Arden Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and facility policy for one (1) of three (3) sampled residents (Resident #1) reviewed for allegations of neglect, the facility failed to ensure Resident #1 received ongoing podiatry care and timely follow-up after abnormalities were identified requiring follow-up within six (6) to eight (8) weeks. The findings include:Cross-reference F656. Resident #1's diagnoses included mild cognitive impairment, dysthymic disorder (a continuous, long-term form of depression), left foot drop and moderate protein calorie malnutrition.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was dependent on staff for personal hygiene, bed mobility and transfers.A Podiatry note dated 9/22/25 at 9:13 AM identified Resident #1's toenails were thick, yellow, brittle and contained subungual debris (crusty debris under the nail) with diagnoses of Peripheral Vascular…

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) sampled residents (Resident #1) reviewed for behavioral concerns, the facility failed to develop and implement a comprehensive care plan with person-centered interventions to address intrusive behaviors. The findings include: Resident #1's diagnoses included severe dementia with psychotic disturbances (abnormal thinking and perceptions of reality), adjustment disorder with mixed anxiety and depressed mood.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4) and required supervision assistance for transfers and ambulation.The Resident Care Plan (RCP) dated 1/21/26 identified Resident #1 exhibited or was at risk for distressed/fluctuating mood symptoms, had impaired cognitive function related to dementia and impaired communication as evidenced by impaired hearing. Interventions…

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) sampled residents (Resident #1) reviewed for a room change, the facility failed to ensure ongoing social services monitoring for a resident with severe cognitive impairment and psychiatric diagnoses during the seventy-two (72) hour adjustment period after relocation. The findings include:Resident #1's diagnoses included severe dementia with psychotic disturbances (abnormal thinking and perceptions of reality), adjustment disorder with mixed anxiety and depressed mood. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4) and required supervision assistance for transfers and ambulation. The Resident Care Plan (RCP) dated 1/15/26 identified Resident #1 was adjusting to a new memory care environment. Interventions included encouraging reminiscence by discussing meaningful family…

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 three (3) sampled residents (Residents #2, #3, and #4) reviewed for medication administration, the facility failed to administer anxiolytic medications in accordance with the provider's order to prevent the administration of an incorrect, higher dose of a controlled medication and omitting doses of controlled medications. The findings include: 1. Resident #2's diagnoses included vascular dementia with mood disturbances, anxiety disorder and depressive episodes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #2 was alert and oriented and received anti-anxiety, antidepressant and anticonvulsant medications. The Resident Care Plan dated 10/18/25 identified Resident #2 exhibited or was at risk forDistressed or fluctuating mood symptoms related to sadness/depression caused by depressive…

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) sampled residents (Resident #1) who were reviewed for an allegation of abuse and/or neglect, the facility failed to ensure an allegation of neglect was reported to the State Agency when identified. The findings include:Resident #1's diagnoses included epilepsy (a chronic disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), multiple sclerosis (disorder where the body's immune system attacks the protective covering of the nerve cells, disrupting the flow of information within the brain and between the brain and the body and causing muscle weakness, vision changes, numbness and memory issues), repeated falls and adjustment disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating Resident #1 rarely or never made decision…

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) sampled residents (Resident #1) who were reviewed for allegations of abuse and/or neglect, the facility failed to provide documentation the allegations of abuse and/or neglect were thoroughly investigated. The findings include: Resident #1's diagnoses included epilepsy (a chronic disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), multiple sclerosis (disorder where the body's immune system attacks the protective covering of the nerve cells, disrupting the flow of information within the brain and between the brain and the body and causing muscle weakness, vision changes, numbness and memory issues), repeated falls and adjustment disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicating Resident #1 rarely or never made…

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) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure anti-seizure medications were refilled prior to not having a supply available and not borrowing from another resident's supply. The findings include:Resident #1's diagnoses included epilepsy (a chronic disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), multiple sclerosis (disorder where the body's immune system attacks the protective covering of the nerve cells, disrupting the flow of information within the brain and between the brain and the body and causing muscle weakness, vision changes, numbness and memory issues), repeated falls and adjustment disorder. A physician's order dated 5/18/25 directed to administer levetiracetam tablet 1000 milligrams (mg), give one (1) tablet by mouth twice daily for seizures and oxcarbazepine tablet 300 mg,…

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 sampled residents (Resident #2) who received medications that required laboratory monitoring, the facility failed to ensure bloodwork was obtained per the physician's order. The findings include:Resident #2's diagnoses included vascular dementia with mood disturbances, anxiety disorder and depressive episodes. A physician's order dated 8/21/25 directed to administer Depakote sprinkles delayed release oral capsule 125 milligrams (mg), give six (6) capsules by mouth at bedtime for bipolar disorder (chronic mental health disorder causing extreme mood swings ranging from extreme highs to sever lows). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating Resident #2 was alert and oriented and received anti-anxiety, antidepressant and anticonvulsant medications. The Resident Care Plan…

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 #4), reviewed for medication administration, the facility failed to inform the resident of a new diagnosis, discuss available treatment options, and provide education regarding the risks of refusing treatment, thereby failing to support the resident's right to make an informed decision regarding care and treatment. The findings included:Resident #4 was admitted to the facility in March of 2023 and had diagnoses that included type 2 diabetes mellitus, chronic diastolic (congestive) heart failure, and end stage renal disease. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was dependent for bathing, personal hygiene, and oral hygiene.The Resident Care Plan (RCP) dated 2/7/24 identified Resident #4 required total assistance of one with activity of living…

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 clinical records, interviews, facility documentation and facility policy, for one (1) of three (3) residents (Resident #4) reviewed for medication administration, the facility failed to document the removal/wasting of a controlled substance on the Controlled Substance Distribution Record (CSDR); and for two (2) of three (3) residents (Residents #4 and #5) reviewed for medication administration, the facility failed to record the administration of controlled medications on the Medication Administration Record (MAR). The findings included:1.Resident #4 was admitted to the facility in March of 2023 and had diagnoses that included Type 2 Diabetes Mellitus, chronic diastolic (congestive) heart failure, and End Stage Renal Disease. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was dependent with bathing, personal, and oral hygiene.Review of the Resident Care Plan…

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 #4) reviewed for medication administration, the facility failed to administer medications in accordance with provider orders by administering an incorrect dose of a controlled medication and by administering a controlled medication prior to receiving a provider's order. The findings included:Resident #4 was admitted to the facility in March of 2023 and had diagnoses that included type 2 diabetes mellitus, chronic diastolic (congestive) heart failure, and end stage renal disease. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was dependent for bathing, personal hygiene, and oral hygiene.Review of the Resident Care Plan (RCP) dated 2/7/24 identified Resident #4 required total assistance of one with activity of living care for bathing,…

