Douglas Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policy for 2 of 2 residents (Resident#37 and #50) reviewed for choices, the facility failed to provide medically related social services to facilitate discharge. The findings included: 1. Resident # 37 diagnoses included abnormal posture, spinal instabilities, and pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact, required setup for eating and hygiene and was dependent on staff for toileting, and transfers. Additionally, the MDS identified Resident #37's overall goal was to return to the community and active discharge planning already occurred. The Resident Care Plan dated 2/4/25 failed to identify a discharge plan. Interview with Resident #37 on 4/14/25 at 9:53 AM identified that he/she was waiting for a representative from Money Follows the Person (MFP), (a federal Medicaid program designed to help individuals transition out of nursing homes into home and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policy for medication storage and labeling, the facility failed to ensure medication carts were locked when unattended and narcotics were secured properly. The findings include: 1. An observation on 4/14/2025 at 10:00 AM identified an unattended and unlocked medication cart outside the door of room [ROOM NUMBER] in the hallway. Two unsupervised residents were in the hallway, 1 resident rolled past the unlocked cart in his/her wheelchair. An interview with Licensed Practical Nurse (LPN) #1 on 4/14/25 at 10:13 AM identified that she forgot to lock the medication cart before entering a different room to provide routine care for a resident because she was rushing. She indicated she was aware of the facility policy to lock medication carts when not in use, not in view, and unattended. 2. An observation on 4/14/2025 at 11:22 AM identified an unattended and unlocked medication cart and an unattended and unlocked treatment cart in the Frog Lane hallway. An 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.

Based on review of facility documentation, facility policy and interviews for 4 of 5 employee files, the facility failed to ensure that the mandatory employee training/in-services were completed. The findings include: 1. LPN #1's date of hire was 11/11/2021. Review of facility documentation for LPN #1 identified that she worked in the facility between 11/11/2021 and 4/22/25. Review of the employee file for LPN #1 failed to identify that in-service training had been provided (Resident Rights, Communication and Behavioral Health) and included in the files from 2023 until present. 2. NA #1's date of hire was 8/8/2019. Review of facility documentation for NA #1 identified that she worked in the facility between 8/8/2019 and 4/22/25. Review of the employee file for NA #1 failed to identify that in-service training had been provided (Resident Rights, Communication and Behavioral Health) and included in the files from 2023 until present. 3. NA #3's date of hire was 10/11/2023. Review of facility documentation for NA #3 identified that she worked in the facility between 10/11/2023 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 observations, interviews, clinical record review, and review of facility policy for 1 of 2 sampled residents (Resident #37) reviewed for choices, the facility failed to ensure the resident's wheelchair of choice was able to be utilized. The findings include: Resident #37 diagnoses included abnormal posture, spinal instabilities, and pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was cognitively intact, required setup for eating and hygiene, and was dependent on staff for toileting and transfers. The Resident Care Plan dated 2/5/25 identified Resident #37 required modified wheelchair positioning for proper body alignment. Interventions included referral to therapy as needed for change in wheelchair positioning, monitor for complaints of pain or evidence for skin breakdown, and transfer out of bed into the modified wheelchair as ordered. A physician's order dated 4/14/25 directed Resident #37 was to be out of bed to the adapted…

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 and record review for 1 of 3 residents, (Resident #19), sampled for advanced directives, the facility failed to identify a code status in the electronic health record. The findings included: Resident #19's diagnoses included chronic obstructive pulmonary disease, anemia and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was moderately cognitively impaired, and required substantial/ maximal assistance with dressing, eating and repositioning in bed. The Resident Care Plan dated 2/10/25 identified Resident #19's advance care planning code status was DNR/DNI/RNP (do not resuscitate, do not in tubate, Registered Nurse may pronounce). Interventions included a physician's order and documentation of the resident's code status and advance care planning in the resident's clinical record. The Resident Advance Directives form signed 3/7/24 identified Resident #19 had a code status of do not resuscitate (DNR). The physicians' orders failed to identify a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation, facility policy, and interviews for 2 of 3 sampled residents, (Resident #28 and Resident #63), reviewed for abuse, for Resident #28, the facility failed to report an allegation of misappropriation of funds, and for Resident #63, the facility failed to report an allegation of neglect in a timely manner. The findings include: 1. Resident #28's diagnosis included depression, stroke, and spinal cord dysfunction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had a Brief Interview of Mental Status (BIMS) score of 14 indicating cognition was intact, was independent with eating after set up, was dependent on staff for dressing and transfers, and used a wheelchair for mobility. The Resident Care Plan dated 9/10/2024 identified Resident #28 had impaired Activities of Daily Living (ADL's) requiring assistance related to a history of a stroke. Interventions directed staff to assist with bathing, dressing, and personal…

