Willows Center

Based on observations, resident interviews and staff interviews, this facility failed to ensure meal preferences were obtained, updated and followed per policy and or best practice as provided per District Manager for Food and Nutrition. This was a random finding during the Annual Long Term Care Survey Process. Facility Census 92 Resident identifiers #58, #31, #37Findings include: 12/15/2025 12:00PM , Resident #58. Resident interview The food is terrible, they have not updated any meal preferences with me, I asked the manager almost (3) three months ago to come talk with me 12/15/25 12:50PM , Resident #58, meal served, Resident meal was Turkeyburger, with lettuce, tomato and baked beans on plate, per resident This is what I ordered, I am glad ,observation: baked beans running on plate under Hamburger Bun. Resident #58 informed this surveyor I wish they would have put those beans in a bowl. 12/15/25 1:30PM Staff interview with Food Service Director, questioned her if she or anyone has updated resident #58 meal preferences, she informed this surveyor No I have not Spoke with Food…

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 store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect more than an isolated number of residents. Facility census: 92. Findings include: a) 12/16/25 8:30 AM during an observation of food delivery carts five (5) of five (5) each had food debris on the bottom shelves, outside of the cart along bottom of doors, and along outside of each cart was a dried substance. 12/16/25 9:00 AM during a staff interview, district manager for food and nutrition, reviewed the five (5) of five (5) food delivery carts and confirmed there was food debris on the bottom shelves, outside of the cart along bottom of doors, and along outside of each cart dried substance. On 12/15/25 at 11:40 AM the surveyor completed an initial walkthrough of the kitchen. The Director of Dining (DOD) accompanied the surveyor during and acknowledged…

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 complete and accurate medical records. This deficient practice affected three (3) of 28 residents reviewed in the long-term care survey sample. Resident identifiers: #2, #96 and #69. Facility census: 92. Findings included: a) Resident #2 Record review on 12/17/25 at 10:36 AM revealed the facility failed to ensure an accurate care plan for Resident #2. The wrong name was used in this resident's care plan. This finding was confirmed with the administrator on 12/17/25 at 10:30 AM. b) Resident #69 Review of Resident #69's physician's orders showed an order written on 10/23/25 for No BP (blood pressures) or needle sticks in left or right arm due to dialysis access. Utilize thigh cuff for BP. This order was written because the resident had an arteriovenous (AV) dialysis fistula in his left arm and a Permacath dialysis catheter in his right chest area. On 12/17/2025 at 11:38 AM, Resident #69 stated staff used his leg and not his arms to obtain blood pressure readings. He stated his left arm was used for blood…

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

Based on facility documentation and staff interviews, the facility failed to have required quarterly meetings. Additionally, the facility did not have required attendees present or sign in at the Quality Assessment and Assurance (QAA) meeting. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 93.Findings included: a) QAA Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no meeting was conducted in the first quarter or the third quarter of 2025.During an Interview 12/22/25, at 11:30 AM the Administrator verified the required members did not sign in for the quarterly QAA meetings and there was no documentation of QAA meetings in the first and third quarter. No other information was provided prior to the end of the survey.

Based on observation, record review, 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. The facility failed to follow accepted standards of practice related to enhanced barrier precautions. Facility staff also failed to perform hand hygiene between residents while giving the residents ice and failed to maintain the ice cart in a clean and sanitary manner. These were random opportunities for discovery that had the potential to affect more than a limited number of residents. Resident Identifiers: #5, #69, and #3. Facility Census: 92. Findings included: a) Policy ReviewThe facility's procedure titled Enhanced Barrier Precautions with effective date 08/01/23 and revision date 05/01/25 stated Enhanced Barrier Precautions apply to residents with chronic wounds and/or indwelling medical devices (e.g., central line, urinary catheter, enteral feeding tube, tracheostomy,…

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 two (2) residents received a dignified dining experience. This failed practice was a random opportunity for discovery. Resident identifiers: #95 and #3. Facility census: 92. Findings include: a) Resident #95 On 12/17/25 at 11:40 AM the lunch meal observation revealed Resident #52 was served a meal at table with Resident #95. Staff did not serve Resident #95 until 11:50 AM. Staff were observed serving other tables prior to serving Resident #95. During the the interview with Staff #23 the staff said, His tray must still be in the kitchen. b) Resident #3 The facility's procedure titled Feeding a Patient/Resident with effective date 08/31/20 and revision date 03/01/24 gave instructions to sit in a chair at eye level with the resident when feeding a resident. On 12/15/25 at 12:47 PM, Registered Nurse (RN) #65 was observed feeding Resident #3 in his room. Resident #3 was in his bed and RN #65 was standing beside him while she used a spoon to put food into the resident's mouth. There was a chair at the bedside. When…

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 provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #72. Facility census: 92.a) Resident #72 Resident #72 reamined in the facility after 07/10/25 whcih was the last day of Medicare Skilled Coverage. The NOMNC was issued on 07/08/25 but there was no evidence that the SNF ABN was ever issued. During an interview on 12/18/25 at 11:25 AM, Bookkeeper #72 stated, I don't think so. I can check After searching in the electronic medical record, checking in the business office files, and then checking in the Administrator's office, she returned with the Business Office Manager. The Business Office reported that a SNF ABN had NOT been issued.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of ten (10) resident rooms observed during the long-term care survey process. room [ROOM NUMBER]. Facility Census: 92.Findings included: a) room [ROOM NUMBER]During the initial tour of the facility, on 12/15/25 at 2:30 PM, the following issue was identified:-The wall beside Resident #52's bathroom was in poor repair. There were unfinished joint compound layers on top of the drywall without paint covering it, approximately 12 inches in width and spanning approximately 2 1/2 feet up the wall.-The ceiling right above Resident #52's bed had unfinished joint compound layers on top of the drywall without paint covering it, approximately 15 inches long.-The rest of the room has multiple small areas of wall and paint damage that measure 1 - 2 inches in size.-The Air conditioner / heater filter was soiled with about three eights inch (3/8) thick of dust and debris.The Administrator at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with a newly evident or a possible serious mental health disorder. This was true for two (2) out of three (3) sampled residents reviewed under the PASARR pathway during the Long-Term Care Survey Process. Resident identifiers: #1 and #6. Facility census: 92Findings included:a) Resident #1A record review, completed on 12/17/25 at 11:09 AM, revealed:Resident #1 was admitted to the facility on [DATE].On 06/27/25, the resident was given a Bipolar diagnosis.The only PASARR on file was dated 05/02/25. This PASARR did not reflect the resident's Bipolar diagnosis During an interview on 12/17/25 at 11:29 AM, the Director of Social Services (DOSS) reported a new PASARR had not been completed to capture Resident #1's diagnosis of Bipolar. b) Resident #6 On 12/16/2025 10:27 AM the record review for Resident #6, noted WV Pre-admission Screening and Resident review (PASARR)…

