Teays Valley Center

Based on record review and staff interview the facility failed to ensure one (1) resident had orthotics in place for a contracture and range of motion. This was true for one (1) of three (3) residents reviewed for limited range of motion. Resident identifier: #103. Facility Census: 120. a) Resident #103 02/17/2026 3:20 PM a medical record review revealed Resident #103 was supposed to have a Left Resting Hand Splint applied daily as tolerated. The staff were supposed to attempt to get at least 2 fingers under the straps. In the care plan, it stated the resident would refuse the heel protectors but there was no mention of the resting hand splint. In a review of tasks in the care plan,there was no documentation of staff attempting to don the heel protectors. Multiple observations during the survey were performed to see if the resident was wearing any of the orthotics and those observations revealed they were not in place. Physical Therapy and Occupational Therapy evaluations and clinical notes make zero mention of using hand splint and suggests heel protectors. Two full months of tasks…

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 environment is free from accident hazards over which it has control. This was a random opportunity for discovery. Resident Identifier: #63 Facility Census: 120 Findings Included: a) Resident #63 On 02/16/26 at 11:48 AM while walking through the 500 hall it was observed that Resident #63 was absent from his room and his bed mattress did not have a sheet on it. At that time is was observed the mattress was a standard mattress. Upon stopping Registered Nurse (RN) #93 and asking what type of mattress she would describe on the bed, she stated, a standard mattress. The surveyor ask her if a resident is ordered a defined perimeter mattress, would it look like this? She stated, No, they are built up a little on the edges to assist in prevention of the resident falling out of the bed. At that time it was confirmed with RN #93 that Resident #63 did have an order from the Physician as a fall intervention for a defined perimeter mattress and it was not on his bed. She agreed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews the facility failed to maintain food items in their personal refrigerators to ensure safe and sanitary storage, handling, and consumption. This was true for five (5) of six (6) personal refrigerators observed. Resident Identifiers: #29, #46, #52, #75, #98. Facility Census: 120 Findings Include:On 02/15/26 at 11:00 AM observation of the following personal refrigerators found the temperatures had not been performed on a daily basis. Upon further observation it was found that the refrigerators were dirty, had unlabeled food items in them as well as expired food items, making them unsafe.According to the Food and Nutrition Services Refrigerator/Freezer Temperature Log that is placed on the front of each personal refrigerator in their room Resident #29's refrigerator had not had the temperature checked daily as required. According to the facility Policy #OPS192 Refrigerators: Patient In Room: .refrigeration must be labeled with the date the food was placed in 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 upon record review and staff interview, the facility failed to ensure an accurate and complete medical record related to informing 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 one (1) of one (1) resident reviewed during the long term care survey process. Resident identifier: #50. Facility census: 120. Findings included: a) Resident #50 This resident has capacity to make his/her own decisions regarding the care or treatment received. A review of the medical record documents the resident to have the following mental health conditions:-ANXIETY DISORDER, UNSPECIFIED, diagnosed on [DATE] at Admission/Readmission-DEPRESSION, UNSPECIFIED, diagnosed on [DATE] at Admission/ReadmissionAdditionally, the resident had an additional diagnosis: -INSOMNIA, UNSPECIFIED, diagnosed on [DATE] at Admission/readmission For these…

