Noble Horizons

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation review, facility policy review, and interviews for 1 of 3 nurse aides (NA#1), reviewed for In-service training the facility failed to ensure the nurse aide received the required In-service training. The findings include: Review of facility documentation and interview with RN #2, Infection control/staff development nurse, on 2/25/2026 at 2:00 PM identified that all NA's are required to receive a minimum of twelve (12) hours of in-service education annually. RN #2 was unable to locate in-service education for NA #1 for 2024 or 2025 that documented that NA #1 received the minimum 12 hours of Inservice education. RN #2 identified that NA #1's education file lacked documentation of education. RN #2 further stated that she should have ensured all the NAs received the minimum of 12 hours annually and had sent an email to the DNS that NA #1 had not completed the 12-hour requirement each year. She could only locate educational documents for NA #1 from 2016. Interview with the DNS 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 review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 2 of 2 sampled residents (Residents #27 and Resident #104) reviewed for Advance Directives, the facility failed to ensure the resident/resident representative were educated and the residents wishes were identified. The findings include1.Resident #27 had diagnoses that included a stroke with memory, speech, and language deficits and dementia. a. A nurse's note dated [DATE] at 4:04 PM identified Resident #27 was admitted to the facility with complaints of weakness to the right side of his/her body. Resident #27 is alert, essentially oriented, but per report he/she has some confusion at night. Review of the nurse's notes and social worker notes dated [DATE] through [DATE] failed to provide documentation that Person #1 (power of attorney) was provided with education on advance directives and that the code status form was signed to identify the resident or resident representative's wishes.…

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 4 residents (Resident # 71) reviewed for medication administration, the facility failed to ensure the physician and resident representatives were notified of medication omissions. The findings include: Resident #71 had diagnoses that included stoke, Parkinson's disease, depression, and cancer.The Resident Care Plan dated 1/18/25 identified Resident #71 had a diagnosis of Parkinson's disease ( neurological disorder that causes a depletion in circulating dopamine levels in the brain) with interventions that directed to monitor for signs and symptoms of shuffling gait, pill rolling tremors, lip smacking, loss of voluntary movements, blank facial expressions, drooling, difficulty swallowing, feeling weak, easily fatigued, feeling heavy and stiff, and notify physician if any changes.The physician's orders dated 1/19/26 directed to administer Acyclovir (antiviral) 200 milligram (mg) twice a day;…

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 review, facility policy review, and interviews for one (1) of three (3) residents (Resident #10) reviewed for accidents, the facility failed to report an injury of unknown origin. The findings include:Resident #10 was admitted with diagnoses that included dementia, chronic obstructive pulmonary disease (COPD), systemic lupus erythematosus (lupus- a chronic autoimmune disease where healthy tissue was inflamed and damaged) and peripheral vascular disease (arteries in leg and arms become blocked).The RCP dated 9/20/3035 identified Resident #10 was at risk for impaired skin due to fragile skin secondary to long term steroid use with interventions that included to monitor skin with transfers and during care reporting any changes.The significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/6/2025 identified Resident # 10 had a Brief Interview for Mental Status (BIMS) score of 11 indicative of moderately impaired cognition, required substantial assistance for transfer 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.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents (Resident #10) reviewed for accidents, the facility failed to complete a thorough investigation for an injury of unknown origin. The findings include: Resident #10 was admitted with diagnoses that included dementia, chronic obstructive pulmonary disease (COPD), systemic lupus erythematosus (lupus- a chronic autoimmune disease where healthy tissue was inflamed and damaged) and peripheral vascular disease (arteries in leg and arms become blocked).The RCP dated 9/20/3035 identified Resident #10 was at risk for impaired skin due to fragile skin secondary to long term steroid use with interventions that included to monitor skin with transfers and during care reporting any changes.The significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/6/2025 identified Resident # 10 had a Brief Interview for Mental Status (BIMS) score of 11 indicative of moderately impaired cognition, required substantial…