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

Based on record review and staff interview, the facility failed to revise residents' care plans when treatment changed. This deficient practice had the potential to affect two (2) of 28 residents reviewed in the long-term care survey sample. Resident identifiers: #69 and #52. Facility census: 92. Findings included:Findings included: a) Resident #52. During a record review on 12/16/25 at 2:00 PM, the following physician order for one-on-one was found, Provide one-on-one supervision, 24 hours per day.The order began on 09/19/25 and was discontinued on 9/26.25. Care Plan printed on 12/16/25 showed one-to-one supervision, 24 hours a day.During an interview with Director Nursing (DON) on 12/16/25 at 3:44 PM, the DON acknowledged that the one-on-one Supervision ended in September 2025 and the care plan was not updated to reflect that. a) Resident #69 Review of Resident #69's physicians' orders showed an order written on 10/23/25 for No BP [blood pressure] or needle sticks in left or right arm due to dialysis access. Utilize thigh cuff for BP. On 12/15/2025 at 1:09 PM, Resident #69 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY PS & Findings [NAME] The facility failed to ensure residents received the appropriate treatment and assistive devices to maintain a resident's vision abilities for one (1) of one (1) resident reviewed for communication/sensory issues. Resident identifier: #59. Facility census: #92 Findings included: a) Resident #59 The facility failed to ensure resident #59 received proper treatment and assistive devices to maintain vision abilities. During an interview on 12/15/2025 at 12:32 PM Resident #59 reported that she had been in the facility for approximately two (2) months. When she arrived here, staff put some of her belongings in storage. She reported her $300 glasses have not been given back to her and she has reported this to the social worker. She said she would like for them to either be found or replaced. She said currently did not have any glasses to use. On 12/16/2025 1:41 PM a review of the grievance log showed no grievances listed in regards to missing glasses for resident. On 12/16/2025 2:45 PM during an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to assess and treat pressure ulcers within accepted standards of care. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of pressure ulcers. Resident Identifier: #98. Facility census: 92. Findings included: a) Resident #98The facility's policy titled Skin Integrity and Wound Management with effective date 07/01/01 and revision date 09/15/25 stated wound evaluations would be performed for new in-house acquired wounds. The resident was admitted to the facility on [DATE] and was receiving hospice services. On 10/31/25, a nurse practitioner note stated, in part, Resident does have a stage II pressure ulcer to sacrum. No sign of infection noted .Pressure ulcer of sacral region, stage 2. Continue to cleanse with wound cleanser. Pat dry. Apply Sure Prep to periwound and under adhesive contact areas. Cover with Optifoam Gentle every 3 days and as needed. Will monitor and manage as appropriate.The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide care and services within accepted standards of practice for falls. The facility failed to document falls. The facility also failed to assess fall risk and failed to conduct appropriate post fall analyses to prevent further falls. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of falls. Resident Identifier: #96. Facility Census: 92. Findings included:a) Resident #96 The facility's policy titled Falls Management with effective date 09/15/01 and revision date 10/01/25 gave the following instructions: - All residents would be assessed for risk of falls upon admission, with reassessments routinely (e.g., quarterly, post fall). - An assessment would be completed after falls to determine possible injury. - Resident-centered interventions would be implemented and documented. - The circumstances of the fall, post-assessment, and resident outcome would be documented in the risk…

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 quality and continuity of care was arranged for an provided for a resident receiving hospice services. Resident identieir: #38. Facility census: 92. a) Resident #38A record review on 12/16/25 of Resident #38's chart revealed that Resident #38 was admitted to the facility on [DATE] with a fair prognosis under skilled nursing care and then immediately ordered hospice care under (name of hospice) for the diagnosis of Terminal DX for Comfort. The facility has no record of the Hospice admission agreement or any other documentation signed by either Resident #38, their medical power of attorney (MPOA) and/or the facilities medical / social service staff, in either electronic format or in the hard copy binders for each resident.The only signed document on file was a long term care status form denoting routine hospice care. Also, the facility did not have any record of the Amedisys Hospice treatment plan for Resident #38; the expected…

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 family interview the facility failed to inform the Medical power of Attorney (MPOA) of appointments for Resident #46. This failed practice was found true for (1) one of (3) three residents reviewed. Resident identifiers # 46, Facility Census 91.Findings included:Resident # 46 Medical Power of Attorney(MPOA):During a phone interview on 10/29/25 at 11:40 AM,(statement written as reported) The MPOA, for Resident #46 stated, The first time the van driver took him (Resident #46), to a Dr. appointment, wearing a wander guard bracelet and left him without checking to see if I was there was in October of 2024. I found out he had an appointment when I received a phone call from the Dr's office letting me know he was there and stated they were surprised I wasn't with him. They know me there and know that I am always with him. She also stated it happened on January 9, 2025 and January 28 2025. She stated she then complained to the Director Of Nursing (DON) on January 29, 2025 and didn't hear back from her until 02/02/25. The DON told her the Van…

