Haven Of Sedona

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, interviews and facility polity, the facility failed to ensure staff changed oxygen tubing as ordered by the physician for 1 of 1 sampled resident (#2) for respiratory care. This deficient practice could lead to contaminated tubing and increase the risk of respiratory infections.Resident #2 was admitted on [DATE] with diagnoses of quadriplegia, COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia and dependence on supplemental oxygen. A health status note dated March 25, 2026 included that the resident was alert and oriented x 4, answered all questions appropriately and had a caregiver at bedside upon admission. The baseline care plan dated March 25, 2026 included the resident was on oxygen therapy related to COPD. Intervention included oxygen per physician order. The baseline care plan did not include interventions related to oxygen use care such as tubing changes. The physician order dated March 25, 2026 revealed orders for oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure pre and post dialysis assessment was completed for 1 of 1 sampled resident (#3) for dialysis. The deficient practice could result in resident not consistently monitored after returning from receiving offsite dialysis. Findings include:Resident #3 was admitted on [DATE] with diagnoses of hypertensive CHD (chronic kidney disease) and ESRD (end-stage renal disease). The admission evaluation dated March 30, 2026 included that the resident was alert and oriented x 4 and was on EBP (enhanced barrier precautions) for dialysis catheter/port and chronic wounds. The physician order dated March 30, 2026 included for dialysis site care per facility protocol, to observe dialysis access site for signs/symptoms of infection every shift, and dialysis days of Monday-Wednesday-Friday at 5:45 a.m. The care plan dated March 30, 2026 revealed Resident #3 required hemodialysis related to ESRD. Interventions included to obtain…

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, staff interviews, and review of the clinical record and facility policy, the facility failed to ensure consulting pharmacy services identified and reported medication irregularities for one of 5 sampled residents (#72) for medications. The census was 87. The deficient practice could result in inaccurate administration of prescribed medications, incomplete documentation, and potential adverse medication reactions including toxicity, skin irritation, and drowsiness. Findings include: -Resident #72 was admitted on [DATE] with diagnoses of hip and spinal fractures, Dementia, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, and insomnia. A physician order dated March 13, 2026 included for Lidocaine (topical analgesic) External Patch 4% apply to affected areas topically one time a day for pain and remove per schedule. This order had a discontinued date of March 14, 2026. The progress notes dated March 16, 2026 revealed Lidocaine external patch 4% was administered to the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure proper control and accountability of medications, as evidenced by an unidentified medication left unattended on the floor for approximately 36 minutes, accessible to staff and residents, and not promptly addressed by multiple staff passing by. Additionally, the facility could not account for the origin of the medication. Census was 87.Findings include:Observation: On 04/20/2026 beginning at 9:58 AM, a small white pill was observed on the floor in the 100 hall, in front of room [ROOM NUMBER]. At 9:59 AM, a nurse walked past the pill without identifying or removing it. At 10:00 AM, the resource nurse was seated at the nurses' station; two CNAs walked past the pill, and three residents in wheelchairs passed by it. At 10:04 AM, another nurse and an additional resource staff member walked past the pill without intervention. Two additional residents and CNAs also passed the pill. At 10:09 AM, an RN and the facility chef walked past the pill; an RN was observed standing at the medication…

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 and review of facility policies and procedures, the facility failed to ensure the care plan reflected accurate documentation of the current assessment information for one (#6) of 25 sampled residents for care plan reviews. The census was 87. The deficient practice could result in staff relying on inaccurate or conflicting information, potentially impacting the resident's safety and/or level of independence.Findings include:Resident #6 was admitted to the facility on [DATE], with diagnoses including unilateral primary osteoarthritis (left knee), anxiety disorder, need for assistance with personal care, muscle weakness, post-traumatic stress disorder, history of falls on the same level, depression, and insomnia.A Nursing Smoking Evaluation dated February 3, 2026 included Resident #6 had no impairments and was assessed as able to smoke independently.Review of the care plan revealed a smoking focus initiated on February 3, 2026, indicating that Resident #6 wished 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 staff and resident interviews, and review of the clinical record and facility policy, the facility failed to ensure that vaccinations were administered in accordance with professional standards for one of five sampled residents (#87). The universe was 87. The deficient practice could result in the acquisition, transmission, or complications from influenza or pneumococcal disease.Findings include:-Resident #87 was admitted on [DATE], with diagnoses that included primary adrenocortical insufficiency, ulcerative colitis, immunodeficiency due to drugs, and adult failure to thrive.The immunization record of the resident revealed that the resident was pending immunization for the influenza vaccine and pneumococcal vaccine. The informed consent for influenza and pneumococcal vaccinations, dated January 13, 2026, revealed that the resident consented to receive both the influenza and pneumococcal vaccinations. Further review revealed that the influenza informed consent documented that the vaccination is to be…