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) sampled residents (Resident #1) who were reviewed for the misappropriation of narcotic medication, the facility failed to ensure a narcotic medication was not removed from the medication cart by a staff member for personal use. The findings include:Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of narcotic medication, the facility failed to ensure a narcotic medication was not removed from the medication cart by a staff member for personal use. The findings include: Resident #1's diagnoses included generalized abdominal pain, interstitial pulmonary disease (a condition that causes inflammation and scarring to the lungs), chest pain on breathing, and anxiety. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for…

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) sampled residents (Resident #3) who required a controlled medication for pain management, the facility failed to ensure that narcotic pain medication was administered per physician's order and documented on accurately. The findings include:Resident #3's diagnoses included chronic pain and type II diabetes mellitus with diabetic polyneuropathy (nerve damage that leads to numbness, tingling, burning pain, loss of coordination). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was alert and oriented to person, place and time. The Resident Care Plan dated 8/11/25 identified that Resident #3 exhibited or was at risk for alterations in comfort related to leg pain secondary to lymphedema. Interventions directed to evaluate pain characteristics, utilizing the pain…

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 facility documentation, facility policy and interviews, the facility failed to ensure Shift Count was conducted by two (2) licensed nurses when the narcotic keys were surrendered from one (1) licensed nursing staff to another and failed to ensure the documentation of narcotics was complete, accurate and unaltered on the Controlled Drug Inventory Sheets. The findings include:The Facility Reportable Incident form dated 9/28/25 identified at 6:00 PM the charge nurse, Licensed Practical Nurse (LPN) #4, notified the nursing supervisor that both a blister pack of oxycodone 5 mg and the corresponding white disposition record sheet were missing from the medication cart and the narcotic count book. The report indicated the medication cart and medication room were searched for the oxycodone and the facility was unable to locate the oxycodone, statements were obtained from all staff who had access to the medication cart, and the Director of Nursing (DON), Administrator, provider, and police were notified. The report identified a new order was placed with the pharmacy to replace 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 six (6) sampled residents (Resident #3) who had a history of wandering and resided on a secured unit, the facility failed to ensure the entrance door to the unit was completely latched (shut tight) so Resident #3 could not exit the secured unit without supervision. The findings include:Resident #3's diagnoses included dementia with agitation, generalized anxiety, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 rarely or never made decisions regarding tasks of daily life and was independent with transfers and ambulating. The Resident Care Plan dated 7/7/25 identified impaired or a decline in cognitive function or impaired thought processes related to dementia. Interventions directed to provide programming on the secured unit, observe and evaluate types of changes in cognitive status, monitor medications for side effects and resident's response contributing 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 the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for wounds, the facility failed to notify the physician when staff did not administer wound treatments. The findings include:a. Resident #1 had diagnoses that included right ankle wound, pressure injuries to the sacral spine, right posterior calf, right medial ankle, and left buttocks, recurrent multifocal osteomyelitis of the right foot and ankle, multiple sclerosis, anemia, depression, anxiety, and chronic pain.The Resident Care Plan (RCP) dated 7/23/2025 identified Resident #1 at risk for skin breakdown related to multiple sclerosis, chronic recurrent osteomyelitis, actual skin breakdown to the right ankle lateral aspect, right heel, right calf, and sacrum. Interventions directed to observe skin condition daily with ADL care and report abnormalities, off load/float heels while in bed with a pillow, pat skin when drying, observe for signs of symptoms of skin…

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 protect the resident's right to be free from neglect when wound treatments were not administered as ordered. The findings includeResident #1 had diagnoses that included a right ankle wound, pressure injuries to the sacral spine, right posterior calf, right medial ankle, and left buttocks, recurrent multifocal osteomyelitis of the right foot and ankle, multiple sclerosis, anemia, depression, anxiety, and chronic pain.The Resident Care Plan (RCP) dated 7/23/2025 identified Resident #1 at risk for skin breakdown related to multiple sclerosis, chronic recurrent osteomyelitis, actual skin breakdown to the right ankle lateral aspect, right heel, right calf, and sacrum. Interventions directed to observe skin condition daily with ADL care and report abnormalities, off load/float heels while in bed with a pillow, pat skin when drying,…

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 abuse, the facility failed to initiate an investigation for an abuse allegation. The findings include: Resident #1 had diagnoses that included right ankle wound, pressure injuries to the sacral spine, right posterior calf, right medial ankle, and left buttocks, recurrent multifocal osteomyelitis of the right foot and ankle, multiple sclerosis, anemia, depression, anxiety, and chronic pain.The admission [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, was occasionally incontinent of bowel, always incontinent of bladder, required substantial assistance with bed mobility, dependent on staff for all ADLs including transfers, was non-ambulatory and dependent on staff for mobility in the wheelchair.The Resident Care Plan (RCP) dated 8/1/2025 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure wanderguard bracelet function was monitored for a resident who was identified at risk for elopement. The findings include: Resident #1's diagnoses included chronic obstructive pulmonary disease, epilepsy, congestive heart failure, major depressive disorder, and anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen (14/15), indicative of being alert and oriented, required assistance with Activities of Daily Living (ADLs) and was independent with mobility in a wheelchair. The Resident Care Plan (RCP) dated 6/17/2025 identified Resident #1 had impaired/declined in cognitive function or impaired thought processes related to attention deficit hyperactivity disorder (ADHD). Interventions directed to observe…

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, interviews, and review of facility policy for 3 of 5 residents (Resident #63, #134, and #153) reviewed for Care Planning, the facility failed to include residents in updating care plans and provide advanced notification of changes to to the resident's care plans. The findings included: 1. Resident #63's diagnoses included End Stage Renal Disease, Dependence on Supplemental Oxygen, and an Acquired Absence of Right Leg Below the Knee. The Resident Care Plan (RCP) dated 10/26/21 identified Resident #63 was independently capable of pursuing his/her own activities. Interventions included informing the resident of facility happenings and checking in to inquire if he/she needed anything. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #63 was cognitively intact, required supervision with bathing, utilized a manual wheelchair for mobilization, and was independent with chair/bed-to-chair transfers. A review of social service progress notes for the time period 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 clinical record reviews, facility policy review and staff interviews for 4 of 6 residents (Residents # 123) reviewed for pressure ulcers and Resident # 136 who utilized a gait belt, and (Resident # 164) reviewed for hydration and (Resident #196) reviewed for discharge, the facility failed to ensure a residents care plans were revised to reflect the needs of each resident and for policy for 3 of 5 residents (Resident #63, #134, and #153) reviewed for Care Planning, the facility failed to provide advanced notice to residents of Care Plan Meetings, provide documentation that Care Plan Meetings were held, and ensure revisions to the care plan to reflected involvement of the resident. The findings included : 1. Resident #123's diagnoses included protein calorie malnutrition, peripheral vascular disease, left below the knee amputation and dementia. A Braden skin risk assessment was completed on 6/9/2024 upon readmission identified at moderate risk for skin break down (score of 13). The quarterly Minimum Data…

