Cedar Ridge Center

Based on record review and staff interview, the facility failed to complete the quarterly assessments for restraint usage for Resident #6. This was true for one (1) of one (1) residents reviewed under the care area of restraints. Resident Identifier: #6. Facility Census: 117. Findings Include: a) Resident #6 On 02/18/26 at 8:30 AM, a record review was completed for Resident #6. The review found the following physician's order dated 04/22/25, Restraint: Positioning device/belt to w/c (wheelchair) while up in w/c for dx (diagnosis) of Cerebral Palsy and involuntary movements of core/ trunk area. Release device/belt every 2 (two) hours for repositioning every 2 (two) hours for seat belt to chair. Also, the review found the last restraint evaluation/reduction was completed on 05/29/25. The evaluation/reducation should be completed quarterly. On 02/18/26 at 10:20 AM, the Administrator was notified and confirmed the evaluation was not completed quarterly. b) Policy On 02/18/26 at 9:45 AM, a review of the facility policy entitled, Restraints: Use of was completed. Under section 6, states,…

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 develop a comprehensive care plan for one (1) of 24 residents reviewed in the long-term care survey sample. Resident identifiers: #3. Facility census: 117. Findings included: a) Resident #3 Review of Resident #3's medical records showed diagnoses of post-traumatic stress disorder (PTSD) and exposure to disaster, war and other hostilities were documented on 01/20/26. On 02/17/26, the following focus was initiated on the resident's comprehensive care plan: Resident reports past experience of trauma as evidenced by: Feeling upset when reminded of a stressful experience from the past related to PTSD. On 02/18/2026 at 11:27 AM, Corporate Nurse #156 confirmed Resident #3 had not been care planned for PTSD until 02/17/26. No further information was provided through the completion of the survey process.

Based on record review and staff interviews th facilty failed to revise care plans related to one (1) on one(1) activities and PEG tube length. This failed practive was found true for two (2) of 24 residents care plans reviewed during the Long Term Care Survey Process. Resident identifiers: #50 and #47. Facility Census: 117Findings include: a) Resident #50 On 02/16/26 at 11:27 AM a Review of the participation record for Resident #50 showed most activities Provided were one-on-one activities. further record review of Resident #50's care plan revealed nothing in the care plan for Resident #50 to receive one (1) on (1) activities. Record review completed on 02/17/26 Revealed the one (1) on one (1) list provided from Activity Director (AD) #14 showed the resident was on the one (1) on one (1) program list to receive one (1) on one (1) activities. During an Interview with AD #14 on 02/17/26 at 3:40 PM she confirmed the one-on-one activities were not in the resident's care plan. b) Resident #47 Review of Resident #47's physician's order showed an order written on 02/06/26 to check the…

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

Based on record review, resident interview, and staff interview, the facility failed to follow a physician's order for oxygen settings for Resident #20. Facility census 117. a) Resident #20. Based on observation, interview, and record review, the facility failed to ensure services were provided in accordance with physician orders. Specifically, the facility failed to ensure oxygen was administered at the ordered rate. On 02/18/26 at 9:19 a.m., observation of Resident #20 revealed oxygen delivered via nasal cannula at 4 liters per minute. Record review of the physician's orders indicated an active order for oxygen at 2 liters per minute via nasal cannula. On 02/18/26 at 9:19 a.m., interview with Nurse #111 confirmed the oxygen was set at 4 liters per minute and verified the current physician order was for 2 liters per minute. An interview with the Director of Nursing (DON) indicated that any increase in oxygen flow rate would require documentation of a change in condition and updated physician orders. However, as of 9:40 a.m. on 02/18/26, review of the medical record did not reveal…

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

Based on record review and staff interview, the facility failed to ensure the posted daily nurse staffing information was accurate for one (1) of 20 days reviewed, resulting in incorrect staffing and census information being displayed. Facility Census: 117Findings include:Review of the facility's nurse staffing posting on 02/18/26 for staffing dated 07/06/25 showed the posted Hours Per Patient Day (HPPD): 2.19 and the posted facility census: 109 residentsDuring surveyor review, the facility administrator provided verified staffing documentation and census reports showing actual HPPD for 07/06/25 was 2.58 and actual facility census for 07/06/25 was 105 residentsDuring an interview the discrepancies were reviewed with the facility administrator On 02/19/26 at 11:00 AM when the administrator confirmed the staffing posting contained incorrect HPPD and census information.

Based on observation and staff interview the facility failed to ensure the residents received the proper portion sizes. This failed practice has the potential to affect more than an isolated number of residents and was a random opportunity for discovery found during the completion of the dining observation pathway during the long-term care survey process. Resident #44 and #91. Facility Census: 117. Findings include: a) The Healthcare Services Group policy 004 titled Menus shows the following: Menus will be planned in advance to meet the nutritional needs of the residents / patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Menu Cycles will include standardized recipes. Menu cycles will include nutrient analysis to ensure that all clients nutritional needs are met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academics, and the Dietary Guidelines for Americans, 2020 - 2025 edition. Menus will be served as written,…

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

Based on observation, record review, resident interview, and staff interview, the facility failed to ensure that the resident's received a therapeutic diet for a renal diet and the 2 gram sodium diet. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #42, #56, #80, #78, #132, # 90, #98, #105 and #117 . Facility census: 117.Findings include: a) 02/18/2026 12:15 PM A review of Healthcare Services Group (HCSG) policy 008 titled Therapeutic Diets revealed Therapeutic diet is defined as a diet ordered by a physician, or delegated registered licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of the therapeutic diet is to eliminate or decrease specific nutrients in the diet, or to increase specific nutrients in the diet. All nine (9) residents that were on a Renal diet and / or the 2 gram sodium diet, did not receive low sodium marinara meat sauce for the lunch meal on 02/28/2026, as per the recipe and diet guide used by the facility, The tray ticket also showed that they…

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

Based on record review and staff interview, the facility failed to ensure a complete and accurate comprehensive care plan in the area of medication refusals. This deficient practice had the potential to affect one (1) of three (3) residents in the survey sample. Resident Identifier: #111. Facility Census: 110.Findings included:a) Resident #111Review of Resident #111's medication administration record (MAR) and progress notes showed the resident began refusing medications on 09/04/25, the day after admission to the facility. Medications refused included atorvastin for hyperlipidemia, dapagliflozin for diabetes, divalproex for depression, famotidine for gastroesophageal reflux disease, insulin for diabetes, losartan for hypertension, melatonin for sleeplessness, metformin for diabetes, metoprolol for hypertension, and trazodone for depression. The medication refusals were frequent. On 11/13/25, the following focus was written on Resident #111's comprehensive care plan, Resident/Patient is resistive to care related to: Alzheimer's Disease hx [history] of resisting care, refusing…

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 complete and accurate medical records. Psychiatric telemedicine notes contained an inaccurate history of present illness (HPI) for Resident #111. This was a random opportunity for discovery. Resident Identifier: #111. Facility Census: 110.Findings included:a) Resident #111 Review of Resident #111's medical records showed the resident was seen by psychiatric telemedicine services on [DATE], [DATE], and [DATE]. Each of the notes written during these sessions had the following paragraph for history of present illness (HPI): 92 -year-old widowed female with a hx [history] of dementia, depression, anxiety. She was initially admitted to [facility] on [DATE] after an acute hospital stay at [hospital name]. [Resident's name] ambulates without assistance. She has three children, one is deceased . Son, [name] is HCS [health care surrogate] and supportive. However, the resident's age, admission date, first name, and HCS's name were incorrect in 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 and staff interviews, the facility failed to maintain an environment free of accident hazards for 1 out of 26 residents. Facility census 112. Scope and Severity D On 11/11/25 at approximately 11:07 p.m., observed a medicine cup with 1 pill in it located on the bedside table of resident #8. I then notified the Director of Nursing (DON) to come to the room and verify that there was a medication cup with 1 pill in it on the bedside table. The DON verified that the medication cup was on resident #8 bedside table. The DON and myself went and checked 26 residents (Rms 1-16) and there was only 1 out of 26 residents that had the medication cup with meds left at their bedside. The DON verified that medication pill pass was performed by employee # 81. The medication identified was a 1/2 tab of Senokot.On 11/11/25 at approximately 11:08 p.m., interview the DON verified that employee #81 did leave a medication cup with a 1/2 tablet of Senokot on the bedside table of resident #81. This deficiency was also again verified by the DON and acknowledged by the Administrator upon…

