Bickford Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy review, and interviews for one of four residents (Resident #1 and #3) reviewed for wandering behaviors, the facility failed to ensure physician orders were obtained that directed to check the wander guards function, and failed to ensure an elopement risk assessment was completed timely. The findings include: Resident #1's diagnoses included dementia. Elopement risk evaluation dated 11-24-2025 identified Resident #1 ambulated independently, was cognitively impaired with poor decision-making skills, made statements that he/she was leaving and displayed behaviors that may indicate an attempt to leave. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicating moderate cognitive impairment, had no behaviors, transferred with moderate assistance, ambulated independently with supervision, and had no wander/elopement alarm. Physician order 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.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written agreement for laboratory services to ensure required laboratory services are available timely to meet resident needs. The findings include: Review of facility documentation failed to identify a written agreement or contract verifying arrangements with a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory for the provision of laboratory services when such services are not provided directly by the facility. Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to locate the requested laboratory services contract at the time of survey. The Administrator stated that due to a recent facility-wide evacuation, binders containing important documents were relocated; however, the requested agreement could not be produced. The facility was unable to provide documentation verifying how laboratory services are formally arranged and maintained in compliance with regulatory requirements.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written agreement for radiology and other diagnostic services to ensure required diagnostic services were available timely to meet resident needs. The findings include: Review of facility documentation failed to produce a written agreement or contract verifying arrangements for radiology and other diagnostic services when such services are not provided directly by the facility. Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to locate the requested radiology services contract at the time of survey. The Administrator reported that due to a recent facility-wide evacuation, binders containing important documents were relocated; however, the requested agreement could not be produced. The facility was unable to provide documentation verifying how radiology and other diagnostic services are formally arranged and maintained in compliance with regulatory requirements.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide evidence of physician coverage available 24-hours per day for emergency care. The findings include: Review of facility documentation failed to produce a written agreement, contract, or other documentation verifying physician services are available 24-hours a day to respond to resident medical emergencies Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to provide documentation demonstrating how physician services are ensured on a 24-hour basis. The Administrator reported that due to a recent facility-wide evacuation, important binders were relocated; however, the requested documentation could not be produced at the time of survey. Additionally, the facility was unable to provide a policy or procedure outlining how 24-hour physician availability is arranged, maintained, and verified to ensure timely medical oversight during emergencies.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written transfer agreement policy to ensure appropriate transfer arrangements with a hospital. The findings include: Review of facility documentation failed to produce a written transfer agreement policy outlining the facility's process for transferring residents to a hospital when medically necessary.Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to provide the requested transfer agreement policy at the time of survey. The Administrator reported that due to a recent facility-wide evacuation, binders containing important documents were relocated; however, the requested documentation could not be produced.Additionally, the facility was unable to provide evidence of a current written transfer agreement or documentation verifying formalized arrangements with a hospital to ensure timely transfer of residents requiring acute care services.

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide evidence of a written agreement designating a Medical Director responsible for implementation of resident care policies and coordination of medical care in the facility. The findings include:Review of facility records failed to produce a written contract or agreement verifying the appointment and ongoing contractual relationship between the facility and the Medical Director. Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to locate the Medical Director contract at the time of the survey. The Administrator reported the facility recently experienced a facility-wide evacuation during which important binders were relocated; however, the requested contract could not be produced. Additionally, the facility was unable to provide a policy or procedure outlining the process for maintaining, retaining, or ensuring accessibility of the Medical Director contract.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy review and interviews for three of four residents (Resident #1, #2, and #3) reviewed for wandering behaviors, the facility failed to ensure the clinical record was complete and accurate to include rounds performed for resident location (Resident #1's care checks) and to accurately document the resident's (#1, #2, and #3) wander guard devices. The findings include: Resident #1's diagnoses included dementia. Elopement risk evaluation dated 11-24-2025 identified Resident #1 ambulated independently, was cognitively impaired with poor decision-making skills, made statements that he/she was leaving and displayed behaviors that may indicate an attempt to leave. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of ten (10) indicating moderate cognitive impairment, had no behaviors, transferred with moderate assistance, ambulated independently with supervision, and had…

