Bethel Lutheran Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 sampled residents (Resident 1). When the Licensed Vocational Nurse (LVN) 1 obtained a urine specimen by straight catheterization (invasive thin flexible tube used to drain urine from the bladder) without a physician order for catheter.This failure had the potential to place the resident at risk for unnecessary pain, infection, and psychosocial harm.During a review of Resident 1's Order Summary Report (OSR) dated 8/8/25, at 1307 the OSR indicated, .May have UA (urinalysis medical test that examines urine to help diagnose medical conditions). One time only for foul order for 3 days.During a review of Resident 1's OSR dated 8/10/25 at 0305 the OSR indicated .May have UA with C&S (culture and sensitivity a more detailed test of the urinalysis indicates a possible infection) if indicated one time only for foul odor for 3 days.During a review of Resident 1's admission Record (AR) dated 8/22/25,…

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 rights of two of three sampled residents (Resident 1 and Resident 2) right to a dignified private and personal space was respected when one facility male employee laid down on the bed with Resident 1 and had taken a nap with her for several minutes; and when Resident 1's roommate, Resident 2, observed this. This failure resulted in the potential for psychosocial harm such as emotional distress for Resident 1 and Resident 2. Findings: During a review of the facility document titled SOC 341/5 Day Report (Report) , dated 11/18/24, the Report indicated, On 11/13/24, [at approximately 4 p.m.] Administrator was notified by [Resident 2] that a male CNA [Certified Nursing Assistant 1] had taken a nap in [Resident 1's] bed with her. An investigation was started immediately by the management team. Resident [1] was interviewed by [Licensed Nurse] and [Social Services Director]. Watched video footage of B-Wing Hall [hall where Resident 1 and 2 resided]. Staff member from B-wing hall interviewed. Confirmed incident was found…

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 three employees' (CNA 1 and CNA 3) orientation to the facility and education documentation was thorough and completed by the Director of Staff Development (DSD). This failure had the potential for staff education requirements to not be verified by the DSD, enabling poorly trained staff to work in the facility with residents. Findings: During a review of the facility document titled, Job Description – Director of Staff Development (DSD) , dated 1/24, the Job Description indicated, The Director of Staff Development (DSD) plays a key role in creating a positive learning culture within [the facility], overseeing training and continuing education to support the growth and professional development of nursing and support staff. This role ensures that all personnel maintain the required licensure and certifications, comply with facility policies and are well-equipped with the knowledge and skills necessary for providing high-quality resident care. The DSD coordinates with all mandatory training programs, evaluates…

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 three employees ' (Certified Nursing Assistant, or CNA 1) education on Resident ' s Rights was thorough and completed by the Director of Staff Development (DSD). This failure resulted in staff education on Resident Rights to not be completed and verified by the DSD for CNA 1, enabling CNA 1 to be untrained on Resident Rights while working with residents, including Resident 1 [cross-reference with F550]. Findings: During a review of the facility document titled, Job Description – Director of Staff Development (DSD), dated 1/24, the Job Description indicated, The Director of Staff Development (DSD) plays a key role in creating a positive learning culture within [the facility], overseeing training and continuing education to support the growth and professional development of nursing and support staff. This role ensures that all personnel maintain the required licensure and certifications, comply with facility policies and are well-equipped with the knowledge and skills necessary for providing high-quality…

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 store, prepare, and serve food in accordance with professional standards of practice for food service safety when: 1. A walk- in freezer had beef stew meat with ice crystals inside the bag labeled 7/14/24. 2. A foam cup containing food with staff name undated labeled was stored on shelf in walk-in refrigerator. 3. An open yogurt container with no opened date was found in the walk-in refrigerator 4. A white bin containing oats was not labeled with open and received date in the storage room. 5. Cookies, snacks and 2-liter sodas brought from family members, were found with no label of date opened, date received, or initials, in two of six sampled residents' (Resident 2 and 24) room. These failures had the potential to transmit food-borne illnesses to residents. 1. During a concurrent observation and interview on 10/22/24 at 8:23 a.m. in the walk- in freezer with the Dietary Service Supervisor (DSS) a bag containing stew meat dated 7/14/24 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation, interview, and record review the facility failed to ensure privacy and confidentiality for two out of four residents (Resident 10 and Resident 15) during medication administration and medical treatment when: 1. Resident 10's curtains were not pulled during blood glucose testing (a measurement of the amount of sugar in a person's blood. It involves a finger prick or blood draw from the vein) and administration of insulin (a medication that lowers the amount of sugar in the blood). 2. Resident 15's curtains were not pulled during the administration of eye drops. These failures had the potential to place Resident 10 and Resident 15 at risk of losing their privacy and confidentiality during their medical treatments, and not attaining, or maintaining physical, mental, and psychosocial well-being. Findings: 1. During a concurrent observation and interview on 10/23/24 at 11:16 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 10's room, Resident 10 was observed dressed, sitting in his…

