Katherine Healthcare

Based on observation, interview, and record review, the facility failed to ensure to implement comprehensive person-centered care plan for two of 14 sampled residents (Resident 4 and 29) when:Bilateral (both) heel boots were not applies while in bed for Resident 4;Floor mat (padded mat to reduce the risk of serious injury from fall) was not placed while Resident 29 was in bed. Above these failures had potentially affect Resident 4 and 29 's quality of care for prevention of pressure ulcer and injury in the facility. Findings: 1. During a review of Resident 4's physician order dated 4/29/25, it indicated, Keep weight off heels: use heel boot on right foot while in bed and check placement every shift (QS). During a review of Resident 4 's care plan for the potential impairment to skin integrity, revised on 8/6/25, care plan indicated, Boots to heels when in bed for preventative measure. During an observation on 09/02/2025, at 10:19 a.m., Resident was in bed and there were bilateral boot left on the bedside table. No pillow under her feet for offloading pressure for both feet.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 to provide a restorative nurse assistant (RNA, a nursing program to increase and/or to prevent decrease in range of motion [ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point] exercise) program for one of 14 sample resident (Resident 4 ). Above this failure had the potential to result in further decline of ROM for sample Resident 4. Findings: 1. During a review of Resident 4's clinical record indicated she had diagnoses including Parkinson disease (a brain disorder that causes problems with movement, such as tremors (shaking), stiffness, and slow movement) and muscle weakness (a lack of muscle strength). Review of Resident 4's minimum data set (MDS, an assessment tool) assessment dated [DATE], she was totally dependent on her activities of daily living (ADL, such as eating, grooming, dressing, walking, transferring, and toileting). Resident 4 had impaired ROM on both sides of upper 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 interview and record review, the facility failed to ensure one out of 18 sampled resident (Resident 5) was appropriately treated for a urinary tract infection (UTI, an infection of the bladder [body organ that collects urine] which causes burning while urinating, abdominal pain and blood in the urine) with an appropriate medication as ordered by the physician. This failure had the potential for further progress of UTI and affect Resident 5's overall health condition.Findings:Review of Resident 5's clinical record indicated he was admitted on [DATE] with diagnoses including acute kidney failure (failure of the kidneys [pair of organs that produces urine], due to an outside cause such as other diseases or infection), hepatorenal syndrome (a complication of advanced liver [a large organ in the digestive system] disease that affects the kidneys), spontaneous bacterial peritonitis (an infection in the abdominal area due to bacteria) and Unspecified Cirrhosis (destruction of healthy liver tissue). 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 residents receiving dialysis (medical treatment that filters blood to remove waste and excessive fluids from body to sustain life) treatment received care consistent with professional standards for two of three sampled residents (Resident 3 and 35) when:1. Inadequate communication from dialysis center (a place which provides dialysis treatment) to nursing facility for Resident 3; 2.Order for milk of magnesia (MOM: medication used to treat constipation [problem with passing stool]) for Resident 3 with dialysis status;3.Antibiotic (medication used to treat infection) order was not discontinued as ordered for Resident 3;4.No documented evidence for side effects (S/E, unwanted or unexpected effects that occur when taking medication) monitoring for use of antibiotic medications x2 for Resident 3;5.Dialysis emergency kit (to prepare for emergency where regular dialysis treatments may be unavailable to manage condition) not available 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 interview and record review, the facility failed to ensure accurate accountability of controlled substances (that can be easily abused and are under strict government control) when controlled medications were signed out of the controlled drug record (CDR, an accountability sheet of controlled medications) but not documented on the medication administration record (MAR) to show they were administered for 2 out of 4 residents (Residents 54 and 55). This resulted in facility not having accurate accountability and the potential for abuse/loss of controlled medications.Findings: During the survey, the CDRs for 4 residents receiving as-needed medications were requested for review.During a concurrent interview and record review with the Director of Nursing (DON) and Registered Nurse (RN) A on 9/3/25 at 10:37 a.m., the DON stated whenever an as needed controlled medication is requested by a resident, the nursing staff needs to assess the resident, remove the medication from the medication cart, sign it out of…

