Mountain View Care Center

Based on staff interview, observation and record review, the facility failed to ensure food was prepared and served in a manner that prevents food borne illness to the residents. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY.Findings included:a) On 10/12/2025 at 12:59 PM, the facility ran out of chicken and hamburger patties were substituted. [NAME] #73 went to the freezer and removed the hamburger patties and began frying them in a skillet.Cook #119 and [NAME] #73 did not take the temperature of the fried hamburger before placing it on the bun and placing it on the tray to be served to the residents The State Surveyor intervened and asked the cook to take the temperatures of two hamburger patties. The hamburgers patties straight from the stove top were tempt and were 149 degrees and 151 degrees. Food Safety. Gov stated beef should be cooked to 160 degrees and ground meat should be cooked to 165 degrees.b) [NAME] #119 told kitchen staff to put the two trays with the hamburgers that did not reach a safe temperature on 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 The facility failed to ensure residents heating, ventilation and air conditioning (HVAC) filter was free of debris. This was true for one (1) of six (6) HVAC units observed on the A Hall. Room identifier: 126-2. Facility census: 106.Findings included: On 01/14/25 at 11:30 AM, in the presence of the Maintenance Director (MD), he confirmed that the filters in room [ROOM NUMBER] had gray dust bunnies covering both HVAC filters. When asked who was responsible for cleaning the filters, the MD stated that the Housekeeping Department was responsible for cleaning the filters on a weekly basis.An additional interview with the Director of Housekeeping at 11:40 AM on 10/14/25 confirmed both HVAC filters needed to be cleaned as they were covered in gray dust bunnies. She stated that she would take care of this.

Based on record review and staff interview, the facility failed to assess and review significant weight loss and failed to obtain weekly weights per recommendation of Registered Dietician and the risk management. The facility failed to assess and provide care to a resident with significant weight loss. This deficient practice was identified for one(1) out of three(3) residents with reported weight losses. Resident identifier #28. Facility census: 106 Findings included; a) Resident #28 This resident was identified to have significant weight loss as documented in the Registered Dietician (RD) notes as follows, 1 month: 08/02/25- 144 pounds(#) (8#, 5.6%), 3 month: 06/02/25 149# (12.6#, 8.5%), 6 month: 3/4 162# (26#, 16%). The RD recommended double portions and check weights every 4 weeks. On 10/15/25 at 12:25 PM the Director of Nursing (DON) verified that weights were not completed. The DON stated I don't have an answer, weekly weights fall off when stable. Weights were as follows 10/02/25 140.2 pounds(#), 08/02/25 144#, 06/02/25 149#, and 03/04/25 162#. The facility failed to 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.

Based on observation, record review and staff interview, the facility failed to prepare food in the form to meet the individual needs of the resident as ordered by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #71. Facility Census: 106.Findings included:a) Resident #71 was ordered a Mechanical Soft texture diet with nectar thickened liquids. The resident was care planned for a Regular Diet, Mechanical Soft texture and Nectar-like fluids.b) On 10.14.2025, Resident #71 was served a pureed lunch meal. [NAME] #119 reported a resident on a mechanical soft diet would get chopped broccoli. At 11:50 AM, Acting Dietary Manager #72 confirmed the tray was pureed consistency and the tray was sent to the dining room without any changes

Based on record review and observation , the facility failed to provide drinks consistent with the resident's needs and diet order. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #39. Facility Census: 106.Findings included:a) Resident #39 had a physician's order for a puree diet and nectar consistency liquids. The resident's care plan stated to provide diet as ordered: Regular diet, puree texture, and Nectar liquids consistency.b) On 10/14/2025 at 12:40 PM, Dietary Aide #89 reported to the Director of Nursing the resident's drink was honey thick. The resident was given the honey thick liquid by the Director of Nursing (DON) in the dining room during the lunch meal. On 10/15/2025 at 11:16 AM, the resident's care plan was reviewed with the DON concerning the resident's consistency of liquids and that the resident received honey thickened liquids during the lunch meal the previous day.c) The facility's policy and procedure for thickened liquids stated that the order will specify the consistency of the resident's liquids and care…

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 a dignified dining experience. This was a random opportunity for discovery. Resident identifiers: #85, #547, #42. Facility census: #106. Findings include: a) Resident #85 On 02/17/25 at 12:35 PM Resident #85 was sitting with two (2) other residents at the dining room table. Resident #38 and #53 were served and being assisted with their meal at 12:35 PM. Staff continued to pass meal trays to other tables in the dining room. Resident #85 did not receive the meal until 12:43 PM after bringing it to the attention of the Director of Activities #41. It was confirmed with the Director of Activities #41 on 02/17/25 at 12:43 PM that Resident #85 had not been provided the right to a dignified dining experience. b) Resident #457 On 02/18/25 at 5:42 PM Resident #42 was a tablemate with Resident #457. Resident #42 was served her tray at this time, however Resident #457 was not served for thirty three (33) minutes afterwards, at 6:15 PM. At this time all other residents had left the dining room. This was confirmed with…

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 Council meeting, record review, and staff interview the facility failed to act promptly upon the grievances/concerns from Resident Council. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents during the Long-Term Care Survey Process. Facility census: 106. Findings include: a) Resident Council Meeting Minutes A review of the Resident Council Meeting Minutes on 02/18/25 at 10:00 PM, revealed a resident/family concern form dated 07/16/24 that had the following concerns listed from resident council: * Residents requesting drinks be passed with meals instead of before the meal trays make it to the hallways. * Repeated meals being served too frequently. * Directions not being followed on meal tickets. Likes/dislikes not being observed and/or monitored. * Menu does not match the meals being served. Would like an alternative on the menu also. Further review of the Resident Council Meeting Minutes revealed an impromptu (AD-HOC), Quality Assurance (QA) meeting was held on 07/25/24 at 2:00 PM as a response…

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 council interview, observation and staff interview the facility failed to have the results from the last standard survey posted in a place easily accessible by residents. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents during the Long-Term Care Survey Process. Facility census: 106. Findings Include: a) Resident Council During the Resident Council (RC) Meeting on 02/18/25 at 2:00 PM, the RC as a whole said that they did not know they had access to the findings from the last standard survey. During an interview and observation on 02/18/25 at 3:45 PM, at the desk at the front door, The Administrator pulled a book out from behind the desk and stated, It usually sits on the desk not behind it. The Administrator then looked at Receptionist #78 and stated, This book has to stay right here. During an interview on 02/18/25 at 3:48 PM, Receptionist #78 stated, This book has always been behind this desk, since I started here (3) three months ago.