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 that met professional standards of quality of care for one of six sampled residents (Resident 3) when Resident 3's Hoyer lift sling (a mobile device which helps caregivers safely transfer patients) was used incorrectly during a transfer from his wheelchair to the bed. This failure caused Resident 3 to experience pain and discomfort and had the potential to result in injury as a result of using the lift improperly. Findings: During a review of Resident 3's admission Record (AR- a document which provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 10/25/2024, the AR indicated Resident 3 was admitted with the following conditions: contracture of muscles (stiffness or tightening of the muscles which causes inability to move), generalized weakness (overall lack of strength), and generalized abdominal pain (pain in the stomach area). During an observation on 10/23/24 at 11:46 a.m. in Resident 3's room, Certified Nursing Assistants (CNA) 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 During observation, interview, and record review, the facility failed to ensure accurate labeling of resident medications, and storage of resident medications at proper temperatures to preserve their integrity in accordance with accepted professional standards of practice when: 1. One of two medication carts had two out of 199 pill packets with no visible expiration dates. 2. Seven out of seven boxed medications did not have the inside medication container labeled with resident information. 3. One of two medication refrigerators was below the facility required temperature range of 36 degrees Fahrenheit (F) and 46 degrees F. These failures put residents at risk for unsafe administration of medications. Findings: 1. During a concurrent observation and interview on 10/24/24 at 12:00 p.m. with Licensed Vocational Nurse (LVN) 2, in the B-wing nurse's station, the B-wing medication cart was observed to have two of 199 resident pill cards (a packet containing a set number of prefilled prescription medications) without…

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 56 of 56 sampled residents received safe and appetizing temperature food when Dietary [NAME] (DC) did not check temperature of food on steam table on 10/23/24 before serving. This failure had the potential for all 56 residents to be served cold food and for all 56 residents to contract food borne illnesses. Findings: During an observation on 10/23/24 at 10:19 a.m. in the kitchen with the DC, the DC removed tray #1 lasagna from oven and placed the lasagna on steam table. During an observation on 10/23/24 at 11:33 a.m. the DC removed tray #2 lasagna from oven and placed the lasagna on steam table. During an observation on 10/23/24 at 11:39 a.m. in the kitchen during tray line (food service assembly line system where workers add components to a tray as it moves along a line),the following items were observed on the steam table: tray #1 lasagna stacked on top of tray #2 lasagna, a silver tray of boiled vegetables, six foam containers (three pureed lasagna and three pureed vegetables) were on the steam…

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 monitor and maintain essential equipment in a safe operating condition for one of two medication room refrigerators, when the refrigerator temperature reading was below the acceptable range for safe holding of medication. This failure had the potential to put residents whose medications were held in the B-wing medication refrigerator at risk of receiving unsafe and ineffective medications. Findings: During a concurrent observation and interview on 10/24/24 at 11:18 a.m. with the Minimum Data Set Nurse (MDSN) in the B-wing medication room, the medication refrigerator temperature was observed at 32 degrees Fahrenheit ( F). The MDSN stated the refrigerator temperature of 32 degrees F was too cold to hold medications. The MDSN stated having the refrigerator temperature below the accepted temperature range of 36 degrees F could damage the medications and make them unsafe for resident use. During a concurrent interview and record review on…

