Grandview Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documents and policies, and interviews, for one of three residents (Resident #5) reviewed for abuse, the facility failed to ensure a resident was free from mistreatment. The findings include: Based on review of clinical records, facility documents and policies, and interviews, for one of three residents (Resident #5) reviewed for abuse, the facility failed to ensure a resident was free from mistreatment. The findings include: Resident #5 had diagnoses which included dementia, schizoaffective disorder, and bipolar disorder. Record review identified Person #12 was a court appointed Conservator of Person. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of intact cognition, required assistance for ambulation with a rolling walker, and was independent with wheelchair mobility. The Resident Care Plan (RCP) dated 8/14/2025 identified Resident #5 had bipolar…

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

Based on review of facility documentation and interviews for 2 of 4 personnel files reviewed, the facility failed to ensure staff working at the facility were properly screened prior to working. The findings include: A request on 10/14/25 at 10:45 AM to review RN#1 personal files revealed that RN #1 is employed through Nursing Scheduling Agency (NSA), therefore, there were no records on file. ADNS indicated that RN #1 received orientation, which covered workplace compliance, customer service, Resident rights, Abuse/ Neglect, fear of retaliation, workplace violence, and smoking on 10/7/25. Review of personnel files from all contracted scheduling agencies affiliated with the facility along with the facilities nursing schedule, revealed that RN #1 and #3 from NSA began working prior to the completion of their background checks. No background check documentation was found on record for either RN #1 or RN #3. Interview with Person #1 on 10/14/25 at 12:05 PM indicated that the facility is responsible for completing the background checks. He reported NSA only does a driver's licenses…

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, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for a potential allegation of staff-to-resident abuse, Resident #1 was not provided the right to be free from abuse when the resident was yelled at, called inappropriate names, and was attempted to be physically hit by a staff member. The findings include:Resident #1's diagnoses included unspecified fracture of shaft of humerus, left arm, unspecified fracture of left femur, acute pain due to trauma, and adjustment disorder with anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place and time, and was dependent on staff for personal hygiene, toileting hygiene, and lower body dressing. The nurse's progress note dated 9/4/25 at 2:10 PM identified an altercation between Resident #1 and a nurse aide occurred after Resident #1 requested to receive morning care at a specific time. The note indicated that…

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 facility's Personal Funds Account, facility documentation, facility policy, and interviews for 3 of 6 sampled resident (Residents #7, #104, and #114) reviewed for personal funds, the facility failed to honor same day requests for withdrawals of personal funds and failed to provide access to resident funds outside of the facility's posted banking hours. The findings include:1.Interview with Resident #7 on 7/16/2025 at 9:50 AM identified that he/she had a personal fund account with the facility but was unable to take out funds from the account on weekends. Resident # 7 's diagnoses included quadriplegia, anxiety, and chronic pain.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #7 had moderate cognitive impairment. 2. Interview with Resident #104 on 7/22/2025 at 11:21AM identified he/she had a personal fund account with the facility and had been told he/she could not take out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, facility policy, and interviews for 10/122 of sampled residents (Resident #2, #19, #39, #98, #99, #106, #107, #500, #501, #502) reviewed for personal funds, the facility failed notify residents when their accounts were within $200.00 of the Social Security Income (SSI) resource limit and failed to covey personal funds within 30-days of a resident's discharge from the facility. The findings include:Review of the facility's Trial Balance report and interview with the Business Office Manager and Administrator on [DATE] at 1:58 PM identified on [DATE] Residents #2, #19, #39, #98, #99, #106, #107 resided in the facility, were on Medicaid, and had account balances exceeding the SSI resource limits as follows:Resident #2 had an account balance of $1,620.65Resident #19 had an account balance of $1,799.39Resident #39 had an account balance of $2,125.10Resident #98 had an account balance of $2,234.64Resident #99 had an account balance of $1,611.98Resident #106 had an account…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 8 sampled residents (Resident #15, Resident #55, and Resident #58) reviewed for abuse, the facility failed to report or report timely, allegations of abuse. The findings include: 1. Resident #15's diagnoses included encephalopathy, cirrhosis of the liver and a personal history of a traumatic brain injury.Review of the facility Reportable Event (RE) form dated 7/16/25 at 10:00 AM identified Resident #15 reported a staff member placed his hands around his/her neck and used derogatory names towards the resident and his family. The RE indicated a state classification indicating abuse. The Advanced Practice Registered Nurse (APRN) was notified of the incident at 10:30 AM and the RE was signed and dated on 7/16/25 by the Director of Nursing (DNS).The annual Minimum Data Set (MDS) dated [DATE] identified Resident #15 was severely cognitively impaired and required partial/moderate assistance with bed mobility and was…

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 5 of 8 sampled residents (Resident #4, Resident #43, Resident #55, Resident #58, and Resident #59) reviewed for abuse, the facility failed to ensure complete, thorough, and timely investigations were conducted. The findings include:F610 Grandview merged Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 of 8 sampled residents (Resident #4, Resident #43, Resident #55, Resident #58, and Resident #59) reviewed for abuse, the facility failed to ensure complete, thorough, and timely investigations were conducted. The findings include: 1. Resident #4's diagnoses included mononeuropathy, type 2 diabetes, and chronic respiratory failure with hypoxia (low level of oxygen). A nurse’s note dated 6/30/2025 at 2:22 PM by Registered Nurse (RN) #6 identified that LPN #7 informed her that Resident #4 was missing his/her bank card. RN #6 spoke with Resident #4 and was informed…