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

Based on record review and staff interview, the facility failed to ensure that narcotics in the facility were managed and controlled in a safe manner. This is true for eleven (11) of eleven (11) residents reviewed during the survey. All residents that receive pain medication in the facility have the potential to be affected. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning. This did occur, however due to the facility identifying the missing medications and replacing them immediately for the Residents that remained in the facility no Residents were harmed by this incident. Resident Identifier: #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12. Facility Census: 112 Findings Include:a) Residents #11 and #12Resident #11On 10/15/25 at 9:10 AM, record review of a reportable facility incident revealed that on 06/28/25 when a staff member attempted to reorder Resident #11's Hydrocodone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to complete all Physicians orders for wound treatment. This was true for one (1) of three (3) residents reviewed during this investigation. Resident Identifier: #1 Facility Census: #112 Findings Include:a) Resident #1On 10/16/25 at 9:10 AM record review of Resident #1 orders and Treatment Administration Records (TAR) for August, September and October 2025 found missing documentation as shown below. All orders and TAR's were reviewed for the period of 08/01/25 - 10/31/25. None of the following Physician orders were completed on 10/09/25, 10/16/25, 10/21/25 or 10/22/25.Clean DTI (deep tissue injury) to left buttocks with wound cleaner, pat dry, apply skin prep to area and leave open to air every day shift.Clean left outer foot (amputation site) with wound cleaner, pat dry, apply Betadine and leave open to air every day shiftClean venous ulcer to left dorsum 1st digit (hallux) with wound cleaner, pat dry, apply Betadine and leave open to air every day…

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

Based on observations and resident and staff interviews, the facility failed to deploy sufficient direct care staff to meet the needs of the resident population of the facility. This had the potential to affect all residents residing in the facility. Resident identifiers: #94, #58, #51, #85, #91, and #84. Facility census: 111. Findings include: a) Resident #94 On 04/13/25 at approximately 3:09 PM, an interview was conducted with Resident #94. Resident #94 stated the facility was very understaffed. Resident #94 said, They keep telling me they're hiring people, but no one ever stays. The ones that don't do their job, they keep because they can't keep other people, so they have no choice but to keep them. At approximately 9:05 PM on 4/14/25, the call light for Resident #94's room was observed ringing in the North Hall of the facility. At approximately 9:16 PM, Resident #94 was observed yelling Hello multiple times from inside his room, but did not receive an answer. During this time, Licensed Practical Nurse (LPN) #36 and Nurse Aide (NA) #21 were on the hallway. LPN #36 was passing…

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 the residents' right to to receive mail on Saturdays was honored. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 111. Findings included: a) The facility's policy and procedure stated, The Recreation Director or designee will: .1.2 Ensure that mail is delivered to the person unopened or postmarked (for outgoing mail) within 24 hours, including Saturdays. b) On 04/14/25 at 02:05 PM during the Resident Council Meeting, the residents reported that mail was not delivered on Saturdays. c) On 04/15/25 at 10:13 AM, the Administrator confirmed mail was to be delivered on Saturdays. The Administrator stated, Mail was supposed to be delivered. She reported the two activities directors will begin working the weekends since they had recently had an assistant leave and there are two open positions in that department. The Administrator reported she will educate and begin an audit for the residents to receive mail timely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow administration directions for medications prescribed for the control of phosphorous levels for dialysis patients. This was true for 5 of 5 residents on dialysis. Resident Identifiers: Residents #33, #88, #94, #105 and #108. Facility census:111. Findings Include: a) Resident #33 Record review and interview on 04/13/25 at 2:35 PM revealed, Resident #33 is a [AGE] year-old female on hemodialysis diagnosed with the following conditions: Chronic systolic heart failure Chronic respiratory failure with hypoxia Type 2 diabetes mellitus with polyneuropathy End-stage renal disease on hemodialysis Dilated cardiomyopathy History of nicotine dependence Hypertension Morbid obesity Gastroesophageal reflux disease Anemia A review of the resident's medication orders on 04/15/25 at approximately 11:55 AM revealed Resident #33 was prescribed: Renvela Oral Tablet 800 MG (Sevelamer Carbonate). Give 3 tablets by mouth before meals for end stage renal…

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 each resident received the proper portion size of pork during the evening meal on 04/16/25. This failed practice has the potential to affect more than an isolated number of residents and was random opportunity for discovery found during the completion of the kitchen pathway during the long-term care survey process. Facility Census: 111. Findings Include: On 04/16/25 at 5:32 PM the surveyor was observing meal service from the steam table in the facility's kitchen. [NAME] #130 was serving the food from the steam table. She was observed using tongs to serve the pork. The Director of Operations (DOO) was asked how she was sure the pork she was serving was two ounces (OZ) she stated she should be using a 2 oz scoop and not tongs. She corrected the situation; however, the North Short Hall and the South Short Hall had already been served. A review of the menu found each resident should be served 2 ounces of pork.

Based on observation and staff interview the facility failed to ensure all residents received meals at regular times comparable to normal mealtimes in the community. The lunch meal on 06/04/25 was served 45 minutes late to 19 residents due to the facility running out of prepared food. This was true for Resident #95, #3, #68, #60, #90, #21, #29, #24, #56, #6, #61, #5, #41, #79, #38, #58, #36, #45, and #49. Facility Census: 101 Findings Include: a) An observation of the lunch meal began at 12:00 PM on 06/04/25 found the facility was serving ham, macaroni and cheese and beets as the main meal for the residents. At 1:10 PM [NAME] #1 stated, I ran out of food. I'm going to have to make more. The Corporate Director of Operations then began preparing and directing the staff on what to make to continue to the feed the remaining 18 residents. The Corporate Director of Operations, indicated they did not know what happened. They said they made more than the production sheet called for but was still short on servings. The final resident was served at 1:56 PM on 06/04/25 which was 46 minutes…

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 interview, the facility failed to ensure infection control procedures were adhered to in the residents' shower room. This failed practice had the potential for infection of a limited number of residents. This was true for one (1) of two (2) shower rooms inspected during the survey process. Facility Census: 111. Findings included: a) During an inspection of the male and female shower rooms, accompanied by Licensed Practical Nurse (LPN) #26 on 04/14/25 at approximately 1:20 PM, five bottles of unlabeled shampoo bottles were observed in the male shower room. LPN #26 confirmed the bottles of shampoo were not labeled with any resident names. On 04/14/25 at approximately 2:30 PM, the Director of Nursing (DON) confirmed all unlabeled shampoo bottles had been removed from the shower room.

Based on observation and resident interview, the facility failed to ensure Resident #94 was treated in a dignified manner, by allowing him to sit in a soiled brief for an extended period of time. This was a random opportunity for discovery. Resident Identifier: 94. Facility census: 111. Findings included: A) Observation At approximately 9:05 PM on 4/14/25, the call light for Resident #94's room was observed ringing in the North hall of the facility. At approximately 9:16 PM, Resident #94 was observed yelling Hello multiple times from inside his room, but did not receive an answer. During this time, Licensed Practical Nurse (LPN) #36 and Nurse Aide (NA) #21 were on the hallway. LPN #36 was passing medications and NA #21 was observed going back and forth between other resident rooms. At approximately 9:20 PM, NA #21 went to a soiled linen bin outside of Resident #94's room, at which time he yelled , Can I get an aide please? NA #21 placed items into the soiled linen bin, walked down the hallway, and did not acknowledge the resident. At approximately 9:23 PM NA #13 entered the Hallway…

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 interview, the facility failed to ensure the resident's right to voice a grievance to the facility without fear of reprisal for Resident #58. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifier: #58. Facility Census: 111. Findings included: a) Policy Review The facility's policy and procedure stated, The patient/resident (hereinafter patient) has the right to voice grievances to the Center or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding their Center stay. b) Resident Council A resident Council Meeting was held on 04/14/25 at 02:05 PM. The residents expressed you couldn't voice a concern at times without worrying that someone will get back at them. Several residents reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and record review, the facility failed to ensure Resident #26 and Resident #70 were not neglected. Resident #70 asked for a snack for over 30 minutes she was eventually given a snack but it was the wrong consistency. The nurse aide then had to take it from her which upset the resident. The facility also failed to give Resident #26 his medication even though it was available in the pyxis machine. This was true for two (2) of seven (7) residents reviewed for the care area of abuse during the long term care survey. Resident Identifiers: #70 and #26. Facility Census: 111. Findings Included: a) Resident #26 An interview with Resident #26 on 04/13/25 at 2:44 PM found the Licensed Practical Nurse's (LPN) often let him run out of medication and he don't get it until it comes in from the pharmacy. When asked if knew what medications he runs out of he stated, I don't know the names of them, but I know one of them was for my restless leg syndrome. He indicated it…

