Saint John Paul II Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents ( Resident # 71), reviewed for Preadmission Screening and Resident Review ( PASARR), the facility failed to ensure a newly identified mental health diagnosis was referred to appropriate state- designated mental health authority for a level 2 evaluation. The findings include: Resident #71's diagnoses included schizoaffective disorder, mild cognitive impairment and delusional disorder. Review of Resident # 71 clinical records indicated identified a Level II was done on April 13, 2022, with a qualified diagnosis delusion. Further review of Resident #71 clinical records indicated a new diagnosis of schizoaffective was identified on 10/8/23. However, there was no evidence of a referral submitted to the appropriate state- designated mental health authority for a level 2 evaluation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was severely cognitively impaired.…

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, review of facility policy and staff interviews for 1 of the 3 residents reviewed for Activities of Daily Living (ADL) for (Resident #111), the facility failed to ensure the resident consistently received scheduled showers. The findings include: Resident #111's diagnoses included Guillain-Barre Syndrome (a neuromuscular disease) and muscle weakness. The care plan dated 4/29/2025 identified Resident #111 required assistance to perform activities of daily living, such as bathing and grooming, related to limited mobility. Interventions included helping with transfers with a rolling walker. The quarterly MDS assessment dated [DATE] identified Resident #111 was cognitively intact and required partial/moderate assistance for bathing/showering and partial/moderate assistance for transferring to and from the tub/shower. On 5/6/2025, an interview with Resident #111 indicated his/her shower day was Wednesday on the 3:00 PM to 11:00 PM shift. The resident indicated she/he had 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 review clinical record reviews, observation, facility documents, review of policy and interviews for 1 of 4 residents reviewed for accidents (Resident #38), the facility failed to ensure a physician order was written for a diagnostic x-ray after a fall and for 1 of 1 resident reviewed for positioning (Resident #271), the facility failed to ensure the resident's cervical collar was positioned appropriately. The findings included: 1.Resident #38's diagnosis included dementia with behavioral disturbance and repeated falls. The annual MDS assessment dated [DATE] indicated Resident #38 was severely cognitively impaired, had 2 or more falls since prior assessment with no injury, no impairment of the upper and lower extremities and utilized a walker with supervision or touch assist to walk 10 feet once standing. The care plan in place on 7/30/2024 indicated Resident #38 was at risk for falls due to cognitive loss and lack of safety awareness. Interventions included: provide verbal cues for proper pacing 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, observation, facility policy and staff interviews for the only resident reviewed for Pressure Ulcer (Resident #99), the facility failed to ensure a physician order was obtained for mattress setting for a specialty mattress and failed to ensure licensed staff checked the settings per the facility policy. The findings include. Resident #99s diagnosis include dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #99 was severely cognitive impairment and a stage 3 pressure ulcer that was not present on admission. The care plan dated 4/15/2025 indicated in part Resident #99 was at risk for skin breakdown due to impaired cognition, incontinence, limited mobility, poor safety awareness and noted a Stage 3 pressure ulcer of the right trochanter. Interventions included: to provide a pressure redistribution surface to the chair and bed, to provide wound treatments as ordered and to reposition 4 times per shift. An observation on 5/5/25 at 12:23 PM noted…

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, facility policy review and staff interview for 1 of 4 residents (Resident #117) reviewed for nutrition, the facility failed to ensure weights were obtained per facility policy for a resident with weight loss. The findings include. Resident #117's diagnosis included obesity, dysphagia and aphasia. The electronic documentation section labeled vital signs/weights indicated on 3/4/2025 noted Resident #117 weighed 155.0 pounds. The electronic documentation section labeled vital signs/weights indicated on 4/13/2025 Resident #117 weighed 147.6 pounds (6.4 pounds weight loss in 39 days and no re weight obtained to verify the weight loss). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #117 had severe cognitive impairment, held food in mouth cheeks, weight was 148 pounds with no loss or gain of 5% in the last 30 days or 10% in the last 6 months, and noted the resident was on a mechanically altered diet. The care plan dated 5/6/2025 indicated in part Resident #117…

