Palm Valley Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, interviews, and the facility policy and procedures, the facility failed to ensure that the physician and resident representative were notified of missed and rescheduled dialysis treatments for three of 10 sampled residents (#3, #9, #19); failed to ensure that pre and/or post dialysis assessment(s) were completed for resident (#18); and, failed to ensure dialysis policy contained the minimum requirements for the provision of dialysis services according to professional standards. The deficient practice could result in dialysis treatments and care not being met and not safely administered. Findings include: Regarding Incomplete pre and post dialysis assessments: -Resident #18 was admitted on [DATE] with diagnoses that included encephalopathy, dependence on renal dialysis, fluid overload, and unspecified kidney failure. A review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 15, which indicated…

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 clinical record review, observation, interviews, and the facility policy and procedures, the facility failed to protect the rights of one resident (#63) to be free from physical abuse by another resident (#48). The deficient practice could result in residents being physically injured. Findings include: -Resident #63 was admitted on [DATE] with diagnoses of Alzheimer's disease, depression, and history of falling. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 99, which indicated the resident was unable to complete the interview. The care-plan initiated on November 29, 2024 revealed that Resident #63 was resistive to care related to dementia, behaviors of refusing care, aimless wandering, exit seeking, intrusive at times. The goal was for resident to have decreased episodes of behavior. Interventions included to attempt to have 1:1 time when resident was having behaviors, allow wandering in safe areas within 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 review of resident council minutes, resident and staff interviews, and facility policy and procedures, the facility was failed to ensure concerns from the resident council meeting were considered or acted upon by facility staff. The facility census was 161 and the sample size was 32. The deficient practice could result in the residents' concerns, views, grievances or recommendations that affect their care, treatment and quality of life are not valued and considered. Findings include: The resident council minutes dated August 27, 2024 revealed that a resident brought up a concern of being served the same food for 2 days, not enough coffee brought down for meals, not having enough snacks and one resident's bed was making noise. The resident council minutes dated September 24, 2024 included the following issues were brought up in the meeting: -CNAs (certified nurse assistants) needed to help residents with simple tasks like opening blinds and getting the things residents asked for; -Food was cold at times; -Food portions seemed to get smaller; and, -One resident would like…

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 -Resident #38 was admitted on [DATE] with diagnoses of major depressive disorder-single episode, anxiety disorder and schizoaffective disorder. The care plan dated December 14, 2021 included that the resident used an antidepressant medication related to depression and an antipsychotic medication related to schizoaffective disorder bipolar type. Interventions included to administer medications as ordered and psych follow-up as needed. The Level I PASRR (Pre-admission Screening and Resident Review) dated December 19, 2023 revealed that the resident had SMI (serious mental illness) diagnoses that included major depression and bipolar disorder; had mental disorder (MD) diagnoses of anxiety disorder.; and had no primary diagnosis of dementia. Per the documentation the resident had a recent psychiatric/behavioral evaluation on November 28, 2023 and was prescribed with psychotropic medications within the last 6 months. Further, the documentation included that a referral for Level II determination was determined. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY -Resident #153 was admitted on [DATE] with diagnoses of encephalopathy, type II diabetes mellitus, and acute pulmonary edema. A respiratory note dated December 9, 2024 revealed that resident was on 2 liters per minute of oxygen via nasal cannula. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The MDS assessment also coded that the resident was receiving oxygen therapy. A nurse practitioner (NP) note dated January 24, 2025 revealed the resident was on oxygen via nasal cannula. An observation was conducted on February 3, 2025 at 11:30 a.m. showing that resident #153 lying in bed wearing an oxygen nasal cannula that was connected to an oxygen concentrator by the bedside. The oxygen concentrator was on and set to 3 liters of oxygen. In another observation conducted on February 5, 2025 at 11:34 a.m., resident #153 was sitting up in bed wearing an oxygen nasal cannula that was connected to an oxygen…

