Hidden Valley Center

Based on a review of a facility reported incident (FRI) and staff interview it was determiend the facility failed to use the results of the investigation to determine the appropriate action to take regarding education of staff following a resident's fall with major injury. Resident identifier: #78. Facility census: 74. a) Resident #78 An investigation for a Facility Reported Incident (FRI) was initiated on 04/20/26. A random discovery was found pertaining to an additional FRI dated 06/13/25 that was reviewed during the investigation. It was determined the facility failed to implement corrective action for staff education following a fall with major injury for Resident #78 for FRI dated 06/13/25. The Initial Report of Allegations dated 06/13/25 stated the resident had a fall and was sent to the hospital. The hospital called the facility and stated the resident had a fracture of the right shoulder and collarbone on 06/14/26. The Five-Day Follow-Up Investigation Report, submitted 06/18/25, stated the nurse assessed the resident for injuries, noting a hematoma to the top right side 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide an accurate Minimum Data Set (MDS) assessment upon discharge for Resident #79. This was true for one (1) of four (4) residents reviewed under the care area of discharges. Resident Identifier: #79. Facility Census: 74.Findings Include: a) Resident #79 On 04/21/2026 at 1:20 PM, a record review was completed for Resident #79. The review found the resident was discharged from the facility on 08/27/24. The resident would not be returning to the facility. However, the MDS, dated [DATE], indicated the resident was discharged but return to the facility was anticipated. On 04/21/26 at 1:40 PM, Corporate Nurse #80 confirmed the resident was discharged from the facility and did not return.

Based upon record review and staff interviews, the facility failed to refer one (1) of one (1) residents who had a newly evident serious mental health disorder diagnosis for a level II review. This was true for one (1) of one (1) records reviewed. Resident identifier: #20. Facility census: 74. a) Resident #20 On 04/14/26 During a record review for Resident #20, the surveyor could not find the level II PASARR. 04/15/26 9:22 AM Record review and interview revealed that on 03/27/26 a PASARR was completed on Resident #20. A level II was identified as needing to be completed and never was. At 8:58 AM, the surveyor asked the Administrator why the Level II was not completed as required. She stated, I will find out and get back to you. 04/15/26 11:08 AM On 04/15/26 at 11:08 AM Corporate nurse (CN) #80 stated, The level II PASARR has not been completed yet, but is scheduled for tomorrow (04/16/26). 4/15/26 09:45 AM a reivew of a General Note revealed, A phone call was made to Level II Evaluator (Name and phone #) regarding the completion of the Level II Evaluation. (Name) reported that she…

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 resident's Pre-admission Screening and Resident Review (PASARR) included a diagnosis of Post-Traumatic Stress Disorder (PTSD). This was true for one (1) of 28 residents reviewed during the survey process. Resident #13. Facility Census: 74. Findings Include: a) Resident #13 Resident #13 was admitted on [DATE]. A review of the resident's comprehensive minimum data set (MDS) with an assessment reference date (ARD) of 03/03/26 revealed a diagnosis of Post-Traumatic Stress Disorder (PTSD). A review of the PASARR dated 02/20/26 found that the diagnosis of Post-Traumatic Stress Disorder (PTSD) was not included in the PASARR. On 04/13/26 at 4:00 PM, Corporate Registered Nurse (RN) #80 confirmed the PTSD diagnosis was not included on the PASARR.

Based on record review and staff interview, the facilty failed to develop a care plan regarding a urinary catheter for Resident #5 and failed to implement a care plan for blood glucose monitoring for Resident #8. Resident Identifiers: #5 and #8. Facility Census: 74.a) Resident #8 Review of clinical documentation revealed a blood glucose (BG) result of 67 mg/dL on 04/1/26 at 08:07 AM The resident's care plan specified that the physician must be notified for blood glucose readings less than 70 mg/dL or greater than 450 mg/dL. However, the medical record contained no evidence that the physician was notified of the low blood glucose result as required by the care plan. This failure to implement the care plan interventions placed the resident at risk for delayed recognition and treatment of hypoglycemia. This was confirmed with Corporate Nurse #80 on 04/15/26 at approximately 9:00 AM. Findings Include: b) Resident #5 On 04/20/2026 at 11:40 AM, a record review was completed for Resident #5. The review found on the care plan, a incomplete focus area for a urinary catheter. The focus area…

