North Pointe Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one out of 37 sampled residents (Resident 42) when Resident 42 was suspected for elderly financial abuse by her conservator (a court-appointed individual who manages the financial and/or personal affairs for someone unable to do so themselves) and was not reported to the state agency, local ombudsman, adult protective services, and law enforcement officials.This failure resulted in a delayed investigation of the suspicion of Resident 42's financial abuse and placed Resident 42 at risk of experiencing further financial abuse, and possible serious psychosocial harm.Findings:A review of Resident 42's clinical record indicated Resident 42 was admitted May of 2023 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function…

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 interview and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one out of 37 sampled residents (Resident 42) when Resident 42 was suspected for elderly financial abuse by her conservator (a court-appointed individual who manages the financial and/or personal affairs for someone unable to do so themselves) and was not investigated.This failure resulted in Resident 42 experiencing further financial abuse, and possible serious psychosocial harm.Findings:A review of Resident 42's clinical record indicated Resident 42 was admitted May of 2023 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), dementia (memory loss that interferes with daily functions), and need for assistance with personal care.A review of Resident 42's Minimum Data Set…

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 interview and record review, the facility failed to update and revise resident's care plans (documents that summarizes resident's needs, goals, and care/treatment) for one of 37 sampled residents (Resident 4), after the physician discontinued orders for resident's splint (a device to immobilize joint) and fluid restriction (means limiting person's intake of liquids due to health conditions).These failures increased the potential to result in confusion in the delivery of care and services to Resident 4 and the resident continued to receive care and treatment that was discontinued. A review of the admission Record indicated that the facility admitted Resident 4 in 2015 with multiple diagnoses, which included metabolic encephalopathy (brain disfunction, leading to confusion, memory issues, and personality changes), dementia (a progressive state of decline in mental abilities), muscle weakness, and contracture of muscle in right hand (a condition when tissue under the palm thickens and fingers are curled,…

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, interview, and record review, the facility failed to ensure two out of 37 sampled residents (Resident 13 and Resident 146) were assisted with nail care as part of his Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 13 and Resident 146 had long fingernails with blackish substance underneath. This failure had the potential for Resident 13 and Resident 146 to sustain skin injury and/or to acquire an infection and not achieve their highest practicable well-being.Findings:1. A review of Resident 13's clinical record indicated Resident 13 was admitted March of 2026 and had diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), muscle weakness, and need for assistance with personal care.A review of Resident 13's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 12/15/25, indicated Resident 13 was rarely/never understood. A review of Resident 13's MDS Functional Abilities, dated 12/15/25, indicated 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.

Based on observation, interview and record review, the facility failed to ensure one out of 37 sampled residents (Resident 38) received care in accordance with professional standards of practice, and facility's policy and procedure (P&P when Resident 38's foley catheter (a tube inserted through the urethra into the bladder to drain urine) bag was left on the floor.This failure had the potential for Resident 38 to develop infection and possible foley catheter complications.Findings:A review of Resident 38's clinical record indicated Resident 38 was admitted June of 2023 and had diagnoses that included dementia (memory loss that interferes with daily functions), neuromuscular dysfunction of bladder (the nerves and muscles in the urinary bladder don't work together properly), obstructive and reflux uropathy (occurs when the urine cannot drain through the urinary tract), retention of urine (caused by a blockage or a failure of the bladder to squeeze hard enough to expel all of the urine), catheter use, and muscle weakness.A review of Resident 38's Minimum Data Set (MDS- a federally…

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, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for 1 of 8 sampled residents when:Resident 130's oxygen tubing/nasal cannulas (a medical device connected to an oxygen source used to deliver supplemental oxygen directly into the airways) were not labeled with the date it was first used.This failure had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 130.Findings:A review of Resident 130's clinical record indicated Resident 130 was admitted in June of 2025 and had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems) and muscle weakness.A review of Resident 130's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/23/2130, indicated Resident 130 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 10 out of 15…

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

Based on observation, interview, and record review, the facility failed to provide food in accordance with the physician's prescribed diet for one out of 37 sampled residents (Resident 146) when Resident 146 who was on 2 gram (gm/g- unit of measurement) low salt diet (a dietary restriction that limits the intake of salt to 2 grams for the whole day) received a salt packet during the 1/6/26 lunch meal.This failure had the potential to negatively affect Resident 146's medical condition and for Resident 146 not to achieve his highest practicable well-being.A review of Resident 146's clinical record indicated Resident 146 was initially admitted August of 2024 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), diabetes (elevated sugar in the blood), and hypertension (high blood pressure).A review of Resident 146's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 11/17/25, indicated Resident 146 had a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe and homelike environment was provided when horizontal blinds in three (room [ROOM NUMBER], 26 and 35) of 53 rooms were broken, for a census of 157. This failure had the potential to cause injury and unsafe condition to vulnerable residents residing in these rooms. During an observation conducted on 1/6/26 at 9:14 a.m., the horizontal blinds in room [ROOM NUMBER] were broken. There were 5 residents in this room. Further observation was conducted on 1/6/26 at 1:16 p.m., the horizontal blinds in room [ROOM NUMBER] had broken edges. There were 4 residents in this room. During a concurrent observation and interview with the Assistant Director of Nursing (ADON) on 1/6/26 starting at 1:17 p.m., the ADON confirmed the blinds in room [ROOM NUMBER] and room [ROOM NUMBER] were broken. The ADON stated maintenance made rounds daily and the staff who found the broken blinds should write in the maintenance log. During an interview with the…