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 the clinical record, facility documentation, facility policies, and interviews for one (1) of five (5) residents (Resident #4) reviewed for unnecessary medications, the facility failed to develop and implement a comprehensive care plan to address the resident's diagnosis of dementia. The findings include:Resident #4 was admitted with diagnoses that included dementia, presence of right artificial knee joint, age related cognitive decline, diabetes mellitus, and hypertension.The admission orders dated 8/21/25 identified Resident #10 had a diagnosis of dementia.The nursing admission note dated 8/21/2025 at 4:14 PM identified Resident #10 had diagnoses that included weakness, diabetes, chronic kidney disease, and dementia. The note further identified Resident #10's family provided consent for psychiatric evaluation.The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/28/25 identified that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition, and an active diagnosis 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 review, facility policy review and interviews for 1 of 4 residents (Residents #71) reviewed for medication administration, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: Resident #71 had diagnoses that included stoke, Parkinson's disease, depression, and cancer. The Resident Care Plan dated 1/18/25 identified Resident #71 had a diagnosis of Parkinson's disease ( neurological disorder that causes a depletion in circulating dopamine levels in the brain) with interventions that directed to monitor for signs and symptoms of shuffling gait, pill rolling tremors, lip smacking, loss of voluntary movements, blank facial expressions, drooling, difficulty swallowing, feeling weak, easily fatigued, feeling heavy and stiff, and notify physician if any changes.The physician's orders dated 1/19/26 directed to administer Acyclovir (antiviral) 200 milligram (mg) twice a day; Amlodipine (used to lower…

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

Based on review of facility documentation, facility policy and interviews for three (3) of three (3) nurse aides (NA #1, NA #2 and NA #3), the facility failed to complete performance reviews at least once every 12 months as required. The findings include: Review of NA #1's personnel file identified a hire date of 11/14/2008. NA#1 was listed on the current nursing staff contact list.Review of NA #2's personnel file identified a hire date of 7/6/1992. NA# was listed on the current nursing staff contact list. Review of NA #3's personnel file identified a hire date of 7/17/2001. NA# was listed on the current nursing staff contact list. Interview with the Administrator on 2/25/26 at 10:00 AM identified that the Director of Nursing (DNS) is responsible for ensuring annual performance reviews are completed. The Administrator stated he was not surprised that NA #1, NA #2, and NA #3 had not received recent performance reviews because there had been recent transition in the DNS position. due to a recent transition in the DNS position. Interview and review of the employee files with the Human…

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: 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: Develop and implement a water management plan.Prevent and mitigate Legionella growth in the facility's water.Ensure the State Agency was notified, in a timely manner, of reportable events.Ensure injuries of unknown…

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 the clinical records, facility documentation, facility policy, and interviews, the facility failed to ensure the antibiotic stewardship program included a process for tracking antibiotic use, protocols, trends, and outcomes, and failed to develop, promote, and implement a facility-wide system to monitor the use of antibiotics. The findings include: Interview and review of the facility infection control program with RN #2 (Infection Preventionist) on 2/25/26 at 11:30 AM identified the facility does not maintain current or complete tracking of antibiotic use. RN #2 identified she has not implemented antibiotic stewardship principles to reduce adverse events, including antibiotic-resistant organisms, resulting from unnecessary or inappropriate antibiotic use. RN #2 identified the facility does not have a facility-wide system to monitor antibiotic use.Interview with RN #2 on 2/25/26 at 12:28 PM identified the facility uses a 3-day urine protocol (a diagnostic or surveillance approach focused on indwelling catheters) to prevent overuse of antibiotics; however, no other…

