Resolve Harmony Center, LLC

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 protect the rights of one resident (#4) to be free from abuse by another resident (#6). The deficient practice could result in further resident abuse.Findings: -Regarding Resident #4Resident #4 was admitted to the facility on [DATE], with a diagnosis that included schizophrenia, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, recurrent, unspecified.A review of the Annual MDS (minimum data set) assessment dated [DATE], revealed a BIMS (brief interview of mental status) score of 07, which indicated the resident had severe cognitive impairment. Further review of the MDS revealed no indicators for mood, no indicators for behaviors, but concerns with wandering daily.Review of Care Plan initiated on October 9, 2025, with reviewed/revised date of August 16, 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 clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of residents to be free from abuse by another resident (#777, #222, #444). The deficient practice could result in residents being harmed physically and emotionally. -Regarding Resident to Resident altercation between Resident #1001 and #777: -Resident #1001 was admitted to the facility on [DATE] and discharged on May 22, 2023. Diagnoses included schizoaffective disorder depressive type, dysphagia following cerebral infarction, and human immunodeficiency virus (HIV). The care plan dated April 10, 2023 revealed that the resident was involved in an altercation with another resident. He rammed his chair into the resident's feet. The resident will not be involved in another altercation with another resident through the next review date. Interventions included that the wheelchair was revoked as directed and to monitor the resident's behavior as indicated. The MDS dated [DATE] included a brief a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure that one resident (#1000) was treated with dignity and respect by another resident.Based on documentation, staff and resident interviews, the facility policy and procedures, the facility failed to ensure that one resident (#1000) was treated with dignity and respect by another resident (#1001). The deficient practice could result in psychosocial harm. Findings included:Resident #1000 was admitted to the facility on [DATE] and discharged on October 3, 2022. The diagnoses included post traumatic disorder (PTSD), major depressive disorder, bipolar disorder, and anxiety disorder.The Minimum Data Set, dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It also included that the resident ambulated with a wheelchair.The care plan dated September 6, 2022 revealed that the will feel safe through the next review date. The resident reported being sexually assaulted by another resident that he touched and massaged her shoulder…

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 update the fall care plan for one resident.Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to update the fall care plan for one resident (#4). The deficient practice could result in residents not receiving the care needed to prevent further accidents.The findings included:The resident was admitted to the facility on [DATE] with diagnoses that included abnormality of gait, generalized muscle weakness, dorsalgia, usnspecified fall, and wedge compresision fracture of third lumbar vetebra, The resident expired on [DATE]. The MDS dated [DATE] included a brief interview for mental status score of 8 indicating the resident had a moderate cognitive impairment. It also included that the resident had a fall in the last month and had a fracture related fall in the last six months. The fall care plan dated [DATE] stated that the resident was at risk for falls. Review of the plan revealed that all the interventions on the care plan were implemented…

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 one resident's (#484) received services to meet professional standardsBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#4) received services that met professional standards. The deficient practice could result in residents not receiving the care needed in a timely manner. Findings included: Resident (#4) was admitted to the facility on [DATE] with diagnoses that included abnormality of gait, generalized muscle weakness, unspecified fall, and wedge compression fracture of third lumbar vertebra, The resident expired on [DATE]. The MDS dated [DATE] included a brief interview for mental status score of 8 indicating the resident had a moderate cognitive impairment. It also included that the resident had a fall in the last month and had a fracture related fall in the last six months. Review of a nurse's progress note dated [DATE] revealed that resident stated that he slid from his chair and onto 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 and resident interviews, and facility policy, the facility failed to protect the rights of four out of the seven sample residents to be free from abuse by another resident. The deficient practice could result in other residents being abused.Findings Include: - Regarding a resident-to-resident altercation that occurred on June 20, 2025 involving Resident # 35, Resident #13, and Resident #72. -Regarding Resident #35Resident # 35 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, urinary tract infection, and heart failure. A quarterly MDS (Minimum Data Set) assessment, dated February 2, 2025, revealed a BIMS (Brief Interview for Mental Status) score of 12, indicating moderately impaired cognition. -Regarding Resident #13Resident #13 was admitted to the facility on [DATE], with diagnoses of major depressive disorder, hyperlipidemia, and hypothyroidism A quarterly MDS assessment dated [DATE], revealed that resident #13 had a BIMS score of 15, which…

