Rehab At Scottsdale Village Square

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse was reported timely to required entities for one resident (#6). The deficient practice could lead to ongoing abuse leading to harm of a resident.Findings include--Regarding Resident (#6)Resident #6 was admitted to the facility on [DATE], with diagnoses that included depression, schizophrenia, quadriplegic, depression, and hypertension.A quarterly MDS (minimum data set) dated November 12, 2025, revealed that the resident was a BIMS (brief interview for mental status) score of 10 which indicated moderately impaired cognition.A behavior charting assessment dated [DATE], revealed that Resident #6 was very upset and started to get physically and verbally aggressive with staff.Review of the clinical record revealed no evidence of a skin assessment after the altercation between staff and resident on January 26, 2026.The clinical record revealed no evidence that the incident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse investigation report was submitted within 5 working days to the State Survey Agency for one resident (#6). The deficient practice could lead to ongoing abuse leading to harm of a resident.Findings include--Regarding Resident (#6)Resident #6 was admitted to the facility on [DATE], with diagnoses that included depression, schizophrenia, quadriplegic, depression, and hypertension. A quarterly MDS (minimum data set) dated November 12, 2025, revealed that the resident was a BIMS (brief interview for mental status) score of 10 which indicated moderately impaired cognition.A behavior charting assessment dated [DATE], revealed that Resident #6 was very upset and started to get physically and verbally aggressive with staff.A request was made on February 4, 2026, at 3:20 p.m. for facility's 5-day investigation report for abuse allegation between CNA (Staff #34) and Resident #6. 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 reviews, staff and resident interviews, and policy, the facility failed to protect the rights of 3 of 3 residents (#1, #2, #3) to be free from physical abuse by other residents and family members. The deficient practice could result in further abuse.Regarding a resident-to-resident altercation that involved Resident #1 and Resident #2. -Regarding Resident #1 Resident #1 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses of dementia, major depressive disorder, anxiety disorder, epilepsy, and bipolar disorder. The care plan dated November 06, 2025, had a focused care area for Resident #1, having a behavior problem related to taking things and flushing them down the toilet. Interventions included administering medication as ordered, monitoring/documenting for side effects and effectiveness, anticipating and meeting the resident's needs, and, if reasonable discuss the resident's behavior. explain/reinforce why the behavior is inappropriate and/or…

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 records, and review of facility policy and procedure, the facility failed to protect the rights of four of eight sampled residents (#24, 15, 20, and 9) to be free from abuse by other residents (#20, 22, 11, 18). The deficient practice could lead to ongoing abuse, leading to harm to other residents.-Findings include:Regarding Resident #24Resident #24 (alleged victim) was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, post-traumatic stress disorder, anxiety disorder, and insomnia.A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS further revealed that Resident #24 had exhibited no verbal or physical behavioral symptoms directed towards others during the assessment…

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 records, and review of facility policy and procedure, the facility failed to protect the rights of three of seven sampled residents (#10, #8, and #20) to be free from abuse by other residents (#22, 16, and 6). The deficient practice could lead to ongoing abuse, leading to harm of other residents.-Findings include:Regarding Resident #10Resident #10 (alleged victim) was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, major depressive disorder, anxiety disorder, encounter for palliative care, benign prostatic hyperplasia with lower urinary tract symptoms, and senile degeneration of brain.A review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired. The MDS further revealed that resident #10 had exhibited no verbal or physical behavioral symptoms directed towards others during the assessment period. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, review of facility documentation and policies, the facility failed to protect the rights of four residents (#1, #2, #10, and #20) to be free from abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken.Findings include:Regarding incident involving Resident #20 and Resident #2:-Regarding Resident #20 (alleged perpetrator):Resident #20 was initially admitted at the facility on August 20, 2021, with diagnoses of dementia, chronic obstructive pulmonary disease (COPD), and generalized anxiety disorder.A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6.0, severely impaired, and no behavioral symptoms exhibited.A review of the care plan dated August 19, 2025, revealed the resident has a cognitive deficit related to dementia with behavioral disturbance. The intervention included for the staff to attempt to keep her away…

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 two out of the four sample residents to be free from abuse by another resident. The deficient practice could result in other residents being abused. Regarding a resident-to-resident altercation that involved Resident # 50 and Resident #55. -Regarding Resident #50Resident # 50 was admitted to the facility on [DATE], with diagnoses of Bipolar Disorder, Alzheimer's Disease, and Anxiety. Orders dated May 24, 2025, revealed an order for Chlorpromazine HCL Oral Tablet 25 MG given for behaviors relating to Bipolar Disorders. Orders dated July 31, 2025, revealed an order for sertraline HCL oral Tablet 50 mg given for depression. A quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed resident #50 had a BIMS (Brief Interview for Mental Status) score of 03, which indicated severe cognitive impairment. A Progress note dated September 13, 2025, 14:40 hrs. revealed that Resident #50…

