Winslow Campus Of Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure that residents are free from abuse from another resident (Residents #1 and #3). The deficient practice could lead to additional resident-to-resident altercations, thereby creating an unsafe environment.Findings include:-Regarding Resident #1:Resident #1 was admitted on [DATE], with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance, and unspecified dementia, severe, with psychotic disturbance.A quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (brief interview for mental status) score of 05, indicating that the resident had severe cognitive impairment. The MDS assessment also revealed that within the last seven days before the assessment, Resident #1 exhibited verbal behavioral symptoms directed towards others one to three days out of the seven; other behavioral symptoms not directed towards others occurred four to six days, but…

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 procedures, the facility failed to ensure that two sampled residents (#88 and #71) were not physically abused by residents (#76 and #84). The sample size was 6. The deficient practice could lead to physical and psychosocial harm to residents.Findings Include:-Regarding residents #88 and #76Resident #88 was admitted to the facility on [DATE] with diagnoses including: unspecified dementia, with other behavioral disturbance, and insomnia.An admission minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 7, indicating severe cognitive impairment. Review of the care plan for resident #88 reveals a focus starting on July 16, 2025, for exhibiting behaviors of pacing in common areas, wandering, invading others personal space.A nursing progress note dated September 12, 2025 revealed that resident #88 was self-ambulating in the hallway when another female 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 (#6) was not abused by another resident (#3). The deficient practice could lead to physical and psychosocial harm to residents. Regarding Resident #6: Resident #6 was re-admitted to the facility on [DATE], with diagnoses that included senile degeneration of brain, paroxysmal atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. A quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. A progress note dated April 18, 2025, revealed at 7:45 AM, the nurse was notified by certified nursing assistants (CNAs) that another resident hit Resident #6 in the right arm during breakfast. CNAs intervened and immediately separated the residents. Upon review of video recording, it was observed that the resident was trying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, observation, staff interviews and policy review, the facility failed to ensure that one resident (#41) was free from physical abuse by a resident (#37). The deficient practice could result in further incidents of resident to resident abuse and could lead to injury. Findings include: Resident #41 was admitted to the facility on [DATE] with diagnoses that included nontraumatic subarachnoid hemorrhage, dementia without behavioral disturbance, and stage five chronic kidney disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #41 had a short-term memory problem and had a moderate impairment to decision making skills. Resident #37 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, restlessness and agitation, and major depressive disorder. Review of Resident #37's care plan revealed a problem, initiated on November 27, 2024, which indicated that Resident #37 may show behaviors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and review of facility documentation and policy, the facility failed to evaluate and implement effective care plan interventions related to falls for one resident (#11). The deficient practice resulted in the resident experiencing multiple falls in the facility, and could result in other residents failing to receive effective fall-prevention measures. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, cardiomyopathy, and pulmonary fibrosis. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of the resident care plan revealed a problem initiated on February 15, 2021, which indicated that the resident was at risk for falls related to advanced aging, dementia, and a history of falls. This problem also indicated that the resident refused to use the wheelchair and would get…

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, observation, staff interviews, and policy review, the facility failed to ensure that two residents (#25 and #20) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse and lead to injury. Findings include: -Regarding Resident #25: -Resident #25 was re-admitted to the facility on [DATE], with diagnoses that included dementia with other behavioral disturbances, other pulmonary embolism, cardiomyopathy, and pulmonary fibrosis. Review of an annual minimum data set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment score of 3, indicating severe cognitive impairment. The MDS further indicated that the resident had noted physical behavioral symptoms directed toward others. A care plan dated February 15, 2021, revealed that Resident #25 may exhibit behaviors of physical aggression toward staff and other residents, with interventions to avoid placing 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, facility documentation, and staff interviews, the facility failed to ensure eight residents (#1, #2, #3, #4, #5, #6, #7 and #8) were provided adequate supervision to prevent resident abuse. The deficient practice could result in residents being at risk for abuse. Findings included: Regarding Resident #1 and Resident #2: -Resident #1 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, dysphasia, and anemia. Review of care plan dated March 7, 2023 revealed resident has decreased communication skills related to hard of hearing. The interventions included adjust voice and repeat as needed, communicate in the resident's language whenever possible, make sure all basic needs are met, and use quiet setting as needed. Review of care plan dated March 7, 2023 revealed resident has minimal visual impairment. The interventions included assist resident through doorways, and around corners and objects as needed. Review of resident's quarterly MDS assessment 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 observations, clinical record review, staff interviews and facility policy, the facility failed to ensure that 7 residents were not abused (72, 76, 92, 42, 67, 54, 32 and 19). The deficient practice could result in physical and emotional harm to residents. Findings include: Regarding the incidents between resident #72 and unknown victim -Resident #72 was admitted on [DATE] with diagnoses of traumatic brain injury, other frontotemporal neurocognitive disorder and mild cognitive impairment. A care plan dated February 5, 2024 included this resident may exhibits the behaviors of verbally rude to staff and other residents and short temper with other residents. Interventions include document behaviors and psychiatric consult. A progress note [DATE] included that the writer overheard a Certified Nursing Assistant (CNA) in the hallway saying (Resident #72) Stop!. This note included that Resident #72 was observed holding onto another male resident's wheelchair handles and aggressively shaking the wheelchair 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.

