Morgantown Heights Of Journey

Based on interview, and record review, the facility failed to ensure medically related socail services were provided to one (1) resident. The facility failed to notify the resident that the Notice of Medicare Non-Coverage issued to him was deemed invalid, that Medicare would continue to pay for services, and that no specific date had been set for discharge. This was true for one (1) of thirty-one (31) residents surveyed. Resident Identifier: #62. Facility Census: 72.b) Resident #62During an interview with Resident #62 on 09/03/25 at approximately 11:35 AM Resident #62 stated that he was scheduled to be discharged from the facility on 09/04/25 because he had received a Notice of Medicare Non-Coverage (NOMNC). Resident #62 was concerned about the clutter in his house. He states that he would be unable to wheel his walker or wheelchair through the house because there is no clear path. Resident also stated that he had spoken to the Social Worker (SW) on 09/02/25 and asked her about his appeal. He stated that he had not received any notification that his appeal had been successful.During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received necessary dental services, including routine dental care. Additionally, the facility failed to provide the assistance needed or requested by residents to obtain these services. This finding applied to one (1) of the thirty-one (31) residents surveyed Resident Identifier: #68. Facility Census:72.Findings include a) Resident #68 During a brief interview on 09/03/25 at approximately 3:04 PM it was observed that Resident #68's teeth were severely discolored and decayed. During an interview with Resident #68's Case Manager at Adult Protective Services (APS) on 09/04/25 at approximately 10:45 AM, she stated the following: I signed consent for dental surgery for the resident on 12/26/24. My coworker signed consent for Medicaid 360 services in November of 2024. There are no other mentions of dental issues in the system. Below is a general description the oral surgeon provided:Full Mouth Debridement Silver Diamine…

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 record review the facility failed to provide resident with the appropriate assistive devices to maintain or improve their ability to eat or drink independently. This was true for one (1) of thirty-one (31) residents sampled. Resident #5. Facility Census: 72.Findings Includea) Resident #5On 09/03/25, at approximately 12:20 PM, during a dining observation, Resident #5 was seen in the dining room struggling with her utensils. After unwrapping them, she awkwardly attempted to use the fork to pick up her food.When asked why she was having trouble with her utensils, Resident #5 explained that she was supposed to have right-angled adaptive equipment for feeding herself. She added, But today, they gave me these!A review of the resident's tray ticket indicated specific instructions for right-angled utensils.During an interview with Dietary Manager (DM) #18, she confirmed that Resident #5 required right-angled adaptive equipment. DM #18 stated that she would immediately provide the resident with a set of adaptive utensils

Based on record review and staff interview, the facility failed to maintain an accurate medical record for two (2) of 31 sampled residents reviewed in the Long-Term Care Survey process. The facility failed to obtain a resident's signature on a Physician Orders for Scope of Treatment (POST) form and the facility failed to document an accurate weight for a resident. Resident identifiers: #60 and #20. Facility census: 72. Findings included: a) Resident #60 An electronic medical record review, completed on 09/03/25 at 9:45 PM, identified Resident #60 had a Physician Orders for Scope of Treatment (POST) form on file. The attending physician signed the form on 06/16/25. However, Resident #60 had never signed the form. The 2021 POST Form Guidance instructs the signature section provides a declaration on behalf of the patient related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient must sign and date this section for the form to be legally valid. During an interview on 09/04/25 at 11:15 AM, LPN #103 acknowledged the…

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

Based on record review, resident interview, and staff interview the facility failed to provide care in accordance with professional standards of care by not following physician 's orders for woundtreatments, and medication administration. This failed practice was found true for (5) five of (5) five residents reviewed for medication administration and wound care during the complaint survey. Resident identifiers: #80, #5, #40, #76 and #6. Facility Census: 84 Findings included:a) Resident #80On 06/11/25 at 3:33 PM, the Emergency Medical Services (EMS) staff, reported to the ED that the resident was found to be lying in urine and feces, and red, raw irritated skin was noted on the buttocks as well as the perineum. Upon examination the ED doctor documented the condition of the wound were as follows:A left leg wound that is necrotic and decubitus to the sacral area and severe skin breakdown.Upon further review of the ED Physician affidavit, obtained from Adult Protective Services (APS) stated, Unclean physical condition, significant excoriations to the perineal and groin area, which…

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

Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishmentpantry. This had the potential to affect all residents in the facility. Facility census: 84.residents in the facility. Facility census: 84. Findings included:a) On 07/07/25 at 12:27 PM, during a Brief Tourof The Kitchen, with The Dietary Manager # 87who acknowledged the following in the Chest Freezer with no label or dates:- A Bucket of vanilla ice cream.- 2 pints of ice cream inside a brown paper bagOn 07/08/25 at 6:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: ColdFoods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers,labeled and dated, and arranged in a manner toprevent cross contamination.03/4/25 11:30 AM Observation of Kitchen Pantry:- A Package of Elbow Macaroni with no label or dateOn 07/08/25 at 6:00PM during a review of facility policy marked HCSG Policy 018 Food Storage:Dry Goods, listed under procedures number six(6) stated:…

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

Based on observation and staff interview, the facility failed to provide a dignified experience while receiving an administration of insulin for Resident #44. This was a random opportunity fordiscovery. Resident Identifier: #44. Facility Census: 84.Findings Include: a) Resident #44On 07/08/25 at 12:08 PM, an observation of Licensed Practical Nurse (LPN) #45 administering Humalog insulin to Resident #44 in the hallway.On 07/0/25 at 12:09 PM, an interview was held with LPN #45. LPN #45 was asked, Did you administer an injection in the hallway? LPN #45stated, Yes, but I'm running behind, there is always an issue with obtaining the blood sugars in the morning, night shift won't do it.On 07/08/25 at 12:11 PM, the Corporate Registered Nurse (RN) was notified and confirmed the injection should not have been given in the hallway.

Based on observation and staff interviews, the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident'sroom. This was a random opportunity for discovery. Resident identifier: #12. Facility Census 84Findings include: a) Resident #12On 07/07/25 at 1:10 PM, Resident #12 was heard yelling for help and continued yelling until 1:35 PM. Upon checking on the resident and entering her room, Resident #12 was observed sitting in her wheel chair at the end of her bed. Her call bell was out of her reach on her bed near the pillow.On 07/07/25 at 1:35 PM, in and interview withLicensed Practical Nurse #17, she acknowledged the call button was not within reach of the resident and stated that she was unaware as a nurse aide was just with the resident.

Based on record review and staff interview, the facility failed to develop the a comprehensive personal care plan for Resident #80. This was true for one (1) of six (6) residents reviewedduring the survey process. Resident Identifier: #80. Facility Census: 84Findings Include: a) Resident #80On 07/08/25 at approximately 2:00 PM, the care plan was reviewed for Resident #80. The review found the care plan was blank under multiple focus areas. The following areas were included:--Focus area: The resident has or a potential for: (acute pain-less than 30 days/sub acute pain 30-90 days/Chronic pain greater than 90 days)Pain/Pain Potential is Related to: (Typed as written.) No further information was listed under the focus area.Under the interventions of this focus area lists the following: The resident prefered to have pain controlled by: (SPECIFY) medication, treatment). No further information was listed with thisintervention.--Focus area: The resident has bowel incontinence r/t (related to). No further information is listed under the focus area.--Focus area: The resident has 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.