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 clinical records, facility documentation, facility policy and interviews for 3 of 4 sampled residents (Resident #2, Resident #24, and Resident #45) reviewed for activities, the facility failed to ensure individualized activities were provided to bedbound residents, dependent residents, and failed to ensure activity calendars were revised to reflect actual activities provided. The findings include:1.Resident #2's diagnoses included chronic pain syndrome and pressure induced deep tissue damage of sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment and was totally dependent on staff for bed mobility, washing, dressing, and did not transfer out of bed.The Resident Care Plan dated 6/9/25 identified that Resident #2 needed socialization and self-directed leisure pursuits to support feelings of fulfillment and empowerment. Interventions 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 observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 sampled residents (Resident #6) reviewed for accidents, the facility failed to update the Resident Care Plan with new interventions following falls and failed to complete neurological checks following a fall, for 1 of 4 sampled residents (Resident #27) reviewed for accidents, the facility failed to ensure a safe and effective system was in place during non-medical Leave of Absences (LOA), to account for residents in the event of an emergency, for 1 of 8 sampled residents (Resident #59) reviewed for abuse, the facility failed to follow a physician's order for an assist of 1 staff to keep a resident free from accidents/incidents and for 6 of 31 sampled residents (Resident #1, #31, #33, #85, #91, and #122) reviewed for the environment, the facility failed to maintain an accident free environment for resident with impaired cognition, due to a lack of water temperature monitoring from September 2024…

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, clinical record review, facility documentation, facility policy, and interviews, the facility failed to administer its resources effectively and ensure timely and effective administrative oversight of staff and resident care to maintain the highest practicable physical, mental, and psychosocial well-being of residents. The findings include: The facility administration failed to: Ensure residents were provided with an environment free from verbal abuseEnsure residents were provided with an environment free from involuntary seclusion.Ensure the State Agency was notified, in a timely manner, of events needing to be reported according to the requirement. Ensure allegations of abuse were investigated timely and thoroughly and that staff accused of abuse were removed from the schedule timely. Ensure resident personal needs accounts were managed according to the requirements. Ensure individualized activities were provided to bedbound residents, dependent residents, and failed to ensure activity calendars were revised to reflect actual activities provided.Ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical records, interviews, and review of facility documentation and policy for 5 of 15 residents (Residents #8, 57, 68, 108, & 114) reviewed for physical environment, the facility failed to ensure an effective pest control program was maintained to prevent rodents. The findings include:1. Resident #8's diagnoses included multiple sclerosis, type 2 diabetes, and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Mental Interview for Mental Status (BIMS) of 15 indicative of intact cognition. Interview with Resident #8 on 7/15/2025 at 12:45 PM identified he/she observed mice and ants on 7/14/2025 in his/her room. Further, Resident #8 stated he did not make anyone aware at the time because everyone knows. 2. Resident #57's with diagnoses included diabetes, post-traumatic stress disorder (PTSD), coronary artery disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) 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 observations, review of the clinical record, facility policy, and interviews for 1 of 10 sampled residents (Resident #19) reviewed for Activities of Daily Living (ADLs), the facility failed to identify and implement communication devices for effective communication. The findings include:Resident #19 's diagnoses included hemiplegia (paralysis 1 side) and hemiparesis (weakness on 1 side) following a stroke, sensorineural (neurological) hearing loss on both sides.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was modified independence with cognitive skills and daily decision making, had inattention and disorganized thinking, highly impaired hearing and required assistance with eating, partial moderate assistance with dressing, personal hygiene, transfers, and was independent with bed mobility. Review of the Resident Care Plan dated 6/2/2025 failed to identify Resident #19 had a communication deficit related to highly impaired hearing loss (deafness). A. Observation…

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 2 of 3 sampled residents (Resident #48 and Resident #55) reviewed for advanced directives and for the only sampled resident (Resident #120) reviewed for death, the facility failed to ensure a choice for an advance directive was completed. The findings include: 1. Resident #48’s diagnosis included schizoaffective disorder, metabolic encephalopathy (brain dysfunction), and borderline intellectual functioning. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #48 had a Brief Interview of Mental status score of 15 indicating no cognitive impairment and was independent with Activities of Daily Living (ADL’s) The Resident Care Plan in effect for [DATE] failed to identify a care plan for an advanced directive. A physician’s orders in effect for [DATE] identified that Resident #55 was to be fully coded (receive Cardiopulmonary Resuscitation, CPR) in the event of his/her heart stopping. Interview and review of the clinical…