Based on observations and staff and resident interviews, the facility failed to ensure a safe, clean, comfortable, homelike environment by not cleaning and sanitizing Resident #10's wheelchair, cleaning the kitchen ceiling and exhaust fan and cleaning the shower room's ceiling and peeling paint. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier: #10. Facility census: 106. Findings included: a) Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. On 02/26/25, Resident #10's wheelchair was found to have a dirty footboard with dried food-like substance and liquids. The dirty footborad was observed on 02/17/25 at 08:30 AM, 02/18/25 at 12:15 PM, 02/19/25 at 02:11 PM, and 02/24/25 at 9:20 PM. On 02/19/25 at 02:11, Licensed Practical Nurse (LPN) #111 was interviewed…

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

Based on observation and staff interviews the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident Identifier: #8. Facility Census: #106. Findings included: a) Unlocked medication cart On 02/16/25 at 11:00 AM observation of the treatment cart was sitting in the hallway by the conference room at the beginning of the A hallway. There were no staff members near the cart. There were residents near the unlocked, unattended treatment cart. It was confirmed with Licensed Practical Nurse #7 on 02/16/25 at 11:05 AM this was an accident hazard, at which time she agreed. b) Resident #8 Observation of Resident #8 on 02/16/25 between the hours of 5:30 p.m. to 6:30 p.m., revealed the facility reported an elopement of resident on 10/01/24. Resident lacked capacity and had a BIMS score of 3. The resident was assessed as an elopement risk on 09/30/24, 10/23/24, and and 02/14/25. Resident had a…

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

Based on record review and resident and staff interview, the facility failed to deploy sufficient nursing staff in order to meet resident needs. This has the potential to affect more than an isolated number of residents residing in the facility. Facility census: 106. Findings include: a) Record review During review of the facility's Payroll Based Journal (PBJ) data, the facility flagged for excessively low weekend staffing from the time period of 10/1/24-12/31/24. b) Resident interviews Multiple interviews were conducted with residents who, during the survey process, relayed concerns about staffing at the facility. On 2/17/25 at approximately 11:37 AM, an interview was conducted with Resident #14. Resident #14 stated Sometimes it takes hours for them to answer my call light. I got to where I would scream and yell when they wouldn't answer my light and they won't answer that now. There are times I will press my light and I will have to wait three (3) to five (5) hours. On 2/16/25 at approximately 12:04 PM, Resident #45 stated the following about facility staffing, Sometimes I will…

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 observation the facility failed to ensure residents were receiving food in the amount, type, and consistency to meet acceptable nutritional values. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifier #58, #20. Facility Census 106. Findings include: a) Resident #58 An observation on 02/17/25 at 12:37 PM, of Resident #58 eating lunch, revealed a meal ticket that had typed on it { Puree, Nectar Thick, Double portion all meals.} During an interview on 02/17/25 at 12:38 PM, Resident #58 non-verbally communicated that he wanted double portions by giving a thumbs up. During an interview on 02/17/25 at 12:40 PM, Nursing Assistant (NA) #122 stated, No, that is not double portions. I will go get him some more. During an interview on 02/17/25 at 12:45 PM, Certified Dietary Manager (CDM) #67 confirmed that Resident #58's tray did not include double portions. A record review on 02/17/25 at 2:10 PM, revealed a…

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

Based on Record Review, Observations and Resident Interviews, the facility failed to hold or serve food at acceptable/palatable temperatures. This failed practice had the potential to affect more than a limited number of residents. Facility census: 106. Findings included: a) The facility's Policy and Procedure for Food Temperatures stated, all hot items held and served at a temperature of at least 135 degrees Fahrenheit, hold foods at or below 41 F (degrees Fahrenheit) for cold foods or above 135 F (degrees Fahrenheit) for hot foods (to keep food out of the temperature danger zone) and Foods sent to the units for distribution (such as meals, snacks, nourishments oral supplements) will be transported and delivered to unit storage areas to maintain temperatures at or below 41 F (degrees Fahrenheit) for cold foods and at or above 135 F ( degrees Fahrenheit) for hot foods. a) On 02/18/25 at 05:55 PM, the temperatures of food provided on the test tray for D hall were completed and verified by Dietary [NAME] #124 included: Regular Steak- 118.6 French fries-110.9 Spinach-120 Pureed meat-…