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, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #28) reviewed for personal property, the facility failed to investigate an allegation of misappropriation of funds, and for the only sampled resident (Resident #63) reviewed for abuse, the facility failed to thoroughly investigate an allegation of neglect, investigate an allegation of neglect in a timely manner, and prevent access to the resident by the staff member following the allegation of neglect. The findings include: 1. Resident #28's diagnosis included depression, stroke, and spinal cord dysfunction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had a Brief Interview of Mental Status (BIMS) score of 14 indicating cognition was intact, was independent with eating after set up, was dependent on staff for dressing and transfers, and used a wheelchair for mobility. The Resident Care Plan dated 9/10/2024 identified Resident #28 had impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, facility policy, and interviews for the only sampled resident, (Resident #28), reviewed for urinary catheter care, the facility failed to perform weekly skin assessments; for the only sampled resident, (Resident #35), reviewed for positioning, the facility failed to ensure a positioning plan for a resident in a customized wheelchair was followed, for the only sampled resident, (Resident #42), reviewed for a non-pressure skin related condition, the facility failed to report a change in a resident's skin condition to a licensed nurse, and for 2 of 2 sampled residents, (Resident #28 and #63) reviewed for abuse, the facility failed to provide timely incontinent care. The findings included: 1. Resident #28's diagnosis included stroke, spinal cord dysfunction, and hemiplegia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review for 1 of 3 sampled residents, (Resident #68), reviewed for accidents, the facility failed to follow a post fall care plan for safety interventions. The findings included: Resident # 68 diagnoses included dementia, lack of coordination, and Parkinsonism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #68 was moderately cognitively impaired, and required partial/moderate assistance with transfers, toileting, and changing position in bed. The Resident Care Plan dated 3/15/25 identified that Resident #68 was a fall/safety risk. Interventions included keeping the bed at the lowest position and place floor pads to each side of bed. The Accident and Incident Reportable Event dated 12/21/24 identified Resident #68 was found on the floor next to the bed on 12/21/24 at 7:30 AM positioned on her/his right shoulder, stating she/he was getting out of bed and slipped due to a tissue that was on the floor. Observations on 4/15/25 at 9:14 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, review of clinical record, facility policy and interviews for the only sampled resident (Resident #133) reviewed for respiratory care, the facility failed to obtain a physician's order for a resident who received oxygen. The findings include: Resident #133 was newly admitted , diagnosis included a fracture of the sacrum, muscle weakness and difficulty walking. The admission assessment dated [DATE] identified Resident #133 was cognitively alert, lungs were clear, denied shortness of breath, and was not on oxygen. The Resident Care Plan initiated on 4/11/2025 identified Resident #133 was at risk for cardiac issues related to hypertension. Interventions included administering oxygen as ordered, administering medications as ordered, and observing for signs and symptoms of cardiac/respiratory distress. Observation of Resident #133 on 4/14/2025 at 12:16 PM identified the administration of oxygen at 2 liters per minute via nasal cannula. Interview and review of the clinical record with LPN #7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and review of facility policy for the only sampled Resident, (Resident #30), reviewed for dental services, the facility failed to accurately assess the residents oral status upon admission, failed to include a comprehensive Resident Care Plan (RCP) related to oral status, failed to code the Minimum Data Set (MDS) accurately related to dentition, and failed to ensure dental services were provided, as required, according to payor type. The findings include: Resident #30's diagnoses included epilepsy, left sided hemiplegia, and chronic obstructive pulmonary disease. A. The Nursing Clinical admission assessment dated [DATE] identified Resident #30 had all his/her own teeth, did not have dentures or partials, but failed to include an examination of Resident #30's oral/dental status. B. Review of the RCP in effect from 7/7/2023 through 4/17/2025 failed to address Resident #30's edentulous (without teeth) status. C. 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 observation, staff interviews, record review, and facility policy for 2 residents requiring precautions (Resident #15, #70), who were reviewed for infection control practices, the facility failed to ensure the appropriate precaution sign was placed outside the door for 2 residents with a history of a Multi Drug Resistant Organism (MDRO) and 1 resident with an indwelling medical device. The findings include: 1. Resident #15's diagnoses included hemiplegia and hemiparesis, chronic obstructive pulmonary disease, frequent urinary tract infections, and type 2 diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was dependent on upper and lower body dressing and toileting hygiene and required maximal assistance with rolling left and right. A Resident Care Plan (RCP) dated 2/17/2025 identified Resident #15 had a history of a MDRO, Extended Spectrum Beta-Lactamase (ESBL),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for an allegation of potential physical abuse, the facility failed to report the allegation to the Administrator and/or his/her designee immediately and to the state agency within two (2) hours after the resident reported the allegation to another staff member. The findings include: Resident #2's diagnoses included traumatic brain injury and left-side hemiplegia (weakness or paralysis). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Basic Interview for Mental Status (BIMS) score of 13 out of 15 indicating some memory recall deficits and required maximum assistance of two (2) staff for mobility and activities of daily living. The nurse aide care card identified Resident #2 as at risk for falls and required two (2) staff members for care and transfers with the Sara lift. The nurse's note dated 2/13/25 at 11:06 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 clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for an allegation of potential abuse, the facility failed to ensure the resident was transferred utilizing a mechanical device (Sara lift) and two (2) person assistance. The findings include: Resident #2's diagnoses included traumatic brain injury and left-side hemiplegia (weakness or paralysis). The Resident Care Plan revised on 11/12/24 identified Resident #2 was at risk for decreased mobility and falls. Interventions directed two (2) staff to provide care, and transfer with a mechanical device (Sara lift) and two (2) person assistance. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Basic Interview for Mental Status (BIMS) score of 13 out of 15 indicating some memory recall deficits and required maximum assistance of two (2) staff for mobility and activities of daily living. The nurse aide care card identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure staff removed smoking paraphernalia in a resident's possession timely when a resident was found in possession of smoking paraphernalia including lighters. The findings include: Record review identified Resident #2 was admitted to the facility during 11/2023 and responsible for him/herself. Resident #2's diagnoses included anxiety, depression and nicotine dependence. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 2 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment, was supervision for ambulation, and independent with manual wheelchair use. The Resident Care Plan (RCP) dated 11/8/2024 identified Resident #2 was a recent smoker and declined use of a nicotine patch. Interventions directed facility smoking policy, 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 #1), reviewed for falls, the facility failed to complete an assessment on a resident who had a fall with a subsequent injuries. The findings include: Resident #1's diagnoses included dementia without behavioral disturbances, anxiety, syncope and collapse, transient cerebral ischemic attack (stroke), atrial fibrillation (irregular heart rate) and unsteadiness in the feet. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required supervision for bed mobility, moderate assistance for transfers and was dependent with toileting. Additionally, it identified that the resident had a history of falls prior to admission to the facility. The Resident Care Plan dated 12/12/23 identified that Resident #1 was a fall/safety risk with interventions that included keeping the call bell within reach, encouraging the use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation and interviews for one (1) of three (3) residents reviewed for falls (Resident #2), the facility failed to supervise a resident in the bathroom who was cognitively impaired and required assistance, resulting in a fall with injury. The findings include: Resident #2's diagnoses included dementia without behavioral disturbances, a history of transient ischemic attack and cerebral infarction (stroke), muscle weakness and unsteadiness on feet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was moderately cognitively impaired and required extensive assistance of two (2) for bed mobility, transfers, toileting and personal hygiene. Additionally, it indicated that the resident had a history of falls, one of which resulted in a major injury in the facility. The Resident Care Plan dated 5/3/21 identified that Resident #2 was at risk for falls due to impaired mobility, incontinence and impaired safety awareness with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #20 and 479) reviewed for grievances, the facility failed to ensure the grievance policy was followed for a complaint regarding medications; and failed to ensure a grievance was completed when the resident reported missing personal items. The findings included: 1. Resident #20 was admitted to the facility with diagnoses that included migraines, osteoarthritis and pain of both hips, polyneuropathy, bipolar disorder, and chronic obstructive pulmonary disease. The admission MDS dated [DATE] identified Resident #20 had intact cognition and frequent pain limiting his/her day-to-day activities and sleep at night. The care plan dated 1/20/23 identified the resident had polyneuropathy and left shoulder pain. Interventions included to monitor pain, administer medications as ordered, monitor and document effects of pain medications. Interview with Resident #20 on 3/6/23 at 11:00 AM indicated she…