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

Based on interviews and record review, the facility failed to protect one of four (4) sampled residents' (Resident 1) right to be free from physical abuse when a facility staff member pushed Resident 1 on his face causing him to fall on the ground. This failure resulted in an emergency hospital transfer of Resident 1 for further evaluation.Findings:Resident 1 was admitted to the facility in July of 2025 with diagnoses which included symptoms affecting memory, cognition, social abilities and muscle weakness. A review of Resident 1's Order Summary Report (ORS) indicated, Resident [Resident 1] does not have the capacity to make his/her decisions.A review of Resident 1's Minimum Data Set (a standardized assessment tool used in nursing homes), dated 7/24/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment.A review of Resident 1's Care Plan (CP), dated 7/25/25, indicated, Resident [Resident 1] involved in an accident where they became physically aggressive toward staff during care, striking staff 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.

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse, when Licensed Nurse 1 (LN 1) hit resident in the face causing face abrasions. This failure resulted in Resident 1 experiencing unnecessary pain, fear, and mental anguish and had the potential to cause further psychosocial harm to the resident. Findings: A review of the admission Record indicated the facility admitted Resident 1 in 2017 with multiple diagnoses which included dementia (a progressive state of decline in mental abilities), anxiety, and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/24/24, indicated a BIMS (Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 7, which indicated that the resident had a moderately impaired cognition. A review of the ' Altered Behavior ' care plan initiated 5/28/23…

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, and record review, the facility failed to promote, maintain, and treat five of 37 sampled residents (Resident 77, Resident 119, Resident 44, Resident 21, and Resident 6) with respect and dignity when: 1. Resident 77 was not provided with privacy when receiving phone calls; 2. Resident 119's requests were ignored; 3. Residents were referred to as feeders and residents were not asked if they wanted to wear a bib during a meal; 4. Certified Nursing Assistant (CNA) 6 was standing while feeding Resident 21 and 44; and 5. Resident 6 was not provided with privacy during medication administration. These failures increased the potential for residents not to be able to exercise their rights for privacy, to be treated with dignity and respect, and to receive the services and care necessary to maintain their highest possible mental, physical, psychological, and social well-being. Findings: 1. A review of Resident 77's admission Record indicated he was admitted with diagnoses including…

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 interview and record review, the facility failed to ensure the POLST (Physician Orders for Life-Sustaining Treatment which include code status with instructions on what to do if the resident had no pulse and stopped breathing) forms were completed and updated when: 1. Two of 37 sampled residents' (Resident 3 and 44) POLST forms were not signed and completed; and 2. Two of 37 sampled residents' (Resident 104 and 111) code statuses were not updated in their EMR (Electronic Medical Record) after new POLSTs were put in place. These failures had the potential to result in the facility not acting in accordance with residents' wishes and following physician orders in the event of an emergency. Findings: 1a. During a review of Resident 3's facesheet (a document that gives a resident's information at a quick glance) dated [DATE], it indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE], and the resident had a guardian/responsible party assigned. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a homelike environment was provided for three of 37 sampled residents (Residents 18, 41, and 74), when there were no clocks available in the residents' rooms. This failure increased the potential for the residents not attaining their highest practicable well-being. Findings: During a review of Resident 18's admission records, the records indicated Resident 18 was admitted to the facility in December 2022 with diagnoses which included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), mood disorder, and dementia (impaired memory). During a review of Resident 18's Minimum Data Set (MDS, an assessment tool), dated 6/24/24, the MDS indicated Resident 18 had severe memory impairment. The MDS further indicated that it is very important for Resident 18 to do her favorite activities and choose her own bedtime. During a review of Resident 18's care plan initiated on 1/12/23, the care plan indicated,…

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, interview, and record review the facility failed to adequately maintain pharmacy services for two out of a census of 156 when: 1. A controlled drug (medication that may be abused or cause addiction) destruction record log was inaccurate. 2. Two tablets of lacosamide (a medication given for seizures) were in one single dose unit of the medication card and not accounted for by the nursing staff. This failure had the potential to cause inaccurate accountability of controlled medications and the potential to result in diversion of the residents' medication. Findings: 1. During a review of the controlled drug destruction record log for three random resident's controlled drugs, 20 syringes of Lorazepam gel (a medication used for anxiety) was not recorded in the destruction record log. During a concurrent observation and interview on 9/11/24 at 2:55 p.m. with the Director of Nursing (DON), of the controlled medication storage in the DON's office, the DON verified that the 20 syringes of lorazepam were not documented and signed in the destruction log. The DON stated…

