Wellsprings Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to notify the state mental health agency promptly after a significant change in the resident's mental condition for one (#7) of four residents out of 39 sample residents. Specifically, the facility failed to notify the state mental health agency authority of Resident #7's necessity for inpatient psychiatric hospitalization.Findings include:I. Facility Policy and ProcedureThe Pre-admission Screen and Resident Review (PASRR) policy, dated 9/26/23, was provided by the nursing home administrator (NHA) on 9/11/25 at 9:15 a.m. It revealed in pertinent part, If a resident's psychiatric status changes after admission. The social services staff are responsible for contacting Omnibus Budget Reconciliation Act (OBRA - state mental health agency) coordinator via completion and submission of a PASRR level I screen and indicate the reason for referral as a change in mental health status or psychiatric diagnosis. Notification of changes are to be made within 10…

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 ensure the medication error rate was less than five percent (%).Specifically, the facility had a medication error rate of 8%, or two errors out of 25 total opportunities for error.Findings include:I. Facility policy and procedureThe Medication Administration policy, dated 8/4/25, was provided by the nursing home administrator (NHA) on 9/10/25 at 10:02 a.m. It read in pertinent part, Resident medications are administered in an accurate, safe, timely, and sanitary manner. Verify the medication label against the medication administration record (MAR) for accuracy of drug frequency, duration, strength, and route. The nurse is responsible to read and follow precautionary or instructions on prescription labels. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. Report any discrepancies to the pharmacy. Do not administer 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 and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication carts.Specifically, the facility failed to:-Ensure residents' medications were labeled and dated appropriately with the resident's name, the date the medication was opened and the expiration date, as applicable; and,-Ensure over-the-counter (OTC) medications stored in medication carts were not expired.Findings include:I. ObservationsOn [DATE] at 10:48 a.m. medication cart #1 on the first floor was observed with licensed practical nurse (LPN) #1. The following items were found:-There was an albuterol sulfate 90 microgram (mcg) inhaler stored in an appropriately labeled medication box; however, the inhaler inside the box was not labelled with the resident's name for Resident #2.-Resident #2's albuterol sulfate inhaler was labeled with a medication expiration date of [DATE].-There was a Breo ellipta 50/25…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents received the required therapy services which were ordered by the physician for one (#74) of three residents reviewed for therapy services out of 39 sample residents. Specifically, the facility failed to ensure Resident #74 received specialized rehabilitative services as ordered on admission to the facility, to maintain the resident's highest practicable level of physical, mental, functional and psycho-social well-being.Findings include:I. Professional referenceAccording to [NAME], D (2023) Tips for a Comprehensive Post-admission Medical Record Review, retrieved on on 9/18/25 from: https://www.aapacn.org/article/tips-for-a-comprehensive-post-admission-medical-record-review American Association of Post-Acute Care Nursing, Omissions and inaccuracies in the medical record can hinder resident quality of care. Omitting or incorrectly transcribing medications or treatments can lead to adverse outcomes due to incorrect dosage, missed…

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 and interviews, the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation for two out of four shower rooms. Specifically, the facility failed to ensure ventilation fan covers were kept clean and operational in the resident shower rooms. Findings include:A. Professional referenceAccording to the U.S. Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021 retrieved on 9/19/25 from: https://docs.nrel.gov/docs/fy21osti/79150.pdf., Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults. Good ventilation can improve the health and wellbeing of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can significantly enhance the safety…

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 that services provided or arranged in accordance with the resident's plan of care were delivered by individuals who have the skills, experience and knowledge to do a particular task or activity for four (#2, #4, #6 and #7) of seven residents out of 11 sample residents. Specifically, the facility failed to: -Ensure Resident #2, Resident #5, Resident #6 and Resident #7's post fall assessments were completed timely by a qualified person and documented in the residents medical record. Findings include: I. Facility policy and procedure The Fall Management policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/24/25 at 4:00 p.m. It read in pertinent part, All fall risk evaluation will be completed within the first 24 hours of admission and a baseline care plan will be initiated for residents to be at risk. If a resident experiences a fall with a head injury, the fall is unwitnessed, or the resident self-reports a fall,…