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 interview, the facility failed to conduct nursing staff competencies for years 2021 and 2022. Further, based on facility documentation and interviews, the facility failed to ensure adequate staff education and competency skills during an 11 month COVID-19 outbreak and failed to ensure competency for glucose testing and handwashing. The findings include: 1. Interview and review of facility documentation with the DNS on 3/10/23 at 10:40 AM failed to reflect competencies for 2021 and 2022 had been completed. The DNS identified that multiple changes in the facility's staff development personnel, combined with the additional responsibilities associated with the Covid 19 pandemic as key factors in the facility's inability to complete clinical competencies. Although requested, the policy regarding staff competencies was not provided. 2. Interview and review of facility documentation with the Infection Control Nurse (RN#2) on 3/13/23 at 2:48 PM identified that he had been employed at the facility since December 2022. RN #2…

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 10 residents (Resident #3) and 9 of 10 other residents who utilize adaptive equipment (Resident #14, 17, 35, 41, 48, 51, 54, 65, and 71) the facility failed to ensure adaptive equipment was provided during a GI outbreak (13 days). The findings include: Resident #3 was admitted to the facility with diagnoses that included dysphasia, Parkinson's disease, and dementia. Facility documentation dated 10/5/22 identified Resident #3 weighed 118.6 lbs. Facility documentation dated 1/1/23 identified Resident #3 weighed 108.2 lbs. Physician's monthly orders for February 2023 directed to provide a lactose reduced diet, puree texture, nectar thick liquids, no bread, and 1:1 feed for all meals. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition and was totally dependent on staff for eating. The care plan dated 2/28/23 identified the resident had weight loss and to provide the…