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

Based on observations of the kitchen, review of facility documentation, review of policy and staff interviews, the facility failed to ensure the kitchen was clean and sanitary and kitchen equipment was operating properly. The facility also failed to consistently monitor temperature logs and ensure food items were dated and labeled. The findings included: 1 . a. An observation and interview with the Dietary Manager on 2/18/2025 starting at 10:15 AM and ending at 11:15 AM identified water and food debris on the floor under the prep sink area that had two open drains directly draining dirty water onto the kitchen floor near a floor drain. The Dietary Manger identified the sink drain strainer help to keep the food debris from going down the drain was missing and needed to be replaced which caused the drains to empty directly onto the floor and the fluid is expected to reach and go down the floor drain. The Dietary Manager pointed out some tiles on the floor in the prep sink area that were missing from the repeated water buildup. S/he further indicated the facility has no basement 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 and interview for the only sample resident (Resident #449) reviewed for dignity, the facility failed to ensure a urinary collecting device was handled in a manner to maintain dignity. The findings include: Resident #449 's diagnoses included unspecified Obstructive and Reflux Uropathy, unspecified unpacified dementia, moderate, without behavioral disturbance, psychotic disturbance. Mood disturbance and anxiety and Urinary Tract infection (UTI). The admission Minimum Data Set assessment dated [DATE] identified moderately impaired cognition and the resident requires moderate assistance with toileting hygiene, lower and upper body dressing The care plan dated 2/20/2025 identified Resident #449 requires indwelling catheter due to obstructive uropathy. Interventions included providing privacy bags, leg bags when appropriate and providing privacy and comfort. A physician's order dated 2/8/2025 directed to perform indwelling catheter care as needed. Observation of 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.

Based on observations of dining, review of facility policy and interview for 1 of 6 dining rooms, the facility failed to ensure staff provided a homelike dining experience for residents. The findings include: An observation of 2/18/2025 at 12:48 PM identified the dining room area had six tables; two residents seated at four tables, four residents sitting at one table and three residents at another table. There were also three residents ( Residents #53, #71 and #157) in wheelchairs seated on the left of the dining room facing the residents seated and the dining tables, one other resident ( Resident #96) was seated in a wheelchair without a table, facing residents seated at tables on the right side of the dining room area. At 12:50 PM the meal cart arrived to the unit and two nurse aides (NA) initiated serving the meal trays to resident rooms on the unit and two other nurse aides initiated serving the meal trays in the dining room. Residents seated at the dining room tables were served their meals on trays. An interview with NA #1 on 12/18/2025 at 1:00 PM identified she/he worked at…

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, observations, facility documentation, facility policy and interviews for the only sampled resident (Resident #136) reviewed for Physical Restraints, the facility failed to ensure the resident was free from physical restraints. The findings include: Resident #136's diagnoses included Alzheimer disease, paranoid schizophrenia and hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident # 136 as severely impaired and requires maximal assistance with bed mobility, personal hygiene and partial assistance with toilet transfers. The MDS further indicated no restraints utilized. The care plan dated 12/6/2024 identified Resident #136 demonstrates poor body alignment requiring use of custom wheelchair. Interventions included to report for any signs or symptoms of pain, fatigue, discomfort, poor tolerance while in custom wheelchair and report as indicated. The physician's orders failed to reflect an order for Resident #136's pelvic positioning belt. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for 1 of 3 residents (Resident #153) reviewed for pain management, the facility failed to follow physician's orders for pain management. Resident #153's diagnoses included fracture of the left femur, liver disease, and hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #153 had moderate cognitive impairment, was dependent on staff for personal hygiene and dressing, required maximal assistance with rolling left and right in bed, and utilized a manual wheelchair. The Resident Care Plan (RCP) dated 2/12/25 identified Resident #153 was at risk for alterations in mobility related to a left hip fracture. Interventions included : monitoring for pain and stiffness, medicate as ordered, and report to physician as indicated. The RCP further identified Resident #153 was at risk for substance abuse related to a history of addiction. Interventions included observing for evidence of substance use…

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, observations, facility policy and interviews for 1 of 6 (Resident #123) reviewed for Pressure Ulcer/Injury, the facility failed to prevent the re-occurrence of a pressure injury on a resident identified at risk for pressure ulcers and failed to consistently apply a pressure relieving boot while out of bed and failed to consistently turn and reposition the resident ordered and for 2 of 6 residents ( Residents # 67 and # 143) at risk for pressure ulcer development, the facility failed to consistently conduct wound assessments according to facility practice and policy. The findings included: 1.Resident #123's diagnoses included protein calorie malnutrition, Peripheral Vascular Disease (PVD), left below the knee amputation and dementia. A Braden Skin Risk Assessment completed on 6/9/2024 upon readmission identified at moderate risk for skin break down (score of 13). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #123's cognitive status was moderately…

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

Based on observations and staff interview, the facility failed to ensure the oxygen room, the eye washing room that contain medical supplies and soiled linen room were locked appropriately to ensure residents on a secured unit had no access to prevent a potential accident The findings include: a. Observation on 2/18/2025 at 11:46 AM of the secured unit (A/B wing) identified the oxygen room, with 4 oxygen tanks, eye washing room with medical supplies (mask and gloves) and the soiled lining rooms with soiled lining were not locked. Despite the Eye washing room and the Soiled Linen room having coded locks on were not utilized. Observation on 2/18/2025 at 11:53 AM of staff entering Eye washing room and soiled linen room without the benefit utilizing codes. Observation on 2/18/2025 at 12: 15 PM identified residents wandering the hall and holding on the eye washing door to help propel themselves. Interview with DNS and the Regional Clinical Director on 2/18/2025 at 1:56 PM identified all the storage areas should be locked and not accessible to residents. The DNS further indicated 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 review, review of facility documentation, review of policy and staff interviews for 1 of 6 residents (Resident #105) reviewed for nutrition, the facility failed to ensure a nutritional assessment included the resident's food preferences for a resident at risk for nutrition with a significant weight loss. The findings include: Resident #105 was admitted on [DATE] with diagnoses that included diabetes mellitus and Adult Failure to Thrive (a syndrome in older adults characterized by progressive decline in physical and mental functioning). A nutritional assessment dated [DATE] identified Resident # 105's meal preferences were obtained but the information did not indicate any specific resident preferences. The quarterly MDS assessment dated [DATE] indicated Resident #105 as cognitively intact with adequate hearing and clear speech. The MDS assessment further indicated the resident required set-up or clean us assistance for eating and noted the resident had not experienced a significant weight…

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

Based on observations, facility policy review and staff interview for 4 of 8 medication rooms observed (Unit 2A/B and 3 C/D), the facility failed to ensure stock medications were not expired. The findings include: Observation of medication stock rooms located on Unit 2A/B on 2/26/25 at 10:39 AM with RN#6 identified the following expired medications; 1 bottle of Aspirin 325 mg expired 8/24, Carbamide Peroxide ear drops 65% expired 12/24, and 3 Heparin Flush IV syringes expired 11/24. Observation of medication stock rooms located on Unit 3 C/D on 2/26/25 at 10:50 AM with RN #6 identified a bottle of Aspirin 325 mg expired 8/24. In with the Regional Director of Nursing and the Director of Nursing Services on 2/26/25 at 11:00 AM identified the process to ensuring that all medications are not expired consists of the Central Supply Office staff member who stocks the medication rooms look at the expiration dates of the stock. Central Supply Office staff member will move the newest medications to the back and bring the oldest medications to the front to ensure they are used first. However,…

