Willow Tree Care Center

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for two of four medication storage carts. Specifically, the facility failed to:-Date residents' insulin pens with the date they were opened; and,-Discard expired medications in a timely manner.Findings include:I. Professional referenceAccording to the manufacturer, Sanofi-Aventis, Prescribing and Safety information, revised May 2025, retrieved on 3/4/26 from https://products.sanofi.us/Lantus/Lantus.pdf. The 3 milliliter (ml) single-patient use SoloStar prefilled pen can be stored unopened in a refrigerator until the expiration date, stored unopened at room temperature for 28 days and used for 28 days after opened at room temperature.According to the manufacturer, Sanofi-Aventis, Prescribing and Safety information, September 2025, retrieved on 3/4/26 from https://www.novolog.com/taking-novolog.html, Store unused NovoLog pens, PenFill cartridges, and vials at room temperature up to 86 degrees Fahrenheit (F) for up to 28 days. Store unused NovoLog pens and vials in the…

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

Based on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for two out of five certified nurse aides (CNA) reviewed.Specifically, the facility failed to ensure CNA #3 and CNA #4 received 12 hours of continuing education annually.Findings include:I. Facility policy and procedureThe All Staff In-Service Training policy and procedure, undated, was provided by the regional corporate resource on 2/27/26 at 10:22 a.m. It read in pertinent part, All staff are required to participate in regular in-service education, including all new and existing personnel, individuals providing services under contractual agreements, and volunteers. Training requirements will be met prior to staff providing services to residents, annually, and as necessary based on the facility assessment. Based on the outcome of the assessment, additional training may be required.Completed training will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure four (#3, #4, #7 and #8) of eight residents out of 10 sample residents were free from abuse.Specifically, the facility failed to:-Prevent physical abuse between Resident #3 and Resident #4;- Protect Resident #7 from physical abuse by Resident #9; and,- Protect Resident #8 from physical abuse by Resident #4. Findings include: I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention policy, last revised April 2021, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention…

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 record review and interviews, the facility failed to thoroughly investigate allegations of abuse for one (#4) of seven residents out of 10 sample residents.Specifically, the facility failed to thoroughly investigate two allegations of physical abuse by Resident #4. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation-Investigating and Reporting policy, revised September 2022, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. The policy read in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. All allegations are thoroughly investigated. The administrator initiates investigations.Investigations may be assigned to an individual trained in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#4 and #6) of seven residents reviewed out of 10 sample residents.Specifically, the facility failed to:-Effectively implement person-centered approaches for dementia care to prevent resident-to-resident altercations for Resident #4; and, -Effectively implement person-centered approaches for dementia care to prevent verbal and physical aggressive behavior as well as wandering/elopement behavior for Resident #6.Findings include: I. Facility policy and procedureThe Dementia Clinical Protocol policy and procedure, revised November 2018, was provided by the director of nursing (DON) on 7/23/25 at 5:12 p.m. The policy read in pertinent part, For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify 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, record review and interviews, the facility failed to ensure one (#1) of three residents out of three sample residents received treatment and care for optimal skin condition of a pressure wound, in accordance with professional standards. Specifically, the facility failed to: -Develop and implement a care plan for Resident #1's pressure ulcers; and, -Ensure interventions were implemented timely to prevent the development and worsening of a pressure injury for Resident #1. Findings include: I. Professional reference According to the All [NAME] Tissue Viability Nurse Forum, Best Practice Statement on the Prevention and Management of Moisture Lesions, September 2023, retrieved online 4/4/25 from:chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.wwic.[NAME]/uploads/files/documents/Professionals/Clinical%20Partners/AWTVNF/All_Wales-Moisture_Lesions_final_final.pdf Individuals with incontinence may also have problems with mobility and, as a result, be at risk of developing pressure…