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

Based on observation, record review, resident interview and staff interviews the facility failed to ensure residents' food likes and dislikes were honored and food substitutes of equal value were offered. Resident Identifiers: #25, #84, #79 and #68 Facility Census: #106 Findings Include: a) Resident #25 On 02/16/25 at 12:15 PM it was observed that Resident #25 had broccoli florets on the lunch tray. The meal ticket stated Dislikes/DO NOT SERVE as Broccoli Florets. It was confirmed with the Director of Activities #41 on 02/16/25 at 12:17 PM that Resident #25 should not have received broccoli, she agreed. On 02/18/25 at the lunch meal Resident #25 was served broccoli again as substitute for roasted Brussels sprouts. It was confirmed with Nurse in Training #108 that Resident #25 should not have received broccoli. On 02/18/25 at the dinner meal Resident #25 was served buttered spinach as a substitute for baby carrots. The meal ticket stated Dislikes/DO NOT SERVE as Buttered Spinach. It was confirmed with Licensed Practical Nurse Unit Manager #12 that Resident #25 should 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 record review, observation, and staff interview, the facility failed to provide ordered adaptive equipment to Residents #68 and 60 during meals. These were random opportunities for discovery. Resident identifiers: #68, #60. Facility census: 106. Findings include: a) Resident #68 During review of Resident #68's record on 2/17/2025, it was discovered the resident had the following order: Regular diet, Regular texture, Regular/Thin consistency doesn't eat turkey, fish, or chicken for plateguard with meals Diet Active 2/21/2024 12:16 10/18/2024. The resident had the following focus and intervention listed on her care plan: Focus- Resident is at potential nutrition risk r/t (related to) underweight BMI; medical dx (diagnosis) that may affect weight; intakes and nutritional status. Date initiated: 1/31/2024 Revision on: 1/7/2025. Interventions/Tasks- Plateguard with meals. Date initiated: 2/21/2024. During lunch service at approximately 12:15 PM on 2/18/2025, Resident #68 was served lunch with no plateguard. The Administrator acknowledged the Resident did not have a plateguard,…

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 store and label food, store utensils and ensure food preparation equipment was clean and sanitary in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility census: 106 Findings included: a) Kitchen Observation initiated 02/16/25 at 11:10 AM: Ice chest with scoop laying inside. Handwashing sink had soiled, wet cloth on it and eye wash station/sink had used gloves and a sponge in it. Dry Goods: a) Cart with open bag of Penne pasta was against the sinks - opened , not sealed and not dated. b) Three bags of pasta were found, not sealed and not dated. c) Dented can of pumpkin. d) Brownie base with no date e) Dry cereal in bowls and large plastic containers not labeled or dated. Contained: rice krispies. cornflakes, fruit loops and cheerios. f) Box of oil on the floor propping the door open to the dry goods pantry. g) Bread ([NAME]…

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

Based on observation, record review and staff interview, the facility failed to properly dispose of garbage in accordance with professional standards for food service safety and to ensure garbage was not hanging out of the trash can and on the ground below. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 106 Findings included: a) On 02/16/25 at 11:00 AM, the facility's trash dumpsters were observed with lids open, bags of trash overflowing and trash on the ground with items such as paper and gloves observed. This was confirmed by the Dietary Manager in Training (DMIT) at 11:10 AM. The DMIT reported the trash trucks ran on Mondays, Wednesdays, and Fridays. The Dietary Manager in Training (DMIT) asked if the dumpsters went against the kitchen.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interview, the facility failed to maintain accurate records for three (3) of 43 residents. The record was inaccurate pertaining to blood pressures for Resident #52. There was discrepancies between orders and the care plan for Resident #457, and daily meal percentages for Resident #106. Facility census: 106. Findings include: a) Resident #52 Resident #52 was admitted to the facility on [DATE] with the following order: NO BLOOD PRESSURE OR LABS in LUE (Left Upper Extremity). Restricted limb d/t (due to) AV fistula. Every shift. Resident #52 confirmed in an interview on 02/17/25 at approximately 12:15 PM that she had a dialysis access on her left arm. Upon review of the resident ' s medical record, it was determined the facility listed twenty-two (22) times they had taken blood pressure from Resident #52 ' s left arm. Those days are: 1/15/2025 11:00 132 / 76 mmHg Sitting l/arm 1/15/2025 14:47 124 / 70 mmHg Sitting l/arm 1/16/2025 02:24 130 / 74 mmHg Sitting l/arm…

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 resident and staff interviews, the facility failed to thoroughly investigate an allegation of abuse involving Resident #39. This was true for one (1) of nine (9) residents reviewed for abuse and neglect during the survey process. Resident identifier: 39. Facility census: 106. Findings include: During review of a facility reported incident (FRI), on 02/25/25, it was noted the facility reported an allegation of staff to resident abuse on 02/07/25. According to the FRI, a staff member was alleged to have yelled at Resident #39 after she slid out of her recliner and into the floor, stating, You shouldn ' t be getting up without asking for help.Resident #39's daughter reported the incident to the facility, further stating the employee Very roughly jerked Mom's arm and pulled her up out of the bed. The resident's daughter was not present at the facility at the time of the incident. The staff member was determined to to be Nurse Aide (NA) #5. NA #5 was suspended pending investigation. During review of the investigation conducted by the facility, it was noted…

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 accurate Minimum Data Set assessments for two (2) of 43 residents in the long-term care survey sample. Resident identifiers: #8 and #44. Facility census: 106. Findings included: a) Resident #44 Resident #44's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 12/31/24 coded a trunk restraint was used less than daily. Review of Resident #44's physician's orders showed no current or past orders for restraints. Review of the resident's comprehensive care plan showed no current or past focus or interventions related to restraints. On 02/18/25 at 4:57 PM, the Administrator acknowledged Resident #44's MDS with ARD 12/31/24 was incorrect in coding restraint use. b) Resident #8 Review of Resident #8's medical records showed the resident had a diagnosis of depression, unspecified, since 09/05/23. Review of Resident #8's physician's orders showed the resident had been receiving the medication trazodone for major depression since 08/14/24. Resident #8's Minimum Data Set (MDS) with Assessment Reference…