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 administer the Influenza vaccine in a timely manner in order to prevent the spread of influenza and its complication. The facility failed to follow the current recommendation from the Center for Disease Prevention and Control (CDC) guidance for the Influenza vaccine. This was true for one (1) of five (5) Influenza immunization records reviewed. Resident Identifiers: #91. Facility Census: 120 Findings Included: a) Resident #91 On 02/17/26 at 9:30 AM record review for Resident #91 immunizations shows the resident was not administered an influenza immunization. According to the facility Policy #IC600 Influenza Immunization Program the .purpose of the immunization is to prevent the spread of influenza and its complications to employees and other residents.the process is to achieve the highest level of immunity during the peak of flu seasons . Record review shows Resident #91's Patient Representative consented to the influenza vaccine on 01/26/26, however as of 02/17/26 the resident had not received the vaccine. 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 ensure resident had a person-centered comprehensive care plan, developed and implemented, with specific interventions of care to address the resident's medical, physical, mental, and psychosocial needs for (one) 1 of (thirteen) 13 sampled residents reviewed. Resident #120's care plan failed to address resident being assessed as high fall risk. Census: 115Findings Included: a) Resident #120On 10/21/25 a review of document titled Fall Risk Evaluation completed upon admission [DATE], effective 09/21/24 revealed the following: Resident #120 upon admission had a history of falls (past 3 months): (one)1- (two)2 falls in past (three) 3 months. Level of consciousness / mental status: Disoriented x (three) 3 at all times. Resident is chairbound / continent. Predisposing disease: 1-2 present. Resident had a change in condition in the last 14 days. Resident is prescribed medication that could put him at risk for falls. Fall Risk Score: 15.0On 10/21/25 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 Interview and Record review the facility failed to ensure the resident environment was clean and in good repair. This was true for three (3) resident rooms on the 400 and 500 halls. Room identifiers: #404, #407, and #500. Facility census: 115. Findings Include: a) Resident Rooms During and initial tour of the facility on 12/09/24 the following issues were identified in resident rooms: room [ROOM NUMBER] - The blind had brown stains on it. The floor had a pink substance which was not able to be wiped up. The top of the toilet tank did not fit the tank appropriately and the sink was not affixed to the wall completely. room [ROOM NUMBER]- The light fixture in the bathroom was dislodged from the ceiling and was hanging down. The light fixture was also covered in dust. room [ROOM NUMBER]- Resident #24 who resided in room [ROOM NUMBER] stated she had been asking them for a year to paint over the flowers they have stuck to the wall. She stated she did not like them and wanted them covered…

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, staff interview, resident interview and observation, the facility failed to provide an accurate Minimum Data Set (MDS) for five (5) of 34 residents. MDS issues were found with Resident #10's hearing assessment, Resident #99's intravenous (IV) access, a cancer diagnosis for Resident #93, the use of insulin for Resident #79 and Resident #56's dental status. Resident Identifiers: #10, #99, #93, #79 and #56. Facility Census: 115. Findings include: a) Resident #10 On 12/10/24 at approximately 11:30 AM, the resident was interviewed and found to be hard of hearing. A record review found the care plan recognized impaired communication due to impaired hearing. The MDS section B dated 12/04/24 indicated the resident's ability to hear is adequate. The medical record was found to not have any information regarding a hearing test or an assessment for hearing aids. On 12/16/24 at 5:15 PM, the Director of Nursing (DON) confirmed the resident did have impaired hearing and a hearing assessment had 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 record review and interviews the facility failed to develop and implement comprehensive care plans. This was found true for 12 of 34 residents' care plans reviewed. Resident identifiers: #48, #26, #366, #61, #103, #70, #102, #12, #99, #93, #65, and #98. Facility census:115. Findings include: a) Resident #26 A record review on 12/16/24 revealed care plan stated no blood pressure (b/p) or lab stick to right extremities (RE). Further record review of the care plan contained a plan of care for not taking b/p in RE. Focus Resident at risk for decreased ability to perform ADL's in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting, related to: recent illness, hospitalization resulting in fatigue, activity intolerance. Goal Resident will improve current level of function in: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting by next review as evidence by improved ADL scores. Interventions - No BP(Blood Pressure) or Lab sticks to RE(Right Extremity) Further record review of the…