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

Based on observation, interview, and record review, the facility had a medication error rate of 7.89% when three medication errors occurred out of 38 opportunities during the medication administration for three out of six residents (Residents 3, 27, and 35). Resident 35 did not receive calcium acetate (brand name: Phoslo; medication to treat high phosphate in the blood, in patients with end stage kidney disease) as in accordance with the manufacturer's specifications; Resident 27 received an insulin (medication to lower blood sugar) injection not in accordance with the manufacturer's specifications; and Resident 3 did not receive his metoprolol (medication to treat high blood pressure [BP]) as ordered.The failures resulted in the residents not receiving medications as prescribed or per manufacturer's specifications, which had the potential for complications of their medical conditions (such as high phosphate level, high blood sugar, or high BP).Findings: 1. During a medication administration observation with Registered Nurse (RN) A on 9/2/25 at 10:25 a.m., RN A was observed…

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 to conserve nutritional food value and palatability for one of 42 sampled resident (Resident 47), when:1. Resident 47 stated vegetables were soft, mushy and overcooked;2. A test tray for cooked vegetable was soft.This failure had the potential to compromise nutritional quality and palatability of meals for sampled resident 47.Findings: 1.During an initial room rounds on 9/2/2025 at 11:10 a.m., Resident 47 stated food in facility horrible, bland, no taste, veggies served soft, mushy and overcooked. Review of Resident 47's face sheet (FS: a document that gives resident's information at a quick glance) indicated Resident 47 was admitted to facility on 7/14/2024. Review of Resident 47's minimum data set (MDS: clinical assessment tool) assessment dated [DATE] indicated Resident 47's brief interview for mental status (BIMS) score of 13 (score of 0-7: severe cognitive impairment, 8-12: moderate cognitive impairment, 13-15: intact…

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 proper use of bed or side rails (adjustable rigid bars attached to the side of a bed) for five (Residents 26, 145, 194, 17, and 4) of five sampled residents (residents who used bed or side rails) when: 1. There was no documentation that indicated the facility followed the manufacturers' recommendations and specifications for installation and maintenance of the facility's beds and side rails for five of five sampled residents (Residents 26, 145, 194, 17, and 4); 2. There was no documentation that indicated alternatives were offered and/or attempted prior to the use of bed or side rails for three of five sampled residents (Residents 194, 17, and 4); 3. There was no documentation that indicated an entrapment risk assessment was completed prior to the use of bed or side rails for two of five residents (Residents 17, and 4); 4. There was no updated bed or side rail assessment form completed for one of five residents (Resident 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 and interview, the facility failed to maintain hygiene in the kitchen and to ensure food was stored in accordance with professional standards for food safety when: 1. Past use-by date food, rotten bananas, and dented cans were found in the freezer and on the shelves in the kitchen; 2. [NAME] K's (CK K) and dietary aid L's (DA L) hair were out of their hair nets; the maintenance director (MD) did not wash his hands when he entered the kitchen and opened the ice machine; the dietary director (DD) did not sanitize the thermometers before checking the food temperatures; and, 3. The screw in the ice storage bin was rusty with rusty water that dripped down onto the ice, and the ice machine did not have an air gap. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illnesses and cross-contaminated food for residents eating at the facility. Findings: 1. On 4/22/24 at 9:25 a.m., during an observation of the ice cream freezer, walk-in freezer, and the storage shelves in the kitchen, with the Dietary Director (DD), 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 implement infection control practices when: 1. Licensed vocational nurse A (LVN A) picked up clean gauges and Silver Alginate (a sterile dressing for wounds with moderate to heavy exudate that helps prevent infection of wounds while providing optimum environment to facilitate healing) with her contaminated gloved hands for the treatment of Resident 9's wound; 2. Certified nursing assistant H (CNA H) did not sanitize her hands before serving a lunch tray to Resident 35; 3. LVN A went to Resident 17's room wearing the same gloves that she wore to give insulin to Resident 195, and then walked out of Resident 17's room with the same gloves on; 4. Restorative nurse assistant (RNA) did not perform hand hygiene in between residents during meal assistance; 5. Licensed vocational nurse C (LVN C) touched the privacy curtain with dirty gloves, did not change gloves afterwards, and continued to used her contaminated gloves for wound treatment; 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 interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for four of 13 sampled residents (Residents 34, 27, 17, and 7) when: 1. Resident 34's two different MDS assessments did not reflect the following: hospice care, facility acquired pressure injury (PI, damage to the skin caused by prolonged pressure), nutritional intervention, and the physician orders for life-sustaining treatment (POLST, a tool for end-of-life planning); 2. Resident 27's behavior of rejection of care was not reflected in the MDS assessment; 3. Resident 17's left sided weakness was not reflected in MDS assessment; and, 4. Resident 7's behavior of rejection of care was not reflected in MDS assessment. These failures resulted in inaccurate MDS assessments, which had the potential to affect the residents' care. Findings: 1. During a concurrent interview and record review on 4/25/2024 at 10:17 a.m., minimum data set coordinator (MDSC, licensed nurse in charge of the assessment)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents received the necessary care and services for six of 13 residents (1, 7, 9, 22, 27,145 ) when: 1. Licensed vocational nurse A (LVN A), who worked with Resident 1 for a year, did not know Resident 1 had a pacemaker (a small battery-operated device that helps the heart beat in a regular rhythm); the facility did not have information on Resident 1's cardiologist and pacemaker, and did not schedule for Resident 1's pacemaker to be checked; 2. Resident 7 refused vitamin D3 4000 international unit (IU), cyanocobalamin (a manufactured version of vitamin B12) 1000 micrograms (ug, a metric unit of mass), and levothyroxine (used to treat an underactive thyroid gland which is a gland located beneath the voice box) 75 ug multiple times, and her refusals were not reported to the physician; 3. LVN A did not follow the physician order for the treatment of Resident 9's suspected deep tissue injury (SDTI) on his second, third, and fourth left toes;…