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 develop/implement a person centered care plan to meet and/or address the residents medical, physical, mental, and psychosocial needs. This failed practice was found true for (2) two of 43 care plans reviewed during the Long-Term Care Survey Process. Resident identifiers: #22 and #68. Facility census: 106. Findings include: a) Resident #22 The initial observation, on 02/17/25 at 10:25 AM, showed Resident #22 lying in bed with his head covered up with the sheet and his buttock sticking out of the sheet which revealed that Resident #22 was not wearing a brief. Further observation on 02/18 25 at 2:30 PM, revealed Resident #22 lying in bed with the sheet at his feet and no brief on at this time. An observation on 02/19/25 at 11:00 AM, revealed Resident #22 lying in bed with a sheet and his buttock sticking out of the sheet showing that Resident #22 did not have a brief on. An observation on 02/19/25 at 2:09 PM, revealed Resident #22 up to a Geri chair wearing a black, short sleeve one piece outfit. 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 record review, observation, and staff interview, the facility failed to revise the care plan for Resident #14 after the order for adaptive equipment during meals was not renewed. This was true for one (1) of 43 care plans reviewed during the survey process. Resident identifier: 14. Facility census: 106. Findings include: a) Resident #14 During review of Resident #14's record on 2/17/2025, it was noted the resident was care planned to have a Kennedy cup with all meals. However, no order for a Kennedy cup was found on the resident's record. Upon further review, it was noted the resident had a recent hospital stay and returned to the facility on 1/12/2025. Review of the resident's completed/discontinued orders revealed she had an order for a Kennedy cup with all meals before leaving for the hospital. After returning on 1/12/2025, the order for the Kennedy cup was not renewed, but the care plan was not updated. At approximately 12:45 PM on 2/25/2025, Licensed Practical Nurse (LPN) #21 confirmed Resident #14 did not receive a Kennedy cup with her meal. Resident #14 had not been…

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 conduct yearly evaluations on Nurse Aides (NA). This has the potential to affect more than a limited number of residents. Employee idenifier: Nurse Aide (NA) #4 Facility census: 106. Findings include: a) NA #4 During review of facility staffing documentation on 2/25/2025, it was noted Nurse Aide (NA) #4 had a hire date of 11/19/18, with their last evaluation being completed on 1/25/24. At approximately 12:00 PM on 2/26/25, the Regional Director of Operations (RDO) confirmed there was not a current performance review on file for NA #4.

Based on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. An insulin pen had not been discarded 28 days after opening. This was a random opportunity for discovery during the facility task of medication storage and labeling. Resident identifier: #56. Facility census: 106. Findings included: a) Resident #56 On 02/18/25 at 8:44 AM, the D Hallway medication cart was inspected with Licensed Practical Nurse (LPN) #26 in attendance. In the medication cart was a Novolog insulin pen for Resident #56. On the pen packaging, the date of opening of 01/10/25 was written in marker. An expiration date of 02/06/25 was also written in marker on the pen packaging. A pharmacy label on the Novolog insulin pen packaging stated the medication could be stored at room temperature for up to 28 days after opening. LPN #26 stated Resident #56 was still prescribed Novolog insulin. She acknowledged the insulin pen had been opened for more than 28 days and should not be used. Review of…

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

Based on record review and staff interview, the facility failed to perform laboratory testing according to physician's orders for two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #8 and #95. Facility census: 106. Findings included: a) Resident #8 Review of Resident #8's physician's orders showed an order written on 05/03/24 for laboratory testing consisting of a basic metabolic panel, complete blood cell count, lipid panel, and liver panel to be done every six (6) months, in April and October. On 02/19/25 at 2:25 PM, the Director of Nursing (DON) was asked to provide a copy of the laboratory testing results for October 2024, as it had not been scanned into the resident's electronic health record. The DON provided laboratory testing results for a basic metabolic panel, complete blood cell count, and lipid panel that had been performed on 10/08/24. The results did not contain liver panel studies. On 02/19/25 at 3:13 PM, the DON confirmed the physician's order to perform liver panel laboratory testing for Resident #8 in October…

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 establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Facility census: 106. Findings include: A) room [ROOM NUMBER] At approximately 1:50 PM on 2/17/2025, an observation was made in room [ROOM NUMBER] of the facility of dirty clothes lying on the floor of the bathroom. Housekeeping Aide #81 stated, One of the residents in there puts her clothes in the floor and the aides are supposed to pick them up when they go in there. At approximately 1:55 PM, MDS Nurse #15 confirmed the dirty clothes on the floor of the bathroom.

Based on record review and staff interview, the facility failed to ensure the medical director/designee attended quarterly Quality Assessment and Assurance (QAA) meetings. This had the potential to affect all residents that resided at the facility. Facility census: 109. Findings included: a) QAA meetings Review of the QAA sign in sheets, with the Administrator #56 at 2:40 PM, on 06/28/23 found the medical director/designee did not attend any QAA meetings in the first quarter of 2023. Meetings were held on 01/31/23 and 02/22/23. Review of the sign-in sheets found no indication the medical director or designee attended or was present by telephone, zoom, etc during these meetings. A meeting was not held in March 2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and facility documents, 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 failed practices were found in the areas of monitoring and prevention of Legionella, establish and implementing a surveillance program, donning appropriate Personal Protection Equipment (PPE) while providing care for residents placed in Enhanced Barrier Precautions, and using proper PPE when entering a Contact Isolation room. These failed practices had the potential to affect more than a limited number of residents who currently reside at the facility. Facility census 109. Findings included: a) Water management A review of the facility documents found the facility failed to take measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the buildings' water systems…