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 upon review of the clinical record, staff interviews, and facility policy for 1 of 5 sampled resident (Resident #84) reviewed for unnecessary medications, the facility failed to notify the physician of an elevated blood sugar. The findings include: Resident #84's diagnosis included diabetes, schizophrenia, and chronic kidney disease. Review of Resident #84's Medication Administration Record (MAR) for 7/11/25 at 5:25 PM identified a blood sugar level of 331 (normal is 70 - 100). Physician's orders in effect from 7/1/25 through 7/24/25, directed to notify the physician if results of Resident #84's blood sugars were elevated. The order failed to include any blood sugar parameters, which would direct staff, when the physician should be notified. Review of clinical record, nursing notes and physician notes failed to identify that the physician was notified of Resident #84's elevated blood sugar level. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #84 had a Brief Interview of Mental…

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, documents, facility policy, and interviews for 1 of 8 residents (Resident #4) reviewed for abuse, the facility failed to ensure a resident was free from misappropriation of his/her bank card and use of the bank card. The findings include:Resident #4's diagnoses included mononeuropathy, type 2 diabetes, and chronic respiratory failure with hypoxia (low level of oxygen).A nurse's note dated 6/30/2025 at 2:22 PM by Licensed Practical Nurse (LPN) #7 identified that Resident #4 informed her that he/she went to the bank on 6/30/2025 with Person #3 (Resident #4's family member) and noticed his/her bank card was missing and money was missing from his/her bank account. The nurse's note further identified her supervisor, Registered Nurse (RN) #6, was made aware, the Police Department was called, and social services had started an investigation.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had a Brief Interview of Mental Status (BIMS) score of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of the clinical record, and facility policies for 1 of 5 sampled residents (Resident #1) reviewed for nutrition, the facility failed to provide treatment in accordance with standards of care for a resident with heart failure. The findings included: Resident #1's diagnoses included hypertensive heart disease with heart failure, diabetes mellitus, and hyperlipidemia.The Resident Care Plan (RCP) dated 6/23/25 identified Resident #1 had altered cardiovascular status related to hypertension and hyperlipidemia. Interventions included encouraging a low fat low/salt intake and obtain lab testing as needed.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, independent for transfers and toileting, and required substantial/maximal assistance for lower body dressing. Additionally, the MDS identified Resident #1 had a weight gain of 5% or more in the last month or 10% or more in the last 6 months and was not a physician…

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 policy, and staff interviews for 1 of 10 residents (Resident #99) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure fingernail care was provided to a dependent resident. The findings include: Resident #99 diagnoses included dementia, anxiety disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #99 had a BIMS score of 13, indicating no cognitive impairment, and was dependent for showering/bathing and personal hygiene.The Resident Care Plan dated 5/6/2025 identified Resident #99 has an ADL self-care performance deficit related to deconditioning and multiple comorbidities. Interventions include that the resident requires assist of one for bathing.Physician's orders in effect for July 2025 directed staff to provide a shower every Thursday on the day shift and every Sunday on the evening shift. Observation and interview with Resident #99 on 7/15/2025 at 11:53AM 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 observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 sampled residents (Resident #2) reviewed for medication administration, the facility failed to follow the physician's orders to obtain a blood sugar level and failed to administer insulin at the correct time and for 1 of 4 sampled residents (Resident #27) reviewed for pressure ulcers, the facility failed to follow a physician's order for wound care. The findings include: Resident #2 ‘s diagnoses included diabetes with ketoacidosis without coma, and long-term drug therapy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required set up assistance with eating, substantial maximum assistance with upper body dressing and personal hygiene, and was dependent for bed mobility. Additionally, Resident #2 received insulin injections for the previous 7 days. 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 observations, review of the clinical record, facility policy, and interviews for 1 of 10 sampled residents (Resident #19) reviewed for Activities of Daily Living (ADLS), the facility failed to appropriately assess a contracture, failed to initiate splint use to prevent potential worsening of a contracture, failed to correctly code the Minimum Data Set (MDS) related to a contracture, and failed to include the contracture in the Resident Care Plan. The findings include: Resident #19's diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke, muscle weakness, and limitation of activities due to a disability.Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified modified independence with cognitive skills for daily decision making with inattention and disorganized thinking. Further Resident #19 required assistance with eating, partial moderate assistance with dressing, personal hygiene, and transfers. and was independent with bed mobility. The MDS…

