Haven Of Lakeside

Based on documentation, staff interviews, and facility policies the facility failed to ensure that two staff members (#21 and #58) are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. The deficient practice could result in staff not being familiar with residents' rights. Findings include:On September 15, 2025 at 9:11 a.m., a written request for personnel files which included staffs #21 and #58 was submitted specifically asking for proof of training for Resident Rights. -Regarding Staff #21Review of the personnel record for a Registered Nurse (RN/staff #21) revealed a hire date of August 1, 2024. Additionally, the personnel file revealed a signed job description dated August 4, 2024 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. However, review of the personnel file provided by the facility did not reveal any evidence that staff #21 completed Resident Rights training. Review of the Inservice training log/binder conducted on September 15,…

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 documentation, staff interviews, and facility policies the facility failed to ensure that one staff member (#21) was educated on abuse, and that seven staff members (#21, #58, #24, #1, #12, #55 & #11) and one nursing aide (NA) student (staff #255) received Elder Justice Act training. The deficient practice could result in staff not being familiar with the detection, prevention and reporting of abuse, neglect, and exploitation of property.Findings include:On September 15, 2025 at 9:11 a.m., a written request for personnel files which included staffs #21, #58, #24, #1, #12, #55 & #11) was submitted specifically asking for proof of training for Abuse and Elder Justice Act. Additionally, a written request for personnel file for staff #255 specifically asking for proof of training for Abuse and Elder Justice Act was submitted on September 15, 2025 at 10:16 a.m. -Regarding Staff #21Review of the personnel record for a Registered Nurse (RN/staff #21) revealed a hire date of August 1, 2024. Additionally, the personnel file revealed a signed job description dated August 4, 2024 that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure that the advance directive was consistent and correct for one Resident.(#7)Number of residents sampled: 20Number of residents cited: 1 Based on clinical record review, staff interviews, and facility policy and procedure, the facility failed to ensure that the advance directives were consistent throughout one (#7) of twenty sampled resident's clinical records. The deficient practice could result in residents receiving services that are not in accordance with their wishes. Findings include: Resident #7 was admitted to the facility on [DATE],.2025 with diagnoses that included Chronic Obstructive Pulmonary Disorder, Atrial Fibrillation and Vascular Dementia. The resident was admitted to Hospice on August 18,2025. A Prehospital Medical Care directive signed by the resident's representative on August 18,2025 provided by the Hospice, revealed the resident chose the code status of DNR. (Do not resuscitate). The advance directive form signed by the resident on August 22, 2025 found 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of facility documents and policy, the facility failed to ensure one resident (#14) was referred for Level II Pre-admission Screening and Resident Review (PASRR). The deficient practice could result in residents not receiving appropriate services to meet their needs.Number of residents sampled: 20Number of residents cited: 1Findings include:Resident #14 was initially admitted on [DATE] and was readmitted to the facility on [DATE] with a diagnosis that included myocardial infarction, depression, anxiety disorder, bipolar disorder, and schizoaffective disorder.A review of care plan dated January 3, 2024 revealed resident use antipsychotic and antidepressant medications related to schizoaffective disorder. Interventions included to administer medications as ordered, monitor side effects of the antipsychotic medication and report side effects and adverse reactions of medication to provider; and consult with pharmacy and provider to consider gradual dosage reduction…