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 and interviews the facility failed to provide a safe, clean, sanitary and comfortable homelike environment throughout the facility in three out of four hallways. Specifically the facility failed to: -Ensure resident rooms were clean and odor free; -Ensure the residents had clean bed linens and privacy curtains; -Ensure the dining room and common areas were clean; and, -Ensure the facility was free from institutional odors. Findings include: I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the nursing home administrator (NHA) on 6/4/25 at 12:24 p.m. The policy read in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included a clean, sanitary and orderly environment, clean bed and bath linens that are in good…

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 notify the resident representative when there was a significant change in the resident's condition for two (#7 and #8) of three residents reviewed out of 12 sample residents. Specifically, for Resident #7 and Resident #8, the facility failed to: -Keep the resident's current designated representative's name and contact information updated in the resident's record; and, -Make additional attempts or try alternative methods to contact the representative when the representative was not reachable. Findings include: I. Facility policy and procedure The Change of Condition policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 6/4/25 at 12:24 p.m. It read in pertinent part, The resident, attending physician and legal representative or interested family member are notified when changes in condition or certain events occur. Communication with the IDT (interdisciplinary team) and caregivers is also important to ensure that consistency 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 three (#1, #2 and #5) of three residents reviewed for abuse out of 12 sample residents were kept free from abuse. Specifically, the facility failed to: -Ensure Resident #2 and Resident #5 were kept free from physical abuse from each other; and, -Ensure Resident #1 was kept free from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse policy and procedure, dated 5/3/23, was provided by the nursing home administrator (NHA) on 6/4/22 at 12:24 p.m. It revealed in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. If a resident experiences a behavior change resulting in aggression toward other residents, the facility…

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 and interviews, the facility failed to provide a safe, clean, sanitary, and comfortable environment throughout the facility. Specifically, the facility failed to: -Ensure resident rooms were clean, sanitary and odor-free; -Ensure the resident common areas were clean and odor-free; -Ensure residents' bed sheets were changed regularly and when soiled; and, -Ensure residents had hand towels available for use in their rooms. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, revised February 2021, was provided by the corporate nurse consultant (CNC) on 2/13/25 at 2:14 p.m. It read in pertinent part, The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. Clean bed and bath linens that are in good condition, and have pleasant natural scents. The facility staff and management minimizes, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure three (#12, #14 and #23) of five residents reviewed for abuse out of 23 sample residents were kept free from abuse. Specifically, the facility failed to: -Prevent Resident #12 from being sexually abused by Resident #13; -Prevent Resident #14 and Resident #23 from being physically abused by Resident #13; and, -Implement a care plan focus to assess and monitor Resident #13 for inappropriate behavior when he had a known history of violent aggression and other inappropriate behaviors. Findings include: I. Facility policy and procedure The Abuse Policy, revised 5/3/23, was provided by the corporate nurse consultant (CNC) on 2/13/25 at 2:14 p.m. It read in pertinent part, Community does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative,…

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 ensure one (#7) of one resident out of 23 sample residents was protected from exploitation and misappropriation of property. Specifically, the facility failed to prevent a staff member from taking $5,060 from Resident #7. Findings include: I. Facility policy and procedure The Staff Acceptance of Gifts, Gratuities and Payments policy, dated 2/2/17, was provided by the corporate nurse consultant (CNC) on 2/13/25 at 2:15 p.m. It read in pertinent part, Staff are not to accept or solicit gifts, including items such as cash, loans, gratuity, service, or promise of future employment. Offered gifts are to be politely and respectfully declined. This policy is not meant to apply when the gift is of nominal value of $5.00 or less. II. Resident #7 A. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician's orders (CPO), diagnoses included stroke (damage caused by blocked blood vessels in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure the resident's second floor smoking patio was free from debris and the fire blanket was visible; -Ensure the outdoor refuse area was free from debris and items were properly disposed of; and, -Ensure a resident's room was free of long standing stains on the floor. I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the quality mentor (QM) on 12/4/24 at 12:30 p.m. The policy revealed in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximizes, to the extent possible, 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 ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#1) of six residents reviewed out of 11 sample residents. Specifically, the facility failed to ensure Resident #1, who was dependent on staff for bathing, received her scheduled showers. Findings include: I. Facility policy and procedure. The Activities of Daily Living policy, revised March 2018, was provided by the quality mentor (QM) on 12/4/24 at 11:20 a.m. The policy read in pertinent part, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). II. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to 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 record review and interviews, the facility failed to ensure one (#6) of one resident out of 11 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Ensure Resident #6 was weighed weekly per physician orders; and, -Ensure Resident #6's care plan was updated to include new weight monitoring interventions related to his diagnosis of atrial fibrillation and heart failure. I. Resident status Resident #6, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), depression, atrial fibrillation (irregular heartbeat), high blood pressure and heart failure. The 11/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He needed set up assistance with showers and tub transfers, supervision…