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 a care plan in regard to pain for one of one residents (Resident 3), when staff did not pre-medicate Resident 3 with an analgesic (a medication that reduces pain) prior to physical therapy. This failure to not follow the care plan, resulted in Resident 3 to have unmanaged pain. Findings: During a review of Resident 3's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 3 was admitted to the facility on [DATE] with a diagnosis which included Generalized Abdominal Pain (pain that affects more than half of the abdomen), Poly-osteoarthritis (arthritis that affects five or more joints at the same time), Muscle Weakness (loss of muscle strength) and Contracture of Muscles (bilateral [both sides of body] lower legs- a permanent tightening of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the right to be free from pain for one of one residents (Resident 3), when Resident 3 was not given analgesia (pain medication), per his care plan, before physical therapy. This failure resulted in Resident 3 experiencing pain during a transfer from his wheelchair to his bed and during physical therapy. Findings: During a review of Resident 3's Face Sheet (a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 3 was admitted to the facility on [DATE] with a diagnosis which included Generalized Abdominal Pain (pain that affects more than half of the abdomen), Poly-osteoarthritis (arthritis that affects five or more joints at the same time), Muscle Weakness (loss of muscle strength) and Contracture of Muscles (bilateral [both sides of body] lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the, the facility failed to ensure the physician order (set of instructions written by a doctor) was followed for one of the six sampled residents (Resident 14) was served an incorrect scoop size for small portion diet on 10/23/24. This failure had the potential for Resident 14 to received more than the recommended number of calories ordered by the physician. Findings: During an observation on 10/23/24 at 11:39 a.m. in the kitchen during tray line (food service assembly line system where workers add components to a tray as it moves along a line) Dietary [NAME] (DC) used number 8 scoop size on the steam table. DM stated he should have given less for residents with order for smaller portions. During an interview on 10/24/24 at 9:33 a.m. with the Dietary Services Supervisor, the DSS stated, there should be a number 8 scoop size regular portion) and number 10 scoop size (small portion) during tray line. The DSS stated, Resident 14 had an order for small size…

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 meal preferences were followed for one of seven residents (Resident 51) when Resident 51 was served items on her list of disliked foods of chicken with skin and beets. This failure had the potential to cause Resident 51 to experience inadequate nutrition and weight loss as a result of not eating. Findings: During a review of Resident 51's admission Record (AR- a document which provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 10/24/2024, the AR indicated Resident 51 was admitted with the following conditions: diverticulitis(swelling or infection of small pouches in the intestines), protein calorie malnutrition (occurs when a person does not eat enough protein and calories in their food to meet their nutritional needs), and diarrhea (frequent loose-bowel movement) During a review of Resident 51's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 8/5/2024, the MDS indicated 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 interview and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for one of six sampled residents (Resident 8), when Resident 8's antipsychotic consent forms were incomplete. This failure put Resident 8 at risk of receiving antipsychotic medication prior to being informed of the risks and benefits of taking the medication. Findings: During a review of Resident 8's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 10/28/24, the AR indicated Resident 8 was admitted on [DATE] with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere 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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of infections for 56 of 56 sampled residents when Contractor Technician (CT) did not wash his hands upon entering kitchen. This failure had the potential to cause cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and foodborne illnesses to 56 residents, staffs and visitors that received ice from the ice-machine. Finding: During a concurrent observation and interview on 10/25/24 at 8:55 a.m. in the kitchen, a contractor technician (CT) walked to ice-machine and started scooping ice from bin without washing his hands. The CT stated, he did not wash his hands prior to scooping ice. The CT stated he should have washed his hands when entering kitchen. The CT stated hand washing was important to prevent the spread of cross-contamination (the physical movement or transfer of harmful bacteria…