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

Based on record review and staff interview, the facility failed to revise the care plan for five (5) of 34 residents reviewed during the survey process. Care plan revisions were notdone for Resident #31's actual fall, a house supplement for Resident #266, an incorrect diagnosis for Resident #79 and psychiatric diagnoses for Resident #55. Resident Identifiers: #31, #266, #79 and #55. Facility Census: 115. Findings Include: a) Resident #31 On 12/14/24 at 2:08 PM, a record review was completed for Resident #31. The review found the care plan focus of at risk for falls: decreased mobility. However, the resident did have an actual fall on 12/09/24. On 12/16/24 at 12:19 PM, the Administrator was notified and confirmed the care plan had not been revised regarding the actual fall. b) Resident #266 On 12/14/24 at 3:30 PM, a record review was completed for Resident #266. The review found an intervention under the focus of nutritional risk due to advanced age, therapeutic and mechanically altered diet and dysphagia as house supplement daily as ordered. A further review on the 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 record review and staff interview the facility failed to ensure Resident #97 who is dependent on staff for showering received at least two showers per week as scheduled. This was true for one (1) of four (4) residents reviewed for the care area of Activities of Daily Living (ADLS) during the long term care survey process. Resident Identifier: 97. Facility Census: 115. Findings Include: a) Resident #97 A review of Resident #97's medical record on 12/11/24 at 1:11 PM, found Resident #97 was scheduled to receive a shower twice a week on Monday and Thursday. From 09/01/24 through 12/11/24 the resident should have received 29 showers. She only received 10 showers; she refused one shower on 12/02/24. She received a shower on the following dates: 09/02/24 09/09/24 10/03/24 10/07/24 10/24/24 10/25/24 11/04/24 11/07/24 11/21/24 and 11/25/24. An interview with corporate Registered Nurse #155 on 12/11/24 at 1:20 PM confirmed Resident #97 did not receive her showers as scheduled. A follow up interview with the Director of Nursing at 1:50 PM on 12/11/24 confirmed if a resident 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 record review, observation, resident interview and staff interview the facility failed to ensure residents were provided with the care and services to enable them to maintain and/or attain their highest practicable physical, mental and psychosocial well being. This was true for four (4) of 34 sampled residents. Resident identifiers: #98, #99, #89 and #26. Facility Census: 115. Findings Include: a) Resident #98 During an interview with Resident #98 on 12/09/24 at 12:36 PM, she stated she had a lot of trouble with being Compacted in her bowels and it causes her pain. She stated, I don't know why they can not just give me stool softeners or anything to help with it. A review of Resident #98's medical record on 12/17/24, found the resident on 4 occasions since the beginning of September found on the following occasions Resident #97 went more than three (3) days without having a bowel movement those dates are as follows; 09/17/24, 09/18/24, 09/19/24 10/21/24, 10/22/24, 10/23/24, 10/24/24 11/03/24, 11/04/24, 11/05/24,11/06/24 11/23/24, 11/24/24, 11/25/24, 11/26/24, 11/27/24,…

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 nutritional maintanence was maintained for Resident #266, #102, #12, #65 and #98. This was true for five (5) of six (6) residents reviewed under the care area of nutrition. Resident Identifiers: #266, #102, #12, #65 and #98. Facility Census: 115. a) Resident #266 On 12/16/24 at 3:25 PM, a record review was completed for Resident #266. The record review found the resident was noted to have significant weight loss. The care plan focus area was at nutritional risk related to advanced age, therapeutic and mechanically altered diet and dysphagia. An intervention listed house supplement day as ordered. (Typed as written.) However, the resident was scheduled to receive the house supplement twice daily. Upon further review, the documentation on the Medication Administration Record (MAR) from November, 2024 through December, 2024 indicated zero (0) % was taken on the following dates: --11/09/24 PM --11/10/24 AM and PM --11/12/24 AM and 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 resident interview, staff interview and record review, the facility failed to ensure three (3) of four (4) resident's food allergies were acknowledged. food the Resident (#103) was allergic to was not served and the Resident #70 and #61 tray cards were accurate for documented food allergies. This was true for three (3) of four (4) residents with food allergies. Resident indentifiers: #103, #70, #61. Census: 115. a) Resident #103 Resident #103 reported she was served shrimp on 11/10/24 for the lunch meal. Documentation and patient report stated the resident was allergic to shellfish. On 12/16/ 24 3:08 PM the resident reported she had a severe reaction to shellfish. The resident reported her face swells, she gets puffy patches on skin and her skin is itchy. The resident stated, If severe, I have problems breathing. In the past, I had to go to the hospital. The resident presented the State Surveyor a picture of a meal served 11/10/24 from lunch. The resident was served shrimp which was touching all other foods on the plate per photograph and verbal report. According to the…

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

Based on observation, record review and staff interview, the facility failed to store and label food and store utensils and in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 115 Findings confirmed by the Certified Dietary Manager (CDM) on 12/09/24 during the initial kitchen investigation initiated at 11:00 AM included: a) A Ziploc bag of soup was opened and not labeled or dated. b) An opened pie crust was not dated. c) A trash bag of French bread loaves tied in a knot that were not labeled or dated. d) Serving utensils were stored in a drawer in the dining room with handles all turned different ways. The CDM reported the cook likes to keep her serving utensils in the drawer. The CDM stated, She keeps this drawer. The Certified Dietary Manager (CDM) stated, At one point there were dates. I'll go throw these out. concerning the food items found in the freezer.