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

Based on observation, review of facility documentation, facility policy and staff interview, the facility failed to record the dishwashing temperature for 2 meals during a facility GI outbreak. The findings include: The facility was in an ongoing GI outbreak since 3/1/23, impacting 41 residents, with 20 residents having been resolved as of 3/4/23 and 4 resolved 3/6/23, as 17 residents continued to remain symptomatic with symptoms of nausea, vomiting and or diarrhea. Review of the dishwashing temperature log identified no documentation of food temperatures on 3/2/23 and 3/3/23 for dinner. Interview with the Dietary Supervisor on 3/6/23 at 10:10 AM identified the dishwashing temperatures for dinner on both for 3/2/23 and 3/3/23 were not documented on the dishwasher temperature log. The Dietary Supervisor identified it is the responsibility of dietary staff to log the temperature with each meal and he did not know why it wasn't documented. The facility policy indicates that dishwasher temperatures will be monitored and recorded 3 times a day by dietary aide.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility documentation, facility policies, and interviews reviewed for infection control practices during multiple, concurrent outbreaks, the facility staff failed to redirect a visitor lacking Personal Protective Equipment (PPE) use, failed to implement appropriate environmental disinfecting following a lack of PPE use and lack of handwashing, failed to initiate timely contact tracing for a newly identified COVID-19 positive resident, failed to test COVID-19 symptomatic residents per CDC guidelines, failed to separate a COVID-19 symptomatic resident from a roommate, failed to maintain COVID-19 isolation protocols in accordance with standards, failed to appropriately cohort a resident with a multidrug resistant resident (MDRO) history, failed to perform appropriate hand hygiene with glove use, failed to follow appropriate blood glucose monitoring testing procedures, failed to follow the manufacturer's instructions for cleaning a glucose monitoring device. The findings include: Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #3 and 62) reviewed for dignity, the facility failed to ensure dignified care related to dining and urinary catheters. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that included dysphasia, Parkinson's disease, and dementia. Facility documentation dated 10/5/22 identified Resident #3 weighed 118.6 lbs. Facility documentation dated 1/1/23 identified Resident #3 weighed 108.2 lbs. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition and was totally dependent on staff for eating. The care plan dated 2/28/23 identified to provide the resident a nosey cup (adapted drinking cup) for all meals, 1:1 feeding assistance, encourage at least 50% intake of meal and offer substitute if the resident doesn't eat greater than 50%. Review of the nurse aide care card, undated, for Resident #3 identified the resident required a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #62 and 65) reviewed for resident rights, the facility failed the ensure the resident or resident representative had the opportunity to participate in the process of care planning and making decisions about his or her care; and failed to complete a care plan meeting following admission. The findings included: 1. Resident #62 was admitted to the facility with diagnoses that included diabetes, cardiomyopathy, and chronic kidney disease. The care plan dated 10/27/22 identified essential support people for Resident #62 with interventions to have the essential support people review the plan of care with each care conference and staff to educate the essential support people. A care conference social worker quarterly note dated 10/27/22 at 11:24 indicated the care conference included the care plan nurse, social worker, and the family member. Resident #62 just had a re-admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #20) reviewed for medication administration, the facility failed to notify the physician or APRN when medications were administered outside of the ordered time. The findings include: Resident #20 was admitted to the facility with diagnoses that included migraines, osteoarthritis and pain of both hips, polyneuropathy, bipolar disorder, and chronic obstructive pulmonary disease. The admission MDS dated [DATE] identified Resident #20 had intact cognition and had frequent pain limiting his/her day-to-day activities and sleep at night. The care plan dated 1/20/23 identified pain management for polyneuropathy and left shoulder pain. Interventions included to monitor pain, administer medications as ordered, and monitor and document effects of pain medications. An APRN #1 progress note dated 1/29/23 identified Resident #20 was seen for increased acute and chronic pain with history of osteoarthritis,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #3 and 36) reviewed for abuse, the facility failed to ensure the residents were free from abuse. The findings include: 1. Resident #3 was admitted to the facility in November 2020 with diagnoses that included Parkinson's disease, atrial fibrillation, and congestive heart failure. Facility documentation dated 4/21/21 identified the facility had contracted with a local nursing school to allow clinical site training by the LPN students in the program. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition and required extensive assistance with personal hygiene and eating. A reportable event form dated 5/26/21 identified the Registered Nurse Nursing Instructor, (Nursing Instructor #1) reported a student nurse, (Student Nurse #6) had been rough during care with Resident #3 and the incident had been witnessed by another student nurse on 5/18/21, 8 days earlier.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #3) reviewed for abuse, the facility failed to report an allegation of abuse/mistreatment to the state agency. The findings include: Resident #3 was admitted to the facility in November 2020 with diagnoses that included Parkinson's disease, atrial fibrillation, and congestive heart failure. Facility documentation dated 4/21/21 identified the facility had contracted with a local nursing school to allow clinical site training by the LPN students in the program. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition and required extensive assistance with personal hygiene and eating. A reportable event form dated 5/26/21 identified the Registered Nurse Nursing Instructor, (Nursing Instructor #1) reported a student nurse, Student Nurse #6 was rough during care with Resident #3 and the incident had been witnessed by another student nurse on 5/18/21. Resident #3…