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 daily staffing information posted was the current date. This failure had the potential to result in nurse staffing misinformation to residents, families, and visitors. Findings: During facility rounds on 4/22/2024 at 11:42 a.m., the Census and Direct Care Service Hours Per Patient Day (DHPPD-a form containing daily staffing information) form was posted in front of the nurse station located in the facility's first floor, dated 4/5/2024 (17 days past). During facility rounds on 4/22/2024 at 11:45, on facility's second floor, the DHPPD form was posted at the hallway beside the charting room, dated 4/2/2024 (20 days past). During an interview with director of staff development (DSD) on 4/24/2024 at 8:40 a.m., DSD stated she was the one in charged to initiate, post, and update the DHPPD postings. DSD further stated DHPPD posting should have the current date. DSD confirmed the DHPPD posted on 4/22/2024 was outdated. DSD stated she was on vacation, and nobody updated the DHPPD posting. During an interview…

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 drug regimen review were done and acted on for three out of five residents (Resident 11, 15, and 31) when 1. Interim Medication Regimen Review (iMRR, a medication regimen review done when a resident had significant changes prior to the monthly drug regimen review) was not done for Resident 11 after multiple episodes of falls; 2. Consultant Pharmacist (CP) failed to identify and report irregularities related to a lack of monitoring of the blood pressures (BP, the pressure of blood on the walls of the arteries as the heart pumps blood) and heart rates of Resident 11 and Resident 15; and, 3. The facility did not act on the pharmacist's recommendation to administer Coreg (used to treat high blood pressure and a condition in which the heart cannot pump enough blood to all parts of the body) 3.125 milligrams (mg, a metric unit of mass) with food for Resident 31. These failures had the potential for residents experiencing possible adverse effects 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 ensure resident's needs were accommodated for one of five sampled residents (Resident 17) when Resident 17's urinal (a container used to collect urine) was not within reach to use. This failure resulted in Resident 17 to not be able to reach his urinal. Findings: Review of Resident 17's admission Record indicated, Resident 17 was admitted to the facility with diagnoses including urinary tract infection (UTI, an infection caused by a bacterium (germs) that get into the bladder or kidneys (a pair of organs that are found on either side of the spine, just below the rib cage in the back)), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hemiplegia (paralysis of one side of the body/a severe or complete loss of strength in the arm, leg, and sometimes face on one side of the body) affecting nondominant side (part of the body not used as much as, or does not have as much effect as)…