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

Based on record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) for Resident #13 upon discharge from the facility. This was true for one (1) of thirty-eight (38) residents. This was a random opportunity for discovery and was true for Resident #13. Resident Identifier: #13. Facility Census : 111. Findings included: a) Resident #13 Resident #13's date of stay was from 10/23/24 through 11/11/24. The following Minimum Data Sets were completed for Medicare: Entry/MDS 3.0, Medicare 5 -Day/MDS 3.0 and admission -None PPS/MDS 3.0. A discharge MDS was not found during the record review. On 04/16/25 at 1:34 PM, the state surveyor interviewed MDS Coordinator #77. MDS Coordinator #77 confirmed a discharge MDS had not been completed. The MDS Coordinator stated, I did miss it. and We will fix it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure the care plan was implemented regarding pain management interventions for Resident #42, and regarding tracheostomy care for Resident #111. This was true for two (2) of 38 resident care plans reviewed during the survey process. Resident identifiers: #42, #111. Facility census: 111. Findings included: a) Resident #42 Resident #42 is receiving hospice services due to an end stage diagnosis of History of CVA (cerebrovascular accident). Resident #42 has an order for: Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 10 mg by mouth every two (2) hours as needed for pain/dyspnena. Give 0.50 ML. Hold for Sedation 0.50 ml, every two hours as needed for pain. At approximately 11:30 AM on 4/13/25, during observations in the North hall of the facility, Resident #42 was observed to be yelling out. Review of the resident's record on 4/13/25, it was noted some indicators for pain were yelling out, restlessness, tenseness. Resident #42…

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

Based on observation, record review, residen interview, staff interview, and facility policy review, the facility failed to assist dependent residents with activities of daily living (ADL's) in accordance with the residents assessed needs for care. This was true for two (2) of five (5) residents reviewed for ADL care.Resident Identifiers: #416 and #85. Facility Census: 111. Findings Included: a) Resident #416 On 04/16/25 at 11:28 AM, a review of Resident #416's toileting / toileting hygiene documentation in November 2024 found: --Day shift- three (3) entries of 97- Not applicable in 30 days. --Evening shift- three (3) entries of 97- Not applicable in 30 days. --Night shift- 12 entries of 97- Not applicable in only 30 days. During an Interview on 04/16/25 at 12:08 PM the Director of Nursing (DON) verified there was no documentation that Resident #416 received Toileting hygiene as needed. b) Resident #87 At approximately, 12:45 PM on 4/13/25, an interview was conducted with Resident #87. During the interview, the resident was asked if he received assistance from the staff 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 record review, observation, staff interview and resident interview, the facility failed to follow a physician's order for no straws for Resident #10 and failed to ensure Resident #26 received medication as ordered. These failed practices had the potential to affect more than a limited number of residents. Resident Identifiers: #10 and #26. Facility Census: 111. Findings included: a) During the initial interview process on 04/14/25 at 11:00 AM, the state surveyor observed a straw in Resident #10's water pitcher. Additional observations with the straw in the resident's water pitcher were completed at 12:16 PM, and 12:40 PM. The resident reported she drinks water out of the pitcher. Review of the resident's eating task found the resident to be set-up to independent for eating. At 12:50 PM, Registered Nurse #69 reported the resident had no straws because they were a high risk for aspiration. The straw was not removed at that time. The straw was observed to be removed from the water pitcher at 1:18 PM. Registered Nurse #69 stated, I know her well. At 01:45 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 observation, interview, and record review, the facility failed to notify the physician of a newly admitted resident's indwelling catheter, and failed to obtain a physician's order for the care and maintenance of the catheter. In addition, the facility failed to provide the appropriate catheter care to prevent potential Catheter Associated Urinary Tract Infections (CAUTI's). This was true for one (1) of five (5) residents reviewed for catheter care. Resident Identifier: #266. Facility census: 111. Findings Included: a) Resident #266 During an interview on 04/13/25 at approximately 2:14 PM, Resident #266 stated she was looking forward to getting her catheter removed. Upon being asked if the facility provided catheter care, resident stated the staff usually emptied her catheter bag when it filled up. A review of the Minimum Data Set (MDS) data presented to the surveyors upon entry indicated Resident #266 was admitted to the facility on [DATE]. The MDS did not show Resident #266 had an indwelling urinary…

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 upon record review and staff interview, the facility failed to ensure resident received mental health referral and treatment. This was true for 1 (one) of 38 (thirty-eight) residents reviewed during this annual survey process. Resident identifier: #110. Facility census: 111 Findings included: A) Resident #110 A review of Resident #110's medical record found the following: Diagnosis Included: Post traumatic stress disorder Anxiety Disorder Depression A review of the MDS quarterly assessment on 04/03/25, recorded the following: Section D - Mood D0160: Total severity score of 18 D0170 Social Isolation was marked as always feeling lonely or isolated from those around you. Section E - Behavior Verbal behaviors towards others occuring 4 - 5 days per week Section I - Active Diagnoses Psychiatric/Mood Disorder: Anxiety Disorder Depression Post Traumatic Stress Disorder The most recent PASARR: Was completed on 02/04/25 by (Name of Local Hospital) and contained the following: Q23 Medical conditions/symptoms: Mental disorders None Section III: MI/MR Assessment Current diagnosis: None is…

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

Based on record review and staff interview the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled to enable them to identify and correct any possible drug diversions. There were some discrepancies related to Resident #97's controlled substance log. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #97. Facility Census: 111. Findings Include: a) Resident #97 A review of Resident #87's medical record on the morning of 04/16/25 found the resident was ordered Hydrocodone 5-325 by mouth every 6 hours for pain, The medication administration record for the month of 03/2025 and the month of 04/2025 along with the controlled substance log coinciding with these months was requested. Upon review of the MAR and the controlled substance log it was found on 03/21/25, a nurse signed out…

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 interview, the facility failed to ensure the attending physician reviewed and acted on the Consulting Pharmacist's recommendations. In addition, the facility failed to ensure that the physician reviewed and documented a response to the recommendations. This was true for five (5) of five (5) residents surveyed. Resident Identifier: Resident #17, # 28, #53, #74 and #87. Facility Census: 111. Findings include: a) Resident #17 On 04/14/25 at 3:11 PM a review of the Consulting Pharmacist's review for Resident #17's medications revealed the following: The Consulting Pharmacist's medication review on 09/20/24 showed the following recommendations: Resident is on Quetiapine 25 MG at bedtime for muscle weakness. This is not an appropriate diagnosis. Recommendation: An antipsychotic medication should be used only for the following conditions/diagnoses. Please check the appropriate indication for this resident: Huntington Disease Mood disorders (e.g. bipolar disorder, severe depression refractory to other therapies and/or with psychotic features) Medical illnesses…

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 Resident #70's medication regimen was free from unnecessary antipsychotic medications. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the long-term care survey process. Resident identifiers: #70. Facility's Census: 111. Findings Include: a) Resident #70 On 04/14/25 at 9:05 PM the facility was entered on the night shift due to resident complaints of care on the night shift. Upon entrance to the facility Resident #70 was observed sitting in the doorway of the Cafe, the resident was yelling for help and asking for a snack. She later began asking for a specific snack of a peanut butter sandwich. Numerous staff were in the area and could have easily heard her asking for a snack. This continued until about 9:33 PM when Nurse Aide (NA) #55 walked by and she asked her for a peanut butter sandwich. NA #55 then stated to another employee, I think she is puree I will get her an apple sauce or pudding in just one (1) minute. Shortly after 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 interview, the facility failed to update orders to discontinue dialysis access care, and monitoring of the dialysis access graft/fistula. In addition, the facility failed to update orders and a care plan when a C-collar was discontinued. Resident Identifiers: #88, and #10. Facility Census: 111. Findings Include; a) Resident #88 During an interview, on 04/15/25 at approximately 1:20 PM, Resident #88 stated the dialysis access in her right upper arm was no longer patent. The resident stated he now had a dialysis catheter in her right upper chest, which was used during hemodialysis treatments. Record review on 04/15/25 at approximately 2:15 PM revealed the following order dated 10/08/24: External hemodialysis catheter 2 lumens (location) right chest wall with transparent dressing. DO NOT Change END caps. Further record review revealed the following orders dated 08/31/24: AV fistula/graft location: right upper extremity Change AV fistula/graft site dressing every Thursday Monitor AV fistula/graft site for S/S infection, edema, bleeding and upon…