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 record review and interviews, the facility failed to ensure residents or their representative were aware of the nature and implications of the facility's arbitration agreement to inform their decision on whether or not to enter into such agreements for six residents (#21, #22, #36, #42, #43 and #46) of six out of 32 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure residents and/or resident representatives understood the agreement before signing the arbitration agreement; -Accurately inform residents and/or resident representatives when the agreement could be rescinded before the agreement was signed; and, -Ensure staff reviewing the arbitration agreement with residents and the residents' representatives understood the components of the agreement. Findings include: I. The Arbitration Agreement The Voluntarily Executed Mutual Arbitration Agreement, undated, was provided by the nursing home administrator (NHA)…

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

Based on observations, interviews and record review, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure: -The residents in the dining room did not have prolonged wait times of 30 minutes or longer for their meal to be served; and, -Room trays were delivered to all neighborhoods and served to the residents at the regular posted meal times. Finding include: I. Posted meal times Meal times were posted across the facility as the following: Breakfast at 8:00 a.m. Lunch at 12:00 p.m. Dinner at 5:00 p.m. II. Observations On 1/22/24 at 11:50 a.m., three residents were in the dining room waiting for lunch. -At 12:21 p.m. the first meal went to [NAME] Halls. -At 12:53 p.m. East Halls still had yet to be served their trays. -At 1:11 p.m. the meal cart was placed in the East Halls and the certified nurse aide (CNA) started serving C Wing first. -At 1:24 p.m. the meal cart went to the East Hall to serve…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to act promptly upon the grievances in the resident council meeting. Specifically, the facility failed to document and respond to the resident council's grievances over the past four months regarding nursing care and dietary concerns. Findings include: I. Facility policy The Filling Grievances or Complaints policy, revised April 2017, was provided by the nursing home administrator (NHA) on 1/25/24 at 10:40 a.m. read in pertinent: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff. -Any resident, family member or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior fo other residents, staff members, theft of property or any other concerns regarding his or her stay at the facility. -Grievances may also be voiced or filed regarding care that has not been furnished. -All grievances, complaints or recommendations stemming from residents…

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 record review and interviews, the facility failed to ensure freedom from resident-to-resident abuse involving four (#33, #201, #21 and #41) of five residents reviewed for abuse out of 33 sample residents. Specifically, the facility failed to: -Investigate and implement measures to prevent altercations between Resident #33 and Resident #201 on 2/20/23 and 6/7/23; -Prevent resident-to-resident abuse involving Resident #33 and Resident #201 on 8/6/23, 8/16/23 and 9/16/23; and, -Prevent resident-to-resident abuse involving Resident #21 and #41 on 1/18/24. Findings include: I. Facility policies The Resident Abuse Prevention policy, revised August 2017, was provided by the nursing home administrator (NHA) on 1/22/24 at 9:00 a.m. and read in pertinent part: The community will not tolerate any form of abuse, neglect or exploitation of our residents. This policy is to assure that allegations of abuse, neglect or exploitation are identified, investigated, reported, documented and followed up with interventions to…

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

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive at the appropriate temperatures and met the nutritional needs of the residents. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and appearance. Findings include: I. Resident interviews Resident #11 was interviewed on 1/22/24 at 12:15 p.m. He said the food was not good. He said he did not like the food the facility prepared. He said if cauliflower was served it was just cauliflower stems and they were tough. He said he loved over-easy eggs but received scrambled eggs a lot. Resident #11 said he started buying personal food to eat when he was served something he did not like. Resident #9 was interviewed on 1/22/24 at 2:34 p.m. She said she ate in her room and meals were getting served later and later. She said hot foods and cold foods were lukewarm by the time they were served to the halls. She said the dessert was usually an individual ice cream and was usually melted by the time it was served in the rooms.…