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 their abuse policy for two of three residents (Resident 19 and 146) when Resident 19 had an allegation of verbal abuse, and Resident 146 had allegation of financial abuse, but the allegations were not reported to the Adult Protective Services (APS). This failure left APS unaware of these allegations of abuse. Findings: 1. Review of Resident 19's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Dysarthria (difficulty speaking) and Anarthria (complete loss of speech), Depression (a mood disorder) , Insomnia due to other mental disorder , Schizophrenia ( a mental disorder characterized by disruptions in though processes , perceptions, emotional responsiveness). Review of SOC 341 (form used for reporting elder/dependent adult abuse) sent by the facility to the Department, dated 2/16/23, indicated Resident 19 alleged that a Certified Nurse Assistant (CNA) made a joke on stating…

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 follow their policy and procedure to obtain a hospice admission order for one of two sampled residents (Resident 41) when Resident 41's admission orders had no indication of a hospice order. This failure had the potential to affect Resident 41's well being and care. Findings: Review of Resident 41's admission Record indicated, Resident 41 was admitted to the facility with admitting diagnosis of encounter for palliative care (a specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), atherosclerotic heart disease of native coronary artery (a plaque buildup [fat deposits] in the wall of the arteries that supply blood to the heart), hemiplegia (paralysis of one side of the body/a severe or complete loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) following…

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 complete and transmit the Minimum Data Set (MDS, an assessment tool) discharge assessment in a timely manner for one of three residents (Resident 12). This failure resulted in Resident 12's discharge assessment not being transmitted and received by the Center for Medicare and Medicaid System (CMS) within the time requirement. Findings: Review of Resident 12's admission Record indicated, Resident 12 was admitted to the facility on [DATE] and was discharged on 1/10/2024. During a concurrent interview and record review on 4/26/2024 at 9:35 a.m., minimum data set coordinator (MDSC, a licensed nurse in charge of completing an assessment) reviewed Resident 12's list of MDS assessments. MDSC confirmed she completed and transmitted Resident 12's MDS discharge assessment on 4/22/2024. MDSC stated the director of nursing (DON) signed the completion of the discharge assessment on 4/22/2024. MDSC confirmed she was late in the completion and submission of 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 interview and record review, the facility failed to ensure a pre-admission screening and resident review (PASARR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurately completed for two of 13 sampled residents (Residents 27 and 21). These failures had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability, or related conditions. Findings: 1. Review of Resident 27's admission Record indicated, Resident 27 was admitted to the facility with diagnoses including pneumonia (infection of one or both lungs), bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and other psychoactive substance abuse (a patterned use of a drug 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 ensure that proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for one of two sampled residents (Resident 15) when Resident 15's physician order for oxygen administration was not followed. This failure had the potential to result in complications related to improper treatment while receiving O2 therapy. Findings: Review of Resident 15's admission Record indicated, Resident 15 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe), chronic respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), chronic diastolic heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and dependence on supplemental oxygen. Review of Resident 15's Order Summary Report, indicated Resident 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 interview, and document review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis on weekends based on, Census and Direct Care Service Hours Per Patient Day (DHPPD, a form containing daily staffing information). This failure had the potential to affect resident's care, health, and psychosocial wellbeing. Findings: Review of a document titled, DHPPD, from January through March 2024, indicated the following dates with Actual Certified Nursing Assistant (CNA) DHPPD were below 2.4: 1/6: 2.28 and 1/7: 2.39. Further review revealed on 2/17/2024 the actual DHPPD was 3.35 (3.5 required staffing) and the actual CNA DHPPD was 2.35. During an interview with the director of staff development (DSD) on 4/29/2024 at 9:13 a.m., DSD confirmed she did the DHPPD calculation. DSD stated their director of nursing (DON) did the licensed nurses schedule and CNA J did the CNA schedule. DSD further stated, CNA J did the staffing on weekends as well. DSD confirmed the actual DHPPD should be 3.5 and the actual CNA DHPPD should be 2.4. During a concurrent interview…