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 and interviews, the facility failed to maintain a clean and sanitary homelike environment for residents on three of four units. Specifically, the facility failed to: -Ensure residents experienced a clean and sanitary homelike environment with living spaces free from odors, dirt, debris and soiled areas; and, -Ensure that mouse droppings were removed and the surfaces were properly sanitized from possible rodent contamination. Findings include: I. Professional reference According to the Centers for Disease Control Controlling (CDC) Wild Rodent Infestations, (4/28/24), retrieved on 10/21/24 from https://www.cdc.gov/healthy-pets/rodent-control/index.html#:~:text=Rodents%2C%20such%20as%20rats%2C%20mice,Rodent%20bites, What to know: Rodents can carry many diseases that can spread directly or indirectly to people. Rodents, such as rats, mice, and chipmunks, are known to carry many diseases. These diseases can spread to people directly, through handling of rodents, contact with rodent droppings…

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 ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to: -Ensure staff wore hair restraints to prevent hair from contacting food; -Ensure the freezer was within appropriate operating range to maintain frozen foods solid; -Ensure dry goods were stored in sealed containers to prevent rodents; -Ensure staff practiced appropriate hand hygiene and glove use when necessary during food preparation activities; and, -Ensure food in the nourishment refrigerator was dated. Findings include: I. Ensure staff wore hair restraints A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 2/15/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean…

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 staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects. Specifically, the facility failed to: -Ensure all dumpster lids were closed and not overflowing with garbage; and, -Ensure garbage was cleaned up around and under dumpsters. Findings include: I. Facility policy and procedure The Pest Control policy and procedure, last revised May 2008, was provided by the nursing home administrator (NHA) on 2/14/19 at 4:05 p.m. It revealed in pertinent part, The facility shall maintain an effective pest control program. Garbage and trash are not permitted to accumulate and are removed from the facility daily. Maintenance services assist, when appropriate and necessary, in providing pest control services. II. Observations On 2/12/24 at 9:34 a.m. the dumpster area was found to have one of the two lids open on the dumpsters.There were used gloves, used cups, rotisserie chicken, a bag of lettuce and plastic bags on the ground next to and behind 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 and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of four units in the facility. Specifically, the facility failed to: -Ensure high touch areas were cleaned appropriately by the housekeeping staff; -Ensure proper proper disinfectant times were utilized by staff; -Ensure housekeeping staff performed hand hygiene while cleaning resident rooms; -Ensure each resident was provided with hand hygiene prior to meals; -Ensure hand sanitizer dispensers were operational; and, -Ensure resident laundry was covered while being transported in the hallways. Findings include: I. Housekeeping failures A. Professional reference The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 2/15/24 read in pertinent part, High-Touch…

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 and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure resident rooms, dining rooms, hallways, and the elevator were free from debris and food; -Ensure the dumpsters were closed at all times and the area was free from debris, food, and trash; -Ensure kitchen was free from mice droppings and dry storage was stored properly; and, -Ensure the entrance to the facility was free from extinguished cigarette butts disposed on the ground. Findings include: I. Facility policy The Homelike Environment policy, undated, was provided by the nursing home administrator on 2/16/24 at 2:03 p.m. It read in pertinent part, The resident has the right to a safe, clean, comfortable and homelike environment. Environment refers to any environment in the facility that is frequented by residents, including the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios,…

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 four residents (#27, #39, #212 and #6) of six residents reviewed for abuse were kept free from abuse out of 37 sample residents. Specifically, the facility failed to ensure Residents #27, #39, #212 and #6 were kept free from physical abuse from Resident #49. Findings include: I. Facility policy The Abuse policy, dated 5/3/23, was received from the nursing home administrator (NHA) on 2/12/24 at 2:02 p.m. It revealed in pertinent part, Communities does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents. Residents have the right to be free from abuse. Resident abuse was defined as the wilful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish,deprivation of goods or services that were necessary to attain or maintain physical, mental, or psychosocial well being.…

