Princeton Health Care Center

Based on observation, medical record review and staff interview, the facility failed to revise the residents comprehensive care plan. Residents had one-on-one (1:1) interventions put in place without being care planned or being care planned timely. This was a random opportunity for discovery during the long term care survey process. Resident identifiers: #47, #75 and #101. Census: 114. Findings included: a) Resident #47 On 05/06/24 at 11:13 PM Resident #47 was observed to be sitting in her room with an apparent black eye. A staff member was observed at this time to be sitting in the room with the resident. On 05/07/24 at approximately 12:15 PM Resident #47 was observed to have a staff member sitting with her in her room. 05/07/24 at 07:45 PM during a medical record review, Resident #47 nursing note dated 05/03/24 identified that the resident had a fall as she was observed sitting in front of toilet in bathroom on floor, resident assessed for injuries noted to have skin tear to behind left ear and left side of face near chin, noted to have bump forming on top of left eyebrow noted to…

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

The facility failed to create and sustain an environment that humanizes and individualizes each resident's quality of life as they were not provided a person-centered care to honor and support the residents individual preference, choices, values and beliefs. This was a random opportunity for discovery during the long term survey process. This had the ability to affect a limited number of resident's. Resident identifiers: #75, #47, #101. Facility census: 114. Findings include: a) During a facility tour on 05/06/24 at approximately 2:50 PM, it was noted Resident #75 had a Health Team Aide (HTA) sitting at her bedside. At that time, an interview with Resident #75 and the HTA #136 was conducted. HTA #136 revealed that she was providing one on one care to Resident #75 and that a HTA sat with Resident #75 24 hours a day providing this service. When asked why, HTA #136 responded, I am not sure, I think she had a fall a while back. HTA #136 was unable to tell me when the one on one was initiated or how long it was to continue. Resident #75 was unable to provide further information. 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 and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current. The Daily Staffing Posting Form was not posted in a prominent place readily accessible to residents and visitors; the Daily Staffing Posting Form did not accurately reflect the direct care staff; and the Daily Staffing Posting Form did not identify the actual number of staff and or the actual hours worked. This was identified during the long-term care survey process of reviewing the sufficient and competent nursing staff. This has the potential to affect potential to affect more than a limited number of residents and visitors. Identifiers: Accurate and current data of direct care, Accurate and current date of actual numbers of staff and or the actual hours worked; and the Daily Staffing Posting Form was not posted in a prominent place readily accessible to residents and visitors. Facility Census: 114. Findings included: a) Accurate and current data- direct care staff On 05/07/24 at approximately 10:15 AM during a review of the Daily Staffing…

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 cooking/serving pans were completely dry before storing them on the shelf wet nesting. Wet nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow. Hot/Cold compress pack was stored in the resident pantry refrigerator where cold snacks are stored. This failed practice was found during the initial kitchen tour during the Long-Term Care Survey and had the potential to affect more than a minimal number of residents residing in the facility. Facility Census: 114 Findings Include: a) wet nesting During the initial Kitchen tour on 05/06/24 at 11:00AM with Certified Dietary Manager (CDM) #132 Pans were stacked under the counter, when one was pulled it was observed to be wet on the right side. CDM #123 confirmed staff should have ensured pans were dry before stacking and storing them. On 05/06/24 at 1:00 PM CDM provided educations signed by staff ensuring dishes are dry when putting them up. b) Hot/Cold compress in pantry…

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 by not serving residents sitting together at the same time. This was a random opportunity for discovery and had the potential to affect a minimal number of residents in the facility. Facility Census: 114 Resident Identifiers: #14, #52, #106 Findings Include: On 05/08/24 at 12:20 PM in the South Dining room Resident #52 and #106 were observed setting together and Table one (1) and Resident #14 observed setting to herself at Table two (2). Further observation on 05/08/24 at 12:25 PM revealed Resident #52 was served first at table one (1) then Resident #14 was served at table two (2) at 12:26 PM. Resident #106 waited Three minutes at table one(1) while Resident #52 ate. Resident #106 was served at 12:29 PM. Staff interview was conducted on 05/08/24 at 12:33PM with Certified Nursing Assistant (CNA) #168 asking why Resident #14 was served before Resident #106 CNA #168 stated because there was a mix up with the ticket and did not want Resident #14's food to get cold. During Staff…