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 policy, and interviews for 1 of 5 sampled residents (Resident #9) reviewed for unnecessary medications, the facility failed to ensure a pharmacy recommendation for lab work was completed and failed to include interventions in the Resident Care Plan for the occurrence of behavioral issues, other than to use medications. The findings include:Resident #9's diagnoses included schizophrenia, paranoia, and HIV.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was moderately cognitively impaired and required substantial/maximal assistance with dressing and rolling in bed.A. The Resident Care Plan (RCP) dated 11/29/2024 identified a self-care performance deficit. Interventions included praise efforts, Physical Therapy/Occupation Therapy, and assist of 1 staff with ambulation.Physician's orders in effect from 11/1/2024 and 7/23/2025 directed to administer Dolutegravir lamivudine 50-300 milligrams (mg) 1 tablet by mouth in the morning 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 interviews, review of the clinical record, review of documentation, and facility policy for 1 of 8 sampled residents (Resident #58) reviewed for abuse, the facility failed to revise the Resident Care Plan (RCP) to include allegations of abuse. The findings include:Resident #58's diagnoses included fracture of the left arm humerus, fracture of the left femur, displaced fracture of the right tibia, and acute pain due to trauma.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, did not experience episodes of delusions or verbal behavioral symptoms towards others, and was dependent for his/her personal hygiene and rolling left and right in bed.The Resident Care Plan (RCP) in effect from 5/15/2025 through 7/20/2025 failed to indicate Resident #58 had reported 2 allegations of mistreatment and failed to ensure the RCP had interventions that Resident #58 would be monitored 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 policies and interviews for one (1) of six (6) sampled residents (Resident #1) who were reviewed for an allegation of misappropriation of money, the facility failed to ensure Resident #1's debit card was not removed from the facility by a facility staff member and used without authorization from the resident. The findings include: Resident #1's diagnoses included left total hip replacement and anxiety. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time, and situation. Review of the inventory of personal belongings upon admission identified Resident #1 had a debit card. The nurse's note dated 4/22/25 at 2:25 PM identified the charge nurse was informed by a nurse aide that Resident #1 was upset due to someone having used his/her debit card and spent $300 dollars on the debit card and it was not Resident #1. The note indicated all parties were notified. The nurse's 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 clinical records and staff interviews for 1 of 4 residents (Resident # 68) reviewed for abuse, the facility failed to ensure staff interacted with residents in a dignified manner. The findings include: Resident #68 was admitted with diagnoses that included legal blindness, bipolar disorder, and impulse disorder. A Resident Care Plan (RCP) dated 10/5/2024 identified Resident #68 had the potential to be verbally aggressive, shouting at staff and exhibited anger easily due to poor impulse control and mental/emotional illness. Interventions included: Interventions before agitation escalate, engaging calmly in conversation, and if the resident's response was aggressive, staff were directed to walk calmly away and approach later. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #68 was cognitively intact and exhibited verbal behavioral symptoms directed toward others. An Accident and Incident report (A&I) dated 1/17/2025 indicated Resident #68 had been yelling at staff and 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, policy review and interviews for 1 of 2 residents reviewed for choices (Resident #27), the facility failed to honor the resident's choices regarding personal food. The findings include: Resident #27 was admitted on [DATE] with diagnoses that included a heart attack, diabetes mellitus, and stroke. A physician's order dated 12/27/2024 directed a consistent carbohydrate diet with regular texture and a thin consistency of liquids. The admission MDS assessment dated [DATE] identified Resident #27 was cognitively intact and independent with eating and that having snacks available between meals was somewhat important to the resident On 2/3/2024, an interview with Resident #27 indicated she/he kept personal snacks, noodles, and canned soups in his/her room because she/he did not like the facility's food. The personal food sometimes requires heating. However, Resident #27 indicated two weeks prior to the interview, staff were unwilling to heat up his/her food. Resident #27 further…

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 4 residents for (Resident # 86) reviewed for abuse, the facility failed to ensure the resident was free from physical abuse by (Resident#29). The findings include: 1.Resident #86 's diagnoses included unspecified dementia without behavioral disturbance, difficulty in walking and localized edema. The care plan dated 10/8/2024 identified mood problems related to schizophrenia, Major Depressive Disorder, anoxic brain damage, dementia. Interventions included: to administer medications as ordered, monitor/document for side effects and effectiveness and to have behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #86 was cognitively impaired and dependent on staff for transfers, bed mobility and lower body dressing. 2.Resident # 29's diagnoses included personal progressive neurological condition, cancer, schizophrenia. The MDS quarterly…

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 4 residents for (Resident # 86) reviewed for abuse, the facility failed to implement interventions to prevent further physical abuse from Resident # 29. The findings include: 1.Resident #86 's diagnoses included unspecified dementia without behavioral disturbance, difficulty in walking and localized edema. he nursing progress notes dated 1/08/25 at 1:00 PM noted in part Supervisor called to the unit regarding a resident altercation that resulted in this residents' feet getting run into and over by another resident. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #86 was cognitively impaired and dependent on staff for transfers, bed mobility and lower body dressing. 2.Resident # 29's diagnoses included personal progressive neurological condition, cancer, schizophrenia. The MDS quarterly 10/24/24 identified the resident as cognitively intact, no behaviors exhibited and utilize 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 review of clinical records, observations, facility policy and staff interviews for 2 of 4 residents for ( Residents (#17 and # 42) reviewed for pressure ulcers , the facility failed to ensure staff revised the resident's care plan to reflect the resident's need to offload heels from pressure and current pressure ulcer status. The findings included. 1.Resident #17's diagnosis included diabetes mellitus and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17's cognitive status was severely impaired, the resident was at risk for pressure ulcers and had one unstageable Deep Tissue Injury (DTI) and noted the resident was receiving pressure ulcer care. A physician's order dated 12/18/2024 directed to utilize an offloading boot to the left foot while in bed every shift for off-loading pressure to the left heel. Resident #17's care plan dated 1/15/2025 for resident at risk for exhibiting non-compliance with treatment. Interventions included: to allow the resident 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, facility policy, and staff interview for 1 of 4 residents reviewed for accidents (Residents #32), the facility failed to ensure safe smoking receptables were readily accessible for residents. The findings include: Observations on 2/10/2025 at 9:45 AM of the facility's supervised resident smoke break identified the following: The resident smoke break took place under a covered patio. Seven residents attended the smoking break, all sitting against the edges of the covered patio. There were three metal cigarette disposal receptacles also located at the edges of the covered patio not readily accessible to residents. There were also two staff members supervising the smoking session: a Smoking Monitor and NA #4. Resident #32 was observed smoking one cigarette, and after she/he had finished the cigarette, Resident # 32 was unable to dispose of the cigarette butt. Resident #32 handed the cigarette to the Smoking Monitor, who then disposed of the cigarette butt into a receptacle. An interview with NA#4 indicated residents would ask for assistance to extinguish cigarette…