Based on observation, record review and staff interview, the facility failed to properly dispose of garbage in accordance with professional standards for food service safety and to ensure garbage was not hanging out of the trash can and onto clean pots and pans in the surrounding area. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 115 Findings included: a) Observations made on 12/09/24 at 11:00 AM revealed the following: Garbage from the trash can was overflowing under the handwashing sink in the kitchen beside clean pots and baking sheets. Garbage from the trash can was on the storage rack with clean pots and baking sheets. CDM asked if he should remove the trash can. Food was on tables and floor with dirty napkins and straws in the dining room. The CDM reported housekeeping cleans this after dinner. Dirty silverware on table. The CDM reported breakfast was not served in the dining room. The CDM picked up some of the food and trash off the floor. The kitchen staff were preparing for lunch at this time. These findings were…

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

Based on record review and staff interview the facility failed to ensure the resident record was complete and accurate for four (4) of 34 sampled residents reviewed during the long term care survey. Resident identifiers: #99, #56, #14 and #55. Facility Census: 115. Findings Include: a) Resident #56 During an observation, of Resident #56, on 12/09/24 at 2:30 PM, during the initial phase of the Long term care survey process it was noted Resident #56 had multiple missing teeth and the teeth remaining were in poor repair. An observation completed with the Director of Nursing (DON) on 12/11/24 at 3:00 PM found the resident had multiple missing teeth but did have some teeth remaining. Review of the residents record found a dental consultation dated 04/19/24. This consult indicated the resident had the following missing teeth 1, 2, 7-10, 13-19, 21-32. This indicates teeth 3-6, 11, 12, and 20 were not missing. The most recent oral health evaluation contained in Resident #56's medical record was dated 11/24/23. This assessment indicated Resident #56 was edentulous. This incorrect 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 to provide a notice and/or an accurate notice of the discharge to the resident, resident family and/or the receiving facility to ensure a safe and orderly continuance of care. This was true for Resident #99 on two (2) of three (3) of her transfers to an acute care facility. Resident identifier: #99. Facility Census: 115. Findings include: a) Resident #99 A review of Resident #99's chart on 12/11/24 at 9:24 AM found she was discharged to an acute care facility on 07/19/24, 09/25/24 and 10/05/24. Further review of the record found a transfer form dated 09/25/24. On this form the date of the transfer was listed as 07/19/24. Further review of the record found there was no transfer form for the discharge date of 07/19/24. During an interview with the Director of Nursing (DON) in the afternoon of 12/16/24 she confirmed, there was not a transfer form completed for Resident #99's discharge on [DATE] and the transfer form for 09/25/24 listed the incorrect transfer…

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

Based on record review and staff interview, the facility failed to ensure an accurate accounting of bed - hold days was provided to Resident #99's healthcare decision maker when the resident was discharged from the facility to an acute care hospital. This was true for three (3) of three (3) discharges reviewed. Resident identifier: #99. Facility Census: 115. Findings include: a) Resident #99 A review of Resident #99's chart on 12/11/24 at 9:24 AM, found the resident was discharged to an acute care facility on 07/19/24, 09/25/24 and 10/05/24. On 12/16/24 the facility was asked to provide the bed -hold notice for each of the three (3) discharges. The facility provided the notices. The notices were blank except for a nurse's signature, the resident's name, medical record number and the state abbreviation. The number of Medicaid bed - hold days available was not completed. The price per day of the bed hold was not completed and there was no indication notice was provided and/or reviewed with Resident #99's responsible party. Therefore, it was not noted if the person responsible wished…

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 identify diagnoses for two (2) of three (3) residents reviewed for the area of pre admission screening and resident review (PASARR). Resident identifiers: #55 and #18. Facility census: 115 a) Resident #18 A diagnosis of Bipolar Disorder and Post-Traumatic Stress Disorder (PTSD) were not identified on the most recent PASARR dated 11/14/23 for Resident #18. On 12/17/24 11:45 AM, the State Surveyor reviewed and confirmed the discrepancies with the orders, care plan and PASARR with the Director of Nursing. b) Resident 55 Record review on 12/10/24 at 01:15 PM revealed the following medical diagnoses Schizoaffective Disorder Anxiety Disorder Biploar Disorder Further record review on 12/10/24 revealed the Pre admission Screening and Resident Review (PASRR) did not identify Bipolar disorder Corporate Registered Nurse # 155 confirmed the PASRR did not identify Bipolar disorder.