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

Based on medical record review and staff interview the facility failed to ensure an informed consent was obtained for a psychotropic medication. This was true for one (1) of five (5) residents reviewed for unnecessary medication during the long term care survey. Resident identifier: #43 Census: 114. Findings included: a) Resident #43 On 05/07/24 at 12:50 PM during a medical record review for Resident #43, it was identified that the resident was prescribed aripiprazole 20 mg tablet for inappropriate sexual behaviors related to unspecified psychosis not due to a substance or known physiological condition. During this medical record review an informed consent for psychotropic medication use could not be identified for the use of aripiprazole 20 mg tablet. On 05/07/24 at approximately 2:45 PM during an interview with the Director of Nursing (DON), the DON agreed that the psychotropic medication aripiprazole 20 mg did not have an informed consent for psychotropic medication use and that she would have this corrected.

Based on observation, record review and staff interview the facility failed to ensure residents' information was protected. This failed practice was found true for (1) one of (1) one resident looked at for privacy during the Long-Term Care Survey Process. Resident Identifiers #19. Facility Census 114. Findings include: a) Resident #19 An observation on 05/06/24 at 11:15 AM, found a sign posted behind Resident #19's bed that read: (Resident # 19 name) has an allergy to Latex.} Further observation found that the sign was visible from the hallway when the door and curtain were open. A record review on 05/08/24 at 1:00 PM, revealed that Resident #19 was in fact allergic to Latex. On 05/08/24 at 2:30 PM, a review of the facilities policy titled {Confidentiality of Personal and Medical Records}, number (8) eight reads: Paper notes or reminders with resident's personal or medical information shall not be left unattended or viewable by unauthorized persons. During an interview on 05/08/24 at 4:00 PM, the Administrator confirmed that the sign infringed on Resident #19's privacy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews the facility failed to provide a clean, comfortable, and homelike environment. A strong unpleasant odor was observed when entering a resident's room. This was a random opportunity for discovery during the long-term care survey process. Room Identifier: room [ROOM NUMBER]. Census: 114. Findings included: a) room [ROOM NUMBER] During a tour of the 200 hall on 05/06/24 at approximately 11:15 AM a strong unpleasant odor was observed when entering room [ROOM NUMBER]. During a tour of the 200 hall on 05/06/24 at 03:05 PM a strong unpleasant odor was again observed when entering room [ROOM NUMBER]. Licensed Practical Nurse (LPN) #91 was asked to help identify the odor in the room. LPN #91 stated that one of the residents will place her soiled undergarments in bags and put them in drawers and that may be what the smell is. She stated she would have the staff help check for what the odor is from and get it cleaned up. During a tour of the 200 hall on 05/07/24 at 09:06 AM a strong…

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 Ombudsman of resident #45's discharge to the hospital.This was true for one (1) of one(1) residents reviewed for the carrier of hospitalization. Resident identifier; #45. Facility census: 114. Findings include: A) Resident #45 A record review found The resident was discharged to the hospital 12/06/2024 at 12:48 pm. Interviewed Social Worker on 05/06/2024 to ask if the ombudsman was notified of resident discharge to the hospital and she said yes but could not provide verification of that notification.

The facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid. The PASARR was not resubmitted for residents with newly evident or possible serious mental disorder. This was true for two (2) of six (06) residents PASARR reviewed during the long term care process. This had the ability to affect a limited number of residents. Resident Identifier: Resident #67, Resident #80; Census: 114. Findings Included: a) Resident #67 During a medical record review on 05/07/24 at 11:02 AM for Resident #67, the PASARR was dated 05/04/22. Further record review of the residents diagnosis identified an updated diagnosis of delusions due to known physiological condition dated 5/06/22. No further PASARR's were identified to have been completed for this diagnosis dated 05/06/22. On 05/07/24 at 02:46 PM during an interview with Social Worker #129 she stated she did not have an updated PASARR for the diagnosis of delusions due to known physiological condition dated 5/06/22 and that she would need to complete one.