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

Based on observation, record review, and staff interview, the facility failed to ensure bed rails were implemented within accepted standards of care. Three (3) of three (3) residents reviewed for the care area of bed rails did not have current orders for bed rails. One (1) of three (3) residents reviewed for the care area of bed rails did not have valid informed consent for bed rails. Resident identifiers: #12, #15, #96. Facility census: 111. Findings include: a) Policy and Procedures The facility's policy titled Bed Rails with effective date 07/01/18 and revision date 09/01/22 stated if the Bed Rail Evaluation determines that the patient would benefit from side rails, an order for the bed rails would be obtained from the physician or advanced practice provider (APP). The policy also stated informed consent would be obtained from the resident or, if applicable, the resident representative. b) Resident #12 Based on observation, record review, and staff interview, the facility failed to ensure bed rails were implemented within accepted standards of care. Three (3) of three (3)…

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 foot care was provided to dependent residents. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of foot care. Resident identifier: #12. Facility census: 111. Findings include: a) Resident #12 On 07/18/24, The Office of Health Facility Licensure and Certification received that Resident #12's toenails had not been cut since he was admitted to the facility. Review of Resident #12's medical records showed the resident was admitted in February 2024. The resident had a diagnosis of type 2 diabetes mellitus. No nail care was documented in the medical records. On 08/28/24 at 9:08 AM, Resident #12's toenails were observed with assistance from Registered Nurse (RN) #59. They were somewhat long. The left great toe was discolored and was cream and light gray colored. RN #59 stated the podiatry service comes to the building every three (3) months. RN #59 stated Resident #12 would be seen by podiatry on their next visit. Review of the facility's…

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

Based on record review, staff interview and observation, the facility failed to provide adequate supervision to residents and to maintain an environment free of accident hazards. This failed practice was found true for (1) one of (1) one resident reviewed for accident hazards during the survey process. Resident identifier: #111. Facility Census 111. Finding Include: a) Resident #111 A review of the facilities reportables, on 08/29/24 at 8:45 AM, revealed a reportable dated 06/28/24 alleging Resident #11 was witnessed drinking from a bottle of wound cleanser which was left on the crash cart. A record review on 08/29/24 at 8:50 AM, revealed a general progress note date 06/28/24 which read as follows: Resident was witnessed drinking from a bottle of wound cleanser; another resident reported to nursing resident had consumed content from a bottle, staff immediately responded; Resident denied pain or distress; no obvious signs of GI discomfort noted upon assessment; resident denied burning or discomfort to mouth; mouth care provided; resident continued to repeat I am o.k.; Resident has…

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 received treatment and care in accordance with professional standards of practice. Physician-ordered medication parameters were not followed. This deficient practice had the potential to affect (1) of four (4) residents reviewed during the investigation. Resident identifier: #39. Facility census: 110. Findings included: a) Resident #39 Resident #39 had the following physician-ordered medication parameters: - Amlodipine besylate, 10 mg, one (1) tablet by mouth one (1) time a day for hypertension. Hold for pulse below 60 or SBP [systolic blood pressure] less than 110 or DBP [diastolic blood pressure] less than 70 and notify provider, ordered on 02/23/23. - Propranolol, 20 mg, one (1) tablet by mouth two (2) times a day for hypertension. Hold for pulse below 60 or SBP less than 110 or DBP less than 70 and notify provider, ordered on 01/08/24. According to the resident's Medication Administration Record (MAR), at the following dates and times, amlodipine besylate was administered despite the resident's…

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

Based on observation, record review and staff interview, the facility failed to ensure services to meet professional standards of care. A medication labeled by the pharmacy to be used for a specific resident was used for another resident. This was a random opportunity for discovery found during medication administration observation. Resident identifiers: #4 and #52. Facility census: 110. Findings included: a) Residents #4 and #52 The facility's policy titled Medication Administration General Guidelines dated January 2024 gave the following procedure: - Medications supplied for one resident are never administered to another resident. On 07/18/24 at 7:38 AM, Licensed Practical Nurse (LPN) #28 was observed administering medications to Resident #4. The resident had an order written on 06/25/24 for Lactulose, 10 grams in 15 milliliters concentration, give 45 ml by mouth two (2) times a day for hyperammonemia (high ammonia level). LPN #28 could not find lactulose for Resident #4. There was an unopened Lactulose bottle with a label for Resident #52. The Lactulose concentration was 10 grams…

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 staff interview and record review, the facility failed to provide a qualified activity professional for recreational services. This failed practice was a random opportunity for discovery and had the potential to affect all residents. Facility census: 110. Findings included: a) Activity Professional On 12/12/2023 at 3:00 PM the appointed Recreation Director (RD) #105 stated she has not had the activity professional qualification course but was set to have it in the upcoming January 2024 class. During an Interview on 12/13/2023 at 10:00 AM the Administrator stated the RD was enrolled into the Modular Education Program for Activity Professionals (MEPAP) course in November 2023 through National Certification Council for Activity Professional (NCCAP). Record review showed a copy of the enrolment email for RD #105 to attend the (MEPAP) course with an enrollment date of 11/03/23. During an interview on 12/13/23 at 11:03 AM Activity Consultant Certified (ACC) #301 Instructor verified the facilities recreation director was enrolled in MEPAP the course starting January 8th, 2024. ACC…

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 review, record review and staff interviews, the facility failed to ensure resident to resident altercations were reported to all the proper State Agencies. This is true for four (4) of ten (10) incidents reviewed for resident to resident alterations. Resident Identifiers: Resident #83, Resident #92, Resident #79, Resident #40, Resident #95, Resident #11 and Resident #54. Facility Census: 110. Findings Included: A review of a facility policy titled OPS300 Abuse Prohibition: with a revision date of 10/24/22 read as follows. .Process: .7.4 Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source) suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury. .9. The Administrator or designee will: .9.2 Report findings of all the completed investigations within five (5) working days to the Department of Health using the state on-line reporting system or state approved forms. A 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.

Based on record review and staff interviews, the facility failed to ensure one (1) of four (4) residents reviewed, who were unable to carry out activities of daily living, received services to maintain personal hygiene. Resident Identifiers: Resident #105. Facility census: 110. Findings included: a) Resident #105 During a record review on 09/26/23 at 7:30 PM, Resident #105 medical record reviews revealed a showers schedule indicated Resident #105 should receive showers on Mondays, Wednesdays and Saturdays. Further record review revealed Resident #105 received showers on the following days: -09/02/23 -09/06/23 -09/10/23 -09/13/23 -09/16/23 -09/18/23 Bed Bath -09/22/23 Bed Bath This documentation indicated Resident #105 did not receive a shower on the following scheduled days and was coded Not Applicable: -09/04/23 -09/09/23 -09/11/23 -09/18/23 -09/20/23 -09/23/23 -09/25/23 During the record review on 09/26/23 8:02 PM, Medical record review revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/23 revealed the following: Section G, titled Activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician-ordered medication parameters were not followed for one (1) of three (3) residents reviewed receiving antihypertensive medications. Resident identifier: #105. Facility census: 110. Findings included: a) Resident #105 Review of Resident #105's physician's orders showed an order written on 09/08/23 for carvedilol 3.125 mg, one (1) tablet by mouth, two (2) times a day, for hypertension, at 8:00 AM and 8:00 PM. The medication was to be held if the resident's blood pressure was less than 110/60 or heart rate below 60. Review of Resident #105 Medication Administration Record (MAR) for September 2023 showed the resident's blood pressure was not recorded on the [DATE]/08/23, 09/09/23, and 09/10/23. According to the MAR, the resident's carvedilol had been administered at 8:00 AM on 09/08/23, at 8:00 AM and 8:00 PM on 09/09/23, and at 8:00 AM and…