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 record, facility policy, facility documentation, and interviews for 3 of 5 residents (Resident #9, #26, and #100) reviewed for pneumococcal immunizations, the facility failed to ensure the resident and/or resident representatives were educated and given an opportunity to consent or decline the pneumococcal vaccine and for 1 of 5 residents (Resident #26) reviewed for influenza immunizations, the facility failed to offer the influenza immunization to the resident upon admission. The findings include: 1.Resident #9 was admitted to the facility on [DATE] and had diagnoses that included hypertension, stroke, and arthritis.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 had intact cognition and Resident #9 had received the pneumococcal vaccine.Review of Resident #9's immunization record identified the resident had a pneumococcal vaccine on 1/1/2018. However, the clinical records and consent records failed to identify Resident #11 was offered 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 the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to review and revise the care plan timely after the resident sustained a fall. The findings include: Resident #1 had diagnoses that included cerebral infarction (a stroke), muscle weakness, abnormalities of gait and mobility. The admission fall risk assessment dated [DATE] identified Resident #1 at risk for falls. The care plan dated 3/25/2024 identified Resident #1 at risk for falls with interventions that directed to assist with maintaining a clutter free environment, physical therapy and occupational therapy to increase muscle tone and endurance, and to utilize a gait belt for transfers and when walking the resident. The admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition, required extensive assistance with bed mobility, transfers, and toileting, and had one one fall since admission to the…

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

Based on facility documentation review, facility policy and interviews, the facility failed to ensure nurses were assessed to be competent in intravenous (IV) therapy. The findings include: A review of the nursing IV competencies identified that the last review was completed on 12/23/22. An interview with the Staff Educator on 3/19/24 at 9:59 AM identified she was responsible for ensuring IV competencies are provided annually. The Staff Educator became aware that IV competencies were outdated sometime after July 2023 when she became employed at the facility. The Staff Educator felt she herself needed training in IV certification before educating staff and discussed the concern with the Director of Nursing Services who indicated the need would be addressed. The Staff Educator further identified she had not yet received training. An interview with the DNS on 3/19/24 at 11:16AM identified IV competencies should be completed according to policies. A review of the facility policy for Skills Assessment/Continued Competencies directed all employees will have specific skills assessed 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 a tour of the kitchen, facility policy, and staff interview, the facility failed to ensure that expired food was discarded. The findings included: A tour of the kitchen on 3/15/24 at 10:30 AM with the Director of Dining Services identified the following in the dry storage room and the overflow dry storage room: a. 12- 6 lb. cans of beets expired 12/28/23. b. 6-6 lb. cans of corn expired 12/28/23. c. 3- 8.8 boxes of [NAME] Chickpea Rotini expired 8/21/23. An interview with Director of Dining Services on 3/15/24 at 10:45 AM identified he checks the food storage monthly for expiration dates and discards outdated food. Further, all dietary staff should be checking dates. The Director of Dining Services could not explain why the expired foods were not discarded. Review of the Dietary Services policy dated 7/28/21 directs in part, all food must have a date when it is opened and dated when it is stored. Most recent dates are utilized first, and new orders are stocked to the back of the rotation to prevent…

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.

A review of the Facility Assessment sheet failed to ensure the facility assessment included therapeutic facility pets and individualized resident pets to meet the needs of the residents and failed to ensure the therapy pets were up to date with vaccinations and veterinary visits per facility policy. The findings included: Interview and review of facility document with the Director of Recreation on 3/21/2024 at 10:50 AM indicated 2 cats live in the facility (Cat #1 and Cat #2) and are available to all residents one of which had documentation of up-to-date vaccination for rabies and wellness examination, no distemper (Cat #1) and the other (Cat #2)was overdue for Rabies vaccine since 2020( initial vaccine 11/4/2019 due for booster 10/4/2020( 3 years 5 months ago) then the three year rabies vaccine was due 11/3/2022 ( 2 years 4 months ago). Further review of facility documentation identified Cat #2's last wellness exam was 11/4/2019 (3 years 5 months ago) and no evidence of a distemper vaccine. After surveyor inquiry, the Recreation Director indicated Cat #2 had an appointment…