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 2. A review of Resident 150's admission Record indicated Resident 150 was admitted in June 2024 with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and thinking skills) and dementia with behavioral disturbance. Resident 150's MDS, dated [DATE] indicated, severe cognitive impairment. During a review of Resident 150's clinical record included the following documents: A physician's order, dated 8/28/24, indicated an order for risperidone (an antipsychotic), 1 mg (milligrams, a unit of measurement)/1 ml (milliliter, a unit of measurement) solution, Give 0.5 mg by mouth one time a day. An MDS Section E, dated 6/25/24, indicated that Resident 150 had no potential indicators of psychosis. During a review of Lexicomp (a nationally recognized drug information resource) indicated, ALERT: US Boxed Warning .Risperidone is not approved for the treatment of patients with dementia-related psychosis. During a review of [manufacturer's name] full prescribing information for risperidone, 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, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (%) when two medication errors occurred out of 29 opportunities during medication administration for two residents (Resident 6 and Resident 71) of five selected residents during medication pass. This failure resulted in medications not given in accordance with the physician's orders and potential to affect the residents' clinical conditions. Findings: A review of Resident 6's admission Record, Resident 6 was admitted to the facility in early 2023 with admitting diagnosis of Type 2 Diabetes (a long term condition in which the body has trouble controlling sugar in the blood). Resident 6's Minimum Data Set (MDS, an assessment tool), dated 7/1/24 indicated, severe cognitive impairment. During a medication administration observation on 9/11/24 at 8:21 a.m., Licensed Nurse 2 (LN 2) was observed preparing to administer Resident 6's insulin aspart (rapid acting injectable…

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, interview and record review, the facility failed to ensure one of 5 selected residents during medication pass (Resident 6) was free of significant medication errors when a licensed nurse administered insulin aspart, (short acting injectable medication used to lower blood sugar level) not in accordance with physician orders. This failure put the resident at risk for suffering adverse consequences from the medication. Findings: A review of Resident 6's admission Record, Resident 6 was admitted to the facility in early 2023 with admitting diagnosis of Type 2 Diabetes (a long term condition in which the body has trouble controlling sugar in the blood). Resident 6's Minimum Data Set (MDS, an assessment tool), dated 7/1/24 indicated, severe cognitive impairment. During a medication administration observation on 9/11/24 at 8:21 a.m., Licensed Nurse 2 (LN 2) was observed preparing to administer Resident 6's insulin aspart. During a medication administration observation on 9/11/24 at 8:30 a.m. LN 2 administered 2 units of insulin aspart to Resident 6. During 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 observation, interview, and record review the facility failed to ensure medications were properly stored and labeled, when: 1. Medications were not properly stored per manufacturer instruction, 2. Expired and discontinued medications were available for resident use, 3. Loose pills and loose medical supplies were found in the drawers and the back of medication cart and 4. Refrigerated medications were not stored in accordance with facility Policy & Procedure (P&P). These deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage, and diversion or misuse of medications from not being securely stored. Findings: 1. During an inspection of medication cart B on 9/10/24 at 11:00 a.m. alongside Licensed Nurse 4 (LN 4), a bottle of Acidophilus (a supplement that promotes the growth of good bacteria) was found stored in the medication cart. LN 4 confirmed the finding and stated the medication should 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 observation, interview and record review food storage, service and distribution were not completed in accordance with professional standards when: 1. Kitchen vents, fans, and floors were found dirty and/or dusty, 2. Worn food preparation equipment was kept in storage and not discarded when it could no longer be sanitized, 3. Foods in storage found expired, open to the environment, and/or improperly labeled, and 4. Kitchen staff were unable to demonstrate how to test for proper sanitation concentration levels. These failures had the potential to cause food borne illness for the 155 residents receiving facility prepared foods. Findings: 1a.) During the initial kitchen observation on 9/10/24 at 9:01 a.m., the vents in the kitchen ceiling had whitish-gray build-up on the ventilation slats (where air exists the heating and air conditioning unit). 1b.) During the initial tour and on follow up visits on 9/10/24, fans in the kitchen had visible build-up of dirt/dust. 1c.) During an inspection of the storage…

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 4. During a concurrent inspection of medication cart B and interview on 9/10/24 at 11:00 a.m. with Licensed Nurse (LN) 4, food items (a sandwich and an opened pudding) were found stored in the medication cart. LN 4 confirmed the finding and stated the food items should not be stored in the medication cart. LN 4 acknowledged that medication carts should only be used for medications. During a concurrent inspection of medication cart B and interview on 9/10/24 at 11:05 a.m. with LN 4, 3 nail clippers were identified and stored next to eyedrops. LN 4 confirmed the finding and stated that the nail clippers should be clean. LN 4 acknowledged that medication carts should only be used for medications. During an interview on 9/11/24 at 2:40 p.m. with the DON, the DON stated all food items should be in the ice bucket on top of the medication cart. DON further stated that nail clippers should not be stored in medication carts due to sanitary concerns. During review of the facility's P&P titled, Medication Storage 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.