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, clinical record review, facility documentation and staff interviews, the facility failed to ensure medications/treatment for two residents (#316 and #93) were not left at bedside. The facility census was 161 and the sample size was 32. The deficient practice could result in resident injury, medication over-dose or contraindications. Findings include: -Resident #316 was admitted on [DATE] with diagnoses of cerebral infarction, unspecified symptoms and signs involving cognitive functions and awareness, need for assistance with personal care, pressure ulcer of the sacral region and altered mental status. An observation was conducted on February 3, 2025 at 8:17 a.m. and revealed that there was a hydrophilic wound dressing containing petroleum, zinc oxide and dimethicone on the resident's bedside table. Resident #316 stated that the staff were aware that the cream was on her bedside table. In another observation was conducted on February 4, 2025 at 8:47 a.m., the hydrophilic wound dressing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, resident and staff interviews and policy review, the facility failed to ensure respiratory care related to BiPAP (Bi-level positive airway pressure)/CPAP (Continuous positive airway pressure) devices for one of 3 sampled residents (#98) and oxygen administration for one of 3 sampled residents (#153) consistent with professional standards was provided as ordered by the physician. The deficient practice could result in residents not receiving the necessary respiratory care and services to meet their needs. Findings include: -Resident #98 was admitted on [DATE] with diagnoses of Parkinson's disease, mentation fluctuations, obstructive sleep apnea, dependence on other enabling machines and devices, and need for assist with personal care. The admission summary note dated January 20, 2025 revealed that that the resident admitted to the facility for 8-week respite. A physician order dated January 20, 2025 included for Respiratory Therapy (RT) evaluation and treatment as…

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 resident council minutes, resident and staff interviews, a food test tray, and policy review, the facility failed to ensure food was palatable; and, failed to ensure food was at an appetizing temperature for resident consumption. The facility census was 161 and the sample size was 32. The deficient practice has the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals. Findings include: The resident council minutes dated September 24, 2024 included an issue was brought up in the meeting that food was cold at times. The resident council minutes dated October 29, 2024 revealed a concern that rice served to resident was not fully cooked at times. The resident council minutes dated November 26, 2024 revealed issues reported that fish served was always dry. The resident council minutes dated December 31, 2024 revealed concerns that meals served were cold. During an interview conducted with a random an alert and oriented resident conducted on February 2, 2025 at 8:17 a.m., the resident stated that food served…