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, interviews and record review, the facility failed to protect residents' rights to be free from physical abuse for two of three sampled residents (#28 and #14). The deficient practice could result in psychosocial or physical harm to residents. -Regarding resident #14 Resident #14 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, bipolar disorder, hyperlipidemia, type 2 diabetes, mood affective disorder, anxiety disorder, benign prostatic hyperplasia, depression, hypertension, gastro-esophageal reflux disease, and insomnia. An Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. A behavior progress note dated September 6, 2025 at 12:15 p.m. revealed that the resident was observed to become agitated with another resident over a seating arrangement, which escalated into a verbal and physical altercation. The note revealed that one Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure adequate supervision was provided to one resident (#10). The deficient practice resulted in placing resident's safety at risk with a non-authorized person. Findings include:Resident #10 was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia, Unspecified Severity with Agitation, and Schizoaffective Disorder, Bipolar. Review of a care plan initiated on April 24, 2025 revealed that resident #10 had an Activities of Daily Living (ADL) self-care performing deficit related to Dementia diagnosis. The goal was the resident will maintain current level of function in (Specify) through the review date. The interventions were to encourage the resident to participate to the fullest extent possible with each interaction. (with a target date of 4/24/25). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident #10 had moderate severe…

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 advanced directives were accurately completed and maintained for two residentsNumber of residents sampled: 2Number of residents cited: 2Based on clinical record review, staff interview, and facility policy and procedure, the facility failed to ensure that the advance directives were consistent throughout for two of 103 sampled resident's (#66 & 86) clinical record. The deficient practice could result in residents receiving services that are not in accordance with their wishes.Findings include:Resident #66 was admitted to the facility on [DATE] with diagnoses that included Hypertension, hyperlipidemia, epilepsy, schizoaffective disorder, intracranial injury with loss of consciousness, disorders of brain and major depressive disorder.A physician's order dated [DATE] revealed that the resident was full code status.Review of the Pre-hospital medical care directive, signed by the resident on [DATE] revealed that the resident did not want CPR (cardiopulmonary resuscitation), and 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 observations, interviews and record review, the facility failed to protect residents' rights to be free from physical abuse for 22 residents (#129, #123, #67, #127, #124, #32, #24, #130, #75, #36, #7, #29, #51. #182, #57, #112, #114, #43, #115, #117, #118, #59). The deficient practice could result in psychosocial or physical harm to residents. Findings Include:-Regarding residents #57 and #29: Resident #57 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, encounter for palliative care, major depressive disorder, and dementia. Review of the care plan focus dated October 2, 2023 revealed that resident #57 had a behavior problem regarding dementia. Staff was to intervene as necessary to protect the rights and safety of others, remove resident #57 from situation, and take to an alternate location. An admission minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 3, indicating severe cognitive…

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 facilityfailed to ensure that the abuse policy was adhered to following an incident of resident-to-resident abuse for two residents (#111 and #24). The deficient practice could result in continued resident-to-resident abuse. -Regarding Resident #111 Resident #111 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), schizoaffective disorder, bipolar disorder, Asperger's syndrome, anxiety disorder, autistic disorder, and hypertension. A care plan focus initiated on March 8, 2023 revealed a behavior problem as evidenced by physical aggression and a history of peer altercations. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A progress note dated August 20, 2023 at 11:07 p.m. revealed that Resident #111 grabbed Resident #24's left arm, attempting to drag him to the floor, and 3 staff members…

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 facilityfailed to ensure that an incident involving abuse between two residents (#111 and #24)was reported in a timely manner. The deficient practice could result in continued resident to resident abuse. -Regarding Resident #111 Resident #111 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), schizoaffective disorder, bipolar disorder, Asperger's syndrome, anxiety disorder, autistic disorder, and hypertension. A care plan focus initiated on March 8, 2023 revealed a behavior problem as evidenced by physical aggression and a history of peer altercations. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A progress note dated August 20, 2023 at 11:07 p.m. revealed that the nurse was attempting to administer Resident #111's medication when she told the nurse to give Resident #24 his medications…