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, observations, facility policy and interviews for the only sampled resident (Resident #6) reviewed for Respiratory Care, the facility failed to follow physicians order related to oxygen liter flow rate. The findings include: Resident #6 's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Fibrosis and Type 2 diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was moderately cognitively impaired and required moderate assistance with personal hygiene and bed mobility and was independent with eating.The MDS also identified Resident #6 as receiving Oxygen Therapy. The care plan dated 12/20/24 identified Resident #6 is at risk for altered respiratory status/ difficult breathing related to sleep apnea. Interventions in part included: to administers medications as ordered, monitor for signs and symptoms of respiratory distress and shortness of breath. A physician's order dated (facility did not provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and staff interviews for 1 of 5 residents ( Resident #17) reviewed for Medication Regimen Review, the facility failed to ensure target behaviors were being monitored while a resident was receiving psychoactive medications including an antipsychotic medication. The findings include: Resident #17 was readmitted to the facility on [DATE]. A physician's order dated 12/8/2024 directed to provide Rexulti (an antipsychotic medication) 2.0 Milligrams (MG) orally once a day for dementia. A physician's order dated 12/8/2024 directed to provide Trazadone 25 MG by mouth twice daily (an antidepressant). A pharmacist Drug Regimen Review completed on 12/9/2024 indicated the need to add behavioral monitoring with appropriate target behaviors for Resident #17 utilization of psychoactive medications. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #17 as severely cognitively impaired, the resident exhibited physical and verbal behavior towards…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, review of facility documentation, review of facility policy and staff interviews for 1 of 3 residents (Resident #118) reviewed for Environment, the facility failed to ensure a functioning call bell system was in place at the time of admission. The findings include: Resident #118's diagnosis includes Alzheimer's disease. Resident #118 was admitted to the facility on [DATE]. The care plan dated [DATE] indicated Resident #118 had a self-care deficit. Interventions included: to encourage the use of the call bell for assistance. An Occupational Therapy Evaluation and Plan of Treatment dated [DATE] indicated Resident #118's upper extremity function and strength was within functional limits, was independent with eating and noted impaired safety awareness. The plan of treatment also noted impaired fine and gross motor coordination with goals of increasing Resident #118's independence with bathing dressing and toileting. The admission Minimum Data Set (MDS) assessment 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 clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure a privacy curtain was not removed. The findings include: Resident #1's diagnoses included end stage renal disease, psychoactive substance abuse, and major depressive disorder. Record review identified Resident #1 had a court appointed Conservator of Person (COP). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being alert and oriented, required assistance for mobility. The Resident Care Plan (RCP) dated 10/24/2024 identified Resident #1 was at risk for injury to self and others secondary to unsafe smoking practices and had stored smoking supplies on his/her person and/or in his/her room. Interventions directed to provide one-to-one (1:1) staff for supervision, assign a companion to go 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 review, facility documentation review, facility policy review and interviews for two of three residents (Resident #1, #2, and #3) reviewed for accidents, the facility failed to ensure residents on one-to-one observation did not use a vape pen inside the facility and did not have possession of items not permitted in the facility, including knives and a machete. The findings include: 1. Resident #1's diagnoses included end stage renal disease, psychoactive substance abuse, and major depressive disorder. Record review identified Resident #1 had a court appointed Conservator of Person (COP). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being alert and oriented, required assistance for mobility. The Resident Care Plan (RCP) dated 10/24/2024 identified Resident #1 was at risk for injury to self and others secondary to unsafe smoking practices and had…

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

Based on clinical record review, facility documentation review, facility policy review, and interviews for facility Administration review, the facility failed to ensure the facility administered its resources effectively and to ensure effective administrative oversight of staff and resident care timely to maintain the highest practicable physical, mental and psychosocial well-being of residents. The findings include: The facility administration failed to: Ensure residents who were on one-to-one (1:1) observation did not have possession of contraband in the facility. Ensure residents did not smoke vape pens inside the facility. Ensure residents did not have knives of a machete in the facility. Please cross reference F583 and F689. Please cross reference F689 survey exit dates 7/23/2024, 9/17/2024 and 10/9/2024. Interview with Medical Director #1 (MD #1) on 12/11/24 at 9:00 AM identified the facility was experiencing a high level of vaping occurrences among residents. MD #1 stated smoking cessation and counseling were offered, and the residents with multiple occurrences have 1:1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for three (3) of three (3) residents (Resident #1, 3 and 5) reviewed for abuse, the facility failed to ensure the residents were provided social services support timely after abuse within the facility. The findings include: 1. Resident #1's diagnoses included anxiety disorder and hypertension (high blood pressure). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required supervision for bed mobility and was independent with transfers and ambulation. The Resident Care Plan dated 9/10/24 identified that Resident #1 has limited physical mobility related to weakness. Interventions included that the resident is independent with ambulation with the use of a rolling walker. Review of the facility Accident and Investigation (A&I) dated 9/18/24 identified that on 9/18/24 at 2:30 PM, Resident #1 was outside for a scheduled smoke break…