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 employee files, facility documentation for skills competency and interview for 1 licensed staff (LPN # 8), the facility failed to ensure licensed staff completed clinical competency validations to provide nursing and related services to meet the residents' needs safely for the year 2024. The findings include:. A review of LPN #8's personnel file identified the date of hire as 5/23/23. However, the employee file failed to identify that Clinical Competency Validations were completed for the year 2024 for LPN # 8 and other licensed staff members. The Facility assessment dated [DATE] identified in part, employee competency assessment and education are an integral part of maintaining proper care of Residents. Staff should possess a clear understanding of their scope of practice and the duties they are responsible for daily. Interview with the Director of Nursing Services (DNS) on 5/13/25 at 11:30 AM identified no licensed staff received clinical competency validations for the year 2024. The DNS…

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 and staff interviews for 2 of 5 residents reviewed for (Residents # 26 and # 58) reviewed for vaccinations, the facility failed to obtain an influenza vaccine consent or refusal from the resident's responsible party. The findings include: 1 Resident #26 was admitted to the facility with diagnoses that included [NAME] encephalopathy (a severe neurological condition caused by a Vitamin B1 deficiency). An annual MDS assessment dated [DATE] indicated Resident #26 had severe cognitive impairment A care plan reviewed on 4/14/2025 indicated Resident #26 had a court-appointed conservator with interventions that included involving the conservator in care planning. On 5/7/2025 at 11:50 AM during record review and interview with the facility Infection Preventionist (LPN#5) identified Resident #26's Conservator of Person (COP) had consented to yearly influenza vaccination on 9/25/2023. The resident's immunization record identified that on 10/3/2023, the resident refused the influenza…

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 discharge, the facility failed to provide discharge education for a diabetic resident newly prescribed insulin and failed to ensure medication reconciliation prior to discharge resulting in a resident being discharged home without prescribed medications and supplies. The findings include: a. Resident #1 had diagnoses that included type 2 diabetes mellitus, zoster, lack of coordination, and pneumonia. Review of a hospital note dated 2/16/2025 at 5:23 P.M. by MD #2 identified Resident #1 would start taking a steroid, h/her blood sugars may increase, and to continue with insulin sliding scale. The nursing admission assessment dated [DATE] at 1:49 P.M. by the Assistant Director of Nurses (ADNS) identified care management teaching and training education was not provided. APRN #1's note dated 2/24/2205 at 9:18 P.M. identified Resident #1's blood sugar levels 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 Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for medication administration, the facility failed to ensure the physician was notified when the resident refused medication. The findings include: 1. Resident #1 had diagnoses that included seizures, anxiety, depression, attention-deficit hyperactivity disorder, and gender identity disorder. The care plan dated 10/8/24 identified Resident #1 exhibits or has the potential to demonstrate verbal behaviors related to anxiety, depression, ADHD, gender identity crisis, and Resident #1 is at risk for seizure activity with interventions that directed to medicate as ordered and monitor for effectiveness as well as side effects report to physician as needed and monitor medications especially new/changed/discontinued for side effects and resident's response contributing to verbal behaviors. a) A physician's order dated 10/9/24 directed to administer Primidone 50…

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 develop and implement a comprehensive care plan to address the resident's history of often refusing medications. The findings include: Resident #1 had diagnoses that included seizures, anxiety, depression, attention-deficit hyperactivity disorder, and gender identity disorder. The care plan dated 10/8/24 identified Resident #1 exhibits or has the potential to demonstrate verbal behaviors related to anxiety, depression, ADHD, gender identity crisis, and Resident #1 is at risk for seizure activity with interventions that directed to medicate as ordered and monitor for effectiveness as well as side effects report to physician as needed and monitor medications especially new/changed/discontinued for side effects and resident's response contributing to verbal behaviors. A physician's order dated 10/9/24 directed to administer…