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

Based on record review and staff interview, the facility failed to ensure a resident's plan of care was updated for a Change in Condition (CIC). This failed practice had the potential to affect a limited number of residents. Resident Identifier: #46. Facility Census: 74.Findings included: a) Resident #46 A Change in Condition (CIC) was completed on 04/14/26 for Resident #46 for the following: Nursing observations, evaluation, and recommendations are: resident was scratching right cheek and left a scratch. Fingernails were checked and were short. Resident was educated not to scratch face. A scratch was observed on the resident's right cheek by the state surveyor on 04/13/26 and 04/14/26. The resident's care plan was reviewed and no update was found for the CIC.b) On 04/20/26 at 11:50 AM, Corporate Registered Nurse #80 confirmed that the Change of Condition for Resident #46 was not initially updated on the care plan and stated, I updated the care plan.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, resident interview and observation, the facility failed to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental, and psychosocial well-being of the residents. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #68 and #69. Facility Census: 74.Findings included: a) Resident #68 On 04/13/26, during the initial interview process, Resident #68 stated, I don't get to go outside enough. I'm an outdoor person. The resident stated that the facility Need[s] to have more activities. The resident was waiting for his lunch and stated it was a long break before now and suppertime.The resident's care plan stated, It is important for me to go outside when the weather is good and enjoy eating/drinking, napping, sitting, talking/visiting, walking, sitting with wife. b) Resident #69 On 04/13/26, during the initial interview process, Resident # 69…

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 follow physician orders regarding required notification parameters for abnormal blood glucose results. Resident #8.The physician order directed staff to notify the physician when blood glucose levels were less than 70 mg/dL or greater than 450 mg/dL. On 4/1/2026 at 08:07, a blood glucose reading of 67 mg/dL was obtained and documented; however, the physician was not notified of this abnormal result.During confirmation on 4/15/2026 at 4:30 PM with Corporate Nurse, it was acknowledged that physician notification did not occur as required. This failure to follow physician orders placed the resident at risk for delayed medical intervention and potential adverse outcomes related to hypoglycemia.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure pharmacy recommendations were acted upon by the resident attending physician. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: 72. Facility Census: 74. Findings Include: a) Resident #72 A review of Resident #72's medical record found a pharmacy recommendation dated 10?04/25 which read as follows: This resident is diagnosed with dementia and receiving the antipsychotic Zyprexa 5 mg twice daily. Please indicate the appropriate clinical situation the continued use of this medication: () Behavioral symptoms present a danger to the resident or other AND one or both of the following() Symptoms identified due to mania or psychosis (auditory, visual hallucinations, delusions (paranoia or grandiosity) or () Behavioral interventions have been attempted and included in the plan of care. Resident continues to benefit from continued therapy. Further review of this recommendation…

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

Based on record review and staff interview, the facility failed to ensure a Physician's Order for Scope of Treatment (POST) and eight (8) consents were signed and dated by Resident #13, who has capacity, and ensure a resident's code status was correctly documented in the medical record for Resident #48. This was true for two (2) of 28 residents reviewed during the survey process. Resident Identifiers: Resident #13 and #48. Findings Include: a) Resident #13 On 04/14/2026 at 1:12 PM, a record review was completed for Resident #13. The review found the resident had capacity to make medication decisions. The physician's determination of capacity was completed by the facility physician on 03/04/26. Upon further review, the following forms and consents were not signed by the resident: --POST form --Influenza Vaccine informed consent --Vaccination informed cosent/declination for varicella (chicken pox), shingles, respiratory syncytial virus (RSV), Measles, Mumps, Rubella, Varicella (MMRV) and Tetanus, Diptheria, Pertussis (Tdap) --Psychotropic Medication Administration 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 resident interview, staff interview, record review and observation, the facility failed to ensure a call light was placed within a resident's reach while in bed. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #40. Facility Census: 74.Findings included: a) Resident #40 On 04/13/26 at 3:00 PM, during the initial interview process, Resident #40's call light was behind the resident's headboard, on the floor, and tangled in cords under the bed. When the state surveyor asked the resident where his call light was, the resident patted his blanket and pillow and reported he didn't know its location. At 3:11 PM, Nurse Aide #41 confirmed the call light's location, retrieved it, and fastened it to the resident's blanket. b) Resident #40's Care Plan stated that the resident is at risk for falls and required staff to place call light within reach while in bed or close proximity to the bed. c) The facility's policy and procedure for Call Lights stated, 4. Staff will ensure the call light is within reach of the patient and secured as…

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, hospital, and ombudsman interviews, the facility failed to ensure Resident #80 was permitted to return to the facility following a hospitalization for behavioral evaluation. The facility's refusal to readmit the resident was based solely on behaviors that occurred prior to the hospitalization. This deficient practice resulted in an involuntary discharge without adherence to federal discharge requirements. Resident Identifier: #80 Facility Census: 77Findings include:Record review revealed Resident #80 was transferred to hospital on [DATE] due to aggressive behavior and bipolar disorder. Progress notes from [DATE] documented that the resident exhibited increased agitation, verbal aggression, and non-redirectable behaviors, and was sent to the hospital for further evaluation per physician order.Further review of nursing documentation showed multiple instances of behavioral escalation throughout [DATE], including verbal aggression toward staff, sexually inappropriate comments, and…