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

Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 5 sampled residents (Resident #529) who was reviewed for Preadmission Screening and Resident Review 2 (PASSR 2), the facility failed to implement a PASSR 2 recommendation. Review of PASSR 2 identified the following rehabilitative service recommendations: Service or Support for socialization, leisure and recreation activities; mental health counseling; ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms; supportive counseling from NF staff; a guardian/conservator for decisions regarding health and safety, and training in ADL's. All recommendations care planned except for appointment of guardian/conservator for decisions related to health and safety. 3/7/2023 at 10:00 am: Interview with Social Worker identified nothing has been done regarding the PASSR recommendation for guardianship/conservatorship for Resident #529. Social Worker stated resident #529 was alert and oriented and would do well with a power of attorney appointment. Social Worker…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #62 and 65) reviewed for care planning, the facility failed to revise and update the comprehensive care plan with a significant change of condition; and failed to complete a comprehensive care plan within seven days of completing a comprehensive assessment. The findings include: 1. Resident #62 was admitted to the facility with diagnoses that included diabetes, cardiomyopathy, and chronic kidney disease. The care plan dated 10/27/22 identified essential support people for Resident #62 with interventions to have the essential support people review the plan of care with each care conference and staff to educate the essential support people. A care conference social worker quarterly note dated 10/27/22 at 11:24 indicated the care conference included the care plan nurse, social worker, and the family member. Resident #62 just had a re-admission from the hospital and on antibiotics. Code…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #58) reviewed for unnecessary medications, the facility failed to ensure the Abnormal Involuntary Movement Scale (AIMS) was conducted when required and by qualified staff per facility policy. The findings include: Resident #58 was admitted to the facility with diagnoses that included gastro-esophageal reflux disease and dementia. A physician's order dated 9/23/22 directed to administer Reglan (medication for the stomach) 5 mg before meals. The annual MDS dated [DATE] identified Resident #58 had severely impaired cognition. The care plan dated 11/15/22 identified potential for gastro-intestinal distress. Interventions included to provide medications as ordered and to perform an AIMS as ordered. Review of the clinical record failed to reflect an AIMS test had been completed subsequent to the initiation of Reglan on 9/23/22. Interview with MD #1 on 3/8/23 at 7:00 AM identified he was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews for the only sampled resident reviewed for activities of daily living, the facility failed to ensure weekly showers or bed baths were given to a dependent resident. The findings included: Resident #479's diagnoses included heart failure, chronic obstructive pulmonary disease, and depression. Interview with Person #1 on 3/9/23 at 9:30 AM, indicated Resident #479 was not showered consistently, was not clean, and his/her skin had an odor. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #479 had intact cognition and was dependent for toileting, hygiene, and bathing. The Resident Care Plan dated 2/13/22 identified Resident #479 required assistance with activities of daily living (ADL's) related to his/her impaired mobility. Interventions directed facility staff to assist Resident #479 with bathing, dressing, and hygiene as ordered. Additional interventions directed facility staff to use a mechanical lift for transfers and a 2 person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 7 residents (Resident #20 and 479) reviewed for medication administration, the facility failed to ensure medications were given in a timely manner; and failed to ensure medications were given as ordered. The findings include: 1. Resident #20 was admitted to the facility with diagnoses that included migraines, osteoarthritis and pain of both hips, polyneuropathy, bipolar disorder, and chronic obstructive pulmonary disease. The admission MDS dated [DATE] identified Resident #20 had intact cognition and had frequent pain limiting his/her day-to-day activities and sleep at night. The care plan dated 1/20/23 identified pain management for polyneuropathy and left shoulder pain. Interventions included to monitor pain, administer medications as ordered, and monitor and document effects of pain medications. A physician's order dated 2/23/23 directed to administer Tramadol 50 mg tablet every 12 hours for pain, Fioricet…