Based on resident interview record review and staff interview the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities by failing to identify religious preferences in the care plan. This failed practice was found to be true for one (1) of three (3) residents reviewed under the activities care area during the Long-Term care survey process. Facility census:115 Resident identifier:#48 Findings include: a) Resident #48 On 12/09/24 At 12:34 PM An interview with Resident #48 who stated I can't say anyone comes to invite me to anything, I have gone to a church service and they do ask about bingo but I don't believe in gambling and I don't do that. I can turn on preaching on Sundays, I used to me a minister before i came here Record review completed on 12/10/24 at approximately 10:00 am revealed resident #48's care plan revealed no preferences to religion and being of the Baptist faith or history of being a minister. On 12/10/24 at 12:05 PM the Administrator…

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, staff interview, resident interview and observation, the facility failed to evaluate Resident #10's hearing impairment. This was true for one (1) of three (3) residents reviewed under the care area of activities of daily living. Resident identifier: #10. Facility Census: 115. Findings Include: a) Resident #10 On 12/10/24 at approximately 11:30 AM, the resident was interviewed and found to be hard of hearing. A record review found the care plan recognized impaired communication due to impaired hearing. The medical record was not found to have any information regarding a hearing test or an assessment for hearing aids. On 12/16/24 at 5:15 PM, the Director of Nursing (DON) confirmed the resident did have impaired hearing and a hearing assessment had not been performed since admission to the facility on [DATE] .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure residents receive proper treatment and care to maintain mobility and good foot health. This was true for one (1) of four (4) residents reviewed for activities of daily living during the long-term care survey process. Resident identifier: #97. Facility Census: 115. Findings include: a) Resident #97 An observation of Resident #97, on 12/10/24 at 9:06 AM, found she had long toenails on each foot. The nails extended out from the tip of the toe and were curled on the ends. A review of Resident #97's medical record, on 12/11/24, found Resident #97 was admitted to the facility on [DATE]. The resident did not have any diagnosis which would prevent the staff from providing nail care to the resident. There was no indication in the medical record that the resident had ever seen the podiatrist at the facility. An observation with the Director of Nursing (DON) on 12/11/24 at 8:38 am confirmed the residents toe nails were long and 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 wear proper personal protective equipment (PPE) with Resident #12 during activities of daily living (ADL) and wound care while in Enhanced-Barrier Precautions (EBP). This was a random opportunity for discovery. Resident identifier: #12. Facility Census: 115. Findings included: a) Resident #12 On 12/12/24 at 9:41 AM, Nurse Aide (NA) #35 was observed providing ADL care for Resident #12. The resident is in EBP due to wounds, suprapubic catheter and a feeding tube. When the resident is in EBP, the staff must wear gown and gloves while providing dressing, bathing, providing hygiene, changing linens, changing briefs and wound care. NA #35 was not wearing PPE while providing the ADL care. Upon entering the room to observe wound care, Registered Nurse (RN) #102 and Licensed Practical Nurse (LPN) #1 did not donn PPE prior to providing wound care. On 12/12/24 at 11:25 AM, the Director of Nursing (DON) was asked to come to the resident's room. Upon arrival, the EBP signage was turned backward and could not be seen…

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 provide a safe, sanitary, and homelike environment. Resident room walls were in disrepair. This was a random opportunity for discovery. Room identifier: #500, # 618 and #316. Facility census: 113. Findings included: a) room [ROOM NUMBER] An observation on 10/30/23 at 1:40 PM, revealed the back wall behind bed B, had large scrapes with deep grooves. An interview on 11/01/23 at 9:58 AM, with the Maintenance Director confirmed this should have been fixed. He stated, the wall was damaged by the power bed. b) room [ROOM NUMBER] An observation on 10/30/23 at 2:12 PM, revealed the back wall behind bed B, had large scrapes with deep grooves. An interview 11/01/23 at 10:07 AM, with the Maintenance Director confirmed this should have been fixed. He stated, the wall was damaged by a wheelchair. c) Room # 316 On 10/30/23 at 12:14 PM, the bathroom for room [ROOM NUMBER] was noted to be scraped and have missing paint on the door and the wall to the left 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 interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward the resolution. This was true for four (4) of four (4) residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #45, #6, #2 and #10. Facility census: 113. Findings Included: a) Facility Policy Record review of the facility's policy titled, Grievance / Concern, revision dated 07/19/23, showed: -Upon receipt of grievance/concern, the Grievance/Concern form will be initiated by the staff member receiving the concern. -Upon receipt of the Grievance/Concern Form, the Administrator or designee will document the grievance/concern on the Grievance/Concern Log. -Notify the person filing the grievance of the resolution in a timely manner. -Completed Grievance /Concern forms will be reviewed and retained by the Administrator for a period of no less than three (3) years from the issuance of the grievance decision 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 and staff interview the facility failed to have the cabinet under the steam table cleaned and sanitized. This has the potential to affect all residents who receive their nutrition from the kitchen. Facility Census: 113. Findings included: a) Steam Table The second kitchen tour on 10/31/23 at 12:05 PM found under the steam table to be unclean and in disrepair. The contact paper was pealing, the plywood was exposed, there was sticky food debris, and an unidentifiable black substance. During an interview with the kitchen manager and corporate dietary manager they confirmed the steam table was not clean was in disrepair. They indicated the kitchen had notified the maintenance department but the issue has not yet been fixed. During an interview on 11/01/23 at 9:45 AM the Maintenance Director verified under the steam table would be hard to clean and sanitize. He stated, he would get it fixed this day.