Based on record review and staff interview the facility failed to report an allegation of suspected abuse within (2) two hours after discovering the occurrence. This failed practice was found true for (1) of (3) residents reviewed for reportable allegations of abuse, neglect, and misappropriation of property. Resident identifier: #40. Facility Census: 68. Findings Included: a) Resident #40 A review of the facilities reportables, on 05/21/24 at 9:00 AM, revealed that Resident # 40 had a bruise of unknown origin on the posterior upper left arm described as large deep purple bruising according to the skin assessment completed on 04/25/24. The incident was reported on 04/26/24 at 3:45 PM, which was 16.5 hours post incident. A medical record review, on 05/21/24 at 9:15 AM, revealed a nurse's note written on 04/25/24 at 11:15 PM, that reads as follows: Called to room by aide. Large deep purple bruise noted to posterior left upper arm. Denies pain at present. Normal ROM to arm. No warmth or nodules noted to the area. MD, Administrator, and DON notified. Further medical record review…

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

Based on record review, staff interviews, the facility failed to follow the physician's order for antibiotics. Resident #73 did not receive Zyvox as ordered by the attending physician. Resident identifier: #73. Facility census: 68. Findings included: a) Resident #73 A medical record review revealed Resident #73 had a physician order for Zyvox dated 02/14/24. The medication was ordered to be given twice a day. During a confidential interview with a nurse the nurse said when they went to administer the morning dose on 02/14/24 they clicked administered but the medication was not available in the Alixa. The nurse said they needed to strike themedicaiton out and called Alixa to see if the medication was approved or enroute. The nurse said that LPNs or floor nurses are not allowed to approve medications nor do they receive emails to approve medications. On the evening of 02/14/214 the medication was ordered but had not arrived in the facility. The nurse said the medication was on hold due to the cost. The cost had to be approved by the facility. The Director of Nursing approved 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, staff interviews, the facility failed to provide pharmaceutical services to meet the needs of a resident. Resident #73 did not receive Zyvox as ordered by the attending physician. Resident identifier: #73. Facility census: 68. Findings included: Based on record review, staff interviews, the facility failed to follow the physician's order for antibiotics. Resident #73 did not receive Zyvox as ordered by the attending physician. Resident identifier: #73. Facility census: 68. Findings included: a) Resident #73 A medical record review revealed Resident #73 had a physician order for Zyvox dated 02/14/24. The medication was ordered to be given twice a day. During a confidential interview with a nurse the nurse said when they went to administer the morning dose on 02/14/24 they clicked administered but the medication was not available in the Alixa. The nurse said they needed to strike themedicaiton out and called Alixa to see if the medication was approved or enroute. The nurse said that LPNs or floor nurses are not allowed to approve medications nor do they receive…

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

Based on observation and staff interviews the facility failed to ensure the activities program is directed by a qualified professional. This had a potential to affect all residents residing in the facility. Facility Census: 82. Findings Include: a) Qualified Activity Professional During an observation on 02/26/24 at 12:35 PM, the activity office was void of any documentation of a certification of an activity professional. During an interview on 02/26/24 at 12:35 PM, the Activity Director(AD) was asked to see her activity certification. The AD stated I do not have a certificate, I will start the class in March. The Occupational Therapist reviews my stuff. I was thrown into this position when the other person was let go. During an interview on 02/27/24 at 2:44 PM, the Director of Nursing (DON) stated the Occupational Therapist stated she has not been working with the activity department for a few months. The DON acknowledged there is no certified Activity Professional.

Based on observation, record review, resident interview, and staff interview, the facility failed to ensure nursing staff possessed the competencies and skill sets necessary to provide nursing and related services. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 82. Findings included: #600 #610 all findings for #697 #684 late med pass

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, record review and staff interview the facility failed to ensure, the binding arbitration agreement was explained to each resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. This failed practice has the potential to affect more than a limited number of residents. Resident Identifiers: #72, #8, and #500. Facility Census: 82. Findings Include: a) Resident #72 On 03/06/24 at 11:39 AM during an interview with Resident #72, the resident stated he knew the facility Alternative Dispute Resolution Agreement had to do with a dispute between him and this facility and there would be someone else to fix it. He stated he knew he didn't have to sign it but was not aware of being able to revoke it. Resident #72 has a Brief Interview for Mental Status (BIMS) of 15 on the Minimum Data Set (MDS) dated [DATE]. Resident #72's physician determined he has capacity to make medical decisions.…

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 interviews, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment. A glove that appeared soiled was observed on the handrail; clean linens were not available; and dining room chairs were observed to be unclean. These failed practices were a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 82 Findings include: a) glove On 03/03/24 at 11:33 PM during a tour of facility, a glove which appeared tog be soiled was observed balled up and stuck in the top back edge of the hallway handrail at the entrance of room [ROOM NUMBER]. During an interview with Certified Nursing Assistant (CNA) #9 and CNA #56, both agreed the glove was stuck in the top back of the handrail and appeared soiled. CNA #9 then took the glove from the handrail and threw it away. b) clean linens On 03/05/24 at 10:34 AM during a tour of the building, the North Unit clean linen closet had no towels or…

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, and resident interview the facility failed to develop and/or implement care plans related to dementia, pain, dialysis and Diabetes. This failed practice was found true for (4) four of 24 residents reviewed for care plans during the Long Term Care Survey Process. Resident identifiers #23, #181, #40, and #7. Facility Census 82. Findings include: a) Resident #23 During an interview on 02/27/24 at 4:45 PM, with Resident #23, she stated, The pain medicine does not always help me. A record review on 03/05/24 at 10:03 AM, revealed Resident #23 is prescribed Percocet Tablet 10-325 MG (oxycodone-Acetaminophen) for pain, and she has a diagnosis of Dementia. Further record review showed Resident #23 does not have a care plan developed for pain or Dementia. An interview on 03/05/24 at 11:22 AM, with Assistant Director of Nursing (ADON) #42 , He confirmed a care plan for pain or Dementia was not developed for Resident #23. b) Resident #181 During an interview on 2/27/24 at 1:00 PM,…

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

Based on record review, resident interview and staff interview, the facility failed to revise the care plan regarding bathing preferences and refusals of showers for Resident #58, diagnosis for antibiotic therapy and end-of-life wishes for Resident #76, multiple diagnoses including the use of a foley catheter, Gastromy (G-tube) tube and supplemental oxygen for Resident #179, pain for Resident #19, a splint for Resident #68, actual pain for Resident #10, and a diagnosis of dementia and pain for Resident #23. This was true for seven (7) of 24 residents reviewed during the survey process. Resident Identifier: #58, #76, #179, #19, #68, #10 and #23. Facility Census: 82. Findings Included: a) Resident #58 On 03/05/24 at 9:25 AM, a record review was completed for Resident #58. Upon completion of the review, the resident does not have a bathing preference or refusals of showers noted. The resident prefers bed baths to showers. On 03/05/24 at 11:00 AM, the Director of Nursing (DON) stated, she refuses a lot (showers) she would rather have a bed bath. The DON also confirmed the care plan 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, staff interview, and resident interview the facility failed to ensure residents were receiving the necessary services to maintain good personal hygiene. Resident #44, #58 and #234 were not receiving showers. This failed practice was found true for (3) three of (9) nine residents reviewed for Activities of Daily Living (ADL's) during the Long Term Care Survey Process. Resident identifiers #44, #58, and #234. Facility census 82. Findings include: a) Resident #44 During an interview on 02/26/24 at 3:58 PM, Resident #44 stated, I don't always get my showers. A record review on 03/04/24 at 12:31 PM, of Resident #44's care plan found following: -Focus: Requires assistance with ADL's due to self care deficit, weakness, decreased mobility, debility, pain. -Goal: Will continue to have needs met on a daily basis through review date: remaining clean, dry, dressed, groomed and free of odors. -Intervention: Showering Assit: ( Independent, Supervision/Oversight, Set-Up, Verbal Cues/Encouragement,…