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 clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to ensure a blister pack that contained seven (7) tablets of a controlled medication, Oxycodone, and the controlled disposition sheet were not removed from the facility by a licensed nurse. The findings include: Resident #1's diagnoses included encounter for orthopedic aftercare following surgical amputation, generalized muscle weakness, and pain in unspecified joint. A physician's order dated 8/30/24 directed to administer Oxycodone 5 milligrams (mg) every six (6) hours as needed. Review of the September 2024 Medication Administration Record indicated the Oxycodone was administered on 9/1/24 at 3:10 AM and on 9/6/24 at 12:16 PM for pain. The Facility Reported Incident form dated 9/11/24 identified on 9/8/24 a blister pack of Oxycodone 5mg tablets and the controlled medication disposition sheet for the medication were reported missing from the controlled…

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 clinical record reviews, review of facility policy, review of facility documentation, and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to report an incident to the State Agency when the facility became aware a controlled medication was removed from the facility by a licensed nurse. The findings include: Resident #1's diagnoses included encounter for orthopedic aftercare following surgical amputation, generalized muscle weakness, and pain in unspecified joint. A physician's order dated 8/30/24 directed to administer Oxycodone 5 milligrams (mg) every six (6) hours as needed. The Facility Reported Incident form dated 9/11/24 identified on 9/8/24 a blister pack of Oxycodone 5mg tablets and the controlled medication disposition sheet for the medication were reported missing from the controlled medication lockbox on Unit 1 North. The investigation identified a 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #2, had last seen the blister pack and the controlled…

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 grievances, the facility failed to ensure residents are notified of the grievance resolution. The findings include: Resident #1 was admitted with diagnoses that included overactive bladder, acute kidney failure, chronic diastolic congestive heart failure, anxiety, and depression. The quarterly MDS assessment dated [DATE] identified Resident #1 had intact cognition, was frequently incontinent of bowel, occasionally incontinent of bladder, and required extensive assistance with bed mobility, transfers, personal hygiene, and toilet use. The Resident Care Plan dated 2/14/2024 identified Resident #1 at risk for skin breakdown related to incontinence. Interventions directed to provide preventive skin care with lotions, barrier creams as ordered and observe skin daily with care. The care card dated 2/14/2024 directed to offer Resident #1 incontinent care 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for neglect, the facility failed to ensure a resident who was incontinent of bowel and bladder received incontinent care in accordance to their plan of care resulting in a finding of neglect. The findings include: Resident #1 was admitted with diagnoses that included overactive bladder, acute kidney failure, chronic diastolic congestive heart failure, anxiety, and depression. The quarterly MDS assessment dated [DATE] identified Resident #1 had intact cognition, was frequently incontinent of bowel, occasionally incontinent of bladder, and required extensive assistance with bed mobility, transfers, personal hygiene, and toilet use. The Resident Care Plan dated 2/14/2024 identified Resident #1 at risk for skin breakdown related to incontinence. Interventions directed to provide preventive skin care with lotions, barrier creams as ordered and observe skin 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.

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 neglect, the facility failed to report an allegation of neglect to the state agency within the required time frame. The findings include: Please reference F 600 Resident #1 was admitted with diagnoses that included overactive bladder, acute kidney failure, chronic diastolic congestive heart failure, anxiety, and depression. The quarterly MDS assessment dated [DATE] identified Resident #1 had intact cognition, was frequently incontinent of bowel, occasionally incontinent of bladder, and required extensive assistance with bed mobility, transfers, personal hygiene, and toilet use. The Resident Care Plan dated 2/14/2024 identified Resident #1 at risk for skin breakdown related to incontinence. Interventions directed to provide preventive skin care with lotions, barrier creams as ordered and observe skin daily with care. The care card dated 2/14/2024 directed…