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 review, the facility failed to report alleged violations involving abuse for two residents (#35 and #13 ). The deficient practice resulted in allegations of abuse not being reported, not investigated, and residents not being protected from further abuse.Regarding a resident-to-resident altercation that occurred on June 20, 2025 involving Resident # 35, Resident #13, and Resident #72. -Regarding Resident #35Resident # 35 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, urinary tract infection, and heart failure. A quarterly MDS (Minimum Data Set) assessment, dated February 2, 2025, revealed a BIMS (Brief Interview for Mental Status) score of 12, indicating moderately impaired cognition.A progress note for Resident #35 dated June 21, 2025, revealed that on June 20, 2025, Resident #35 and Resident #13 were relocating kittens across the courtyard to prevent them from being injured, and Resident #72…

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 resident (#2) did not abuse another resident (#4). The deficient practice could result in residents being physically harmed. Findings Include: - Regarding Resident #2: Resident #2 was admitted on [DATE] with diagnoses that included dementia, chronic ischemic heart disease, chronic obstructive pulmonary disease and major depressive disorder. An admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 13, which indicated the resident is cognitively intact. A progress noted dated February 16, 2023 at 03:10 a.m. revealed that Resident #2 was involved in an altercation with Resident #4 outside on the patio. Resident #4 named Resident #2 as the resident that knocked her tooth out and that Resident #4 hit Resident #2 with a stick. The Police were immediately notified and APS notified. A care plan focus initiated on [DATE] revealed a focus on 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 reviews, resident and staff interviews, facility documentation, policy, and procedures, the facility failed to ensure that residents (154), (145),(125) and (D1) were free from resident-to-resident abuse. The findings include: Resident (154) was admitted to the facility on [DATE], with diagnosis that consisted of hemiplegia and hemiparesis following cerebral infarction affecting the non-dominant side, paraplegia unspecified, type 2 diabetes mellitus with hyperglycemia, morbid obesity, and adjustment disorder. The resident care plan consisted of the following: Resident involved an altercation with another resident. [NAME] states that she was hit a few times by resident and shirt ripped at neckline. was able to point to areas to the left forehead and to the base of the left eye. The left side of the frontal forehead was slightly raised and intact. There is no bruising present at this time. The area below the left eye appears to be puffy with skin intact. The same can be visualized to 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, clinical record review, staff interviews, and policy review, the facility failed to maintain a safe, clean, and comfortable environment for 2 of 2 sampled residents (#35 and #39), and failed to maintain a clean and sanitary environment in 3 of 3 shower rooms. The deficient practice could result in spread of infection, pest infestation, and resident rooms not having a homelike environment. Findings Include: - Regarding the shower rooms: On December 13, 2024, at 12:49 PM, a walk-through was conducted in the facility's north shower room with a certified nursing assistant (CNA/ Staff #82), while all of the shower rooms were not in use by residents. In the shower stall area, on the caulk line between the shower wall and shower basin area underneath the water spout, a black and brown to orange appearing residue substance was noted. It was noted that an area where the shower wall separated from the shower basin underneath the shower head, where the caulk had separated, leaving unsealed access for…

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

Based on observation, staff interviews, and policy documentation the facility failed to ensure that the daily nurse staffing information posted were accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information. Findings include: A review of seven randomly chosen days of staff postings compared with the staff assignment sheets revealed that none of the staff postings matched the actual number of staffs that worked. Daily Staffing report vs punch detail August 29, 2024 - September 4, 2024. Review of the Daily Staffing reports revealed evidence that they were inaccurate: The daily staffing report dated August 29, 2024 revealed that the actual hours worked by licensed direct care staff and certified nursing assistants were '0' for the day shift, the evening shift, and, for the night shift. The daily staffing report dated August 30, 2024 revealed that the actual hours worked by licensed direct care staff and certified nursing assistants…

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 -Regarding Resident #39: Resident #39 was admitted on [DATE], with diagnoses that included schizophrenia, anxiety disorder, depression, repeated falls, and heart failure. A physician order dated December 05, 2024, indicated for Linezoid-0.9% sodium chloride parenteral solution; 600 mg/300 mL, to be given intravenously twice a day. There was no evidence of an order for Enhanced Barrier Precautions (EBP), or any other type of transmission-based precautions for Resident #39. A care plan revised December 04, 2024, for IV central line indicated that the resident will exhibit no signs of IV complications during period of intravenous requirements and post removal. There was no evidence of a care plan focus for EBP, or any other transmission-based precautions. A formal request was made to the facility to provide evidence of annual training on the topic of infection control for a licensed practical nurse (LPN / Staff #40). The facility provided an In-Service Sign-In Sheet, dated May 08, 2024, on the subjects of…