Based on observation, interview, and record review, the facility failed to ensure that one of 37 sampled residents (Resident 119), who was observed with cold and allergy nasal spray at the bedside, was assessed and had an order to self-administer medication. This failure had the potential to result in overmedication for Resident 119 and exposed other residents to accidental access to the nasal spray. Findings: According to admission record, the facility admitted Resident 119 in August 2024 with multiple diagnoses which included chronic lung disease and anxiety. A review of the Minimum Data Set (MDS, an assessment and care planning tool) dated 8/27/24, indicated Resident 119 was cognitively intact and had no memory problems. A review of Resident 119's clinical record contained a document titled, Nursing - Self-Administration of Medication Observation, dated 8/21/24 at 8:52 p.m. The document had the following question, Does resident want to self-administer medications? and the nurse who performed the assessment documented No. There was no further documented evidence indicating…

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, interview, and record review, the facility failed to maintain the resident's right to privacy and confidentiality of personal and medical records for a census of 156 residents when computer screen that showed confidential personal and medical information was left unsecured. This failure had the potential to result in unauthorized access of residents' personal and medical information. Findings: During a concurrent observation and interview on 9/10/24 at 10:58 a.m. in the hallway with the Wound Nurse (WN), a computer in medication cart B was observed open with resident clinical information including resident's picture, name, and medications displayed. Multiple residents and staff were also observed walking in the hallway. The WN came out of a resident's room and confirmed the observation and stated, It's a HIPAA (Health Insurance Portability and Accountability Act - a federal law that protects sensitive health information from being disclosed without consent) violation, this is resident medical information. During an interview on 9/10/24 at 10:59 a.m. 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 interview and records review, the facility failed to ensure one of 37 sampled residents (Resident 119) received treatment and care in accordance with professional standards and practice, when the facility did not follow up on resident's request for allergy medication for six days. This failure resulted in a delay of Resident 119's allergy medication. Findings: According to admission records, the facility admitted Resident 119 in August 2024 with multiple diagnoses which included chronic lung disease and anxiety. A review of the Minimum Data Set (MDS, an assessment and care planning tool) dated 8/27/24 indicated Resident 119 was cognitively intact and had no memory issues. During an observation and interview on 9/11/24 at 8:15 a.m., Resident 119 was sitting on his bed, alert and pleasant. Resident 119 stated that sometimes facility staff ignored him and added, I have a severe allergy. Have been asking [nurses] for medication for days and they keep saying that doctor has not prescribed yet. A review of Resident 119's clinical record contained nursing progress note 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.

Based on observation, interview, and record review, the facility failed to ensure 1 of 37 sampled residents (Resident 138) received necessary services to ensure proper grooming when Resident 138 had black material under her nails. This failure had the potential to cause infection to Resident 138 due to poor hygiene. Findings: A review of Resident 138's admission Record indicated Resident 138 was admitted to the facility in October 2023 with multiple diagnoses including dementia (loss of memory, problem solving, and thinking abilities). A review of Resident 138's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 8/5/24, indicated Resident 138 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 5 out of 15 that indicated Resident 138 had severe cognitive impairment. A review of Resident 138's MDS, Functional Abilities and Goals, dated 8/5/24, indicated Resident 138 required moderate assistance for personal hygiene. During an observation on 9/11/24 at 9:37 a.m. of Resident 138, observed black material under Resident 138's fingernails.…

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, interview and record review, the facility failed to provide an ongoing activity program to meet the needs and interests for one of 37 sampled residents (Resident 44) when the activities care plan was not followed. This deficient practice had the potential to affect the resident's psychosocial well-being, self-worth and meaning in life. Findings: During a review of Resident 44's comprehensive MDS (Minimum Data Set, a clinical assessment tool) dated 2/19/24, the MDS indicated a Brief Interview for Mental Status [BIMS, a tool used to assess cognition (knowing, learning, and understanding things)] was not conducted due to Resident 44 was rarely/never understood. A staff assessment for mental status was performed which indicated Resident 44's Cognitive Skills for Daily Decision Making was severely impaired. It also indicated Preferences for Customary Routine and Activities: listen to music you like, do your favorite activities, and go outside to get fresh air when the weather is good were very important to Resident 44 per family or significant other. During a review…