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

Based on facility document review, policy review, and staff interview, the facility failed to maintain and provide a written transfer agreement policy to ensure appropriate transfer arrangements with a hospital. The findings include: Review of facility documentation failed to produce a written transfer agreement policy outlining the facility's process for transferring residents to a hospital when medically necessary.Interview with the Administrator on 2-13-2026 at 5:00 PM identified she was unable to provide the requested transfer agreement policy at the time of survey. The Administrator reported that due to a recent facility-wide evacuation, binders containing important documents were relocated; however, the requested documentation could not be produced.Additionally, the facility was unable to provide evidence of a current written transfer agreement or documentation verifying formalized arrangements with a hospital to ensure timely transfer of residents requiring acute care services.

Based on review of facility documentation, review of facility policy, and interviews, reviewed for infection surveillance and water management, the facility failed to ensure that the infection control surveillance data collected monthly was analyzed for trends and was included into the quarterly infection control report, and the facility failed to provide documentation that the water management plan was implemented to identify an established flushing program logs of low flow areas, eyewash station protocol, and annual water management committee meetings were held. The findings include:Review of the infection control program for the period of April 2024 to January 2026 with the Infection Preventionist (RN #4) on 1/7/26 at 11:48 AM failed to provide documentation that reflects analysis of trends identified in the monthly infection surveillance data collected for the period of April 2024 to January 2026. Review of the Quarterly Infection Control Report provided for the period of April 2024 to January 2026 with the Infection Preventionist (RN #4) on 1/7/26 at 11:48 AM failed to reflect…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, review of facility documentation, review of facility policy and procedures and interviews for the facility and one resident (Resident #24) investigated for environment, the facility failed to ensure resident rooms were kept at comfortable and safe temperature levels between the regulatory recommended temperatures of 71 degrees to 81 degrees. The findings included:Resident #24 was admitted to the facility in January 2024 with diagnoses that included dementia, psychotic disturbance, mood disturbance and anxiety.The annual MDS assessment dated [DATE] identified Resident #24 had moderately impaired cognition, did not exhibit any behaviors or rejection of care, was independent with self-care and utilized a rolling walker with supervision.The care plan dated 1/8/26 failed to identify any concerns with Resident #24's room being cold to the resident.Interview with Resident #24 on 1/5/26 at 11:45 AM identified Resident #24 had reported to the facility that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, review of facility policy/procedures, and interviews for 3 of 5 sampled residents (Resident #11, Resident #39, and Resident #42) reviewed for (PASRR), the facility failed to ensure the recommendations from a level II PASRR determination were included in the resident's care plan. The findings include:Resident #11 was admitted to the facility in December of 2025 and had diagnoses that included Down syndrome, adjustment disorder with anxiety, and nontraumatic intracerebral hemorrhage.The PASRR level II screening dated 12/17/2025 identified Resident #11 had a positive level II PASRR and identified recommendations that should be addressed by the facility. The admission MDS assessment dated [DATE] identified Resident #11 had moderately impaired cognition, had no behaviors. The assessment further identified Resident #11 was dependent on care for personal hygiene, oral hygiene, dressing, transfers, bed mobility and was non-ambulatory. The care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, review of facility documentation review of facility policy and interviews for one sampled resident (Resident #48) reviewed for death, the facility failed to ensure resident's care plan was revised to reflect hospice services and recommendations, and for one of five residents (Resident #3) reviewed for (PASRR), the facility failed to ensure the recommendations from a level II PASRR determination were included in the resident's care plan and for one sampled resident (Resident #38) reviewed for Hospice services, the facility failed to ensure the care plan was reviewed and revised to include the Hospice recommendations. The findings include: Resident #48 was admitted to the facility in August of 2025 and had diagnoses that included chronic systolic congestive heart failure, dementia, type 2 diabetes mellitus, and chronic kidney disease stage 3. The admission MDS assessment dated [DATE] identified Resident #48 had moderately impaired cognition, required maximal assistance 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 Number of residents sampled:Number of residents cited:Resident #2's diagnoses included dementia, muscle weakness, and chronic obstructive pulmonary disease. The quarterly MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition, required maximal assistance with toileting hygiene, lower body dressing, personal hygiene, transfers, and bed mobility. The assessment further identified the resident was non-ambulatory, did not exhibit behaviors, utilized a wheelchair, and had skin tears. The care plan dated 10/21/25 identified Resident #2 was at risk for skin tears and bruising related to fragile skin, history of skin tears and history of bumping arms with interventions that included, check skin weekly and provide daily moisturizing lotion to extremities. The reportable event report dated 12/14/25 at 2:30 PM identified Resident #2 had a skin tear to the left lower leg that measured 3.0 centimeters (cm) in length by 1.0 cm in width. The nurse's note dated 12/14/25 at 2:51 PM written by 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 observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure it had an established system of audit and reconciliation for controlled substances. The findings include:Interview with the DNS on 1/6/26 at 12:18 pm identified the narcotic audit process involved going through the two medication carts on the units and counting the narcotics and checking the expiration dates. The DNS indicated that when a narcotic medication comes into the facility the white controlled substance disposition record is placed on the cart with the medication and the yellow/pink CSDR sheets are placed in a binder that is kept in the IP nurse's office. The DNS identified that the audits are signed off for November and December 2025 when she first came to work at the facility but failed to identify any audit paperwork from November 2025 back to September 2024. The DNS indicated that the yellow/pink CSDR sheets kept in the binders were not used to complete the audits in the facility. When asked how the DNS ensured that all controlled…