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 policy review, the facility failed to ensure food items were labeled and dated; failed to ensure temperature logs were maintained; and, failed to ensure kitchen was clean when preparing food for resident. The deficient practice could increase the risk of foodborne illness. Findings include: -Regarding food labeling, dating and storage During the initial kitchen observation conducted on February 3, 2025 at 7:26 a.m., the following items were found opened in the walk-in freezer: -Box of black bean burger; and, -Box of French toast bread. Both boxes had a plastic bag inside the box that was left opened exposing all the patties and the bread. During the initial observation of the nutrition refrigerator located in the unit conducted on February 3, 2025 at approximately 8:26 a.m., an unmarked or unlabeled Ziplock bag filled with single use creamer packets with use by or expiration date. The bottom bin of the refrigerator was filled with single use packets of syrup and jelly that was also not labeled with a used by or expiration date. There was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY -A medication administration observation was conducted with licensed practical nurse (LPN/staff #221) on February 4, 2025 at 9:05 a.m. The LPN entered a resident's room with prepared medications. There was an EBP (enhanced barrier precaution) signs posted outside of the resident's room. The LPN sanitized her hands, donned gloves on, mixed the crushed medications with water in separate medication cups, paused and disconnected the residents tube feeding, flushed the tube feeding with water and then administered the medications one at a time through the feeding tube. The LPN then flushed the feeding tube with water, reconnected and resumed the tube feeding then took her gloves off and sanitized her hands. However, the LPN did not don a gown prior to administering the medications to the resident. An interview was conducted on February 4. 2025 at 9:29 a.m. with the LPN (staff #221) who stated that the resident was on enhanced barrier precautions due to the resident having a tube feeding; and, the certified nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to protect and value the resident's private space by staff failing to knock on doors and requesting permission before entering rooms of two residents (#69 and #66); and, failed to ensure staff explained the care/treatment prior to performing ADL (activities of daily living) care for to one resident (#69). The deficient practice could result in residents' individuality not respected and residents not being treated in a dignified manner. Findings include: -Resident #69 was admitted on [DATE] with diagnoses of anoxic brain damage, hydrocephalus, altered mental status, seizures, quadriplegia, psychosis, depression, and anxiety disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had severe cognitive impairment; and that, the resident rejected care on 1-3 days during the look back period of 7 days of the assessment. Review of a care plan revised on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, and review of facility policy and procedures, the facility failed to ensure call light within reach for one sampled resident (#466). The deficient practice could result in residents not having their needs met timely which could negatively impact resident safety. Findings include: Resident #466 was re-admitted to the facility on [DATE] with diagnoses that included encephalopathy, type 2 diabetes mellitus, chronic pulmonary edema, acute respiratory failure, COVID-19, repeated falls, and chronic obstructive pulmonary disease. The admission summary note dated January 30, 2025 included that the resident was alert and oriented to self, was placed on oxygen upon arrival to the unit, had a G-tube (gastrostomy tube) and was on precautions due to being positive with COVID. A care plan dated January 31, 2025 revealed the resident was on ESP (enhanced standard precautions0 due to G-tube and wounds; was at risk for potential bleeding and bruising due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of one resident (#4) to be free from physical abuse by another resident. The deficient practice could result in further abuse of residents and appropriate action not taken. Findings include: -Resident #4 (alleged victim) was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, dementia, bipolar disorder, schizoaffective disorder, anxiety disorder and major depressive disorder. A physician order dated September 4, 2019 included for resident to reside on secured behavioral unit related to mental illness. Review of the psychological-behavior care plan revised on May 13, 2024 revealed the resident exhibited or was at risk for behavioral symptoms, physical/verbal aggression and throwing things due to schizophrenia, schizoaffective disorder, anxiety and major depressive disorder. Interventions included to administer medication as ordered, monitor for side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure that mitt restraints were removed following physician orders for 2 of 2 sampled residents (#69 and #133). The deficient practice could result in a lack of re-evaluation for the ongoing safe use of these restraints placing residents at risk for possible injury. Findings include: -Resident #69 was admitted on [DATE] with diagnoses of anoxic brain damage, hydrocephalus, altered mental status, seizures, quadriplegia, deformity of head, psychosis, depression, and anxiety disorder. The Adaptive Restraint Evaluation dated December 2, 2024 revealed that the resident was alert, disoriented, had a short attention span, unable to ambulate, falls/leans sideways bilaterally, no recovery of balance, needed to be repositioned and had medication change or addition in the past month. The NP (nurse practitioner) note dated December 8, 2024 included that the mitts were in place. Review of a Minimum Data Set…

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 staff interviews, review of facility documentation, policy and procedures the facility failed to implement their policy to protect one resident (#4) from abuse and failed to thoroughly investigate an allegation of abuse for one resident (#4). The deficient practice could result in abuse continuing and not being prevented. Findings include: -Resident #4 (alleged victim) was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, dementia, bipolar disorder, schizoaffective disorder, anxiety disorder and major depressive disorder. The eINTERACT Change in Condition evaluation dated January 30, 2025 revealed that the resident had a change in condition related to an alleged physical contact in the morning of January 30, 2025. Per the documentation, a certified nursing assistant (CNA) reported that the resident was struck with an open hand; and that the resident had no injuries. The NP (nurse practitioner) note dated January 30, 2025 included that the resident was punched by another…

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 clinical record review,staff interviews and review of facility documentation and policy/procedure, the facility failed to ensure an allegation of abuse was thoroughly investigated. The deficient practice could result in allegations of abuse not being investigated and abuse/neglect occurring in the facility. Findings include: -Resident #4 (alleged victim) was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, dementia, bipolar disorder, schizoaffective disorder, anxiety disorder and major depressive disorder. The eINTERACT Change in Condition evaluation dated January 30, 2025 revealed that the resident had a change in condition related to an alleged physical contact in the morning of January 30, 2025. Per the documentation, a certified nursing assistant (CNA) reported that the resident was struck with an open hand; and that the resident had no injuries. The NP (nurse practitioner) note dated January 30, 2025 included that the resident was punched by another resident in the face.…