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 policy and interviews for 1 of 1 resident, (Resident #134) reviewed for dental, the facility failed to identify and provide emergency dental services for a resident who dentures were lost. The findings include: Resident #134's diagnoses included vascular dementia, left sided hemiplegia and hemiparesis, and chronic pain syndrome. The Resident Care Plan dated 9/1/23 identified Resident #134 exhibited or was at risk for oral health care. Interventions included monitoring for mouth pain and providing oral hygiene/mouth care twice per day and as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #134 had no cognitive impairment, required clean-up assistance with eating, was at risk for malnutrition, and was dependent with rolling left and right. A provider note dated 12/18/24 identified Resident #134 had no oral or mouth pain and was eating food provided to her/him by the facility. The note further identified the resident had 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.

Based on observations of the linen storage area and staff interviews, the facility failed to ensure clean linens were stored appropriately. The findings include: On 2/25/2025 at 11:30 AM during a tour of the laundry with the Infection Control Nurse (ICN) identified food items in a room containing clean linen for the 11:00 PM to 7:00 AM shift. The linen was stored in open, partially filled linen carts. The food items included an empty can of orange soda, an empty bag of crackers, aluminum foil with yellow residue on it, a can of cashews with cashew crumbs inside, an open single-serve packet of mayonnaise that still contained mayonnaise, an open piece of a red candy cane, two plastic forks with residue, two packets of unopened tea bags, one unopened cough drop, one unopened packet of sugar. The top shelf had two clean incontinence pads and several clean folded towels. On the bottom section of the shelf, there were two clean curtains and a folded, clean fitted sheet. The ICN identified the food items, the medication bottle, and the nail polish should not have been stored there. An…

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, review of the facility Immunization Program and staff interviews for 2 of 4 residents (Residents #110 and # 164) reviewed for vaccination, the facility failed to ensure residents received annual education on influenza vaccines and obtain annual informed consent. The findings include: 1. Resident #110 was admitted on [DATE] with diagnoses that included Alzheimer's disease and heart failure. The quarterly MDS assessment dated [DATE] identified Resident #110 had severe cognitive impairment. A record review and interview with the Infection Control Nurse (ICN) on 2/25/2025 at 11:00 AM failed to identify the administration of an influenza vaccine for the 2024-2025 season and failed to identify a written consent or refusal for the administration of the 2024-2025 influenza vaccine. The ICN was unable to indicate a reason why Resident #110 had not received an influenza vaccine for the 2024-2025 season. 2. Resident #164 was admitted on [DATE] with diagnoses that included dementia 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 facility documentation, review of policy and interviews for 1 of 7 residents ( Resident #102) reviewed for Environment, the facility failed to ensure a three-foot clearance was maintained around a resident's bed. The findings include: Resident #102's diagnosis includes Type 2 diabetes mellitus. The quarterly MDS assessment dated [DATE] indicated in part Resident #102 was moderately cognitively impaired and independent for bed mobility and transfer. An observation on 2/18/25 at 11:33 AM identified Resident #102 asleep in bed. The left side and foot of the bed was noted up against the wall. An observation and interview on 2/25/25 at 1:48 PM with the Administrator identified Resident #102 in bed and asleep with a side of the bed against wall . The resident's foot of the bed close to the wall. After exiting the room, the Administrator indicated she/he had possession of some letters requesting waivers dated 2019 from the previous owner and would locate them for view. A discussion…

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 six of six residents (Resident #3, #5, #6, #7, #8, #9) reviewed for comprehensive care plans, the facility failed to ensure the care plan was reviewed and revised timely to include placement on a secured unit. The findings include: 1. Resident #3's diagnoses included Alzheimer's disease and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had severely impaired cognition and had dementia. The Resident Care Plan (RCP) dated 12/17/2024 identified Resident #3 exhibited physical behaviors related to cognitive loss/dementia. Interventions directed psychiatry/behavioral health, evaluate triggers of physical behaviors, and adjust care delivery appropriately. Clinical record review identified Resident #3 was admitted to the secured unit on 11/27/2024. Record review failed to identify the RCP included placement on a secured unit. 2. Resident #5's diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for six of six residents (Resident #3, #5, #6, #7, #8, #9) reviewed for quality of care, the facility failed to ensure the residents were assessed for clinical criteria that required placement on a secured unit and failed to ensure consent was obtained for the placement. The findings include: 1. Resident #3's diagnoses included Alzheimer's disease and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had severely impaired cognition and had dementia. The Resident Care Plan (RCP) dated 12/17/2024 identified Resident #3 exhibited physical behaviors related to cognitive loss/dementia. Interventions directed psychiatry/behavioral health, evaluate triggers of physical behaviors, and adjust care delivery appropriately. Clinical record review identified Resident #3 was admitted to the secured unit on 11/27/2024. Record review failed to identify an assessment was completed 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, review of facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for the misappropriation of personal property, the facility failed to ensure a controlled medication, Oxycodone, and the controlled disposition sheet were not removed from the facility by a licensed nurse. The findings include: Resident #2's diagnoses included paraplegia (immobility of upper or lower extremities), Depression, chronic pain syndrome, A physician's order dated 6/26/24 directed to administer Oxycodone 5 milligrams (mg), one (1) tablet every eight (8) hours as needed for pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented to person, place and time. The Resident Care Plan dated 8/17/24 identified cirrhosis (liver disease) relating to chronic pain, obesity, and inability to self-turn. Interventions directed to evaluate for pain, and to encourage the resident to request pain…

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, review of facility documentation and interviews for 1 of 3 sampled residents (Resident #2) who were reviewed for the misappropriation of personal property, the facility failed to ensure shift to shift count of the controlled medications was conducted by two (2) licensed nurses when one (1) nurse left before the shift ended and at the change of shift. The findings include: Resident #2's diagnoses included paraplegia (immobility of upper or lower extremities), Depression, chronic pain syndrome, A physician's order dated 6/26/24 directed to administer Oxycodone 5 milligrams (mg), one (1) tablet every eight (8) hours as needed for pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented to person, place and time. The Facility Reported Incident form dated 10/11/24 identified a charge nurse reported she believed a card of controlled medication was missing from the medication cart. The summary report dated 10/18/24 identified on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of abuse, the facility failed to ensure Resident #1 was free from physical and verbal abuse by a staff member. The findings include: Resident #1's diagnoses included a Stage III pressure ulcer on the upper back, type 2 diabetes, and chronic pain syndrome. The admission Minimum Data Set assessment dated [DATE] identified Resident #1's cognition was intact, required moderate assistance with dressing, bathing, hygiene, bed mobility, and had one (1) Stage III pressure ulcer. A physician's order dated 9/14/24 directed to apply gauze soaked with Vashe to the thoracic spine wound bed for ten (10) minutes, pat dry, apply skin prep to the peri wound, apply Aquacel Ag to the wound bed tucking into the undermined areas at three (3) to six (6) o'clock, slightly overlap to peri wound, followed by a bordered foam dressing, and change three (3)…

