Mozaic Senior Life

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #125) reviewed for accidents and hazards, the facility failed to follow physician's orders for a resident with a known behavioral issue. The findings include:Resident #125's diagnoses included Alzheimer's disease, anxiety, and epilepsy.A physician order in effect on 9/22/25 directed staff to follow the Resident Care Plan (RCP) as outlined.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #125 had a Brief Interview of Mental Status (BIMS) score of 0 indicating severely impaired cognition, exhibited verbal and physical symptoms directed towards others 4 to 6 days a week, and was dependent on staff for personal hygiene, dressing, and with chair/bed-to-chair transfers.The Resident Care Plan in effect on 9/22/25 identified Resident #125 was at risk for an activity of daily living problem due to the resident being observed throwing silverware across the table towards…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #21) reviewed for pressure ulcers, the facility failed to complete a timely Registered Nurse (RN) assessment of a pressure ulcer, failed to clarify and follow a physician order for pressure ulcer treatment, and failed to ensure the appropriate air mattress pressure setting according to the Resident Care Plan (RCP). The findings include:Resident #21 had diagnoses that included Alzheimer's disease (dementia), pulmonary fibrosis, and heart failure.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, was at risk for developing pressure ulcers, used a wheelchair, and was dependent for bed mobility and transfers with no noted current pressure ulcers.The Resident Care Plan (RCP) dated 11/21/24 identified Resident #21 had a potential for alteration in skin integrity related to the need for staff assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #228) reviewed for change in condition, the facility failed to prevent a significant (designation based on accepted clinical standards of practice without regard to the status of the resident) medication error for a resident with a transdermal narcotic medication. The findings include:Resident #228 had diagnoses that included progressive neuropathy, asthma, and chronic pain syndrome.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #228 was cognitively intact, required supervision or touching assistance with eating, and substantial/maximal assistance with bed mobility and transfers, and received opioid pain medication. The Resident Care Plan (RCP) dated 4/24/25 identified Resident #228 had a diagnosis of chronic pain. Interventions included to update the physician with new or increased pain, administer medications per current physician orders, and 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 observations, interviews, and facility policy review, for 1 ([NAME] House) of 21 units within the facility failed to safely store medications and biologicals. The findings include:Observation on 9/22/25 at 9:38 AM identified the [NAME] House nurses' station/ medication room door unlocked and the door fully open. The charge nurse was observed at the end of the unit, with her medication cart, out of sight of the medication room door. Observation on 9/22/25 at 11:37 AM identified the [NAME] House nurses' station/ medication room door unlocked and open. The medication cart had been stored in the room and was noted to be unlocked and visible from the hallway. Two residents were self-propelling in their wheelchairs in the hallway, and one visitor was in the dining area outside of the nurse's station/medication room. No staff were visible in the area.Interview and observation with Licensed Practical Nurse (LPN) #2 on 9/22/25 at 11:46 AM identified the facility policy directed medication carts be locked when…

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, review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #21 and Resident #179) reviewed for pressure injury, the facility failed to perform hand hygiene and wound care under clean conditions and for 1 of 2 residents (Resident #250) reviewed for urinary collection devices, the facility failed to maintain appropriate infection control practices. The findings include:1. Resident #21 had diagnoses that included Alzheimer's disease (dementia), pulmonary fibrosis, and heart failure. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, had 1 unhealed Stage 4 pressure ulcer, and was dependent for bed mobility. The Resident Care Plan (RCP) dated 7/17/25 identified Resident #21 had an alteration in skin integrity related to a left gluteal Stage 4 pressure injury. Interventions included having the wound team follow the resident, ensure offloading (pressure reduction), perform…

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 for one (1) of three (3) residents reviewed for medication errors (Resident #1), the facility failed to ensure the five rights of medication administration were followed, and subsequently, a resident was administered an excess of 26 units of the prescribed dose of Humalog insulin (a medication to lower blood glucose levels). The findings include: Resident #1 had diagnoses that included type 2 diabetes mellitus, heart failure, and hypertension. The physician's order dated 4/3/2025 directed to monitor blood sugars before meals and at bedtime and to administer 14 units of Humalog insulin 100 units/ml for blood sugar of 155 or less after meals, for a blood sugar of 155 or greater before meals, at 8:00 A.M., 12:00 P.M. and 5:00 P.M. hold insulin for a blood sugar of 90 or less. The admission [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), was continent of bowel and bladder,…