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

Based on record review and interviews, the facility failed to provide required written notice to the resident, resident representative, and the long-term care ombudsman prior to discharging Resident #80 and refusing readmission following hospitalization. The facility's failure to issue appropriate notice deprived the resident and representative of their right to appeal and participate in discharge planning. Resident Identifier: #80 Facility Census: 77Findingd Include:Record review showed Resident #80 was transferred tohospital on 8/31/25 and remained hospitalized beyond the bed-hold period. Despite hospital documentation showing the resident was ready for return, the facility declined readmission.Interviews with the Hospital Care Manager and Ombudsman confirmed the resident and representative were not notified in writing of the facility's decision to refuse return. There was no evidence that:A written discharge notice was provided to the resident and representative;The notice contained the reason for discharge, effective date, and appeal rights;The state long-term care ombudsman…

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 the observation and staff interview the facility failed to maintain a comfortable and sanitary environment for residents. These findings had the potential to affect more than an isolated number of residents. Facility census: 74. A tour of the facility on 09/08/25 at 11:00 AM revealed the following observations: a) room [ROOM NUMBER] A brown substance was around the base of the toilet. The room had lots of white dry wall mud patches. b) room [ROOM NUMBER] Dry wall mud patches were on the walls of the room. A toilet paper roll holder was missing, and the toilet paper was sitting on top of the back of the commode. c) room [ROOM NUMBER] The ring around the base of the toilet was brown. The room had several dry wall mud patches throughout. The painted finish was observed coming off the handrails on the Alzheimer's/Dementia Unit. d) room [ROOM NUMBER] On 09/08/25 at 11:20 AM broken window slats were observed in the window covering e) room [ROOM NUMBER] Observation revealed no toilet paper roll holder. The…

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

Based on record review and staff interview, the facility failed to proved sufficient nurse staffing numbers. This had the potential to affect all residents. Facility census: 77. Findings included: a) Resident Interviews During an interview on 09/23/24 at 03:50 PM, resident #39 reported that staff would turn off her call light and tell her they would be right back to assist her and she has had to wait 2 hours for them to come back. On 09/24/24 at 08:38 AM, an interview with resident #7 who reported that she had to wait from 4:30 PM to 7:30 PM and at dinner time she had to wait to get her brief changed due to low staff numbers. On 09/24/24 at 08:57 AM, during an interview with resident #72 who reported that he usually had to wait half an hour for his call light to be answered due to low staffing. b) record review On 10/01/24 at 3:00 PM, review of the Daily Nurse Staffing Form for the following days, revealed that there was not sufficient staffing for the following days: 09/15/24- 2.01 Census 75 Nursing Hours 150 09/28/24- 2.06 Census 80 Nursing Hours 165.50 09/29/24- 2.1 Census 80…

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

Based on record review and staff interview, the facility failed to ensure a Registered Nurse was available 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents at the facility. Facility census: 77. Findings included: a) A review of the facility staff postings revealed that on 09/14/24 and 09/28/24 no Registered Nurse (RN) was scheduled to work on the above dates. A review of timecards for all staff working on 11/19/23 and 12/03/24 found no RN coverage. On 09/15/24 and 09/22/24 there was RN coverage reported but no proof on time card, notes, medication administration that there was RN coverage on those days. b) On 10/01/24 at 3:48 PM, an interview with Scheduling and Payroll Manager #15 was conducted. She acknowledged that she had no documentation made by RN scheduled to be on duty for dates and no RN on listed on the schedule for dates 09/15/24 and 09/22/24 in which RN coverage was reported. She also acknowledged that there was no RN coverage reported for 09/14/24 and 09/28/24.

Based on record review, resident interview and staff interview, the facility failed to prevent potential further abuse of all residents while investigating an allegation of resident-to-resident abuse and failed to complete a thorough investigation. Resident identifiers: #72 and Resident #31. Facility Census: 77. Findings included: a) Resident #72 09/24/24 9:00 AM During an interview with Resident #72, Resident denied having any conflict or issues with other residents in the recent months. He declined/was unable to discuss the incident. 09/26/24 at 8:30 AM, a review of the Five-Day Follow-up on an incident dated 05/13/24 Resident # 72 reported he was leaving bingo and was halfway out the door when Resident #31 hit him with his wheelchair. Resident #72 turned around and yelled at Resident #31 who started hitting Resident #72, knocking oxygen out of his nose and knocking glasses off his face. Resident #72 reacted by hitting Resident #31. The incident resulted in an abrasion to upper lip, with blood noted to Resident #72. Resident #72 denied pain or discomfort. The resident reported…