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, interview, and record review, the facility failed to provide care to maintain vision for one of 37 sampled residents (Resident 143), when Resident 143 was not sent to the hospital for an acute onset vision loss. This failure had the potential to cause deterioration of vision leading to increased fall risk and greater loss of independence. Findings: A review of Resident 143's admission Record indicated Resident 143 was admitted to the facility in January 2024 with multiple diagnoses including dementia (loss of memory, problem solving, and thinking abilities), malignant neoplasm of endometrium (cancer in the lining of the uterus), and diabetes (too much sugar in the blood). A review of Resident 143's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 7/29/24, indicated Resident 143 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 2 out of 15 that indicated Resident 143 was severely cognitively impaired. A review of Resident 143's SBAR [Situation, Background, Assessment, Recommendation] Communication Form…

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, interview, and record review, the facility failed to ensure one of 37 sampled residents (Resident 38) received care and services in accordance with the physician order, when the staff failed to place the hand roll to the resident's right hand. This failure had the potential for Resident 38 to experience a further decline in use of her right hand and loss of ability to feed self independently, and result in skin breakdown. Findings: A review of Resident 38 admission Record indicated the facility admitted the resident in 2016 with multiple diagnoses including muscle weakness. A review of Resident 38's Order Summary Report, dated 11/14/23, contained an active physician order for staff to apply a hand roll or soft cloth in her right hand every shift to prevent further contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joint to shorten and become very stiff). A review of Resident 38's clinical record had no care plan addressing right hand contracture and the use of hand roll daily to prevent decline in her right…

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 interview, and record review, the facility failed to protect one of six sampled residents (Resident 2) from abuse when the hospitality aide [HA] got upset and slapped Resident 2 on the cheek repeatedly. This failure had the potential to cause injury, fear and distress to Resident 2. Findings: During a review of Resident 2's admission record, Resident 2 was admitted in September 2023 with diagnoses that included dementia (loss of thinking, remembering, and reasoning skills), depression (persistent feeling of sadness and loss of interest), muscle weakness, lack of coordination, and need for assistance with personal care. Resident 2's Minimum Data Set (MDS, an assessment tool) indicated Resident 2 had severe cognitive impairment, exhibited physical and other behavioral symptoms not directed toward others, and required supervision or touch cueing assistance while eating. During a review of Resident 2's care plan initiated on 11/30/23, the care plan indicated, The resident is/has potential to be physically aggressive amongst peers r/t Anger, Dementia, Depression, poor impulse…

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 interview and record review, the facility failed to ensure the comprehensive care plan was implemented and monitored for effectiveness for one of six sampled residents (Resident 1) when there was no documented evidence Resident 1's hip protectors were applied as directed by the care plan to minimize the impact of falls. This failure decreased the facility's potential to minimize the serious consequences of falls for the resident. Additionally, Resident 1 had a witnessed fall and sustained a hip fracture. Findings: During a review of Resident 1's admission records, Resident 1 was admitted in [DATE] with diagnoses that included Dementia (loss of thinking, remembering, and reasoning skills), protein calorie malnutrition (reduced availability of nutrients that leads to changes in body composition and function), and unsteadiness on feet. Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had severe cognitive impairment. During a review of Resident 1's progress notes dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the comprehensive care plan was implemented and updated for one of 5 sampled residents (Resident 1) when Resident 1's ileostomy (a surgically created opening in the abdomen to allow waste to leave the body through a new skin opening called the stoma) bag was leaking. This failure resulted to increased redness and irritation to Resident 1's ileostomy site and surrounding skin. Findings: A review of the admission RECORD indicated Resident 1 was admitted with diagnoses including dementia (loss of ability to think, remember, and make decisions), Crohn's disease (causes swelling in the lining of the digestive tract), and ileostomy status. A review of Resident 1's physician's orders indicated the following: - Abdominal binder as resident allows was ordered on 6/23/23; and -update tx:Right Ileostomy dermatitis (inflammation of the skin) cleans skin with saline [NAME] guze (sic) only, avoided adhesive dressing, use hydrocolloid (waterproof dressing,…

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, interview, and record review, the facility failed to ensure the fluid intake for one of 8 sampled residents (Resident 8) was accurately monitored and communicated to the physician. This failure increased the potential for Resident 8 to experience signs of fluid overload (too much fluid in the body) such as swelling of the feet and weight gain. Findings: A review of the admission Record indicated Resident 8 was admitted in 12/2023 with diagnoses including dementia (progressive decline affecting how a person thinks, behave and perform everyday tasks) with behavioral disturbance and chronic congestive heart failure (a heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of Resident 8's physician's orders indicated the following: - Fluid Restriction 2000 ml [milliliters, unit of measurement] or 2 liters per 24 hours [per day] dated 3/8/24; and - Fluid Restriction 1000 ml (1 Liter) per day dated 4/13/24. A review of Resident 8's electronic Medication Administration Record (eMAR) indicated the following fluid intake: - The…