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 clinical record review, staff interviews, and policy review the facility failed to ensure one of 3 sampled residents (#77) and/or resident representative was provided with written notice regarding the bed hold policy upon transfer to the hospital. The deficient practice could result in residents and/or resident representatives not being informed of the facility's bed hold policy and not permitted to return to the facility. Findings Include: Resident #77 was re-admitted on [DATE] with diagnoses of type 2 diabetes, end stage renal disease (ESRD), atherosclerosis of arteries, peripheral vascular disease and congestive heart failure. The information provided in the resident's admission packet revealed no evidence that the bed hold policy was provided to the resident and/or the resident representative. An annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The 72-hour charting note dated…

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, clinical record review, resident and staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that the Minimum Data Set (MDS) assessment for one of 32 sampled residents (#98) was accurate. The deficient practice could result suboptimal care planning and resident not receiving the care/services according to their needs. Findings include: Resident #98 was admitted on [DATE] with diagnoses of Parkinson's disease, mentation fluctuations, obstructive sleep apnea, dependence on other enabling machines and devices, and need for assist with personal care. The admission summary note dated January 20, 2025 revealed that that the resident admitted to the facility for 8-week respite. A physician's order dated January 20, 2025 included for Respiratory Therapy (RT) evaluation and treatment as indicated. A physician's order dated January 21, 2025 revealed an order written for RT BiPAP/CPAP (bilevel positive airway pressure/continuous positive airway pressure) 2 -…

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, clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure that a baseline care plan was developed and implemented regarding the use of BIPAP (Bilevel Positive Airway Pressure)/CPAP (continuous positive airway pressure) care/treatment within 48 hours for one of three sampled residents (#98). The deficient practice could result in lack of instructions for the provision of effective and person-centered care to the resident and staff not being aware of the equipment being used. Findings include: Resident #98 was admitted on [DATE] with diagnoses of Parkinson's disease, mentation fluctuations, obstructive sleep apnea, dependence on other enabling machines and devices, and need for assist with personal care. The admission summary note dated January 20, 2025 revealed that that the resident admitted to the facility for 8-week respite. A physician's order dated January 20, 2025 included for Respiratory Therapy (RT) evaluation and treatment as…

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 clinical record review, observations, staff interviews and facility policy, the facility failed to ensure that an individualized on-going program of activities that met the interests and supported the well-being were consistently provided for 1 of 1 sampled residents (#69). The deficient practice could result in resident's interests, the physical, mental and psychosocial well-being, decreased socialization and stimulation not being met. Findings Include: Resident #69 was admitted on [DATE] with diagnoses of anoxic brain damage, hydrocephalus, altered mental status, seizures, quadriplegia, deformity of head, psychosis, depression, and anxiety disorder. An activity care plan revised on April 16, 2024, revealed the resident was dependent on staff for activities and was unable to physically participate due to poor mobility, one-on-one activities for cognitive stimulation, social interaction related to cognitive deficits, immobility and physical limitations. Interventions included keeping the television on…

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

Based on observation, staff interviews, and facility policy, the facility failed to ensure that medications were not left unattended on top of the medication cart. The deficient practice could result in residents having access to unnecessary medications. The facility census was 161 and there were 32 sampled residents. Findings include: A medication administration observation was conducted with a licensed practical nurse (LPN/staff #221) on February 5, 2025 at 6:13 AM. During the observation, the LPN dispensed 1 tablet of metoclopramide (antiemetic) and 1 tablet of omeprazole (proton-pump inhibitors) into a medication cup. The LPN then placed metoclopramide container cup back into the medication cart, locked the medication cart and then walked down the hallway to a resident's room to administer the medication. However, the LPN did not put the omeprazole medication container back into the medication cart and was left on top of the medication cart unattended. An interview was conducted on February 5, 2025 at 6:40 a.m. with the LPN (staff #221) who stated that the omeprazole container…