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 residents with orders for insulin received necessary treatment and services as per their physician orders. The facility failed to recheck blood sugar levels when they were above 400. This was true for one (2) of seven (7) residents reviewed. Resident identifiers: #18 and #503. Facility census: 109. Findings included: a) Resident #18 During an interview on 06/27/23 at 2:08 PM, Resident #18 reported he received insulin on a sliding scale. A medical record review, completed on 06/28/23 at 2:15 PM, revealed the following physician order: HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 999 = 12 units administer 12 units and recheck within 2 hours; if remains > 400, notify PCP [primary care physician] for further instruction; subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH KETOACIDOSIS WITHOUT COMA Start Date 05/30/2023 2100 Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #47 expressed to the surveyor he smoked at the facility without staff supervision and kept his own cigarettes and lighter. An interview with the Resident's Licensed Practical Nurse (LPN) #37 confirmed the Resident had asked her earlier in the day to take him out to smoke. The LPN's only response was, you know you are not allowed to smoke. Twenty seven (27) additional residents were identified as lacking capacity and being able to ambulate/wander throughout the facility. Any of the 27 residents could have obtained access to the cigarettes or lighter, potentially causing serious harm and/or death to self or others due to their cognitive impairments and decreased safety awareness. In addition, Resident #47 was at risk of serious harm and/or death from possible burns resulting from smoking off 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 facility record review, observations and staff interview the facility failed to display the daily staff posting at an accessible height for residents to view. This practice had the potential to affect more than a limited number. Facility census: 109. Findings included: a) Observations on 06/26/23 and 06/27/23 found the daily staff posting outside the Administrator's office approximately five feet from the floor. The CMS-672 form completed by the facility notes 50 of the current 109 residents are in a chair most of the time and only 20 of the 109 residents walk independently. On 06/28/23 at 11:58 AM, the Staffing coordinator reported there was only one staff posting in the facility and it is located outside of the Administrator's office. The staffing coordinator acknowledged the daily posting was approximately five feet from the floor and agreed it is too high for residents in wheelchairs to view.

Based on observation and staff interview the facility failed to ensure all multiple use vials and/or pens of insulin were dated with the initial date they were opened. This was true for six (6) out of nine (9) vials and/or pens in the Medication cart on the A hall. Resident identifiers: #553, #50, #19, #1, #34, #70, and #97. Facility census 109. Findings included: a) observation of the medication cart During an observation of medications in the A Hall medication cart on 06/27/23 9:00 AM, in the presence of Licensed Practical Nurse (LPN) #138, found six (6) out of nine (9) insulin vials/pens did not have an open date on the pens and/or vials. The insulin belonged to the residents listed below: Resident # 553 Lispro vial Resident # 50 Humalog vial Resident # 19 Novolog vial Resident # 1 Novolog Pen Resident # 34 Humalog Pen Resident # 70 Humalog Kwik pen Resident # 97 Lantus vial On 06/27/23 at 11:35 AM, the above findings were presented to Corporate Nurse #139. No further information was provided.

Based on observation, staff interview and resident interview, the facility failed to ensure food items were served at the preferable temperature for the residents. This has the potential to affect more than a limited number of residents. Facility census: 109. Findings included: a) Food temperatures At 12:50 PM on 06/27/23, the last tray to be served on D hallway belonged to Resident #69. Interim Dietary Manager (DM) #118, obtained the temperatures of the following food items: Pears were 59 degrees Broccoli - 120 degrees Meatballs with gravy - 120 degrees Corn -115 degrees. Coffee - 117 degrees DM #118 said she would like the temperature of hot foods to be at least 140 degrees and cold foods to be no more than 40 degrees at the time of service. DM #118 provided a copy of the food item temperatures obtained before the tray left the kitchen: The corn and broccoli were 175 degrees Meatballs and gravy were 167 degrees Fruit was 36 degrees. Several residents attending the Resident Council Meeting at 3:00 PM on 06/27/23, complained of cold food and coffee served at times, especially if…

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

Based on observation and staff interview, the facility failed to maintain properly stored and dated food. This had the potential to affect more than a limited number of residents. Census 109. Findings included: a) Kitchen On 06/26/23 at 10:55 AM, an initial walk through of the kitchen was conducted with #118, Interim Dietary Manager (DM.) One of the walk-in refrigerators had opened tomato soup stored in a clear container with a lid that did not seal. This green lid did not appear to fit the container and would not close. DM #118 stated the staff must have used the wrong lid. She got the correct lid for the container. At 10:56 AM, the same refrigerator was observed to have a package of Natural Choice sliced ham that was opened and wrapped in cling wrap. There was no expiration or open date on the ham. DM #118 confirmed it was not dated and threw it in the trash. At 10:59 AM, observation of the pantry found a 6.4 oz bag of cornbread stuffing seasoning sitting on the shelf, not boxed, without an expiration date. DM #118 confirmed there wasn't a date of expiration and threw the bag in…

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

Based on observation and staff interview, the facility failed to maintain proper garbage disposal. This had the potential to affect all residents residing at the facility. Census 109. Findings included: a) Dumpsters On 06/26/23 at 11:10 AM, the outside dumpsters were observed with Interim Dietary Manager (DM) #118. The top of the dumpster had two (2) missing lids, and one (1) lid was warped causing a gap of approximately 12 inches in length by approximately 8 inches in height between the dumpster rim and the lid. DM #118 confirmed the facility was aware of the missing lids and they were in the process of replacing them. DM #118 said that the missing lids had been like that for a week but she had not noticed the warped lid.