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 facility policy and procedure, the facility failed to coordinate with hospice to ensure quality care and services for one resident (#29). The deficient practice could result in residents not receiving the appropriate interventions for their comfort and end of life services.Findings include: A hospital record dated June 12, 2025 documented resident's plan of care included full liquid diet and continue supportive care. The plan indicated that the resident is to remain on full liquid diet indefinitely. Resident # 29 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of the pancreas, atherosclerotic heart disease, type 2 diabetes mellitus, and anxiety disorder. Review of the hospice respite care document dated August 29, 2025 revealed a diagnosis of malignant neoplasm of the pancreas. The paperwork indicated the resident's diet as as tolerated. A care plan revised on August 29, 2025 revealed that the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and review of facility policies and procedure, the facility failed to ensure appropriate treatment and services was provided to 1 of 3 sampled residents (#22) with limited ROM.Findings include: Resident #22 was admitted on [DATE] with diagnoses of dementia, hemiplegia/hemiparesis following cerebral infarction, cerebral atherosclerosis, dysphagia, and dysarthria. The OT (occupational therapy) evaluation dated November 1, 2021 included that resident required skilled OT services to improve rehab potential, increase functional activity tolerance, increase independence with ADLs (activities of daily living) and increase safety awareness. Per the documentation, the resident presented with deficits in ADL performance, strength, functional mobility and cognition; and that, skilled OT services was required to maximize functional performance, address deficits and promote safe discharge. Musculoskeletal assessment included that ROM (range of motion) of both…

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 interviews, review of facility documentations and policy, the facility failed to ensure that medications were secured and stored properly. The deficient practice could result in unauthorized access to medications and could place resident's safety at risk.Findings include:A medication administration observation was conducted with Licensed Practical Nurse (LPN/Staff #47) on September 15, 2025 at 11:19 AM. There was a gray basin covered with a white towel located on top of the medication cart. Staff #47 pulled a bottle of lactobacillus acidophilous (probiotic) from the gray basin then took one capsule from the bottle placed it in the medication cup and administered the medication to a resident. An interview was conducted with the LPN (Staff #47) on September 15, 2025 at 11:29 AM. Staff #47 stated that the gray basin which was covered with white towel and located on the top of the medication cart contained apple sauce, acidophilous (probiotic), and ensure (supplement). She stated that she keeps the bottle of lactobacillus acidophilous in the basin to keep 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 documentation, staff interviews, and facility policies the facility failed to ensure that two staff members (#21, and #58) are educated on infection control and prevention. The deficient practice could result in staff not being familiar with process and procedures for the control and prevention of infection. Findings include:-Regarding Staff #21Review of the personnel record for a Registered Nurse (RN/staff #21) revealed a hire date of August 1, 2024. Additionally, the personnel file revealed a signed job description dated August 4, 2024 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed August 4, 2025. However, it did not indicate what training were covered under this orientation. Further review of the personnel file provided by the facility did not reveal any evidence that staff #21 completed Infection Control training. Review of the Inservice training log/binder conducted on September 15, 2025 at 4:03 p.m. 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 documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#21, #58, #1, #55 & #11) received Dementia Care training. The deficient practice could result in staff not being familiar with process and procedures to care for residents with dementia.Findings include:On September 15, 2025 at 9:11 a.m., a written request for personnel files which included staffs #21, #58, #24, #1, #55 & #11) was submitted specifically asking for proof of training for Dementia Care. -Regarding Staff #21Review of the personnel record for a Registered Nurse (RN/staff #21) revealed a hire date of August 1, 2024. Additionally, the personnel file revealed a signed job description dated August 4, 2024 that outlined tasks and responsibilities which stated that staff will participate in all required meetings, trainings and events. The file also included a New Employee Orientation Acknowledgement signed August 4, 2025. However, it did not indicate what training were covered under this orientation. Further review of the personnel file provided by 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 interviews, review of clinical record, and facility policy, the facility failed to protect the residents' (#26, #24, #4, and #6) right to be free from physical abuse by a resident. The deficient practice could result in physical and psychosocial harm.Regarding Resident #26 and Resident #24:-Resident #26 was admitted to the facility November 6, 2023, with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance, prediabetes, type 2 diabetes mellitus, chronic kidney disease, cardiomegaly, delirium due to known physiological condition, anxiety disorder, bradycardia, and adult failure to thrive.An admission minimum data set (MDS) assessment dated [DATE], revealed a brief interview for mental status (BIMS) score of 1, indicating severe cognitive impairment. Section C revealed the resident had inattention and disorganized thinking. Section E revealed the resident had wandering behavior that occurred daily.A care plan dated November 15, 2023, revealed the Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure an alleged violation involving two residents (#37 and #42) was reported to the State Agency. Based on clinical record review, resident and staff interviews, review of the facility documentation and policy, the facility failed to ensure an alleged violation involving two residents (#37 and #42) was reported to the State Agency (SA).Findings include:Regarding Resident #37Resident #37 was admitted on [DATE], with a diagnosis of anxiety disorder, chronic obstructive pulmonary disease, dependence on supplemental oxygen, dementia, and cognitive communication deficit.Review of the Minimum Data Set (MDS) assessment revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating the resident had moderate cognitive impairment. The care plan, focusing on behavior, dated May 2, 2023, revealed the resident frequently misplaced items accusing others of taking them, and then needed help finding them. Review of a progress note dated June 27, 2025, indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure a complete investigation involving an alleged violation with two residents (#37 and #42) was conducted.Based on clinical record review, resident and staff interviews, review of the facility documentation and policy, the facility failed to ensure a complete investigation involving an alleged violation with two residents (#37 and #42) was conducted. Findings include:Regarding Resident #37Resident #37 was admitted on [DATE], with a diagnosis of anxiety disorder, chronic obstructive pulmonary disease, dependence on supplemental oxygen, dementia, and cognitive communication deficit.Review of the Minimum Data Set (MDS) assessment revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating the resident had moderate cognitive impairment. The care plan, focusing on behavior, dated May 2, 2023, revealed the resident frequently misplaced items accusing others of taking them, and then needed help finding them. Review of a progress note dated June 27, 2025,…