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 facility medication error rate did not exceed five percent (eight percent) when: 1. Licensed Vocational Nurse (LVN) 5, administered Resident 5's (brand name) calcium tablet (used to prevent or treat low blood calcium levels in people who do not get enough calcium from their diets.) with vitamin D (nutrient the body needs for building and maintaining healthy bones) for an order of (brand name) Calcium 500 mg. This failure had the potential for Resident 5's Vitamin D level to go higher and lead to serious medical condition. 2. LVN 2 administered Resident 30's Multivitamin (used to treat or prevent vitamin deficiency due to poor diet, certain illnesses or during pregnancy) gummies (chewy gelatin-based) for an order of multivitamins-minerals. This failure had the potential for Resident 30's daily mineral needs to be not met. Findings: 1. During a concurrent observation and interview on 11/28/23 at 7:35 a.m., in B-wing, LVN 5 was passing medication. LVN 5 prepared Resident 5's medications. LVN 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During a review of Resident 26's admission Record (AR), (undated), the AR indicated, . Resident 26 was admitted to the facility on [DATE] . During a review of Resident 26's paper chart the Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], the POLST indicated, Resident 26 did not have an advanced directive. Resident 26's Health Care Power of Attorney Appointment of Health Care Agent and Proxy document dated [DATE] was located in Resident 26's paper chart. During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated [DATE], the MDS indicated Resident 26's Brief Interview for Mental Status (BIMS - an evaluation of attention, orientation and memory recall) score of 99 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment, score of 99 resident unable to complete the interview), Resident 26 was unable to complete the interview. During a concurrent…

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 was treated with dignity and respect for one of four sampled residents (Resident 5) when Licensed Vocational Nurse (LVN) 5 administered medication to Resident 5 in the hallway. This failure resulted in Resident 5 not being provided with respect and dignity while taking her medications. Findings: During a concurrent observation and interview on 11/28/23 at 7:35 a.m., in B wing hallway, Resident 5 was sitting up in her wheelchair appropriately dressed for the weather. LVN 5 prepared Resident 5's medications. LVN 5 administered Resident 5's medications in the hallway with other residents and staff walking by. During a review of Resident 5's clinical record titled, admission Record, (document containing resident personal information) dated, 11/29/23, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included: . dementia (impaired ability to remember, think, or make decisions that interferes with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide access to personal funds for one of two sampled residents (Resident 10) when he was unable to request his personal funds on the weekends. This failure resulted in Resident 10 not being able to access his funds on the weekends for his personal needs. Findings: During a review of Resident 10's admission Record (AR) (undated), the AR indicated, . Resident 10 was admitted to the facility on [DATE] . During an interview on 11/29/23 at 10:57 a.m. with Resident 10, Resident 10 stated the facility held his funds. Resident 10 stated he was able to access funds on the weekdays but was not able to access funds on the weekends or holidays. Resident 10 stated . They do not have anyone [Business office staff] here on weekend . Resident 10 stated accessing funds on the weekends was . something you just don't do . Resident 10 stated he would request his funds from the business office staff and would use the funds to buy gum, cookies, and coffee. 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 observations, interviews, and record reviews, the facility failed to provide residents with accessibility to file a grievance, anonymous grievance or complaint and did not update the grievance policy to ensure the prompt resolution of grievances for seven of ten sampled residents (Resident 25, Resident 10, Resident 17, Resident 18, Resident 19 and Resident 48, Resident 37) when: 1. Resident 37 filed a grievance in September 2023 requesting a room change and the grievance was not documented and followed up on by the facility staff. 2. Resident 25, Resident 10, Resident 17, Resident 18, Resident 19 and Resident 48 did not know how to file a grievance anonymously. 3. The facility's policy and procedure (P&P) titled Grievances did not include the right to file a grievance in writing or orally, the right to file a grievance anonymously, the right to obtain the review in writing, the required contact information of the grievance official, the contact information of independent entities with whom grievances…