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

Based on observations, facility documentation, staff interviews, and Center for Disease Control (CDC) guidelines, the facility failed to execute an antibiotic stewardship program. The facility census was 59 residents. The deficient practice could result in improper antibiotic use and adverse outcomes to residents. Findings include: The Facility Infection Prevention and Control Program was approved by the governing body to improve antibiotic use February of 2024. The facility was unable to provide any documentation/evidence of the following components of their Antibiotic Stewardship Program: - Nursing home antibiograms for antibiotic selection. - Use of the Situation Background Assessment and Recommendation (SBAR) protocol for residents. - Antibiotic Use Tracking Sheets completed in entirety. - Reports of Negative Outcomes or events related to antibiotic use. Review of the Personal Improvement Plan (PIP) for Quality Assurance and Performance Improvement (QAPI) QAPI dated February 10, 2024 revealed no evidence of any antibiotic trend/usage discussion. Education was provided regarding…

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, staff interviews, review of facility records and policies and procedures, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. The deficient practice could result in ongoing pest problems and residents not having a homelike environment. -Findings include: A facility walkthrough was conducted on December 10, 2023, with the following observations: -8:30 AM: From the doorway of room [ROOM NUMBER], it was observed that the resident was not currently in the room, a meal tray was on the bedside table with the lid on, and a fly was present flying around the room. The fly landed on the lid of the meal tray. -8:35 AM: In room [ROOM NUMBER], a fly was observed to be flying around the resident laying in the bed nearest to the window. -8:40 AM: In room [ROOM NUMBER], a fly was flying around the resident's room. It was also observed that several plastic containers of mostly-eaten food were stacked on the windowsill in the resident's room. The lids…

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, clinical record review and policy, the facility failed to ensure that dignity was maintained for one resident (#28). The deficient practice has the potential for additional residents to be treated with a lack of dignity and respect. Findings include: Resident #28 was admitted on [DATE] with a diagnosis that included noninfective gastroenteritis, major depressive disorder, anxiety disorder, and colitis. Review of a behavioral care plan initiated on May 24, 2021 revealed that resident #28 has a history of making false allegations towards staff. Interventions included to assess for contributing factors for behavior, medications as ordered, provide supervision as required. A care plan with a start date of June 6, 2023 identified that the resident has feelings of anxiety, fear, delusional or social isolation and uses a baby doll for emotional support. The target goal indicated that the resident will demonstrate decreased feelings of anxiety, agitation, 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 Regarding Resident #43: Resident #43 was initially admitted on [DATE] with diagnoses that included anxiety disorder due to known physiological conditions, schizophrenia, mood disorder and major depressive disorder. A care plan initiated on October 27, 2023 and revised November 11, 2024 revealed that the resident was at risk for self-harm related to feelings of helplessness, sadness, hopelessness, hearing voices, suicidal ideation, depression, and anxiety secondary to psychiatric disorder schizophrenia. Interventions included encouraging follow-up with the community, and to notify providers for any issues. The antipsychotic drug therapy care plan initiated on October 27, 2023 revised November 10, 2024 included interventions that included to administer medications as ordered and monitor/document side effects, and monitor/document behaviors. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident ' s active diagnosis included schizophrenia, anxiety disorder and major…

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 policy review, the facility failed to ensure the physician was notified of a medication not administered according to professional standards for one of one sampled resident (#19). The deficient practice could result in a resident not receiving medication to meet their needs and the physician not being aware of the resident's status. -Findings Include: Resident #19 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease, schizophrenia, bipolar disorder, and drug induced subacute dyskinesia. A care plan dated April 16, 2024, indicated that Resident #19 has tardive dyskinesia (movement disorder), and will participate in self care activities at the highest level of independence. A physician order dated August 07, 2024, indicated for Austedo XR (deutetrabenazine) tablet extended release 24 hour, 6 mg, once a day. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief…