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

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from mental abuse by facility staff for one of four sampled residents (Resident 1) when facility staff took a picture of Resident 1 with an unsecured facility cell phone while Resident 1 was lying the floor with his pants around his ankles, without undergarments, and trying to cover his naked buttocks with the edge of his nightshirt. This failure portrayed Resident 1 in an undignified manner and had the potential for multiple staff members, other residents and family members, to view the photograph, which could cause mental anguish to Resident 1. Findings: Resident 1 was admitted to the facility mid-2024 with diagnosis which included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder, lack of coordination, muscle weakness, and anxiety disorder. Resident 1 was not his own responsible party (RP). During a review of Resident 1's Face Sheet (FS, a document that contains patient information), the…

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

Based on observation, interview, and record review, the facility failed to notify the responsible party (RP) and physician for one of four sampled residents (Resident 1) when Resident 1 had an unwitnessed fall, which resulted in bleeding and an injury to the lip. This failure delayed prompt medical monitoring, treatment and left the family unaware of the situation. Findings: Resident 1 was admitted to the facility in mid-2024 with diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder, lack of coordination, muscle weakness, and anxiety disorder. Resident 1 is not his own responsible party. During a review of Resident 1's Face Sheet (FS, a document that contains patient information), the FS indicated a family member was the RP. During a review of Resident 1's Order Summary Report [OSR], dated 7/2/24, the OSR indicated, Resident does not have the capacity to make his/her own decisions related to Alzheimer's. During a review of Resident 1's BRIEF INTERVIEW FOR MENTAL STATUS [BIMS], 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.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was monitored timely for neurological changes (injury or changes that result from an injury to the head that affect the brain) after an unwitnessed fall. This failure had the potential for Resident 1 to have neurological deterioration that was not assessed or monitored by staff. Findings: Resident 1 admitted to the facility mid-2024 with diagnoses which included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder, lack of coordination, muscle weakness, and anxiety disorder. Resident 1 was not his own responsible party. During a review of Resident 1's Face Sheet (FS, a document that contains patient information), the FS indicated a family member was the responsible party (RP). During a review of Resident 1's Progress Notes [PN], dated 6/15/24 at 10:00 a.m. the PN indicated, Called [name of after hour hospital service] for reporting Fall (sic) from last night . During a review of Resident 1's…

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

Based on interview and record review, the facility failed to ensure the representative or Responsible Party (RP) was informed of the skin discoloration for one resident (Resident 1), for a census of 155. This failure resulted in Resident 1's RP not being informed of the skin changes. Findings: A review of Resident 1's clinical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that affects memory, thinking, and behavior) and Bipolar II disorder (pattern of depressive episodes [sadness or hopelessness] and hypomanic episodes [persistently elevated or irritable mood]). A review of Resident 1's 'Nurse's Note' dated 5/24/24 at 08:24, indicated, .RP was very [sic] expressing her concerns that [Resident 1] has bruises on her arm from wrist to her neck . This note was written by the Director of Nursing (DON). A review of Resident 1's '72-hour Charting' dated 5/23/24 at 16:46 [4:46 p.m.]' indicated, Body skin assessment done: Res [Resident 1] has scattered old purplish discoloration to bilateral forearms. Lt [left] forearm…

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, interview, and record review, the facility failed to provide supervision to ensure safety for 2 of 3 sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 had a verbal and physical altercation in the back yard. This failure resulted in Resident 1 sustaining a scratch on the cheek and Resident 2 had skin tear to left hand. Findings: A review of Resident 1's clinical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a progressive disease that affects memory, thinking, and behavior) and Bipolar II disorder (pattern of depressive episodes [sadness or hopelessness] and hypomanic episodes [persistently elevated or irritable mood]). A review of Resident 1's SBAR [Situation, Background, Appearance, Review and Notify] dated 5/23/24, indicated, .Was told by staff that [Resident 1] had a verbal altercation with [Resident 2] that turned into physical altercation. [Resident 2] was yelling at the] [Resident 1] and pulled her hair and slapped her on the face. Staff was then able to separate residents away…

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

Based on observation, interview and record review, the facility failed to follow infection control standards of practice for Resident 1 when the indwelling catheter (tube placed into bladder to collect urine) bag was lying on the floor under resident's bed. This failure decreased the facility's potential to prevent the spread of infection. Findings: Resident 1 was admitted to the facility early 2024 with diagnoses which included obstructive and reflux uropathy (a urinary tract disorder that causes obstructed flow of urine). A review of Resident 1's Order Summary Report [OSR] dated 4/10/24, the OSR indicated, .Secure indwelling catheter tubing using anchoring device to prevent movement and urethral traction. A review of Resident 1's Care Plan Detail [CP], dated 2/18/24, revised 3/13/24, the CP indicated, The resident has an Indwelling [brand name of urinary catheter] .[resident] will have no complications or infections related to urinary device .will show no signs/symptoms of urinary infection through review date .ensure there is no dependent looping of catheter tubing. In 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.