Based on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was part of the resident's medical record. This was true for one (1) of 26 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #30. Facility census: 109. Findings included: a) Resident #30 An electronic medical record review, completed on 06/27/23 at 11:20 AM, identified there was a Physician Determination of Capacity, dated 05/08/23, indicating Resident #30 lacked capacity to make her own medical decisions. There was no Medical Power of Attorney (MPOA) or Health Care Surrogate (HCS) form scanned in the electronic medical record. On 06//28/23 at 9:45 AM, review of Resident #30's medical chart at nurses station found there was no Medical Power of Attorney (MPOA) or Health Care Surrogate (HCS) form on file. During an interview on 06/28/23 at 10:00 AM, the Social Worker confirmed Resident #30 had never completed a Medical Power of Attorney (MPOA) prior to losing capacity. The Social Worker then stated to her recollection a Health Care Surrogate had…

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 representatives in a timely fashion when a residents experienced changes in condition, appointments were scheduled, x-rays were done, and new medications were ordered. This was true for two (2) of 25 residents reviewed in the Long-Term Care Survey Process. Resident Identifiers: #30 and #101. Facility Census: 109. Findings included: a) Resident #30 A medical record review was completed on 06/28/23 at 10:00 AM. The review revealed a Physician Determination of Capacity, dated 05/08/23, which indicated, Resident lacks capacity to appreciate the nature and implication of health care decisions. Further record review found the following instances where Resident #30's Health Care Surrogate (HCS) was not notified: -05/16/2023 at 1:18 PM Plan of Care Note, IDT [Interdisciplinary Team] Review for unwitnessed fall on 05/13/23 at 1:15 PM. Resident is alert and verbal. Resident has a DX [diagnosis] of left artificial knee, age related…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, observation, and staff interview, the facility failed to ensure residents had a safe/functional/sanitary and comfortable environment. The call light did not work in room [ROOM NUMBER]. Slats were missing from window blinds for rooms [ROOM NUMBERS]. Resident #90's wheelchair was in disrepair as well as a night stand for Resident #504. Resident identifiers: #38, #98, #90, #504. Facility census: 109. Findings included: a) room [ROOM NUMBER] During the resident council meeting which began at 3:00 PM on 06/27/23, Resident #38 said she resides in room [ROOM NUMBER]. She said her window blinds had missing slats that would allow people from the road outside to see inside her room. She also said the blinds did not open and close easily. Observation with Registered Nurse (RN) #114 on 06/07/23 at 3:56 PM, confirmed she could not get the blinds to open and close correctly and 2 slats were missing from the left side of the double window blinds. RN #114 said she was calling the maintenance man…

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 new Pre-admission Screening and Resident Review (PASARR) for a resident with newly evident or a possible serious mental disorder. This was true for one (1) out of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #1. Facility census 109. Findings included: a) Resident #1 A review of the medical record revealed Resident #1 last had a PASARR completed on 12/07/2015. No level II was needed. The PASARR noted the resident had a diagnosis of depression. On 01/26/23 Resident #1 received a new diagnosis of schizoaffective disorder and a new PASARR was not completed. During an interview with the Admissions Director (AD) on 06/28/23 at 11:44 AM, she confirmed the last PASSAR was completed on 12/07/2015. A new PASARR was not completed when the resident received a new diagnosis of schizoaffective disorder during her stay at the facility on 01/26/23. The AD said she was unaware that a new PASARR needed to be done. She went on to say she thought a resident…

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

Based on resident interview, staff interviews, observation, and record review, the facility failed to revise a care plan, for one (1) of six (6) residents reviewed for the category of accidents , during the long term care survey. Resident identifier #47. Census 109. Findings Included: a) Resident #47 A resident interview was conducted on 06/26/23 at 11:53 AM. The resident stated he did not like the smoking situation at the facility. The resident admitted to going off the property to smoke. The resident also stated he knows he is not supposed to but he keeps his lighter and cigarettes in his murse, attached to his wheelchair. (He defined a murse as a man purse). A follow up interview with the resident on 06/26/23 at 1:00 PM, confirmed the resident had been smoking at the facility for a while. He stated a previous administrator, (name of administrator), had a conversation with the resident about not being allowed to smoke at the facility. During a staff interview with LPN #37, on 06/26/23 at 2:02 PM, LPN #37 stated this resident asked her to take him out to smoke this morning but she…

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

Based on observation and staff interview, staff failed to administer medications via percutaneous endoscopic gastrostomy (PEG) tube according to professional standards. Crushed medications and flushes were pushed into the PEG tube and not administered by gravity flow. This was a random opportunity for discovery which has the potential to affect only a limited number of residents. Resident identifier: #22. Facility census: 109. Findings include: a) Resident #22 On 06/26/23 at 8:20 PM, Registered Nurse (RN) #67 crushed the following medications and mixed each with five milliliters (ml) of tap water in separate medication cups: Baclofen 10 milligrams (mg), Norco 5-325 mg, Labetalol 100 mg, and Atorvastatin 10 mg. RN #67 stopped the continuous feeding, pushing five ml of tap water with a large piston irrigation syringe. RN #67 pushed each med diluted with five ml of tap water with a five ml push of tap water in between. RN #67 flushed the PEG tube with a push of 50 ml of tap water and then restarted the continuous feeding. During an interview on 06/27/23 at 1:47 PM, the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, observation, and staff interview, the facility failed to ensure two (2) of 109 Residents had a functioning call system to alert staff when assistance was needed. Resident identifiers: #98 and #38. Facility census: 109. Findings included: a) Resident #38's interview During the resident council meeting which began at 3:00 PM on 06/27/23, Resident #38 said the call light system was broken in her room. Resident #38 said some men came in here to work and tore it up. Resident #38 said she looked out after her roommate and in the past had called for help for the roommate. Observation with Registered Nurse (RN) #114 on 06/07/23 at 3:56 PM confirmed neither the call light for bed A (Resident #98) or bed B (Resident #38) was working. RN #114 said she was calling the maintenance man to get it fixed. On 06/28/23 at 10:35 AM, observation of the call light system in room [ROOM NUMBER] with the Administrator #56 found the call system was still not working. The Administrator said Resident #38 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to ensure the [NAME] Virginia Physician Orders for Scope of Treatment (POST) forms were completed correctly for eight (8) of nine (9) residents reviewed during the long term care survey process. Resident identifiers: #5, #18, #16, #79, #65, #73, #82 and #76. Facility census: 83 Findings included: a) Resident #5 On [DATE] at 10:00 AM a record review found the POST form dated [DATE] directed cardiopulmonary resuscitation (CPR) - Attempt resuscitation including mechanical ventilation, defibrillation and cardioversion with full treatments was not completed appropriately. On [DATE] at 10:15 AM an interview with the Director of Nursing (DON) confirmed the POST form was not completed correctly due to missing information relating to the residents address and social security number. On [DATE] at 10:49 PM a review of the Physician Determination of Capacity form dated [DATE] indicated the Resident does not have capacity. According to [NAME] Virginia Center…