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, review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#46). The deficient practice could result in residents not receiving necessary services for oral and dental care. Findings include: Resident #46 was initially admitted to the facility on [DATE] and was re-admitted to the facility on [DATE] with diagnoses that included paraplegia, Atherosclerosis of aorta, adrenocortical insufficiency, pain, depression and adjustment disorder with mixed disturbance of emotions and conduct. Review of a nutrition care plan initiated on April 24, 2024 indicated that the resident is at risk for imbalanced nutrition. Interventions included to ensure dentures etc. are in place before meals and fit properly. A hospice care plan initiated on April 28, 2024 revealed that the resident was originally on hospice. However, the hospice care plan was resolved on November 8, 2024 when hospice was discontinued. Further review of…

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

Based on observations, staff interviews, and policy reviews, the facility failed to ensure food items were not expired and the vent across from tray line was clean. The deficient practice could increase the risk of foodborne illness. Findings include: -Regarding sanitary kitchen and conditions: During the initial kitchen observation conducted on December 10, 2024 at 08:36 a.m., it was observed the vent across from tray line was coated with a layer of dust. The air vent grille was visibly layered with gray thick, fuzzy dust. The filter can be slightly seen and it was also layered with dust. A second observation was conducted on December 11, 2024 at 10:53 a.m. The kitchen vent across from tray line was still coated with a layer of dust. The air vent grille still had visible layers of gray, thick, fuzzy dust. During the third kitchen observation on December 12, 2024 at 12:07 p.m., the air vent across from the tray line was again noted to have a layer of gray, thick, fuzzy dust. An interview was conducted with the Dietary Manager (staff #68) on December 12, 2024 at approximately 12:17…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, interviews, and review of facility policies, the facility failed to ensure three residents (#35, # 39, and #216) was provided a means to communicate with the staff by having a call light accessibility. The deficient practice could result in residents not having the means to communicate with staff. Findings include: - Regarding Resident #35: Resident #35 was admitted to the facility December 14, 2022, with diagnoses that included Type 2 Diabetes, anticoagulant therapy, unspecified dementia, anxiety, and unsteadiness on feet. A care plan dated June 30, 2024 revealed the resident it at risk for falls, with four previous falls without injury at the facility. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. December 10, 2024, resident observed lying in bed during initial pool screening at approximately 9:22 a.m. Resident's push button for call…

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 interviews, and facility policy review, the facility failed to maintain an effective training program for three of ten sampled staff (#62, #75, and #82). The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: - Regarding the dietary staff (Staff #62): Review of personnel file for the dietary staff (Staff #62) revealed a hire date of January 03, 2023. Physical sign-in sheets provided by the facility revealed that Staff #62 did not complete required annual training for resident rights, dementia, abuse and neglect, and, infection control for the year of 2024. - Regarding the registered nurse (RN/Staff #75): The personnel file for the RN (Staff #75) revealed a hire date of August 01, 2016. Physical sign-in sheets provided by the facility revealed that Staff #75 did not complete required annual training for resident rights, dementia, abuse and neglect, and, infection control for the year of 2024 - Regarding the certified nursing assistant…

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 interviews, and facility policy review, the facility failed to ensure three of ten sampled staff sampled staff (#62, #75, and #82) received ongoing education on residents' rights. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: - Regarding the dietary staff (Staff #62) Review of personnel file for the dietary staff (Staff #62) revealed a hire date of January 03, 2023. Physical sign-in sheets provided by the facility revealed that Staff #62 did not complete required annual training for resident rights, dementia, abuse and neglect, and, infection control for the year of 2024. - Regarding the registered nurse (RN/Staff #75) The personnel file for the RN (Staff #75) revealed a hire date of August 01, 2016. Physical sign-in sheets provided by the facility revealed that Staff #75 did not complete required annual training for resident rights, dementia, abuse and neglect, and, infection control for the year of 2024 - Regarding 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 personnel file review, staff interviews, and facility policy review, the facility failed to ensure two of ten sampled staff sampled staff (#62 and #75) received ongoing education on abuse, neglect, exploitation, and providing care to those with Alzheimer's or other dementia. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: - Regarding the dietary staff (Staff #62) Review of personnel file for the dietary staff (Staff #62) revealed a hire date of January 03, 2023. Physical sign-in sheets provided by the facility revealed that Staff #62 did not complete required annual training for resident rights, dementia, abuse and neglect, and, infection control for the year of 2024. - Regarding the registered nurse (RN/Staff #75) The personnel file for the RN (Staff #75) revealed a hire date of August 01, 2016. Physical sign-in sheets provided by the facility revealed that Staff #75 did not complete required annual training for resident rights, dementia, abuse and neglect,…