Based on observations, staff interviews, facility process and procedures, the facility failed to ensure that dishes and utensils were cleaned using professional standards of practice for sanitary conditions. The deficient practice could result in residents becoming ill. Findings include: On January 28, 2025 at 12:17 PM, a brief kitchen inspection was conducted with the kitchen manager/Staff #201. Staff #201 stated that they use low temperature dishwashing machine. They have to run the dishwashing machine a few times so temperature will reach to par at 120 degrees Fahrenheit (F) because the pipes get cold. At 12:27 PM, staff #201 run the low dishwashing machine twice, then the dishwashing machine reached to 120 degrees F. In addition, Staff #201 stated that they use sanitizer/chlorine for the dishwashing machine. At this time, Staff #201 conducted a test strip to determine sanitation. Staff #201 stated that the strip is between 100 parts per million (ppm) and 200 ppm, and stated that it is about 150 ppm. On January 30, 2025 at 12:05 PM, surveyor received the requested documents for…

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

Based on observation, record review, interviews, and facility policy, the facility failed to ensure that monitoring and evaluation of physical restraints are completed for the continued use of physical restraints for one resident (Resident #36). The deficient practice could lead to increased isolation and/or other psychosocial harm. Findings include: Resident #36 was initially admitted into the facility on January 1, 2019, with the diagnosis of atrial fibrillation, depression, pain in right and left knee, unspecified dementia and anxiety. Review of the nursing progress note dated May 31, 2024 by licensed practical nurse (LPN, staff # 450), revealed that the resident had a fall and hit his head. However, no visible injuries were noted. Resident was very weak and unsteady on his feet. Resident granddaughter was notified and nurse implement an order for a bed/wheelchair alarm for safety. Review of an order dated May 31, 2024, revealed that resident has an order for bed alarm on while in bed. Review of an order dated May 31, 2024, revealed that resident has an order for a wheel chair…