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

Based on observation, record review and staff interview, the facility failed to provide nutritional adequacy by providing inconsistent portions of the food to maintain perimeters of health. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility census: 110. Findings included: a) Inconsistent Portions During a tour of the kitchen on 09/26/23 at 12:30 PM with the Director of Dining Services (DDS)#23 revealed the following issues: -During the observation [NAME] #27 was preparing the lunch meal trays from the serving steam table of meatball subs. The meatball subs were getting two (2) meatballs, some three (3), then she was cutting some in half and placing them on the buns. The DDS #23 stated the meatballs are not the 4 ounce size called for on the menu, I think those are bigger, was unable to tell this surveyor how many ounces was being provided to each resident. The menu stated two (2) four (4) ounce meatballs. -Cook #23 was serving french fries with a gloved hand and placing them on the Resident's plate,…

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, staff, and resident interview, the facility failed to ensure Resident #6 was provided with the appropriate supplemental oxygen. This failed practice was true for one (1) of three (3) residents reviewed for oxygen therapy. Resident identifier: #6. Facility census: 118. Findings included: Record review showed an order with start date of 10/31/22 for Oxygen at 2 liters/minute via Nasal Cannula continuous, every day and night shift. On 09/14/23 at observation was made of Resident #6 eating lunch in the dining hall sitting in her wheelchair. Resident #6 was noted not have any supplemental oxygen in use. Resident #6's wheelchair did not have any portable O2 attached for use and no portable tank was located within the dining area belonging to the Resident. Licensed Practical Nurse (LPN) #45 was present in the dining room and verified Resident #6 was not wearing O2. LPN #45 stated, I have never seen [resident's first name] wear O2 while up in her wheelchair, but if the order says continuous then it should be on. Record review showed Resident #6 to have…

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

Based on observation and staff interview, the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards for food service safety. This had the potential to affect all Residents at the facility. Facility census: 115. Findings included: a) Observation the the kitchen area At 8:10 AM on 08/02/23 a tour of the kitchen with the Dietary Manager (DM) #109 found the following: Walk in refrigerator - approximately 2 inches from the floor extending upward on the entire length of the outside of the door was a black substance with dirt and debris. The baseboards in the corners of the door had a black substance littered with debris from the floor extending upward about 2 inches from the floor. DM #109 said the door was rusted; however, the baseboards on either side of the door were rubber and had the black substance also. Rags were found stuffed in a hole at the base of the wall in the dish room. The DM said water leaked through the hole in the wall and the rags were to stop the leaking. A metal serving pan was on the floor under the 3…

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 provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Hand washing was not provided for residents prior to meals. In addition, a bloody bandage was found on the floor in a resident room. These were random opportunities for discovery and have the potential to affect more than an isolated number of residents who reside at the facility. Facility census: 115. Findings included: a) Observation of the morning meal on 08/01/23 At 8:07 AM on 08/01/23, observation of the morning meal being served on the long hall of the North wing found staff provided no hand hygiene prior to the meal. Nursing assistants (NA's) #75 and #14 as well as Licensed Practical Nurse (LPN) #52 stated they have no means to sanitize the Resident's hands. The staff members stated hand wipes were once on the trays…

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

Based on observation, resident interview, and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The carpet in the hallways and the activity room was heavily soiled. This had the potential to affect all residents at the facility. Facility census: 115. Findings included: a) Observation of the Carpet At approximately 10:00 AM on 08/01/23, observation of the carpet on North hallway long and short hall and South hallway long hallway with the Environmental Services Director (ESD) #101 found the following: The carpet on the North side of the facility was heavily soiled. Many large black spots, some as big as dinner plates were present on the carpet on the North side of the building. Long streaks of black marks extended the length of the carpet on the hallway. The carpet at the entrances to each resident room was gray in color and heavily stained. The carpeted area around the north nurses was soiled and littered with paper and food debris. The carpet was a black/gray color outside the doorway 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.

Based on observation and staff interview, the facility failed to ensure the daily staff posting was correct. This had the potential to affect more than an isolated number of residents. Facility census: 115. Findings included a) Observation of staff posting At 8:13 AM on 08/01/23, observation of the staff posting for 08/01/23 with nurse Aide (NA) #75 on the South hallway found the posting reflected the nursing staff working was: 9.94 NA's, 5 Licensed Practical Nurses, and 4 Registered Nurses. The day shift census was not completed. At 9:30 AM on 08/01/23, the Director of Nursing (DON) confirmed only 9 NA's were working, the facility had a staff member who called in and the staff posting was not updated when the number of nurse aides changed. She confirmed the facility census was 115, which was not documented on the posting form.

Based on observation, staff interview and resident interview, the facility failed to ensure menus were followed. This had the potential to affect more than an isolated number of residents. Facility census: 115. Findings included: a) Observation of the tray line At 8:15 AM on 08/02/23, the cook, Employee #99 was observed serving the morning meal. The food items being served were cereal, oatmeal, eggs, and bread. E #99 was asked if the residents were going to receive any meat with breakfast. E #99 said the regular diets got bacon but the facility ran out of bacon. Employee #99 said, I don't have any sausage because today is food truck day and we ran out of that also. E #99 served the last of the food items on the steam table with the last tray. E #99 was asked, what would happen if residents wanted more food. She stated, I guess I would have to cook some more food. At 8:25 AM on 08/02/23, the cook was informed by a nursing assistant, the facility had a new admission last night - Resident #118 and Resident #118 never received a tray. The Resident was to receive a regular diet. E #99…

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, staff interview and resident interview the facility failed to maintain an environment free from flies and gnats. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #22, #79, #100, #51. Facility census: 115. Findings included: a) Resident #22 08/01/23 at 10:02 AM Resident #22 asked if the State was going to make them [the facility] do anything about these gnats and flies. Resident #22 stated, If I don't hold my tray [meal tray] down they will carry it off before I get it ate. Resident further stated the flies in his room aggravate him at night while he trying to sleep, landing on his face and nose. Resident said he keeps the air turned up on high, so the flies will not be landing on and around him as much. The Surveyor observed several flies on the resident's over the bed table, with one fly positioned on the resident's drink cup. Resident #22 has capacity and Brief Interview for Mental…

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

Based on review of the facility's grievance concern forms and staff interview, the facility failed to ensure a prompt response to a resident grievance/concern. This was true for one (1) of 35 grievances reviewed. Resident identifier: #106. Facility census: 115. Findings included: a) Resident #106 Review of the grievance/concerns forms on 08/01/23 found the following grievances/concerns made by Resident #106 on 03/20/23: -Resident reports that 2-3 weeks maybe a month, there was a big deal about a Saturday night shower. A nurse asked about why he was washing up in the sink, she asked about his shower. He states he was not asked about a shower. The CNA (certified nurse assistant) told the nurse the resident refused. The resident stated he was never asked. -Several weeks ago, a new catheter was placed and it was bothering the resident. Resident stated it took a few days before they changed it again. -One evening he asked to be changed at 9:30 PM. One girl said she would be back, and she did come back to provide care. A male came in and stated he would be back, he did not come back for 5…

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

Based on resident interview, staff interview, and record review, the facility failed to ensure one (1) of four (4) residents reviewed, who were unable to carry out activities of daily living, received services to maintain personal hygiene. Resident identifier: #76. Facility census: 115. Findings included: a) Resident #76 During a resident council meeting, requested by the residents, at 10:00 AM on 08/02/23, Resident #76 stated no one would get her up for her showers. She said because no one would get her up, she did not get her showers. She said she had not had a shower for at least a week. She stated, she did not refuse any showers. Record review found the most recent quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/19/23 found the resident Brief Interview for Mental Status (BIMS) score was 15. A score of 15 was the highest score obtainable and indicated the resident was cognitively intact. At 11:45 AM on 08/02/23, the resident's shower schedule was reviewed in the electronic medical record with the Administrator. Documentation found the resident's…

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

Based on observation, record review, staff, and resident interview, the facility failed to ensure Resident #100 had diabetic medication available for administration. This failed practice was a random opportunity for discovery and had the potential to only affect a limited number of residents. Resident identifier: #100. Facility census: 115. Findings included: a) Resident council meeting On 08/02/23 at 10:00 AM, the Resident's requested the surveyors attend a special Resident council meeting. During the meeting, Resident #100 said she takes Trulicity and the medication has not been available for the last 2 weeks. Trulicity is a once - weekly injectable prescription medication used to improve blood sugar (glucose.) She says she is supposed to receive an injection every Wednesday, but the nurses just tell her they do not have the medication. b) Medication Review On 08/02/23 at 11:25 AM Licensed Practical Nurse (LPN) #25 was asked to verify Resident #100's Trulicity medication was available for administration at 10:00 PM on 08/02/23. LPN #25 stated the Trulicity was stored in the…

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

Based on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The dumpster area was polluted with garbage and used medical supplies. This has the potential to affect all residents that reside in the facility. Facility census: 115. Findings included: a) Dumpster area An observation on 03/21/23 found the dumpster area was polluted with garbage and used medical supplies. On 03/21/23 at 10:50 AM during an Interview with the Maintenance Director , he stated the trash has been out around the dumpster for years. He continued to say it is because the staff leave the lid /doors open on the dumpster and the animals get in the dumpster and drag it out.