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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure physician's orders were transcribed and protocols for auditing physician's orders were followed. The findings include: Resident #1 has diagnoses that included Alzheimer's disease, dementia, and disorientation. The quarterly MDS dated [DATE] identified Resident #1 had severely impaired cognition, was on a mechanically altered diet, and required set-up with eating. The care plan dated 3/19/24 identified Resident #1 at risk for unintended weight loss and malnutrition with interventions that directed to provide proper diet chopped with thin liquids and assist with meals as needed. A physician's order dated 4/5/24 directed to provide Resident #1 with a chopped diet with thin liquids. A nurse's note dated 5/26/24 at 1:45 P.M. written by LPN #1 identified Resident #1 was observed coughing while drinking thin liquids 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure readmission medication orders were transcribed accurately, failed to ensure the resident was free from medication errors, failed to ensure staff verified insulin drawn up was the correct dose, and the facility failed to ensure the unit nurse had access to emergency glucagon for a resident having a hypoglycemic event. The findings include: Resident #1's diagnoses included Parkinson's disease, type 2 diabetes mellitus with long term use of insulin, congestive heart failure, major depressive disorder, and psychotic disorder with hallucinations. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented and required extensive assistance with one person assist for ADL's (activities of daily living). The Resident Care Plan (RCP) dated 2/22/2024 identified Resident #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of four (4) residents (Resident #1), reviewed for abuse, the facility failed to ensure a resident(s) was free from physical abuse. The findings include: 1 Resident #2 had diagnoses that included dementia without behavioral disturbance, insomnia. The quarterly MDS assessment dated [DATE] identified Resident #1 was severely cognitively impaired, independent with bed mobility transfers and ambulation. The RCP dated 6/20/23 identified Resident #2 had dementia with exhibited wandering behaviors, agitation and could be abusive towards staff with interventions that directed to provide psychiatric consult as needed to review medications, update the responsible party, always ask for help if the resident became abusive and remove the resident from other resident's rooms or unsafe situations. Physician orders dated 12/12/23 directed Trazadone 25 mg (an antidepressant used to treat agitation) at 1:00 PM 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 clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for abuse, the facility failed to implement the plan of care to ensure a resident was provided the appropriate assistance with bed mobility and application of protective equipment. The findings include: Resident #1's diagnoses included Alzheimer's disease with early onset, functional quadriplegia, and osteoarthritis. A Physician's order dated 1/4/23 directed for the resident to have elbow pads on at all times except during care. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition, functional limitations on both sides of the upper and lower extremities, required total dependence of two staff with bed mobility/transfers, and had no falls since admission. The Resident Care Plan dated 11/1/23 identified Resident #1 had a deficit in activities of daily living (ADL) related to poor body alignment 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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents,(Resident #1), reviewed for accidents, the facility failed to ensure the comprehensive care plan included a resident's resistive behaviors. The findings include: Resident # 1's diagnoses included neurocognitive disorder with Lewy bodies, atrial fibrillation, and congestive heart failure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, required supervision with bed mobility, transfers ambulation on the unit with the use of a walker, one person assist with toileting. The Resident Care Plan dated [DATE] identified Resident #1 had an alteration in activity of daily living (ADL) function and a history of falls with interventions directed to provide assist of one with ambulation with a rolling walker and provide frequent checks to the room for safety. A Physician's orders dated [DATE] directed assist of one with the rolling walker.…

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 for 1 of 3 residents (Resident #228) who was at risk of developing pressure ulcers, the facility failed to ensure measures were in place to prevent development of avoidable pressure ulcers. The findings include: Resident #228's diagnoses included fracture left patella (kneecap) with orthopedic repair, cerebral infarction, osteoporosis, hypokalemia, dementia, and anxiety. The Braden Scale for Prediction of Pressure Sore Risk dated 9/15/23 identified Resident #228 had potential problems related to friction and shearing. Further review identified the resident requires minimum assistance with movement. During a move, the skin probably slides to some extent, against sheets, chair, restraints, or other device. Maintains relatively good position in chair or bed most of the time but occasionally slides down. The resident was identified at risk for pressure ulcers and no interventions were identified. A physician's order dated 9/16/23 directed immobilizer to left lower extremity 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 clinical record reviews, observations, facility documentation, and interviews for 1 of 1 sampled residents (Resident #72) at risk for suicidal ideation, the facility failed to implement the plan of care as directed and ensure the environment remained as free of hazards as possible. The findings included: Resident #72's diagnoses included delusional disorders, major depressive disorders, and unspecified psychosis. Review of the hospital Discharge summary dated [DATE] identified Resident #72 was admitted on [DATE] after cutting him/herself with a shaving razor. Resident #72 indicated hearing multiple people speaking to him/her over the intercom at the nursing facility since 7/6/2023 and stated they constantly chanted his/her name. Resident #72 further identified cutting him/herself with a razor to end his/her life as he/she thought it was the only way to protect his/her money. Further review of the hospital Discharge summary dated [DATE] indicated Resident #72 was on Risperdal and Seroquel in the past but…