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 record review and interviews, the facility failed to ensure a resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for one (#11) of three residents reviewed for bathing preferences out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #11 was offered showers twice a week on the resident's scheduled and preferred days; -Ensure Resident #11 had opportunities to refuse showers at the time the shower was offered but still had a shower available to him on his preferred day and scheduled day or shortly after; and, -Ensure Resident #11 could choose between showers and the resident's preference to attend activities of choice without losing a shower opportunity. Findings include: I. Facility policy The Resident Rights policy, undated, was provided by the facility on 1/25/24. According to the policy, residents have the right for self-determination. The Activities of Daily Living (ADLs), Supporting policy, revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to complete a Level I preadmission screening and resident review (PASARR) for one (#19) of two residents reviewed for PASARR out of 33 sample residents. Specifically, the facility failed to ensure Level I preadmission screening was completed for Resident #19 who had a mental disorder present when admitted to the facility. Findings include: I. Facility policy The PASARR policy was requested on 1/25/24 from the nursing home administrator (NHA) and the NHA said the facility did not have a PASARR policy. II. Resident status Resident #19, over the age of 65, was admitted on [DATE]. According to the January 2024 computerized physician orders, diagnoses included diabetes, multiple sclerosis, cognitive communication disorder, epilepsy and bipolar disorder. The 11/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required partial assistance from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to provide person-centered dementia care and services for two (#21 and #41) of five residents reviewed for dementia care out of 33 sample residents. Specifically, the facility failed to: -Provide dementia care services for Residents #21 and #41 to provide their highest practicable quality of life and care; -Address behaviors, prevent resident-to-resident altercation; and, -Ensure appropriate and non-pharmacological approaches were provided by staff to engage residents with life in the facility. Findings include: I. Facility policy The Dementia Clinical Protocol policy, revised November 2018, was received by the nursing home administrator (NHA) on 1/25/24 at 7:30 p.m. It read in pertinent part, For the individual with confirmed dementia, the facility will identify a resident-centered care plan to maximize the remaining function and quality of life. Direct care staff will support the resident in initiating and completing activities and tasks of daily…

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

Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs that accommodated resident allergies, intolerances and preferences. Specifically, the facility failed to: -Offer residents more options for alternative choices to the main meal; -Honor requests for items indicated on the alternative menu; and, -Offer the main dish sides with the alternative menu choice. Findings include: I. Resident interviews Resident #16 was interviewed on 1/22/24 at 2:55 p.m. She said the facility mainly served Mexican-styled food and she did not want that. She said the alternative meals were sandwiches and were usually served on stale bread. II. Resident group interview The resident group was interviewed on 1/23/24 at 1:42 p.m. with Resident #6, Resident #9, Resident #4, Resident #17, Resident #12 and Resident #13. Resident #17, Resident #4, Resident #12 and Resident #9 said if the residents wanted something else to eat off the bistro menu the staff got mad 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.

Based on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for one (#20) of three residents out of 33 sample residents. Specifically, the facility failed to ensure medical records were provided timely upon request to Resident #20's representative. Findings include: I. Facility policy The Release of Information policy, revised November 2009, was provided by the facility on 1/25/24. The policy read in part: Closed or thinned medical records were maintained in the medical records department and were available only by authorized personnel. Authorized personnel included but were not necessarily limited to nursing personnel; physician; consultant; support services; administration; government agencies; and/or, resident/representative. The resident may initiate a request to release such information contained in his or her records and charts to anyone he or she wishes. Such request will be honored only upon the receipt of a written, signed, and dated request from the resident or representative. The resident may have access to his or…

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 record review and staff interviews, the facility failed to ensure the services provided met professional standards of quality for two residents (#20 and #47) reviewed out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #20 was thoroughly assessed and monitored for injury and safety after the resident spilled a potential hot beverage on herself; and, -Ensure Resident #47 was consistently assessed when she was having a change of condition. Findings include: I. Resident #20 A. Facility policy The Safety of Hot Liquids, revised October 2014, was provided by the facility on 1/25/24. According to the policy, residents would be evaluated for safety concerns and potential injury from hot liquids upon emission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury. The policy read in part: Potential for burns from hot liquids is considered an ongoing concern among residents 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 record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, staff education, staff competencies, and facility based risk assessments. Findings include: I. Record review The facility assessment was last reviewed on 4/8/22 by the nursing home administrator (NHA), director of nurses, and the interdisciplinary team. The facility assessment failed to include the following: -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs are met for all new and existing staff; -Include staff trainings/education necessary to provide the level and types of support and care needed for the resident population; -Identify facility resources needed to provide competent resident support during…