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 representative interview, and staff interviews, the facility failed to process and investigate a reported grievance. This was true for (1) of (3 ) residents sampledResident Identifier: #46 Facility Census: 91 Findings Included:a) Per The Facility Grievance Policy, the grievance officer will oversee grievances through conclusion leading any necessary investigations by the facility, issuing written decisions to the patient, and coordinating with state and federal agencies.b) In an interview with resident # 46's MPOA on 10/28/25 at 2:20pm, she stated the facility had transported Resident # 46 to an appointment more than once without notifying her in advance of the appointments. She stated the first time was in October of 2024. On 01/09/2025 and on 01/29/25. the van driver dropped him off without making sure she was there for him. She stated she called and complained directly to facility Director of Nursing. c) Record reviews:-On 10/28/25 at 03:45 PM, During record review the grievance form, there were not any grievances/complaints from Resident #46'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, record review, and staff interviews, the facility failed to ensure professional care and standards of practice were followed in regards to meal time supervision for resident #4. This was true for one (1) of (3) residents reviewed. Resident Identifiers: # 4, # 61, and # 27 . Facility Census: 91Findings Included:a) Observation:-During an observation of meal pass on 10/29/25 at 12:44PM, Resident # 4 was served his meal by employee identifier # 60. She assisted in setting up his tray and drink and left the resident's room.b) Record Review:-Based on a review of resident #4's meal ticket and his care plan, It was ordered to have supervision at mealtimes.-A review of Facility, Meal Service Policy Practice Standards, 3.2.2, Assure the correct meal is served and 3.2.5 If the patient requires assistance, sit next to patient while assisting to eat or do not deliver tray until assistance can be provided.c) Staff Interviews:-During an interview with the Facility Corporate Coordinator, on 10/29/25 at 1:25PM, He acknowledged the care plan and the meal ticket stated 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 record review and resident and staff interview, the facility failed to include residents/resident representatives to participate in care plan meetings. The facility failed to hold regularly scheduled care plan meetings and to invite residents or their representatives to those meetings. This was true for five (5) of five (5) residents reviewed for care plan meetings. Resident identifiers: #295 #81, #15, #8, #40. Facility census: 94. Findings included: a) Resident #295 At approximately 1:30 PM on 02/05/24, an interview was conducted with Resident #295. During the interview, Resident #295 was asked if the facility held care plan meetings with them or their representatives. Resident #295 stated I'm my own representative and I do not recall ever being a part of these meetings. A record review was conducted for Resident #295 regarding care plan meetings. Record review indicated there were two (2) care plan meetings held regarding Resident #295. These meetings took place on 06/09/21 and 01/12/24. Care plan…

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 provide a safe, clean, comfortable, and homelike environment. A table top in the Transitional Care Unit (TCU) dining area had approximately one third of the laminate covering missing with exposed jagged edges. Resident #43's room floor needed to be cleaned. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents that currently reside in the facility. Resident identifier: #43 Facility Census: 94 Findings included: a) Table top in the TCU dining area; During a tour of the building on 02/06/24 at 08:24 AM a dining table in the TCU dining area was observed to be uncovered. Upon examining the top surface of the table, approximately one third of the table top laminate that covers the inner resin of the table had been torn off. The remaining laminate covering the table top had sharp jagged edges and the inner resin of table was exposed. During an interview with Social Services #80 at 8:19 AM on 02/06/24 and the Director of Nursing (DON) at 8:25 AM 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 observation, record review, and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible, by failing to keep treatment and medication carts locked when they were out of use and out of sight of nursing staff, and by failing to remove razors with no safety caps from Resident #196's room. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 94. Findings included: a) Treatment Cart At approximately 9:43 PM on 02/06/24, an observation found the TCU Treatment Cart having a door open. Upon further inspection, the treatment cart was also unlocked and all doors could be opened. Drawers were full of wound treatment supplies. At approximately 9:45 PM on 02/06/24, an interview was conducted with the Assistant Director of Nursing (ADON) #4. ADON #4 stated I just went down and changed dressings a minute ago and I didn't lock the cart back. b) Resident #196 During an…

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

Based on resident interviews, staff interviews, record review, and resident council, the facility failed to ensure sufficient qualified nursing staff were always available to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental, and psychosocial well-being. Facility census: 94. Findings included: a) Facility Assessment Review of the Facility Assessment, revealed Section A.1. Sufficiency Analysis Summary states, We have daily discussions about unit staffing. Administrator, Scheduler, and Director of Nursing (DON) meet each morning to review current staffing patterns along with any additional needs. If it is determined that there are additional needs due to acuity, additional staff will be added or staffing adjustment will be made. b) Interview with Scheduling and Payroll Manager During an Interview, on 02/07/24 at 9:37 AM, the Scheduling and Payroll Manager stated staffing patterns were determined during the daily discussions held between her, the DON, and the Administrator. She explained it 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 record review and staff interview, the facility failed to complete a performance review for three (3) out of three (3) Nurse Aides (NA) reviewed in the sufficient and competent nurse staffing pathway during the Long-Term Care Survey Process. Employee identifiers: NA #5, #29, and #58. Facility census: 94. Findings included: a) Review of Nurse Aide Personnel Files A review of Nurse Aide (NA) employee personnel files was completed on 02/07/24 at 2:30 PM. There was no evidence that NA #5, NA #29, and NA #58 had a yearly performance review on file. The Manager of Scheduling and Payroll reported a change in Administrators in November 2023. She stated, The QAPI (Quality Assurance Performance Improvement) committee identified a need for a PIP (Performance Improvement Plan) and they had me do a complete audit on all personnel files. I identified the absence of annual evaluations, but no action was taken. The decision was eventually made to start with a clean slate in January 2024. I cannot produce annual evaluations for the three (3) Nurse Aides in question. .

Based on record review and staff interview, the facility failed to keep the daily posted nurse staffing information up-to-date and current. This was true for four (4) out of 12 sampled days during the Long-Term Care Survey Process. Facility census: 94. Findings included: a) Daily Posted Nurse Staffing During a review of the facility's Daily Posted Nurse Staffing and the Daily Time Detail Report reflecting clock-in and clock-out punches for all direct nursing care staff, the following discrepancies were identified: -On Sunday, 07/02/23, the Daily Posted Nurse Staff Form listed a total number of staff hours as 327.00. The Daily Time Detail Report reflecting the actual clock-in and clock-out punches listed a total number of staff hours as 295.52, reflecting a discrepancy of 31.48 hours not worked as planned. -On Saturday, 08/13/23, the Daily Posted Nurse Staff Form listed a total number of staff hours as 279.50. The Daily Time Detail Report reflecting the actual clock-in and clock-out punches listed a total number of staff hours as 247.77, reflecting a discrepancy of 31.73 hours 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, record review and staff interview, the facility failed to ensure medications were dated upon opening in accordance with the accepted professional standards of practice. This was a random opportunity for discovery. Resident Identifiers: #9. Facility Census: 94. Findings Included: a) Undated Medications On 02/06/24 at 2:05 PM, a tour of the medication cart on the Transitional Care Unit (TCU) was completed. The tour found the following over-the-counter (OTC) medications and Resident #9's insulin were not dated upon opening: --one (1) bottle of Acetaminophen 325mg (milligrams) --one (1) bottle of Ferrous Sulfate 325mg --one (1) bottle of Magnesium Oxide 400mg --two (2) bottles of Multivitamins --one (1) bottle of Aspirin 81mg --one (1) bottle of Vitamin D 25mcg --one (1) bottle of Vitamin C 500mg --one (1) bottle of Multivitamins with zinc --one (1) bottle of Calcium 500mg --one (1) bottle of Benadryl 25mg --one (1) bottle of Singular 10mg --Resident #9's Lantus insulin On 02/06/24 at 2:08 PM, Registered Nurse (RN) #4 confirmed the medication was not dated upon…

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.