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, resident interview, and staff interview the facility failed to provide an ongoing program of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This failed practice was found true for (3) three of (4) four residents reviewed for the care of activities during the Long Term Care Survey Process. Resident identifiers #35, #6, and #233. Facility census 82. Findings include: a) Resident #35 During an interview on 02/26/24 at 3:36 PM, Resident #35 stated, I don't like much that they do here. An observation on 02/27/24 at 10:00 AM, of Resident # 35, showed the resident was sitting on his bed, touching and rubbing his catheter tubing and bag that he had taken off of his wheelchair. An observation on 03/04/24 at 11:00 AM, of Resident # 35, revealed the resident was lying in his bed, rubbing his sheets. A record review on 03/04/24 at 2:20 PM, of Resident # 35's Activity Participation Records (APR) revealed…

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 resident interview, record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice had the potential to affect five (5) of 24 residents reviewed in the long-term care survey sample. For residents #44, #40, and #7, physicians' orders were not followed. Additionally, Resident #19 was receiving a medication without an order. Resident #7's diagnoses were not complete in the electronic health records. Resident #179 did not have a physician's assessment for capacity to make medical decisions. Also, a random opportunity for discovery found Residents #331, #64, #330, #65, and #47 were given their evening medications late. Resident identifiers: #44, #40, #19, #7, #179, #331, and #64. Facility census: 82. Findings included: a) Resident #44 During an interview on 02/26/24 at 4:19 PM, Resident #44 stated the physician had ordered a urinalysis test for her, but it took five (5) days for the…

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

Based on observation, record review, staff and resident interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Medications were left in Resident #64's room unsupervised. Resident #236 and #72 were unknowingly smoking without supervision in an outside non-smoking recreation area. These failed practices were a random opportunity for discovery. Resident identifiers: #64, #236, and #72. Facility census: 82. Findings include: a) Resident #64 On 02/28/24 at 12:25 AM, Registered Nurse (RN) #55 was observed taking Resident #64's medications into his room. Surveyor entered the room at after RN #55 exited and found the Resident going through the pills which were left in the room. The Resident stated that they do it all the time, leave the pills for him to take when he wants. At 12:30 PM RN #55 was called back into the room and asked if the Resident had an order to self administer the mediations and she stated no I thought he took them. RN #55 then said to the Resident, Well can you take them now so I don't get…

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 provide dialysis care and services in accordance with professional standards of practice. Resident #40 was erroneously monitored for a thrill and bruit. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for dialysis. Resident identifier: #40. Facility census: 82. Findings include: a) Resident #40 During an interview on 03/05/24 at 12:21 PM, Resident #40 stated she received dialysis through a Permacath access in her right chest. The resident stated she did not have a fistula dialysis access. Review of Resident #40's physician's orders showed an order written on 02/01/24 to Auscultate bruit and palpate thrill every shift. A dialysis fistula is an access made by joining an artery and vein in the arm. To make sure the fistula is working, a bruit, or whooshing sound, is auscultated with a stethoscope and a thrill, or buzzing, is palpated with the fingers. Review of Resident #40's Medication Administration Records (MARs) for February 2024 and March 2024 showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. A syringe of injectable medication had been in use for longer than manufacturer's recommendations. This was a random opportunity for discovery. Resident identifier: #61. Facility census: 82. Findings include: a) Medication Cart - North 2 On [DATE] at 9:11 AM, the North 2 medication cart was inspected with Licensed Practical Nurse (LPN) #44 in attendance. A pen-injector for Resident #61 containing Tymlos (Abaloparatide) was in the cart. This medication is given subcutaneously for osteoporosis. A date written on the pen-injector indicated the medication had been opened on [DATE]. LPN #44 stated she did not know how long Tymlos could be used after the syringe had been opened. There was no product insert with the pen-injector. The Tymlos medication guide available on-line at www.tymlos.com stated, Throw away the Tymlos pen after…

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

Based on observation, resident interview and staff interview the facility failed to ensure food was served at a safe and palatable temperature. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Resident Identifiers: #61. Facility Census: 82. Findings Include: a) Resident #61 During an interview on 02/26/24 at 3:33 PM, Resident #61 states my food is often cold. The other day the Salisbury steak was so cold. I sent it back and got tomato soup. b) Noon Meal Temperatures During a dining observation on 03/05/24 at 12:25 PM, the noon meal trays arrived in the North 1 hall. This surveyor asked the Dietary Aide to ask the Dietary Manager (DM) to bring a noon meal tray for the resident and the facility thermometer. At the time of point of service (when the trays are being served to the residents) the temperatures were obtained by the DM using the facility ' s thermometer at 12:34 PM the temperatures were as follows: -Meatballs: 128 degrees Fahrenheit -Vegetables: 117 degrees Fahrenheit -White Rice: 127 degrees Fahrenheit…

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

Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility failed to keep the equipment clean and sanitary. The facility also failed to accurately document resident refrigerator temperature logs. The facility also failed to not store other food in the resident's refrigerator. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen and the Resident's refrigerator. Facility Census: 82 FIndings Include: a) Policy Review During a review of the facility policy titled Labeling and Dating with no date read as follows: Guidelines for Labeling and Dating: -All foods should be dated upon receipt before being stored. -Food labels must include: The food item name The date of preparation/receipt/removal from freezer The use by date as outlined in the attached guidelines Leftovers must be labeled and dated with the date…

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 maintain an accurate and complete medical record for Resident #58's oral assessment, did not obtain a physician's order for the gastrostomy (G-tube) flushes and a diagnosis for the urinary foley catheter for Resident #179, Resident #10's incomplete consent for psychoactive medication, Resident #236's the Physician's Orders for Scope of Treatment (POST) form, documentation of snacks that were not delivered for Resident #32, #57, and #7, a diagnosis of neuropathy for Resident #7, and correct dosage on the physician's orders for medication and documentation for medication side effects for Resident #47. This is true for eight (8) of 24 residents reviewed during the survey process. Resident Identifiers: #58, #179, #10, #236, #32, #57, #7 and #47. Facility Census: 82. Findings Included: a) Resident #58 On 03/04/24 at 9:00 AM, a record review was completed for Resident #58. The review found an oral assessment dated [DATE] was incorrect.…

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 establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections while serving a sandwich to Resident #25. The facility did not complete hand hygiene while administering wound care for Resident #7. Surveyors observing a soiled glove in Resident #235's room. The facility staff did not follow enhanced-barrier precautions for Resident #23. The nursing staff administered nasal spray to Resident #330 without donning gloves and placed a dirty dining tray on a clean dining cart. These were random opportunities for discovery that had the potential to affect more than an isolated number of residents. Resident identifiers: #25, #7, #235, #23 and #330. Findings included: a) Resident #25 On 03/03/24 at 11:58 PM, Nurse Aide (NA) #57 was observed serving Resident #25 a sandwich and milk. However, NA #57 did not don gloves prior to removing 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.

The facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area from the resident's bedside. Resident call light location was not identifiable on the call light annunciator panel. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #237. Census: 82. Findings included: a) Resident #237 During a tour of the facility, on 03/03/24 at 11:30 PM, the call light system was sounding with no light indicator for what room or location was lit on the North or South Unit annunciator panels. On 03/03/24 at 11:40 PM the call light system continued to sound and the Certified Nursing Assistance (CNA) #11 stated, the light indicator on the annunciator panel sometimes doesn't work for the bathroom call lights. CNA #11 then notified all staff who began to check all call lights throughout the facility on 03/03/24 at approximately 11:43 PM. During an interview with the Administrator, at 11:48 PM, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to inform and provide written information to the resident on their right to formulate an advance directive. This was true for one (1) of four (4) residents reviewed for the care area of advance directives during the annual survey. Resident identifier: #179. Census: 82. Findings included: a) Resident #179 On 03/04/24 at approximately 11:00 AM during a record review of Resident #179's medical record it was identified the resident admitted to the facility on [DATE] for short term rehab care. It was noted in the Minimum Data Set (MDS) with the Assessment Reference Date (ARD)/Target of 02/28/24 that Resident #179 had a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. Upon review of the resident's physician orders, there was not an order for end-of-life care. During a review of the miscellaneous uploaded medical records, no end-of-life documents were found on file. No nursing notes were found…

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

Based on observation, record review and staff interview the facility failed to ensure privacy during administration of nasal spray for Resident #330. This was a random opportunity for discovery. Resident identifier: #330. Facility census: 82. Findings included: a) Resident #330 On 02/27/24 at 11:13 PM Resident #330 stated, I need my nasal spray, I want to go to bed. I can't breathe my nose is plugged up. On 02/28/24 at 12:08 AM Resident #330 came out into the hallway in his wheelchair outside of his room door. Resident #330 asked Registered Nurse (RN) #55 if he could have his nasal spray so he could go to bed. RN #55 replied, Yes roll up here (in wheelchair) and I will give it to you. RN #55 then administered nasal spray to Resident #55 while he was sitting in his wheelchair in the hallway. Record review revealed an order for Saline Nasal Solution 0.9 % (Saline). 1 spray resident in each nostril every 6 hours as needed for Dry Nose. During an interview, on 02/28/24 at 10:00 AM, the Assistant Director of Nursing stated RN #55 should not have administered any medications 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.

Based on record review, staff interview, and resident interview the facility failed to report alleged violations related to misappropriation of property and failed to report the results of all investigations to the proper authorities within required time frames. This failed practice was a random opportunity for discovery. Resident identifiers: #64, #65. Facility census: 82. Findings include: a) Resident #64 On 02/26/24 at 3:35 PM Resident #64, stated he is not getting the right meds. Resident said about a week ago on a Sunday (02/18/24) he got the wrong blue pill for pain. Resident produced pictures from his iPhone of the pill he was given and the right medication lying beside it. Resident stated he looked it up and the medicine he was given was Finasteride, that he wasn't even prescribed to take. (Finasteride is used to shrink an enlarged prostate in adult men by decreasing the amount of a natural body hormone). The incorrect blue tablet had F5 stamped on the pill and the Resident knew it wasn't right. The Resident should have gotten morphine sulphate. The resident said the staff…

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 complete and accurate discharge Minimum Data Set (MDS) Assessment for one (1) of one (1) residents reviewed for the care area of discharge. Resident Identifier: #77. Facility census: 82. Findings include: a) Resident #77 Review of Resident #77's medical records showed the resident was admitted for short-term rehabilitation on 11/29/23. He was discharged to home on [DATE]. A Social Service Progress Note written on 12/03/23 stated, Resident had a brief stay here from 11/29/2023 to 12/1/2023 when he opted to discharge to home. He stated he no longer needed to be in SNF [skilled nursing facility] for rehab [rehabilitation]. Review of Resident #77's combined five (5) day and discharge Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) 12/01/23 coded the resident's discharge as Discharge assessment - return anticipated. On 03/05/24 at 05:13 PM, the Assistant Director of Nursing (ADON) confirmed Resident #77's medical…

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

Based on medical record review, family interview, resident interview and staff interviews, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one (1) of 24 residents reviewed during the Long-Term Care Survey (LTCSP). The MDS's for Resident #233 did not accurately reflect the residents' status for communication deficit. Resident Identifiers: #233. Facility Census: 82 Findings Include: a) Resident #233 During the initial interview on 02/26/24 at 3:36 PM, Resident #233 and her daughter were present during the interview. Resident shook her hand to respond yes and no to some answer and looked at her daughter for other responses. The daughter stated she has some communication issues due speaking Spanish and having a stroke. She mostly understands others but has some issues communicating needs to others. She mostly responds by shaking her head. During an interview on 02/27/24 at 4:56 PM, the Director of Nursing (DON) stated they have books and other things to help communicate with (Resident # 233's name). During a record review on 03/04/24 at 2:02 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 medical record review, family interview, resident interview and staff interviews, the facility failed to complete a baseline care plan for Resident #233's communication deficit. This was true for one (1) of 24 residents reviewed during the Long-Term Care Survey (LTCSP). Resident Identifier: #233. Facility Census: 82. Findings Include: a) Resident #233 During the initial interview on 02/26/24 at 3:36 PM, Resident #233 and her daughter were present during the interview. Resident shook her hand to respond yes and no to some answer and looked at her daughter for other responses. The daughter stated she has some communication issues due to speaking Spanish and having a stroke. She mostly understands others but has some issues communicating needs to others. She mostly responds by shaking her head. During an interview on 02/27/24 at 4:56 PM, the Director of Nursing (DON) stated they have books and other things to help communicate with (Resident # 233's name). During a record review on 03/04/24 at 2:06 PM, Resident #233 medical records revealed a care plan with an initiated date of…

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

Based on observation and staff interview, the facility failed to ensure residents with indwelling urinary catheters receive treatment and care in accordance with professional standards of practice. These were random opportunities for discovery. Resident Identifiers: #179 and #29. Facility Census: 82. Findings Include: a) Resident #179 On 03/03/24 at 11:08 PM, the resident was observed to have a urinary foley catheter. The urinary foley catheter drainage bag was touching the floor. On 03/03/24 at 11:12 PM, Licensed Practical Nurse (LPN) #126 was notified and confirmed the urinary foley catheter drainage bag should not be touching the floor. No further information was obtained during the survey process. b) Resident #29 On 02/26/24 at 3:30 PM observation was made of Bedside Urinary Drainage bag under the middle of Resident #29's bed. Urine was backed up in the tubing up to the Resident's leg. Licensed Practice Nurse Unit Manager (LPN) #38 was called into room to verify finding. LPN #38 stated, Oh, well hospice just bathed her a bit ago and must have left it [catheter bag] like that.…