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 (#11) was given an advance notice prior to a roommate change. The deficient practice could result in resident's preference to choose her roommate was not considered. -Resident #41 was admitted on [DATE] with diagnoses of metabolic encephalopathy, dementia and need for assistance with personal care.The NP (nurse practitioner note dated July 24, 2025 included that the resident had a BIMS score of 12 which was consistent with moderate cognitive impairment.The room/roommate change notice signed by resident #41 and social services and dated August 11, 2025 revealed that resident #41 was provided the notice that she was moving to the room of resident #11 and this change was effective August 12, 2025.The census list report revealed that resident #41 had room change on August 12, 2025. -Resident #11 was admitted to the facility on [DATE] with diagnoses that included chronic inflammatory demyelinating…

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, facility documentation and policy review and the State Agency complaint tracking system, the facility failed to follow their abuse reporting policy following an allegation of abuse for one resident (#11). The deficient practice could result in continued abuse and neglect to residents. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuritis, calcific tendinitis of the right thigh, adjustment disorder, hypotension, reduced mobility, muscle weakness, need for assistance with personal care, and polyneuropathy.The care plan dated February 3, 2025 included that resident #11 had functional self-care deficits and/or functional mobility limitations related to malnutrition, pain and weakness and required assistance. The care plan revised on February 14, 2025 revealed that the resident had behavior problem related to recent admission, refusal of care and was verbally…