Based on record review and staff interview the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) reflected the diagnoses sheet for pre admission diagnoses. This was true for two (2) of five (5) residents reviewed for the PASARR care area. Resident identifiers: #80, #1, Facility Census: #114 Findings included: (a) Resident #80 During a record review on 05/07/24, Resident #80's medical record revealed admitting diagnosis for 06/16/22 (admission date) included the following: -unspecified Psychosis not due to a substance or known physiological condition According to the Diagnosis Report provided by the facility and the PASARR submitted 10/12/22 the PASARR did not reflect this admitting medical diagnosis. In an interview with the Social Services/Admissions Director #129 on 05/08/24 at 08:39 AM, it was verified the PASARR should have reflected the Psychosis Disorder upon the admission date of 06/16/22.

Based on record review and staff interview, the facility failed to develop a complete and accurate comprehensive care plan for two (2) of 34 residents reviewed in the long-term care survey sample. Resident identifiers: #115, #67. Facility census: 114. Findings included: a) Resident #115 Review of Resident #115's comprehensive care plan showed the resident had been living at the facility since 2022. On 02/15/24, the resident was discharged to a family members' home. The resident had diagnoses of traumatic brain disorder and dementia. A physician's note written on 02/12/24 indicated the resident had received discharge planning and assistance from a state agency. The discharge summary written on 02/15/24 indicated delivery of durable medical equipment and home health agency visits were arranged prior to discharge. An appointment was also made with the resident's primary care provider and an Adult Protective Services (APS) referral was made. Review of Resident #115's comprehensive care plan showed no focus was developed regarding discharge planning. A focus written on 11/17/22 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.

The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to obtain the physicians order for one on one (1:1) interventions. This was a random opportunity of discovery during the long term care survey process. This had the ability to affect a limited number of residents. Resident Identifiers; Resident #47, Resident #75, and Resident #101. Facility Census: 114. Findings Included: a: Resident #47 On 05/06/24 at 11:13 PM Resident #47 was observed to be sitting in her room with an apparent black eye. A staff member was observed at this time to be sitting in the room with the resident. On 05/07/24 at approximately 12:15 PM Resident #47 was observed to have a staff member sitting with her in her room. 05/07/24 at 07:45 PM during a medical record review, Resident #47 nursing note dated 05/03/24 identified that the resident had a fall as she was observed sitting in front of toilet in bathroom on floor, resident assessed for…

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

Based on record review and staff interview the facility failed to provide services for Post Traumatic Stress Syndrome (PTSD). This failed practice was found true for (1) one of (3) three residents looked at for mood and behavior during the Long-Term Care Survey Process. Resident identifier #76. Facility Census: 114. Findings included: a) Resident # 76 A record review on 05/06/24 at 1:06 PM, of the Minimum Data Set (MDS), Section I, revealed that Resident #76 had PTSD. A record review on 05/08/24 at 11:00 AM, revealed the following trauma related care plan initiated on 10/31/21: Focus: (Resident #76 name) has a Trauma history relating to a car accident that left him badly injured 12 years ago. He has had two major strokes and two brain aneurysms. He lost his son due to a heart attack three years ago. He has a strained relationship with his living son and is close with a grandson. He worked as a social worker for many years at DHHR. No triggers reported. Goal: (Resident #76 name) will not have an increase in adverse symptoms related to trauma history through next review.…

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

Based on record review and staff interview, the facility failed to obtain laboratory services as ordered by the physician. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #80. Facility census: 114. Findings included: a) Resident #80 Review of Resident #80's physician's orders showed an order for the laboratory test hemoglobin A1c (HgbA1-c ) to be performed every six (6) months. HgbA1-c testing measures the average blood sugar level over the past three (3) months. Resident #80 was on a medication, Ziprasidone (Geodon) for psychosis, that can elevate blood sugar levels. Review of Resident #80's laboratory results showed HgbA1-c testing had last been performed on 09/07/23. On 05/08/24 at 1:17 PM, the Director of Nursing (DON) confirmed Resident #80's HgbA1-c testing had not been performed every six (6) months as ordered. She stated a HgbA1-c test would be obtained for the resident today. No further information was provided through the completion of the survey.