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 interviews for 1 of 2 residents reviewed for pressure ulcer/injury, the facility failed to ensure an accurate pressure ulcer assessment and failed to conduct weekly wound measurements. The findings include: Resident #479 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus and chronic obstructive pulmonary disease. An admission nurse's note dated 2/3/22 at 1:30 PM identified an admission skin assessment that Resident #479 had 3 skin areas: a stage 2 sacral pressure ulcer that measured 13 centimeters (cm) by 7 cm, a right heel area (unspecified skin description) that measured 3 cm. by 3 cm., and a left heel area (unspecified skin description) lacking a measurement. Physician's orders dated 2/3/22 directed weekly skin checks and evaluations on bath/shower day, cleanse the Stage 2, coccyx pressure ulcer with normal saline, pat dry, apply TRIAD paste followed by a dry clean dressing once daily and as needed. The physician's order failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 8 residents (Resident #10) reviewed for nutrition, the facility failed to ensure the dietitian completed nutrition assessments after a change in condition and/or quarterly. The findings include: Resident #10 was admitted to the facility in October 2018 with diagnoses that included dementia with behavioral disturbance, depressive disorder, and delusional disorder. Reviewed of the weight summary dated 8/9/22 identified Resident #10 weighed 108.9 lbs. Reviewed of the weight summary dated 9/3/22 identified Resident #10 weighed 106.8 lbs. Reviewed of the weight summary for the month of October 2022 failed to reflect documentation of a weight Resident #10. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition and required supervision with eating. A nurse's note dated 10/12/22 at 2:42 PM identified Resident #10 was noted to have a fractured tooth on the lower left side of the mouth…

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 2 residents (Resident #20) reviewed for pain management, the facility failed to ensure medications to treat pain were administered per physician's orders upon resident request. The findings include: Resident #20 was admitted to the facility with diagnoses that included migraines, osteoarthritis and pain of both hips, and polyneuropathy. The admission MDS dated [DATE] identified Resident #20 had intact cognition and had frequent pain limiting his/her day-to-day activities and sleep at night. The care plan dated 1/20/23 identified pain management for polyneuropathy and left shoulder pain. Interventions included to monitor pain, administer medications as ordered, monitor and document effects of pain medications. APRN #1 progress note dated 1/29/23 identified Resident #20 was seen for increased acute and chronic pain with history of osteoarthritis, and complaints of spasms. APRN added an order the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy, and interviews during a review of facility immunizations records for four of five Residents (Resident #'s 16, 18, 43 and 71), the facility failed to offer and provide influenza and pneumococcal immunizations as required. The findings include: Interview and review of facility immunization documentation with the Infection Control Nurse, RN#2, on 3/13/2023 at 8:52 AM identified the following: 1. Resident #16's diagnoses included unspecified dementia, cerebral infarction, and diabetes mellitus. Review of physician's order identified a standing order since 11/30/2022 to offer the flu vaccine. 2. Resident #18's diagnoses included hypertension, chronic kidney disease, and presence of a cardiac pacemaker. 3. Resident #43's diagnoses included unspecified dementia, cerebral infarction, and hypertensive heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #43 was cognitively intact. Interview with Resident #43 on 3/9/2023 at…

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

Based on observations, facility documentation, and interviews the facility failed to ensure that COVID-19 vaccination information was stored securely. The findings include: On 3/07/23 at 10:30 AM an observation of the Infection Control Office failed to ensure that staff and resident COVID-19 documents were secured from access by residents and staff. The office doors were unlocked and open and staff were not present in the office or outside in the adjacent hall. Interview with RN #2 on 3/07/23 at 10:49 AM indicated that the COVID-19 employee and patient records of vaccination status were kept locked in the Infection prevention office at all times due to HIPAA (to safeguard health information), however, RN#2 was unaware that the door needed to remain closed and locked if he was not in the office but in the building. A second observation on 3/09/23 at 3:17 PM identified that the Infection Prevention Office doors were left unlocked and open to the hall, without facility staff present, and that COVID-19 vaccination for both residents and staff was accessible and unprotected. Although…