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 shower room was clean and homelike on the Bluebird Hall. This was a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 83. Findings Included: During an observation of the Blue Bird Hall shower room on 02/23/22 beginning at 3:33 PM and ending at 3:43 PM with the maintenance director the following issues were observed: -- The vent in the ceiling after entering the shower room door was covered with dust. -- The vent in the corner in the ceiling by the toilet was covered in dust. -- The heater grate in the ceiling was covered in dust. -- The light fixture was broken and hanging down. It had three (3) pieces of medical tape on the fixture where someone had attempted to tape it back up, but it was still hanging down from the light. -- The Cove Base molding was peeling away from the wall and a black substance was observed underneath the molding on wall. The maintenance director agreed the bathroom needed some work. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to notify the Long Term Care Ombudsman of resident discharges from the facility. This was true for three (3) of three (3) residents reviewed for the care area of hospitalizations during the long term care survey process. Resident Identifiers: #336, #79, and #68. Facility Census: 83. Findings included: a) Resident #336 A review of Resident #336's medical record found Resident #336 was discharged to the hospital on [DATE]. Review of the Social Worker's log of transfers from the facility for 07/2021, found Resident #336's name but no proof of Ombudsman notification. In an interview with the Social Worker on 02/24/22 at 12:20 pm she stated she does fax them to the Ombudsman, but has no record to indicate the Ombudsman received the fax. b) Resident #79 A review of Resident #79's record was completed on 02/22/22. The resident was sent to the emergency room on [DATE] at 9:15 AM for a decreased level of consciousness, increased blood pressure, increased…

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 each resident and/or representative with the bed hold policy at the time of discharge. This was true for three (3) of three (3) residents reviewed for the care area of hospitalization during the long term care process. Resident Identifiers: #336, #79, and #68. Facility Census: 83. Findings included: a) Resident #336 Review of the medical record found no bed hold policy for Resident #336's transfer to the hospital on [DATE]. In an interview on 02/23/22 at 3:03 PM the Social Services Director stated we don't have a bed hold policy and I don't inform the ombudsman when they leave. During an interview with the Administrator on 02/23/22 at 3:12 PM, he stated we don't have a bed hold policy, we just keep their bed, we are never at 90% capacity so we don't need a policy. We always let them come back. b) Resident #79 A review of Resident #79's record was completed on 02/22/22. The resident was sent to the emergency room on [DATE] at 9:15 AM 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, staff interview and resident interview the facility failed to provide care required to maintain adequate hygiene to residents who were dependent on staff for Activities of Daily Living (ADL) care. Resident identifiers: #78, #54, and #55 Facility census: 83 Findings included: a) Resident #78 On 02/22/22 at 11:08 AM the Resident stated she was waiting on a shower and she is suppose to get one twice a week. The Resident wasn't sure if the showers were scheduled or not. Her hair was disheveled and she was in a night gown. Upon confirmation with the Director of Nursing (DON) on 02/24/22 at 10:14 AM a shower schedule for the Resident was provided. She only had one shower a week scheduled on Thursdays, day shift, although her choice was two showers per week on Tuesday and Thursday. On 02/24/22 at 10:14 AM the DON provided the Residents shower task sheet. Record review shows the resident only received two (2) showers from her admit date of 01/26/22 through 02/24/22. She should have received nine (9) showers during this time period. This was confirmed with the DON on…

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

Based on observation, record review, staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for three (3) of three (3) Residents reviewed for the Activity Care Area during the long term care survey process. Resident Identifiers: #18, #16, and #82. Facility Census: 83 Findings Included: a) Resident #18 During an interview on 02/22/22 at 12:59 PM, Resident #18 stated what activities, we don't have activities. They do nothing around here. Maybe come talk to me in my room. A review of the monthly activity calendar for December 2021 showed no weekend activities. A review of the monthly activity calendar for January 2022 and February 2022, contained no times for any of the scheduled activities, there were no evening activities and no activities scheduled on Saturday and Sunday. During the Long-Term Care Survey Process, activities were being provided that were not on the large wall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, and staff interview the facility failed to provide care in accordance with professional standards of care. This was true for four (4) of 30 sampled residents reviewed during the long term care survey process. Resident identifiers #79, #336, #67, and #136. Facility census: 83. Findings included: a) Resident #336 The facility failed to provide medical intervention for Resident #336 in a timely manner. Resident #336 had a fall on 07/07/21, the resident complained of pain after the fall on 07/07/21, and did not have an x-ray until 07/13/21 which showed a left hip fracture. In a late entry progress note dated 07/07/21 at 3:33 PM Resident #336 replied (typed as written) .No, I can't get up. I fell earlier and it will hurt if I stand up The Medication Administration Record (MAR) found on 07/11/22 at 8:02 pm Resident #336 received Tylenol 650 mg for leg pain. A progress note dated 07/13/21 at 7:58 pm (typed as written) Resident has been very tearful and emotional this shift. She…

