7, #24, #22, #4, #20, #79, #78, #60, #75, #83, #85, #86, #52, #68, #50, #49, #103, #118, and #95. Facility Census: 118. Findings Included: a) NA Competencies On 02/08/22 at 11:22 am, the Center Nurse Executive (CNE) was asked to provide the competency check list which showed NA #36 and #98 possessed the competency to operate lifts successfully. On 02/08/22 at 1:35 pm the CNE stated they do not have any evidence to show NA #36 and NA #98 was evaluated for competency to operate the lift. At 3:00 pm on 02/08/22 all competencies for all NA's was provided to the survey…

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 each resident's drug regimen was free from unnecessary psychotropic medications. Resident #43 received an as needed (PRN) anti-anxiety medications even though they had demonstrated no target behaviors to warrant the use of the PRN medication and the facility failed to attempt non-pharmacological interventions prior to administering the PRN anti-anxiety medication. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Long-Term Survey Process Survey (LTCSP). Resident identifier: #43. Facility census: 118. Findings include: a) Resident #43 A review of Resident #43's medical record found the following physician's orders for Ativan 0.5 milligrams (mg)- Give 1 tablet by mouth every four (4) hours as needed for anxiety. Review of Medication Administration Record (MAR) for April, May and June 2021 found Resident #43 was administered this medication on the following dates and times without evidence of non-pharmacological interventions before administration of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure professional standards and practices to maintain accurate and complete medical records. This was true for four (4) of 30 residents reviewed during the Long-Term Care Survey Process. Resident Identifier: #60, #111, #37 and #112. Facility Census: 118. Findings Included: a) Resident #60 A review of the medical record for Resident #60 was completed on 02/09/22. This review found a diagnosis list which contained a diagnosis of an unstageable pressure ulcer of left heel. This unstageable pressure ulcer diagnosis was not added until 01/04/22. At which time the onset date was listed as 01/04/22 and resolved date was added for 12/29/21. A progress note dated 12/29/21 by Registered Nurse (RN) #6 stated Wound rounds completed with NP (Nurse Practitioner), pressure area to left heel resolved. Sureprep treatment continues for preventive measures. [Typed as written.] The Skin Integrity Report dated December 2021 indicated the Deep Tissue Injury (DTI)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections including COVID - 19. Nurses failed to maintain infection control procedure during medication pass and the staff failed to dispose of COVID-19 contaminated gowns properly. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers #23 and #90 Facility Census 118 Findings Included: a) Medication Pass 1)Resident #23 On 02/08/22 at 8:20 AM, this surveyor observed Licensed Practical Nurse (LPN) # 110 shake a Sennosides-Docusate Sodium Tablet 8.6-50 MG from the bottle into her hand then place the pill into Resident #23's medication pill cup. LPN #110 then proceeded to take the medication cup to Resident #23 for administration. LPN #110 was asked after medication…

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 #93 was provided care in a manner which preserved his dignity. Resident #93 was placed in a full body lift while in the hallway outside of his room. This was random opportunity for discovery. Resident Identifier: #93. Facility Census: 118. Findings Included: An observation on 02/08/22 at 11:06 am found Nurse Aide (NA) #36 and NA #111 was in the process of transferring Resident #93 from the shower bed back to his bed. The nurse aides lifted Resident #93 up in the total lift from the shower bed while still in the hallway outside of his room. With Resident #93 still in the sling on the lift the nurse aides pushed the lift into resident #93's room to transfer him back to bed. An interview with NA # 36 at 11:18 am confirmed she and NA #111 placed Resident #93 in the lift and lifted him from the shower bed in the hall way. When asked why they did so instead of pushing him into his room and then transferring him she stated it is just to tight in there to get the shower bed in there. She stated, Was this a FUBAR…

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 safe, clean, comfortable, and homelike environment by not providing a clean privacy curtain for Resident #68. This was a random opportunity for discovery. Resident identifier: #68 Facility census: 118. Findings included: a) Resident #68 On 02/08/22 at 11:45 AM an observation of Resident #68's privacy curtain found the curtain was soiled with a brown dried matter. An immediate interview with Registered Nurse #73 confirmed the curtain required replacement. .