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 Facility failed to store medications according to professional standards. Number of residents sampled:Number of residents cited: Based on observations, staff interviews, and a review of facility policies, the facility failed to ensure that expired medications were properly discarded and not available for use. Additionally, the facility failed to ensure medications for one resident (#17) were not left at the bedside. These deficient practices could result in residents receiving expired medications, and could result in resident injury, medication over-dose or contradictions. The facility census was 103. Findings include: An observation was conducted of the Central medication room on 07/31/2025 at 09:55 AM with the Director of Nursing (DON/staff #163). The following expired medications were identified: Two boxes of unopened Alfrin Allergy Sinus nasal spray, with an expiration date of January 2025. Two boxes of unopened Bisacodyl stimulant laxative, with an expiration date of June 2025. One box of unopened Vitamin E…

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 that documentation was completed accurately for six residents (Residents #11, 43, 113, 114, 25 and 115) regarding abuse and resident assessment. This deficient practice could lead to incomplete documentation in residents' medical records.Findings include: -Regarding Resident #11: Resident #11 was admitted to the facility on [DATE], with diagnoses that included Alzheimer’s disease, vascular dementia, end-stage renal disease, dependence on renal dialysis, hypotension, depression and anxiety. On July 29, 2025, upon entrance to the facility, Resident #11 was identified as a resident who received dialysis treatment. During an initial pool interview with Resident #11 on July 29, 2025, at 12:18 PM, he stated that he goes to dialysis on Mondays, Wednesdays and Fridays. He stated that the staff do not check on him when he returns from dialysis. A nursing care plan, revised September 8, 2023, listed an intervention 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 observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#87) was not abused by another resident (#91). The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: Regarding resident #87: Resident #87 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, dementia, personality change due to known physiological condition, chronic ischemic heart disease, heart failure, hypertension, major depressive disorder, and anxiety disorder. A quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 08, indicating moderate cognitive impairment. A nursing progress note dated June 18, 2025 at 2:49 p.m. revealed that resident #87 ate resident #91 ' s cookie and resident swung at resident #87and hit him on the left ear. Residents were separated and no pain was reported by resident #87 and no physical…

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 that six residents (#67, #17, #97, #111, #77, and #50) did not abuse seven residents (#41, #14, #83, #36, #84, #21, and #2). The deficient practice could result in residents being physically harmed. -Regarding Resident #97 and Resident #84 Resident #97 was admitted on [DATE] with diagnoses that included vascular dementia, unspecified mood affective disorder, depression, intracranial hypertension, major depressive disorder, anxiety, adjustment disorder with mixed disturbance of emotions, and presence of cardiac pacemaker. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A nursing progress note dated August 30, 2022 at 3:59 p.m. revealed that the doctor was notified of the resident becoming more sexually inappropriate. The progress note further revealed that the resident was caressing female peers' arms and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#67) was provided with adequate supervision. The deficient practice could result in residents being subjected to preventable accidents and sustaining injuries. Findings include: Resident #67 was admitted to the facility on [DATE] with diagnoses including: dementia with other behavioral disturbance, hypertension, anxiety disorder, hyperlipidemia, and major depressive disorder. Resident #67's care plan initiated on January 28, 2025 revealed that the resident was at risk for psychosocial emotional distress regarding resident-to-resident altercation. The interventions included one-on-one care as needed. Another care plan initiated on March 12, 2025 stated that resident #67 had the potential to be physically aggressive in regards to dementia. Interventions included monitoring, documenting and reporting behaviors as needed. Review of the facility's 2024-2025 Incident Log revealed resident to 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 observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#27) was not abused by another resident (#13). The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: -Regarding resident #27: Resident #27 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, hypertension, post-traumatic stress disorder, adjustment disorder with mixed disturbance of emotions and conduct, migraine, Alzheimer's disease, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 06, indicating severe cognitive impairment. A nursing progress note dated May 30, 2025 at 10:21 a.m. revealed that resident #27 was in the dayroom awaiting breakfast when resident #13 tapped him on the shoulder and told him to move before resident #13 hit resident #27. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#76) did not abuse another resident (#81). The deficient practice could result in residents being physically harmed. Findings include: -Resident #81 was admitted on [DATE] with diagnoses that included type 2 diabetes, chronic atrial fibrillation, hypertension, major depressive disorder, vascular dementia, schizoaffective disorder, panic disorder, and obsessive-compulsive disorder. An Annual Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment with no behaviors exhibited. A skin assessment dated [DATE] at 2:52 p.m. revealed a new skin tear with a flap measurement of 2x2 to the back of his left hand following the resident-to-resident altercation. A progress note dated May 20, 2025 at 3:08 p.m. revealed that Resident #81 reported that his roommate (#76) hit him with his fist while inside 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 reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to ensure residents (#44, #33, #70 and #180) were free from abuse. The deficient practice could lead to further resident to resident abuse. Findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, anxiety disorder, and adjustment disorder with mixed disturbance of emotions and conduct. The care plan dated October 4, 2024 revealed that resident #44 is at risk for psychological emotional distress related to a resident to resident altercation. Interventions included to monitor for any verbal or non-verbal serious symptoms of psychosocial emotional distress for 72 hours, allow resident to verbalize concerns as needed, and psych consult as needed if indicated. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. 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 observation, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that adequate supervision was provided to two residents (#13 and #22) to prevent elopement from the facility. The deficient practice can result in other residents to go missing and/or getting injured. Findings include: - Regarding Resident #13: Resident #13 was admitted to the facility on [DATE] with diagnoses including dementia with agitation, anoxic brain damage, and epilepsy. Review of the elopement evaluation completed by the facility on December 31, 2024 revealed a score of 3.0, indicating the resident was considered At-risk for elopement, due to having a history of elopements at home, history of attempting to leave the facility without staff, and wandering behavior. Review of the nursing note dated December 31, 2024 revealed that upon admission, the resident's sister informed the staff that the resident is an elopement risk and had eloped a couple of times before. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clincal documentation, staff interviews, and the facility policy and procedures, the facility failed to administer medications within the required timeframe to six residents (#66, #55, #12, #2, #15, and #25). The deficient practice could result in symptoms not being managed effectively and/or adverse effects. Findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included obsessive compulsive disorder unspecified, hemorrhoids, rectal prolapse, drug induced subacute dyskinesia, and Parkinson's disease with dyskinesia with fluctuations. The order summary revealed: -September 1, 2024, Benztropine Mesylate oral tablet 0.5 mg give one tablet PO every 12 hours related to drug induced subacute dyskinesia. -September 1, 2024, Docusate Sodium oral tablet 100 mg give two tablets PO two times a day for bowel movement care (BM). -September 1, 2024, Senna oral tablet 8.6 mg give 2 tablets PO two times a day for BC. -September 1, 2024, Sodium Chloride oral tablet 1 gm…