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, resident interview and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #12 had a bottle of vitamins at her bedside, which had the potential to affect more than a limited number of residents. This was a random opportunity for discovery. Additionally, Resident #34 did not have non-slip socks on at the time of a fall. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of falls. Resident identifiers: #12, #34. Facility census: 77. Findings included: a) Resident #12 On 09/25/24 at 8:45 AM, Licensed Practical Nurse (LPN) #52 was observed administering medications to Resident #12. When LPN #52 took the resident's medications into the room, Resident #12 took a bottle of Centrum Women's vitamins off her overbed table, stating I don't like the vitamins that the facility has. She opened the bottle and appeared to be ready to take a vitamin. The vitamin bottle appeared to be at least half full of…

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

Based on observation, resident interview, record review, and staff interview, the facility failed to provide hydration care and services to each resident, consistent with the resident's comprehensive assessment and their needs and preferences. This deficient practice had the potential to affect three (3) of 13 residents reviewed for the care area of hydration. Resident identifiers: #68, #59, and #180. Facility census: 77. Findings included: a) Policy review The facility's polity titled Nutrition/Hydration Care and Services with effective date 01/01/04 and revision date 02/01/23 stated to keep beverages available and within reach, when applicable. b) Resident #68 During an interview on 09/23/24 at 11:47 AM, Resident #68 was asked if he received enough to eat and drink. Resident replied that he received very little water. He had no cups or beverage containers in his room. On 09/26/24 at 10:00 AM, Resident #68 was observed to have a cup of water at his bedside. However, the water did not have ice in it and the cup was not cool to the touch. The resident's quarterly Minimum Data Set…

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

Based on resident interview, staff interview, and test tray temperature measurements, the facility failed to serve food that was palatable and at an appetizing temperature. This failed practice has the potential to affect more than a limited number of residents. Facility Census: 77. Findings Included: a) Resident Interviews During an interview with Resident #68 on 09/23/24 at 11:41 AM he stated the food is always cold and is not good. He stated, he does not like rice, and he gets it at least three (3) times a week. During an interview with Resident #15 on 09/23/24 at 12:00 PM he reported he often orders cheeseburgers from the kitchen because the food does not have a good taste. During an interview with Resident #180 on 09/23/24 at 2:57 PM the resident stated the food is tasteless and it is always cold when it gets to his room. b) Test Tray On 09/25/24 at 1:00 PM the Certified Dietary Manager was asked to take the temperatures on a test tray immediately after the last resident tray was served. The temperatures were as follows: -- Tuna Melt 112 degrees Fahrenheit. -- Potato Wedges 85…

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 food was served in a safe and sanitary manner. This was a random opportunity for discovery and had the potential to affect more than an limited number of residents. Facility Census: 77. Findings Included: a) Tray Line Observation An observation of the meal service for the noon time meal on 09/25/24 beginning at 11:30 am found the following, Resident #52 was served Salisbury steak covered in gravy from the kitchen. The meal went directly from the kitchen to the dining room and was served to the resident. After it was served [NAME] #69 obtained a thermometer to obtain the temperature of the gravy which had been sitting on the stove cooling. The temperature was 122 degree Fahrenheit (F). The cook stated, I need to reheat this and turned on the stove to reheat the gravy. The cook was then asked if the gravy which he just served was from that pot and he said, Yes it was. He reheated the gravy to 150 degrees F and then began serving it again. When asked what the gravy needed to be reheated to he stated, 135 degrees F.…

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 website review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility stored items under a sink area, which had the potential to affect more than a limited number of residents. Additionally, Resident #13's urinal was on the overbed table while he was eating. These were random opportunities for discovery. Resident identifier: #13. Facility census: 77. Findings included: a) Medication Preparation Room On 09/25/24 at 10:42 AM, the medication storage room in the memory unit was inspected with Licensed Practical Nurse (LPN) #42 in attendance. Under the sink were three (3) BinaxNOW boxes containing COVID-19 testing and a bag containing tools. On top of the bag containing tools were a pile of clothes. LPN #42 stated the clothes were probably extra clothes for residents who might need them. She stated she didn't know they were there. LPN #42 stated she would have them washed and stored in…

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

Based on observation and staff interview, the facility failed to ensure Resident #44 was afforded the right for a dignified experience while using the restroom. This was a random opportunity for discovery and was true for Resident #44. Facility Census: 77. Finding included: a) Resident #44 On 09/25/24 at 8:57 AM, while walking down the hall toward Resident #44's room the surveyor observed Resident #44 sitting on the toilet with her pants down in the bathroom. Both the bathroom door and the room door were open, and the resident could be seen from the hallway. The Director of Rehab and Speech Therapist were across the hall. When the surveyor asked if someone could assist Resident #44 the Speech Therapist stated, That was me I am trying to find some toilet paper.