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

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and implement an effective system to identify facility concerns or address need for quality improvement in their QAPI program. Findings include: I. Facility policy The Quality Assurance Performance Improvement (QAPI) policy, updated February 2020, was provided by the nursing home administrator (NHA) on 9/26/22. The policy documented in pertinent part, This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven qapi program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI program are to: -Provide a means to measure current and potential indicators…

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

Based on interviews and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all 36 residents, including four who were currently on antibiotic therapy currently residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/23/22; retrieved on 10/6/22, from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control- recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2 F2019-ncov%2Fhcp%2Flong-term-care.html; read in pertinent part; This guidance is applicable to all U.S.settings where healthcare is delivered (including nursing homes). Nursing homes: Assign…

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

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to post a list of names, addresses and telephone numbers of all pertinent State Agencies in the facility. Findings include: I. Group interview The group interview was conducted on 9/28/22 at 1:35 p.m. The group consisted of six alert and oriented residents selected by the facility. All six residents (#3, #16, #20, #22, #31 and #33) said they did not know where the facility posted information in regard to pertinent State Agencies' contact information. II. Observations Observations throughout the building revealed there was a posting which was located to the right of the front door. The posting was approximately five feet and five inches inside a glass case. The print was between a 12 and 14 font. The phone number to the State Survey Agency was incorrect and no email address was provided. Although there were mailing addresses and telephone numbers of pertinent State Agencies…

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

Based on observations, record review, and interviews, the facility failed to make information on how to file a grievance or complaint available, maintain records of grievances and complaints, or to make prompt efforts to resolve grievances the resident(s) may have had. Specifically the facility failed to ensure: -Resident group grievances were resolved; and, -Individual resident grievances were resolved; Findings include: I. Facility policy and procedure The Grievance and Complaints policy and procedure, revised in April 2017, was received from the director of nursing (DON) on 10/4/22 at 10:30 am, read in pertinent part, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. The investigation and report will include, as applicable, date & time of the incident, circumstances and location of the incident, the witnesses, the residents and the employees account of the incident, 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 record review and interviews, the facility failed to ensure the minimum data assessment (MDS) accurately reflected the residents' status for four (#5, #26, #33 and #34) of 12 out of 26 sample residents. Specifically, the facility failed to ensure the MDS for Resident #5, #26, #33 and #34 were completed accurately to include their dental status. Findings include: I. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the September 2022 computerized physicians orders (CPO), the diagnoses included paraplegia (paralysis lower body), cognitive communication deficit, age related physical debility, repeated falls, and unsteadiness on feet. The 9/21/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. She had no behaviors and did not reject care. Section L (Dental) documented Resident #5 did not have mouth or facial pain, discomfort or difficulty…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews, the facility failed to provide an ongoing program to support residents in their chosen activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#9 and #12) of five out of 26 sample residents. Specifically, the facility failed to: -Offer and provide personalized activity programs for Resident #12 and Resident #9; and, -Offer evening and activity outings. Findings include: I. Facility policy and procedure The Activities Program policy, effective 9/1/14, was received from the director of nurses on 10/3/22 at 4:23 p.m. It was documented in the pertinent part, The community will encourage participation in independent or self-driven activities, as well as offer activities at least three times per week. II. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the September 2022…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#3 and #5) of three residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion, out of 26 sample residents. Specifically, the facility failed to establish a consistent restorative nursing program within the facility to ensure Resident #5 and Resident #3 did not have a potential decline in activities of daily living (ADL). Findings include: I. Facility policy The Restorative Nursing Services policy, revised July 2017, provided by the director of nursing (DON) on 9/29/22 at 4:05 p.m., read in pertinent part: Restorative nursing care consists of nursing intervention that may or may not be accompanied by formalized rehabilitative services (physical, occupational or speech therapies). Restorative goals and objectives are individualized, resident-centered, and are outlined in the resident's plan 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 observations, record review and interviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice, for three residents (#7, #12 and #26) of eight residents reviewed out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #7 had oxygen in her portable tank for mobility and readily available in an event of an emergency; -Ensure Resident #7 was placed on correct order setting for oxygen via nasal cannula; -Ensure Resident #12 had a physician order for specific nasal cannula oxygen requirements and for titration of oxygen requirements; and, -Ensure Resident #26 had a physician order for oxygen. Findings include: I. Facility policy The Oxygen Concentrator policy, effective 9/1/19, was provided by the activity director (AD) on 9/28/22 at 4:00 p.m. The policy read in pertinent part: This document sets forth general information and guidelines in regards to delivering oxygen to a resident using an oxygen concentrator. Once…