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 three (3) of three (3) residents (Resident #1, 3 and 5) reviewed for abuse, the facility failed to ensure the medical records were complete and accurate to include nursing documentation after incidences of abuse within the facility. The findings include: 1. Resident #1's diagnoses included anxiety disorder and hypertension (high blood pressure). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required supervision for bed mobility and was independent with transfers and ambulation. The Resident Care Plan dated 9/10/24 identified that Resident #1 has limited physical mobility related to weakness. Interventions included that the resident is independent with ambulation with the use of a rolling walker. Review of the facility Accident and Investigation (A&I) dated 9/18/24 identified that on 9/18/24 at 2:30 PM, Resident #1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one of three sampled residents (Resident #6) investigated for allegations of misappropriation of property, the facility failed to ensure that the resident's medication was not misappropriated. The findings include: Resident #6's diagnoses included arthropathy, long term use of opiate analgesics, chronic pain, and schizoaffective disorder, The annual MDS assessment dated [DATE] identified Resident #6 had intact cognition, was independent with eating, required supervision or touching assistance with position changes and mobility. The assessment further identified the resident did not have behaviors, had occasional pain and received scheduled pain medication. The care plan dated 8/8/24 identified Resident #6 had a communication problem related to lower left extremity pain requiring opioid medication with interventions to anticipate and meet needs and allow the resident adequate time to respond 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 clinical record review, review of facility documentation, review of facility policy and interviews for one of three sampled residents (Resident #6) reviewed for misappropriation of property the facility failed to ensure a thorough investigation was conducted for an alleged report of missing narcotic medication. The findings include: Resident #6's diagnoses included arthropathy, long term use of opiate analgesics, chronic pain, and schizoaffective disorder, The annual MDS assessment dated [DATE] identified Resident #6 had intact cognition, was independent with eating, required supervision or touching assistance with position changes and mobility. The assessment further identified the resident did not have behaviors, had occasional pain and received scheduled pain medication. The care plan dated 8/8/24 identified Resident #6 had a communication problem related to lower left extremity pain requiring opioid medication with interventions to anticipate and meet needs and allow the resident adequate time 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 review of facility documentation, review of facility policy and interviews, the facility failed to ensure that controlled medications were safe guarded and periodically reconciled to ensure against diversion of medication. The findings include: Interview with the DNS on 9/12/24 at 1:40 PM identified the Controlled Substance Disposition Records (CSDR) come in duplicate form with the controlled medications. The CSDR yellow form is placed in a box in the supervisor's office, and after the medication is completed, the CSDR white forms, with the administration forms get paired with the yellow form and the medication is reconciled. The DNS indicated that job was part of the ADNS duties and, since the ADNS left over a month ago, no one had been assigned to complete the task of narcotic reconciliation. Interview with the DNS on 9/13/2024 at 12:40 PM identified the facility had not conducted a facility narcotic audit for an undisclosed amount of time. The DNS indicated that the ADNS who left in August of 2024 was responsible for maintaining the narcotic reconciliations, and no one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy for eight of eight sampled residents observed for medication administration, the facility failed to ensure medications were administered on time and according to physician's orders. The findings include: A. Resident #13's diagnoses included Type II diabetes mellitus, nausea with vomiting, gastroesophageal reflux disease. Physician's orders for September 2024 identified the following orders: Flush G-tube with 30 cc water prior to medication administration, 10 cc water between each medication and 30 cc after medication administration every shift Glucerna 1.5-250 ml every 5 hours at 7 am, 12 pm Multi-vitamin tablet give 1 tablet via G-tube one time a day Ondansetron HCL oral solution 4mg/5ml give 10 ml via PEG tube every 8 hours as needed for nausea and/or, 5pm, and 10 pm. No feeds between 11 pm and 7 am. Total volume of 1000mls. Acetaminophen tablet 325mg Give 2 tablet via G-tube every 4 hours as needed for generalized pain. Not to exceed 3 gm in a 24-hour…

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 policy, and interviews for one of three sampled residents (Resident #101) reviewed for facility acquired pressure ulcers, the facility failed to ensure the physician was notified after the development of a pressure ulcer. The findings include: Resident #101 was admitted to the facility on [DATE] with diagnoses that included dementia, anemia, heart failure, thrombocytopenia, malignant neoplasm of the rectum, and presence of ileostomy. The physician's order dated 7/23/24 directed to complete skin monitoring and observation weekly. The skin assessment dated [DATE] identified Resident #101 had intact skin. The Braden scale assessment (used to predict risk for development of pressure ulcer/injury) dated 7/23/24 identified Resident #101 had a score of 16 which is indicative of the resident being at risk for the development of a pressure ulcer. The Resident Care Plan (RCP) dated 7/24/24 identified Resident #101 was at risk for the potential for skin breakdown related…