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 facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#11) was reported to the State Agency (SA) within the required timeframe. The deficient practice could result in resident not protected from continued abuse. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuritis, calcific tendinitis of the right thigh, adjustment disorder, hypotension, reduced mobility, muscle weakness, need for assistance with personal care, and polyneuropathy.The care plan dated February 3, 2025 included that resident #11 had functional self-care deficits and/or functional mobility limitations related to malnutrition, pain and weakness and required assistance. The care plan revised on February 14, 2025 revealed that the resident had behavior problem related to recent admission, refusal of care and was verbally abusive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of abuse for one resident (#5) was thoroughly investigated. The deficient practice could result in the appropriate State Agencies not being notified and allegations of abuse not being thoroughly investigated. Findings include:Findings include:Resident # 5 was admitted to the facility on [DATE], with diagnoses of polyneuritis, protein-calorie malnutrition, adjustment disorder, and insomnia. A comprehensive care plan dated February 7, 2025, revealed that Resident # 5 had behavioral problems due to recent admission including, refusal of care and being verbally abusive to staff. Interventions included all personal care and interactions done in pairs. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates Resident # 5 is cognitively intact. Review of an email dated July 29, 2025, from Resident # 5 sent 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 The facility failed to ensure an allegation of resident (#5) abuse was reported to all applicable state agencies.Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of resident (#5) abuse was reported to all applicable state agencies. The deficient practice could result in further allegations of abuse not being reported and investigated by the appropriate state agencies. Findings include: Resident # 5 was admitted to the facility on [DATE], with diagnoses of polyneuritis, protein-calorie malnutrition, adjustment disorder, and insomnia. A comprehensive care plan dated February 7, 2025, revealed that Resident # 5 had behavioral problems due to recent admission including, refusal of care and being verbally abusive to staff. Interventions included all personal care and interactions done in pairs. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure an allegation of resident (#5) abuse was investigated. Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of resident (#5) abuse was investigated. The deficient practice could result in residents being abused. Findings include:Resident # 5 was admitted to the facility on [DATE], with diagnoses of polyneuritis, protein-calorie malnutrition, adjustment disorder, and insomnia.A comprehensive care plan dated February 7, 2025, revealed that Resident # 5 had behavioral problems due to recent admission including, refusal of care and being verbally abusive to staff. Interventions included all personal care and interactions done in pairs. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates Resident # 5 is cognitively intact.Review of an email dated July 29, 2025, from Resident # 5 sent to Executive Director (ED/Staff # 3) 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 interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#10) was not abused by another resident (#15). The deficient practice could lead to psychosocial or physical harm of a resident. -Regarding Resident #10 (alleged victim): Resident #10 was admitted to the facility June 5, 2025, with diagnoses that included alcoholic cirrhosis of liver, hepatic encephalopathy, type 2 diabetes mellitus, portal hypertension, acidosis, hypertension, unspecified head injury, and alcohol dependence. An admission minimum data set (MDS) assessment was still in progress. An Alert Note dated June 15, 2025, revealed a therapist came to the nurse after Resident #10 reported another resident hit her while having lunch in the bistro area on the rehab unit. This writer separated both residents, and ensured everyone was safe. Resident #10 reported being hit in the arm, and having a fork and knife thrown at her, and reports being okay. The nurse observed the area 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, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure the medical record was accurate and complete for one resident (#2). The deficient practice could lead to care team members not being aware of a resident's status and lead to a delay in care or missed treatment. Findings Include: Resident #2 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia, pulmonary fibrosis, type 2 diabetes mellitus, insomnia, anxiety disorder, and depression. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 8, indicating moderate cognitive impairment. A physician order dated February 21, 2025, indicated to complete a skin check weekly. A Weekly Skin Check and Wound assessment dated [DATE], revealed the resident had no new or ongoing skin impairments. An Alert Charting note dated April 27, 2025, revealed at around 2:15 PM, Resident #2 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.

Based on resident and staff interviews, facility documentation and policy review, the facility failed to ensure ensure staffing information submitted was accurate. The deficient practice could result in residents receiving inadequate care due to potential lack of staffing. Findings include: The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for all four quarters in 2024 and, the 1st quarter of 2025. Per the report, submitted weekedng staffing data was excessively low. The facility assessment reviewed on February 4, 2025 revealed that the facility was licensed to provide care for 112 residents, had an average daily census of 60-75 with 20-30+ of this census being short term stays, and, had an average number of admission and discharges of 25-35 per month Staffing plan included the following: -full time Director of Nursing (DON); -At least 1 registered nurse (RN) per 24 hour period; -Up to 6 certified nursing assistant (CNAs) for the AM shift (6:00 a.m. to 2:00 p.m.); -Up to 6 CNAs for evening…

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

Based on review of resident council minutes, resident and staff interviews, and policy and procedures, the facility was unable to demonstrate their response and rationale to grievances and recommendations voiced during resident council meetings. The facility census was 82. The deficient practice could result in residents' concerns, views, grievances or recommendations not being considered or acted upon by facility staff. Findings include: During a resident council interview conducted on April 8, 2025, residents stated that the facility does not act promptly upon grievances and does not consistently provide rationale or explanation if no response if given. The resident council indicated that the Administrator/Executive Director (staff #176) sometimes do not get to their grievances for two months. One of the trending issues still unresolved is the long call light wait times. Review of the resident council meeting minutes dated November 10, 2024, December 29, 2024, and February 23, 2025 revealed that there were grievances reported during the meeting. However, it did not identify what…