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 of three sampled residents (Resident #1) who were reviewed for resident rights, the facility failed to ensure Resident #1 was treated with dignity and respect during a conversation with a staff member. The findings include: Resident #1's diagnoses included bipolar disorder, schizophrenia, psychotic disorder, and insomnia. The Resident Care Plan dated 5/25/23 identified Resident #1 was at risk for distressed and fluctuating mood symptoms related to bipolar disorder, anxiety, and depression. Interventions directed to refer to behavioral health specialist as needed, observe for signs of delirium, including delusions/hallucinations, observe for worsening signs/symptoms of existing psychiatric disorder, encourage resident to seek staff support for distressed mood, refocus resident to something positive, and social service visits to provide support as needed. The admission Minimum Data Set assessment 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 on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #2) who exhibited behavioral symptoms towards others and required transfer to the hospital for treatment, the facility failed to notify and provide a thirty (30) day notice of the resident's room change prior to the resident's re-admission to the facility. The findings include: Resident #2's diagnoses included dementia with agitation, Parkinson's Disease, and psychotic disorder with hallucinations due to known physiological condition. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had no memory recall deficits and had not exhibited behavioral symptoms in the past seven (7) days. The Resident Care Plan dated 4/19/24 identified that Resident #2's thought process was impaired due to dementia and the resident would periodically demonstrate verbal and physical outbursts. Interventions directed medications as ordered, psychiatric and behavioral health…

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 #2), reviewed for abuse, the facility failed to ensure a resident was free from abuse. The findings include: Resident #2 diagnoses included aphasia, vascular dementia, major depressive disorder, hemiplegia, and hemiparesis affecting right non-dominant side. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, was always incontinent of bowel and bladder and was dependent on staff for bed mobility, bathing, toileting hygiene, transfers, dressing upper and lower body. The care plan dated 2/23/2024 identified a Resident #2 was at risk for altercations secondary to difficulty verbalizing needs with interventions that directed to involve other disciplines as necessary to address mood or behavior. Review of the Facility's Reportable Event Form identified the date of the event as 2/23/2024 at 4:30 P.M. RN #1 heard yelling and screaming coming from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 the APRN was notified timely of medication omission. The findings include: Resident #1's diagnoses included Epilepsy, Cerebral Palsy, gastrostomy status (with tube feeding), and a history of aspiration pneumonia. The admission nursing assessment dated [DATE] identified that Resident #1 was alert, responsive, incoherent and able to answer yes/no questions, and the medication list was reviewed with the provider. A physician's order dated 2/29/2024 directed nothing by mouth (NPO), and to administer the following medications via gastrostomy tube: Dilantin (used to prevent seizures) 100 milligrams (mg) daily (at 9 AM, Dilantin (used to prevent seizures) 150 milligrams (mg) daily (at 9 PM) PM, Clobazam (used to prevent seizures) 15 mg daily every evening (at 8 PM), and Lamotrigine (used to prevent seizures) 400 mg…

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 policies and interviews for one of two sampled residents (Residents #2 and #3) who were reviewed for an allegation of resident-to-resident sexual abuse, Resident #3 had the right to be free from sexual abuse by Resident #2. The findings include: Resident #3's diagnoses included amyotrophic lateral sclerosis, anxiety, depression, psychotic disorder, and abnormal gait and mobility. The annual Minimum Data Set assessment dated [DATE] identified Resident #3 made reasonable and consistent decision regarding tasks of daily living. The Resident Care Plan dated 12/12/23 identified Resident #3 had anxiety, depression, psychotic disorder, and difficulty with communication. Interventions directed a consistent routine, emotional support, sufficient time for processing and responding, medications, reorientation to maintain reality, reassurance, and encouraging resident to remain calm. The nurse's note dated 12/20/23 at 2:50 AM identified on 12/19/23 at 9:40…

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 policies and interviews for one of two sampled residents (Residents #2 and #3) who were reviewed for an allegation of resident-to-resident sexual abuse, the facility failed to implement interventions to prevent Resident #2 from gaining access to Resident #3's room after a prior incident of sexual misconduct by Resident #2 towards Resident #3. The findings include: Resident #3's diagnoses included amyotrophic lateral sclerosis, anxiety, depression, psychotic disorder, and abnormal gait and mobility. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 made reasonable and consistent decision regarding tasks of daily living. The current Resident Care Plan initiated on 12/19/23 identified Resident #3 had been a target of inappropriate sexual advancement by another resident. Interventions directed social services to provide emotional support and stop sign placement across Resident #3's entrance door. The social service note…

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, and interviews for seven of thirty residents (Resident #1, 10, 11, 12, 13, 16 and 19) reviewed for medication errors, the facility failed to ensure a facility emergency medication supply was maintained, and failed to ensure medications were administered in accordance with physician orders. The findings include: 1. Resident #1's diagnoses included Epilepsy, Cerebral Palsy, gastrostomy status (G-tube for feeding feeding), and a history of aspiration pneumonia. The admission nursing assessment dated [DATE] identified Resident #1 was alert, responsive, incoherent, able to answer yes/no questions, and the medication list was reviewed with the provider. Review of the admission orders from APRN #1 dated 2/29/2024, directed nothing by mouth (NPO), and to administer the following medications via gastrostomy tube: Famotidine (for gastric reflux) 20 milligrams (mg) two times a day, Mirtazapine (treat depression) 7.5 mg at bedtime, Refresh Plus Ophthalmic…

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

Based on observations, facility documentation review, facility policy review, and interviews, the facility failed to ensure medications were stored at proper temperature controls and failed to ensure room temperatures were monitored timely. The findings include: Observation and interview with the DNS #1 and Maintenance Person #1 on 3/7/2024 at 10:04 AM of the medication room identified the room contained two (2) fans which were running, and the room was warm. Maintenance Person #1 verified the room temperature was 84 degrees Fahrenheit. The DNS indicated since the new Pixis was installed, the room temperature had been high, a temperature log was maintained, fans were placed to attempt to cool the room, and that maintenance was installing a portable air conditioner today to reduce the room temperature. The DNS indicated the room temperature was too high. Review of facility documentation identified the OMNI (pharmacy) Inventory list of medication for Omnicell (Pixis) identified the following medications were stored in the Pixis unit: Alprazolam, Amoxiclav, Amoxicillin, Atorvastatin,…