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

Based on observation and staff interview the facility failed to ensure residents receive necessary respiratory care and services in accordance with professional standards of practice, by not safely storing oxygen tanks. This was a random opportunity for discovery. Facility census 82. Findings include: a) Oxygen storage An observation on 03/03/24 at 11:20 PM, revealed an oxygen tank stored in the corner of the bathroom in the floor of Room # 130. No resident was in the room. During an interview on 03/03/24 at 11:22 PM, with Licensed Practical Nurse (LPN) #61, she stated, No, that oxygen tank should not be in there. It should be locked up. I will have someone get it out. A review of the facilities policy titled Oxygen Tank Storage on 03/04/24 at 10:00 AM, read: -Policy: The facility must ensure that the resident environment remains as free of accident hazards as possible. -Procedure: All pressurized oxygen canisters will be secured in a rack or fastened to a wheeled carrier. This includes full, partially full, and empty canisters, and canisters that are located in the oxygen storage…

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 account for controlled substances within professional standards of practice for Resident #65. This failed practice was a random opportunity for discovery. Resident identifier: #65. Facility census: 82. Findings include: On 02/27/24 at 9:45 AM, LPN #64 stated We got a problem here with controlled substances coming up missing. The DON knows about it . This is my license. See here, this hydromorphone for [Resident #65's name] was signed out and he wasn't even taking it. LPN #64 showed surveyor the controlled substance sign-out book for Resident #65 where Registered Nurse (RN) #55 signed out the pain medication on 02/08/24. LPN #64 then stated, I clean out the med cart at the end of my shift and only leave enough pain meds for the night. That's what I was told to do. Record review shows and order for Hydromorphone HCl Oral Tablet 2 MG (Hydromorphone HCl). Give1 tablet by mouth every 24 hours as needed for pain control. Order was discontinued on 10/17/23. Review of the controlled substance sign-out long showed RN #55…

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 drug regimen of each resident was reviewed at least once a month by a licensed Pharmacist. This failed practice was found true for (1) one of (5) five residents reviewed for unnecessary medications during the Long Term Care Survey Process. Resident identifier #61. Facility census 82. Findings include: a) Resident #61 A record review on 03/05/24 at 1:50 PM, of Resident #61's Pharmacy notes revealed the following Pharmacy reviews: (Typed as written, leaving out the Pharmacist name) -03/3/2024 18:34 Note Text: I reviewed this resident's medication regimen and have noted any irregularities and/or observations on a separate report to the Director of Nursing and prescriber. Pharmacy -02/7/2024 19:00 Note Text: I have completed the Pharmacy MMR for this patient for the month of FEBRUARY 2024, please see the report for specific comments. Thank you. Pharmacy -01/7/2024 13:54 Note Text: I have completed the Pharmacy MMR for this patient for the month of JANUARY 2024, please see report for specific comments. Thank…

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

Based on record review and staff interview, the facility failed to monitor efficacy of psychotropic medications. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #47. Facility census: 82. Findings include: a) Resident #47 Review of Resident #47's medical records showed the resident had been ordered the medication mirtazapine for anxiety since 10/27/23 and the medication trazodone for anxiety since 11/16/23. The resident's comprehensive care plan had a focus related to anxiety disorder. The goal initiated 06/17/23 was I will remain free from signs and symptoms of increased restlessness daily through the next review. Resident #47's medical records contained no documentation the resident was monitored for signs and symptoms of anxiety. During an interview on 03/05/24 at 1:45 PM, the Director of Nursing (DON) confirmed Resident #47's medical records contained no documentation the resident was monitored for signs and symptoms of anxiety. No further information was provided through…

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 review of facility's grievance/concerns, policy review, resident interviews and staff interviews, the staff failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility, and failed to demonstrate their response and rationale for such response. Resident identifiers: #52, #71, #12, #60, #56, #44, and #3. Facility census: 74. Findings included: a) Resident #52 Concern from Resident Council for Resident #53 dated 01/27/22 read: Activities: Don't like the way bingo prizes are given. Laundry: Not getting our laundry back in a timely manner. Housekeeping: Would like them to check bathroom for supplies to make sure we have enough daily. Dietary: Improve on the food quality. Would like alternate options to choose from. Action taken was blank b) Resident #71 Concern form from Resident Council for Resident #71 dated 01/27/22 read: Nursing short staffed and call lights not answered.…

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

Based on medical record review and staff interview the facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End of Life Care. This is true for five (5) of 24 residents reviewed for advance directives. Resident Identifiers: Resident #49, #59, #74, #25 and #273. Facility Census: 74. Findings Included: a) Resident #49 On 07/18/22 at 2:33 PM Resident #49's POST form was reviewed. On the POST form in Section D, signed and dated by the physician on 08/24/21 revealed no date of resident #49's signature. During an interview on 07/19/22 at 9:36 AM the Medical Record Staff #38 acknowledged Resident #49's POST form was not dated when signed by Resident #49. b) Resident #59 On 07/19/22 at 8:30 AM Resident #59's POST form was reviewed. The Post form was illegible and did not dictate proper procedures to provide the advance directive request. On the POST form in Section B titled Medical Interventions: Comfort Measure box was check marked, a line drawn through it, dated 05/18/22 with Resident…

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

Based on record review and staff interviews the facility failed to implement their policy regarding allegations of neglect and injuries of unknown origin, which were not reported within the appropriate time frames and to the appropriate state agencies. These failed practices to implement their abuse policy had the potential to affect more than a limited number of esidents currently residing in the facility. Resident Identifiers: #46, #81 and #177. Facility Census: 74. Findings included: a) Resident #46 Review of the Concern/Complaints found a concern form for Resident # 46, dated 06/02/22 and read as follows: Registered Nurse (RN) #93 reports she asked the Nursing Assistant (NA) #51 to assist the resident to bed at 7:30 pm NA #51 reported to the nurse he doesn't usually go to bed this early, and he is a high risk for falls. RN #93 then told the NA #51 the resident's pants are soaking wet. NA #51 reports she will lay him down as soon as possible. Per the RN #93, NA #51 did not assist resident to bed until 10-10:30 pm. On 07/20/22 at 10:40 am the acting Director of Nursing (DON)…