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 of the kitchen and dietary services and interviews, the facility failed to maintain the kitchen in a sanitary manner. The findings included: During initial tour of the kitchen on 02/02/20 at 9:17 AM, it was identified that three water bottles that belonged to the dietary staff were being stored in the walk-in refrigerator designated for facility food storage. During a subsequent observation of the kitchen on 02/05/20, it was identified that there was a water bottle and a lunch bag belonging to dietary staff being stored in the walk-in refrigerator designated for facility food storage. Observations on all days of survey 02/02/20, 02/03/20, 02/04/20 and 02/05/20 identified the dietary staff utilized Quat 64 to clean and sanitize the food preparation surfaces. The dietary staff identified the spray bottle being utilized as Quat 64. Interview with the Infection Preventionist (IP) on 02/05/20 identified that the dietary staff's personal food items should not be stored in the facility's walk-in refrigerator that stored the facility's food supply because it is a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy and staff interviews for 4 of 10 sampled residents (Residents #3, #31, #72, and #180) reviewed for immunizations, the facility failed to ensure that pneumococcal vaccination history was complete and pneumococcal vaccinations and education concerning the vaccinations were offered. Findings include: Interview on 2/4/2020 at approximately 12:00 PM with the Infection Preventionist (IP) during the time of the record reviews identified that she was in the process of updating all residents' pneumococcal immunization status' and noted that she had not completed the information gathering on all of the residents at that time. Further interview with the IP identified that the facility has a form that is completed by the resident or resident representative that provides information about the pneumococcal immunizations. She further noted that the form has an area where the resident or their representative can provide consent or…

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 and interviews for one of three sampled residents (Resident #71) reviewed for mistreatment, the facility failed to ensure the resident was free from verbal abuse. The findings include: Resident #71's diagnoses included, anxiety, chronic pain, vascular dementia without behavioral disturbances, congestive heart failure and abnormal posture. A quarterly MDS assessment dated [DATE] identified Resident #71 had moderately impaired cognition, required extensive assistance of two with bed mobility, transfers and personal hygiene. The assessment further noted the resident did not ambulate, and had a range of motion impairment to one side of the upper extremities. The Reportable Event summary report dated 01/06/20 identified that on 12/30/19 at 7:15 PM Resident #71 was being transferred to bed via a Hoyer lift (mechanical lift) by NA#4 and NA#5. During the transfer NA#5 and Resident #71 had a verbal altercation where both parties used profanity 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 review of the clinical record, review of facility documentation, and interviews for one of three sampled residents (Resident #50), reviewed for mistreatment, the facility failed to report a potential misappropriation of funds to the state agency. The findings include: Resident #50's diagnoses included dementia and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #50 had severe cognitive impairment, required extensive assistance of one for transfers, dressing and toileting, had no behaviors, delusions or hallucinations. The care plan dated 4/5/19 identified the problem of dementia, impaired decision making and impaired memory with interventions that included, provide reality orientation and validation as needed. A grievance/concern form dated 5/7/19 identified Resident #50 stated he/she was missing a Christmas box that contained $35.00 and two to three Walmart gift cards for $20.00 each. The form further identified that the responsible party was refunded the money. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview for one of three sampled residents (Resident #71) reviewed for mistreatment, the facility failed to implement its policy to ensure the resident was protected after an allegation of verbal abuse was identified. The findings included: Resident #71's diagnoses included, anxiety, chronic pain, vascular dementia without behavioral disturbances, congestive heart failure abnormal posture. A quarterly MDS assessment dated [DATE] identified Resident #71 had moderately impaired cognition, required extensive assistance of two with bed mobility, transfers and personal hygiene. The assessment further noted the resident did not ambulate, had a range of motion impairment to one side of the upper extremities The Reportable Event summary report dated 01/06/20 identified that on 12/30/19 at 7:15 PM Resident #71 was being transferred to bed via a Hoyer lift (mechanical lift) by NA#4 and NA#5. During the transfer NA#5 and Resident #71 had a verbal altercation where both parties used…

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.