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 interview for one of five residents (Resident #204) who was reviewed for Unnecessary Medications, the facility failed to review the pharmacist's recommendations on the medication regimen review documentation. The findings included: Resident #204's diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbance, generalized anxiety disorder, and restlessness and agitation. The Resident Care Plan dated 6/20/23 identified the potential for complications related to antipsychotic medication use. Interventions directed to monitor for hypotension, sedation, anticholinergic and extrapyramidal symptoms. The annual Minimum Data Set assessment dated [DATE] identified Resident #204 had required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. Review of pharmacist recommendations created between 8/1/23 to 8/5/23 and 9/1/23-9/10-23 identified the request to monitor monthly orthostatic blood pressure for current antipsychotic therapy…

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 surveyor observation, record review, and interviews for 4 of 11 sampled medication rooms/carts, the facility failed to secure and store medications appropriately. The findings include: Surveyor observation on 10/16/23 at 11:55AM in the [NAME] House revealed LPN #7, who re-attempted giving medications to a resident in their room that had previously refused, left the medication refrigerator unlocked and the office door open. In the medication refrigerator was ceftriaxone IM and shingrix injection stored. Interview with LPN#7 on 10/16/23 at 11:58 AM identified the medication refrigerator should have been locked prior to leaving to administer the medication, this was not done due to the nurse being nervous with survey being completed. Surveyor observation on 10/16/23 at 12:30PM in the [NAME] House revealed LPN #9 administering medication in the dining area while the medication cart was left unlocked in the office, with the office door unsecured and no other staff present in the office. Interview with LPN#9…

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 surveyor observations, record review and interviews, the facility failed to ensure 1 of 1 staff conducted appropriate glucometer use and cleaning, and completed hand hygiene when changing gloves. The findings include: 1) On 10/16/23 at 11:30 AM observation of LPN # 8 conducting glucometer use to obtain a blood glucose reading via fingerstick. LPN #8 indicated the glucometer is kept on the medication cart with the supplies and is only used for this resident as no other residents require blood glucose reading via fingerstick. LPN #8 brought a cardboard box containing numerous lancets, alcohol wipes and a bottle of glucometer strips into the resident room, placed the box containing these items and a portable sharps container onto this resident bare bedside table without cleaning the table first. Wearing gloves, LPN #8 used a lancet, obtained the drop of blood on the strip, read the reading which was low and repeated the process. LPN #8 removed the used gloves and donned new gloves without conducting hand hygiene between the glove change then went to the medication cart…

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 interview for 1 of 5 residents (Resident #46) reviewed for vaccinations, the facility failed to ensure the pneumococcal vaccine was offered. The findings include: The Minimum Data Set (MDS) dated [DATE] indicated Resident #104 was cognitively intact and the entry for pneumococcal vaccine was not answered. Resident #104's diagnosis included a neurological disorder, heart disease and diabetes. On 10/18/2023 at 9:15 AM an interview, clinical record and facility document review was completed with RN #1. Resident #46 was found not to have documentation of a pneumococcal vaccination consent or declination or evidence the vaccine was offered or given. RN #1 indicated the pneumococcal vaccine form was recently updated reflecting the variety of pneumococcal vaccines that are available and the process for short term and long-term residents are the same and given according to the CDC guidelines with the physician to determine which type of vaccine is needed. RN #1 further indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of six (6) sampled residents (Resident #3, Resident #8 and Resident #11) who were reviewed for abuse, the facility failed to ensure allegations of abuse were reported immediately and notify the state agency of an allegation of abuse in accordance with facility policy. The findings include: 1) Resident #11 had diagnoses that include dementia and major depressive disorder. An annual Minimum Data Set, dated [DATE] identified that the resident severe cognitive impairment, required extensive assistance with activities of daily living, and had no behaviors. A care plan dated 1/18/23 identified that the resident had an alteration in Activities of Daily Living (ADL's) related to dementia with interventions to assist the resident to complete ADL tasks as indicated. A reportable event dated 9/10/23 at 6:23 PM identified that a volunteer had reported that she saw a nurse hit the resident in the arm asking h/her to sit down…