Based on Record review and staff interview the facility failed to ensure that the medical record contained the diagnosis of Post Traumatic Stress Syndrome (PTSD) as indicated on the Minimum Data Set (MDS) and that the Physician Order for Selective Treatment (POST) form was complete and accurate. This failed practice was found true for (2) two of 34 residents reviewed for medical record accuracy during the Long-Term Care Survey Process. Resident identifiers #76, #86. Facility Census 114. Findings include: a) Resident #76 A record review on 05/08/24 at 10:19 AM, revealed that Resident #76's MDS with an Assessment Reference Date (ARD) of 03/22/24, Section I, question 16100, is marked yes for PTSD. Further record review showed that Resident #76 did not have PTSD listed for one of his medical diagnoses. He did however; have a care plan for trauma. During an interview on 05/08/24 at 1:30PM with the Director of Nursing (DON), she confirmed that resident #76's MDS was marked for PTSD and it was not on the current diagnosis list. She further stated, I will see what is going on with that. No…

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

Based on observation, policy review, resident council meeting and staff interview the facility failed to make grievances forms accessible to all resident and/or residents family/representatives residing in the facility. This had the potential to affect an unlimited amount of residents living in the facility. Facility census: 115. Findings Included: a) Grievance Forms A review of the facility policy titled Resident and Family Grievances and Communicated Concern with an implementation date 11/28/16 and a revision date 07/17/21, read as follows. Procedure: .8. A grievance may be filed anonymously During the Long Term Care Survey Process from 07/23/23 to 07/25/23 many observations throughout the facility revealed no evidence of grievance forms made accessible to the residents and/or resident representatives. During the Resident Council Meeting held on 07/25/23 at 10:08 AM, the Residents as a group were asked the question, Do you know how to file a grievance? Do you know where to access your grievance forms? The residents as a group stated No, we don't. We just tell Social Worker # 119…

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 four (4) of 26 Residents reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. A surgical consult was not scheduled for Resident #55 as directed by the nurse practioner, Resident #68's medication was not provided timely, an enteric coated medication was crushed before being administered, and blood pressures were not obtained as ordered by the physician for Resident #102. Resident identifiers: #55, #68, and #102. Facility census: 115. Findings included: a) Resident #55 Record review on 07/24/23 found Resident #55 had an ultrasound of her gallbladder on 01/18/23. The results of this ultrasound found: Gallbladder sludge is noted. No gallbladder wall thickening. No pericholecystic fluid. The results of the ultrasound were reviewed by the Family Nurse Practioner (FNP) on 01/19/23. The FNP wrote on the consult to get a surgical consult for the abnormal ultrasound with Gallbladder sludge. 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 observations and staff interviews the facility failed to assure handrail were firmly secured and affixed to the corridor walls. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing on North Unit 100 Hall. Facility Census: 115 Findings Included: a) Handrails During a tour on 07/24/23 at 1:11 PM this surveyor discovered on 100 Hall the following handrails were not firmly secured and affixed to the corridor walls. -The handrail between room [ROOM NUMBER] and the chapel door -Two (2) handrail between the 113 and the chapel door -The handrail between room [ROOM NUMBER] and 110 -The handrail between room [ROOM NUMBER] and 109 -The handrail between room [ROOM NUMBER] and 107 During an interview 07/24/23 at 1:20 PM, the Administrator acknowledged the rails were not secure and needed repaired. .