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 clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure a thorough investigation for one abuse allegation out of three on a resident to resident abuse complaint, involving resident #88 and #77. The deficient practice could result in appropriate corrective action not taken and an inaccurate investigative outcome. Findings include: -Resident #77 was admitted on [DATE] and discharged on July 27, 2024 with diagnosis including dementia of unspecified severity with other behavioral disturbance, Alzheimer's disease, polyarthritis, chronic obstructive pulmonary disease, end stage renal disease and polyneuropathy. A review of the quarterly MDS (minimum data set) dated April 16, 2024 revealed a BIMS (brief interview of mental status) score of 9, indicating moderate cognitive impairment. -Resident #88 was admitted on [DATE] with diagnosis including dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance,…

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 documentation, staff interviews and the facility policy and procedures, the facility failed to ensure that one resident (#2) was free from abuse from another resident (#12). This deficient practice could result in other residents being abused. Findings include: Resident #2 was admitted on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The minimum data set (MDS) included a brief interview for mental status (BIMS), with a score of 03. Indicating the resident had a severely cognitive impairment. The care plan revealed that Resident #2 had potential to demonstrate physical and verbal behaviors towards staff during cares. The date initiated was August 19, 2024. Goals were written to demonstrate effective coping skills through the review date. Interventions included to analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Resident #12 was admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff and resident interviews, facility documentation and policies, the facility failed to ensure that one resident (#1) was free from abuse by another resident (#2). Findings include: Regarding Resident #1: Resident #1 was admitted at the facility on October 13, 2023 with diagnoses of encephalopathy, Alzheimer's disease, and dementia. A review of resident #1 Quarterly Minimum Data Set (MDS) dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score section was blank. In addition, revealed resident #1 had short and long-term memory problems, cognitive skills for daily decision making wass severely impaired, physical and verbal behavioral symptoms directed towards others were not exhibited, and wandering behavior occurred daily. A review of care plan initiated on November 1, 2023 revealed resident #1 was at risk for psychosocial behaviors or was at risk for behavioral symptoms such as physical aggression toward staff, throwing items (food tray), verbal aggression 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, facility documentation, policies and procedures, the facility failed to protect resident rights (#4002) to be free from sexual abuse by another resident (#4805). The deficient practice has the potential for further abuse resulting in harm to residents. Findings include: -Resident #4002 (alleged victim) was admitted on [DATE] with a diagnosis of Unspecified Dementia, Bipolar disorder, unspecified and Anxiety Disorder, unspecified. The annual MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) of 14 suggesting that the resident had intact cognition. A progress notes on 3/6/24 at 1:26 AM revealed that the resident #4002 was being monitored for 72 hours related to being inappropriately touched by a male resident. The eINTERACT summary dated March 5, 2024 revealed resident #4002 was inappropriately touched in her left buttock by another resident (#4805); and that, resident #4002 complained that a male resident touched…

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 clinical record review, staff and family interviews, and review of facility policy and documentation, the facility failed to ensure personal privacy and confidentiality of medical records were maintained for one resident (#604). The deficient practice could result in unauthorized disclosure of resident information. Findings include: Resident # 604 was admitted on [DATE] with diagnoses of unspecified psychosis, anxiety disorder, type 2 diabetes mellitus, and depression. A health status note dated October 28, 2022 included that the resident was alert, verbally responsive and oriented to self, place and situation with forgetfulness; and was admitted with diagnoses of anxiety disorder, late effect stroke and diabetes mellitus (DM) type II. The eINTERACT summary dated October 29, 2022 revealed that the resident had a change in condition; and that the resident reported burning when urinating. Per the documentation, UA (urinalysis) and CS (Culture sensitivity) tests were ordered for a diagnosis of dysuria. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation and policy and procedure review, the facility failed to protect the rights of one residents (#79) to be free from sexual abuse by another resident (#252); and, failed to protect the rights of one resident (#33) from physical abuse by another residents (#354 and #356). The deficient practice could result in further abuse of residents to occur. Findings include: Regarding resident #79 and #252 -Resident #79 (alleged victim) was admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, history of TBI (traumatic brain injury) and epilepsy. The comprehensive care plan included the resident had anxiety and delusions, was at risk for falls related to dementia with poor cognition. Interventions included to administer psychotropic medications as ordered. Goals included that resident will show decreased episodes of signs/symptoms of anxiety, depression and fewer indications of decreased well-being. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY -Resident (#65) was admitted on [DATE] with diagnoses of rhabdomyolysis, ESRD (end-stage renal disease and chronic peripheral venous insufficiency. The eINTERACT summary dated December 24, 2023 included the resident had a change in condition: abnormal vital signs, altered mental status and shortness of breath. Review of the clinical record revealed the resident was transferred to the hospital on December 24, 2024 for diagnoses of influenza and pneumonia. Further review of the clinical record revealed that the resident was readmitted back to the facility on December 28, 2024 into a private room for isolation due to Influenza A diagnosis. However, continued review of the clinical record revealed no evidence that the resident/ representative was notified in writing of the reason of the transfer. There was no documentation that the Ombudsman was notified of the resident's transfer/discharge. Review of the copies of notification of discharges and transfers for November through December 2023 and January 2024 revealed…