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 a copy of the notice of one of one discharges for one resident (# 101 ) to a representative of the Office of the State Long-Term Care Ombudsman. The failure may result in residents not having the advocacy and support from the State Long-Term Ombudsman during the discharge process. Findings include: Resident # 101 was admitted on [DATE] with a diagnosis of dementia, hypertension, and dysphagia. The quarterly review Minimum Data Set assessment (MDS) on September 05, 2024 , revealed a Brief Interview of Mental Status (BIMS) score of 99 . Indicating that the resident assessment was not completed. A review of clinical records of progress notes dated November 09, 2024 revealed residents were sent out to the Emergency Department. An interview was conducted on January 30, 2025 at 11:30AM with Social Service ( staff #171) who stated that the ombudsman will be notified at the start of each month. Staff # 171 also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and facility policy, the facility failed to ensure that residents care plans were revised as needed for 3 residents (#72, #76, and #45). Findings include: - Resident #45 was admitted on [DATE] with diagnoses of dementia, muscle weakness, and adult failure to thrive. An annual Minimum Data Set (MDS) dated [DATE] included that this resident requires extensive assist for dressing. An annual MDS dated [DATE] includes that the resident was dependent for all cares. A care plan with a start date of September 14, 2020 includes that this resident requires assistance with self-cares related to dementia, adult failure to thrive and muscle weakness. However, there was no care plan regarding this resident's physical decline or a care plan related to therapy. -Resident #72 was admitted on [DATE] with diagnoses of traumatic brain injury, other frontotemporal neurocognitive disorder and mild cognitive impairment. A care plan dated February 5, 2024 included this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one of one sampled residents (#304) was safe to self-adminster medication. The deficient practice could result in a medication overdose. Findings Include: Resident #304 was initially admitted on [DATE] with a diagnosis of dementia, type 2 diabetes, and dysphagia. Review of physician orders revealed active orders for the following medications: Bisacodyl 10mg Polyethylene glycol 3350 power solution Melatonin 3 mg tab Docusate sodium 100mg cap Quetiapine 25 mg tablet Acetaminophen 325 mg tab Diclofenac sodium 1 percent topical cream A in progress admission Assessment Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Review of the clinical records of progress notes dated January 29, 2025 revealed that a CNA (Certified Nurse Assistance) found a bag of medication in a plastic bag in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and facility policy, the facility failed to ensure that resident #45 received specialized services to meet therapeutic needs. Findings include: Resident #45 was admitted on [DATE] with diagnoses of dementia, muscle weakness, and adult failure to thrive. A care plan with a start date of September 14, 2020 includes that this resident requires assistance with self-cares related to dementia, adult failure to thrive and muscle weakness. However, there was no care plan regarding this resident's physical decline or a care plan related to therapy. An annual Minimum Data Set (MDS) dated [DATE] included that this resident requires extensive assist for dressing. However, an annual MDS dated [DATE] includes that the resident was dependent for all cares. Review of the clinical record did not include any other assessment of the resident's loss of ability or any therapeutic interventions for this loss. An interview was conducted on January 30, 2025 at 9:52 AM 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 interviews, record review, facility document review, and facility policy review, the facility failed to ensure that one resident (#66) was offered pneumococcal vaccine. The deficient practice could pose the risk of the residents contracting pneumonia and its associated complications. Findings included: Resident #66 was initially admitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, seizure, major depressive disorder, and pneumonia. Review of a document titled, Consent/Pneumonia Vaccine revealed a signed consent to receive the pneumonia vaccine on the initial admission date in August 08, 2022. The record revealed that resident #66 would like to receive an immunization of Pneumococcal Prevnar13 vaccine and there was no evidence that the resident received the vaccine. The admission quarterly minimal data set (MDS) dated [DATE] revealed a brief Interview for mental status (BIMS) score of 09 indicating moderate cognitive impairment. An interview was conducted on January 29, 2025 at…

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, record review, interviews, and review of facility documentation and policy, the facility failed to ensure two residents (#2, and #3) were not abused by one resident (#1). The deficient practice could lead to physical harm, mental anguish, and psychosocial harm to a resident. Findings include: Regarding Resident #2 and Resident #1: -Resident #2 was admitted on [DATE], with diagnoses that included dementia, type 2 diabetes mellitus, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) assessment score that was unable to be assessed due to the resident being rarely or never understood. Additionally, Section E revealed that Resident #2 had physical behavioral symptoms directed toward others occurring between 4 and 6 days, and verbal behavioral symptoms toward others occurring between 1 to 3 days. A Progress Note dated December 23, 2024, revealed that at 11:45 AM, the nurse was notified by 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, facility surveillance footage, the State Agency (SA) complaint tracking system, and policy review, the facility failed to ensure resident #3 was free from abuse from resident #4. The deficient practice could result in further resident abuse. Findings include: Related to resident #3- Resident #3 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety and hypertension. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed resident #3 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident was cognitively impaired. A review of a Progress Note, written by Registered Nurse (RN, staff #78) and dated December 1, 2024 at 10:35 AM, noted that at 9:00 AM a Certified Medical Assistant (CMA, staff # 19) notified the nurse (staff # 78) that resident #3 and another resident (#4) were kicking each other and then were immediately separated. The progress note also indicated that a video recording captured resident #3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure the care plan was implemented related to the need for repositioning for one resident's (#2). The deficient practice could result in residents not receiving the services as outlined in their care plan. Findings include: Resident #2 was admitted on [DATE] with diagnoses of chronic pain, constipation, open wound-right lower leg, diabetes mellites and age related physical debility. A review of the MDS (minimum data set) assessment dated [DATE] revealed staff had been unable to complete the cognitive assessment of the MDS. The assessment also included that the resident required substantial to maximal assistance rolling left to right in the bed, was always incontinent of both bowel and bladder, was at risk for developing pressure ulcer and had both a stage 1 and a stage 2 pressure ulcer. The comprehensive care plan dated July 31, 2024 included the resident had a pressure injury and an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's infection control program documentation, staff interviews, personnel files, and facility policy and procedures, the facility failed to implement a COVID-19 screening and consistent testing program during a COVID-19 breakout. The deficient practice could result in residents becoming ill. Findings include: Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include COVID-19 acute respiratory disease, Pneumonia, end stage renal disease, and chronic pain. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident was cognitively intact. The care plan dated June 14, 2024 revealed that the resident may require use of oxygen (O2) to keeps saturation up. Interventions included to check O2 saturation every shift. Hospital documentation revealed that the resident was transported to the emergency room (ER) on July 10, 2024 for shortness of breath. Diagnoses included: bilateral pleural…