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 interviews, and facility policy review, the facility failed to ensure two of ten sampled staff sampled staff (#62, #75, and #82) received ongoing education infection control. The deficient practice could lead to a deficit in staff or volunteers' knowledge and/or skills which could affect resident care, leading to harm. Findings include: - Regarding the dietary staff (Staff #62) Review of personnel file for the dietary staff (Staff #62) revealed a hire date of January 03, 2023. Physical sign-in sheets provided by the facility revealed that Staff #62 did not complete required annual training for resident rights, dementia, abuse and neglect, and, infection control for the year of 2024. - Regarding the registered nurse (RN/Staff #75) The personnel file for the RN (Staff #75) revealed a hire date of August 01, 2016. Physical sign-in sheets provided by the facility revealed that Staff #75 did not complete required annual training for resident rights, dementia, abuse and neglect, and, infection control for the year of 2024. - Regarding the certified…

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 (#3) was not neglected. The deficient practice could result in residents not receiving the care and services needed to improve and maintain health. Findings include: Resident #3 was admitted to the facility April 9, 2024 and readmitted on [DATE] with diagnoses that included acute respiratory disease, pneumonia due to corona virus disease, wheezing, and spinal stenosis. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. Review of the order summary revealed an order dated May 17, 2024 for oxygen-apply O2 at 2 liters per nasal cannula as needed for O2 saturation below 90%. As needed: PRN 1, PRN 2, PRN 3. Review of the order summary revealed an order May 17, 2024 for Amlodipine tablet 5 mg oral for hypertension once a day 7:00 a.m. to 10:00 a.m. Review of the care plan did not reveal a plan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure that comprehensive care plans were developed for two residents (#166 and #30). The deficient practice could result in residents needs based on the comprehensive assessment not being met. Findings include: -Resident #166 was admitted on [DATE] with diagnoses of infection following a procedure, multiple fractures of pelvis without disruption of pelvic ring and moderate protein-calorie malnutrition. A nursing note dated June 1, 2022 included the resident was observed in the bathroom smoking a substance that smelled like an illicit drug. The note also included that the resident was alert but, appeared altered and giddy in appearance and had extinguished the smoking material Per the documentation, the resident was assessed and new orders were written to hold pain medications and pass privileges; and that, the staff would continue to monitor the resident. A nursing note dated June 1, 2022 included that staff…

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 policy and hospital record review, the facility failed to ensure adequate supervision was provided for one resident (#166) related to illicit drug use. The deficient practice could result in a decline in the resident's health condition or death. Findings include: -Resident #166 was admitted on [DATE] with diagnoses of infection following a procedure, multiple fractures of pelvis, other muscle spasms and pain in unspecified hip. A physician order dated May 18, 2022 included for oxycodone (narcotic opioid) 5 mg (milligram) for pain level of 7-10 four times a day as needed. The physician order dated May 18, 2022 included to give Narcan (narcotic antagonist) nasal spray, 4 mg per actuation for signs and symptoms of a possible opioid overdose. A nursing note dated June 1, 2022 included the resident was observed in the bathroom smoking a substance that smelled like an illicit drug. The note also included that the resident was alert but, appeared altered and…

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

Based on a review of the facility documentation, staff interviews and policy review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, seven days a week; and, failed to designate a registered nurse to serve as the director of nursing (DON) on a full-time basis. The deficient practice could result in not meeting the critical needs of the residents. Findings include: -Regarding RN coverage: A review of the Facility Assessment Tool dated 12/2022 revealed that the general staffing plan for nursing staff providing direct care was to provide an RN coverage in the 6:00 a.m. to 6:00 p.m. and the 6:00 p.m. to 6:00 a.m. shift. The daily staffing record for January 7, 2023 revealed that an RN (staff #65) worked on this day. However, there was no evidence found that staff #65 worked on January 7, 2023. There was also no evidence found that an RN worked for at least 8 consecutive hours on January 7, 2023. An interview was conducted with the acting DON on February 16, 2023 at 2:34 p.m. The acting DON stated that the expectation was to have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to provide one resident (#40) a clean and homelike environment by not storing boxes for activities in the room. Findings include: Resident #40 was admitted on [DATE] with diagnoses of heart failure, cerebral palsy, nicotine dependence, diabetes mellitus, exocrine pancreatic insufficiency, and anxiety disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident had intact cognition. Further, the assessment included resident had no behaviors exhibited. An observation of the resident's (#40) room was conducted on February 13, 2023 at 2:18 p.m. and revealed there were multiple boxes of food stacked on the floor and against the wall. There were also a table next to the wall with boxes stacked on top and underneath. An interview was conducted with Resident #40 on February 13 2023 at 2:18 p.m., who…