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 interview, facility documentation and policy review, the facility failed to protect the rights of five residents (#132, #23, #283, #187 and #483) to be free from physical abuse by another resident. The deficient practice could result in further resident abuse. Findings include: Regarding residents #132 and #12: -Resident #132 was admitted on [DATE] with diagnoses of vascular dementia, cerebral infarction, stage 3 CKD (chronic kidney disease) and antiphospholipid syndrome. The care plan with revision date of January 16, 2013 included that resident had impaired cognitive function and behavior problem of cursing at other residents and staff related to dementia, history of CVA (cerebrovascular accident) and TIA (transient ischemic attack) and recent BIMS ((Brief Interview for Mental Status) score. Interventions included to administer meds as ordered; monitor/document /report to physician any changes in cognitive function, specifically changes in: decision making…

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 interview, and policy and procedure, the facility failed to ensure that 2 residents (#29 and #37) out of 18 sampled, that were newly admitted , had a level I pre-screening to determine if the residents may have had an MI (mental illness) or ID (intellectual disability). The deficient practice could result in residents not receiving the necessary specialized services required. Findings include: Resident #29 was admitted on [DATE] with diagnosis including autistic disorder, depression, schizoaffective disorder, and bipolar disorder. A review of the 5-day MDS (minimum data set) dated March 20, 2025 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. The MDS revealed a mood severity score of 01, indicating minimal impact. There were no noted potential indicators of psychosis or behaviors. The MDS further revealed that the resident was on antidepressants and anticonvulsant medications. A review of the care plan…

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, observations, and policy review, the facility failed to ensure that two residents (#190 and #79) received treatment and care in accordance with professional standards of practice by failing to follow physician's orders for resident care. Findings include: Related to resident #190- Resident #190 was admitted to the facility on [DATE] with diagnosis that included aphasia, acute osteomyelitis of the right ankle and foot, type 2 diabetes, history of strokes, and cognitive communication deficit. Resident #190 was admitted to the facility from the hospital after an Open Reduction and Internal Fixation (ORIF) of the right ankle fracture and with discharge orders which included to follow up with orthopedic surgery for the broken right foot and broken wrist. Page 11 of the hospital documents indicated the follow-up was to take place 1 week following discharge and (to) maintain (the) wound VAC until then. The same document also indicated that an orthopedic appointment 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 observations, clinical record reviews, staff and resident interviews and review of policies and procedures, the facility failed to ensure that one resident (resident #21) was assessed for self administration for medications. The deficient practice could result in an adverse event for the resident. -Regarding Resident #21 Resident #21 was admitted on [DATE] with diagnosis including heart disease, atrial fibrillation, nonrheumatic mitral valve insufficiency, presence of a prosthetic heart valve, symptomatic epilepsy and epileptic syndromes with complex partial seizures, malignant neoplasm of the brain, repeated falls, insomnia, osteoporosis, anxiety disorder, and depression. A review of the quarterly MDS (minimum data set) dated November 26, 2024 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. A review of the physician orders revealed no evidence of an order to self-administer medications or orders for Pepto Bismol, Aspercream,…