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 the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 17.24%, which was five errors out of 29 opportunities for error. Findings include I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route…

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 provide bed hold documentation for residents being discharged to the hospital for one (#27) of two residents reviewed for the bed hold policy out of 37 sample residents. Specifically, the facility failed to provide Resident #27 with an appropriate bed hold notification when being transferred to the hospital on [DATE] and 11/29/23. Findings include: I. Facility policy and procedure The Bed hold policy and procedure, dated 10/1/21, was provided by the nursing home administrator (NHA) on 2/16/24 at 11:20 a.m. It read in pertinent part, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave. Bed-hold: holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. The facility will have a process in place to ensure…

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 resident (#8) of four reviewed for dialysis care out of 37 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to communicate with the dialysis center when the communication form was not completed. Findings include: I. Facility policy The Hemodialysis policy, dated 5/4/23, was provided by the nursing home administrator (NHA) on 2/14/24 at 11:20 a.m. It read in pertinent part, The facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve outcomes in coordination/collaboration with the dialysis center. A dialysis communication record is initiated and sent to the dialysis center each appointment; ensure it is received upon return. II. Resident #8 Resident #8, age below 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included hypertensive heart…

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 and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of four medication carts. Specifically, the facility failed to: -Ensure insulin (medication used for blood glucose control) pens were labeled with resident name and open dates; -Ensure medications were not left unattended on the medication cart; -Ensure medications were disposed of properly; and, -Ensure medication carts were kept clean. Findings include: I. Professional reference According to the Lantus glargine package insert, retrieved [DATE] from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, when not in use store in refrigerated temperatures of 36 to 46 degrees. When in use, it can be kept at room temperature for up to 28 days. According to the Humalin N kwikpen instructions for use, retrieved on [DATE] from: https://pi.lilly.com/us/HUMULIN-N-KWIKPEN-IFU.pdf, Throw away the Humulin N pen after 14 days even if it still has insulin in it. II.…

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, document review, and facility policy review, the facility failed to maintain proper kitchen sanitation when Dietary Aide (DA) #1 continued to wash dishes using a low temperature dish machine without ensuring the proper sanitizer concentration. The facility further failed to maintain a log of refrigerator and freezer temperatures. These deficient practices had the potential to affect all residents residing in the facility who received food from the kitchen. Findings included: 1. A review of the facility's Warewashing policy, dated 05/2014 and revised 09/2017, revealed, The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. The policy further revealed, Temperature and/or sanitizer concentration logs will be completed, as appropriate. A review of the October 2022 Dish Machine Log revealed DA #1 recorded a sanitizer concentration of 100 parts per million (ppm) for the morning of 10/31/2022. During a concurrent observation and interview 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 interviews, record reviews, document review, and facility policy review, it was determined the facility failed to report an allegation of staff-to-resident abuse to the state survey agency (SSA) within two hours after the allegation was made for 1 (Resident #3) of 4 sampled residents reviewed for abuse. On 10/31/2022 at approximately 6:30 AM, Resident #3 alleged that Certified Nursing Assistant (CNA) #1 yelled at the resident and made an inappropriate hand gesture toward the resident. The facility did not report the allegation to the SSA until 11:29 AM, approximately five hours after the resident made the allegation. Findings included: Review of a facility policy titled, The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedures, dated 2017, revealed the purpose of the policy was, To facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, document review, and facility policy review, the facility failed to protect 1 (Resident #3) of 4 residents from further potential abuse while an abuse allegation investigation was being conducted. On 10/31/2022, at approximately 7:43 AM, Registered Nurse (RN) #1 sent Certified Nursing Assistant (CNA) #1 home after Resident #3 reported that CNA #1 yelled at the resident and made an inappropriate hand gesture by raising the middle finger. However, the facility allowed CNA #1 to return to work at 9:22 AM before an investigation was completed. Findings included: A review of the facility policy The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedures, dated 2017, revealed the purpose of the policy/procedure was To facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free 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.