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 document and policy and procedure review, the facility failed to ensure that one resident (#23) was not sexually abused by another resident (resident #30). The deficient practice could result in residents being inappropriately touched. Findings include: -Regarding Resident #23 (alleged victim) Resident #23 was admitted to the facility on [DATE] with diagnoses that included paraplegia, quadripledia, hematuria, sleep terrors, cervicalgia, schizoaffective disorder, bipolar disorder, and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. Furthermore, it revealed that the resident utilized a wheelchair to assist in her mobility. A care plan revision dated July 22, 2022 indicated that the resident had episodes of suggestive sexual behaviors and comments towards male staff. It noted that when they do not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of facility documentation, State Agency Database, policy and procedures, the facility failed to implement their policy on reporting and investigation of an allegation of misappropriation of property for one resident (#14). The deficient practice could result in misappropriation of property to continue and not prevented. Findings include: Resident #14 was admitted on [DATE] with diagnoses that included Schizoaffective disorder, bipolar type, major depressive disorder, anxiety disorder due to known physiological condition, pseudobulbar affect, bipolar disorder, Hypothyroidism and Hyperlipidemia. A Minimum Data Set assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. A nursing note dated September 5, 2022 at 1:41 am included that the Resident reported to this writer that someone went into his room, made up his bed and stole his money from his pillow case. The note included that the amount of money…

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 review of the clinical record, facility documentation, review of the State Agency database, staff interviews and review of policy and procedure, the facility failed to ensure one allegation of misappropriation of property for one resident (#14) was thoroughly investigated. The deficient practice could result in allegations of abuse not being investigated and abuse occurring in the facility. Findings include: Resident #14 was admitted on [DATE] with diagnoses that included Schizoaffective disorder, bipolar type, major depressive disorder, anxiety disorder due to known physiological condition, pseudobulbar affect, bipolar disorder, Hypothyroidism and Hyperlipidemia. A Minimum Data Set assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. A Nursing note dated September 5, 2022 at 1:41 am included that the Resident reported to this writer that someone went into his room, made up his bed and stole his money from his pillow…

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 policy review the facility failed to ensure that the daily nurse staffing information posted were accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information. Findings include: A review of four randomly chosen days of staff postings compared with the staff assignment sheets revealed that none of the staff postings matched the actual number of staffs that worked. Daily Staffing report vs punch detail 1/7/2023 - 1/10/2023. Review of the Daily Staffing reports revealed evidence that they were inaccurate: The daily staffing report dated January 7, 2023 revealed there were had three licensed practical nurses (LPNs) working 36 hours on the day shift; and, one RN coverage was noted. However, review of the punch detail for January 7, 2023 revealed that only 2 LPNs worked the day shift; and, there was no punch detail found for an RN who worked the shift. The daily staffing report dated January 8,…

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 and review of the facility policy, the facility failed to ensure there was adequate indication for the use of antipsychotic medication for one resident (#23). The deficient practice could result in resident receiving unnecessary psychotropic medication. Findings include: Resident # 23 was admitted on [DATE] with diagnoses of sleep terrors, body dysmorphic disorder, bipolar disorder, schizoaffective disorder, and major depressive disorder. A behavior care plan initiated on January 24, 2022 included a goal that the resident would have fewer episodes. Interventions included to assess for contributing factors for behavior, encourage increased activity participation per preference, administer medication(s) as ordered, observe for effectiveness/side effects of psychotropic drug therapy and review medications as indicated. A provider order dated November 1, 2022 included for Abilify (antipsychotic) give one 30 mg (milligram) tablet orally twice a day for…

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