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 interviews, review of facility documentation, and review of policy and procedures, the facility failed to implement their policy to report and investigate allegations of neglect for one resident (#8) and failed to protect a reporter from retaliation. The deficient practice could result in allegations of neglect not being reported and investigated timely, which could result in continuing neglect. Findings include: Resident #8 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, post-polio syndrome, chronic pain syndrome, asthma, and dyspnea. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview or Mental Status (BIMS) score of 15, indicating intact cognition. Additionally, Section E revealed that the resident had no potential indicators of psychosis, and no physical behavioral symptoms. A physician order dated February 12, 2025, at 10:58 AM, indicated to send Resident #8 to the emergency room (ER)…

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 interviews, review of facility documentation, and review of policy and procedures, the facility failed to assess a resident for a change of condition timely, and provide timely transfer to emergency services for one resident (#8). Additionally, the facility failed to obtain a physician order for administration of oxygen therapy according to professional standards for one resident (#8). The deficient practice could result in a delay of care for a resident, leading to a worsening medical condition, and could lead to a physician not being aware of a resident's respiratory status regarding oxygen use. Findings Include: -Regarding resident assessment and timely transfer to emergency services for Resident #8: Resident #8 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, post-polio syndrome, chronic pain syndrome, asthma, and dyspnea. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of facility documentation, and review of policy and procedures, the facility failed to maintain a complete and accurate medical record for one resident (#8) regarding administration of oxygen therapy dose. The deficient practice could result in an incomplete medical record which could lead to interdisciplinary team members not being aware of a resident's respiratory status regarding oxygen use. Findings Include: Resident #8 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, post-polio syndrome, chronic pain syndrome, asthma, and dyspnea. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview or Mental Status (BIMS) score of 15, indicating intact cognition. Section O indicated that the resident was not receiving oxygen therapy on admission or while a resident. Review of the O2 Sats Summary log revealed the resident was on room air on all log entries except the following entries…