According to observation, staff interview, resident interview, and policy review, the facility failed to serve food at safe and palatable temperatures by serving cold food at higher temperatures than directed. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 94. Findings included: a) Food Temperatures At approximately 11:25 AM on 02/05/24, Dietary Manager (DM) #123 was observed taking temperatures of the food prior to service. DM #123 took the temperature of cottage cheese on the serving line, the cottage cheese had a temperature of 42.4 degrees Fahrenheit (F). A policy on food handling was requested. Upon policy review, it was determined that foods that are to be served cold should be served at 41 degrees F or below. DM #123 was made aware and acknowledged the temperature of the cottage cheese was higher than the policy stated. b) Unit tray temperatures At approximately 12:16 PM on 02/06/24, food temperatures were taken by DM #123 on a tray delivered to the floor. The tray contained french fries…

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 maintain safe and working equipment by failing to repair the ice machine in the facility's kitchen. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 94. Findings included: At approximately 11:20 AM on 02/05/24, an observation was made of the ice machine during a tour of the kitchen. The ice machine was leaking from underneath, causing puddles to form in the floor of the kitchen. When asked about the leak, Dietary Manager (DM) #123 stated It's been leaking for a while. I put a work order in on TELS (building maintenance program), it just hasn't been fixed yet. At approximately 2:49 PM on 02/05/24, a copy of the work order for the repair of the ice machine was requested from DM #123. DM #123 produced the work order for the ice machine, dated 01/15/24 at 12:47 PM. At approximately 10:59 AM on 02/06/24, an interview was conducted with Senior Maintenance Director (SMD) #130 regarding the ice machine. SMD #130 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.

Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #43. This was a random opportunity for discovery. Resident identifier: #43. Facility Census: 94. Findings included: a) Resident #43 On 02/06/24 at 8:18 AM, an observation was made of Resident #43 being fed. However, Nurse Aide (NA) #59 was standing while assisting the resident with breakfast. On 02/06/24 at 8:25 AM, the Director of Nursing was notified and confirmed the NA should not be standing while feeding the resident.

Based on observation, review of the facility grievance/complaint forms, Resident Council meeting minutes, Resident Council meeting and staff interview, the facility failed to consider resident group views and act upon grievances and recommendations. The facility also failed to provide these groups with responses, action, and rationale taken regarding their concerns pertaining to issues of resident care and life in the facility. This was a random opportunity for discovery. These practices had the potential to affect more than a limited number of residents which reside in the facility. Resident identifier: #16, #44, #66 and #77. Facility Census: 94 Findings included: A review of the Center Operations Policies and Procedures policy title OPS204 with a revision date of 01/08/24 revealed the following: The Policy outline includes but is not limited to; The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process, including the Civil Rights grievances/concerns, receiving and tracking grievances through to their conclusions, leading any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to maintain privacy and confidentiality of medical records for Resident #43 and #295. These were random opportunities for discovery. Resident Identifiers: #43 and #295. Facility Census: 94. Findings Included: a) Resident #43 On 02/06/24 at 9:03 AM, while observing medication administration, Licensed Practical Nurse (LPN) #31 left the computer screen unattended with Resident #43's information visible. LPN #31 stated, I thought I locked it. On 02/06/24 at 9:30 AM, the Director of Nursing (DON) was notified and confirmed the computer screen should have been locked prior to leaving the area. b) Resident #295 On 02/06/24 at 9:30 PM, a tour of the 100 hall was completed. During the tour, the medication cart was sitting by room [ROOM NUMBER] in which Resident #295 resides. An observation of the computer screen unattended was made with Resident #295's information visible. LPN# 44 was inside of room [ROOM NUMBER] assisting the residents. LPN #44 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 observations, review of the facility grievance/complaint policy, Resident Council meeting and staff interview, the facility failed to make information on how to file a grievance or complaint available to the resident. This was a random opportunity for discovery. This practice had the potential to affect more than a limited number of residents which reside in the facility. Resident identifier: #16, #44, #66 and #77. Facility Census: 94. Findings included: A review of the Center Operations Policies and Procedures policy title OPS204 with a revision date of 01/08/24 revealed the following: The Process outline includes but is not limited to; 1. A description of the procedure for voicing grievances/ concerns will be on each unit in a prominent location and must include: 1.1 The right to file a grievance orally (meaning spoken) or in writing, the right to file grievances anonymously; 1.2 The contact information of the grievance official with whom a grievance can be filed, that is, their name, business address (mailing and email) and business phone number; 1.3 A reasonable…

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 the State Ombudsman of acute care transfers for Resident #6 and Resident #53. This is true for two (2) of four (4) residents reviewed under the care area of hospitalizations. Resident identifiers: #6 and #53. Facility census: 94. Findings included: a) Resident #6 On 02/07/24 at 11:12 AM, a record review was completed for Resident #6. The review found the resident had been transferred to an acute care facility on 06/12/23 for a temperature and headache and on 10/23/23 for chest pain. Upon completion of the review, the medical records department was asked to provide the confirmation of the State Ombudsman being notified of the transfers to the acute care facility. Medical Records Manager #10 provided the monthly fax receipts for June and October of 2023. However, the review found Resident #6's name was not listed on either monthly fax receipt. On 02/07/24 at 2:00 PM, Medical Records Manager #10 stated, I do not know why these transfers were not included in the monthly faxes. b) Resident #53 On 02/07/23 at 12:10…