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 clinical record reviews, facility documentation, facility policy and interviews for two (2) of six (6) residents (Resident #3 and Resident #8) who were reviewed for abuse, the facility failed to complete a thorough investigation following an allegation of sexual abuse and in a timely manner. The findings include: 1. Resident #8 was admitted with diagnoses that included Alzheimer's disease and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had severe cognitive impairment, required two person assist with bed mobility, transfers and locomotion using a wheelchair. The Resident Care Plan (RCP) dated 3/3/23 identified Resident #8 had problem in psycho-social wellbeing related to a history of traumatic memories with interventions directed to encourage resident to vent feelings and observe for changes in mood. 2. Resident #3 had diagnoses that included unspecified dementia and disorientation. The RCP dated 4/5/23 identified Resident #3 had required…

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 clinical record reviews, facility documentation, facility policy and interviews for four (4) of twenty-nine (29) residents (Resident #11, Resident #12, Resident #13, and Resident #14) who were reviewed for physician visits, the facility failed to ensure physician visits were conducted according to standard of practice. The findings include: 1. Resident # 11's diagnoses included metabolic encephalopathy and urinary tract infection. The admission History and Physical dated 6/1/23 was completed by the physician one day following admission. The baseline Resident Care Plan (RCP) dated 6/1/23 identified a psychosocial adjustment to the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was without cognitive impairment and required assistance with activities of daily living. Interventions directed to explain all procedures and allow to vent concerns. A review of the physician progress notes dated 6/1/23 through 9/30/23 identified no documented 30-day physician visits…

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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of two (2) residents, (Resident #2), who were reviewed for elopement risk, the facility failed to notify to the responsible party of an elopement occurrence in a timely manner. The findings include: Resident #2 had diagnoses that included dementia, aphasia (difficulty communicating) and delusion disorders. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment, was sometimes understood, and required supervision with unassisted ambulation on and off the unit. The Resident Care Plan dated 7/26/23 identified Resident #2 utilized a wandering device with a history of wandering off the unit, was at risk for falls and a communication deficit related to aphasia with interventions that directed to provide cues and supervision, use a Wander guard (wander device), check the placement each shift, check functioning according to policy and allow time to relay…

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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of six (6) sampled residents who were reviewed for abuse, (Resident #2), the facility failed to ensure a resident was free from sexual abuse. The findings include: 1.Resident #2 had diagnoses that included dementia, aphasia (difficulty communicating) and delusional disorders. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment, was sometimes understood, and required supervision with unassisted ambulation on and off the unit. The Resident Care Plan dated 7/26/23 identified Resident #2 had cognitive loss due to dementia wandering behaviors with interventions that directed to provide gentle touch and speak slowly with short sentences redirect out of peer's rooms. 2.Resident #3 had diagnosis of unspecified dementia. The quarterly MDS dated [DATE] identified Resident #3 had severe cognitive impairment and required one person assist with locomotion on 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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of two (2) residents, (Resident #1), who were reviewed for accidents, The facility failed to ensure the community emergency medical response system was activated for a resident who experienced a suspected significant choking episode and subsequently expired. Resident #1 was admitted with diagnoses that included dementia and osteoarthritis. An Advanced Directive dated 6/19/23 for Resident #1 directed 'Do Not Resuscitate', DNR (no life saving measures in the event one's heart stopped). A physician's order dated 6/19/23 directed a regular diet with thin liquids. A speech screen dated 6/20/23 identified Resident #1 had no speech deficits and showed no signs of dysphagia while eating regular solids with thin liquids. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had moderate cognitive impairment, required two persons assist with bed mobility, transfers, was independent with eating and had no…

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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of five (5) residents, (Resident #2), who was reviewed for abuse, the facility failed to care plan to a reported history of sexual trauma in a timely manner. The findings include: 1) Resident #2 had diagnoses that included dementia, aphasia (difficulty communicating) and delusion disorders. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #2 had severe cognitive impairment, was sometimes understood, and required supervision with unassisted ambulation on and off the unit. A facility reported event dated 8/18/23 identified a Nurse Aide, NA #3 observed another resident, Resident #3 with his/her hand under this Resident #2's shirt. The residents were immediately separated, the Nursing Supervisor was notified and assessed both residents. The Director of Nursing (DNS), responsible party, physician and police were notified. Resident #3 was placed on enhanced supervision with checks every…