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, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that four residents (#24, #68, #10, #12) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse. Findings include: Regarding Resident #24 -Resident #24 was admitted to the facility on [DATE] and discharged on September 30, 2023 with a re-admission date of October 3,2023. Resident passed away on October 9, 2023 with diagnosis including Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, schizoaffective disorder, unspecified. A review of the quarterly MDS (minimum data set) dated June 22, 2023 revealed a BIMS (brief interview of mental status) score of 06, indicating that the resident had severe cognitive impairment. The MDS further indicated that 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, resident and staff interviews, and policy review, the facility failed to ensure one of three sampled residents (#1) was not abused by another resident (#2). The deficient practice could result in residents being physically and emotionally harmed. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage without loss of consciousness, metabolic encephalopathy, dementia, delirium, depression, and anxiety. The OBRA (Omnibus Budget Reconciliation Act) admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident's Brief Interview for Mental Status (BIMS) score was 99, which indicated severe cognitive impairment. The assessment also revealed that the resident was exhibiting behavioral symptoms including physical and verbal on one to three days, and utilized a wheelchair and walker for mobility. A skin assessment dated [DATE], revealed that there was a resident 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 documentation, staff interviews, and the facility policy and procedures, the facility failed to protect the rights of two residents (#24 and #15) to be free abuse by residents (#6 and #34). The deficient practice could result in residents being physically and mentally harmed. Findings include: Regarding resident #24 and #6 -Resident #24 was admitted to the facility on [DATE] with diagnoses of hemiplegia, unspecified affecting the right dominant side, major depressive disorder, anxiety, and schizoaffective disorder. A care plan dated July 12, 2021 revealed the resident had the potential to demonstrate physical and verbal behaviors (hitting and swearing, threatening) related to poor cognition and understanding of situations. Interventions included that when the resident becomes agitated, intervene before agitation escalates; guide away from the source of distress; engage calmly in conversation; and if the resident was aggressive, staff were to walk away, and approach later. The care plan dated January 28,…

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 concerns identified during the survey, review of the facility assessment, staff interviews, Quality Assurance (QA) documentation, and policy review, the Quality Assessment and Assurance (QAA) committee failed to ensure the director of nursing (DON) attended the QAA meeting. The deficient practice can result in quality care concerns not being identified and corrected. Findings include: During the survey which was conducted on June 3, 2024 through June 6, 2024, concerns were identified regarding the attendance of the director of nursing during QAA meeting. Review of the facility document titled, QAPI Attendance Record revealed that on January 25, 2024 the executive director, medical director, DON, Infection Preventionist (IP), and others revealed a signature for each attendee except the pharmacy consultant. But for the months of February through May 2024, the document revealed the DON's QAPI Attendance Record signature was left blank. Furthermore, a review of the facility document titled, Facility Assessment revealed a list of Persons involved in completing assessment. 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 resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure one resident (#31) was able to make choices about their care. The deficient practice could result in residents being denied the right to make their own choices. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included spondylolisthesis, anxiety disorder, chronic obstructive pulmonary disease, and osteoarthritis. The Quarterly Minimum Data Set assessment from 02/29/2024, the Brief Interview for Mental Status (BIMS) score was 10 which suggested moderate cognitive impairment. There was no evaluation of bathing ability due to the bathing activity not being performed in the lookback period. Care plan initiated on 10/13/2022 had a goal for a performance deficit for activities of daily living (ADL) related to her diagnoses. It documented that she is bedfast most of the time and interventions included encouraging resident to participate to the fullest extent…

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 and policies and procedures, the facility failed to ensure that one resident (#304) was free from abuse by another resident (#20). Findings include: Resident #20 was admitted on [DATE] with diagnoses that included cerebrovascular accident (CVA), epilepsy, traumatic brain injury (TBI), major depressive disorder, and schizoaffective disorder. Review of the care plan initiated on January 28, 2022 and revised on April 4, 2022 revealed that resident #20 have a psychosocial well-being problem related to anxiety, ineffective coping, lack of acceptance to current condition, TBI, schizophrenia, verbal and physical aggression. It also stated that he had been involved in altercation with peer. The interventions initiated on January 29, 2022 included need of assistance/encouragement/support to identify problems that cannot be controlled, and identify precipitating factor(s)/stressors. Another care plan initiated on July 12, 2021 revealed resident #20…