Based on record review and staff interview, the facility failed to report an injury of unknown origin to the proper authorities for Resident #72. This was true for one (1) of two (2) residents reviewed for unsafe wandering. Resident identifier: #72. Facility census: 115. Findings included: a) Resident #72 Record review found the following nursing note dated 06/13/23 at 6:47 AM: When a staff member was dressing the resident, he noticed bruising to her left arm and left outer hip that he had not noticed the bruising throughout the night. Upon inspection, the resident had a large bruise on her upper left arm measuring 5 cm (centimeters) wide x 4 cm long, as well as a small bruise to her left outer hip measuring 4 cm wide x 2 cm long. Both bruises were deep purple and yellow in color. The Resident was unable to give a description. Vital signs were assessed and all were found to be within normal limits. The Resident is not displaying any signs or symptoms of pain or discomfort to the site at this time. No swelling or redness to surrounding skin noted, skin is intact. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to accurately code the Minimum Data Set for resident's diagnosis. This was true for two (2) of five (5) reviewed for unnecessary medications. Resident identifiers: #49 and #79. Facility census: 115. Findings included: a) Resident #49 Review of Resident #49's medical records found the resident had been in the hospital from [DATE] through 07/12/23. She was treated for community acquired pneumonia and a urinary tract infection (UTI). Resident is currently on antibiotics for the treatment of pneumonia. Review of the MDS with a reference date (ARD) of 07/17/23 under section I (current diagnosis) did not have pneumonia or UTI in the last 30 days marked. Interview with the Director of Nursing (DON) on 07/25/23 at 2:10 pm. She confirmed the MDS with ARD of 07/17/23 was inaccurate. She confirmed the resident was treated in the hospital for a UTI and pneumonia and continued currently on antibiotics for treatment of pneumonia. b) Resident #79 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) when the resident was admitted to the hospital. Resident identifier: #53. Facility census: 115. Findings include: a) Resident #53 Review of Resident #53's medical record found she was admitted to the hospital on [DATE]. No MDS discharge tracking could be found. Interview with the Director of Nursing (DON) on 07/24/23 at 11:00 am. She confirmed a discharge MDS tracking form was not completed on 05/0/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to complete a baseline care plan for one (1) of two (2) newly admitted residents reviewed during the long term care survey. Resident identifier #366. Census 115. Findings Included: a) Resident #115 The surveyor requested copies of the resident's most recent minimum data set (MDS,) list of diagnoses, care plans, and Pre admission Screening (PAS) on 07/24/23. A record review of these records indicated the resident was admitted to the facility on [DATE] with the diagnosis of schizophrenia and bipolar disorder. The care plan received did not address either diagnosis. The PAS, dated 7/5/23, listed both diagnoses. The MDS is still in progress, therefore is not completed. The electronic medical record reviewed on 07/24/23 did not list either diagnoses under the Medical Diagnosis section, but the printed diagnosis list indicated the facility added both diagnoses on 07/24/23 to the list of the resident's diagnosis, with the onset date of 07/07/23. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan to include the diagnosis of pneumonia. Resident identifier: #49. Facility census: 115. Findings include: a) Resident #49 Review of Resident # 49's medical records show the resident was in the hospital from [DATE] through 07/12/23 and was treated for pneumonia and the resident continues medication for the treatment of pneumonia. Review of Resident #49's care plan did not have a care plan for pneumonia. An interview with the Director of Nursing (DON) on 07/24/23 at 11:00 am, confirmed the resident did not have a care plan for pneumonia. .

Based on record review, resident interview, and staff interview, the facility failed to update the care plans of two (2) of five (5) residents reviewed for the care area of nutrition after both residents had a weight loss and a diet change. Resident identifiers: #55 and #83. Facility census: 115. Findings included: a) Resident #55 Review of the medical record found a nutritional/dietary weight loss note, dated 7/19/2023. The Resident lost 8.4 pounds in 30 days, which was an 6.1% loss and an 11 pound weight loss in 90 days for a 7.8% weight loss. The resident receives a regular sugar substitute diet with fortified foods. On 7/11/23 the interdisciplinary team met to discuss a current weight of 130.2 pounds which was a 8.4 pound weight loss in 30 days a 6.10% weight loss and a 90 day weight loss of 7.8%. Fortified foods were added to lunch and dinner. On 07/24/23, the Registered dietician met with the Resident and added chocolate milk to her diet. Review of the current care plan, revised on 03/14/23, found the following focus/problem: (Name of Resident) has a potential to have weight…