Based on record review and staff interview the facility failed to ensure all falls which resulted in serious bodily injury was reported to the appropriate state agencies within the required time frames. Resident #55 fell from bed and fractured her left hip. This was not reported within two (2) hours of the facility having knowledge of the fracture (serious bodily injury). This was true for one (1) of nine (9) residents reviewed for the care area of falls during the long term care survey process. Resident Identifier: #55. Facility Census: 118. Findings Included: a) Resident #55 A review of Resident #55's medical record on 02/08/22 found the resident had a fall from bed on 11/16/21 which resulted in a fracture to her left hip. A review of the incident report related to this fall contained the following information: Root Cause/Conclusion: CNA (Nurse Aide) at bedside had asked resident, who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side underestimated the edge of the bed, and fell on right side of the bed onto the…

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

Based on record review and staff interview the facility failed to investigate a fall with a serious bodily injury to determine the cause and to initiate corrective action to prevent similar instances from happening again as required. This was true for one (1) of nine (9) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifier: #55. Facility Census: 118. Findings included: a) Resident #55 A review of Resident #55's medical record on 02/08/22 found the resident had a fall from bed on 11/16/21 which resulted in a fracture to her left hip. A review of the incident report related to this fall contained the following information: Root Cause/Conclusion: CNA (Nurse Aide) at bedside had asked resident, who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side underestimated the edge of the bed, and fell on right side of the bed onto the floor. Further review of Resident #55's medical record on 02/07/22 found the following Minimum Data Sets (MDS) with the Assessment…

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 transfer documents and appropriate information were communicated with the receiving health care facility. This was true for one (1) of three (3) Residents reviewed during the Long-Term Survey Process. Resident Identifier # 111 Facility Census 118 Findings Included: a) Resident # 111 Record review found Resident # 111 was sent to the local hospital on [DATE] at 5:30 PM. A copy of the interact transfer form was provided to the local hospital on [DATE]. The reason for the transfer was behavioral reasons. On 02/08/22 at 1:32 PM, the Corporate Nurse (CN) stated the facility has a check list of items they send to the hospital but the facility doesn't keep a copy of each document sent with the resident to the hospital. The CN provided a copy of the check list with the Resident's name at the top of the check list. The checklist form did contain a place to check the current medication list and or current MAR (medication administration record), but…

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 are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital. This was true for one (1) of three (3) Residents reviewed during the Long-Term Survey Process. Resident Identifier # 111 Facility Census 118 Findings Included: a) Resident # 111 A record review found Resident # 111 was sent to the local hospital on [DATE] at 5:30 PM. The reason for the transfer was behavioral reasons. A copy of the bed hold notice policy and authorization form shows the Resident's name printed on top of form and a registered nurse signature at the bottom of the page dated 10/17/21. The review found the rest of the form was not complete. On 02/08/22 at 1:15 PM, the Administrator acknowledged the bed hold paperwork was not filled out and they could not provide proof of what paperwork was sent with Resident # 111 on 10/21/21 at 5:30 PM.

Based on record review and staff interview, the facility failed to ensure the Minimum Data Sets (MDS)accurately reflected the resident's status. This was true for two (2) of thirty (30) resident's MDSs reviewed during the Long-Term Survey Process (LTCSP). Resident #43's MDS was inaccurate in the area medication (gradual dose reduction (GDR)). Residents #112s MDS was inaccurate in area of nutritional/weight. Resident's identifiers: #43, and #112. Facility census: 118. Findings include: a) Resident #43 Review of Resident #43's physician's orders revealed she was receiving, Risperdal, an antipsychotic, for dementia. Resident #43's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/09/21, Section N, Item N0410, A, Medications Received, stated the resident received antipsychotic medication seven (7) of the last seven (7) days. Section N, Item N0450, A, Antipsychotic Medication Review, stated the resident had received antipsychotic since the prior assessment. Section N, Item N0450, B, regarding whether a GDR was attempted was answered No. Due to Section N, Item NO450 C 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 a person-centered comprehensive care plan was developed. This was true for two (2) of 30 residents reviewed during the long term care survey process. Resident Identifier: #317 and #55. Facility Census: 118. Findings Included: a) Resident #317 1) Smoking Status On 02/07/22 at 3:43 PM, Registered Nurse (RN) # 63 stated there are no current smokers except the one resident who is grandfathered in. Please note that Reisdent #317 is not resident allowed to smoke. On 02/08/22, a review of Resident #317's Care Plan dated 02/01/22 states resident may smoke independently. The Smoking assessment dated [DATE] states the resident may smoke independently as well. An admission Minimum Data Set (MDS) dated [DATE] Section J1300 was coded as (0) which indicates no tobacco use. On 02/08/22 at 10:15 AM, Social Worker (SW) #69 verified the resident may not smoke independently due to facility being a non-smoking facility. SW #69 stated there was a mix 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 record review, observation, and staff interview the facility failed to ensure Resident #55's care plan pertaining to falls was revised when the residents condition changed. This was true for one (1) of 30 resident reviewed during the long term care survey process. Resident Identifier: #55. Facility Census: 118. Findings Included: Observation of Resident #55 on 02/07/22 01:48 pm found she was a bilateral below the knee amputee. A record review of Resident #55's medical record on 02/08/22 found the following care plan. Focus Statement: Risk for further falls and injury related to recent fall with left hip fracture, new right BKA (Below the knee amputation). history of right trimalleolar fx (fracture), cardiac and narcotic medical use, impaired gait balance, incontinence, Dementia, very cluttered room (resident will not comply with keeping room uncluttered), incontinence, impaired vision, history of falls, including history of fall with ankle fracture and left hip fx, left BKA with prothesis use, and history of tib/fib fracture that occurred during transfer. This focus…