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 and staff interviews, clinical record review, and facility policy, the facility failed to ensure that alleged violations involving abuse were reported within required timeframe for one resident (#16). Findings include: Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include hypertension, chronic obstructive pulmonary disease, cardiomegaly, and dementia. Review of Quarterly Minimum Data Set assessment from 01/18/2024 revealed resident #16 Brief Interview for Mental Status (BIMS) score was unable to be assessed due to the resident being rarely or never understood. Staff assessment indicated there were short- and long-term memory problems and resident's cognitive skills were severely impaired. There was no fall history documented. Review of care plan initiated on 12/02/2019 reveal that resident #16 did have a goal related to her risk for falls with interventions that were updated after her 03/23/2024 fall which included being on the Falling Leaf…

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 and staff interviews, clinical record review, and facility policy, the facility failed to ensure one resident (#27) received necessary services to maintain personal hygiene. The deficient practice may cause a decline or decrease in a resident's quality of life. Findings include: Resident #27 admitted to the facility on [DATE] with diagnoses that included myotonic muscular dystrophy, acute respiratory failure with hypoxia, and major depressive disorder. Care plan initiated on 02/04/2023 had a goal for a performance deficit for activities of daily living (ADL) related to her diagnoses. Interventions included encouraging resident to participate to the fullest extent possible with each interaction, use the call light to call for assistance, and assistance with bathing/showering per bath schedule preference and as necessary. Review of quarterly Minimum Data Set (MDS) assessment from 04/04/2024 revealed resident #27 the Brief Interview for Mental Status (BIMS) score was 13 which indicated no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure baseline care planning as required for 4 residents (#1, #62, #64, and #88). The sample was 35 residents. The deficient practice could result in lack of resident involvement in the plan of care. Findings Include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included acquired absence of left leg above knee, anxiety disorder, chronic kidney disease, and chronic obstructive pulmonary disease. Review of the clinical record did not reveal documentation that the facility provided the resident and their representative with a summary of the baseline care plan as required. An interview was conducted on December 8, 2022 at 1:27 p.m. with the [NAME] President of Clinical Operations (staff #84). She stated the baseline care planning was not completed as required for Resident #1. -Resident #62 admitted to the facility on [DATE] with diagnoses that included sepsis, pneumonia, acute…

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 resident interviews and policy review, the facility failed to ensure one resident (#47) or resident's representative was able to participate in the care planning process. The sample was 35 resident. The deficient practice could result in residents and representatives not participating in and understanding their plan of care. Findings include: Resident #47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, hypertension, and major depression. The quarterly Minimum Data Set (MDS) dated [DATE] included a staff assessment for mental status which indicated the resident had some difficulty making decisions in new situations. Review of the care plan dated April 6 2020 for impaired cognitive function/dementia or impaired thought processes related to dementia, short-term memory loss included the intervention that resident needs supervision/assistance with all decision making. Review of facility documentation did not reveal documentation 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, facility documentation, staff interviews, and policy, the facility failed to ensure that an appropriate level of supervision was provided for one resident (#8) resulting in two another residents (#24 and #6) being slapped and grabbed. The sample was 7 residents. The deficient practice could result in other residents being physically harmed. Findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, unspecified intellectual disabilities, unspecified mood affective disorder, and schizoaffective disorder. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status score of 8 indicating the resident had a moderate cognitive impairment. Review of the progress notes revealed the following: -January 28, 2022 a registered nurse (RN) notified that this resident struck another peer in the arm. Staff member states that resident was walking down the hall when the resident struck peer in the arm without…