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

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 three (3) of three (3) residents reviewed during the long care survey process for the care area of Oxygen. Resident identifiers: #67, #74, and #28. Facility census: 83 Findings included: a) Resident #67 On 02/22/22 at 11:23 AM an observation found Resident #67's oxygen tubing for the nasal canula was not dated with a change out date. This was confirmed with the Director of Nursing (DON) on 02/22/22 at 11:25 AM. The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated with the date it was changed. b) Resident #28 Observation of Resident #28's room on 02/22/22 at 11:05 a.m. found oxygen tubing with a nasal canula laying on the resident's bed with no date that would verify when the tubing was changed. In an interview with temporary Nurse Aide (NA)#7 at 11:05 am on 02/22/22, NA #7 confirmed the tubing should have 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 observation and staff interviews, the facility failed to store food in a safe and sanitary manner. The foods stored in the kitchen and nourishment refrigerators were not labeled correctly and foods were not discarded when they expired. The facility also failed to keep dishes in an sanitary area, and to keep kitchen equipment clean. This failed practice had the potential to affect more than a limited number of residents currently receiving nutrition from the facility's kitchen. Facility Census: 83 Findings Included: a) Walk-in Refrigerator During an initial tour of the kitchen with the Dietary Director (DD) beginning on 02/22/22 at 11:00 AM, the following issues were found in the walk-in refrigerator: --Minced Garlic in a jar with an open date of 02/04/22 and had no use by date. --Lemon Juice with an open date of 02/07/22 and had no use by date. --Soy Sauce with an open date of 09/24/21 and had no use by date. --Italian Dressing which was open and not dated to indicate when it was opened and had no use by date. --17 individual packages of cream cheese with a manufacturer…

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 develop and implement an infection control program designed to prevent the spread of disease and illnesses. This process had the potential to affect more than an isolated number of residents. Resident identifiers # 75 and #76. Facility census: 83. Findings included: a) Resident # 75 During an observation of medication administration by Licensed Practical Nurse (LPN) # 94 on 02/24/22 at 8:30 am, LPN #94 failed to place a clean barrier on the bed of Resident #75 prior to sitting the plastic bag the eye drops were stored in, and the eye drops bottle on the bed. After administering the eye drops, the bottle was then placed back in the bag, and the bag was placed back into the medication cart where other resident's medication were stored. In an interview on 02/24/22 at 2:30 pm the Director of Nursing (DON) confirmed a clean barrier should have been used prior to placing medication on the resident's bed. b) Resident #76 An observation on 02/22/22 at 11:45 a.m. during the lunch meal pass on the Bluebird Lane hallway found…

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

Based on observation and staff interview, the facility failed to main equipment in a safe operating condition. Two (2) ice machines did not have a one (1) inch air gap for drainage. The steamer was leaking water around the seal and onto the a shelving unit containing clean dishes. The walk in freezer had a bucket on the top shelve for draining water because the drain to the outside of the freezer was not working properly. This failed practice had the potential to affect more than a limited number of residents currently receiving nutrition from the kitchen. Facility Census: 83 Findings Included: During an initial tour of the kitchen with the Dietary Director (DD) on 02/22/22 beginning at 11:00 am found the following issues. -- The ice machine in the service hallway and in the kitchen area, did not have a one (1) inch air gap to prevent contamination of back flow. --The steamer was leaking water onto a shelving unit containing clean steam table pans. The DD stated,The steamer is leaking around the seal. We need to get a new one. --The inside of the walk in freezer had a bucket on the…

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

Based on record review, staff interview, and resident interview the facility failed to ensure residents were given the opportunity to make choices regarding their bathing preferences and bathing schedules. Resident identifier: #78. Facility census: 83. Findings included: a) Resident #78 On 02/22/22 at 11:08 AM the Resident stated she was waiting on a shower and she is suppose to get one twice a week. The Resident wasn't sure if the showers were scheduled or not. Her hair was disheveled and she was in a night gown. Upon confirmation with the Director of Nursing (DON) on 02/24/22 at 10:14 AM a shower schedule for the Resident was provided. She only had one shower a week scheduled on Thursdays, day shift, although her choice was two showers per week on Tuesday and Thursday. On 02/24/22 at 10:14 AM the DON provided the Residents shower task sheet. Record review shows the resident only received two (2) showers from her admit date of 01/26/22 through 02/24/22. Resident #78 should have received nine (9) showers during this time period. This was confirmed with the DON on 02/24/22 at 10:17…

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

Based on record review and staff interview the facility failed to report falls which resulted in serious bodily injury to appropriate state agencies as required. These were random opportunities for discovery. Resident Identifiers: # 336 and #30. Facility Census: 83. Findings included: a) Resident #336 A review of Resident #336's medical record found, Resident #336 had a fall in the facility in the shower room on 07/07/21. The facility obtained an order on 07/14/21 for: New order for x-ray to Left leg, Right leg, and pelvis. The facility received the xray results on 07/14/21 at 3:00 pm. The results were typed as written: Note Text: X-ray results obtained. Pelvis, Acute displaced Left femoral neck fracture noted. Right Femur, No acute osseous abnormality. Recommend repeat x-ray or CT (Computerized Tomography Scan) in 1 week or sooner if symptoms have not not resolved. Left Femur, fracture of the femoral neck with superior displacement of the distal fragment. PCP (primary care physician) notified. Review of the reportable incidents for the month of 07/2021 found no evidence this…

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

Based on observation, record review and staff interview, the facility failed to ensure their narcotics were reconciled every shift. This was a random opportunity for discovery. This had the potential to affect more than an isolated number of residents. Facility Census: 83. a) Medication Administration On 02/24/22 at 8:20 AM, a review of the narcotic count book was completed. The following dates were missing signatures between shifts: --02/18/22 7:00 AM shift to 7:00 PM shift --02/22/22 7:00 AM shift to 3:00 PM shift A review of the Controlled Substances Policy states At the End of Each Shift: .Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together . On 02/24/22 at 8:40 AM, the Director of Nursing (DON) confirmed the narcotic count book was missing signatures. The DON stated I'll get some education and in-services going right now. No further information was obtained during the survey process. .