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 Minimum Data Set (MDS-a resident assessment tool used to identify resident care needs) assessment accurately reflected the residents' current status for one of six sampled residents (Resident 19) when Resident 19's MDS assessment of Health Conditions (Section J) was not coded accurately. This failure placed Resident 19's at a potential of her smoking needs to be not met. Findings: During a concurrent observation and interview on 11/28/23 at 9:33 a.m., in Resident 19's room. Resident 19 stated she was a smoker and the facility provided her with a smoking schedule. Resident 19 pointed to a sheet with the smoking times listed, pinned to the bulletin board in her room. During an interview on 11/28/23 at 10:33 a.m., with Certified Nursing Assistant (CNA) 9, CNA 9 stated Resident 19 was a smoker. During a review of Resident 19's MDS assessment Section C Cognitive Patterns, dated 11/1/23, the MDS assessment, Section C Cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (A plan that provides direction for individualized care of the resident) was developed and implemented to meet the needs for two of five sampled residents (Resident 47, Resident 7) when: 1. Resident 47 did not have a care plan for activities. This failure had the potential to result in Resident 47's activities to go unmet and could result to self isolation. 2. Resident 7 did not have a care plan for milk allergy. This failure had the potential for Resident 7 to receive milk products which could result in breathing difficulty or other health complications. Findings: 1. During a concurrent observation and interview on 11/27/23 at 11:29 a.m., with Resident 47, in Resident 47's room, Resident 47 was observed laying in bed with eye patch covering her eyes. Resident 47 stated this was her second time in the facility. Resident 47 stated she did not feel like getting out of bed. Resident 47 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 Based on observation, interview, and record review, the facility failed to meet professional standards of practice for one of six sampled residents (Resident 46) when Licensed Vocational Nurse (LVN) 4 left Resident 46's morning medication at bedside accessible to others. This failure placed Resident 46 at risk for not taking the medications, medication error, other residents or unauthorized personnel to access Resident 46's medications. Findings: During a review of Resident 46's admission Record (AR-a document containing resident medical and personal information), undated, the AR indicated, Resident 46 was admitted to the facility on [DATE] with diagnoses which included, atrial fibrillation (afib- abnormal heartbeat which can lead to blood clots in the heart), anemia (lower than normal healthy red blood cells), muscle weakness, protein-calorie malnutrition (lack of sufficient nutrients in the body) and adult failure to thrive (a decline of health and ability in older adults). During a review of Residents 46's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications (medications which affect the mind, emotions, and behavior) for one of four residents (Resident 34) when Resident 34 was given divalproex (an anticonvulsant medication used to treat seizures [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness]) without consistent indication for use, documented non-pharmacological interventions, and clinical justification to support the use of divalproex. This failure resulted in Resident 34 receiving unnecessary psychotropic medications and placed the Resident 34 at an increased risk for developing adverse (harmful) side effects due to taking divalproex. Findings: During a review of Resident 34's admission Record (AR), dated 11/29/23, the AR indicated, Resident 34 was admitted on [DATE] with diagnoses which included,…

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

Based on observation, interview, and record review, the facility failed to ensure medications used were labeled and stored in accordance with professional standards when: 1. Resident 5's (linaclotide brand name - medication used to treat constipation) medication label did not match the medication order. This failure had the potential for the medication not to be administered according to the physician's order and resident's need. 2. A medication cart in B-wing unit was left unlocked and unattended by Licensed Vocational Nurse (LVN) 5. This failure placed all residents' health and safety at risk when drugs were left unattended and accessible to unauthorized individuals. 3. A bottle of over the counter (OTC) medication was left on top of the medication cart, unattended by LVN 5. This failure placed all residents' health and safety at risk when drugs were left unattended and accessible to unauthorized individuals. Findings: 1. During a review of Resident 5's Order Summary Report, dated 11/29/23, the Order Summary Report, indicated, . [linaclotide brand name] capsule 290 MCG…

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 garbage was properly contained in dumpsters (garbage containers) covered with lids for one of five dumpsters when one garbage dumpsters outside of the facility was left uncovered, with lids to the side. This failure had the potential to attract rodents, insects and flies and spread infection placing residents at risk of foodborne illness. Findings: During a concurrent observation and interview on 11/27/23 at 9:50 a.m., with the Dietary Supervisor (DS), outside the trash collection area, there were five large dumpsters. One large trash dumpster was open with both lids flopped on the side. The DS stated, the lids (dumpster) were normally covered (closed), not sure why one dumpster was left open. The DS stated having the lids which were not closed could attract animals and potentially cause cross-contamination and the spread of bacteria causing disease. During a concurrent observation and interview on 11/28/23 at 10:45 a.m., with the Maintenance Supervisor (MS), at back of facility, there were five large…

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 an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of infections when: 1. One of three sampled resident's (Resident 4) foley catheter (indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) tubing was lying the floor on two separate occasions. This failure placed Resident 4 at risk for catheter contamination and a urinary tract infection (UTI- an infection in any part of the urinary system [kidneys, ureters, bladder]). 2. Two of two non-kitchen staff (staff position unknown and Maintenance Director [MS])entered the kitchen area without wearing proper hair covering and washing their hands. This failure had the potential to cause cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and spread of infection. Findings: During a concurrent…

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.