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 3 of 4 residents (Resident #27, 105, 114 and 115) reviewed for care planning, the facility failed invite the resident/resident representative to participate in the care plan meetings. Additionally, the facility failed to ensure that residents who had a diagnosis of dementia were invited to care plan meetings. The findings include: 1. Resident #27 was admitted to the facility on [DATE] with diagnoses that included fibromyalgia and end stage renal disease. The social worker care plan meeting notes dated 6/16/22 - 5/16/23 identified there were 2 meetings during that timeframe, 1 care plan meeting on 6/16/22 with Resident #27 not present and 11/1/22 and Resident #27 was present. The Medicare 5-day MDS dated [DATE] identified Resident #27 had intact cognition. Interview with Resident #27 on 5/9/23 at 10:20 AM indicated he/she has not had a care plan meeting in the last year but met with the social worker a couple of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, review of job descriptions, and interviews the facility failed to ensure the environment was maintained in good repair and a homelike manner and failed to ensure environmental rounds are completed. The findings include: Review of the infection control monthly rounds log identified the last infection control monthly round was completed on 12/22, 5 months ago. Observations on 5/10/23 at 4:00 PM through 5:00 PM with DNS, and LPN #1, on 5/17/23 at 8:04 AM and on 5/17/23 at 9:55 AM with the Director of Maintenance identified the following issues: a. Damaged, chipped, stains and/or marred bedroom walls on One North C wing in rooms 102, 105, 107, and 110. One North A wing in rooms 111, 112, 114, and 120. One North B wing in rooms 123, 124, 125, 126, 127, 129, 131, and 132. Two North A wing in rooms 230, 232, 233, and 235. Two North B wing in rooms 223, 225, 237, 238, 238, 239, 241, 243, and 244. b. Damaged, torn, stains and/or peeling wallpaper in the bedroom 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.

Based on review of facility documentation, facility policy, and interviews for 4 licensed staff (RN #5, RN #6, LPN #4, and LPN #5) the facility failed to ensure background checks were completed prior to hire. The findings include: RN #5 was hired on 8/20/21. RN #5's employee file lacked a complete background check prior to hire and allowing RN #5 to work at the facility. RN #6 was hired on 8/4/14. RN #6's employee file lacked a complete background check prior to hire and allowing RN #6 to work at the facility. LPN #4 was hired on 7/28/20. LPN #4's employee file lacked a complete background check prior to hire and allowing LPN #4 to work at the facility. LPN #5 was hired on 4/28/20. LPN #5's employee file lacked a complete background check prior to hire and allowing LPN #5 to work at the facility. Interview with Human Resources Person (HRP #1) on 5/17/23 at 1:00 PM identified he has been employed by the facility since April 2022. HRP #1 indicated the staff were employed before he started at the facility. HRP #1 indicated the expectation is that a background check is conducted 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, facility policy and staff interviews for 3 of 5 residents (Resident #93 and 115) reviewed for unnecessary medications, the facility failed to review and respond to pharmacy recommendations. The findings include: 1. Resident #93 was admitted to the facility on [DATE] with diagnoses that included dementia, psychosis, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #93 had severely impaired cognition, was always incontinent of bowel and bladder, and required the assistance of 2 or more staff members with transfers, dressing, and toileting. The MDS also identified Resident #93 was receiving hospice care and had a history of falls. The care plan dated 2/2/23 identified Resident #93 was at risk for increased symptoms of delirium related to dementia and psychiatric conditions. The interventions included to monitor medications for side effects. The physician's orders dated 2/1/23 directed to administer Seroquel (an antipsychotic medication…

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 a tour of the Dietary Department with the Food Service Director, and staff interviews the facility failed to provide lunch that was at appropriate temperatures. On 5/10/23 at 1:00 PM, a test tray was conducted. The following was identified: The lunch meal was plated and left the Dietary Department in 3 metal carts at 1:09 PM, arrived on the 2 North Unit and placed in the hall outside of the resident Dining Room at 1:09 PM. Nurse Aides (NA) were then observed to place beverages on the meal trays within the metal carts (juice, coffee and soda) from 1:09 PM to 1:15 PM. At 1:15 PM, the doors were closed to the 3 metal carts. At 1:20 PM, NAs were observed to keep opening the 6 doors to 3 metal carts looking for specific trays by reading the meal tickets. Interview with NA #1 at that time identified that she kept opening the cart doors searching for the resident's who were eating in the Dining Room. Additionally, at 1:30 PM, meal trays were transferred from the short cart to a long cart for residents that were eating in their rooms. The long cart was then noted to be brought 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 a tour of the Dietary Department with the Food Service Director, facility policy and staff interviews, the facility failed to conduct appropriate hand hygiene and maintain the kitchen in a sanitary manner. Tour of the Dietary Department with the Food Service Director on 5/8/23 at 10:33 AM identified the following: 1a. The Unit 2 refrigerator which consisted of milk was noted to have green debris and white drip stains on the bottom shelf. b. Multiple ceiling exterior vent plates noted to have a heavy accumulation of grayish white marks. c. The ceiling vent grille above the shelf that holds the spices, seasonings and coffee machine was noted to have a heavy accumulation of black and brown sediment. d. The flour container labeled with an expiration date of 6/6/23 was noted to have a tannish brown drip stain inside the container. Interview with the Food Service Director on 5/8/23 at 10:33 AM identified the Unit 2 refrigerator should be cleaned once a week but had not been cleaned in three weeks due to short staffing. Additionally, the ceiling exterior vents should be cleaned…