Based on observation, interview, and record review the facility failed to maintain nail care for one Resident (Resident 8) of eight sampled residents, when Resident 8's toenails were long, cracked and unevenly trimmed. This failure decreased the facility's ability to assist Resident 8 to reach his highest practicable level of well-being. Findings: A review of Resident 8's admission record indicated Resident 8 was admitted to the facility in the summer of 2018 with diagnoses which included dementia (impaired ability to remember, think, or make decisions). A review of Resident 8's Care Plan, dated 6/6/23, indicated Resident 8 had activities of daily living (ADL) self-care performance deficit related to confusion and dementia. The care plan further indicated Resident 8 required ADL assistance by the CNA (Certified Nursing Assistant) staff. During an observation on 1/3/23 at 11 a.m. in Resident 8's room, Resident 8's toenails were long, uneven and had rough edges. During an interview on 1/3/23 at 11:10 a.m. with Certified Nursing Assistant 2 (CNA 2), the CNA 2 confirmed Resident 8's…

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

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of four sampled residents (Resident 1), when baseline care plan did not identify the resident as an elopement risk and there was no frequent monitoring and supervision included in the care plan interventions. This failure resulted in Resident 1 leaving the facility and not attaining his highest practicable well-being. Findings: Resident 1 was admitted in late 2023 with diagnoses which included unsteadiness of feet, lack of coordination, depression, and cognitive communication deficit. During a review of a document titled, Nursing - Elopement Risk Observation/Assessment, dated 11/20/23, the document indicated, If total score is greater than 10, the Resident would be considered to be At Risk for Elopement .The Resident has made 1 or more attempts in the last year. The Elopement Risk Score was 22. During a review of Resident 1's Nursing Care Plan (NCP) dated 11/20/23, the NCP indicated, Elopement: Resident is at risk for elopement/exit seeking related 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.

Based on observation, interview and record review, the facility failed to provide safety monitoring and supervision for one of four sampled residents (Resident 1), when the resident jumped off the fence of the facility and has not been located. This failure had the potential to result in Resident 1's harm, including accidents, falls and injuries. Findings: Resident 1 was admitted in late 2023 with diagnoses which included unsteadiness of feet, lack of coordination, depression, and cognitive communication deficit. During a review of a document titled, Nursing - Elopement Risk Observation/Assessment, dated 11/20/23, the document indicated, If total score is greater than 10, the Resident would be considered to be At Risk for Elopement .[Resident 1] is fully ambulatory .wanders aimlessly .has made 1 or more attempts in the last year. The Elopement Risk Score was 22. During a review of Resident 1's Nursing Care Plan (NCP) dated 11/20/23, the NCP indicated, Elopement: Resident is at risk for elopement/exit seeking related to history of elopement and unspecified depression .Allow wandering…

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 interview and record review, the facility failed to create a comprehensive person-centered care plan for 1 of 2 high risk elopement residents (Resident 1), when interventions to prevent elopement were not developed and implemented for Resident 1. These failures resulted in an avoidable elopement from a secured locked facility, (locked memory care units provide a place for residents with any type of dementia/memory problems to live safely, with increased supervision and support as their diseases progress), compromising the health and safety of Resident 1. Findings: During a review of Resident 1's admission record and a concurrent interview with the Director of Nursing (DON) on 8/24/23 at 12:30 p.m., the admission record indicated, Resident 1 was readmitted to the facility on [DATE], with diagnoses including, dementia (memory problems) with behavior disturbance, lack of coordination, and heart failure. In a concurrent interview with the DON, the DON stated Resident 1 was formerly living in an unsecured,…

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 interviews and record review, the facility failed to provide the necessary supervision Resident 1 required to ensure his safety when Resident 1 eloped from the facility's Behavior Intervention Monitoring Program Room (BIMP, a program designed to provide supervision of specific behaviors which are based on an evaluation from a psychiatrist). This failure resulted in Resident 1's elopement and increased the potential for physical injury and psychosocial harm to Resident 1 during his unsupervised time away from the facility. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in April 2023 with diagnoses which included dementia (a loss of memory and problem-solving abilities which interfere with daily life), generalized muscle weakness, difficulty walking, and a lack of coordination. This admission record also indicated Resident 1 was not his own Responsible Party (RP). A review of Resident 1's discharge paperwork upon admission to the facility from the hospital included a history and physical note from the hospital, dated 2/12/23, which…