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 all alleged violations involving abuse/ neglect and injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation is made to the appropriate agencies. These were random opportunities for discovery and was true for three (3) residents. Resident identifiers: #46, #81, and #177. Facility Census: 74 Findings Included: a) Resident #46 Review of the Concern/Complaints found a concern form for Resident # 46, dated 06/02/22 and read as follows: Registered Nurse (RN) #93 reports she asked the Nursing Assistant (NA) #51 to assist the resident to bed at 7:30 pm NA #51 reported to the nurse he doesn't usually go to bed this early, and he is a high risk for falls. RN #93 then told the NA #51 the resident's pants are soaking wet. NA #51 reports she will lay him down as soon as possible. Per the RN #93, NA #51 did not assist resident to bed until 10-10:30 pm. On 07/20/22 at 10:40 am the acting Director of Nursing (DON) reviewed the concern for Resident #46 dated 06/02/22.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to ensure the receiving facility received all required paperwork to ensure a safe and orderly transfer from one facility to another. The facility failed to send physicians orders or Medication Administration Records (MAR) upon transfer. This was true for three (3) of the three (3) Residents reviewed during the long term care survey process. Resident Identifiers: # 75, # 177 and # 28. Facility Census: 74. Findings Included: a) Resident # 75 A review of Resident #75's medical record found the following dated entry: 5/24/22 at 8:18 PM, Nurses Note: Resident was transferred out to (Local Hospital Name) by EMS (Emergency Medical Services) resident was calm and all vitals were stable at the time of transfer, (Local Hospital Name) called to ask last application of fentanyl Patch and last meds (medication) given nurse reported transfer was completed to (Local Hospital Name). A review of a facility provided form labeled Transfer/Discharge Report for…

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

Based on record review and staff interview the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. This was true for three (3) of three (3) Residents reviewed during the long term care survey process. Resident Identifiers: # 75, # 177 and # 28. Facility Census: 74 Findings Included: a) Resident # 75 A review of Resident #75's medical record found the following dated entry: 5/24/2022 at 8:18 PM, Nurses Note: Resident was transferred out to (Local Hospital Name) by EMS (Emergency Medical Services) resident was calm and all vitals were stable at the time of transfer, (Local Hospital Name) called to ask last application of fentanyl Patch and last meds (medication) given nurse reported transfer was completed to (Local Hospital Name). A further review of Resident #75's medical Record found no Ombudsman notification for the transfer to a local hospital on 5/24/2022 at 8:18 PM. 07/20/22 at 11:16 AM, The Interim Administrator acknowledged the Ombudsman was not notified regarding Resident # 75's…

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

Based on observation, resident interview, medical record review and staff interview the facility failed to develop and/or implement a comprehensive person-centered care plan with measurable objectives, in the areas of fall prevention, Hospice, and Advance directives. This is true for three (3) out of 24 residents reviewed during the long-term care survey process. Resident Identifiers: Resident #177, # 74, and #71. Facility census: 74. Findings included: a) Resident #177 A review of Resident #177's medical records revealed Resident #177 had unwitnessed falls that occurred in her room on the following days: *4/29/22 * 4/27/22 *4/29/22 *6/16/22 *6/20/22 * 6/21/22: 12:31-4:01 pm *6/22/22 *7/3/22 2:15 pm and 7:11 PM Further review of Resident #177's care plan found it was void of realistic interventions to prevent falls. Resident #177 had 10 falls in a four (4) month time frame. the following are the interventions that were put in place which were contained on the care plan: *Dycem to her wheelchair to prevent the cushion from slipping out. *Encourage resident to attend activities of…

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

Based on observation, staff interview, and medical record review the facility failed to follow physician orders in regard to neuro checks after a fall, providing nutritional supplemental snacks, monitoring of blood sugars for diabetics, and administering antibiotics. Resident Identifiers: Resident #46, #70, #28, #1, #48, #40, #32, #18, #17, #30, #22, #6, #424, #7, #62, #36, #52, #68, #67, #28, and #273. Facility census 74. Findings included: a) Resident #46 On 07/20/22 at 11:35 PM, evening snacks were found on the food cart beside of the of the north side nursing station. These snack were undelivered to the residents. A review of the MAR (Medication Administration Record) for Resident #46 read: House 2.0 (pudding with higher nutrition than water, with added protein and calories) to be given three times a day at 9:00 AM, 1:00PM, and 5:00 PM. On 07/19/22 at 5:00 PM, it was documented by Licensed Practical Nurse (LPN) #52 that Resident #46 had consumed 100 percent of the snack which was undelivered to the resident. On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) 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 observation, record review and staff interview the facility failed to maintain an environment that was free of accidents and hazards. Medication was left unattended in Resident #68's room. A Medication cart was left unlocked and unattended for an extended period. Fall protocol was not followed for Resident #6. Resident #22 consumed a snack not permitted within his diet order. The facility failed to modify and monitor the effectiveness of fall interventions for Resident #273 and Resident #177. These findings were a random opportunity for discovery and had the potential to affect more than a limited number of Residents. Resident identifiers: #68, #6, #22, #273, and #177. Facility census: 74. Findings included: a) Resident #68 On 7/18/22 at 12:33 PM an observation was made of Phytoplex protectant z-guard paste (used for wetness protection to prevent and treat diaper rash) laying on the Resident's wheeled over bed table in the Resident's room. The tube of paste had the Resident's last name written on it…

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 assure that all nursing staff possess the competencies and skill sets to provide care and services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. (In relationship with reporting and resolving grievances, abuse and neglect policies including following policy, prevent, reporting and investigating of allegations of abuse/neglect, transfer requirements and use of Bedhold policy to ensure a safe and effective transfer/discharge of residents, following physician orders, providing appropriate respiratory care, provide pharmacy needs concerning monthly review and use of unnecessary prn psychotropic prn medication use, proper labeling and storage of medication, an effective infection control program, and appropriate education and administration of Covid-19 vaccinations . This deficient practice had the potential to affect all residents residing in the facility. Facility census: 74 Findings include: a) Cross Reference 585 b) Cross…

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 observation, policy, and staff interview, the facility failed ensure all multi-dose vials which have been opened or accessed (e.g., needle-punctured), and medications designed for multiple administrations (e.g., inhalers, eye drops) are dated with the initial date they were opened and accessed. This was a random opportunity for discovery and had the potential to affect more than a limited number of newly admitted residents. Resident identifiers: #49, #21, #18, #68, #39, #9, #29, #71, #424, #67, and #4. Facility census 74. Findings included: a) Medication cart 135-150 On 07/19/22 at 8:51 AM, an observation of the medication cart 135-150, with Licensed Practical Nurse (LPN) #52. LPN #52 verified the following: No open dates on the any of the multi-dose medications. Two (2) out of eight (8) insulin pens: Resident # 49's Lantus Resident # 21's Lantus One (1) out of two (2) tubes of eye ointment: Resident # 18's Gentle tear ointment, One (1) out of two (2) bottles of nitroglycerin: Resident # 68's nitro Seven (7) out of eight (8) inhalers: Resident # 39's Albuterol Resident # 49's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, food temperature measurement, resident and staff interview the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature. This was true for seven (7) out of 10 residents reviewed for food. Resident identifiers: Resident #3, #60, #56, #44, #67, #29, and #71. Facility census 74. Findings included: a) Resident #3 On 07/18/22 at 2:32 PM, Resident #3's daughter stated her father is not happy with the diet and feels like he does not get enough to eat. On 07/19/22 at 2:32 PM, Resident # 3 did not get his lunch until 2:32 PM today, and it was penne noodles and meatless red sauce. Resident # 3 stated he would be happy to eat a ham sandwich. When he gets a hot dog, it is only one with a [NAME] on a bun two packets of mustard and ketchup, portion sizes are small. Food is not always very warm. b) Resident #60 During the first phase of the survey process Resident #60 reported on 07/18/22 at 2:21 PM, that the food is not good, no seasoning, not…