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 review of facility documentation and interviews the facility failed to designate a specific individual (with the required training and qualification) to oversee the infection control program between 1/2023 through 5/2023, (5 months). The findings include: Interview with LPN #1 on 5/11/23 at 12:18 PM identified she has been employed by the facility since 5/8/23 as the Infection Preventionist (IP). LPN #1 indicated she is in the process of going through the infection prevention and control program training to obtain the IP certificate. LPN #1 indicated the DNS and the ADNS are overseeing her at this time. Interview with the DNS on 5/11/23 at 12:40 PM identified she has been employed by the facility since 4/11/23. The DNS indicated the facility has just hired LPN #1 on 5/8/23 as the Infection Preventionist. The DNS indicated that she was aware that the facility did not have a dedicated IP and indicated that the administrative staff, including herself, were all new to the facility and that there have been many changes in management over the past year. The DNS indicated there…

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 1 resident (Resident #105), the facility failed to ensure advance directives were reviewed with the resident or resident representative on admission to ensure that their wishes were honored. The findings include: Resident #105 was admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness, and difficulty walking. The care plan dated [DATE] identified Resident #105 had a decline in cognitive function related to dementia. Interventions included to allow Resident #105 to make daily decisions. The care plan also identified Resident #105 had an established advance directive of full code (full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Interventions included that the resident's expressed advance directive wishes would be activated and followed. The admission MDS dated [DATE]…

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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #107) the facility failed to ensure the physician and conservator were updated of a weight loss in a timely manner. The findings include. Resident #107 was admitted to the facility on [DATE] with diagnoses that included stroke affecting the left non dominant side, aphasia, and dysphasia. a. The Weight and Vital Summary dated 6/20/22 identified Resident #107 weighed 160 lbs. The Weight and Vital Summary dated 6/27/22 identified Resident #107 weighed 147 lbs., a loss of 13 lbs. The Weight and Vital Summary dated 7/1/22 identified Resident #107's weighed 144.2 lbs. Review of progress notes dated 6/20/22 - 7/4/22 failed to reflect that the physician or resident representative had been notified of the residents 15.8 lbs. weight loss. Interview with the Dietitian on 5/11/23 at 9:41 AM indicated from admission Resident #107 received most of his/her nutrition via the feeding tube, with a small…

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, and interviews for 2 of 5 sampled residents (Resident #26 and Resident #94) reviewed for Pre-admission Screening and Record Review (PASARR), the facility failed to obtain approval for long term care placement when the PASARR agency did not approve a long term care stay (Resident #26) and failed to complete a Level 2 determination when the 30-day approval stay expired (Resident #94). The findings include: 1. Resident #26's diagnosis include personal history of suicidal behavior, cognitive communication behavior, borderline personality disorder, major depressive disorder, and bipolar disorder. Resident #26 was admitted to the facility on [DATE]. A PASARR Level 1 screen dated [DATE] identified Resident #26 was referred for a Level 2 onsite evaluation. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was cognitively intact and required supervision with bed mobility, transfers, ambulation dressing and toileting. Additionally,…

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 3 of 5 residents (Resident #9, 91 and 115) reviewed for care planning, for Resident #9 the facility failed to develop a care plan related to a protective head covering, for Resident #91 the facility failed to revise and update the care plan after a fall with injury, and for Resident #115 the facility failed to revise and update care plan according to established timeframes. The findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's early onset, dementia with behavior disturbances, paranoid schizophrenia, and neuroleptic induced Parkinsonism. The quarterly MDS dated [DATE] identified Resident #9 has a conservator of estate and person, had severely impaired cognition, walks with oversite in the corridor without mobility devices, 2 falls with no injury and 2 falls with minor injury for the 3-month reviewed period. The care plan dated 3/21/23 identified…