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 that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For Resident #25, the facility failed to follow physician ordered parameters for Midodrine, a medication to treat hypotension and Resident #107, had neurological checks, after a fall, which were incomplete. Resident identifiers: #25 and #107. Facility census: 118. Findings include: a) Resident #25 Review of Resident #25's medical records found an order for Midodrine 5 milligrams (mg) by mouth for treatment of orthostatic hypotension with meals three times daily. Hold of systolic blood pressure is greater than 150. Started on 11/18/21, which was the date of admission to the facility. Review of Medication Administration Record (MAR) for October, November, December 2021 and January and February 2022, found Resident #25's blood pressure (B/P) was taken once daily at 8:00 am. No blood pressures were taken at 12:00 pm and 5:00 pm prior to…

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

Based on observation, staff interview and record review the facility failed to maintain an environment appropriate to prevent urinary tract infections and trauma by not having Resident #46's catheter tubing secureed to his leg. This was true for one (1) of one (1) residents investigated for the care area of catheter care. Resident Identifier # 46 Facility Census 118. Findings Included: a) Resident # 46 On 02/08/22 at 3:00 PM, this surveyor observed Nursing Aide (NA) #38 complete catheter care on Resident # 46. During catheter care it was observed Resident # 46's catheter tubing was not secured to his leg . When NA #38 was asked what was used to secure Resident #46's catheter tubing, NA #38 stated the RN (Registered Nurse) was in charge of that. On 02/08/22 at 3:05 PM, RN #113, was asked if Resident # 46 should have a securing device on his catheter. RN # 113 stated she would have to ask. They do not routinely place them on. A review of the Facility Policy titled: Catheter: Indwelling Urinary-Care of with an effective date of 06/01/96 and a revision date of 06/01/21: Found 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, medical record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. This was true for two (2) of two (2) residents reviewed during the survey process. Resident identifiers: #33, and #82. Facility census: 118 Findings included: a) Resident #33 Observation on 02/07/22 at 11:43 AM found Resident #33's oxygen tubing for her nasal canula was dated 01/27/22. This was confirmed with Registered Nurse (RN) #73 at 11:45 AM on 02/07/22. The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date. b) Resident #82 Observation on 02/07/22 at 11:35 AM found Resident #82's oxygen tubing for her nasal canula was dated 01/27/22. This was confirmed with Registered Nurse (RN) #73 at 11:38 AM on 02/07/22. The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date. .

Based on observation, staff interview, and medical record review, the facility failed to provide necessary care and services for Resident #39, who required hemodialysis due to end stage renal disease. The facility failed to assess the arteriovenous fistula in the left arm prior to and after receiving dialysis treatments and they obtained blood pressures (b/p) in the left arm eventhough it was a restricted limb. Resident identifier: #39. Facility census: 118. Findings include: a) Resident #39 Medical record review found Resident #39 was receiving hemodialysis via an arteriovenous fistula (A/V) in the left arm three (3) days a week, on Mondays, Wednesday, and Fridays, at an offsite Dialysis center. The facility was to complete the top half of the communication form, which included the resident's vital signs before the resident left the facility for dialysis, an examination of the access site (bruit/thrill) and any significant changes since last dialysis treatment. The dialysis center was to complete the middle section of the form which also included obtained vital signs, completed lab…

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.