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 hazardous medications (medications that known to cause harm) were handled correctly and the safe and effective use of medications for two out of five (Resident 145 and 10) sampled residents when: 1. Two out of two licensed nurses were not knowledgeable on handling hazardous medications. This failure had the potential of harmful exposure for the staff through skin absorption. 2. Resident 145 received ferrous sulfate (iron, for prevention/treatment of iron deficiency anemia) tablet and magnesium oxide (medication used to relieve heartburn) tablet at the same time every day, when the co-administration could lead to decreased absorption of iron. This failure had the potential for the resident to not receive the amount of prescribed iron supplement as needed. 3. Resident 10 received ferrous sulfate and Calcium-Vitamin D (a medication used to prevent or treat low blood calcium levels) at the same time. This failure had the potential for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two out of five residents (Resident 11 and Resident 15) were free from unnecessary medications when: 1. An order for Carvedilol (a medication to treat high blood pressure and heart failure) did not include hold parameters (a fixed limit on when a medication should be given or held) relevant to blood pressure (bp, the pressure of blood on the walls of the blood vessels as the heart pumps blood) and heart rate for Resident 15. 2. An order for gabapentin (a medication to treat seizures) had an incorrect indication for Resident 11. 3. An order for amiodarone (a medication used to treat life-threatening heart rhythm problems) did not include heart rate monitoring for Resident 11. These failures had the potential for inadequate care and side effects of these medications to go undetected or recognized for timely intervention. Findings: 1. A review of Resident 15's physician order dated 4/25/24, indicated, Carvedilol 6.25 mg tablet Give 1…

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 one of five sampled residents (Resident 11) was free from unnecessary psychotropic medications (medications that cause changes in mood, feelings, or behavior) when: 1. Evaluation or Gradual Dose Reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose) of psychotropic medications was not considered after multiple falls. 2. There was no baseline Abnormal Involuntary Movement Scale (AIMS, a rating scale designed to measure involuntary movements which are side effects of long-term treatment of antipsychotic medications) for the use of aripiprazole (a medication used to treat mental/mood disorders). 3. Care plan for bipolar disorder (a mental health condition that causes extreme mood swings) did not include specific target symptoms, interventions, and potential adverse effects. These failures had the potential for increased risks associated with the use of psychotropic medications that include,…

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 had an 11.11% medication error rate when three medication errors out of 27 opportunities were observed during a medication pass for two out of five sampled residents (Residents 145 and 38) when: 1. Carvedilol (a medication to treat high blood pressure) tablet was not administered with food for Resident 145. Magnesium oxide (a medication used to treat heartburn) tablet and ferrous sulfate (an iron supplement) tablet were given at the same time for Resident 145. 2. Metformin (a medication used to treat high blood sugar) tablet was not administered with food for Resident 38. These deficient practices resulted in medications not given in accordance to manufacturer's specifications, which may result in unsafe and/or less than optimal therapeutic effect of the medications. Findings: 1. During a medication pass observation with Licensed Vocational Nurse (LVN) B on 4/22/24 at 9:46 a.m., LVN B was prepared 12 medications for Resident 145, which included Carvedilol 25 milligrams (mg, unit of measurement) tablet, magnesium oxide…

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 proper medication storage and labeling of medications when: 1. An opened multi-dose insulin (a medication used to control high blood sugar) vial and an insulin pre-filled pen were found without labelling for their open dates. 2. An expired insulin pen and four expired over-the-counter medications were found. These failures had the potential for residents to receive medications with reduced efficacy. Findings: 1. During concurrent observation and interview regarding a Station 2 medication cart with licensed vocational nurse (LVN) C on [DATE] at 1:49 p.m., an opened multi dose vial of insulin was found without open date label. LVN C verified the manufacturing label indicated Discard unused portion 31 days after first opening. During concurrent observation and interview regarding a Station 1 medication cart with licensed vocational nurse (LVN) B on [DATE] at 3:10 p.m., a pre-filled insulin pen was found without an open date label. LVN…

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 maintain accurate and systematically organized documentation in accordance with accepted professional standards and practices for one of five sampled residents (Resident 41) when Resident 41's pronouncement of death was not properly documented. This failure resulted to an inaccurate documentation of Resident 41's death. Findings: Review of Resident 41's admission Record indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses including encounter for palliative care (a specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), atherosclerotic heart disease of native coronary artery (a plaque buildup [fat deposits] in the wall of the arteries that supply blood to the heart), hemiplegia (paralysis of one side of the body/a severe or complete loss of strength in the arm, leg, and sometimes face on one side of the body), and hemiparesis (a relatively mild loss of strength in the arm,…