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 clinical record reviews, facility documentation, facility policy and interviews for two (1) of six (6) residents (Resident #8) who were reviewed for allegations of abuse, the facility failed to ensure that the social worker assessed the resident after an allegation of abuse. 1) Resident #8 was admitted with diagnoses that included Alzheimer's disease and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had severe cognitive impairment, required two person assist with bed mobility, transfers and locomotion using a wheelchair. The Resident Care Plan (RCP) dated 3/3/23 identified Resident #8 had problem in psycho-social well being related to a history of traumatic memories with interventions that directed to encourage resident to ventilate feelings and observe for changes in mood. 2. Resident #3 had diagnoses that included unspecified dementia and disorientation. The RCP dated 4/5/23 identified Resident #3 had required assistance with activities…

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 clinical record review, Review of facility documentation, review of facility policy and interviews for 1 of 4 sampled residents (Resident #177) reviewed for pressure ulcers, the facility failed to ensure a pressure wound was assessed upon admission, or within 24 hours as per facility policy. The findings include: Resident #177's diagnoses included renal disease, diabetes and weakness. A skin documentation tool dated 9/23/21, with no documentation to identify the author, identified a sacral/coccyx opening and left heel maceration. No measurements were noted on the form. Physician orders dated 9/23/21 directed: Cleanse coccyx wound with normal saline or wound cleanser, apply calcium alginate and dry clean dressing once a day; cleanse left heel wound with normal saline or wound cleanser, apply calcium alginate and apply dry clean dressing daily. The nursing admission assessment dated [DATE], with RN completion date of 9/24/21, identified RN #3 completed the assessment, and identified that the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of policies and procedures, and interviews for 1 sampled resident (Resident #13) reviewed for accidents the facility failed to maintain a safe and hazard free environment. The findings include: Resident #13 's had a diagnosis of Alzheimer's disease and dementia. A quarterly MDS assessment dated [DATE] identified Resident #13 had severe cognitive impairment, required extensive assistance with ambulation and locomotion. The assessment further identified that the resident utilized a wheelchair for mobility and that the resident had sustained two falls in the last three months. The care plan dated 08/21/2021 identified that Resident #13 had a history of falls, ambulates without staff assistance, has impulsive ambulation and has reduced insight for unsafe situations and poor negotiation of obstacles. During a tour of the third floor (D unit) on 11/07/2021 at 6:07 AM resident rooms [ROOM NUMBER] (all the rooms were inhabited) were noted to have the entrance 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.

Based on observation and interview, the facility failed to provide competent staff to ensure resident safety. The findings include: Observation of the third floor E unit on 11/07/2021 at 06:20 AM identified LPN #1 seated at the computer located in the medication room/office. LPN #1 was noted to have her eyes closed and appeared to be asleep. LPN #1 was also noted to be making noises that sounded like snoring. Upon approach by the surveyor, LPN #1 opened her eyes and appeared startled. Interview with LPN#1 following observation identified that she did not offer an explanation for the state she was observed in. She offered no reasons making snoring noises and appearing to be asleep. Interview with RN #2 (day shift supervisor) on 11/08/2021 at 7:12 AM indicated that it was unacceptable for facility licensed staff to sleep while on duty because they are supposed to be readily available to their residents and ancillary staff. Facility employee handbook identified in part; examples of serious types of infractions which were subject to termination included any abuse of residents and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility policy, and interviews for 1 of 4 sampled residents (Resident #182) reviewed for Medication Administration, and for 1 of 11 medication rooms reviewed, the facility failed to ensure insulin vials and pens were dated when opened, and failed to ensure a medication room was secured. The findings include: 1. Resident #182 was admitted to the facility in June 2021 with diagnoses that included type 2 diabetes and diabetic neuropathy. The quarterly MDS assessment dated [DATE] identified Resident #182 had severely impaired cognition, required limited assistance for personal hygiene, toileting, and transfers. The care plan dated 10/20/21 failed to address the resident's diagnosis of diabetes. A physician's order dated 11/5/21 directed to check blood glucose before meals and at bedtime with a sliding scale, give Novolog U-100 insulin 3 units subcutaneous before meals 7:30 AM, 11:30 AM, and 4:30 PM. In addition, the order directed to administer Lantus…

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.