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 policies and interviews for one of three sampled residents (Resident #1) who were reviewed for a change in respiratory condition, the facility failed to notify the physician or Advanced Practice Registered Nurse when the resident required suctioning and the user of an as needed inhaler. The findings include: Resident #1's diagnoses included emphysema, tracheostomy, acquired absence of larynx, dysphagia, vascular dementia, and history of cerebral infarction. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required extensive assistance of one (1) for turning and repositioning when in bed, and Resident #1 did not receive respiratory therapy, oxygen, or suctioning. The Resident Care Plan dated 12/6/23 identified Resident #1 was at risk for respiratory complications. Interventions directed to observe respiratory rate, signs and symptoms of dyspnea, use 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 clinical record reviews, review of facility policy, review of facility documentation, and interviews for one of three sampled residents (Resident #4) who required staff assistance with personal care and were reviewed for an allegation of neglect, the facility failed to reapproach the resident when the resident refused care and inform the licensed nurse the resident had refused care. The findings include: Resident #4's diagnoses included vascular dementia with mood disturbance, diabetes mellitus, and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had no problems with short or long-term memory recall, made reasonable decisions regarding tasks of daily living, required extensive two (2) person assistance for turning and repositioning when in bed and toileting, was frequently in continent of urine and always incontinent of bowel. The Resident Care Plan dated 1/26/24 identified that Resident #4 was at risk for decreased ability to perform 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 reviews, review of facility policy, review of facility documentation, and staff interviews for one of three sampled residents (Resident #4) who were reviewed for an allegation of neglect, the facility failed to ensure the allegation of resident neglect was reported to the Administrator or Director of Nursing at the time the event was reported to the Nursing Supervisor. The findings include: Resident #4's diagnoses included vascular dementia, moderate, with mood disturbance, generalized muscle weakness, and difficulty in walking. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had no problems with short or long-term memory recall, made reasonable decisions regarding tasks of daily living, required extensive two (2) person assistance for turning and repositioning when in bed and toileting, was frequently in continent of urine and always incontinent of bowel. The Facility Reported Incident form dated 2/5/24 identified Resident #4 did not receive evening care…

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 policies and interviews for one of three sampled residents (Resident #1) reviewed for respiratory care, the facility failed to implement interventions in accordance with the resident care plan. The findings include: Resident #1's diagnoses included emphysema, tracheostomy, acquired absence of larynx, dysphagia, vascular dementia, and history of cerebral infarction. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required extensive assistance of one (1) for turning and repositioning when in bed, and Resident #1 did not receive respiratory therapy, oxygen, or suctioning. The Resident Care Plan dated 12/6/23 identified Resident #1 was at risk for respiratory complications. Interventions directed to observe respiratory rate, signs and symptoms of dyspnea, use of accessory muscles indicating respiratory distress, obtain respiratory therapy consult as…

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 policy review, and interviews for one resident (Resident #6) reviewed for resident rights, the facility failed to ensure an alert, oriented, independent resident's rights were honored and failed to ensure the resident was allowed Leave of Absence from the facility. The finding includes: Resident #6's diagnoses included hemiplegia and hemiparesis following cerebral infarct, diabetes mellitus, hypertension, and adjustment disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was alert and oriented and required supervision with locomotion on/off unit. The Resident Care Plan (RCP) dated 9/8/2023 identified Resident #6 was at risk for substance use (alcohol/drugs) related to a history of cocaine use per hospital records/labs. Interventions directed to observe for signs/symptoms of withdrawal for detox, monitor conditions that may contribute to substance use, evaluate need for psych/behavioral health consult, reinforce the need for 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 clinical record review, facility documentation review, facility policy review and interviews for one of five Residents (Resident #2) reviewed for abuse, the facility failed to ensure adequate supervision to ensure residents were free from mistreatment. The findings include: 1. Resident #1 was admitted with diagnoses that included dementia, stroke with resultant right sided hemiplegia (lack of muscle movement on one side of the body) and hemiparesis (muscle weakness on one side of the body). A quarterly MDS assessment dated [DATE] identified Resident #1 was alert and oriented and was independent to walk with a cane. The Resident Care Plan (RCP) dated 8/2/2023 identified Resident #1 had impaired thought and cognitive function. Interventions directed to observe and evaluate changes in cognitive status that included confusion, decision making capabilities and impulsivity and to evaluate the need for psych/behavioral consult. Clinical record review identified Resident #1 was responsible for him/herself.…

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 resident (Resident #6) reviewed for discharge planning, the facility failed to ensure staff conducted adequate discharge planning timely for an independent resident. The finding includes: Resident #6 was admitted during June 2023 with diagnoses that included hemiplegia and hemiparesis following cerebral infarct, diabetes mellitus, hypertension, and adjustment disorder. Clinical record review identified Resident #6 was responsible for him/herself (had no Power of Attorney or court appointed Conservator that was responsible for him/her). Review of the social services notes dated 6/12/2023 at 3:35 PM identified Resident #6 was admitted for an expected short-term stay, and a resident/family conference was initiated, with Resident #6, SW #1, and financial advisor present. Resident #6's expectations for length of stay was 31-100 days. The interdisciplinary team (IDT) determination for projected length of stay…

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 eight residents (Resident #7) reviewed for accidents, the facility failed to ensure an RN assessment was performed timely after a witnessed fall. The findings include: Resident #7's diagnoses included vascular dementia, muscle weakness, chronic pain syndrome, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had moderate cognitive impairment and required extensive with two staff assistance for transfers, and required one staff assistance for ambulation and toilet use. The Resident Care Plan (RCP) dated 9/30/2023 identified Resident #7 had dementia and required assistance with ADLs. Interventions directed to provide moderate assistance for toileting needs and transfers, and to provide cueing for safety and sequencing to maximize current level of function. A facility incident report and investigation dated 10/21/2023 at 10:30 AM identified Resident #7…

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 five Residents, (Resident #3), reviewed for abuse, the facility failed to ensure the clinical record was complete and accurate to include an RN assessment after an allegation of abuse, and for three of eight residents (Resident #6, #7 and #8) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include document when a resident leaves and returns from a leave of absence, the facility failed to ensure a resident fall was documented timely, and the facility failed to ensure attendance/rescheduling of medical appointments were documented in the clinical record timely and failed to ensure a resident's scheduled medical appointments were documented in the clinical record and white out was not used on facility documentation for medical appointment scheduling. The findings include: a. Resident #3 was admitted with diagnoses that included agoraphobia (fear 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 clinical record review, facility documentation, facility policies and interviews for one sampled resident (Resident #1) who was reviewed for an allegation of sexual abuse reported to the facility by hospital personnel, the facility failed to report the allegation to the State Agency at the time the allegation of abuse was reported. The findings include: Resident #1's diagnoses included Alzheimer's disease, dementia, contracture right and left knee, contracture right and left hand. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required extensive assistance with getting in and out of the bed and chair, turning and repositioning when in bed, dressing, toilet use, personal hygiene, had functional limitation in range of motion to the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) on both sides, and was always incontinent of bowel and bladder. The Facility Reported…