Based on record review and staff interview, the facility failed to ensure residents were given the opportunity to make decisions regarding end-of-life care. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of advance directives. Resident identifier: #59. Facility census: 77. Findings included: a) Resident #59 Review of Resident #59's medical records showed a Physician Orders for Scope of Treatment (POST) form completed by the resident's family member on 07/14/23. The POST form communicated the resident's wishes for end-of-life care. Further review of Resident #59's medical records showed a Physician Determination of Capacity form dated 08/28/24. The physician determined Resident #59 had the capacity to make his own health care decisions. On 09/25/24 at 9:55 AM, the Social Services Director stated when Resident #59 was admitted in August 2024, the resident's family member was his representative. The resident had a POST form that had previously been completed. The Social Services Director stated she had reviewed the POST form…

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 proof the required Notification of Medicare Non-Coverage (NOMNC) liability and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) notices were issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. NOMNC was improperly dated. This failure had the potential to place the resident at risk of not being informed of their appeal rights prior to the end of Medicare covered services as well as being informed of their rights prior to the end of Medicare Part A covered services . Resident identifier: #281. Facility census: 77. Findings included: a) Resident #281 On 09/25/24 05:35 PM, Review of Notice of Medicare Non-Coverage form for Resident # 281 revealed the resident's services were due to end/last covered day of Part A Services on 5/28/24. The resident's representative was notified telephonically on 03/23/24 at 10:03 AM by Office Manager #24. Observation 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 resident interview, the facility failed to provide a safe, clean and comfortable home like environment. Resident #50 did not have a screen in his window. This failed practice was found true for (1) one of 12 residents reviewed for the environment during the Long-Term Care Survey Process. Resident identifier #50. Facility Census 77. Findings Included: a) Resident #50 During the initial interview on 09/23/24 at 1:38 PM, Resident #50 stated, I cannot open this window because there is not a screen in it. I have asked several times to get a screen but still do not have one. An observation on 09/23/24 at 1:38 PM, revealed that Resident #50 had four (4) windows in his room and the second window did not have a screen. On 09/24/24 at 3:30 PM, The Maintenance Director confirmed that the screen was not on the window and stated, I will get one in there as soon as I can.

Based on record review and staff interview, the facility failed to ensure Resident #20's Minimum Data Set (MDS) was correct in the area of falls with injury. This was true for one (1) of 12 residents reviewed for the care area of accidents during the long-term care survey process. Resident identifier: #20. Facility census: 77. Findings included: a) Resident #20 On the first day of the survey 09/23/24 in the afternoon the facility matrix provided by the facility was reviewed and indicated Resident #20 had a fall with an injury. A review of Resident #20's medical record found the resident had a fall on 07/07/24 but had no injury. A review of Resident #20's MDS with an Assessment Reference Date (ARD) of 07/13/24 found section J1900 was coded to represent a fall without injury since the last MDS assessment and a Fall with injury since the last MDS Assessment. An interview with Registered Nurse #40 at 12:20 PM on 10/01/24 found the resident had only sustained one (1) fall since the last MDS assessment and she was not injured because of the fall. She indicated the fall with injury should…

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 correctly identify diagnosis on a new Pre-admissions Screening and Resident Review (PASSAR). This failed practice was found true for (1) one of (2) two residents reviewed for PASSAR accuracy during the Long-Term Care Survey Process. Resident Identifier: #1. Facility Census 77. Findings Included: a) Resident #1 A record review on 09/23/24 at 3:30 PM, revealed that Resident #1 has a diagnosis that included Schizophrenia and Epilepsy. Further record review revealed that a new PASSAR was completed on 02/17/22 and did not include the diagnosis of Schizophrenia and Epilepsy. During an interview on 09/25/24 at 12:28 PM, the Social Worker (SW) stated, I must have missed that one. When I first started I had to do an audit of them all so I guess I missed that one. The SW confirmed that the diagnosis was not on the most current PASSAR.

Based on observation, record review and staff interview, the facility failed to develop and/or implement care plans related to fall interventions and depression. This failed practice was found true for (1) one of (5) five residents reviewed for mood and behavior and (1) one of 12 residents reviewed for accidents. Resident identifiers #34 and #42. Facility Census: 77. Findings Included: a) Resident #34 A record review on 10/01/24 at 9:30 AM revealed that Resident #34 had a fall on 08/21/24. On 08/22/24 Resident #34 was complaining of pain where it was revealed that she had a right hip fracture. Further record review revealed a fall care plan that reads as follows: Focus: Resident has experienced falls and is at risk for further falls r/t cognitive loss, lack of safety awareness, history of fall with fracture. Goal: Resident will have no further falls with injury through next review. Interventions: · Provide resident/patient with opportunities for choice · Bed in low position · Medication review as needed · Non skid footwear as tolerated. · Non skid strips in front of recliner. ·Non…