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, facility documentation and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need. Findings include: The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for all four quarters in 2024 and, the 1st quarter of 2025. Per the report, submitted weekedng staffing data was excessively low. The facility assessment reviewed on February 4, 2025 revealed that the facility was licensed to provide care for 112 residents, had an average daily census of 60-75 with 20-30+ of this census being short term stays, and, had an average number of admission and discharges of 25-35 per month Staffing plan included the following: -full time Director of Nursing (DON); -At least 1 registered nurse (RN) per 24 hour period; -Up to 6 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 observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#52) was treated with dignity regarding privacy of a foley catheter bag. The deficient practice could lead to a resident having psychosocial harm from lack of dignity. -Findings include: Resident #52 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, pneumonia, encephalopathy, post-traumatic stress disorder, schizophrenia, depression, and anxiety. An admission MDS (minimum data set) assessment, dated March 24, 2025, revealed the resident had a brief interview for mental status (BIMS) assessment code of 99, indicating the resident was unable to complete the interview. A physician order dated March 19, 2025, indicated for a foley catheter size, and to change foley catheter as needed for leaking, soiling, blockage, or as ordered by physician. A progress note dated April 7, 2025 revealed the resident had 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 closed record review, staff interviews, review of facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure a safe and appropriate transfer of one resident (#182). The deficient practice could result in residents not receiving appropriate care and services during the transition of care. Findings include: Resident #182 was readmitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, Type 2 Diabetes Mellitus, Chronic Respiratory Failure with Hypoxia, anxiety disorder and severe protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12.0 indicating moderately impaired and resident requires continuous oxygen therapy treatment. Review of orders revealed an order for oxygen at zero to five liters per minute as needed to keep oxygen saturation above eighty-nine percent. Review of care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was accurate for one resident (#80). The deficient practice could result in incorrect discharge tracking information and data that is not accurate for quality monitoring. Findings include: Resident #80 was admitted on [DATE] with diagnoses that included cellulitis in the left lower extremity, endocarditis and acute and chronic respiratory failure. A social service note dated March 5, 2025 revealed that the resident's PICC (peripherally inserted central catheter) line was removed so the resident could return home. The resident declined a referral for home health. A health status note dated March 5, 2025 revealed that the resident was discharged in a private vehicle with a friend. The note further revealed that the resident verbalized understanding of all discharge instructions. The Discharge summary dated [DATE] revealed 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 review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that a Pre- admission Screening and Resident Review (PASRR) Level 2 referral was completed for one resident (#28). The sample size was 18. The deficient practice could lead to residents not receiving needed care and services. Findings include: Resident #28 was admitted on [DATE] with diagnosis including major depressive disorder, single episode, anxiety disorder, bipolar disorder, type 1 diabetes, and schizoaffective disorder. A review of the quarterly MDS (minimum data set) dated December 26, 2024 revealed no noted BIMS (brief interview of mental status) score. The MDS revealed no noted potential indicators of psychosis and no noted behaviors. The MDs revealed diagnosis including anxiety disorder, depression, bipolar disorder and schizophrenia. A review of the care plan revealed focus areas to include anti-psychotic medication use for schizoaffective disorder. The care plan revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure showers were provided for one resident (#36). Findings include: Resident was admitted on [DATE] with diagnoses of bipolar disorder, hemiplegia, and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. Review of the resident's care plan report did not reveal any concern regarding personal hygiene or rejection of care. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was unable to complete the Brief Interview for Mental Status (BIMS) evaluation. The MDS assessment indicated that the resident did not exhibit rejection of care behavior during the assessment period. The assessment also revealed that the resident required substantial/maximal assistance for shower/bathing activities. A progress note dated February 28, 2025 documented that resident requested a shower. However, due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, staff and resident interviews and review of policies and procedures, the facility failed to ensure physician orders, for hydration, were followed for resident #383. The deficient practice could result in fluid overload, electrolyte imbalance and a detrimental impact on kidney function. Findings include: Resident #383 was admitted on [DATE] with diagnosis including unspecified dementia, psychotic disturbance, anxiety, essential hypertension, constipation, chronic kidney disease, cognitive communication deficit, reduced mobility and need for assistance with personal care. A review of the admission MDS (minimum data set) dated December 21, 2022 revealed a BIMS (brief interview of mental status) score of indicating moderate cognitive impairment. A review of the care plan revealed that the resident is to be assisted with meals as needed and to anticipate needs. It further revealed that the resident's PO (per os-referring to oral intake) intake is to be monitored 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, facility documentation and policy review, the facility failed to ensure pain medications were administered following the physician-ordered parameter of two residents (#3 and #133). The deficient practice could result in residents' pain not adequately managed. Findings include: -Resident #3 was admitted on [DATE] with diagnoses of quadriplegia, chronic pain syndrome, constipation and opioid dependence. The care plan dated December 24, 2022 revealed that the resident had or was at risk for pain related to stage 4 pressure area. Interventions included to anticipate the resident's need for pain relief, respond as soon as possible to any complaint of pain and opioid analgesic to treat pain per physician orders. The physician order dated December 24, 2022 included for pain evaluation using pain scale of 0-10 every shift. The care plan dated December 28, 2022 included that the resident had pain and takes opioid/non-opioid and/or analgesic related to general discomfort.…