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 policies and interviews for one sampled resident (Resident #1) who was reviewed for an allegation of sexual abuse reported to the facility by hospital personnel, the facility failed to initiate an investigation of the allegation of sexual abuse at the time the allegation of abuse was reported. The findings include: Resident #1's diagnoses included Alzheimer's disease, dementia, contracture right and left knee, contracture right and left hand. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required extensive assistance with getting in and out of the bed and chair, turning and repositioning when in bed, dressing, toilet use, personal hygiene, had functional limitation in range of motion to the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) on both sides, and was always incontinent of bowel and bladder. The nurse's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and interviews for one sampled resident (Resi dent #1) who was dependent on staff for activities of daily living, the facility failed to ensure a resident did not sustain injuries of unknown origin. The findings include: Resident #1's diagnoses included Alzheimer's disease, dementia, contracture right and left knee, contracture right and left hand. The Resident Care Plan dated 7/14/23 identified Resident #1 was at risk for falls due to moderate intellectual disability and lack of safety awareness. Interventions directed when in bed, leave bed in a lower position and place the call light within reach while in bed or close proximity to bed. The Resident Care Plan dated 7/14/23 identified Resident #1 required assistance with Activities of Daily Living care in bathing, grooming, personal hygiene, dressing, eating, turning, and repositioning when in bed, getting in and out of the bed and chair, movement on the unit, and toileting. Interventions directed total…

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 2 residents (Resident #175) reviewed for dignity, the facility failed to ensure a urinary device was covered for privacy. The findings include: Resident #175 was admitted to the facility with diagnoses that included cervical mass with lymphadenopathy with invasion to right ureter and right hydro nephrosis. A physician's order dated 5/1/22 directed right nephrostomy tube to gravity drainage every shift for urinary drainage, empty drainage bag every 8 hours and document output. Additionally, change dressing to urostomy insertion site every shift, cleanse with wound cleanser apply dressing every 11:00 PM – 7:00 AM shift. The admission MDS dated [DATE] identified Resident #175 had intact cognition, required extensive assistance for toileting, personal hygiene, and dressing and 2-person assistance with transfers. The care plan dated 5/25/22 identified Resident #175 had a nephrostomy tube 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 review of the clinical record, facility documentation, and interviews for 1 of 4 residents (Resident #143) reviewed for positioning, the facility failed to complete an RN assessment after a change in skin condition. The findings include: Resident #143 was admitted with diagnoses that include hemiplegia/hemiparesis of the left side, diabetes and dementia. A significant change MDS dated [DATE] identified that Resident #143 had severely impaired cognition, required extensive 2-person assistance for bed mobility and personal hygiene and was at risk for developing pressure ulcers. The care plan dated 5/13/22 identified Resident #143 required bilateral leg splints due to contractures, with interventions that included the resident to wear bilateral knee splints morning to evening, caregiver to check skin prior to donning. Additionally, the care plan identified that Resident #143 was at risk for skin breakdown due to bilateral leg splints, impaired sensation, and limited mobility. A nursing progress note 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 2 of 4 residents (Resident #115 and 201) reviewed for pressure ulcers, for Resident #115 the facility failed to have an RN conduct an initial wound assessment when the new wound was identified, and for Resident #201, the facility failed to identify a new pressure ulcer and provide treatments in accordance with professional standards. The findings include: 1. Resident #115's diagnoses included Alzheimer's disease, dementia, anemia, peripheral vascular disease, hypertension and contractures. The care plan dated 4/4/21 identified Resident #115 was at risk for skin breakdown related to actual skin impairment, abnormal posture, weight loss and contractures. Interventions included staff to complete weekly skin assessments to include measurements and stage of wound and provide wound treatment as ordered. The annual MDS dated [DATE] identified Resident #115 had severely impaired cognition, required extensive assistance…

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 3 residents (Resident #16) reviewed for accidents, the facility failed to ensure the resident was assessed by a Registered Nurse after the resident fell out of bed and prior to an LPN moving the resident off the floor. The findings include: Resident #16 was admitted on [DATE] with diagnoses that included dementia and diabetes. The quarterly MDS dated [DATE] identified Resident #16 had severely impaired cognition, required 2-person extensive assistance for transfer, was non-ambulatory and dependent for dressing, toileting, hygiene and eating. The corresponding care plan dated identified Resident #16 was at risk for falls related to dementia, cognitive loss, history of frequent falls and lack of safety awareness. Interventions included to always place call light within reach, when in bed - place all necessary personal items within reach and staff to check if resident had blanket and provide her blanket if needed…

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 and interviews for 1 of 2 residents (Resident #205) who were reviewed for nutrition, the facility failed to follow physician's order to monitor the resident ' s weight. The findings include: Resident #205's diagnoses included hypertension, diabetes, anemia, gastritis, and post feeding tube placement 4/12/22. The admission MDS dated [DATE] identified Resident #205 required extensive assistance with bed mobility, dressing toilet use and personal hygiene and required total assistance with eating. The MDS further identified that the resident had a swallowing disorder that included coughing or choking during meals or when swallowing medications. The care plan dated 5/18/22 identified Resident #205 had a feeding tube to meet nutritional needs because of swallowing difficulties related to brain injury. Interventions included to maintain nothing by mouth to eat, weigh and alert dietitian and physician to any significant loss or gain in weight 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #99) reviewed for food and nutrition services, the facility failed to ensure the resident was not served foods the resident had an allergy to and caused an allergic reaction. The findings include: Resident #99 was admitted to the facility with diagnoses that included fibromyalgia, epilepsy, narcolepsy, and irritable bowel syndrome. The Nutrition assessment dated [DATE] at 11:49 AM by the Dietitian noted liberalized diet in place, multiple food allergies. The quarterly MDS dated [DATE] identified Resident #99 had intact cognition and required supervision for eating. The care plan dated 4/12/22 identified Resident #99 requires assistance for ADL's (activities of daily living). Interventions included to provide the resident with set up for eating. A physician's order dated 4/25/22 directed to provide a regular liberalized diet. The orders indicated the resident had allergies 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 observation interviews and review of the facility policy, the facility failed to store food in sanitary conditions. These findings include: Observation with the Dietary Services Manager on 5/31/22 at 11:00 AM identified that two of the two refrigerators had four (4) opened 32 ounce containers of liquid whole egg gallon without the benefit of a date on the containers. Each container was 1/2 to 3/4s full. Interview with the Dietary Services Manager at the time of the observation identified that all food items should be labeled and dated when opened. She further identified that the food service worker who opens or stores the item, is responsible to label the items. Review of the Facility Policy and Procedure, Food and Nutrition Services use by dating guidelines identified that eggs that are stored in the refrigerator should be dated so a used by date could be established with the day of preparation or opening is considered Day 1 in the use by date. Subsequent to the surveyor's inquiry, the Dietary Services Manager disposed of all unlabeled items on 5/31/22.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure the environment was maintained in a clean, sanitary, and homelike manner. The findings include: 1. Observations on the 2 AB unit on 10/21/19 at 11:00 AM, on 10/23/19 at 1:00 PM and on 10/24/19 at 12:00 PM with the Director of Maintenance and the Maintenance Supervisor identified the following: In the shower stall; a shower head with continuous dripping water. In room [ROOM NUMBER]; a ceiling tile with holes in 2 areas, and a ceiling tile with a large brown stain. In a shared bathroom; a large linear hole in the sheet rock located below and behind the sink. Interview with the Maintenance Supervisor on 10/24/19 at 11:45 PM identified that the maintenance department does not do rounds on each room to inspect the environment because there are so many other repairs to do. The Maintenance Supervisor indicated they rely on staff to inform them of concerns with the environment which is done either…