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

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference F689 accident hazards, F692 nutrition, and F744 dementia care. Findings include: I. Resident census and conditions According to the 9/26/22 Resident Census and Conditions of Residents report, the resident census was 36 and the following care needs were identified: -23 residents needed assistance of one or two staff with bathing and seven residents were dependent. Three residents were independent. -13 residents needed assistance of one or two staff members for toilet use and six residents were dependent; 15 residents were…

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 V. Resident #30 A. Resident status Resident #30, age [AGE], was admitted to the facility on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses included repeated falls, Parkinson's disease, neurocognitive disorder with Lewy bodies, cognitive communication deficit, difficulty in walking, muscle weakness, and a need for assistance with personal care. According to the 8/27/22 minimum data set (MDS) assessment, a brief interview for mental status (BIMS) was not conducted. According to the staff assessment for mental status, the resident had severe impairment for making decisions regarding tasks of daily life. Resident #30 had a short and long term memory problem. The assessment identified the resident displayed inattention and disorganized thinking. The MDS assessment indicated Resident #30 required limited assistance of one person for dressing, toileting and personal hygiene. He required supervision with set up for bed mobility transfers and eating. According to the MDS 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 II. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the September computerized physicians orders (CPO), the diagnoses included unspecified dementia, psychotic disturbance, mood disturbance, depression, and generalized anxiety disorder. The 6/20/22 minimum data set (MDS) assessment revealed, the resident had cognitive impairment with a brief mental status score (BIMS) of four out of 15. He had inattention and disorganized thinking. He required supervision with dressing and was independent with all other activities of daily living (ADL). He had no behaviors and did not reject care. He wandered daily which placed him at risk of getting into a potentially dangerous place. He received anti anxiety medication daily. B. Record review The anti-anxiety medication care plan, revised 6/20/22, documented the resident used the medication for adjustment issues, anxiety, and periods of agitation. Pertinent interventions listed were to administer medications as ordered by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and infection for one out of two units. Specifically, the facility failed to: -Ensure housekeeping staff cleaned high-touch surfaces in resident rooms and follow manufacturer surface contact time during routine daily cleaning; -Ensure housekeeping staff followed the appropriate procedure when cleaning resident rooms and bathrooms; and, -Implement appropriate hand hygiene with glove changes. Findings include: I. Professional standards The Centers for Disease Control and Prevention (2020) Preparing for COVID-19 in Nursing Homes, updated 11/15/21, retrieved on 10/11/22 from: https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html/, revealed in part: For environmental cleaning and disinfection: develop a schedule for regular…

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 record review and interviews, the facility failed to ensure all staff had current abuse and dementia care training. Specifically, the facility failed to ensure five out of five licensed nurses and CNAs reviewed within the previous year received dementia management training and abuse prevention training. Findings include: I. Record review Staff annual training for the selected nursing staff (CNAs and licensed nurses) were requested from the director of nursing on 10/3/22 at approximately 2:30 p.m. The facility was unable to provide the annual training which included, abuse, neglect and exploitation training and dementia care training. II. Staff interview The director of nurses was interviewed on 10/5/22 at 9:00 a.m. She said she did not have the training records and competency checklists. She said the assistant director of nursing (ADON) was no longer employed and she could not find the employee training logs and competency checklists. The DON said the abuse training and dementia training was completed on a computerized program, however, no logs could be found for completion…