The facility failed to ensure the person who was explaining the binding arbitration agreement to the residents and the residents representatives understood the agreement and was able to explain the agreement correctly. The admission coordinator was not aware the binding arbitration agreement waived the residents right to a trail by a judge and jury. This failed practice has the potential to affect every resident currently residing in the facility. Facility Census: 115. Findings Included: a) A review of the binding arbitration agreement found the following: .THIS AGREEMENT WAIVES THE RIGHT TO TRAIL BY JURY. PLEASE READ CAREFULLY BEFORE SIGNING. 1. Arbitration. Arbitration is an alternative means of resolving a dispute without involving the courts. The parties agree Arbitration is a property right. In using Arbitration, the dispute is heard and decided by one or more neutral individuals called Arbitrator. The dispute will not be heard or decided by a jury. You have the right to be represented by a lawyer in Arbitration. Arbitrators can award the same damages and other individualized…

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 Quality Assessment and Assurance Committee failed to correct quality deficiencies of which it was aware. This deficient practice had the potential to affect all residents residing in the facility. Resident census: 115. Findings included: a) Cross reference F 584 b) Cross reference F 804 c) Cross reference F 814 d) Interview with Administrator During an interview on 03/23/23 at 11:24 AM, the Administrator stated she had received a complaint regarding the water temperatures in the facility. The Administrator stated the water temperatures had been checked following the complaint and was within acceptable limits. The Administrator also stated the facility had been working on improving the food served to the residents. Interventions implemented included interviews with residents and families, training for kitchen staff, and having staff taste test the food being served. The Administrator stated she believed the food had improved. During the interview, the Administrator also stated the facility had been aware of the trash…

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 meaningful participation by the Medical Director in the Quality Assessment and Assurance (QAA) Committee. The Medical Director or designee did not attend quarterly QAA meetings. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115. Findings included: a) Quality Assessment and Assurance Committee meetings During an interview 03/23/23 at 10:03 AM, the Administrator stated the Quality Assessment and Assurance (QAA) Committee meets every month. Sign-in sheets were reviewed for the last year. For the QAA Committee meetings held on 06/22/22, 07/27/22, 08/22/22, and 09/22/22, there was no evidence the Medical Director or designee had attended these meetings. The Administrator confirmed there was no evidence that the Medical Director or designee had attended QAA Committee meetings at least quarterly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure three (3) of 37 residents reviewed during the long-term care survey process had a the right to request, refuse and or discontinue treatment and to formulate an advanced directive. A Physician Order for Scope of Treatment Form (POST Form) was not completed to Honor a resident's decision to refuse documented, directives of life sustaining wishes. The POST forms were unsigned by the Resident or Medical Power of Attorney (MPOA), A POST form was not updated when a Resident regained capacity. Resident identifiers: Resident #267, #25 and #103. Facility census: 115. Findings Included: a) Resident #267 A medical record review on [DATE] at 2:48 PM found Resident #267's had a POST form with the following directives: --Section A Cardiopulmonary Resuscitation Order. Attempt Resuscitation, including mechanical ventilation, defibrillation, and cardioversion. --Section B Initial Treatment Orders. Full treatments, goal the attempt to sustain life by all…

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, anonymous resident interviews, and Resident council meeting, documentation, and staff interview the facility failed to ensure a safe, clean, comfortable, homelike environment. Water temperatures were at a comfortable temperature, also there were holes in the shower floor, and a black substance on the shower wall. This failed practice has the potential to affect more than isolated number of residents. Facility census 115. Findings included: a) Comfortable water temperature On 03/20/23 at 2:52 PM, there were many residents during the initial interview process who complained about the temperature of the water for showering. These residents said it did not matter what time of day it was at best the water felt lukewarm and on cold days the water feels colder. A Resident council meeting was on held with the residents 03/21/23 at 2:00 PM, there were eight (8) residents in attendance. The residents were very boisterous about the water temperature not being warm enough to be comfortable. During an interview on 03/21/23 at 4:13 PM, Maintenance Director (MD) was asked 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 record review, resident interview, and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for three (3) of 37 residents reviewed in the long-term care survey sample. Resident identifiers: #88, #47, and #103. Facility census: 115. Findings included: a) Resident #88 Resident #88's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 02/23/23 showed the resident had received no antibiotics during the seven (7) day look back period. Review of Resident #88's Medication Administration Record (MAR) for February 2023 showed the resident had received the antibiotic piperacillin/taxobactam intravenously 02/17/23 through 02/22/23. During an interview on 03/22/23 at 10:53 AM, the Clinical Reimbursement Coordinator confirmed Resident #88's MDS assessment with ARD 02/23/23 was incorrect and should have indicated the resident received six (6) days of antibiotic during the look back period. b) Resident # 47 A record review of the quarterly MDS which was completed in February 2023 indicated Resident #47 had not received…

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 develop and or implement a comprehensive care plan for five (5) of 37 sampled residents. Resident Identifiers: #64, #96, #1, #17, and #20. Facility Census: 115. Findings Included: a) Resident #64 An observation of Resident #64 during the noon time meal on 03/20/23 and 03/21/23 found the resident was served her meal in a Styrofoam container and had plastic utensils to eat with. All other residents were not served on Styrofoam. An interview with the Director of Nursing (DON) on 03/23/23 at 8:51 am found Resident #64 is served on Styrofoam with plastic utensils because she has tried to stab the nurses with a fork so they put this intervention in place as a result of the behavior. The DON referred to a physicians order dated 01/31/23 which read as follows, feed assist as resident will allow. Please put meal in Styrofoam. no metal utensils. The DON was asked to review Resident #64's care plan to determine if this intervention had ever been added to the comprehensive care plan. After…

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

Based on record review, staff interviews, and resident interviews the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care for six (6) of 37 residents in the sample. Resident identifiers #103, #23, #82, #1, #17, and #5. Census 115. Findings Included: a) Resident Identifier #103 Electronic Record review on 03/21/23, revealed a care plan that stated the following: .Resident lacks capacity to make his own medical decisions; mom is HCS (health care surrogate). Resident/Patient or healthcare decision maker shall participate in decisions regarding medical care and treatment x (times) 90 days . On 03/23/23 at 10:15 AM a Staff Interview was conducted with social worker (SW) #95. SW #95 states the resident does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview, the facility failed to provide activities of daily living (ADL's) to maintain good personal hygiene for dependent residents and failed to provide catheterization for a dependent Resident. This is true for three (3) of eight (8) resident reviewed for ADL care. Resident Identifiers: #95, #20, and #5. Facility census: 115. Findings included: a) Resident #95 During an interview on 03/20/23 at 11:19 AM, Resident #95 stated she doesn't get her showers as ordered or her preference. A continued record review of Resident #95's quarterly 02/08/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status) indicates physical help with bathing. MDS Section E (Behaviors) also indicated Resident #95 does not reject care. A review of Resident #95's ADL documentation found, no showers noted on 12/28/22, 01/21/23, 02/12/23 and 03/12/23. On 03/23/23 at 10:03 AM the Infection…

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 interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of the resident smoking area had a help button which was not effective and also had or lightening should the residents go outside after dark. In addition fall precautions were not implemented and the grab bars in resident bathrooms were loose and not properly affixed to the wall. Resident Identifiers: # 67, #52, #42, #40, #61, #76, #23, #89, #95, #60, #103, #56, #24, #69, #63, #84, #9, #97, #41, #417 and #66. Room Identifiers 38 and 44. Facility census: 115. a) Resident smoking area 1) Safety Alarm On 03/21/23 at 12:15 PM two 2 surveyors pushed the help button in the Resident designated smoking area, no staff came to answer the help signal. At 12:42 PM on 03/21/23 the help button was pushed again, no one answered the help signal in the Resident designated smoking area. On 03/21/23 at 12:50 PM the help button…