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, interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#26) did not abuse another resident (#32). The deficient practice could result in residents being physically and/or emotionally injured. Findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis, generalized anxiety, dementia in other diseases classified elsewhere, anoxic brain damage, and disruptive mood dysregulation. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status indicating the resident had a severe cognitive impairment. The care plan dated May 16, 2015 revealed that the resident has a problem with exessive yelling, history of sitting or forcefully placing herself on floor at times, intrusiveness, physically aggressive behaviors, being combative with care, exposing herself, and spitting. Interventions included to attempt to redirect behaviors, and see the behavior plan for up to date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident #100 did not elope from the facility. The deficient practice could result in residents eloping and being physically and/or emotionally harmed. Findings include: Resident #100 was admitted to facility on June 1, 2015 and readmitted [DATE] with diagnoses that included schizophrenia, anxiety disorder, adjustment disorder with mixed disturbance of emotions and conduct, major depressive disorder, unspecified psychosis, and vascular dementia. The care plan dated February 5, 2016 revealed that the resident was an elopement risk associated with schizophrenia and associated impaired safety awareness. The patient attempts putting different codes in the keypad to leave the unit and pushes the door setting off the alarm. There was an elopement attempt on March 9, 2021. Interventions included to conduct Wanderguard safety check; staff will ambulate the resident up to/through all door(s)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility documentation and staff interviews, the facility failed to ensure that adequate supervision was provided to two residents (#3 and #4) to prevent abuse. The deficient prectice could increase the risk of resident to resident abuse. Findings include: - Regarding Resident #3: Resident #3 was readmitted to the facility on [DATE] with the diagnosis that included Post-Traumatic Stress Disorder, anxiety disorder, other specified depressive episodes, restlessness and agitation, adjustment disorder with mixed disturbance of emotions and conduct. Review of care plan dated May 4, 2021 revealed a trauma informed care, post traumatic stress disorder (PTSD). The goal included to avoid triggers related to previous traumas throughout stay. The intervention includes to continue to monitor for triggers. A review of resident #3 clinical record revealed a progress note, eINTERACT SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated October 4,…