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 notify the resident and/or resident representative regarding the facility bed hold notice of policy and authorization. This is true for three (3) of four (4) residents reviewed under the care area of hospitalizations. Resident Identifiers: #6 , #53 and #10. Facility census: 94. Findings included: a) Resident #6 On 02/07/24 at 11:12 AM, a record review was completed for Resident #6. The review found the resident had been transferred to an acute care facility on 06/12/23 for a temperature and headache and on 10/23/23 for chest pain. Upon completion of the review, the medical records department was asked to provide the signed bed hold notice of policy and authorizations to the acute care facility. Medical Records Manager #10 provided the bed hold policies for both transfers. However, the bed hold policies dated for 06/12/23 and 10/23/23, did not have the signature of the resident or resident representative or date. The Center representative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to coordinate with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs by failing to update the Pre-admission Screening and Annual Resident Review (PASARR) for Resident #40 following a diagnosis of Major Depressive Disorder. This is true for one (1) of four (4) residents reviewed for PASARRs during the survey process. Resident Identifier: 40. Facility Census: 94. Findings included: At approximately 3:00 PM on 02/05/24 a record review was conducted for Resident #40. During record review, it was determined that Resident #40 was admitted to the facility on [DATE] with no diagnosis of a Level II mental illness. Resident #40 was diagnosed with Major Depressive Disorder on 01/24/19 and the facility did not update the PASARR for the resident, to reflect that diagnosis. At…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to develop and implement a baseline care plan that included the minimum healthcare information necessary to properly care for the immediate needs of residents. This was true for two (2) of 23 residents reviewed during the Long-Term Care Survey Process. Resident identifiers: #196 and #347. Facility census: 94 Findings included: a) Resident #196 A record review, completed on 02/06/24 at 11:00 AM, revealed Resident #196 had been admitted to the facility on [DATE]. The baseline care plan identified Resident #196 was at risk for decreased ability to perform Activities of Daily Living (ADLs) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. The following interventions were not complete and failed to indicate the correct level of staff assistance needed: -Provide resident/patient with ______(specify: set-up, supervision, limited, extensive, total) assist of _____(specify #) for bed mobility. -Provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to develop and/or implement a person-centered care plan regarding Post-Traumatic Stress Disorder (PTSD) for Resident #35. This was true for one (1) of one (1) residents reviewed under the care area of mood and behavior. Resident Identifier: #35. Facility Census: 94. Findings Included: a) Resident #35 On 02/05/24 at 11:30 AM, the facility matrix was reviewed. Resident #35 was identified with a diagnosis of PTSD. A record review was completed. A Social Services assessment dated [DATE] identified the resident was a victim of a violent assault. However, the care plan was not developed regarding the diagnosis of PTSD. On 02/07/24 at 10:00 AM, Social Services (SS) #80 was notified regarding the care plan not including the diagnosis of PTSD. On 02/07/24 at 12:00 PM, SS #80 stated, I updated the care plan to include PTSD. No further information was obtained during the survey process.

Based on record review and staff interview, the facility failed to revise care plans to accurately reflect the conditions of residents. The facility failed to revise a care plan for depression for Resident #15, a COVID diagnosis for Resident #78, and tube feeding for Resident #53. This was true for three (3) of three (3) residents reviewed for care plan revision during the survey. Resident identifiers: #15, #53, #78. Facility census: 94. Findings included: a) Resident #15 At approximately 10:00 AM on 02/06/24, a record review of Resident #15 was conducted. During record review, it was noted that Resident #15 was care planned for a focus of distressed/fluctuating mood symptoms related to: Sadness/depression caused by history of mood disorders, long term care placement. Two interventions for this focus were observed to be Observe for pain and effectiveness of current interventions. Attempt non-pharmacological interventions (initiated on 11/08/21, created on 11/08/21, revised on 11/08/21) and Administer pain medication as ordered and document effectiveness/side effects (initiated 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 observation, record review, resident interview, and staff interview, the facility failed to provide Activities of Daily Living (ADL) care that is necessary to maintain good oral hygiene care. This was true for one (1) of 23 residents. Resident identifier: #44. Facility Census: 94. Findings included: a) Resident #44 During an interview on 02/05/24 at 1:25 PM Resident #44 stated that she has a hard time with getting her oral care done because she was dependent on the staff and they did not always help her. She was not able to physically get the items she needed to perform oral care but can perform it once they have given her the needed items. During a medical record review, on 02/06/24 at 8:56 PM, of the [NAME] task for Resident #44 Task: Mouth care-cleaning of teeth/dentures/mouth Look Back: 30 (days). This report identified seven (7) days that no oral care was provided by staff and/or self completed by the resident. These dates were marked not applicable. -01/15/24, 01/19/24, 01/20/24, 01/21/24,…

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

Based on record review and staff interview, the facility failed to follow a physician's order regarding an enteral feeding for Resident #53. This was true for one (1) of one (1) residents reviewed under the care area of tube feeding. Resident identifier: #53. Facility census: 94. Findings included: a) Resident #53 On 02/07/24 at 2:00 PM, a record review was completed for Resident #53. The review found a physician's order dated 12/28/23 stating, as needed give 237ml (milliliter) per G-tube (gastrostomy tube) if <(less than) 50% (percentage) of meal is consumed. Osmolite 1.5. (one point five). (Typed as written.) The resident's weights were reviewed. The resident's weight has remained stable. Upon reviewing the Medication Administration Record for December 2023, the following dates should have had an as needed feeding administered based on the documentation: --12/29/23 lunch (25%) Upon reviewing the Medication Administration Record for January, 2024, the following dates should have had an as needed feeding administered based on the documentation: --01/01/24 breakfast (resident not…

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

Based on record review and staff interview, the facility failed to monitor Resident #15 for side effects of psychotherapeutic medications. This was true for one (1) of (1) residents reviewed for monitoring of side effects during the survey process. Resident identifiers: #15. Facility census: 94. Findings included: a) Resident #15 On 02/06/24 at approximately 9:30 AM, a record review was completed for Resident #15. The review found the resident was taking an antidepressant (Sertraline) for depression. The Medication Administration Record (MAR) dated November, 2023 through January 2024 were reviewed and found a physician's order for Sertraline 50mg (milligram) daily for depression dated 09/24/23. The physician's order included a question regarding behavior, Yes or No. However, the physician's order did not include any specific behaviors to monitor. At approximately 12:30 PM on 02/07/24, the Director of Nursing (DON) #56 was notified and confirmed there was no documentation of specific behaviors listed to be monitored.