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

Based on observation, and staff interview, the facility failed to properly store food in a sanitary manner in accordance with professional standards for food service safety. The facility also failed to correctly document the three compartment sink temperatures, the walk-in refrigerator and two freezer temperatures. This deficient practice has the potential to affect more than a limited number of residents. Facility Census: 74. Findings Included: a) Walk-In Refrigerator During an initial visit of the kitchen on 07/18/22 at 11:10 AM with Account Manager (AM) #92 the walker-in refrigerator revealed a plastic bin labeled employee drinks with: -one (1) two (2) liter bottle of opened mountain dew -one (1) two (2) liter bottle of unopened mountain dew -one (1) unopened can of sprite -one (1) unopened can of mountain dew -one (1)unopened can of coke. During an interview AM #92 stated The Health department said as long as they are in a separate bin we can store the employee drinks in the same refrigerator as the residents food. b) Three- Compartment Sink Temperatures On 07/18/22 at 11:10 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation and staff interview the facility failed to implement and maintain visitor and employee surveillance for COVID-19 and to ensure and maintain an infection prevention control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to monitor employees entrance screening surveillance for COVID-19, Staff was not wearing PPE upon surveyor entry to the facility, Residents in Isolation for COVID-19 rooms had doors open and gowns hanging on outside of door, perform hand hygiene before meals, Hand wipe container taken into Resident rooms, staff coming out of Resident room without N95 mask on and staff wearing PPE (personal protective equipment) improperly. This had the potential to affect more than a limited number of residents residing in the facility. Facility Census 74. Findings Included: a) entrance screening A Review of 07/19/22 Tuesday's Facility…

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 educate and obtain consent prior to administering their COVID-19 vaccinations. This was true for 4 (four) of 5 (five) residents reviewed for vaccinations. Resident Identifiers: #14, #32, #52, and #71 Facility Census: 74 Findings Included: On 7/20/22 while reviewing vaccinations records on 5 (five) randomly selected residents the following information was gathered. Consents and refusals were reviewed and correct for influenza, pneumonia, and Prevnar vaccinations. However, COVID vaccine education and consents could not be located for 4 (four) of the 5 (five) records reviewed. This was confirmed with the Interim Administrator #90 on 7/20/22 at 10:00 AM and again with the Staff Development Coordinator #29 on 7/21/22 at 10:40 AM. The following residents were found to be out of compliance: -- Resident #14 influenza 10/11/21 pneumonia refused refusal reviewed Prevnar refused refusal reviewed COVID 1) 12/23/20 2) 1/20/21 3) 11/23/21 no education or consents -- Resident #52 influenza 10/11/21 pneumonia 2/1/12 Prevnar 12/4/17…

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 call light system used for communication was functioning properly throughout the facility. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 74. Findings Included: During an after-hour survey on 07/19/22 at 11:34 PM an observation was made of call lights constantly alarming (beeping) with no indicator lights on the panel box to specify what room. Licensed Practical Nurse (LPN) #5 stated That's the ghost light it does that. One of the bathroom lights may not be pushed up all the way, it beeps all the time. It has been doing it for a long time. On 07/20/22 at 8:12 AM Maintenance Director #21 stated that the call lights not working properly was nothing new. Maintenance Director #21 further stated that the main panel was just replaced on June 23rd, 2022, and the staff know that if it is alarming all the time, the bath stations may need reset. Maintenance Director #21 stated, They [staff] have to take the time 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, medical record review, resident interview and staff interview the facility failed to ensure Resident #71 was provided care in a manner which preserved her dignity. Resident #71 was wearing an adult disposable brief with adhesive tabs instead of a panty line which was her preference. This was an random opportunity of discovery. Resident Identifier: #71 Facility Census: 74 Findings included: a) Resident #71 During the Resident Council meeting held on 07/19/22 at 2:33 PM Resident #71 stated staff informed the Residents the facility was unable to get panty liner pads, I have to use paper towels for my panty liner or wear a diaper. An observation of the central supply room on 07/19/22 at 3:40 PM with Medical Record Staff (MRS) #38, This surveyor along with another survey found six (6) packages of 30 count Restore panty liner pads on the central supply shelving unit. An observation on 07/19/22 at 3:56 PM this surveyor along with another survey observed several adult disposable brief with adhesive tabs laying on residents #71's bed . An observation on 07/20/22 at 8:00…

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, resident interview and staff interview, the facility failed to promote and facilitate resident self-determination through support of resident choice in regard to having access and choosing their undergarment preference and the right to choose when and how often to shower. Residents' identifier: Resident #3, and #71. Facility Census: 74. a) Resident #3 During an interview with Resident #3 on 07/18/22 at 11:44 AM, Resident #3 stated he normally (before coming here) would shower daily. Since being here at the facility it has been three (3) to four (4) days before can get showers. A review of Resident #3 medical records in regards to shower documentation found, his shower days are scheduled for Mondays and Thursdays. A 30 day look back of the shower documentation revealed Resident #3 was actually documented as to having a total of seven (7) showers, on the following dates: 06/22/22, 07/07/22, 07/08/22, 07/09/22, 07/10/22, 07/14/22, and 07/18/22. During an interview with Corporate Nurse #91 was informed of the above findings and asked if there…

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 notify a family member of a fall that occurred at the facility. This failed practice had the position to affect a limited number of residents. Resident identifiers: #177. Facility census 74. Findings included: a) Resident #177 During a review of medical records, it found Resident #177 had an unwitnessed fall on 04/29/22. On 04/29/22 it was found the space for who was notified was wrote: self, (Resident #177 lacked capacity at this time). On 07/21/22 at 9:30 AM, Corporate Nurse #91 was notified of the above and no additional information was provided. .

Based on observation and staff interview the facility failed to maintain a sanitary and comfortable environment that includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care area clean and at a desirable temperature. The curtain in a Resident's room was dirty and the facility temperatures were not within a comfortable and safe temperature range. This had the potential to affect a limited number of residents residing in the facility. Resident Identifier # 34. Facility Census 74 Findings Included: a) Resident #34 On 07/18/22 at 1:28 PM, during the long term care survey process this surveyor noticed Resident # 34 room curtain was soiled with several brown smudged spots. A review of Resident #34's care plan focus found the following: --I occasionally smear and chew my feces. On 07/19/22 at 9:38 AM, in an interview with the Environmental Service Director (ESD) regarding Resident # 34's curtain and care plan the ESD stated I was unaware of the care plan. On 07/20/22 at 1:20 PM, Corporate Nurse acknowledged there were no interventions in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility's grievance/concerns, policy review, resident interviews and staff interviews, the staff failed to act promptly to resolve individual complaint/concerns voiced by the residents. Some of which remain problems during the Long Term Care Survey. Resident identifiers: #74, #52, #71, #60, #56, #44, #3 and #26. Facility census: 74. Findings include: a) Resident #74 Concern form for Resident #74 dated 01/25/22 read: Takes staff a while to answer call bell. Food is sometimes cold when served. Desires staff to empty Foley catheter bag more frequently. Would like the physician to evaluate pain medication for increased pain control. Action taken read: Spoke with resident. Notified resident that nursing staff will communicate pain medications evaluation with physician, Nursing staff education regarding call light wait times and emptying catheter bag every shift. Meet with dining service staff to ensure that the meals are being temped and that they are the correct temps. Also spoke with nursing…