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 that resident (#2) and or representative was informed of the risks and benefits of psychotropic medications prior to the administration of the medications. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and the potential adverse side effects of psychotropic medications. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA), aphasia, non-Alzheimer's dementia, and hemiplegia. A review of resident #2 care plan initiated on May 28, 2024 revealed that resident used psychotropic medications related to schizoaffective disorder, bipolar with hallucinations and disorganized thinking. The interventions included administer antipsychotic medications as ordered by physician. Monitor for side effects and effectiveness every shift. A review of resident #2 MDS dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to ensure one resident (#1) with a diagnosis of mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #1 had a Pre-admission Screening and Resident Review (PASRR) level one completed on March 6, 2024 at an outside hospital. A review of resident #1 clinical record revealed a PASRR level one completed and signed from the hospital on March 6, 2024; however, the referral determination section D was blank. Resident #1 was admitted to the facility on [DATE]. Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, anxiety disorder, type 2 diabetes mellitus, and bipolar disorder. A review of resident #1 Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for 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, facility documentation and policy review, the facility failed to protect the rights of one resident (#40) to be free from sexual abuse by another resident (#49); and, failed to protect the rights of two residents (#25 and #5) to be free from abuse by another resident (#6). The deficient practice could result in the potential for harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. Findings include: -Resident #40 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia in other diseases with agitation, with anxiety, other behavioral disturbance, wandering in diseases classified elsewhere. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had severe cognitive impairment, had physical and verbal behavioral symptoms directed towards others placing the resident at significant risk for physical injury that occurred 1-3 days of the lookback period. The care…

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/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to report allegations of abuse to the State Agency (SA), Adult Protective Services (APS) and local law enforcement for three sampled residents (#40, #25 and #5). The deficient practice could result in abuse not identified and investigated and place all residents at risk for further abuse. Findings include: Resident #40 admitted on [DATE] with diagnoses including Alzheimer's disease, unspecified, dementia in other diseases classified elsewhere, unspecified severity, with agitation, with anxiety, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, wandering in diseases classified elsewhere. A nurse note dated August 28, 2024 stated certified nurse assistant (CNA) found resident cornered outside with another resident (#49) who touched resident #40 inappropriately. Per the documentation, 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 an allegation of abuse for two residents (#40 and #36) by another resident (#49 and #25) were thoroughly investigated. The deficient practice could result in appropriate corrective action not taken to prevent further abuse. Findings include: -Resident #40 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia in other diseases with agitation, with anxiety, other behavioral disturbance, wandering in diseases classified elsewhere. A nurse note dated August 28, 2024 stated certified nurse assistant (CNA) found resident cornered outside with another resident (#49) who touched resident #40 inappropriately. Per the documentation, the CNA separated both residents,15-minute checks were initiated and the POA (power of attorney), DON (director of nursing) and physician were notified. A Psych Follow-Up Note dated August 28, 2024 included resident was seen for follow up after an incident where…

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 there was sufficient staffing to provide adequate supervision for multiple residents. The deficient practice could result in residents' not receiving the supervision needed to ensure resident safety. Findings include: -Resident #40 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia in other diseases with agitation, with anxiety, other behavioral disturbance, wandering in diseases classified elsewhere. A nurse note dated August 28, 2024 stated certified nurse assistant (CNA) found resident cornered outside with another resident (#49) who touched resident #40 inappropriately. Per the documentation, the CNA separated both residents,15-minute checks were initiated and the POA (power of attorney), DON (director of nursing) and physician were notified. A Psych Follow-Up Note dated August 28, 2024 included resident was seen for follow up after an incident where another resident (#49) grabbed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#650) was free from abuse of another. The deficient practice could result in other residents being abused. Findings include: Resident #650 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included bipolar disorder and mild cognitive impairment. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident is cognitively intact. The MDS also indicated that the resident had not exhibited psychosis, behavioral symptoms or wandering behavior during the assessment period. A care plan initiated on July 30, 2024 indicated that the resident is at risk for not meeting emotional, intellectual, physical, and social needs regarding bipolar disorder. Interventions included to ensure that activities resident attends are compatible with physical 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 observations, staff interviews, facility documentation, review of the Centers for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure infection control standards were followed by failing to ensure that Personal Protective Equipment (PPE) was donned. The deficient practice could result in the spread of infection, including COVID-19 to residents and staff. Findings include: Review of the COVID+ Residents facility bulletin board on the electronic record dashboard indicated that there were 12 residents that were COVID positive. The notice was posted on August 7, 2024 and listed the names of the residents and the date they tested positive. During sign-in at the front desk on August 19, 2024 at 10:56 a.m., an orange sign posted on the wall was observed. The sign read Attention! COVID-19 OUTBREAK. All visitors and staff are required to sign in at the kiosk located by the Reception Desk. All Staff are required to wear CDC recommended PPE including N95 Masks while in the Facility. However, during sign-in, the Concierge (staff #80) at 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 reviews, resident/staff interviews, facility documentation and policy review, the facility failed to ensure allegations of abuse was thoroughly investigated. The sample was 3. The deficient practice could result in residents at continued risk for further abuse. Findings include: Regarding Resident #23 Resident #23 admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type, dementia and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 12 indicating that the resident had moderate cognitive impairment. The assessment included that resident was coded for delusions and verbal behavioral symptoms directed towards others. The psych follow-up note dated July 17, 2024 revealed that the resident was demanding and had false accusation behaviors on July 12, 2024; was screaming during care and continued to ask to be changed and moved then did not want the care on July 13, 2024;…