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, facility policy and interviews for 8 out of 11 sampled residents, (Residents #5, # 8, #13, # 25, # 29, #31, #35, and # 38) observed eating lunch in the [NAME] dinning/activity room, the facility failed to ensure the residents experienced a dignity dining by not serving food on a dietary tray. The findings include: Observation of the noon meal service on 3/13/24 at 12:15 PM identified 8 residents (Residents #5, # 8, #13, # 25, # 29, #31, #35, and # 38) were served their meal on a dietary tray. The residents' food and drink items remained on the dietary tray and not on the dining table. Interview on 3/19/24 at 9:35 AM with Nurse Aide (NA#1) identified food remain on the tray because residents spill their food and drink therefore causing a mess. The dietary tray helps to contain the mess. Interview on 3/19/24 at 9:50 with Assistant Director of Nursing Services (ADNS) identified drink and food items should be removed from the dietary tray and set in front of the resident. The ADNS also…

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, and staff interviews for 1of 1 resident (Resident # 57) reviewed for Advanced Directive, the facility failed to ensure that an updated code status form was signed by the resident and physician to reflect Resident #57 wishes and physician's orders. The findings include: Resident #57 was admitted to the facility on [DATE] with diagnoses that included venous insufficiency, urinary tract infection, and anxiety. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 cognitively intact, requires supervision assistance for bed mobility, and personal hygiene, independent for toileting, transfer, and eating. Review of the clinical record identified Resident #57 had a signed Advanced Directive form on 4/17/23 from her/himself along with the physician which identified Resident #57 was a full code. Further review identified a physician's order dated 5/1/23 directed Do Not Resuscitate (DNR). However, the clinical record failed to provide evidence 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 clinical record reviews, facility documentation, facility policy and interviews for 1 of 5 residents, (Resident #52) reviewed for medication administration, the facility failed to ensure the physician was notified of a medication refusal. The findings include: Resident #52's diagnoses included type II diabetes mellitus and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 as cognitively intact, independent with bed mobility, supervision with transfer, toileting, and ambulation. The Resident Care Plan Dated 2/29/24 identified Resident #52 as type II diabetes mellitus. Interventions directed to monitor diet, laboratory values, glucose monitoring and the physician/Nurse Practitioner would review Resident #52's diabetic medications, sliding scale orders, Accu-Check (blood glucose monitoring) schedule, diet, and individualized orders for glycemic management accordingly. The physician's orders dated 3/1/24 directed Humalog insulin (fast acting hormone used in…

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 documents, review of policy and staff interviews for 1 of 5 residents reviewed for accidents (Resident # 40), the facility failed to assess the use of full siderails at night to ensure the resident was free from a physical restraint and failed to obtain a consent for the utilization of the siderails. The findings include: Resident #40 was readmitted to the facility on [DATE] after hospitalization for surgical repair of a hip fracture sustained after having a fall. Resident # 40's diagnosis included aftercare following a joint replace with presence of an artificial hip joint after fracture of part of the neck of the femur, cognitive communication deficit and Alzheimer's disease. A Side Rail Assessment and consent dated 2/22/2024 with no time, indicated Resident # 40 returned from the hospital after having hip surgery had poor safety awareness and family member requested to have 2 full siderails in place. The reason for use indicated for safety with risks 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 and staff interview for 1 of 3 resident (Resident # 47) with a change in condition, the facility failed to ensure a comprehensive resident assessment was completed timely after a significant change in condition was identified and for 1 of 2 residents at risk for weight loss for ( Resident 38), the facility failed to complete a significant change of condition for the resident's weight loss. The findings included: 1. Resident #47's diagnosis included fracture of the right femur, pressure ulcer of the sacrum, deep tissue damage of the left hip and right heel. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 had no pressure ulcers. The care plan dated 3/8/2024 indicated Resident #47 was at risk for unavoidable pressure or currently has an unavoidable pressure injury(ulcer) related to poor nutrition, immobility, and incontinence. Interventions included to provide stage appropriate wound care and controlled risk factors for prevention of additional…