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

Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure expired medications were removed from active circulation and failed to ensure medications were stored according to manufacturer guidelines and failed to ensure controlled substances were monitored correctly and had corresponding administration sign off sheets. The findings include:Observation of the East Medication cart on 1/6/25 at 11:20 AM with LPN#5 identified the following medications in active circulation in the cart that were expired:Methocarbamol tab 750 mg (10 pills remaining) expired 9/24/25Hycosamine tab 1.25 mg (1 pill remaining) expired 9/5/25Lorazepam 2mg/ml (10 ml left in the bottle) This medication should be refrigerated and did not have a corresponding white controlled substance disposition record to record administrations.Interview with LPN #5 on 1/6/26 at 11:30 AM identified expired medications should be removed from the cart and discarded. Additionally, LPN#5 identified that liquid Lorazepam should be refrigerated and all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based clinical record reviews, review of facility documentation, review of facility policy and interview for 3 of 5 residents (Resident #20, Resident #39, and Resident #41) reviewed for immunizations, the facility to ensure that the COVID-19 booster vaccine was offered and administered when requested by residents. The findings included:1.Resident #20's diagnoses included dementia, history of transient ischemic attack (TIA), and hypertension.The quarterly MDS assessment dated [DATE] identified Resident #20 had severely impaired cognition.Review of the Vaccine Administration Record/Informed Consent for Vaccination at Long Term Care Facility and Vaccine Consent form identified Resident #20's Power of Attorney (POA) had signed the forms on 7/3/25 given the facility consent for the administration of the annual COVID-19 vaccine booster.Review of Resident #20's clinical records, immunization consents and Preventative Health Care Report records with the Infection Preventionist (RN #4) on 1/7/26 at 11:20 AM 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.