Based on observation and staff interview, the facility failed to serve food in a safe and sanitary manner by failing to ensure the food was free of contamination and hazards. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 94. a) Test Trays At approximately 11:55 AM on 02/06/24, two (2) test trays containing the facilities lunch menu were delivered by Dietary Manager (DM) #123. The menu for lunch was: Hamburger on roll, lettuce and tomato garnish, grapes, french fries, or cottage cheese fruit platter and a cinnamon muffin. Upon observation of the trays, a pit of a pear was found on the cottage cheese fruit platter. Upon observation of the tray containing the hamburger, a dead insect was found on the lettuce. At approximately 12:08 PM on 02/06/24, DM #123 and the Nursing Home Administrator (NHA) were notified and acknowledged the pear pit as a potential choking hazard and the dead insect on the lettuce.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to maintain a medical record that was complete and accurately documented. The facility failed to obtain a physician signature on a Physician Orders for Scope of Treatment (POST) form for Resident #48 prior to uploading it to the electronic medical record and the facility incorrectly entered a Code Order Status related to the timeframe the Resident #48 desired to have medically assisted nutrition. Additionally, the facility failed to complete a smoking assessment it its entirety for Resident #74. This deficient practice was true for two (2) of 23 resident records reviewed during the annual long-term care survey process. Resident Identifiers: #48 and #74. Facility census: 94. Findings Included: a) Resident #48 During a record review, completed on 02/05/24 at 4:49 PM, the following issues were identified: -The scanned Physician Order for Scope of Treatment (POST) form, signed by resident on 01/15/24, indicated Do Not Resuscitate (DNR), Selective…

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

Based on observation and staff interview, the facility failed to maintain appropriate infection control standards during medication administration for Resident #15, Resident #47, Resident #43 and Resident #42. These were random opportunities for discovery. Resident Identifiers: #15, #47, #43, and #42. Facility Census: 94. Findings Included: a) Resident #15 On 02/06/24 at 8:22 AM, Licensed Practical Nurse (LPN) #31 was observed during medication administration for Resident #15. During the preparation of the medication the following pill was touched by LPN #31's bare hands: --Zoloft 50mg (milligrams) b) Resident #47 On 02/06/24 at 8:35 AM, LPN #31 was observed during medication administration for Resident #47. During the preparation of the medication the following pills were touched by LPN #31's bare hands: --Ativan 0.5mg --Multivitamin --Zoloft 50mg c) Resident #43 On 02/06/24 at 8:51 AM, LPN #31 was observed during medication administration for Resident #43. During the preparation of the medication the following pill was touched by LPN #31's bare hands: --Lasix 20mg d) Resident #42…

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 offer vaccinations to Resident #4 and #6. This was true for two (2) of five (5) residents reviewed under the care area of immunizations. Resident Identifiers: #4 and #6. Facility Census: 94. Findings Included: a) Resident #4 On 02/07/24 at 1:30 PM, a record review was completed for Resident #4. The review found the pneumococcal vaccine (PCV) 20 was not offered to the resident. On 02/07/24 at 3:00 PM, the Infection Preventionist (IP) # 37 was notified and stated, I made a mistake .I should have offered it to her. b) Resident #6 On 02/07/24 at 2:15 PM, a record review was completed for Resident #6. The review found the PCV 20 vaccine was not offered to the resident. On 02/07/24 at 3:10 PM, the IP #37 was notified and stated, she went out to the hospital .I should've followed up with her son sooner. No further information was obtained during the survey process.

Based on observation and staff interview, the facility failed to ensure the activity director was certified as an activity professional by a recognized accrediting body. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 92. Findings included: a) During an interview on 12/19/23 at 12:30 PM, with the facilities Activity Director, the surveyor asked her how long she had been certified and how long she had worked at the facility. She stated, I have worked here 7 years and have been an Activity Director for 5 years. I am not certified. I have been through 6 administrators and have told them I need to do this. I have not had the state approved course yet. During an interview, on 12/19/23 at 1:00 PM, with the Administrator she stated, I was not aware that she was not certified, I have only been here a month. I will definitely check into it. A review of the employees hiring records on 12/19/23 at 1:30 PM, revealed the Activity Director was hired at the facility as a Nursing Assistant on 09/16/16 and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. One (1) of one (1) residents reviewed for non-pressure wounds did not receive wound treatment and care in accordance with professional standards of practice. The facility did not assess or provide treatment to the wounds according to professional standards of care Additionally, the physician-ordered medication parameters were not followed for one (1) of four (4) residents reviewed for medications. Resident identifier: #93. Facility census: 92. Findings included: a1) Resident #93 - non-pressure wounds The facility's policy titled Skin Integrity and Wound Management with effective date 07/01/01 and revision date 02/01/23 gave the following procedures: - Complete comprehensive evaluation of the patient upon admission - Evaluate any reported or suspected skin changes or wounds - Complete wound evaluation weekly Review of Resident #93's medical records…

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 provide catheter care in accordance with professional standards of care. This failed practice had the potential to affect two (2) of four (4) residents reviewed for the care area of catheter care. Resident identifiers: #28, #93. Facility census: 92. Findings included: a) Resident #28 Review of Resident #28's medical records revealed the resident had an order for an indwelling urinary catheter due to urinary retention. Review of the resident's Treatment Administration Record (TAR) showed an order written on 10/08/23 to perform indwelling catheter care every day and evening shift. The order was discontinued on 11/17/23. The order to perform indwelling catheter care every day and evening shift was reordered on 12/13/23. There was no evidence the resident had been out of the facility or had the catheter removed from 11/17/23 and 12/13/23. During an interview on 12/18/23 at 3:40 PM, the Director of Nursing (DON) stated an order had been written on 11/17/23 to discontinue Resident #28's indwelling urinary catheter but 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, resident interview, and staff interview, the facility failed to ensure a resident had reasonable accommodation of needs by failing to ensure the resident had a bed that was long enough for his body length. This was a random opportunity for discovery. Resident Identifier: #88. Facility census: 92. Findings included: a) Resident # 88 During an Observation on 12/19/23 at 8:55 AM, Resident #88 was lying in bed with the head of the bed elevated. His calves were on the foot board and his feet were hanging over the edge of the footboard. During an interview on 12/19/23 at 8:57 AM, Resident #88 stated, I am not comfortable in this bed The surveyor asked the resident if he felt he needed a longer bed and he stated, Well don't you think? A record review on 12/19/23 at 9:15 AM, revealed Resident #88 was admitted on [DATE] with a height of 79 inches (6 feet 7 inches tall.) During an interview, on 12/19/ 23 at 9:20 AM, with Licensed Practical Nurse (LPN) #62 she stated, Yes, he needs a longer bed, he is…