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

Based on observation, interview, and record review, the facility failed to ensure staff were adequately trained and had competency skill sets to provide services to ensure the safety of one of two residents, (Resident 1), when Resident 1 had signed out of the Behavioral Intervention Monitoring Program (BIMP) room, had no supervision, and eloped the locked facility. This failure had the potential for more than minimal harm for one of two residents, (Resident 1), when an unsupervised elopement occured in a locked facility by Resident 1. Findings: During a review of the admission record for Resident 1 on 8/24/23, the record indicated, Resident 1 was readmitted to the facility in July 2023 with diagnoses including, dementia (memory problems) with behavior disturbance, lack of coordination, generalized muscle weakness, confusion, and heart failure. During a review of the original admission Minimum Data Set (MDS-assessment tool) on 8/24/23 at 11 a.m. for Resident 1, the record was dated 4/19/23, and indicated, Resident 1 required supervision with bed mobility, transfers, grooming 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 observation, interview, and record review, the facility failed to provide a safe environment when one of three sampled residents (Resident 1) did not have adequate supervision and had two falls in three months. This failure resulted in Resident 1 experiencing head injuries that possibly caused a subdural hematoma [a pool of blood between the brain and its outermost covering] necessitating a hospital stay. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in December 2022 with multiple diagnoses including Alzheimer's disease (disease that destroys memory and other mental functions), chronic kidney disease (loss of function of the kidneys, do not filter the blood the way they should), and diabetes (too much sugar in the blood). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 6/26/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 0 out of 15 that…

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

Based on observation, interview, and record review, the facility failed to fully establish and implement an infection prevention and control (IPC) program for a census of 108 residents when: 1. There was no documented evidence of an IPC plan; 2. There was no documented evidence of a system of active infection surveillance for all types of infections in the facility to prevent the occurrence or spread of infections; 3. There were no investigations into the potential causes or contributing factors of facility-acquired infections; and, 4. There was no documented evidence of a system for process surveillance used to develop the facility assessment and IPC plan. These failures increased the potential for residents to have acquired infections that could have caused significant pain and discomfort, and could have had significant adverse consequences. Findings: During an interview with the Infection Preventionist (IP, person designated by the facility to be responsible for the IPC program) on 7/7/21, at 2:45 p.m., when asked about the facility-specific IPC plan (a plan designed to prevent,…

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, and facility policy review, the facility failed to ensure two residents (Resident 96 and Resident 4) out of a sample of 33 were treated with respect and dignity when: 1a. A Licensed Nurse (LN) 1, without notifying Resident 96 beforehand, removed Resident 96's covers exposing him; 1b. A Certified Nurse Assistant (CNA) pulled Resident 96 in his recliner chair from behind into his room, and fed him his dinner while standing over him from behind; and, 2. Staff gave Resident 4 a wash basin to store his belongings instead of providing the resident a nightstand. These failures resulted in Resident 96 and Resident 4 receiving undignified care and had the potential to negatively effect their psychosocial well-being. Findings: Review of a facility policy titled Resident Rights, dated 12/16, indicated, Employees shall treat all residents with kindness, respect, and dignity. 1. Review of Resident 96's admission Record indicated he admitted to the facility in March of 2018. A Minimum Data Set…

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 and interview, the facility failed to ensure one resident (Resident 17) in a sample of 33 had an environment that was free from hazards when staff left a pool of urine on the floor under Resident 17's bed with an electrical cord running through it. This failure had the potential to result in an accident leading to potential harm. Findings: During an observation of Resident 17 on 7/6/21, at 10 a.m., there was a smell of urine coming from Resident 17's room. Resident 17 was sitting in a wheelchair between his bed (Bed B) and his roommate's bed (Bed C, Resident 44) with his eyes closed. There was a pool of clear liquid under Bed B that reached out from under the bed to the left side of the bed. The electrical cord that powered the low air loss mattress pump on Bed B lay in the pool of liquid and was connected to the electrical outlet. Resident 44 was sitting in a chair in the hallway outside of their room. During a concurrent observation and interview with Certified Nurse Assistant (CNA) 1 and CNA 4 on 7/6/21, at 10:15 a.m., in Resident 17's room, CNA 1 and CNA 4…

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

Based on observation, interview, and record review, the facility failed to provide basic furniture to meet the needs of one resident (Resident 4) in a sample of 22 when Resident 4 did not have a nightstand to store his personal items. This failure resulted in Resident 4 storing his items in a plastic wash basin on the floor. Findings: Review of Resident 4's admission Record indicated he was admitted to the facility in the Spring of 2021. A Minimum Data Set (MDS, a nursing assessment tool), dated 3/26/21, indicated Resident 4 required supervision with mobility and activities of daily living (eating and toileting). During an observation of Resident 4's room on 7/6/21, at 10:40 a.m., Resident 4 was sitting in a chair next to his bed. There was no nightstand next to Resident 4's bed. On the floor next to him were his shoes and a rectangular, plastic wash basin, which contained Resident 4's personal items. During a concurrent observation and interview with CNA 1 on 7/6/21, at 10:50 a.m., CNA 1 confirmed Resident 4 did not have a nightstand for his personal belongings. CNA 1 stated she…

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.