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

Based on clinical record reviews, facility policy review, and interview for 4 of 4 residents (Residents #12, #32, #53, #56) reviewed for Resident Assessment, the facility failed to ensure the residents quarterly assessments were completed timely. The findings included: Clinical record review of the following completion of the Minimum Data Set (MDS) assessments identified: 1. Resident #12's quarterly MDS assessment with Assessment Reference Date (ARD) of 2/1/24 was due on 2/15/24. However further review identified the resident's quarterly assessment was not completed as of 3/19/24. (33 days late) 2. Resident #32's quarterly MDS assessment with ARD of 1/8/24 was due on 1/22/24. However further review identified the resident's quarterly assessment was not completed as of 3/19/24. (57 days late) 3. Resident #53's quarterly MDS assessment with ARD of 2/6/24 was due on 2/20/24. However further review identified the resident's quarterly assessment was not completed as of 3/19/24. (28 days late) 4. Resident #56's annual MDS assessment with ARD of 2/1/24 was due on 2/15/24. However 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.

Based on clinical record review and interviews for 4 of 4 residents (Residents #12, #32, #53, #56) reviewed for Resident's Assessment, the facility failed to ensure the residents assessment were submitted timely. The findings included: Clinical record review of the following completion of the Minimum Data Set (MDS) assessments identified: 1. Resident #12's quarterly MDS with Assessment Reference Date (ARD) of 2/1/24 was due on 2/15/24 and required submission on 2/29/24; however, Resident #12's assessment was not submitted as of 3/19/24. (19 days late) 2. Resident #32's quarterly MDS with ARD of 1/8/24 was due on 1/22/24 and required submission on 2/5/24; however, Resident #32's assessment was not submitted as of 3/19/24 (43 days late) 3. Resident #53's quarterly MDS with ARD of 2/6/24 was due on 2/20/24 and required submission on 3/5/24; however, Resident #53's assessment was not submitted as of 3/19/24. (14 days late) 4. Resident #56's annual MDS with ARD of 2/1/24 was due on 2/15/24 and required submission on 2/29/24; however, Resident #56's assessment was not submitted as of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record, facility policy and staff interview for 1 of 3 sampled residents (Resident #52) reviewed for accidents, the facility failed to ensure the care plan was comprehensive and individualized for a resident who did not require a safety device. The findings include: Resident #52's diagnoses included type II diabetes mellitus and heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 as cognitively intact, required partial assistance of one with transfers and ambulation and did not require any electronic devices that monitor movement. The Resident Care Plan dated 8/25/23 identified Resident #52 as at risk for falls and took chances transferring him/herself. Interventions directed use of alarms to notify staff that the resident had needs and required assistance, do not leave the resident alone on the toilet during the time the safety device was in use and re-evaluate the need for bed/chair alarms. An observation on 3/18/24 at 7:34 AM…

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 reviews, facility documentation, facility policy and interviews for 2 of 3 residents reviewed for accidents for (Residents # 11 and # 38), the facility failed to revise the care plan after after the resident experienced falls and for 1 of 5 sampled resident, (Resident# 57) reviewed for care planning, the facility failed to ensure the care plan was revised to reflect a resident who frequently refused a daily treatment and for 1 of 3 residents reviewed for accidents, the facility failed to revise the care plan after several falls. The findings included: 1. Resident #11 was admitted to the facility on [DATE]. The resident's diagnoses included heart failure, generalized muscle weakness, and repeated falls. The care plan dated 6/28/23 identified Resident #11 as at risk for falls related to a history of multiple falls. Interventions included arranging the resident's room so that necessary items are kept accessible, remind the resident to use the call bell, ensuring adequate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and staff interviews for 1 of 5 sampled residents (Resident #11) reviewed for accidents, the facility failed to ensure that neurological checks were completed to professional standards after a resident's unwitnessed falls per facility policy. The findings include: Resident #11 was admitted on [DATE] with a diagnosis that included heart failure, generalized muscle weakness, and repeated falls. The care plan dated 6/28/23 identified Resident #11 as at risk for falls related to a history of multiple falls. Interventions included arranging the resident's room so that necessary items are kept accessible, reminding the resident to use the call bell, ensuring adequate lighting, performing safety checks per policy, reviewing medications if needed, and re-evaluating the need for bed/chair alarms. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as cognitively intact and independent in…