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 policy, the facility failed to provide urinary catheter care as ordered to one resident (#64). Three residents were reviewed for urinary catheter/Urinary Tract Infection (UTI). The deficient practice could result in complications with indwelling urinary catheters, including infection. Findings Include: -Resident #64 admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease, flaccid neuropathic bladder, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was always incontinent and required total assist for toileting. Review of the physician's orders for August 23, 2022 revealed: -An order for a Foley Catheter Size 16 french/30 cubic centimeter (cc) balloon. -An order for catheter care with soap & water or wipes every shift for flaccid neuropathic…

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 interviews, personnel record review, facility assessment review, and policy, the facility failed to ensure 2 staff (#26 and #89) possessed the competencies and skills needed to care for residents with behaviors. The deficient practice could result in a delayed and inappropriate response to deescalate behaviors. Findings include: Staff #26 was hired as a licensed nursing assistant (LNA) on November 23, 2021. Review of the employee's personnel record did not reveal that she had completed behavior intervention training. Review of the staff's time card revealed that staff #26 worked October 23, 2022 from 5:57 a.m. to 7:07 p.m. -Staff #89 was hired as a licensed practical nurse (LPN) on August 11, 2022 and resigned on October 26, 2022. Review of the employee's personnel record did not reveal that she had completed behavior intervention training. Review of the staff's time card revealed that staff #89 worked on October 23, 2022 from 5:57 p.m. to 6:04 a.m. Review of a 5-day written investigation report 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 clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one resident (#64) receiving psychotropic medications received consistent monitoring for behaviors and side effects; failed to document the use of non pharmacologic interventions; and failed to ensure a PRN (as needed) antianxiety medication had a duration for treatment. Five residents were reviewed for medication use. The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: Resident #64 admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease, anxiety disorder, and depression. A psychotropic medication informed consent form dated April 28, 2022 was reviewed for Ativan (Lorazepam) which included the medication class as an antianxiety and the target symptoms as restlessness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed: a staff assessment of mental status…

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 policy and procedure, the facility failed to notify one resident (#1), or the resident's representative, and ombudsman in writing of the reason for the transfer/discharge. The sample size was 1. The deficient practice could result in residents not knowing their discharge rights. Findings include: -Resident #1 was readmitted to the facility on [DATE] with diagnoses that included acquired absence of left leg above knee, anxiety disorder, chronic kidney disease, and chronic obstructive pulmonary disease. Review of the resident's Minimum Data Set (MDS) assessments revealed a discharge, return anticipated assessment dated [DATE]. The coding included that it was an unplanned discharge to a acute hospital. Review of a nurse's progress note dated October 14, 2022 included the resident stated that she wanted to go to the hospital because she felt that her kidneys were blocked. The nurse called the on call physician and tried to get an order. 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 clinical record review, staff interviews, and review of policy and procedure, the facility failed to notify one resident (#1), or the resident's representative of the bedhold and reserve bed payment policies at the time of transfer/discharge to the hospital. The sample size was 1. The deficient practice could result in residents not knowing their discharge rights. Findings include: -Resident #1 was readmitted to the facility on [DATE] with diagnoses that included acquired absence of left leg above knee, anxiety disorder, chronic kidney disease, and chronic obstructive pulmonary disease. Review of the resident's Minimum Data Set (MDS) assessments revealed a discharge, return anticipated assessment dated [DATE]. The coding included that it was an unplanned discharge to a acute hospital. Review of a nurse's progress note dated October 14, 2022 included the resident stated that she wanted to go to the hospital because she felt that her kidneys were blocked. The nurse called the on call and tried to get an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure complete and accurate comprehensive Minimum Data Set (MDS) assessments for two residents (#62 and #64). The sample was 35 residents. The deficient practice could result in inadequate assessment of resident needs. Findings include: -Resident #62 was admitted to the facility on [DATE] with diagnoses that included sepsis, pneumonia, acute respiratory failure, and cognitive communication deficit. Review of a comprehensive/admission MDS dated [DATE] included that the Brief Interview for Mental Status (BIMS) should be conducted. There was no information documented for the BIMS and the BIMS score was dashed/- which meant it was not assessed. The staff assessment for mental status was not completed. The assessment included the Mood interview should be completed. Each section of the Mood interview was dashed/-. The staff assessment of mood was not completed. The assessment included the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two residents (#1 and #64). The sample was 35 residents. The deficient practice could result in inadequate assessment of resident needs. Findings include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included acquired absence of left leg above knee, anxiety disorder, chronic kidney disease, and chronic obstructive pulmonary disease. Review of a Quarterly MDS dated [DATE] revealed: The Brief Interview for Mental Status should have been completed, however, the interview questions were left blank and the score has a dash/not assessed. The staff assessment for mental status was not completed. The mood interview should have been conducted, however, all of the mood questions and the severity score contain dashes. The staff assessment of mood questions were not assessed. The pain assessment interview should…