Based on review of facility documentation, review of facility policy and procedure and interviews for the social worker (designee), the facility failed to ensure the employee was appropriately screened prior to employment. The findings include: Review of the Social Worker (designee) employment records on 1/13/25 at 9:40 AM identified SW#1 was hired at the facility as a social worker designee in July of 2020. The employee records did not contain documentation that the facility completed proper screening inclusive of a background check (criminal), reference checks, or employment or education verification.Interview with the Administrator on 1/13/26 at 10:00 AM identified that the employee records did not contain a background check and identified that references are not usually checked and the resume is acceptable for past employment history and noted the facility doesn't normally call to verify references or past employment history. The Administrator further identified that the facility did not have a Human Resources office, but that she and the DNS are responsible for reviewing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy documentation, review of facility policy and procedures, and interviews for one sampled resident (Resident #16) reviewed for an allegation of neglect, the facility failed to report the allegation of neglect to the State Survey Agency. The findings include:Resident #16's diagnoses included Parkinson's disease, dementia, muscle weakness, and type 2 diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #16 had severely impaired cognition, no exhibited behaviors, required maximal assistance with toileting, bathing, and lower body dressing. It further identified the resident was dependent for bed mobility, utilized a wheelchair, was non-ambulatory and always incontinent of bladder and bowel. The care plan dated 11/18/25 identified Resident #16 was at risk for pressure injury/ulcer related to a history of healed stage 3 on the coccyx with interventions that included: provide resident with incontinent care approximately every 2 hours…

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 procedures, and interviews for one sampled resident (Resident #16) reviewed for an allegation of neglect, the facility failed to initiate an investigation of the alleged neglect. The findings include: Resident #16's diagnoses included Parkinson's disease, dementia, muscle weakness, and type 2 diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #16 had severely impaired cognition, no exhibited behaviors, required maximal assistance with toileting, bathing, and lower body dressing. It further identified the resident was dependent for bed mobility, utilized a wheelchair, was non-ambulatory and always incontinent of bladder and bowel. The care plan dated 11/18/25 identified Resident #16 was at risk for pressure injury/ulcer related to a history of healed stage 3 on the coccyx with interventions that included: provide resident with incontinent care approximately every 2 hours and as needed 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 interviews for one of two sampled residents (Resident #7) reviewed for facility acquired pressure ulcers, the facility failed to develop a baseline care plan to prevent pressure ulcer/injury on admission. The findings include: Resident #7 was admitted on [DATE] with diagnoses that included dementia, nutritional deficiency, stage 4 pressure ulcer wound, and osteoarthritis.The nurse's note written by RN #1 dated 8/1/24 at 3:16 PM identified Resident #7 was admitted to the facility in stable condition and was adjusting to his/her room. Resident #7's lower extremity was dry, peeling and had a stage 3 pressure ulcer to the left heel. The left heel pressure ulcer wound measured 1.0 centimeters (cm) in length by 1.0 cm in width with good granulation tissue in the wound bed. Review of the clinical record failed to identify that a Braden Scale assessment (used to predict the risk of pressure ulcer development) had been completed on admission. Resident #7's baseline care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy review, and interviews for one of two sampled residents (Resident #7) reviewed for facility acquired pressure ulcers, the facility failed to ensure the registered nurse assessed a newly admitted resident in accordance with facility practice. The findings include: Resident #7 was admitted on [DATE] with diagnoses that included dementia, nutritional deficiency, stage 4 pressure ulcer wound, and osteoarthritis.Review of the admission/readmission checklist identified tasks that need to be completed within 24 to 48 hours of admission and it identified that a complete nursing assessment should be completed and the information entered into the electronic health record (EHR), such as admission observations, admission nursing assessment, Braden Scale assessment, fall risk assessment, elopement assessment, and measure all wounds and ensure wound care is provided.Review of the clinical record identified that the following assessments required 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 observation, review of clinical records, review of facility documentation, review of facility policy and procedures, and interviews for one sampled resident (Resident #16) reviewed for an allegation of neglect, the facility failed to ensure the resident received incontinent care as outlined in the care plan in a timely manner. The findings include:Resident #16's diagnoses included Parkinson's disease, dementia, muscle weakness, and type 2 diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #16 had severely impaired cognition, did not display behaviors, required maximal assistance with toileting hygiene, bathing, lower body dressing, bed mobility and was dependent with personal hygiene, transfers, and use of a manual wheelchair. The assessment further identified Resident #16 was at risk for pressure ulcers and had pressure reducing devices for chair and bed, was on a turning and repositioning program and was always incontinent of bowel and bladder.The care plan dated 11/18/25…

