Kaplan Healthcare Center

Inspectors wroteBased on observation and interview, the facility failed to ensure the most recent survey results of the facility were posted in a place readily accessible to residents, family members, and legal representatives of residents. The facility's census was 71.

Inspectors wroteBased on observation and interview, the facility failed to ensure staffing information posted daily was accurate and current. The facility's census was 71.

Inspectors wroteBased on interviews, observation, and record reviews, the facility failed to develop a comprehensive person-centered care plan for 3 (Resident #2, Resident #27, Resident #31) out of 35 sampled residents. Resident #27 Review of Resident #27's EMR (Electronic Medical Record) revealed she was admitted to the facility on [DATE] with a diagnosis that included but not limited to polyosteoarthritis, neuropathy, vertebrogenic low back pain, muscle spasm of back, and cutaneous abscess of left lower limb. Further review of Resident #27's medical diagnosis did not reveal a diagnosis for left drop foot. Review of Resident #27 quarterly (Minimum Data Set) dated 10/08/2025 revealed BIMS (Brief Interview for Mental Status) of 14 which indicated Resident #27 was cognitively intact. Review of Resident #27's Medical Progress Note dated 05/14/2025 revealed a diagnosis of left foot drop. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure coordination of care between the physical therapy department and nursing services for a resident who had leg prosthetic devices that no longer fit for 1 (#4) out of 35 sampled residents reviewed for quality of care.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean and sanitary kitchen, as evidenced by: 1. Equipment: A. Build-up of debris and brown substance inside the ice machine. B. Build-up of debris and food particles inside the microwave.2. Food storage: A. Walk-in Refrigerator 1. [NAME] and fuzzy patches on the inside and outside of a honey mustard container. 2. A container of lemon juice with an expiration date of 09/28/2025. B. Stand-up Refrigerator 1. A bag of bread not labeled with the date it was opened. 2. A piece of pie not labeled with the date it was prepared. C. Dry Storage 1. A bag of rice bag opened with an expiration date of 04/23/2025. This deficient practice had the potential to affect 68 residents who ate out of the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to accurately code a resident's MDS (Minimum Data Set) assessment for 1 (Resident #14) out of 1 (Resident #14) investigated for resident assessments. Review of Resident #14's EHR (electronic health record) revealed she was admitted to the facility 07/14/2022 with diagnoses which included unspecified dementia, bipolar disorder, major depressive disorder and anxiety disorder. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. This was evidenced by 1 (Resident #62) having untrimmed and unclean fingernails out of 2 Residents #61 and #62) investigated for ADLs.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to follow professional standards of practice and the comprehensive person-centered care plan to remove the AV (arteriovenous) shunt pressure dressing for 1 (Resident #28 ) out of 1 (Resident #28 ) resident reviewed for dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received a mechanically altered diet as ordered by the physician for 1 (#21) out of 5 (#1, #21, #31, #56, #67) residents reviewed for dining.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain accurate documentation across the resident's record that the resident was discharged from hospice services for 1 (#6) out of 35 sampled residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure CNAs (Certified Nurse Aides) and Shower Aides provided showers and baths for 2 (Resident #5, Resident #R1) of 2 (Resident #1, Resident #R1) sampled residents investigated for ADLs (Activities of Daily Living).

Inspectors wroteBased on observations, interviews, and policy and procedure reviews, the facility failed to maintain clean and sanitary kitchen equipment to prevent cross contamination and the likelihood of foodborne illnesses by failing to clean a Dumbwaiter Cart.

Inspectors wroteBased on record review, observations, interviews, and policy and procedure review, the facility failed to maintain an effective 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 as evidenced by failing to:1. ensure staff wore proper PPE (Personal Protective Equipment) while providing care for 2 (#1 and #2) of 2 (#1 and #2) residents who were on Enhanced Barrier Precautions in a final sample of 6 (#1, #2, #3, #4, #5, #6) residents investigated for infection control practices; and2. ensure the shower facilities and shower equipment were cleaned and disinfected between residents for 1 (Shower room A) out of 4 shower rooms (Shower room A, Shower room B, Shower room C, Shower room D) observed.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure the resident was provided nursing services and care that adhered to accepted standards of quality. Nursing staff failed to reconcile and administer the resident's prescribed anticoagulant medication for 39 days which jeopardized the resident's health and safety for 1 (#37) of 1 residents investigated for nursing services in a final sample of 31 residents. This deficient practice resulted in an Immediate Jeopardy for Resident #37 on 07/29/2024 when S3LPN (Licensed Practical Nurse) failed to resume the resident's anticoagulant Eliquis 5 mg (milligrams) twice daily after undergoing a same-day scheduled procedure at HC1 (Hospital Center) to remove an inferior vena cava (IVC) filter. On 09/06/2024, the nurse observed Resident #37 confused and lethargic with swelling to the left lower extremity. [...]