Based on facility record review and interview the facility failed to explain the Binding Arbitration Agreement in a form and manner residents or Resident Representatives can understand. This has the potential to affect all residents or Residents Representatives that sign a Binding Arbitration Agreement. Facility Censes: 113. Findings included: a) Binding Arbitration Agreement A facility record review found multiple Residents or Residents Representatives had signed a Binding Arbitration Agreement. During an interview 11/01/23 at 2:30 pm, the admission Coordinator was unable to explain a Binding Arbitration Agreement accurately. She stated, the Resident could not consult or obtain a lawyer, there was only one Arbitrator, genesis health care would choose the Arbitrator and they were giving up their right for a lawyer. When the admission Coordinator was asked questions about Binding Arbitration Agreement, she was unable to explain. The admission Coordinator at this time stated, Residents don't usually ask questions about the form. She continued to say she would better familiarize…

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

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The glucometer was not cleaned with a cleaning solution approved by the manufacturer. This deficient practice had the potential to affect residents residing in the unit who receive blood glucose monitoring by fingerstick. Resident identifiers: #324, #178, #179, #51. Facility census: 113. Findings included: a) Glucometer cleaning The facility's procedure titled Fingerstick Glucose Measurement, with an effective date of 01/01/04 and revision date of 06/15/22, stated, Clean and disinfect the blood glucose meter after use with EPA [environmental protection agency] approved disinfectant, following manufacturer's instructions. On 11/01/23 at 8:19 AM, Licensed Practical Nurse (LPN) #8 was observed performing fingerstick blood glucose monitoring using a glucometer. The glucometer brand was EVENCARE G2. Following the completion of the procedure, LPN…

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

Based on record review and staff interview, the facility failed to document the correct discharge destination of Resident #123. This is true for one (1) of two (2) residents reviewed under the care area of hospitalization. Resident Identifier: #123. Facility Census: 113. Findings Included: a) Resident #123 On 10/31/23 at 1:00 PM, a record review was completed for Resident #123. The review found the Minimum Data Set (MDS) Discharge Return Not Anticipated dated 09/05/23 listed the discharge destination of acute hospital. However, the resident was discharged to home with family. The following progress note dated 09/05/23 at 5:07 PM states, Resident discharging home at this time via (Name of ambulance company). Daughter at bedside. Went over discharge paperwork including medication list, no questions concerns. No s/s (signs/symptoms) of acute distress prior to leaving. No complaints/needs. In good spirits. Medications called into (Name of pharmacy) per request. Skin clean, warm, dry with no acute changes. On 10/31/23 at 2:10 PM, Clinical Care Reimbursement (CCR) nurse #129 confirmed 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 coordinate with the appropriate, State-designated authority, to ensure individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs.This is true for one (1) of two (2) residents reviewed during the survey process. Resident Identifier: 12. Facility Census: 113. Findings Included: a) Resident #12 At approximately 2:40 PM on 10/31/23, a review of Resident #12's records were conducted. During this review, it was determined the resident was admitted to the facility on [DATE] with no diagnosis of a Level II mental illness. Record review indicated Resident #12 was diagnosed with Major Depressive Disorder on 3/13/17 and the PASARR was not revised to reflect this diagnosis. At approximately 3:09 PM on 10/31/23, an interview was conducted with the Interim Director of Nursing (IDON) #28 and the Administrator #70. The administrator and IDON confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to develop a care plan regarding a wound infection and intravenous (IV) antibiotic therapy for Resident # 329. This is true for one (1) of 26 residents reviewed during the survey process. Resident #329. Facility Census: 113. Findings Included: a) Resident #329 On 11/01/23 at 12:30 PM, a record review was completed for Resident #329. The review found a care plan had not been developed regarding a wound infection and IV antibiotic therapy for Resident #329. The resident was admitted to the facility on [DATE]. The resident arrived to the facility with a physician's order for Ertapenem Sodium Injection Solution 1 (one) Gram use 500mg (milligram) IV every day through 11/17/23 for an infection which was chronic multifocal osteomyelitis of the left foot and ankle. On 11/01/23 at 1:37 PM, the Interim Director of Nursing (IDON) was notified and confirmed the care plan was not developed regarding the wound infection nor the IV antibiotic therapy. No further…