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, record review and interviews, the facility failed to assist one resident (#40) in obtaining routine dental services. The deficient practice could result in the delay of dental services. Findings include: Resident #40 was admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, Type 2 Diabetes Mellitus, major depressive disorder, anxiety disorder, and mild protein-calorie malnutrition. Review of comprehensive care plan dated December 5, 2023 revealed resident is at risk for oral/dental health problems related to cerebrovascular accident (CVA) with right side weakness. The interventions include consult with dietician and change if chewing/swallowing problems are noted, coordinate arrangements for dental care, transportation as needed as ordered and observe, monitor, document, report to medical doctor as needed signs and symptoms of oral, dental problems needing attention such as pain (gums, toothache,…

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, facility documentation and policy review, the facility failed to educate and offer an influenza vaccine that the resident was eligible to receive in accordance with the current Centers for Disease Control and Prevention (CDC) guidelines for one resident (#42) out of 5 reviewed for immunizations. The deficient practice posed the risk of the resident contracting influenza and its associated complications. Findings include: Resident #42 was admitted on [DATE] with diagnosis including Alzheimer's Disease with late onset, unspecified dementia, encephalopathy, Parkinson's disease, hypertension and reduced mobility. A review of the MDS (minimum data set) dated January 16, 2025 revealed a BIMS (brief interview of mental status) score of 13, suggesting that the resident was cognitively intact. A review of the electronic health record revealed no evidence that the resident received an influenza immunization, nor did the record reveal evidence that the resident received influenza education or signed 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 review, interviews, and review of policies, the facility failed to ensure one resident (#4), was free from significant medication errors, related to the resident receiving the wrong dosage of Parkinson's disease medication. The deficient practice could result in complications and adverse medication side effects. Findings include: Resident #500 was admitted to the facility for respite care on June 18, 2024 with diagnoses that included Parkinson's disease, anxiety disorder, and depression. Review of the order summary revealed a prescription for Carbidopa-Levodopa tablet 25-100MG (milligrams) with an order date of June 17, 2024 which indicated to give 1 tablet by mouth four times a day for Parkinson's Disease. Additionally, the Hospice Admitting Orders dated June 17, 2024 indicated an order for Carbidopa-Levodopa 25-100mg QID (four times a day) for Parkinson's disease. A care plan identifying that the resident is on hospice, initiated June 18, 2024 included an intervention that directed 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 off of clinical record review, staff interviews, observation of current practice, and review of the facility's policies, the facility failed to ensure residents #3, #4, and #5, were free from abuse from other residents. The deficient practice could result in residents experiencing emotional and mental trauma from the abuse. Related to resident #5 Resident #5 was admitted to the facility on [DATE] with diagnoses that included Dementia, a history of strokes, and stage 3 Kidney disease. A review of a Quarterly MDS, dated [DATE] revealed resident #5 had a BIMS assessment completed. Resident #5 scored a 08 which indicated they were mildly cognitively impaired. A review of the care plan reveals it was revised on January 16, 2023 to include behavior issues as an area of focus. The care plan goals included that resident #5 would not harm themselves or others. The care plan interventions included administering medications as ordered, allowing the resident to make their own decisions about their care, anticipating…

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 quality resident care. The deficient practice could result in residents' care needs not being met. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included a fracture of the left femur, Chronic Obstructive Pulmonary Disease (COPD), and Anxiety disorder. The 5-day Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS also indicated resident #1 needed partial/moderate staff assistance for moving from a laying in the bed position to sitting on the side of the bed position. It also indicated that the ability to get on and off the toilet was not assessed due to a medical condition or safety concern. The facility's staff schedule was reviewed for Thursday, May 2, 2024 and Friday, May 3, 2024. Thursday May 2, 2024 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 clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#1) was administered pain medications as ordered. The deficient practice resulted in a resident experiencing unnecessary pain. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included a fracture of the left femur, Chronic Obstructive Pulmonary Disease (COPD), and Anxiety disorder. The 5-day Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of the physician's orders dated April 26, 2024 included Hydrocodone-Acetaminophen (an analgesic opioid) Oral 5-325 milligram (mg) tablet every 4 hours as needed for pain 6-10. A second order was revealed for Acetaminophen 325 mg two tablets every 4 hours as needed for pain 1-5. Review of resident #1's care plan, initiated April 26, 2024, revealed the resident was at risk for pain. Interventions…