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 and staff interview for 1 of 2 residents (Resident # 47) reviewed for at risk for pressure ulcer, the facility failed to consistently document turning and repositioning of the resident in accordance with facility practice. The findings include: Resident #47's diagnosis included fracture of the right femur, pressure ulcer of the sacrum, deep tissue damage of the left hip and right heel. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 had no pressure ulcers. The care plan dated 3/8/2024 indicated Resident #47 was at risk for unavoidable pressure or currently has an unavoidable pressure injury(ulcer) related to poor nutrition, immobility, and incontinence. Interventions included to provide stage appropriate wound care and controlled risk factors for prevention of additional ulcers, pain management and pressure reduction such as specialty mattress, chair cushions, heel protectors, incontinence products/supplies and nutritional supplements. A review…

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 the 2 of 5 sampled resident reviewed for accidents for (Resident # 10), the facility failed to ensure that staff conducted safety checks as directed by the manufacture to ensure the alarm was functional and for (Resident # 11), the facility failed to ensure fall assessment was completed after every fall per facility policy. The findings included: 1. Resident #10 's diagnoses included dementia, abnormalities of gait, and rheumatoid arthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #10 as severely cognitively impaired and required moderate assistance for toilet transfer, maximal assistance for showering, and moderate assistance for upper body dressing. A physician's order dated 8/25/23 directed to use a Tab alarm for safety when the resident was unattended. The Resident Care Plan dated 8/25/23 identified falls as a problem. Interventions included use of a Tab alarm, to anticipate…

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

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 5 residents, (Resident #38) reviewed for unnecessary medications, the facility failed to respond to pharmacy recommendations for a resident receiving psychotropic medications. The findings include: Resident #38 had diagnoses that included anxiety disorder and depression. The admission MDS assessment dated 1/31 24 identified Resident #38 was moderately cognitively impaired and dependent with ADL assist. The RCP dated 2/7/24 identified Resident #38 utilized psychotropic drugs related to anxiety, depression, and dementia. Interventions directed to attempt gradual dose reductions as prescribed and refer to APRN (psychiatric) consults. The physician's orders dated 2/24/24 directed Trazadone 50 mg every 8 Hours PRN (as needed) for agitation with no identified date of discontinuation. A Pharmacy Consult dated 3/4/24 recommended including a 'stop' date for the PRN use of Trazadone with no documented provider response. An interview with the DNS on 3/20/24 at 1:13 PM identified all pharmacy…