Inspectors wroteBased on interviews, observation and record review, the facility failed to ensure care and services were provided according to professional standards of practice resulting in harm for 1 (Resident #37) resident out of 31 final sampled residents. This deficient practice resulted in an Immediate Jeopardy for Resident #37 on 07/29/2024 when the facility's process for medication reconciliation failed as evidenced by: 1. S3LPN (Licensed Practical Nurse) failed to reconcile Resident #37's medications when the resident was readmitted to the facility following discharge from HC1 (Hospital Center) to remove an inferior vena cava (IVC) filter on 07/29/2024. The resident's discharge orders from HC1 included administration of the anticoagulant Eliquis 5 mg (milligrams) twice daily. [...]

Inspectors wroteBased on record review and interviews, the facility failed to notify the physician and/or NP (Nurse Practitioner) of a resident's invasive procdure for IVC (Inferior Vena Cava) filter removal for 1 (Resident #37) out of 1 (Resident #37) residents reviewed for notification of change in a final sample of 31 residents. Review of Resident #37's medical record revealed the following diagnoses, in part: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant side, Acute Embolism and Thrombosis of Left Femoral Vein and Dysphagia following Cerebral Infarction. Review of progress note per S6ADON (Assistant Director of Nursing) on 07/29/2024 read in part: Resident left in stable condition via facility vehicle to HC1 (Hospital Center) for procedure. [...]

Inspectors wroteBased on record review and interviews, the facility failed to report an alleged violation of its failure to provide care to a resident necessary to avoid physical harm to designated state agency for 1 (Resident #37) out of 31 residents reviewed in the sample. On 11/04/2024 at 10:12 a.m., a request was made to the facility for all incidents that had been reported to the state agency in the past 120 days. There were no reports recieved for Resident #37. A request was also made for a policy regarding reportable incidents, but no policy was received prior to survey exit. Review of Resident #37's medical record revealed an admission date of 02/23/2024 with the following diagnoses, in part: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Acute Embolism and Thrombosis of Left Femoral Vein and Paroxysmal Atrial Fibrillation. [...]

Inspectors wroteBased on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) for antipsychotic use for 1 (Resident #42) out of 2 (Resident #42 and #53) residents reviewed for resident assessment discrepancy for antipsychotics. The final sample was 31 residents.

Inspectors wroteBased on observations and interviews the facility failed to provide appropriate pharmaceutical services, by not properly disposing of a contaminated sharp, observed during medication administration.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective infection control and prevention program by failing to ensure staff performed hand hygiene when indicated according to accepted standards of practice during medication administration pass.

Inspectors wroteBased on record review and interview, the facility failed to maintain an effective antibiotic stewardship program to monitor antibiotic use by failing to obtain culture reports, sensitivity data, and review antibiotic usage. The facility's census was 63. A review of the facility's policy titled, Infection Prevention and Control Program read in part: 8. Antibiotic Stewardship a. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities .Infection Preventionist Policy Statement: The Infection Preventionist is responsible for coordinating the implementation, assessment, developing, monitoring and management of the program .Monitoring Compliance with Infection Control Policy Statement: Routine monitoring and surveillance of the workplace are conducted .Policy Interpretation and Implementation 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Ensure compromised cans in the dry storage room were disposed of 2. Follow the 3-step process for manually washing and sanitizing dishware correctly per the manufacturer's instructions and food safety requirements. This deficient practice had the potential to affect the 62 residents who consumed food from the kitchen. The facility's census was 63.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective infection control and prevention program by: 1. Failing to ensure that contract staff wore gloves while changing a dirty mop pad and; 2. Failing to ensure staff sanitize hands during meal tray distribution for Residents #29, #48, #57, and #367. This deficient practice had the potential to affect the 63 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that each resident with urinary catheters had a privacy bag or covering over thier urine collection bag for dignity for 2 (#36 and #41) of 2 (#36 and #41) sampled residents reviewed for urinary catheters.

Inspectors wroteBased on interviews and observations, the facility failed to maintain a homelike environment for 1 (#22) out of 3 (#22, #36, and #39) residents investigated for a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all the residents residing in the facility. The facility's census was 63.

Inspectors wroteBased on record review and interviews, the facility failed to ensure 1 (#37) out of 2 (#32 and #37) residents were administered their tube feeding in a timely manner as ordered by the physician from a total sample size of 36 Residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (#57) of 2 (#2 and #57) sampled residents reviewed for respiratory care by failing to ensure that respiratory equipment was properly stored when not in use.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a resident who was unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain personal hygiene for 2 (#4, R1) of 6 (#1-5, and R1) sampled residents, of a total census of 68 residents.