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, observations, staff and resident interviews and policy review, the facility failed to ensure that one resident (#1) was treated with dignity and respect, and that two residents (#1, #3) were provided privacy during showers. -Regarding Resident #1 Resident #1 was admitted on [DATE] with diagnoses that included right femur fracture, protein calorie malnutrition, depression, reduced mobility, abnormalities of gait and mobility, history of falling, unsteadiness on feet. Review of the care plan revealed the following areas of focus: -Requires assistance with Activities of Daily Living (ADL), initiated September 15, 2022. -ADL self-care performance deficit related to activity intolerance, impaired balance, limited mobility, initiated September 29, 2022. Interventions included cares and pairs with all ADLs, requires skin inspection during routine cares and per bath schedule. -At risk for falls, initiated November 9, 2022. An intervention dated May 10, 2023 revealed that the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical documentation, staff interviews, and facility policy and procedures, the facility failed to implement non-pharmacological interventions for continued use of psychotropic medication for two residents (#6 and #11). The census was 57. The deficient practice could result in resident receiving unnecessary psychotropic medications. Findings include: -Resident #6 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, major depressive disorder, Parkinson's Disease and schizoaffective disorder, bipolar type. A care plan initiated on January 27, 2020 revealed that resident use antipsychotic medication related to a bipolar diagnosis. Interventions included to give medication as per the physician's order, and to report the ineffectiveness of the medication to the physician at any point in the assessment phase. The care plan did not include non-pharmacological interventiosn for the use of antipsychotic medication. Review of the Minimum Data Set (MDS) dated [DATE] included 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 documentation, staff interviews, and facility policy and procedures, the facility failed to ensure that one resident (#11) did not receive unnecessary pain medication. The census was 57. The deficient practice could result in residents being overmedicated. Findings include: Resident #11 was admitted on [DATE] with diagnoses of Alzheimer's Disease, scoliosis, acute kidney failure, and displaced intertrochanteric fracture of the right femur. A care plan dated September 11, 2022 included that the resident was at risk for pain related to a medical condition. Interventions included to evaluate for and adequately respond to any sign or complaint of pain. Review of the Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 7 indicating the resident has a severe cognitive impairment. The care plan dated January 16, 2023 revealed the resident use opioid/and or analgesic related to pain. Interventions included to evaluate the effectiveness of pain interventions…

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, policy and procedures the facility failed to ensure services met professional standards by failing to provide bowel care for one resident receiving opioid therapy (resident #47). This deficient practice could result in residents having complications from constipation including fecal impaction, bowel obstruction or death. Findings include: Resident #47 was readmitted to the facility on [DATE] with diagnoses of morbid obesity, bilateral primary osteoarthritis of knee and need for assistance with personal care. A physician order dated December 18, 2022 Senna S (stool softener) 8.6-50 mg give 1 tablet by mouth two times a day for constipation and to hold medication for loose stool. The care plan dated March 10, 2023 revealed the resident was at risk for pain and takes opioid/non-opioid/and or analgesic related to general discomfort secondary to a sacrum wound. The goal was that the resident will not have an interruption in normal activities due to pain through 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, policy and procedures review, the facility failed to ensure that medications were properly secured for one resident (resident #2). The deficient practice could result in the inappropriate use of medications by residents. Findings include: Resident #2 was admitted on [DATE] with diagnoses of quadriplegia, stage IV pressure ulcer of sacral region, need for assistance with personal care and muscle weakness (generalized). The care plan dated December 24, 2022 did not mention the resident was assessed to be able to do self-administration of medication. Review of the minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment included the resident required extensive assistance with two-person physical assist with bed mobility and transfers; and required extensive assistance with one-person physical assist with eating. A physician order dated March 13, 2023 included…

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.