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, clinical record review, review of facility policy and interviews, for one of seven sampled residents (Resident #94) reviewed for accidents, the facility failed to ensure the care plan was comprehensive to reflect the resident's status of not having a call bell or other hanging items in his/her room. The findings include: Resident #94's diagnoses included Alzheimer's disease, visual hallucinations, anxiety disorder, and schizoaffective disorder. The significant change in status MDS assessment dated [DATE] identified Resident #94 had significantly impaired cognition, behaviors of inattention and disorganized thinking, utilized a walker and required supervision or touching assistance with position changes and ambulation. The care plan dated 7/15/24 identified Resident #94 refused care and had interventions that included: one on one social services support, supervision as needed. The care plan also identified Resident #94 was unaware of safety needs with interventions to be sure the call light…

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, and interviews for one of five sampled residents (Resident #2) reviewed for unnecessary medications, the facility failed to ensure the medication was administered in accordance with the physician's order and for one of three sampled residents (Resident #48) reviewed for possible misappropriation of medication, the facility failed to ensure a medication used to treat anxiety was administered as ordered. The findings include: 1. Resident #2 had diagnoses included dementia, type 2 diabetes mellitus, chronic kidney disease, and anemia. The quarterly MDS assessment dated [DATE] identified Resident #2 had moderate cognitive impairment and required extensive assistance with toileting, hygiene and dressing, was independent with transfers and ambulation and received insulin injections. The RCP dated 5/14/24 identified Resident #2 had diabetes mellitus. Care plan interventions directed to administered diabetic medications as ordered by the physician, monitor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for two of three residents (Resident #68 and #22) reviewed for accidents, the facility failed to ensure residents on 1:1 observation did not have possession of smoking paraphernalia. The findings include: A. Resident #68's diagnoses included end stage renal disease, psychoactive substance abuse, and major depressive disorder. Record review identified Resident #68 had a court appointed Conservator of Person (COP). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #68 was alert and oriented, required assistance for transfers and supervision for mobility with a wheelchair. The Resident Care Plan (RCP) dated 7/23/2024 identified Resident #68 as at risk for injury to self and others secondary to unsafe smoking practices and had stored smoking supplies on his/her person and/or in his/her room. Interventions directed to provide one-to-one (1:1) staff for supervision, assigned a companion to go on 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, review of facility policy, review of facility documentation, and interviews during a review of the Infection Control Program, the facility failed to have the appropriate signage posted for a resident on transmission-based precaution (TBP) and the facility failed to utilize personal protective equipment (PPE) when entering a transmission-based precaution resident's room. Resident #58's diagnoses included type 2 diabetes mellitus, anxiety and polyneuropathy. The annual MDS assessment dated [DATE] identified Resident #58 was cognitively intact, required limited assistance with toileting hygiene, personal hygiene, and dressing. The assessment further identified that the resident was ambulatory, utilized a walker and wheelchair. The physician's order dated 9/6/2024 directed contact precautions secondary to stool for Clostridium difficile (C. diff) ordered and pending every shift. The nurse's note dated 9/9/24 at 6:32 AM identified that Resident #58 remained 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 review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to conduct a thorough investigation and notify the State Agency for a resident identified with smoking paraphernalia on multiple occasions. The findings include: Resident #1's diagnoses included end stage renal disease, non-Hodgkin lymphoma, psychoactive substance abuse, cirrhosis, cerebral infarction, and major depressive disorder. The Resident Care Plan (RCP) dated 4/5/2023 identified Resident #1 was at risk for injury to self and others secondary to unsafe smoking practices (storing smoking supplies on his/her person and/or in his/her room). Interventions directed to have the resident cooperate with staff performing room/belongings search as needed, review facility smoking policy with resident and have resident re-sign smoking contract, conservator to obtain purchases for resident to avoid resident purchasing smoking…

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 #95), reviewed for abuse, the facility failed to ensure a resident was free from abuse. The findings include: Resident #95 had diagnoses that included schizoaffective disorder, anxiety depression, paraplegia, restlessness, and agitation. The care plan dated 2/23/2024 identified Resident #95 had behavior problems related to traumatic brain injury with interventions that directed to praise any indication of progress or improvement in behavior, approach and speak in a calm manner, divert attention, and educate the resident on successful coping and interaction strategies. A physician's order dated 2/23/2024 directed to provide direct supervision from 7:00 A.M. to 11:00 P.M. to Resident #95 when at his/her doorway, when room door is open, or when Resident #1 is out of his/her room for safety. A significant change Minimum Data Set, dated [DATE] identified Resident #95 had…