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 sample resident (Resident #39) reviewed for podiatry services, the facility failed to ensure podiatry consultation visit was reviewed and the recommendation of treatment by the podiatrist was followed through. The findings include:Resident #39's diagnoses included diabetes mellitus with diabetic retinopathy without macular edema.The physician's orders dated 8/14/24 directed: audiology, ophthalmology, psychiatrist, dental, and podiatry consultations as needed.The podiatry consent to treat dated 8/18/24 identified Resident #39 consented for podiatry services.The quarterly MDS assessment dated [DATE] identified Resident #39 had intact cognition, required extensive assistance with personal hygiene, toileting, dressing, and transfers. The assessment further identified the resident was non-ambulatory.The Resident Care Plan (RCP) dated 2/17/25 identified Resident #39 had diabetes mellitus and was at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, and interviews for one of two sampled residents (Resident #5) reviewed for accidents, the facility failed to provide adequate supervision to prevent the resident from smoking in the courtyard, failed to develop a comprehensive smoking policy and procedures, failed to develop a systems to ensure resident/family aware of the facility's non-smoking status. The findings include: Resident #5's diagnoses included chronic obstruction pulmonary disease (COPD), parkinsonism, chronic back pain, and nicotine dependence.The physician's order dated 8/26/25 directed to administer continuous oxygen at 2 liters per minutes to keep the pulse oximetry above 90 percent.The quarterly MDS assessment dated [DATE] identified Resident #5 had intact cognition, was independent with dressing, hygiene, transfers, ambulated with the assistance of a cane, and was on oxygen therapy.The resident care plan (RCP) dated 11/10/25 identified Resident #5 was observed smoking cigarettes…

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 records, review of facility documentation and interviews for one sampled resident (Resident #16), reviewed for an allegation of neglect, the facility failed to ensure adequate staffing to meet the needs of the residents. The findings include:Resident #16's diagnoses included Parkinson's disease, dementia, muscle weakness, and type 2 diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #16 had severely impaired cognition, did not display behaviors, required maximal assistance with toileting hygiene, bathing, lower body dressing, bed mobility and was dependent with personal hygiene, transfers, and use of a manual wheelchair. The assessment further identified Resident #16 was at risk for pressure ulcers and had pressure reducing devices for chair and bed, was on a turning and repositioning program and was always incontinent of bowel and bladder. The care plan dated 11/18/25 identified Resident #16was at risk for pressure injury/ulcer related to a history…

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, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #38) reviewed for Hospice services, the facility failed to ensure Resident #38's medical record was complete and readily accessible and for one sample resident (Resident #39) reviewed for podiatry visits, the facility failed to ensure the podiatry consultations were included in the resident's medical record. The findings included: Resident #38's diagnoses included protein calorie malnutrition and senile degeneration of the brain. The physician's orders dated 12/3/25 directed Resident #38 to receive Hospice care related to terminal diagnosis of protein calorie malnutrition. The significant change MDS assessment dated [DATE] identified Resident #38 had severely impaired cognition, required substantial/maximal assistance with self-care, rolling left to right and was always incontinent of bowel and bladder, had scheduled and as needed pain medication for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for the one sampled resident (Resident #38) reviewed for Hospice services the facility failed to identify and ensure the communication process between the facility and the hospice provider was established, failed to identify the designated facility staff responsible for the coordination of care, failed to ensure the hospice care plan was in place, and failed to ensure other pertinent documentation related to hospice care was in place, and failed to ensure hospice staff was oriented to the facility 's policies and procedures. The findings include:Resident #38's diagnoses included protein calorie malnutrition and senile degeneration of the brain.The physician's orders dated 12/3/25 directed Resident #38 to receive Hospice care related to terminal diagnosis of protein calorie malnutrition.The significant change MDS assessment dated [DATE] identified Resident #38 had severely 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.