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 facility documentation, the facility failed to ensure the physician was notified of a change in condition for one resident (#1). The deficient practice could result in resident not receiving continuity and coordination of needed care. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included Chronic Kidney Disease, stage 3, chronic pain, and hypertension. The nursing progress note dated May 23, 2024 included that the resident was alert and oriented x3 and was hard of hearing. The baseline care plan dated May 24, 2024 included that the resident required assistance with self-cares related to limited mobility due to aging. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. The clinical record revealed a lab result that indicated the last covid-19 test that was administered was on July 11, 2024 and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, facility documentation, policies and procedures, the facility failed to protect the rights of one resident (#525) to be free from abuse from visitors/family member. The deficient practice could result in further abuse of residents and appropriate action not taken. Findings include: Resident #525 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with behavioral disturbance, agitation, and psychotic disturbance, and hypertension. A behavioral care plan dated June 11, 2024 indicated that the resident may exhibit behaviors of rejection of care, physical aggression towards staff and verbal aggression towards staff related to her dementia with agitation. Interventions included document behaviors, and make sure all basic needs are met. Further review of the care plan did not reveal any reference regarding the resident's risk for abuse from visitors/family members. The facility's visitor log…

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, policy and procedures the facility failed to implement their policy on abuse and resident protection for one resident (#525). The deficient practice could result in abuse continuing and not being prevented. Findings include: Resident #525 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with behavioral disturbance, agitation, and psychotic disturbance, and hypertension. The facility's visitor log for resident #525 revealed that family members #1 and #2 came to visit the resident on June 11 and 13, 2023. The final facility investigation report dated June 17, 2024 revealed that the incident took place on June 11, 2024 at approximately 2:30 p.m. According to the facility report, resident #525 was socializing with other residents when her three family members arrived at the facility for a visit. It included that her family proceeded to remove the resident from 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 review of facility policies, the facility failed to ensure oxygen was administered as ordered by the physician for one of 3 sampled residents (#13). The deficient practice could result in residents not receiving adequate oxygen to prevent hypoxia. Findings include: Resident #13 was admitted on [DATE] with diagnoses of spastic cerebral palsy, vascular dementia with behavioral disturbances, and hypoxemia (low blood oxygen levels). A physician's order dated October 22, 2022 included an order to titrate O2 (oxygen) 1-4 liters to keep O2 saturation level at greater than 90% twice daily and as needed for a diagnosis of hypoxemia. This order was transcribed onto the MAR (medication administration record) for May 2023 and revealed that the resident had O2 sat levels as follows on the following dates: -shift 1 on May 12 was 87%; -shift 1 on May 13 was 89%; -shift 1 on May 17 was 89%; -shift 1 on May 18 was 88%; and, -shift 1 on May 19 85%. The documentation in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that nine residents (#5, #15, #35, #40, #50, #65, #20, #80, and #25) were free from abuse of another. The deficient practice could result in other residents being abused. Findings include: -Regarding Resident # 5 Resident #5 (alleged victim) was admitted on [DATE] with diagnoses that included unspecified dementia, and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 4 indicating that the resident has severe cognitive impairment. The MDS also indicated that the resident have not exhibited psychosis or behavioral symptoms during the assessment period. However, the assessment noted that the resident wandered 4-6 days during the assessment period. A care plan initiated on December 11, 2022 revealed the resident had cognitive impairment 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 closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to report allegations of abuse for two residents in a within the required timeframe (#5 and #15). The deficient practice could