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, record review and Policy and Procedure review the facility failed to provide respiratory care and services within standard principles of practice. This was true for four (4) of four (4) residents reviewed for the care area of respiratory care. Resident Identifiers: #104, #21, #17 and #47. Facility Census: 115 a) Resident #104 On 3/20/23 at 11:10 AM during the initial interview phase of the long term care survey process, it was observed the tubing on his nasal cannula oxygen was dated 3/07/23. This was confirmed with Licensed Practical Nurse #37 on 3/20/23 at 11:12 AM. Record review found the following Physicians order: Order Summary: Oxygen tubing change weekly Label each component with date and initials. According to the facility Oxygen: Nasal Cannula Procedure dated with revision date 6/15/22, #22 states: Replace disposable set-up every seven days. The facility failed to follow their procedure and the Physicians order. b) Resident #21 Observation on 3/20/23 at 11:10 AM found Resident #21's nebulizer mask on her bed. 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 record review, staff interview and resident interview the facility failed to ensure post-dialysis assessments were completed on the Hemodialysis Communication Record. This was true for one (1) out of one (1) reviewed for dialysis. Resident identifier: Resident # 47. Facility census 115. Findings included: a) Resident # 47 During an interview with Resident # 47 on 03/20/23 at 10:24 AM the resident reported she went to dialysis on Tuesdays, Thursdays, and Saturdays. On 03/21/23 at 3:40 PM, the Director of Nursing (DON) was asked for the dialysis communication sheets. A review of the records revealed the forms were incomplete. These forms have three parts to them. The first part (pre dialysis) is to be completed by the facility staff, the second part (this is for the dialysis facility to completed by the dialysis staff) and returned to the facility with the resident. The third part is the post dialysis assessment and should completed by the facility staff. A look back at the Hemodialysis Communication Record starting on 01/24/23 thru 03/21/23 revealed the following: On every…

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 staff had appropriate competencies and skills sets to perform delegated nursing tasks beyond those taught in their basic educational program. Licensed Practical Nurses were administering intravenous antibiotics and flushes of intravenous lines had not received training on intravenous medications while working at the facility. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of antibiotic use. Resident identifier: #88. Facility census: 115. Findings included: a) Resident #88 Review of Resident #88's physician's orders showed an order written on 02/17/23 for the antibiotic piperacillin-tazobactam intravenously every eight (8) hours for 31 days for a left medial thigh surgical infection . The resident received the antibiotic through a midline catheter inserted into her right upper arm at the hospital. A heparin lock flush for the midline catheter three (3) times a day and normal saline flush three (3) times a day were also ordered. Resident #88's…

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

Based on observations, staff interview, and record review, the facility failed to provide each resident food which was palatable. This has the potential to affect all residents who get their nutrition for the kitchen. Facility census: 115. Findings Included: a) Anonymous interviews During Initial tours during the Long Term Care Survey Process (LTCSP) on 03/20/23 multiple Residents throughout the facility verbalized the dislike of the food they receive from the kitchen. The verbalized concerns where the food was not palatable, and the poor quality of the food served. b) Test tray On 03/21/23 at 12:28 PM a surveyor test tray was acquired from the kitchen: --Grilled Cheese was soggy on the one side and crispy on the other. --Tarter Tots had a rubbery texture and had a freezer taste. During an interview on 03/23/23 at 10:30 AM the Corporate Kitchen Account Manager stated they have been trying to give the residents more choices in monthly meals, the daily budget per Resident was recently increased and they change menus every quarter. c) Resident Council A closed Resident Council Meeting…

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 equipment manual review the facility failed to store food in the activity's refrigerator and freezer and store food in the resident pantry on south short hall in accordance with professional standards for food service safety related to storage. The facility also failed to keep the ice machine in a safe operating condition. This has the ability to affect all Residents who get their nutrition from the kitchen, and who attends food related activities. Facility Census: 115. Findings included: a) Initial kitchen tour. During the initial kitchen tour on 03/20/23 at 10:54 PM, an observation found an oxygen concentrator stored in the Residents south pantry. During an interview on 03/20/23 at 10:55 AM the Corporate Kitchen Account Manager confirmed medical supplies should not be stored in the Residents food pantry. b) Activities refrigerator On 03/20/23 at 11:40 AM an observation of the Activities refrigerator found the refrigerator temperature log was not completed for the month of March 2023. Continued observation revealed no items in the…

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

Based on record review, observation and staff interview the facility failed to ensure medical records were complete and accurate. This was true for four (4) of 37 sampled residents. Resident Identifiers: #82, #64, #32 and #21. Facility Census: 115 Findings Included: a) Resident #82 Observations in Resident #82's room on 03/22/23 at 12:00 pm found her 10:00 am snack, a sandwich, was still laying on her bedside table. The sandwich was not eaten. The Activities Director (AD) who was present during the observation placed the sandwich in the trash. A review of Resident #82's medication administration record (MAR) in the afternoon of 03/22/23 found the nurse had documented on the MAR Resident #82 had consumed 50 percent of the sandwich which was discarded by the AD. At 2:00 PM on 03/22/23 the infection preventonist (IP) was asked to review the MAR and confirmed 50 percent was documented as consumed of Resident #82's 10:00 am nourishment. The IP and surveyor then confirmed with the AD the sandwich was not consumed at all and she had thrown the entire sandwich in the trash at 12:00 PM…

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

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Gloves were not worn for eye drop administration to Resident #19. Residents #64 and #100 were found to have wheelchair cushions that could not be properly cleaned. Personal Protective Equipment for Resident #19 was found to be improperly discarded. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #19, #64, #100, #19. Facility census: 115. Findings included: a) Resident #19 The facility's procedure titled Medication Administration: Eye (Drops and Ointments) with an effective date 06/01/96 and revision date 06/01/21 stated nurses were to put on gloves before administration of eye drops or ointments. On 03/21/23 at 8:45 AM, medication administration to Resident #19 by Licensed Practical Nurse (LPN) #54 was observed. Resident #19 was ordered several oral…

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 safe, functional, sanitary, comfortable environment. A black substance was bleeding through the dining room floor. This was a random opportunity for discovery. Facility census: 115. Findings Included: On 03/20/23 at 10:30 AM an Observation of a black substance bleeding through the dining room entrance floor, around the door facings, through a seam running through the dining room floor and various other places on the floor. During an interview on 03/20/23 at 1:56 PM the Maintenance Director, verified that there is a black substance bleeding through the flooring in the dining are. He stated that the black substance was present when he started at the facility, and he has tried to remove it without success. An interview with the infection Preventionist on 03/23/23 at 1:33 PM, confirmed the black substance has been bleeding through the dining area floor for a long time. She stated the facility has tried various cleaning techniques to remove the substance including scrubbing and deep cleaning.

Based on record review and resident interviews, the facility failed to ensure residents had the right to make choices about aspects of their life in the facility that are significant to the resident for two (2) of five (5) residents reviewed for the category of choices, during the long term care survey. Resident identifier #31 and #20. Census 115. Findings Included: a) Resident #31 On 03/20/23 at 10:58 AM, during a resident interview, Resident #31 stated she does not get enough showers, her family comes in to wash her because she does not get cleaned enough by the staff. Electronic record review of the Bathing Task on 03/21/23, indicated in the last 30 days the resident only received four (4) showers and zero (0) bed baths. The Bathing Task also documented the resident refused eight (8) times. The resident's care plan indicated she requires extensive to total assistance for showers, however it does not indicate her preferences for bathing/showering. In the afternoon of 03/21/23 this information was reviewed with the Infection Preventionist and not further information was provided…

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

Based on resident interview, staff interview and record review the facility failed to implement their abuse and neglect policy. This is true for one (1) of two (2) residents reviewed for abuse. Resident Identifier: #10 Facility Census: 115 Findings Included: a) Resident #10 On 3/20/23 at 2:53 PM, Resident #10 stated she hears staff in the hall way talking about her and laughing at her. She says one staff member is hateful to her and talks mean to her. She was crying while talking to this surveyor and upset because she feels Certified Nurse Aid (CNA) #35 is mean to her and is trying to turn others against her. Resident #10 is unable to care for or protect herself due to physical disabilities. During a record review it was found on 11/08/22 at 4:00 PM a grievance was filed by this Resident against CNA #35 for not being nice to her, and the Resident felt like a prisoner in her room, that her stuff just kept getting pushed further to the side. She states CNA #35 and the room mate were laughing at her and she is turning other CNAs against her. The facility Abuse Prohibition Policy…