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

Based on record review and staff interview, the facility failed to report an alleged violation related to abuse, to all the required State authorities. This was a random opportunity for discovery. Resident identifier: #19. Facility census: 92. Findings included: a) Resident #19 Record review of the facility's policy titled, Abuse Prohibition, showed: Physical Abuse Includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment. A complaint investigation on 12/18/23, discovered a reportable for a Resident-to-Resident altercation with alleged abuse on 11/13/23. The incident included Resident #94 wandering into Resident #19's room, when asked to leave the room Resident #94 punched Resident #19 in the head 4 -5 times. --Section Notes, Nursing Home Administrator (NHA) notified Ombudsman of Resident to Resident with alleged abuse. Resident #19's Minimum Data Set (MDS,) Significant Change Assessment with an Assessment Reference Date (ARD) of 10/19/23 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15. A BIMS…

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 pressure ulcer care in accordance with professional standards of care. This failed practice had the potential to affect two (2) of four (4) residents reviewed for the care area of pressure ulcers. The failure to assess and follow the physician's orders for Resident #87's pressure ulcer caused harm to the resident. The resident developed a pressure ulcer infection, requiring intravenous antibiotics while in the faciity, and also was transferred to the hospital for suspected pressure ulcer infection and deteriorating wound. Resident identifiers: #93, #87. Facility census: 92. Findings included: a) Policy review The facility's policy titled Skin Integrity and Wound Management with effective date 07/01/01 and revision date 02/01/23 gave the following procedures: - Complete comprehensive evaluation of the patient upon admission - Evaluate any reported or suspected skin changes or wounds - Complete wound evaluation weekly b) Resident #93 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 medical record review and staff interview, the facility failed to ensure a complete and accurate medical record pertaining to a Covid-19 diagnosis. This practice affected one (1) of three (3), residents reviewed during a complaint survey. Resident identifier #2. Facility census: #93. Findings included: a) Resident #2 A medical record review on 09/27/23, revealed Resident #2's Covid-19 diagnosis on 08/28/23. Continued review found the facility line listing noted Resident #2's Covid-19 diagnosis on 08/31/23. Resident #2 was put in Isolation precautions on this date. During an interview, on 09/27/22 at 12:30 PM, the Director of Nursing (DON) and Administrator verified the medical diagnosis in Resident #2's medical record was inaccurate. It was confirmed Resident #2 was not diagnosed with Covid -19 until 08/31/23.

Based on observation, record review, staff interview, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) prior to entering transmission-based precaution (TBP) room. These failed practices had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: #13. Facility census: 95. Findings included: a) Resident #13 An observation on 08/29/23 at 8:22 AM found Maintenance #25 entering Resident #13's room without PPE. The signage on Resident #13's door showed the room was on Contact Plus Airborne Precautions. The TBP sign stated, Perform Hand Hygiene BEFORE and AFTER patient contact, contact with environment & after removal of PPE. Wear an N95 Respirator, Gown, Face Shield and Gloves upon entering this room. Maintenance Director #25 was observed in Resident #13's room without a gown, face shield, or gloves. During an interview on 08/29/23 at 8:30 AM, Maintenance Director #25 stated he did not know Resident #13 was in isolation. He continued to say he did not see the sign on the door. 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 review of the medical record, staff interview, and family interview, the facility failed to notify the responsible party of changes in a resident's condition for one (1) of three (3 closed records reviewed. Resident identifier: #99. Facility Census: 95. Findings included: a) Resident #99 A review of Resident #99's care plan revealed a plan initiated on 07/12/22, which indicated this resident was receiving Antiplatelet therapy and Aspirin and was at risk for bleeding. The goal for this care plan stated the resident will not exhibit bleeding by the next review and interventions include observing for bleeding, hematuria, bruising, nose bleeds, gums, and blood in stool. This care plan had been continued each quarter. According to the Nursing Notes dated 05/22/23, a skin check was performed on Resident #99 and there were no skin issues. On 05/26/23, it was identified Resident #99 was up to the wheelchair then transferred to the recliner chair via the Hoyer lift. The dressing to the left arm was saturated with dark brown drainage to the skin tear. The dressing was changed for 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 interview and record review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for One (1) of two (2) residents reviewed during a complaint survey. Resident identifiers: #29. Facility census: 95. Findings included: a) Resident #29 On 08/29/23, at 8:52 AM during an interview Resident #28 stated, he has complained about other residents coming in his room and taking his personal belongings. He stated he had talked to Social Services, but nothing was ever done about the missing items or the intruding residents. On 08/29/23 a review of the facility records regarding missing items and grievances revealed Resident #29 had no concerns or grievances filled out. A continued record review of Resident #29's medical record found a Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/31/23, A review of this MDS found the resident's brief interview for mental status was fifteen (15) the highest score obtainable and indicated Resident #29 was cognitively intact. During an…

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

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 Minimum Data Set (MDS) assessment was completed for one (1) of 20 residents in the long-term care survey sample. Resident identifier: #91. Facility census: 93. Findings included: a) #91 Review of Resident #91's medical records showed the resident had been admitted to the facility on [DATE]. Further review of the medical records showed the resident had been receiving hospice services since admission to the facility. Resident #91's MDS assessment with Assessment Reference Date (ARD) 05/23/22 did not document the resident was receiving hospice services. During an interview on 06/08/22 at 11:37 AM, the Administrator verified Resident #91 was admitted to the facility with hospice services. The Administrator also verified the resident's MDS assessment with ARD 05/23/22 did not document the resident was receiving hospice services. No further information was provided through the completion of the survey. .