result in abuse allegations not being reported. Findings include: -Regarding Resident #5 Resident #5 (alleged victim) was admitted on [DATE] with diagnoses that included unspecified dementia, and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 4 indicating that the resident has severe cognitive impairment. The MDS also indicated that the resident have not exhibited psychosis or behavioral symptoms during the assessment period. However, the assessment noted that the resident wandered 4-6 days during the assessment period. A care plan initiated on December 11, 2022 revealed the resident had cognitive impairment 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 interview, facility documentation, policy and procedure, the facility failed to ensure allegations of abuse were thoroughly investigated. The deficient practice could result in allegations of abuse not verified and appropriate corrective action to protect resident not taken. Findings include: Regarding resident #81 (alleged aggressor) and #106 -Resident #81 was admitted on [DATE] with diagnoses of dementia with agitation and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. -Resident #106 was admitted on [DATE] with diagnoses of unspecified dementia with agitation, unspecified psychosis and wandering. Incident #1: March 14, 2023 The facility report dated March 14, 2023 included the type of allegation was physical abuse and video surveillance was reviewed. The report revealed that resident #106 started pushing the wheelchair of resident #81 who then hit resident #106. Per the report, resident #106 hit resident #81 back and several…

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, facility documentation and policy, the facility failed to protect the right to personal privacy of one resident (#95) by failing to prevent another resident (#106) to enter resident #95's room without permission. Sample size was 1 of 1. The defeicient practice could result in resident's privacy being violated. Findings include: -Resident #95 was admitted on [DATE] with diagnoses of delusional disorder, major depressive disorder, trisomy 21 (Downs Syndrome), and altered mental status. The care plan dated May 13, 2021 revealed the resident exhibited behaviors of physical aggression towards staff and the inability to tolerate other residents coming into her room. Interventions included encouraging the resident to come and get a staff member or to use the call light if another resident was wandering into their room. The Minimum Data Set assessment (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 1 indicating resident had 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 Based on clinical record review, staff interviews and the rules of the State Board of Nursing, the facility failed to ensure documentation of behaviors and 15-minute checks were implemented as ordered by the physician. The deficient practice could result in aggressive behaviors not identified, documented and monitored. Findings include: Resident #106 was admitted on [DATE] with diagnoses of dementia, psychosis, and wandering behaviors. A review of the clinical record revealed that resident #106 had been involved in two resident-to-resident altercation on the morning of August 6, 2023. A physician order dated August 7, 2023 included to document the behavior in the progress notes every shift for 72 hours. It also included orders to do every 15-minute checks continuously. However, review of the clinical record from August 7 through 9, 2023 revealed there were no evidence that the resident's behaviors were not documented in the progress notes on the following dates: -Day shift on August 7 and August 9; and, -Night…

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, interview, record review and policy and procedure, the facility failed to ensure that one resident (#41) who was dependent on staff for activities of daily living (ADL) such as grooming and hygiene, received the necessary services to maintain good hygiene. The facility census was 108, and the sample was 22. The risk of not cleaning/trimming nails could result in harboring of bacteria that can contribute to the spread of infections. Findings include: Resident #41 was admitted on [DATE] with diagnoses that included end stage renal disease (ESRD) with dialysis, glaucoma, depression and age-related physical debility. Review of a care plan initiated on April 14, 2019 revealed resident had a risk for skin breakdown and had exhibited behaviors of refusing to shower. Interventions included keeping the nails short and the skin clean and dry; and, to document behaviors. A podiatry note dated August 17, 2022 revealed that a return appointment was required in two months. However, the progress notes…

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.