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 a closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure that a resident's representative was notified of an injury for one resident (#7). The deficient practice could result in resident representatives not being aware of the resident's injuries. Findings include: Resident #7 was admitted on [DATE] with diagnosis including dementia, hypertension, type 2 diabetes mellitus, post-traumatic stress disorder, atherosclerotic heart disease, hyperlipidemia, dysphagia and a personal history of traumatic brain injury and transient ischemic attacks. A review of the electronic health record revealed progress note entries noting that the resident #7 would wander and take other resident's belongings. It was noted that the resident required frequent redirection. The progress notes further revealed that the resident #7 sustained an injury to his left lower leg on March 19, 2024; however, the progress notes revealed no documentation that family had…

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 facility documentation, staff interviews, and review of facility policy and procedures, the facility failed to ensure one resident (#1) was not abused by another resident (#2) The deficient practice could result in residents being physically and psychologically harmed. Findings include: Regarding resident #1: Resident #1 was admitted to the facility on [DATE] with diagnoses of Dementia, Post Traumatic Stress Disorder (PTSD), and Adjustment Disorder with Mixed Disturbance of Emotions and Conduct. The annual Minimum Data Set (MDS) dated , January 22, 2024 revealed that the resident was not able to complete the Brief Interview for Mental Status (BIMS). However, staff were able to complete the Staff Assessment for Mental Status and it was determined that resident #1 had both short-term and long-term memory problems. The assessment also indicated the resident's Cognitive Skills for Daily Decision making was moderately impaired. Regarding resident #2: Resident #2 was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure one resident (#26) was free from abuse of another. The deficient practice could result in other residents being abused. Findings include: -Resident #28 was admitted on [DATE] with diagnoses of Alzheimer's disease, vascular dementia, behavioral disturbance, dementia, and anxiety disorder. Review of a care plan initiated October 16, 2014 revealed the resident had diagnosis of dementia with behaviors; and that confusion and history of disorganized thinking cause him to display behaviors that interfere with his participation. Interventions included to administer medications as ordered, attempt to determine cause, attempt to redirect behaviors, follow the resident specific behavior plan per the clinical director, monitor resident for significant behavioral and medical changes to ensure proper placement of resident, and psych follow up as ordered. A behavioral care plan reviewed and updated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of facility documentation, policy and procedures, the facility failed to implement their policy on abuse investigation for an allegation of abuse for one resident (#26). The deficient practice could result in abuse not identified and investigated. Findings include: -Resident #28 was admitted on [DATE] with diagnoses of Alzheimer's disease, vascular dementia, behavioral disturbance, dementia, and anxiety disorder. -Resident #26 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included delusional disorders and dementia with behavioral and psychosis symptoms. Review of the SA Complaint/Incidents Tracking System revealed that the facility submitted a self-report regarding the incident between residents #26 and #28 on December 23, 2021 at 9:47 p.m. The facility incident report dated December 24, 2021 revealed resident #26 was observed coming from resident #28's room with blood and laceration to the center of his forehead that measured 1.5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure a thorough investigation was completed for an allegation of abuse for one resident (#26). The deficient practice could result in appropriate corrective actions not taken. Findings include: -Resident #28 was admitted on [DATE] with diagnoses of Alzheimer's disease, vascular dementia, behavioral disturbance, dementia, and anxiety disorder. -Resident #26 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included delusional disorders and dementia with behavioral and psychosis symptoms. Review of the facility incident report dated December 24, 2021 revealed resident #26 was observed coming from resident #28's room with blood and laceration to the center of his forehead that measured 1.5 cm (centimeters) x 0.2 cm. Per the documentation, it appeared that resident #26 entered and would not leave the room of the other resident (#28) who hit resident #26 with 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 Based on clinical record reviews, staff interviews, the Resident Assessment Instrument (RAI) manual, and facility policy, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required timeframes for 5 residents (#1, #3, #4, #5, and #8). The census was 91 residents. The deficient practice could result in delayed identification of potential risks and care needs. Findings include: -Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included delusional disorder, Peripheral Vascular Disease (PVD), and mood disorder. Review of the resident's MDS assessments revealed the following: -An annual MDS had been completed on June 2, 2021. -There was no quarterly MDS completed in September 2021, but one was done on November 30, 2021. -There was no quarterly MDS completed from December 2021 through February 2022, but one was completed on March 16, 2022. -Resident #3 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis, 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 clinical record reviews, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments for six residents (#1, #3, #4, #5, #8, and #9) were transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completion. The deficient practice could result in resident specific MDS data for payment and quality measure purposes not being submitted as required. Findings include: -Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included delusional disorder, Peripheral Vascular Disease (PVD), and mood disorder. Review of the resident's MDS assessments revealed the following: -An annual MDS had been completed on June 2, 2021. -There was no quarterly MDS completed/transmitted in September 2021, but one was done on November 30, 2021. -There was no quarterly MDS completed/transmitted from December 2021 through February 2022, but one was completed on March 16, 2022.…