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 1) Based on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that nine out of 18 residents were free from abuse. The deficient practice resulted in physical and/or emotional injury to the residents. Resident #143 is a [AGE] year-old male admitted on [DATE] with admitting diagnosis of urinary tract, infection, end-stage, renal disease, heart failure, rhabdomyolysis, and altered mental status. Resident brief interview for mental status is 15 out of 15 as of [DATE]. Based on the facility ' s five day report, a complaint by the resident was received by the dialysis facility social worker reporting that one of his certified nursing assistants (CNA) was mean to him and grabbed him, roughly and caused bruises on his left arm. Based on Nursing progress note written on [DATE] by a Licensed Practical Nurse (LPN) staff #142, residence care plan was updated, the bruises on his left arm were noted and care planned, the CNA no longer works in the unit and in the building…

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 clinical record review, interviews, and facility documentation and policy, the facility failed to follow its policy regarding reporting and investigating abuse. The sample size was four out of 18 residents. During the investigation conducted on 12/18/2023 through 12/22/2023, revealed documentation that the suspicion of abuse was not reported immediately to the administrator and to other officials according to state law. The policy states the term, immediately, as meaning within two hours of an allegation of abuse involving or resulting in seriously bodily injury or within 24 hours of an allegation that does not involve abuse resulting in serious bodily injury. The policy documents that any employee who has been accused of resident abuse is to be placed on leave with no resident contact until an investigation is complete. A review of facility policy regarding reporting and investigating abuse revealed documentation that the suspicion of abuse must be reported immediately to the administrator and to other…

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 clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident ' s rights were protected by failing to report an accident and injury. Resident #168 is a [AGE] year old male admitted on [DATE] with the admitting diagnosis of dementia, chronic obstructive pulmonary disease, Parkinson ' s disease, acute kidney failure, and history of COVID-19. SBAR evaluation dated [DATE], reveals that resident had a fall that sustained a hematoma to his head. A progress note dated [DATE] at 4:59 PM, a Night Shift CNA was interviewed and he reports that the resident fell at around 5:45 AM on the morning of [DATE], just prior to the morning shift. The resident was up in his wheelchair and was found on floor next to the wheelchair near patio door. During the investigation, on [DATE] at 10:02 AM in the morning, an outgoing call was placed to staff number 189. This investigator was unable to leave a message in her voicemail as there is no outgoing message. On [DATE]…

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 documentation, staff interviews, and the facility policy and procedures, the facility failed to report an allegation of sexual abuse to the stated agency, and failed to complete a 5-day written investigation. The deficient practice could result in residents not being protected from abuse. Findings include, Resident (#80) was admitted to the facility on [DATE] with diagnoses that included unspecified sequelae of cerebral infarction, morbid obesity, post-concussional syndrome, anxiety disorder, unspecified injury of head, subsequent encounter, and an assault by other bodily force, subsequent encounter. Review of the minimum data set (MDS) dated [DATE] reveals a brief interview of mental status score of 15 indicating the resident was cognitively intact. Review of a progress note dated October 5, 2023 revealed that resident #80 discharged home with her husband via a private vehicle. Review of the clinical record revealed a letter dated October 17, 2023 from a solicitor stating resident #80 had retained…

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.