Based on observations, interviews, facility documentation, and policy review, the facility failed to ensure safe water temperatures to areas occupied and accessible by residents on resident care units creating a hazard which could have resulted in a burn injury. The findings include: An observation of water temperatures by Building and Fire Inspection Safety on 11/4/25 at 12:30 PM identified the East Shower Room water temperature to be 135 degrees Fahrenheit, the [NAME] Shower Room to be 129 degrees Fahrenheit, and the T wing hall bathroom to be 142 degrees Fahrenheit.Review of the Water Temperature Log dated 8/4/25 to 11/4/25 identified water temperatures were to be maintained between 105 degrees and 120 degrees Fahrenheit. Out of 170 water temperatures taken, 68 (40%) documented temperatures from the resident occupied/accessible areas of the East Shower Room, [NAME] Shower Room, and T Wing Hall bathroom were above 120 degrees Fahrenheit. Although the documentation reflected the excessive water temperatures, there was no indication of an intervention to prevent resident injury, no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers, the facility failed to notify the practioner timely of deterioration to a pressure ulcer. The findings include: Resident #1's diagnoses included Parkinson's disease (a movement disorder of the nervous system that worsens over time), dementia with behavioral disturbances, type 2 diabetes mellitus and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Staff Assessment for Mental Status completed identifying short-term and long-term memory problems indicative of severely impaired cognition and required supervision assistance with bed mobility, maximal assistance with toileting hygiene and transfers and was dependent on staff for personal hygiene. The Resident Care Plan (RCP) dated 12/31/24 identified that Resident #1 had a new stage 2 pressure ulcer (partial thickness skin loss, presenting as a shallow open ulcer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers, the facility failed to ensure that a pressure ulcer was treated in accordance with physician's orders. The findings include: Resident #1's diagnoses included Parkinson's disease (a movement disorder of the nervous system that worsens over time), dementia with behavioral disturbances, type 2 diabetes mellitus and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Staff Assessment for Mental Status completed identifying short-term and long-term memory problems indicative of severely impaired cognition and required supervision assistance with bed mobility, maximal assistance with toileting hygiene and transfers and was dependent on staff for personal hygiene. The Resident Care Plan (RCP) dated 12/31/24 identified that Resident #1 had a new stage 2 pressure ulcer (partial thickness skin loss, presenting as 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, observations, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents (Resident #7) reviewed for activities of daily living, the facility failed to follow care plan as directed. The findings include: Resident #7's diagnoses included syncope and collapse, altered mental status and peripheral vascular disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 7 had a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), indicative of moderate cognitive impairment and dependent with assist of two (2) for transfers, substantial/maximal assistance for dressing lower body, toilet use and frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 5/26/2024 identified assistance with ADLs due to physical limitations with interventions that directed to provide assistance to the resident with ADLs as per care card and as needed. A physician's order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and interviews for three (3) of five (5) residents (Resident #1, #2, #5), reviewed for medication administration, the facility failed to ensure the clinical record was complete and accurate to include documentation of medication administration and blood sugar monitoring. The findings include: 1. Resident #1's diagnoses included diabetes, depression, muscle spasms, left sided hemiplegia and hemiparesis of and overactive bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated 7/10/2024 identified Resident #1 had a diagnosis of diabetes with interventions that included to monitor/record report blood glucose per MD order, insulin as ordered. Physician orders dated 6/20/2024 directed to administer the following medications at 8:00 AM and 9:00 AM: Acetaminophen 325 mg two (2) tablets two (2) times a day for discomfort, Colace 100 mg one (1) tablet daily…