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 revise the comprehensive care plan when residents' needs and conditions changed. This deficient practice had the potential to affect two (2) of 26 residents reviewed in the long-term care center. Resident identifiers: #54 and #70. Facility census: 113. Findings included: a) Resident #54 Resident #54 had diagnoses of cerebral palsy, aphasia, and severe intellectual disabilities. Review of Resident #54's comprehensive care plan showed a focus related to activities. An intervention was, I enjoy watching/listening TV. [Typed as written.] Resident #54 was observed on the following days and at the following times: - 10/31/23 at 11:59 AM - 11/01/23 at 10:34 AM - 11/01/23 at 2:07 PM The resident's television was turned off at the time of these observations. Resident #54's Recreation Comprehensive assessment dated [DATE] stated it was very important for the resident to watch or listen to television. Resident #54's activity participation…

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 residents receive proper treatment and assistive devices to maintain vision and hearing abilities, by failing to make appointments and arrange transportation to and from the office of the practitioner. This is true for one (1) of two (2) residents reviewed during the survey process. Resident Identifier: #424. Facility Census: 113. Findings Included: a) Resident #424 At approximately 12:55 PM on in 10/30/23, an interview with Resident #424 revealed they had been trying to obtain an appointment with an audiologist for almost a year. Resident #424 states they have hearing problems and it is critical they see an audiologist in a timely manner and they want to go outside of the facility to see the audiologist. Resident #424 stated, they had brought the appointment to the attention of the nurses, nursing aides, and social worker, but had been unable to obtain an appointment up to this point. At approximately 3:15 PM on 10/31/23, an interview was conducted with Social Services Director (SSD) #28…

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 dispose of expired over-the-counter(OTC) medications appropriately and store medication in a safe and secure location. These were random opportunities for discovery. Facility Census: 113. Findings Included: a) Expired Medication On [DATE] at 8:13 AM, while observing medication administration, Licensed Practical Nurse (LPN) #79 needed an over-the-counter (OTC) medication from central supply. While in central supply, an observation found four (4) unopened bottles of Calcium Citrate which expired in July, 2023. On [DATE] at 8:15 AM, LPN #79 confirmed the OTC medication was expired. On [DATE] at 8:20 AM, the Interim Director of Nursing (IDON) was notified and confirmed the medication should have been disposed of upon expiration. b) Unsecured Medication On [DATE] at 8:20 AM on the Blue hall, one (1) bottle of Zinc was found sitting on top of the medication cart. There was no staff member near the medication cart. Upon discovery, the IDON was at 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 maintain a complete and accurate medical record for Resident #41. This is true for one (1) of two (2) residents reviewed under the care area of hospitalizations. Resident Identifier: #41. Facility Census: 113. Findings Included: a) Resident #41 On 10/31/23 at 1:00 PM, a record review was completed for Resident #41. The review found the resident had been transferred to an acute care facility multiple times. Upon reviewing the transfer forms, the following had an incorrect date and time of transfer: --05/02/23 at 1:42 PM had the incorrect transfer date and time of 04/29/23 at 10:40 PM --05/29/23 at 6:53 AM had the incorrect transfer date and time of 05/02/23 at 2:19 PM --07/02/23 at 5:30 PM had the incorrect transfer date and time of 06/15/23 at 7:50 PM --07/09/23 at 7:40 AM had the incorrect transfer date and time of 07/02/23 at 5:44 PM On 10/31/23 at 1:30 PM, the Interim Director of Nursing (IDON) was notified and confirmed the transfer dates and times were incorrect. No further information was obtained 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.