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 policy, observations, and staff interview the facility failed to ensure proper storage of Continuous Positive Airway Pressure (C-pap) while not in use. This was a random opportunity for discovery and has the potential to affect a limited number of residents who currently reside in the facility. Resident Identifiers: # 67, and #3. Facility census 115. Finding included: Facility Policy, titled, Continuous Positive Airway Pressure date of revision:06/15/17. *It is very important to keep the C-pap equipment and supplies clean. *Store in a plastic bag. a) Resident #67 Observation on 07/23/23 02:53 PM, found the C-pap mask was lying on top of personal items on the nightstand not in a bag. Observation on 07/24/23 at 10:15 AM, found the C-pap mask was placed on top of various items such as opened bags of chips, bottles of lotions, and soda bottles on the nightstand not in a bag. Observation on 07/2423 at 2:18 PM, found the C-pap mask was on the nightstand on top mingled with other things, not in a bag. During an observation on 07/25/23 at 9:56 AM, found the C-pap mask 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 complete temperature logs for their reach-in refrigerator, reach-in freezer, walk-in refrigerator, walk-in freezer, and dishwasher. This has the potential to affect more than a limited number of residents at the facility. Facility Census 115. Findings Included: On 07/23/23 at 2:24 PM, the initial kitchen walk through occurred. [NAME] #34 was in charge of the kitchen that day due to it being a Sunday. Observation found the dishwasher temperature log did not have any documentation for the date of 07/22/23, on the afternoon section of the form. The reach-in refrigerator temperature log did not have documentation for 07/21/22, on the PM Time section of the form, or 07/22/23, for the PM Time section of the form. The reach-in freezer temperature log did not have documentation for 07/21/23, on the PM Time section of the form, or 07/22/23, on the PM Time section of the form. The walk-in refrigerator temperature log did not have documentation for 07/21/23, on the PM Time section of the form, or 07/22/23, on the PM Time section…

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

Based on observation, staff interview and record review the facility failed to maintain proper infection control standards during medication pass for Resident #8. This failed practice was a random opportunity for discovery and had the potential to affect only a limited number of residents. Resident identifier: #8. Facility census: 115. Findings included: During observation of medication pass for Resident #8 on 07/24/23 at 09:07 AM, Licensed Practical Nurse (LPN) #20 reached into Resident's medicine cup with her bare fingers, moved the pills around, and pulled out a Memantine capsule. LPN #20 then opened the Memantine capsule and sprinkled the contents into the medication pill crush pouch. LPN #20 stated, I have to crush her medications and mix them in in her protien smoothie to get her to take them. LPN #20 then proceeded to dump the remainder of the pills into the pill crush pouch, crushed the medications, and poured the contents into the Resident's protien smoothie. Record review of the facility's policy titled, Medication Administration revise date 01/01/23, showed that staff are…

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 make a call system accessible to the resident at each toilet and bath or shower facility, and should be accessible to a resident laying on the floor. This was a random opportunity for discovery. Resident Identifiers: Resident #90. Facility Census: 115. Findings Included: a) Bathroom Call Light During the initial tour of the facility on 07/23/23 at 3:23 PM the bathroom call system cord wrapped around the call system, not reaching the floor. During an interview on 07/23/23 at 3:26 PM Licensed Practical Nurse (LPN) #172 stated the cord is very tangled, she was unable to get it untangled and unable to get the cord to reach the floor. During another tour of the facility on 07/24/23 at 9:00 AM, the call light cord was wrapped around and was not accessible to the Resident if lying on the floor. During an record review on 07/24/23 at 11:00 AM, Resident #90's medical record revealed a care plan with an initiated date of 08/03/23, Focus: Resident #90's name is moderate risk for falls r/t(related to) Confusion. Resident #90 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.