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

Based on observations, review of facility documentation and interviews the facility failed to ensure a staff member applied hair/beard net while in the kitchen, consistently logged dishwasher temps daily, document what was done when dishwasher temperatures were not within range, and consistently document food temperatures for all meals daily per facility practice. The findings included: 1. Observation on 4/21/24 at 9:00 AM Dietary Aide #1 identified ( DA#1) washing hands at the sink wearing a baseball style hat with hair noted below the cap lower edges and was also noted with a mustache and short beard without the use of a beard and hair net. Dietary aide #1 at the time of the observation indicated not having a beard and applied a hairnet and a face mask to cover exposed hair. Dietary Aide #1 further indicated his/her shift started at 6:00AM. 2. Observation and review of the kitchen dishwasher temperature log on 4/22/2024 at 11:05 AM with the dietary manager indicated on the following dates first shift 4/10 115 for wash and 125 rinse and 4/19/2024 the wash was noted at 110 and rinse…

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

Based on a review of the facility grievance file, observations, facility documentation, facility policy and interviews, the facility failed to inform residents of how to file a grievance and failed to ensure the required information related to contact information for filing a grievance with government officials were posted in the facility. The facility also failed to maintain the results of all grievances for at least 3 years. The findings included: a. On 4/24/24 at 10:00 AM during the Resident Council Meeting, Residents # # 1, # 7 13, 17 and 34 reported they were not aware of how to file a grievance within the facility. Additionally, the residents were unable to locate information within the facility to direct them on who to contact to file a grievance. b. After the Resident Council Meeting on 4/24/24 at 11:17 AM, observations were made of the main entrance area and on all units of the facility identified no contact information of government official and any language on how to file a grievance posted/displayed for residents and visitors at the time of the observation. c. 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 clinical record reviews, facility documentation, review of policy and staff interviews for 2 of 6 residents reviewed for abuse (Resident #26 and Resident # 44), the facility failed to ensure the residents were protected after an allegation of suspected verbal abuse to prevent further potential abuse and were free from physical abuse. The findings included: 1. Resident #26 was admitted to the facility on [DATE]. The resident's diagnoses included dementia, seizures, and schizoaffective disorder. A Resident Care Plan (RCP) dated 3/27/23 identified Resident #26 was unable to vocalize due to cognitive impairment. Interventions included for staff to observe the resident for crying, yelling, or grimacing behaviors. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 had short and long-term memory problems and was severely cognitively impaired. Additionally, the MDS identified Resident #26 required extensive assistance from at least two people for bed mobility, transfers, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for 2 of 6 sampled residents (Residents #18 and # 26) who were reviewed for abuse, the facility failed to implement facility policies following an alleged incident of resident-to-resident physical and verbal mistreatment. The findings included: 1. Resident #18's diagnoses included Parkinsonian and unspecified dementia. The admission Minimum Data Set, dated [DATE] identified Resident #18 as moderately cognitively impaired, required one to two persons assist with activities of daily living and supervision using a wheelchair. The Resident Care Plan dated 4/27/23 identified Resident #18 had impaired decision making related to dementia. Interventions directed to support and to reassure the resident in new situations. A nurses note dated 5/23/23 at 11:53 PM identified Resident #18 was observed hitting another resident (unknown) with a newspaper on the legs lightly near the nurses' station. Resident #18 stated, We are playing 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 reviews, facility documentation, facility policy and interviews for 3 of 6 sampled residents (Residents #18, # 40 and # 44) reviewed for abuse, the facility failed to report an allegation of staff to resident physical mistreatment and or initiate an investigation timely. The findings included: 1. Resident #18's diagnoses that included Parkinsonian and unspecified dementia. The admission Minimum Data Set, MDS assessment dated [DATE] identified Resident #18 as moderately cognitively impaired, required one to two persons assistance with activities of daily living and supervision using a wheelchair. The Resident Care Plan, RCP dated 3/24/23 identified Resident #18 had impaired decision making related to dementia. Interventions directed to support and to reassure the resident in new situations. A facility Reportable Event dated 4/11/23 at 6:51 PM identified Resident #18 reported to a staff member, Registered Nurse #4 on 4/11/23 at 2:00 PM s/he felt mistreated by a staff member, Licensed…