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

Based on resident interview, record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of activities of daily living. Resident identifier: #6. Facility census: 77. Findings included: a) Resident #6 During an interview on 09/23/24 at 1:47 PM, Resident #6 stated she did not receive twice weekly showers as scheduled. She stated she preferred showers to bed baths. Review of Resident #6's comprehensive care plan showed the resident required assistance for activities of daily living due to a fracture of the leg. The care plan stated the resident required substantial/maximal assistance for bathing. The facility's shower schedule showed the resident was scheduled to receive showers on evening shift on Tuesdays and Fridays. Review of Resident #6's showers for the past 30 days gave the following information: - On Tuesday, 08/27/24, the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, observation, record review, and staff interview, the facility failed to provide pressure ulcer treatment in accordance with professional standards of care. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for the care area of pressure ulcers. Resident Identifier: #34. Facility census: 77. Findings included: a) Resident #34 Review of Resident #34's medical records showed she had a history of MASD/IAD [moisture-associated skin damage/incontinence associated dermatitis] during her admission to the facility. Review of Resident #34's medical records showed the resident returned to the facility from the hospital on [DATE] after surgical repair of a fracture. The hospital discharge summary was in the resident's medical record file. Attached to the discharge summary was a nurse report form that stated, Skin condition: DTI [deep tissue injury] on buttocks foam dressing. On 09/26/24 at 10:08 AM Unit Manager #10 stated the nurse report form was 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, observation, and staff interview, the facility failed to ensure Resident #20's medical record was complete and accurate. This was true for one (1) of 31 sampled residents reviewed during the long-term care survey process. Resident Identifier: #20. Facility Census: 77. Finding Include: a) Resident #20 On 10/01/24 at approximately 10:15 AM Resident #20 was observed sitting in the tv lounge with her 10:00 AM supplement sitting in front of her. The supplement was still three quarters of the way full. A review of Resident #20's medical record at 10:25 am on 10/01/24 found the nurse had documented Resident #20 had consumed 100 percent of her house supplement. The surveyor returned to the TV lounge and Resident #20 still had her house supplement sitting in front of her on the table. It was still three fourths of the way full. An interview with Licensed Practical Nurse (LPN) #52 was interviewed at 10:31 AM on 10/01/24. She was asked if Resident #20 had consumed her 10:00 AM supplement. She pulled up the residents' medication administration record (MAR) and 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.

Based on record review and staff interview the facility failed to follow physician orders for Resident #3 to have accu checks three (3) times a day. This was true for one (1) of 20 sampled residents. Resident Identifier: #3. Facility Census: 76. Findings Include: a) Resident #3 A review of Resident #3's medical record on 04/22/24 found a physician order for Accu Check TID (three times a day). Notify Physician if blood sugar is less than 70 or greater than 450. This order was dated 03/18/24 and was the current order at the time of this review. A review of the medication administration record (MAR) and the blood sugar vital signs tab in the electronic medical record found the facility had not obtained a blood sugar since 04/09/24 at 10:20 am. The facility had missed obtaining the blood sugar for 13 days at the time of this review. During an interview with the Nursing Home Administrator, Nurse Practice Educator, and Unit Manager #40 on 04/23/24 at 12:56 PM the above findings were discussed. At 2:25 PM on 04/23/24, Unit Manager #40 confirmed there was no blood sugars documented since…

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 ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #1 was assessed to be transferred with a total lift with the assistance of two (2) people. There were several occasions the staff indicated in their documentation he was transferred inappropriately. For Resident #4 the facility failed to implement a fall intervention. This was true for two (2) of four (4) sampled residents. Resident Identifiers: Resident #1 and Resident #4. Facility Census: 76. Findings included: a) Resident #1 A review of Resident #1's medical record in the afternoon of 04/22/24 found two (2) Lift transfer evaluations. The lift transfer evaluations were dated 08/28/23 and 11/28/23. Both lift transfer assessments indicated Resident #1 needed to be transferred with total body lift with a two person assist. The resident had a diagnosis of paraplegia, and contractures at the knees and hips. Resident # 1 was…

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

Based on observation and staff interview the facility failed to distribute and serve food in accordance with professional standards for food service safety by activity staff serving ice cream on the unit. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility Census; 76 Findings Include: a) Ice Cream On 04/23/24 at 02:20 PM during a tour of the facility, Activities Assistant (AA) #18 was observed to be pushing a cart down Unit A with 5 open containers of vanilla ice cream. AA #18 stated she was serving the residents ice cream in their rooms if they wanted it. AA #18 stated she was told to prepare the open containers and place them on the cart without lids or covering the containers and to take it out on the floor to distribute. The Activities Director (AD) #14 was in the hallway at this time and acknowledged the open containers of ice cream should not be on the floor without being covered or having lids on them.

Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity of discovery. This had the potential to affect more than an isolated number of residents. Facility Census: #76 Findings included: a) Memory unit Bathtub On 04/24/24 at 9:45 AM, an observation of the walk-in bathtub on the memory unit (Mary's Garden) found two items of clothing with a dark brown substance on them located in the bathtub. This was confirmed with the memory unit Director #35 on 04/24/24 at 9:53 AM at which time she confirmed the clothing items should not be in the tub. b) Memory unit shower room On 04/24/24 at 9:46 AM, an observation of the shower on the memory unit (Mary's Garden) found two washcloths on the floor of the shower. One appeared wet and had a dark brown substance on it while the other appeared wet. This was confirmed with the memory unit…

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

Based on observation and staff interview the facility failed to ensure Resident #19 had a dignified dining experience during the noon time meal on 04/23/24. The facility failed to serve Resident #19 at the time her peers in the same dining area were served. Resident #19 was not served for 30 minutes after the last resident in the same dining room was served their meal. For Resident #18 the facility failed to ensure dignity while she was using the bedside commode. These were random opportunities for discovery and were true for Resident #19 and Resident #18. Resident Identifiers: #19 and #18. Facility Census: 76. Findings Include: a) Resident #19 An observation of the noon time meal began at 11:40 AM on 04/23/24. Upon entering the dining room it was noted Resident #19 was sitting at a table by herself in the back dining room. Also seated in the dining room were seven (7) additional residents. At 12:00 PM the last tray was served to the seven (7) additional residents. Activity Assistant #18 picked up Resident #19's tray and asked Nurse Aide (NA) #5 who was going to feed (Resident #19's…

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

Based on record review, observation and staff interview the facility failed to ensure Resident #4's accident care plan was implemented. This was a random opportunity for discovery and was true for Resident #4. Resident Identifier: #4. Facility Census: 76. Findings included: A) Resident #4 A review of Resident #4's medical record in the afternoon of 04/23/24 found a care plan with the following focus statement, Resident has a history of falls and is at risk for further falls related to impaired mobility, incontinence. Huntington's Disease. This care plan was initiated on 07/07/22. A review of the interventions related to this focus statement found an intervention which read, left side of bed against wall. This intervention was added to the care plan on 04/05/24. An observation of Resident #4 at 4:15 PM on 04/23/24 with the Nursing Home Administrator present found Resident #4's bed was not against the wall. The resident was laying in the bed and the head of the bed was against the wall and a fall mat was laying on either side of the bed.

Based on observation, medical record review and staff interview, the facility failed to revise the comprehensive care plan for the use of a bedside commode. This was a random opportunity for discovery and was true for Resident #18. Resident identifier #18. Census: 76. Findings included: a) Resident #18 On 04/23/24 at 9:06 AM, Resident #18 was observed using a bedside commode sitting directly in front of the residents window which faced the neighboring residential area outside. The window blind was not pulled, the resident door was open and no privacy curtain was pulled. Resident #18 stood herself up, in front of the opened window, and wiped herself. Licensed Practical Nurse (LPN) #76, was outside the room at her medication cart and when made aware of what was observed, stated she did not think she had capacity but as a reasonable person she would not have wanted to use the bedside commode with the blind not pulled, the room door open and no privacy curtain pulled. Staff #76 stated to the Certified Nursing Assistant (CNA) #5 who passed in the hallway at this time to make sure she was…

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

Based on observation and staff interview the facility failed to deploy available staff in a manner which ensured Resident #19 was fed her noontime meal in a timely manner. Resident #19 was not assisted with her noon time meal for 30 minutes after the last resident in the same dining room was served their meal. This was a random opportunity for discovery and was true for Resident #19. Resident Identifiers: #19. Facility Census: 76. Findings Include: a) Resident #19 An observation of the lunch meal began at 11:40 AM on 04/23/24. Upon entering the dining room it was noted Resident #19 was sitting at a table by herself in the back dining room. Also seated in the dining room were seven (7) additional residents. At 12:00 PM the last tray was served to the seven (7) additional residents. Activity Assistant #18 picked up Resident #19's tray and asked Nurse Aide (NA) #5 who was going to feed (Resident #19's Name). NA #5 stated, Just set it over there and when we are done feeding here we will feed her. Activity Assistant #18 returned Resident #19's food to the serving tray area. During this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to ensure Resident #2's medical record was complete and accurate. There was a nutritional assessment which indicated the resident had a significant weight gain when in fact she had not. This was true for one (1) of 20 sampled residents. Resident identifier: #2. Facility Census: 76. Findings include: A) Resident #2 A review of Resident #2's medical record found a nutritional assessment dated [DATE]. This assessment under the section weight status indicated Resident #2 had a 5.1 percent weight gain in a period of one (1) month. This signified a significant weight gain. A review of Resident #2's medical record found the resident weighed 141 pounds on 03/27/24. A month previous she weighed 140.5 pound on 02/28/24. This was a gain of only one half of a pound. This is not a weight gain of 5.1 percent as indicated on the assessment completed on 03/27/24. An interview with the Nursing Home Administrator, the Nurse Practice Educator, and Unit Manager #40 at…