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

Based on review of concerns/grievance reports, medical record review and staff interview, the facility failed to investigate all allegations of abuse and/or neglect. These were random opportunites of discovery. This was true for Resident #46 and #81. Resident identifier:s: #46 and #81. Facility census: 74. Findings included: a) Resident #46 Review of the Concern/Complaints found a concern form for Resident # 46, dated 06/02/22 and read as follows: Registered Nurse (RN) #93 reports she asked the Nursing Assistant (NA) #51 to assist the resident to bed at 7:30 pm NA #51 reported to the nurse he doesn't usually go to bed this early, and he is a high risk for falls. RN #93 then told the NA #51 the resident's pants are soaking wet. NA #51 reports she will lay him down as soon as possible. Per the RN #93 the NA #51 did not assist resident to bed until 10-10:30 pm. On 07/20/22 at 10:40 am the acting Director of Nursing (DON) reviewed the concern for Resident #46 dated 06/02/22. She confirmed this allegation should have been reported and investigated as possible neglect and I will do it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to provide a bed hold notice to the Resident at the time of transfer to an acute care facility. This failed practice was true for two (2) out of three (3) discharged residents reviewed during the long term care survey process. Resident identifiers: Resident #177, and #28. Facility census 74. Findings included: a) Resident #177 A review of Resident #177's medical record found the resident was discharged to the local hospital on two (2) separate occasions on 07/03/22. Further review of the record found there was no a bed hold policy provided to the resident at the time of the discharge. On 07/21/22 at 8:25 AM, an interview with the Administrator confirmed no bed hold policy was sent with Resident #177 when they were sent to the hospital on [DATE]. b) Resident #28 Review of Resident #38S medical records found a nurses note written by Employee #54 Licensed Practical Nurse (LPN) on 07/20/22. The note read: Resident requested to go to the local emergency…

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 review and revise the care plan when Resident #273's Physicians Orders for Scope of Treatment (POST) status changed from Attempt Resuscitation (CPR) to Do Not Attempt Resuscitation (DNR) status. Resident Identifier: #273 Facility Census: 74. Findings Included: a) Resident #273 On [DATE] Resident #273's POST form was completed and signed by his daughter and the Physician to reflect a DNR status. The care plan still states the Resident is a full code (CPR). The above findings were confirmed with Registered Nurse #91 on [DATE] at 2:08 pm. .

Based on observation, record review and staff interview the facility failed to properly store a Nebulizer for Resident #26 and Resident #59. These findings were a random opportunity for discovery and had the potential to affect only a limited number of Residents. Resident identifiers: #26, #59. Facility census: 74. Findings included: a) Resident #26 On 07/18/22 at 12:00 PM observation was made of Resident #26's Nebulizer mouthpiece (circuit) laying on the bedside table without being stored properly in a bag. The Resident states she had not used it for a couple of weeks and only uses it when she has panic attacks. Registered Nurse (RN) #8 verified 12:01 PM the Nebulizer mouthpiece (circuit) should have been stored in a bag for infection control purposes. b) Resident #59 During an initial tour on 07/18/22 at 12:04 PM observed Resident #59's Nebulizer mask laying on his bed side table. During an interview on 07/18/22 at 12:06 PM Registered Nurse (RN) # 8, acknowledged the Nebulizer mask should be have been placed in a storage bag. A facility policy titled Respiratory Infection Control…

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 daily staff posting was accurate and included the actual hours worked for staff directly responsible for the resident's care per shift every day. This had the potential to affect all residents residing in the facility. Facility census: 74. Findings included: Review of daily staff schedule, assignments and timecards for staff providing direct care and actual patient per day ratio (PPD) for period of two (2) weeks beginning on 07/03/22 through 07/16/22; found on the following dates the facility failed to ensure accurate nurse staff posting: -- 07/03/22- Staff posting reflected 2.7 PPD although timecard punches showed actual PPD of 2.52. -- 07/08/22- Staff posting reflected 2.5 PPD although timecard punches showed actual PPD of 2.42. -- 07/09/22- Staff posting reflected unknown (information blank) PPD although timecard punches showed actual PPD of 2.18. -- 07/15/22-Staff posting reflect 2.97 PPD although timecard punches showed actual PPD of 2.80. On 07/21/22 at 9:00am the staff postings and actual PPD…

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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #66 and #67. Facility Census: 74. Findings include: a) Resident #66 Resident #66's physician orders included orders for, Ativan Solution 2 milligrams/milliliters (mg/ml) give 0.6 mg every six (6) hours as needed (prn) for generalized anxiety disorder and Oxycodone 100 mg/5ml give 6 mg every four (4) hours prn for pain. Review of Resident #66's medication administration record (MAR) and narcotic control records (NCR) found on the following…

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 conduct monthly drug regimen reviews for two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #68, and #60. Facility census: 74. Findings included: a) Resident #68 On 07/20/22 at 10:21 AM Corporate Registered Nurse (RN) #91 provided monthly drug regimen reviews (MRR) February 2022 through May 2022. RN #91 stated she would have to look for previous dates. Record review indicated the Resident was admitted to the facility on [DATE]. On 07/21/22 at 9:35 AM, Corporate RN #91 stated no additional documents were found for the time frame prior to February 2022 to indicate monthly drug regimen reviews were conducted for Resident #68. b) Resident #60 During a review of the MRR for Resident # 60 it found this resident was admitted on [DATE]. Therefore the Facility only needed to provide one MRR. On 07/21/22 at 10:43 AM, Interim Administrator provided a list of residents that did not have all of the MRR completed, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to evaluate the as needed (PRN) psychotropic medication ordered for longer than 14 days, without a documented rationale for continued use and failure to implement person-centered, non-pharmacological approaches prior to the administration of the PRN psychotropic (Ativan) medication. Resident #66. Facility Census: 74. Findings included: a) Resident #66 Medical record review for Resident #66 found he was admitted to the facility on [DATE]. Diagnosis included elevated white blood cell count, adult failure to thrive, primary adrenocortical insufficiency, gastroesophageal reflux, nausea, depression, anxiety disorder, alcohol use, hypoxemia, hypertension, obstruction of duodenum, pneumonia, and atrial fibrillation. Resident #66's physician orders included an order for, Ativan Solution 2 milligrams/milliliters (mg/ml) give 0.6 mg every 6 hours as needed (prn) for generalized anxiety disorder. Review of Resident #66's medication administration…

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 the medical record in a manner that reflected a resident's progress toward achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status. The facility did maintain a Medical Regiment Review (MRR) in the Residents chart. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medicaitons. Resident #27. Facility census 74 Finding Included: A) Resident #27 A Review of Resident # 27 medical record failed to reveal a Medical Regiment Review (MRR) from pharmacy. On 07/20/22 at 1:20 PM, Corporate Nurse (CN) provided emails from the facility pharmacist regarding Resident # 27's MRR that read: 07/0722: I Facility Pharmacist have completed the pharmacy MMR for the patient for the month of July 2022, please see report for specific comments, thank you 06/05/22: I Facility Pharmacist have completed the pharmacy MMR for the patient for the month of June 2022, please see report for specific…

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.