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 personnel file review, staff interview, and job description, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in lack of appropriate activity programs for residents. Findings include: A review of the personnel file for the activity director (AD/staff #5) revealed she was hired on June 24, 2020 as an activity assistant, but was identified by the facility as the Activity Manager. Further review of the file did not reveal any experience in a social, recreational, or therapeutic activities program. The personnel file also revealed no evidence of completion of a course and certification in therapeutic activities. A review of the facility staff list revealed that staff #5 was the Activities Manager. During an interview conducted on December 7, 2022 at 11:49 a.m. with human resources (staff #32), ten employee files were reviewed and he identified staff #5 as the Activities Manager. An interview was conducted on December 8, 2022 at 11:43 a.m. with the [NAME] President of Clinical Operations/Regional…

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 and resident interviews, and review of facility policy, the facility failed to assess for interventions for identified decreased Range of Motion (ROM)/contractures for one resident (#64) of two residents reviewed for positioning and mobility. The deficient practice could result in residents not receiving required services and a further decline in resident status. Findings Include: -Resident #64 admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Review of a care plan focus dated April 28, 2022 revealed the resident had impaired functional mobility with a goal to remain free from complications of impaired range of motion. The interventions included to report and document any declines in ability and to refer to therapy as necessary. Review of Occupational Therapy (O.T.) notes for start of care April…

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 closed clinical record review, staff interviews, and policy review, the facility failed to provide pain management in a timely manner in accordance with physician's orders for one resident (#289). The sample size was 6 residents. The deficient practice could result in resident's pain not being managed timely. Resident #289 was admitted to the facility on [DATE] with diagnoses that included scoliosis surgery, fusion of spine, and hypertension. Review of the clinical record revealed the following physicians orders: -Oxycodone Tablet 5 milligrams (mg) 1 tablet by mouth every 6 hours as needed for pain level of 6 to 10. Order dated 11/22/22 10:00 am -Tylenol Extra Strength Tablet 500 mg (Acetaminophen) 2 tablet by mouth every 6 hours as needed for Pain Scale 1-5, not to exceed 3mg per 24/hour period. Order dated 11/22/22 9:54am Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident received extensive assistance on all activities of daily living (ADLs) attempted with 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 observations, resident and staff interviews, and record review, the facility failed to ensure menus were followed in regard to food served. The deficient practice could place residents at risk of nutritional problems and dissatisfaction with their meals. Findings include: Resident #189 was admitted to the facility on [DATE] with diagnoses that included diverticulosis, anemia and hypertension. Review of the residents discharge Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10, which indicated the resident had a mild cognitive deficit. Review of the facility documentation of an event (date not listed) revealed that the menu called for tuna salad, chips, sliced tomatoes, banana pudding and choice of beverage. However, the facility cook served potato salad sandwiches and a bag of chips. The facility was unable to provide documentation that a change in the menu was approved by a registered dietitian nutritionist (RDN). An interview was conducted with 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.