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 two of six residents (Residents 10 and 35) were offered and/or received pneumococcal (common bacteria that can affect different parts of the body) vaccinations. This failure increased the potential for residents to have inadequate immunity to pneumococcal infections (also known as pneumonia, an infection of one or both lungs). Findings: During a concurrent interview and record review on 4/29/2024 at 11:28 a.m., infection preventionist G (IP G) reviewed Resident 10's admission and immunization records. IP G confirmed Resident 10 was admitted on [DATE] and that she had a history of getting the pneumococcal polysaccharide vaccine (PPSV23, a vaccine that can prevent pneumococcal disease) on 6/26/2022. IP G confirmed she missed offering the pneumococcal conjugate vaccine 20 (PCV20, one of the three pneumococcal conjugate that helps protect against bacteria that cause pneumococcal disease) to Resident 10 when she reviewed Resident 10's immunization…

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 follow its abuse reporting policy for one of four sampled residents (Resident 1). This failure resulted in an incident of abuse not being investigated and had the potential to compromise the safety of the residents in the facility. Findings: Review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] and had diagnoses including major depressive disorder (a mental condition characterized by long-term loss of interest or pleasure in life) and bipolar disorder (a mental health condition that causes extreme mood swings). Review of Resident 1's Progress Notes, dated 4/29/23, indicated licensed nurse A (LN A) witnessed Resident 1 yelling and cursing at another resident. The Progress Notes indicated Resident 1 then pushed the other resident's wheelchair with such force that the wheelchair rolled approximately 20 feet before coming to rest. Resident 1 then yelled, And don't come back! There was no documentation that indicated LN 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 interview and record review, the facility failed to follow up on the physician's order for one of three sampled residents (Resident 1) when they did not complete the referral for a urology (a part of health care that deals with diseases of the urinary tract) appointment. This failure had the potential to result in the delayed provision of Resident 1's urology needs and may result in worsening urology problems. Findings: Review of Resident 1's clinical record indicated he was admitted on [DATE] with diagnoses including urinary tract infection (UTI, bladder infection), benign prostatic hyperplasia (BPH, a condition in men in which the prostate gland is enlarged), neuromuscular dysfunction of bladder (a urinary condition that lacks bladder control), and major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest). His Minimum Data Set (MDS, an assessment tool) dated 10/15/2023 indicated a Brief Interview for Mental Status (BIMS) score of 14 (intact cognition). During 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 observation, interview, and record review, the facility failed to maintain room temperatures in accordance with their policy for one of nine sampled residents (Resident 1). This failure had the potential to compromise the resident's comfort, health, and overall well-being. Findings: Review of Resident 1's medical record indicated the resident was admitted on [DATE] and had diagnoses including anemia (a deficiency of red blood cells) and diabetes (disease that affects the body's ability to control blood sugar). Resident 1's Minimum Data Set (MDS, an assessment tool), dated 9/5/23, indicated the resident had a brief interview for mental status (BIMS) score of 15 (a score of 15 indicated the resident was cognitively intact). During an interview with Resident 1 on 10/31/23 at 1:27 p.m., Resident 1 stated the temperature in the facility became colder over the past weekend. Resident 1 explained the facility tried to provide interventions, such as providing blankets that were warmed in the dryer, but 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 provide services according to the accepted standards of clinical practice for two of 12 sampled residents (Residents 15 and 17) when: 1. Resident 15 did not have arm sleeves to protect his skin on the arms as ordered; 2. Resident 17's Advair HFA (an inhaler type of prescription medicine used to treat asthma) was not administered per the manufacturer's specifications. These failures had the potential to affect the residents' health condition and care. Findings: 1. Review of Resident 15's physician order, dated 4/30/21, indicated arm sleeves on both upper extremities every shift. It indicated the resident was on aspirin (an antiplatelet drug preventing platelets [a component of the blood that stops bleeding] from clumping together to form a clot) daily. During an observation on 3/8/22 at 12:25 p.m. and 3/9/22 at 7:30 a.m., Resident 15 had multiple skin discolorations and a skin tear on both arms and hands. The resident was not wearing arm sleeves. During an observation and concurrent interview on 3/11/22 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 2. Review of Resident 15's care plans indicated the resident was at high risk for falls related to history of falls, confusion, gait, and balance problems. Review of Resident 15's clinical records indicated the resident had fall incidents on 1/18/21, 3/3/21, 10/12/21, 1/2/22, 1/24/22, 2/6/22, and 2/18/22. Review of Resident 15's IDT Fall Review, dated 1/19/21, indicated the IDT reviewed the resident's 1/18/21 fall incident and the IDT did not recommend any new interventions or revise the current interventions to prevent falls. Review of Resident 15's IDT fall review, dated 1/26/22, indicated the IDT reviewed the resident's 1/24/22 fall incident and one of the recommendations was to take the resident to assess for bathroom privileges after lunch. Review of Resident 15's IDT fall review, dated 2/8/22, indicated the IDT reviewed the resident's 2/6/22 fall incident and there was no new recommendation to prevent recurrent falls. During an interview on 3/10/22 at 12:19 p.m., the director of nursing (DON) and the SD,…