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 #11) reviewed for range of motion, the facility failed to provide care and services in accordance with professional standards in the assessment and treatment of contractures. The findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia and hemiparesis. A physician's order dated 6/5/18 (and current in October 2019) directed to apply a left elbow extension splint in the morning, and remove at bedtime. Review of an Occupational Therapy Initial Evaluation dated 1/29/19 identified Resident #11 had a right lower extremity knee flexion contracture. The quarterly MDS dated [DATE] identified Resident #11 had severely impaired cognition, was incontinent of bowel and bladder and required total assistance with bed mobility, dressing, and had impairment of range of motion on one side of the upper and lower extremities. The care plan…

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

Based on observations, review of facility policy, and interviews, the facility failed to serve meals in a timely manner to ensure palatable temperatures. The findings include: Interview with the Director of Dietary on 10/24/19 at 9:40 AM identified her expectations for appropriate holding temperatures for meal service range between 125 - 140 degrees Fahrenheit (F). Observation on 10/24/19 on Unit 2C identified the meal truck arrived on the unit at 11:38 AM. A test tray was stored in the meal truck for a total of 47 minutes from time the truck arrived on the unit at 11:38 AM until the last resident was served his/her meal at 12:25 PM. A temperature check of the food on the test tray with the DNS on 10/24/19 at 12:25 PM identified the following food temperatures: a. Pork 114 degrees F. b. Hash brown potatoes 116 degrees F. c. String beans 116 degrees F. Interview with the DNS on 10/24/19 at that time identified she would expect that the residents receive their food within 5 to 10 minutes upon arrival of the food trays on the unit. Review of the food preparation policy identified all…

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, review of facility documentation, facility policy, and interviews, the facility failed to ensure food service in accordance with professional standards. The findings include: 1. Observation on 10/21/19 at 10:00 AM with the Director of Dietary identified Dietary Aide #2 preparing to cook frozen chicken was without the benefit of a hair net. Dietary Aide #2 had approximately 0.5 to 1 inch length hair. Additionally, Dietary Aide #1 was observed washing dishes without the benefit of a beard restraint. Dietary aide #1 had approximately 1 - 2 inch length facial hair. Interview on 10/21/19 at 10:05 AM with the Director of Dietary identified that kitchen staff should utilize hair nets for hair, and beard nets for facial hair while serving/preparing food. Review of the Food and Nutrition Services Policy identified dietary employees will wear hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. Facial hair coverings are used to cover all facial hair. 2. Observation on 10/23/2019 at 12:15 PM during the noon…

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 3 residents (Resident #39) reviewed for abuse, the facility failed to report allegation of abuse to the State agency. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included thoracic spine injury, quadriplegia and chronic pain. The care plan dated 2/18/19 identified Resident #39 was grieving the loss of independence. Interventions included to allow time for expression of feelings, provide empathy, encouragement, and reassurance. Additionally, provide social services visits and support, as needed. A physician's order dated 5/3/19 directed Resident #39 may go on leave of absence (LOA) with non-narcotic medications. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, required extensive assistance of 2 staff for bed mobility and transfers. Additionally, Resident #39 required extensive assist of 1 staff member for personal hygiene and dressing…

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 3 residents (Resident #39) reviewed for abuse, the facility failed to complete a thorough investigation, and failed to take measures to protect the resident while the investigation was in progress. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included thoracic spine injury, quadriplegia and chronic pain. The care plan dated 2/18/19 identified Resident #39 was grieving the loss of independence. Interventions included to allow time for expression of feelings, provide empathy, encouragement, and reassurance. Additionally, provide social services visits and support, as needed. A physician's order dated 5/3/19 directed Resident #39 may go on leave of absence (LOA) with non-narcotic medications. The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, required extensive assistance of 2 staff for bed mobility and transfers. Additionally, 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 review of the clinical record, facility documentation, and staff interview for 1 resident (Resident #752), reviewed for activities of daily living, the facility failed to ensure the resident was offered and provided with a shower according to the care plan and facility policy. The findings include: Resident #752 was admitted to the facility on [DATE] with diagnoses that included pneumonia, hypertension, chronic kidney disease, and heart failure. An initial nursing assessment dated [DATE] indicated Resident #752 was alert and oriented, able to independently move up and down in bed, and able to independently transfer to and from the bed. Skin breakdown or lower extremity edema was not noted. The care plan dated 7/3/19 identified Resident #752 had a problem related to risk for decreased ability to perform care in bathing. Interventions included to provide extensive assistance of 1 for bathing. An intervention dated 7/5/19 indicated choosing a tub bath, shower, or bed bath, or sponge bath was important 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 the clinical record, facility documentation, and staff interview for 1 resident (Resident #752) reviewed for nutrition, the facility failed to ensure daily weights were monitored according to hospital transfer recommendations and physician's orders. The findings include: Resident #752 was admitted to the facility on [DATE] with diagnoses that included pneumonia, hypertension, chronic kidney disease, and heart failure. Review of an Inter-Agency Referral Report dated 7/2/19 identified discharge instructions to obtain daily weights. Additionally, if the resident gains 2 lbs. in 2 consecutive days, start Lasix. A physician's order dated 7/2/19 directed to obtain a weekly weight for 4 weeks, then weigh monthly. An initial nursing assessment dated [DATE] indicated Resident #752 was alert and oriented, able to independently move up and down in bed, and able to independently transfer to and from the bed. Skin breakdown and lower extremity edema was not noted. Review of a weight record dated 7/2/19…

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 staff interview for 1 resident (Resident #68) observed during dining, the facility failed to provide food per resident special request. The findings include: Resident #68's diagnoses included dementia with behavioral disturbances, failure to thrive, dysphagia, anemia, and gastro-esophageal reflux. A significant change MDS dated [DATE] identified Resident #68 had severely impaired cognition, required total assistance with care, and had a weight loss of 5% or more in the last month, or loss of 10% or more in last 6 months. The care plan dated 10/3/19 identified Resident #68 was at nutritional risk related to fluctuating intakes, weight loss, dysphagia and advancing dementia. Interventions included to honor food preferences within meal plan, and to provide diet as ordered. Observation on 10/21/19 at 1:00 PM identified RN #1 was seated at Resident #68's bedside feeding the resident. The lunch tray provided to Resident #68 contained carrots…

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.