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

Based on observation and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Multiple sharp items were found in the kitchen in the dementia care unit which currently houses 24 residents all of which have a diagnosis of dementia. This failed practice had the potential to affect more than an isolated number residents. Resident Identifiers: #1, #2, #5, #13, #14, #16, #17, #21, #25, #29, #32, #37, #38, #41, #42, #43, #44, #47, #54, #55, #65, #68, #72 and #78. Facility Census: 78 Findings Included: a) A tour of the dementia care unit on 09/25/23 at 11:00 am, found the following safety concerns in the resident kitchen area: -- In the drawer beside the refrigerator was two (2) vegetable peelers both of which were sharp. -- In the cabinet to left of the stove was two serrated steak knifes. -- In the cabinet above the stove was an electric vegetable chopper with the blade. This was also very sharp and was safety concern. The door to the kitchen was unlocked and Employee #82 confirmed it is never…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview the facility failed to ensure bathroom call devices were assessable to residents in rooms #27 and #28 if residents were lying in the floor. This failed practice had the potential to only affect a limited number of Residents. Resident identifiers: #28, #21, #44, #37. Facility census: 79. Findings included: Observation on 01/09/23 at 11:30 AM showed the pull cord for the call device in the shared bathroom of Resident Rooms #27 and #28 to only be approximately 4 inches long. The pull cord would have not been assessable for Residents that may be lying in the floor. room [ROOM NUMBER] was occupied by Resident #28 and #21. room [ROOM NUMBER] was occupied by Resident #44 and #37. During an interview at 11:39 AM, Resident #28 was asked if she could easily the reach the pull cord in her bathroom? Resident #24 replied, Not a lot of it there, it's short, I sometimes have a hard time finding it. At 12:10 PM LPN #70 confirmed the pull cords were too short for Residents to reach if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, resident interview and staff interview, the facility failed to provide residents with a safe, clean, comfortable and homelike environment. The facility failed to provide a homelike environment in the dining area. The facility also failed to provide a safe, clean shower area for the residents. The facility also failed to provide residents with furniture in good repair. This had the potential to affect more than a limited number of residents. Resident Identifier: #57 . Facility Census: 79 Findings Included: a) Dining Room A Dining Room observation on 01/09/23 at 11:15 AM revealed the dining room tables were lacking the varnish/vinyl on the top of several tables. The tables did not have tablecloths to cover the tables to provide a homelike environment to cover the poor condition of the tables. On 01/09/23 at 11:40 AM the administrator agreed the dining room tables needed to be re-varnished and could not be cleaned properly for infection control purposes. The Administrator stated 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 medical record review and staff interview the facility failed to ensure a complete and accurate medical record. 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 failed practice was true for three (3) out of (24) reviewed for advance directives Resident Identifiers: Resident #13, Resident #63 and Resident #176. Facility Census: 79. Findings Included: a) Resident #13 A review on 01/10/23 at 8:50 AM , found Resident #13 had a POST form signed and dated by Resident # 13 on 06/02/22. In addition to completing page 2 of the form, the POST requires the signature of the person preparing the form, the printed name of that person and the date. The staff member completing the form wrote Nursing Staff instead of their name. During an interview on 01/10/23 at 9:02 AM, the Director of Nursing (DON) acknowledged the staff that filled out the POST form should have stated their name…

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

Based on observation, resident interview and staff interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection related to clean linen carts and the resident shower/bathroom. This had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 79. Findings Included: a) Clean Linen Carts On 01/09/23 at 11:17 AM a random opportunity for discovery revealed a clean linen cart on the small hallway had two (2) opened boxes of gloves, body wash, shampoos, sprays and wash basins all sitting on the cart with the clean linen. On 01/09/23 at 11:19 AM, an observation of the long hall clean linen cart revealed the following items, three (3) opened boxes of gloves, two (2) lift chair batteries, a basin full of facial masks, and an opened pack of body wipes all sitting on the care with the clean linen. On 01/09/23 at 11:20 AM, an observation of another clean linen cart on…

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

Based on observation, record review, resident interview and staff interview the facility failed to provide care required to maintain hygiene to a resident who was dependent for Activities Of Daily Living (ADL) care. Resident Identifiers: Resident #13. Facility Census: 79 Findings Included: a) Resident #13 A review of facility policy titled Activities of Daily Living with a revision 06/01/21 read as following. Based on the comprehensive assessment of a resident/patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living activities are maintained or improved and do not diminish unless circumstances of the individual's clinical condition demonstrate that a change was avoidable. .Activities of daily living include: Hygiene-bathing, dressing, grooming and oral care. During the initial tour on 01/09/22 at 10:48 AM an observatioto be n found Resident #13's hair disheveled, and her chin was covered with facial hair which had not been removed. During an interview on 01/09/23 at…

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