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 nursing staff assessed one of 12 sampled residents (Resident 7) for removal of an indwelling catheter (a tube inserted into the bladder to drain urine). This failure had the potential for the resident to have an unnecessary indwelling catheter with increased risk of catheter related complications i.e., infection. Findings: During an observation on 3/8/22 at 9:14 a.m., Resident 7 had an indwelling catheter with a drainage bag. Review of Resident 7's Nursing Progress Notes, dated 2/19/22, indicated the resident was transferred to an acute care hospital for respiratory failure. Review of Resident 7's Discharge Summary from the acute care hospital, dated 2/21/22, indicated the resident was discharged with the indwelling catheter. Review of Resident 7's CARE CONFERENCE, dated 2/23/22, indicated on 2/21/22, the resident was readmitted to the facility. During a record review and concurrent interview, on 3/10/22 at 12:37 p.m., the director of nursing (DON) reviewed Resident 7's clinical records and 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.

Based on interview and record review, the facility failed to ensure an attending physician visited and evaluated one of 12 sampled residents (Resident 8) in a timely manner. This failure had the potential to delay identifying the resident's medical needs and providing necessary care and treatment appropriately. Findings: Review of Resident 8's Physician Notes indicated the resident was seen by the attending physician on 9/8/21. During an interview on 3/11/22 at 8:19 a.m., the director of nursing (DON) stated the resident did not like her attending physician, the facility found another physician, and the new attending physician would start providing services for Resident 8. The DON stated the Medical Record staff (MR) monitors the physicians' progress notes indicating the physicians visit the residents on a regular basis. During an interview on 3/11/22 at 12:35 p.m., the MR stated she did not monitor if the physicians visited the residents and made their progress notes. During a phone interview on 3/11/22 at 1:20 p.m., Resident 8's attending physician (AP A) stated the resident…

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

Based on interview and record review, the facility failed to ensure adequate monitoring of psychotropic medications for two of 12 sampled residents (Residents 5 and 15) when the side effects of Ambien (medication used to treat insomnia, a sleep disorder) were not monitored for Resident 5 and the Abnormal Involuntary Movement Scale (AIMS, test to monitor movement disorders in a person taking an antipsychotic medication) assessment was not completed for Resident 15. These failures had the potential to result in unnecessary medications. Findings: Review of Resident 5's clinical record indicated he had diagnoses including cervical disc disorder (changes in the cervical [neck] part of the spine, resulting in pain, tingling, or numbness) with telepathy (injury to the spinal cord). Review of Resident 5's physician orders indicated he had an order for Ambien tablet 10 milligrams (mg, unit of measurement) give 10 mg by mouth every 24 hours as needed for insomnia, dated 3/5/22. Resident 5 also had discontinued order for Ambien tablet 10 mg give 10 mg by mouth every 24 hours as needed 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 interview and record review, the facility failed to ensure two of 12 sampled residents (Residents 6 and 11) had gradual dose reduction (GDR) attempts for their psychotropic medications (drugs that affects brain activities associated with mental processes and behavior). This failure resulted in the residents not having the opportunity to be free from the unnecessary psychotropic medications. Findings: 1. Review of Resident 6's Note to Attending Physician/Prescriber, dated 9/15/21, indicated the resident had been taking the antidepressant, paroxetine (antidepressant medication), 20 milligrams (mg) once a day and the consultant pharmacist recommended gradual dose reduction (GDR). Resident 6's attending physician (AP A) responded by checking, Resident with good response, maintain the current dose. The form's section for the attending physician/prescriber to indicate clinical rationale for continuing medication dosage was blank. During a record review and concurrent interview with the director of social service, on 3/10/22 at 9:47 a.m., the DSS reviewed Resident 6's clinical…

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.