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 reviewed for abuse, (Resident #5), the facility failed to ensure abuse was reported timely. The findings include: Resident #5 was admitted to the facility with diagnoses that included stroke, dementia and mood disorder. The quarterly MDS dated [DATE] identified Resident #5 had severely impaired cognition, had physical behavioral systems that occurred for one (1) to three (3) days a week, was incontinent of bladder and bowel and required assistance of one staff for ADL's. The care plan dated 10/23/23 identified Resident #5 had impaired social interaction due to dementia and mood disorder with interventions that included to provide assistance with ADL's as needed and that staff would provide positive feedback when Resident #5 would participate with ADL's. The care plan further identified Resident #5 had a diagnosis of dementia with interventions that included to cue, reorient 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for behaviors, (Resident #2), the facility failed to clearly transcribe physician's orders resulting in the lack of administration of an as needed medication for behaviors. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included altered mental status, bipolar disorder and alcohol use. The admission assessment dated [DATE] identified Resident #5 was alert to person and required limited assistance with activities of daily living (ADL). The care plan dated 11/27/23 identified Resident #2 had a behavior problem and psychotic disturbances related to dementia associated with alcoholism with interventions that included to administer medications as ordered and to anticipate and meet Resident #2's needs. A physician's order dated 11/27/23 directed to administer Trazodone 50 mg at bedtime for bipolar disorder. A nursing note dated 11/30/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for behaviors, (Resident #2), the facility failed to provide as needed medications in accordance with physicians orders to address behaviors. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included altered mental status, bipolar disorder and alcohol use. The admission assessment dated [DATE] identified Resident #5 was alert to person and required limited assistance with activities of daily living (ADL). The care plan dated 11/27/23 identified Resident #2 had a behavior problem and psychotic disturbances related to dementia associated with alcoholism with interventions that included to administer medications as ordered and to anticipate and meet Resident #2's needs. A nursing note dated 11/30/23 at 2:39 PM identified she was called to the unit by staff and staff reported Resident #2 pushed Resident #3. Resident #2 was placed on 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for behaviors, the facility failed to document every fifteen (15) minute checks in accordance with the plan of care and physician's orders. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included altered mental status, bipolar disorder and alcohol use. The admission assessment dated [DATE] identified Resident #5 was alert to person and required limited assistance with activities of daily living (ADL). The care plan dated 11/27/23 identified Resident #2 had a behavior problem and psychotic disturbances related to dementia associated with alcoholism. Interventions included to administer medications as ordered and to anticipate and meet Resident #2's needs. A nursing note dated 11/30/23 at 2:39 PM identified she was called to the unit by staff and staff reported Resident #2 pushed Resident #3. Resident #2 was placed…

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 the resident was provided supervision and the correct diet in accordance with physician orders. The findings include: Resident #1 was admitted with diagnoses that included dysphagia pharyngeal stage (difficulty swallowing), multiple sclerosis, dementia, and schizophrenia. The nurse aid (NA) Care Card dated 5/3/2023 identified Resident #1 was on a honey thick puree diet and required one to one supervision with meals. A physician's order dated 9/14/2023 directed to provide Resident #1 with a regular diet, puree texture and honey thick consistency, spoon feed honey thick liquids, 1:1 supervision with meals, give one item at a time, and verbal cues to eat slowly. The annual MDS dated [DATE] identified Resident #1 had severely impaired cognition, was on a mechanically altered diet and required supervision with eating. 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 interviews, review of facility documentation and review of video/pictures provided to the surveyor for a resident's room on one of five units (Resident #371), the facility failed to ensure that the facility was free from pests and housekeeping practices were effective. The findings include: Resident #371's diagnoses included dementia, anxiety, and legal blindness. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #371 had severely impaired cognition, and required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Review of a video and pictures from Person #1 on 11/1/23 identified resident's closet on 9/30/23 at 12:41 PM with clothes items, pair of shoes, white hospital blanket and therapy supplies (foam leg abductor and green item with velcro) laying mixed-up in a pile on the bottom of the closet and some clothes hanging above. Further observation identified in-between those items laying on the bottom of the closet were multiple…

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 one (1) of three (3) Residents (Resident #1), reviewed for medication administration, the facility failed to ensure a physician's order was in place to hold Resident #1's medications. The findings include: Resident #1 was admitted with diagnoses that included central cord syndrome with resultant quadriplegia, contracture of the left and right upper arm, osteoarthritis, chronic pain, atrial fibrillation, and hypertension (HTN). A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and required extensive assistance with one (1) staff for bed mobility, extensive assistance of two (2) staff for transfer and supervision with set up help only for eating. A Resident care plan (RCP) dated 5/2/2023 identified Resident #1 had HTN and altered neurological status and to administer medications as ordered. Physician's orders dated 8/27/2023 directed to administer…

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

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 one (1) of three (3) Residents (Resident #1) reviewed for medication administration, the facility failed to ensure the safe storage of a prescribed medication. The findings include: Resident #1 was admitted with diagnoses that included central cord syndrome with resultant quadriplegia, contracture of the left and right upper arm, osteoarthritis, chronic pain, atrial fibrillation, and hypertension (HTN). A medication self-administration evaluation completed 1/2/2022 identified that Resident #1 was not able to self-administer medications. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and required extensive assistance with one (1) staff for bed mobility, extensive assistance of two (2) staff for transfer and supervision with set up help only for eating. A Resident care plan (RCP) dated 5/2/2023 identified Resident #1 had HTN and altered…

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.