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

Based on interviews and record review, the facility failed to ensure nurse aides received the required number of annual in-service training hours to ensure continued competence for four of four staff reviewed. Specifically, the facility failed to ensure certified nurse aides (CNA) #1, #5, #8 and #9 received 12 hours of continuing education annually. Findings include: I. Record review Staff annual 12 hour training for the selected nursing staff CNA #1, #5, #8 and #9 were requested from the director of nursing on 10/3/22 at approximately 2:30 p.m. The facility was unable to provide the annual training which included abuse, neglect and exploitation training and dementia care training, nutrition, accident hazards, emergency preparedness and dignity. II. Interviews The director of nurses was interviewed on 10/4/22 at 4:00 p.m. She said she did not have the training records and competency checklists. She said the assistant director of nursing (ADON) was no longer employed and she could not find the employee training logs and competency checklists. She said that she was actively alerting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and record review, the facility failed to promote resident dignity and respect one resident (#16) out of 12 residents reviewed for dignity out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #16 treated and spoken to in a dignified manner; and, -Ensure Resident #16's bodily privacy was maintained and personal space respected. Findings include: I. Facility policy The Dignity policy, revised February 2021, was provided by the director of nursing (DON) on 10/3/22 at 4:23 p.m. via email. The policy read in part: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Residents' private space and property are respected at all times. Staff speak respectively to residents at all times, including them and dressing them by name. Staff promote, maintain and protect…

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 record review and interviews the facility failed to fully ensure residents had the right to formulate advance directives by not keeping advance directives updated and current for two (#12 and #27) out of 16 residents reviewed for advance directives out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #12 had the proper legal representation in the record and the medical orders for scope of treatment (MOST) form, the facility utilized for advance directives, was signed appropriately; and -Ensure Resident #27's physician order matched her wishes as signed on the MOST. Findings include: I. Professional reference The Colorado Advance Directives Consortium, Guidance for Health Care Professionals website, dated [DATE], retrieved on [DATE] from http://www.coloradoadvancedirectives.com/wp-content/uploads/[DATE]-MOST-Booklet-REV-2015.pdf read in pertinent part, If the individual resides in a nursing facility, the facility staff are responsible for keeping the MOST form updated. Staff…

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 record review and staff interviews, the facility failed to ensure two (#17 and #31) of three residents reviewed for abuse out of 26 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #17 and #31 were kept free from abuse by Resident #4. Cross-reference F744, dementia care. Findings include: I. Facility policy The Abuse and Neglect policy, revised September 2018, was provided by the director of nursing (DON) on 9/29/22 at 4:05 p.m. It documented the following, in pertinent part, Every resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; neglect; explotation; involuntary seclusion; and any physical or chemical restraint not required to treat the resident's medical symptoms or conditions. The administrator was responsible for the oversight and implementation of the Abuse, Neglect, and Exploitation Prohibition and Prevention Program. If the allegation involved another resident, the residents were separated, 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 record review and staff interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner, based on medication regimen review (MRR) for two (#28 and #34) of six reviewed for unnecessary medications out of 26 sample residents. Specifically, the facility failed to ensure response to pharmacist recommendations for: -Resident #28, a discontinue order for diazepam (anti anxiety medication) and an order for serum creatinine laboratory (lab) level was not drawn as requested; and, -Resident #34, failed to ensure the drug regimen review was acted upon in a timely manner. Findings include: I. Facility policy and procedure The Unnecessary Medications policy and procedure, last revised 4/9/07, was provided by the director of nursing (DON) on 9/29/22 at 4:05 p.m. It read in pertinent part: The facility must evaluate the resident, the resident's medication regimen and if necessary consult with the resident's physician: when an irregularity is identified in the pharmacist's monthly…

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 record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#9) of five residents reviewed for immunizations out of 26 sample residents. Specifically, the facility failed to provide the pneumococcal 23-valent polysaccharide vaccine (PPSV23) to Resident #9. Findings include: I. Professional standard According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2020, retrieved from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf (10/6/2022), the routine pneumococcal vaccination for adults aged 65 years or older and were immunocompetent, one dose of PPSV23 should be administered. II. Record review A. Resident #9 Resident #9, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included chronic respiratory failure with hypoxia (lack of blood oxygen).…

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