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 1 of 5 residents (Resident #2) reviewed for unnecessary medications the facility failed to ensure the pharmacy recommendations were followed, and for 1 resident (Resident #79) reviewed for choices, the facility failed to assess the resident for the ability to consume alcohol while a resident at the facility. The findings include: 1. Resident #2 was admitted to the facility with diagnoses that included iron deficiency anemia, gastroparesis, and gastro-esophageal reflux. A physician's order dated 1/19/23 directed to give Aspirin 81 mg and Iron 325mg daily. Pharmacy recommendation dated 2/20/23 recommended to check stool for blood because Resident #2 was on aspirin daily and had an abnormal hemoglobin of 7.3g/dL, (normal range 11.6g/dL - 15g/dL). A physician's order dated 2/21/23 directed to guaiac stool times 3, (the stool guaiac test looks for hidden blood in a stool sample). Review of the TAR dated 2/22/23 -…

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 resident (Resident #81) reviewed for limited range of motion, the facility failed to consistently implement measures and address the residents decline in range of motion to both hands. The findings include: Resident #81 was admitted to the facility on [DATE] with diagnoses that included poly osteoarthritis and spinal stenosis cervical region. The admission MDS dated [DATE] identified Resident #81 had intact cognition, required 1-person physical assistance with hygiene and had no limitation in range of motion to the upper extremities. Review of the OT evaluation dated 2/22/20 identified feeding to continue with supervision, noting fine motor performance skills are performed with mild impairment. The annual MDS dated [DATE] identified Resident #81 had moderately impaired cognition, required extensive 1 person assistance with hygiene and had no limitation of range of motion to the bilateral upper…

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 2 of 5 residents (Resident #49 and 107) reviewed for nutrition, the facility failed to obtain weights and reweights according to professional standards. The findings include: 1. Resident #49 was admitted to the facility on [DATE] with diagnoses that included dementia, dysphagia, and muscle weakness. The quarterly MDS dated [DATE] identified Resident #49 had severely impaired cognition, was always incontinent of bowel and bladder and required the assistance of 2 or more staff members with transfers, dressing, and toileting and required supervision with eating. The care plan dated 3/27/23 identified Resident #49 was at nutritional risk due to dementia and impaired swallow function. Interventions included to monitor for changes in nutritional status including change in intake and unplanned weight loss, report to food and nutrition/physician as indicated, weigh as ordered and notify the Dietitian 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, facility documentation, facility policy, and interviews for 1 resident (Resident #23) reviewed for respiratory therapy, the facility failed to label and date oxygen tubing per facility policy. The findings include: Resident #23 was admitted to the facility with diagnoses that included heart disease and anxiety. A physician's order dated 3/28/23 directed supplemental oxygen to keep saturation levels above 90% every shift for shortness of breath. A physician's order dated 4/25/23 directed to administer Lasix 20 mg once a day indefinitely. The quarterly MDS dated [DATE] identified Resident #23 had moderately impaired cognition and required extensive assistance with dressing and personal hygiene. Additionally, Resident #23 was receiving oxygen therapy at the facility. Observation on 5/8/23 at 11:31 AM and on 5/9/23 at 10:01 AM identified an oxygen concentrator with an oxygen nasal cannula with extension tubing attached lying on the floor not labeled and dated.…