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

Based on facility documentation, staff interviews, and facility policy, the facility failed to ensure that quality control testing was performed for one multi-use glucometer. The deficient practice could result in glucometers that do not function properly and therefore provide inaccurate glucose level results. Findings include: Review of the April 2022 glucometer daily quality control record for the 300 station revealed that there were more than 20 days where the glucometer quality control solution checks were not documented. During an interview with a Licensed Practical Nurse (LPN/staff #73) on 4/26/2022 at 8:30 AM, he said that the glucometer quality control testing is done daily by the night shift and should be documented on the glucometer control check records daily. He said that the purpose of calibrating the glucometer is to verify that it is giving accurate readings. He said that failing to do this could result in inaccurate monitoring. He added that the missing days on the control chart sheet indicated that it may have been overlooked by night shift or they failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one resident (#9). The census was 91 residents. The deficient practice could result in delayed identification of potential risks and care needs. Findings include: Resident #9 was re-admitted to the facility on [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD), Parkinson's disease, and dementia without behavioral disturbance. Review of the resident's MDS assessments revealed that an annual assessment was not conducted in March 2022, but one was dated April 7, 2022 that was not signed as complete by the RN assessment coordinator and showed as in progress as of April 28, 2022. A phone interview was attempted on April 28, 2022 at 2:05 PM with the MDS nurse (staff #161). A voicemail message was left. A second phone interview was attempted at 2:38 PM. A second…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident (#28) received adequate and consistent showers. The sample size was two residents. The deficient practice could result in residents' personal hygiene and grooming needs not being met. Findings include: Resident #28 was admitted to the facility on [DATE] with diagnoses that included borderline personality disorder, bipolar disorder, morbid (severe) obesity due to excessive calories, and chronic pain. Review of the resident's Activities of Daily Living (ADL) care plan, initiated on July 13, 2016, revealed the resident received physical assistance with ADL care, required a mechanical lift for transfers, and used an electric scooter for mobility. The goal was to meet the resident's daily care needs. An intervention included two person assist for all care. The care plan included showers and bed baths as being the resident's preferences. The resident's quarterly Minimum Data Set (MDS)…

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 facility policy, the facility failed to ensure that one resident (#28) was provided adequate care and treatment related to bowel care. The sample size was two residents. The deficient practice could result in residents having discomfort and difficulty having a bowel movement. Findings include: Resident #28 was admitted to the facility on [DATE] with diagnoses that included borderline personality disorder, bipolar disorder, morbid (severe) obesity due to excessive calories, chronic pain, and osteoarthritis. Review of the resident's active incontinence care plan revealed the resident had bowel incontinence related to immobility and behavior and the resident was noted to be at risk for constipation related to medications. The goals included to anticipate the resident's needs, the resident will not experience complications related to incontinence, and the resident will have bowel movements at least every 3 days. Interventions included incontinence care briefs,…

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 that one resident (#37) consistently received care to prevent pressure ulcers and was consistently provided pressure ulcer treatment. The sample size was 3. The deficient practice could result in the development of pressure ulcers, and delayed wound healing or worsening of a pressure ulcer. Findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia with Behavioral Disturbance and Type 2 Diabetes Mellitus with Unspecified Diabetic Retinopathy Without Macular Edema. Review of the care plan initiated on August 10, 2020 revealed the resident was at risk for development of pressure ulcer and impaired skin integrity. Intervention included monitoring for changes in skin integrity, repositioning every 2 hours and as needed, and weekly skin evaluation per protocol. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive skills 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 facility assessment review, personnel record reviews, staff interviews, and facility policy, the facility failed to provide dementia training for three staff members (#49, #72, and #5) and failed to provide resident rights training for one staff member (#5). The sample size was ten staff members. The deficient practice could result in inadequate care for the residents in the facility. Findings include: Regarding Dementia Training: Review of the facility assessment, revised February 18, 2022, revealed that common diagnoses or conditions the facility cared for included: Parkinson's disease, Alzheimer's disease, non-Alzheimer's dementia, Huntington's disease, depression, bipolar disorder, schizophrenia, Post Traumatic Stress Disorder (PTSD), anxiety disorder, behaviors that require interventions, and mood disorders. The facility assessment included that one of the nursing units was designated for residents with dementia and two other nursing units were designated for residents that have dementia with behaviors. -Review of the personnel record for a social services coordinator…