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

Based on resident interview, staff interview and record review the facility failed to report an alleged violation of abuse and/or neglect. This is true for two (2) of two (2) residents reviewed for abuse. Resident Identifier: #10 and #64 Facility Census: 115 Findings Included: a) Resident #10 On 3/20/23 at 2:53 PM Resident #10 stated she hears staff in the hall way talking about her and laughing at her. She says one staff member is hateful to her and talks mean to her. She was crying while talking to this surveyor and upset because she feels Certified Nurse Aid (CNA) #35 is mean to her and is trying to turn others against her. Resident #10 is unable to care for or protect herself due to physical disabilities. During a record review it was found on 11/08/22 at 4:00 PM a grievance was filed by this Resident against CNA #35 for not being nice to her, and the Resident felt like a prisoner in her room, that her stuff just kept getting pushed further to the side. She states CNA #35 and the room mate were laughing at her and CNA #35 is turning other CNAs against her. The facility Abuse…

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 do a complete and thorough investigation related to fall resulting in a major injury. This failed practice was true for 0ne (1) out of three (3) reviewed for falls. Resident identified: Resident #51. Facility census 115. Findings included: a) Resident #51 A review of the medical record for Resident #51, found the resident had five fractures on 11/25/22. Resident #51 is 82-years-old, is bed bound (she does not walk or use a wheelchair), and required the use of a mechanical lift for transfers. The following notes were found in the medical record related to Resident #51's injuries and pain: -- Nurse Practitioner (PN)Note dated 11/21/22. Chief complaint: Left hip pain. History of present illness: Seen for complaints of left hip pain. Patient reported this to staff today. She has dementia but able to answer some questions. There have been no falls or injuries per staff. resident points to lateral aspect of left hip and describing pain and difficultly straightening out her leg. Also having pain with movement. She did yell…

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 ombudsman was notified when a resident required transfer to the hospital. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of hospitalization. Resident identifier: #88. Facility census: 115. Findings included. a) Resident #88 Review of Resident' #88's medical records showed the resident required transfer to the hospital on [DATE]. On 03/22/23 at 10:54 AM, the Director of Admissions provided a list of the residents she had provided to the ombudsman by e-mail at the end of January. The list was of residents who had required transfer to the hospital in the month of January. Resident #88 was not on this list. The Director of Admissions acknowledged Resident #88 was not on this list but should have been. No further information was provided through the completion of the survey.

Based on resident interview, staff interview, Policy review and record review the facility failed to provide an ongoing resident centered activities program. This was true for two (2) of four (4) residents reviewed for activities. Resident Identifiers: #1 and #17. Facility Census: 115 Findings Included: a) Resident #1 On 3/20/23 at 1:34 PM Resident #1 states there is nothing to do except lay in bed all day. This resident has a Brief Interview for Mental Status (BIMS) of 15 and states I like people. The Resident states she wants to get out and do things with other people, socialize, play Bingo, etc. Record review on 3/22/23 at 10:26 AM of the February and March activity logs shows all her activities have been independent. meaning she has done them alone in her room. Activities of participation shows movies/TV, relaxing/looking out the window/resting/thinking, talking on the phone/sending cards/ mail and walking. On 3/22/23 at 10:28 AM during an interview with the Recreation Director# 54, she confirmed on been the Recreation Director for six (6) weeks, and she is still gathering…

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 address a resident's complaints of increased anger and anxiety for one (1) of five (5) residents reviewed for behavior/mood, in the long term care survey. Resident Identifier #103. Census 115. Findings Included: a) Resident Identifier #103 During a resident interview on 03/20/23 at 11:29 AM, Resident #103 stated he stays angry and feels like he needs something for his nerves. He state he takes something for depression but he needs a nerve pill. He says he does not see anyone for psychological services at this time. A review of Resident #103's record found he has not had any psychological services since 10/10/22. Neither psychological consultation discusses the resident's increased anger or anxiety, only depression. On 03/21/23 at 10:51 AM, an interview with Social Worker (SW) #95 was conducted. SW stated the psychological group consults come to the social workers via email and they print them out. SW #95 stated the social workers keep copies of the consults in a folder and give a copy to medical records to be scanned into the chart under consults. SW #95 says…

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 their social services provided or arranged consistent psychological intervention for one (1) of five (5) residents reviewed for the category of behavior/mood, in the long term care survey. Resident Identifier: #103. Facility Census: 115. Findings Included: a) Resident Identifier #103 Resident interview on 03/20/2023 at 11:29 AM, found the resident stating he stays angry and feels like he needs something for his nerves. He states he takes something for depression but he needs a nerve pill. He says he does not see anyone for psychological services at this time. A review of Resident #103's medical record on 03/22/22, indicated he has not had any psychological services since 10/10/22. Consults from a psychological group were found for the dates of 09/21/22 and 10/10/22. Neither consult indicates the termination of their services with the resident. Further review of the record found the resident has a history or a suicide attempt. The resident's psychosocial distress care plan indicated behavioral health services will be provided as an intervention. The…

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

Based on record review and staff interview, the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist. This deficient practice has the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #28. Facility census: 115. Findings included: a) Resident #28 Resident #28's medical records contained no documentation the resident's drug regimen was reviewed by a licensed pharmacist during the month of February 2023. During an interview on 03/22/23 at 10:29 AM, the Director of Nursing (DON) stated she was unable to locate any documentation that Resident #28's drug regimen had been reviewed by a licensed pharmacist in February 2023. No further information was provided through the completion of the survey process.

Based on observation, staff interview and record review the facility failed to ensure storage of medications within accepted principles of practice. This was a random opportunity for discovery had the potential to affect a limited number of residents. Residents identifier: Resident #75 and #217. Facility census 115. Findings included: a) Medication Pass observation On 03/21/23 at 8:12 AM, Licensed Practical Nurse (LPN) #94 was present during an observation of the mediation cart on the south end. LPN #94 verified there two (2) medication cups with medication in them in the top drawer. The medication cups had room numbers on them. -- The cup labeled 41-b belonged to Resident #75. This cup contained Gabapentin, Loratadine, Seroquel, Sennoside Docusate, Baproplia, Amitriptyline, Acetaminophen -- The second cup was labeled 39-A, belonging to Resident #217. The cup contained crushed medications the MAR was checked off for the following as being given: Famotidine, Lorazepam, Memantine HCL, Sennosides Docusate, Zonlsamide On 03/21/23 at 8:20 AM, Director of Nursing (DON) was notified 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.

Based on record review and staff interview, the facility failed to have laboratory reports filed in the resident ' s clinical record. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #28. Facility census: 115. Findings included: a) Resident #28 Review of Resident #28's physician's orders showed orders for the following laboratory testing every September and March: basic metabolic panel (BMP), thyroid stimulating hormone (TSH), fasting liver panel, and hemoglobin A1C (HbA1C). Results for HbA1C testing in September 2022 were not located in the resident's clinical record. Additionally, Resident #28 had an order for complete blood count (CBC) laboratory testing every March, June, September, and December. Results for CBC testing for December 2022 were not located in the resident's clinical record. On 03/22/23 at 10:40 AM, the Director of Nursing (DON) provided testing reports for Resident #28's HbA1C testing in September 2022 and CBC testing in December 2022. The reports did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, record review and staff interview the facility failed to provide dental care in a timely manner. This was true for one (1) of two (2) residents reviewed for the dental care area. Resident Identifier: #111 Facility Census: 115 Findings Included: a) Resident #111 On 3/20/23 at 1:40 PM, Resident #111 stated to this surveyor he has two (2) rotten teeth which need to be cut out. He states the staff keep just telling him you are on the list. This causes him pain and he takes Tylenol for the pain and it does help. He rates his pain at 2-3 on a scale of 1-10. According to an oral health evaluation completed by the facility on 1/26/23 his natural teeth had four (4) or more decayed or broken teeth/roots. During an interview with the Director of Nursing on 3/21/23 at 11:52 AM, she confirmed he had rotten teeth. He was admitted on [DATE] and the in house dental service had not seen him yet. She does not know when the in house dental service will be there to provide the needed services. She made…

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.