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 1 resident (Resident #27) reviewed for specialized service, the facility failed to monitor fluid intake for a resident on a fluid restriction and per the physician's order. The findings include: Resident #27 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease. A physician's order dated 2/6/22 directed a fluid restriction of 1500 ml per day. The Medicare 5-day MDS dated [DATE] identified Resident #27 had intact cognition and received dialysis. The care plan dated 2/23/22 included interventions to monitor fluid restriction per physician's order. The May 2023 MAR failed to reflect the fluid intake that the resident consumed. Interview with the DNS on 5/11/23 at 12:56 PM indicated she was not able to find any intake sheets from 2/6/22 - 5/11/23, over 1 year, for Resident #27. Interview with the Dietitian on 5/11/23 at 10:23 AM indicated she was not responsible to follow up 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 review of facility documentation, facility policy, and interviews the facility failed to ensure adequate staffing to meet the needs of the residents, including the provision of 1:1 monitoring per the physician's orders. The findings include: 1. Review of the detailed census report dated [DATE] identified the facility census was 124. Review of the daily staffing sheet dated [DATE] identified the facility failed to meet the staffing levels required for direct care staff. Interview with the Administrator on [DATE] at 8:45 AM identified he was not aware of the issue. The Administrator indicated the facility was utilizing the agency for nurse aides and on [DATE] the facility stopped utilizing the agency for nurse aides. The Administrator indicated staffing is very challenging. Interview with the DNS on [DATE] at 2:28 PM identified she was not aware that the daily schedule was not meeting the staffing levels required for direct care staff. The DNS indicated staffing is very challenging in 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 clinical record review, facility documentation, facility policy and staff interviews for 1 of 5 sampled residents (Resident #115) reviewed for unnecessary medications, the facility failed to identify target behaviors for the use of psychotropic medication and failed to order as needed (PRN) psychotropics for only 14 days. The findings include: Resident #115's diagnoses included Parkinson's disease and dementia. The Resident Care Plan dated 9/26/22 identified Resident #115 was at risk for complications related to the use of psychotropic drugs (Nuplazid, Clonazepam, Sertraline). Interventions included to monitor Resident #115 for continued need for medication as related to behavior and mood. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #115 was severely cognitively impaired and required limited assistance of 2 for bed mobility, limited assistance with set up help for eating and extensive assistance of 2 for personal hygiene. The MDS also identified Resident #115 was not…

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 facility documentation, facility policy, and interviews, for 1 resident (Resident #23) reviewed for respiratory equipment, the facility failed to maintain oxygen tubing off the floor when not in use, and for 1 resident (Resident #79) reviewed for infection control, the facility failed to ensure supervision and resident education to maintain infection control when independently caring for his/her gastric tube (g-tube) and colostomy, and the facility failed to monitor and conduct quarterly analysis of infection trends within the facility. The findings include: 1. Resident # 23 was admitted to the facility with diagnoses that included heart disease and anxiety. A physician's order dated 3/28/23 directed supplemental oxygen to keep saturation levels above 90% every shift for shortness of breath. A physician's order dated 4/25/23 directed Lasix 20 mg once a day indefinitely. The quarterly MDS dated [DATE] identified Resident #23 had moderately impaired cognition and required extensive…

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 documentation, review of facility policy, and interviews for 1 of 6 sampled residents (Resident #39) reviewed for Pre-admission Screening and Resident Review (PASARR), the facility failed to ensure that a referral was made to the state designated authority (Maximus) when the pre-approved thirty day stay had expired, which delayed the resident's level II PASARR being completed in a timely manner. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia and Personality disorder. A PASARR level one screen dated [DATE] performed while Resident #39 was in the hospital, identified that the resident was approved for a thirty day nursing facility stay and would require re-screening by or before the thirtieth day if the resident was expected to remain in the nursing facility. The care plan dated [DATE] identified that Resident #39 exhibited distressed/ fluctuating mood symptoms related 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 clinical record review, review of facility documentation, review of facility policy, and interviews for one of five residents reviewed for unnecessary medication (Resident #89), the facility failed to follow the pharmacist recommendation. The findings include: Resident #89's diagnoses included Vascular Dementia with Behavioral Disturbances and Acute Right Intertrochanteric Fracture. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #89 was severely cognitively impaired. A physician's order dated 12/21/20 directed to give Lovenox (an anticoagulant) Solution 40 MG/0.4ML subcutaneously once a day for deep vein thrombosis prophylaxis. Review of the clinical record for Resident#89 identified the pharmacist review dated 12/22/20 directed that the facility have a stop date for the Lovenox or discontinue the therapy if appropriate. The pharmacy report rationale for the recommendation added prolonged use of anticoagulants increase the risk for adverse events. Further review of the…

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