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 interviews for 1 of 4 residents reviewed for medication administration opportunities (Resident #57), the facility failed to ensure medications were administered timely and medication errors did not exceed 5%. The findings include. Resident #57's diagnosis included localized swelling and edema, vitamin deficiency and left knee effusion (excess fluid buildup in the knee joint). The physician's order dated 4/17/2023 directed vitamin C 250 mg tablet to be administered orally once daily at 8:00AM. The physician's order dated 11/2/2023 directed Vitamin D3 capsule (600 international units) be given orally daily at 8:00 AM. The physician's order dated 12/19/2023 directed Hydrochlorothiazide 25 mg tablet one orally be given once daily at 8:00 AM for edema. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated in part Resident #57 was cognitively intact. The care plan dated 1/31/2024 indicated Resident #57 with increased weight with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for of 1 of 5 residents, (Resident #52) reviewed for medication administration, the facility failed to ensure a resident was free from a significant medication error following the administration of an unprescribed reduced dose of insulin. The findings include: Resident #52's diagnoses included type II diabetes mellitus and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 as cognitively intact, independent with bed mobility, supervision with transfer, toileting, and ambulation. The Resident Care Plan Dated 2/29/24 identified Resident #52 as type II diabetes mellitus. Interventions directed to monitor diet, laboratory values, glucose monitoring and the physician/Nurse Practitioner would review Resident #52's diabetic medications, sliding scale orders, Accu-Check (blood glucose monitoring) schedule, diet, and individualized orders for glycemic management accordingly. 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, facility policy and staff interview for 1 of 5 residents reviewed for Unnecessary Medications, the facility failed to ensure clinical records were complete and accurate containing pharmacy recommendations. The findings include: Resident #32's diagnosis included dementia with psychotic disturbance, anxiety, and depressive episodes. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #32 was cognitively impaired and received antipsychotic and antidepressant medications. The care plan dated 1/23/2024 indicated resident received psychotropic medications including psychotropic Drugs. Interventions included: to monitor mood and response to the medications, consult with the psychiatric APRN, to conduct an Abnormal Involuntary Movement Scale assessment (AIMS) every 6 months and assess and record effectiveness and side effects of the medication. Interview and record review with the DNS on 3/20/2024 at 10:30 AM indicated a monthly pharmacy review was completed and 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 review of facility documentation, interview, and facility policy, the facility failed to ensure the Medical Director attended Quality Assurance Performance Improvement (QAPI) meetings quarterly. The findings include: On 3/21/24 at 11:20 AM an interview and facility document review indicated QAPI meeting occurred every three months. Although, the Medical Director was on the list of members that were required to attend the QAPI meeting quarterly there was no evidence of the Medical Director's attendance at the QAPI meeting found from January 2023 through 3/21/2024(one year, 2 months). The DNS indicated the Medical Director is aware of his/her need to attend the meetings but may not have been able to attend the meeting. The Medical Director is updated at the medical staff meetings. Evidence of the medical staff meetings was requested but not provided. On 3/21/2024 at 11:44 AM attempts to reach the Medical Director via phone were unsuccessful. The facility policy labeled Quality Assurance Performance Improvement (QAPI) indicated in part the QAPI program is a comprehensive…

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 the facility Infection Control Program, facility policy and interview, the facility failed to ensure infection control policies and procedures were reviewed annually. The findings include: A review of the facility's infection Control policies and procedures during the survey identified the facility failed to provide documented evidence that policies were reviewed annually. An interview and facility documentation review with the Director of Nursing Services on 3/13/24 at 1:00 PM identified the facility never previously required a documented review of current policies and procedures. Although requested, a policy for the review of policies and procedures was not provided.

Based on observation and interview during a tour of the Dietary Department, the facility failed to document monitoring of sanitizing concentrations and ensure that dishwasher temperatures met the minimum requirements. The finding included: During tour of Dietary Department on 10/18/21 at 9:25 AM with the Food Service Director (FSD) the following was identified. 1. The three compartment sink was noted to lack daily testing/ monitoring documentation of the chemical sanitizer solution (concentration level). 2. The dishwasher was noted to fail meeting minimum required temperature. Washing temperature was noted at 140 degrees (manufacturer instructions identified a required temperature as 160 degrees for the wash cycle). The rinse cycle was noted to be at 172 degrees (manufacturer instructions identified a required temperature 180 degrees for the rinse cycle). 3. Two serving scoops were noted to be stored and immersed within the packaged food item (one in the flour and one in the sugar). Interview and review with the FSD on 10/18/21 at 12:46 PM indicated that she immediately switched 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.

On 10/14/21 at 9:30 AM, during document review, the surveyor was not provided with documentation by the Maintenance Representative or the Administrator that identified that the facility had a comprehensive water management plan in place as required by S&C 17-30 ALL. The facility had results of tests that were conducted but had no record of a committee, meeting minutes, or areas of the facility that are a concern.