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, and staff interviews, the facility failed to ensure that pharmacist reported irregularities were reviewed and acted upon for 2 residents (#49 and #37). The sample size was 5 residents. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon. Findings include: -Resident #49 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance and major depressive disorder. Review of the physician's orders revealed the following orders dated 8/20/2021 for antidepressant medications: -Mirtazapine 15 milligrams (mg) at bedtime. -Citalopram hydrobromide 20 mg per day. Review of the resident's psychoactive drug use care plan, initiated on 8/20/2021, revealed the resident used antidepressant medications. Interventions included to monitor the resident closely for adverse side effects, monitor mood/behaviors as indicated, and to evaluate for gradual dose reduction routinely. A physician's order 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 facility documentation, the facility failed to ensure one resident's (#76) clinical record was complete regarding patient therapy records and Preadmission Screening and Resident Review (PASRR). The census was 91 residents. The deficient practice may result in residents' clinical records not being complete and accurate. Findings include: Resident #76 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, major depressive disorder with psychotic symptoms, Parkinson's disease, and Cerebral Vascular Accident (CVA). Regarding therapy records: The resident's CVA care plan, dated January 4, 2022 revealed a goal that the resident would maintain her current level of functioning. An intervention included rehabilitation (rehab) as ordered. Review of a Physical Therapy (PT) evaluation dated February 8, 2022 revealed the plan of therapy treatment was 1-3 times per week for 8 weeks. The certification period was from February 8, 2022 to April 4,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy, the facility failed to ensure that one resident (#76) was provided education regarding the risks and benefits of pneumococcal immunization and failed to ensure the resident was offered the pneumococcal vaccine. The sample size was 5 residents. The deficient practice could result in residents not being informed of risks and benefits of pneumococcal immunization and could result in residents not being offered the vaccine. Findings include: Resident #76 was admitted to the facility on [DATE] with diagnoses of dementia, schizophrenia, depression, and cerebrovascular accident. Review of the resident's admission paperwork revealed a blank pneumococcal vaccine request in the chart. The document was not signed and there was no information to show if the resident consented or declined the vaccination or if the resident was explained the risks and benefits of the vaccination. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed…

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

Based on personnel record reviews, interviews, facility policy, and Centers for Medicare and Medicaid Services (CMS) interim final rule requirements, the facility failed to ensure 3 staff members (staff #17, #130, and #10) were vaccinated for COVID-19 or had approved exemptions. The census was 91 residents. The deficient practice could result in the spread of COVID-19 in the facility. Findings include: Review of personnel health records revealed that two Licensed Practical Nurses (LPNs/staff #17 and #130) and a Certified Nursing Assistant (CNA/staff #10) were listed as not vaccinated and had COVID-19 vaccine exemptions. Their files revealed no evidence of approved exemptions. An interview was conducted with the Executive Director (ED/staff #68) on 4/27/2022 at approximately 12:00 PM. She said that she could not locate the COVID-19 vaccination exemptions for staff #17, #130, and #10. An interview was conducted with the business office manager (staff #36) on 4/28/22 at 8:49 PM. She stated that she organizes staff member's COVID-19 exemptions in their medical record which is stored…

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 record review, a staff interview, and facility documentation, the facility failed to provide abuse training for one staff member (staff #49). The sample size was 10 staff members. The deficient practice could result in staff not being knowledgeable of how to prevent, identify, investigate, and report allegations of abuse. Findings include: Review of the personnel record for a Social Services Coordinator (staff #49) revealed a hire date of February 1, 2018. The personnel record did not reveal evidence of training for abuse and neglect prevention. An interview was conducted on April 27, 2022 at 9:14 a.m. with the Assistant Director of Nursing (ADON/staff #38), who stated that annual training for staff members is required for resident rights, dementia, abuse prevention, and infection control. She said that the administrator, the Director of Nursing (DON), and/or Human Resources (HR) notify her when annual training is required for staff members. She reviewed the in-service documentation and said that she could not find documentation that staff #49 attended training…

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.