Based on observation, record review and staff interview the facility failed to ensure the care plan was revised and accurate in the Food and Nutrition area for Resident #53. This was true for 1 (one) of 20 (twenty) residents reviewed during the survey process. Resident Identifier #53. Facility Census 93. Findings included: a) Resident #53 On 6/06/22 at 3:01 PM it was observed that Resident #53 has a wander guard on his right ankle for elopement precautions. Record review on 6/07/22 at 9:53 AM shows the following elopement evaluations were found to be completed: 6/5/2022, 1/24/2022, 9/04/2021, 7/06/2021, 3/15/2021. There was change of condition documentation for elopement and elopement attempts or exit seeking on the following dates 9-04-21, 1-24-22, 5-14-22, and 6-05-22. According to his care plan the resident has a history of cutting his wander guard off and is to have plastic silverware and no sharp objects in the room. He has a diagnosis of dementia. There is no active order for plastic silverware. Upon observation of the Residents lunch on 6/07/22 at 12:31 PM he does not have…

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. The medication cart was left unlocked when unattended. This was a random opportunity for discovery that had the potential to affect a limited number of residents. Facility census: 93. Findings included: a) Medication Administration Facility Task On 06/07/22 at 08:04 AM, Licensed Practical Nurse (LPN) #44 entered Resident #69's room to administer medications. The medication cart was in the doorway of the resident's room, facing the room. LPN #44 did not lock the medication cart when leaving the cart and entering the room. At 8:05 AM, LPN #44 closed the door to the resident's room for privacy to apply a lidocaine patch to the resident's back. The medication cart remained unlocked in the hallway at this time. At 8:06 AM, LPN #44 opened the resident's door and returned to the medication cart. LPN #44 acknowledged the medication cart was unlocked when she was in the resident's room with the door closed. No further…

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

Based on medical record review and staff interview, the facility failed to evaluate residents experiencing impaired nutrition. Two (2) of five (5) residents reviewed for the care area of nutrition were not weighed as ordered by the physician. Resident identifiers: #89 and #68. Facility census: 93. Findings included: a) Resident #89 Review of Resident #89's medical records showed a physician's order written on 04/13/22 for weekly weights. The weights were to be obtained every Wednesday. Prior to the order, the resident had a weight obtained on 04/08/22, and the resident weighed 100.4 pounds. Following the order, the medical records showed the following information for Resident #89's weekly weights on Wednesdays: - 04/13/22: the resident was not weighed - 04/20/22: the resident was not weighed - 04/27/22: the resident was not weighed - 05/04/22: the resident weighed 97.2 pounds - 05/11/22: the resident weighed 102.7 pounds - 05/18/22: the resident was not weighed - 05/25/22: the resident weighed 101.6 pounds The resident was admitted to the hospital 05/30/22-06/04/22. She was not…

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

Based on observation, medical record review and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. This was true for two (2) of three (3) residents reviewed in the area of respiratory care during the long term care survey process. Resident identifier: #62 and #86. Facility census: 93 Findings included: a) Resident #62 On 6-06-22 at 12:16 PM observation found Resident #62 had oxygen on via nasal canula. The oxygen tubing was not dated with a change out date. This was confirmed with Registered Nurse (RN) #21. The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date. b) Resident #86 On 06/06/22 at 11:02 AM observation found Resident #86 had oxygen on via nasal canula. The oxygen tubing for the nasal canula was not dated with a change out date. This was confirmed with RN #21 on 06/06/22 at 11:04 AM. The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be…

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

Based on record review and staff interview, the facility failed to ensure performance reviews for Nurse Aides were conducted at least once every 12 months. This was true for one (1) of three (3) Nurse Aides reviewed for the sufficient and competent nurse staffing facility task. This deficient practice had the potential to affect a limited number of residents. Facility census: 93. Findings included: a) Sufficient and competent nurse staffing facility task On 06/07/22 at approximately 2:00 PM, the Administrator was asked for copies of the yearly performance reviews for three (3) Nurse Aides, including Nurse Aide (NA) #24. On 06/07/22 at 4:09 PM, the Administrator stated a yearly performance review had not been conducted for NA #24. No further information was provided through the completion of the survey. .

Based on record review and staff interview, the facility failed to ensure PRN (as needed) orders for psychotropic medications were limited to 14 days, or that the rationale for extending beyond 14 days was documented along with the duration of the PRN order. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of fall. Resident identifier: #26. Facility census: 93. Findings included: a) Resident #26 Review of Resident #26's medical records showed an order for written for alprazolam (Xanax) 0.25 mg every night as needed for insomnia. No duration for the order was provided. Additionally, the medical records did not contain a physician's rationale for why the order should be extended beyond 14 days. Review of Resident #26's Medication Administration Record showed the resident last received the PRN alprazolam on 05/28/22. During an interview on 06/07/22 at 2:21 PM, the Director of Nursing (DON) confirmed Resident #26's PRN alprazolam order had been extended for over 14 days without a documented rationale or a duration for the order.…

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

Based on observation and staff interview, it was found that two (2) containers of grape juice stored in the refrigerator had expired. Additional findings included cabinets uses to store pots, pans and baking ware were rusted and could not be sanitized. The wall behind a prep table had peeling yellow paint and rust around the back edge of the table which could not be cleaned and sanitized. These practices had the potential to affect a limited number of residents residing in the facility. Facility census: 106. Findings included: a) Expired juice On 06/06/22 at 11:07 AM an observation with the Dietary Manager (DM) found two (2) containers of grape juice that had expired on 06/04-05/22 in the refrigerator in the kitchen. The DM immediately removed the containers of grape juice and confirmed they were expired. b) Cabinets During this same observation with the DM, two (2) cabinets used to store pots, pans and baking ware were rusted. The DM confirmed the cabinets were rusted and could not be cleaned and sanitized. This contaminated the pots, pans and baking ware. c) Wall During the same…

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 have a complete and accurate order regarding an indwelling urinary catheter. This was true for one (1) of three (3) residents reviewed for the care area of catheters. The order for a catheter for Resident #63 did not specify the size of catheter or the balloon inflation. Resident identifier: #63 Facility census: 93. Findings included: a) Resident #63 A medical record review on 06/07/22, revealed Resident #63's catheter order was incomplete. The order did not specify the size of catheter to be used or the amount of cubic centimeters (cc) needed to inflate the balloon. During an interview on 06/07/22 at 4:20 PM with the Director of Nursing (DON), verified the order for Resident #63's catheter was incomplete. .