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 3 of 6 sampled residents (Resident #18 and Resident # 40) reviewed for abuse, the facility failed to ensure the protection of resident(s) following an allegation of resident-to-resident physical mistreatment. The findings included: 1. Resident #18 had diagnoses that included Parkinsonian and unspecified dementia. The admission Minimum Data Set, MDS assessment dated [DATE] identified Resident #18 as moderately cognitively impaired, required one to two persons assist with activities of daily living and supervision using a wheelchair. The Resident Care Plan, RCP dated 3/24/23 identified Resident #18 had impaired decision making related to dementia. Interventions directed to support and to reassure the resident in new situations. A nurse's note for Resident #18 on 5/13/24 at 9:13 AM identified s/he had a restful night until 5:30 AM when the resident across the hall, Resident #98, turned the television on loud. Resident #18…

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 4 of 6 sampled residents (Residents # 5, # 26, # 27 and # 34) who were reviewed for pressure ulcers, the facility failed to ensure a comprehensive care plan was developed to address the residents at risk for skin break down, prevention of pressure ulcer development and incontinence. The findings included: 1. Resident #5 was admitted on [DATE] with a diagnosis of cervical spine fracture, Alzheimer's disease, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had short-term and long-term memory problems and was severely cognitively impaired. The MDS also identified Resident #5 required substantial to maximum assistance with rolling left and right and moving from a lying position to sitting on the side of the bed. Resident #5 required partial to moderate assistance for walking 10 to 50 feet. Additionally, the quarterly assessment noted incontinent of bowel and bladder. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for 2 of 6 residents ( Resident # 15 and Resident # 40) at risk for pressure ulcer development, the facility failed to revise the residents plan of care timely. The findings included: 1. Resident #15's diagnosis included diabetes mellitus, heart failure, back pain, and anxiety. The care plan dated 2/12/24 at risk for skin break down related to activity intolerance due to pain Interventions included: to encourage position change frequently and on rounds, to observe skin/boney prominences, to provide a cushion to the bedside chair when out of bed and to off load heels and to encourage good nutritional intake. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 had moderate cognitive impairment and identified the resident was a risk. The assessment noted no pressure ulcers. A Braden Scale assessment was completed on 3/8/24 which noted Resident # 15 was at high risk for skin break down. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility policy and staff interviews for 5 of 10 residents ( Residents #1,# 15, #18, # 23 #26 and #34) reviewed for unnecessary medications and 5 of 5 residents (Resident # #3, #10, #12, #18, #23 and #33) observed during medication pass, the facility failed to ensure a reason or the rationale for the use of the routine and when needed medications were noted in the physician's orders to meet professional standards. The findings included: 1. Resident #1's diagnoses included diabetes mellitus, chronic venous hypertension, and cerebrovascular disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had mild cognitive impairment, received insulin and an antidepressant medication. The physician's medication orders from 3/1/2024 through 4/25/2024 did not indicate the reason for use for all medications ordered during the above time. 2. Resident #3's diagnoses included vascular dementia, diabetes mellitus, cancer, hypertension, and paroxysmal…

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, review of policy and staff interviews for 4 of 6 residents reviewed for pressure ulcers (Residents #5 # 26 # 34 and # 40), the facility failed to initiate interventions to prevent the development of a pressure ulcer for a resident at risk for developing pressure injuries and who later developed a pressure ulcer and the facility failed to ensure a healed pressure did not reopen. The findings included: 1. Resident #5's diagnoses included cervical spine fracture, Alzheimer's disease, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had short-term and long-term memory problems and had severe impairment of cognitive skills for daily decision making. The MDS also identified Resident #5 required substantial to maximum assistance with rolling left and right and moving from a lying position to sitting on the side of the bed. The resident was frequently incontinent of bowel and bladder. The MDS further identified 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 on clinical record reviews, facility documentation, facility policy and interviews for 3 of 4 Residents (Residents # 22, # 27 and #34) reviewed for nutrition, the facility failed to follow their policy for weight loss. The findings included: 1. Resident #22's diagnoses included protein-calorie malnutrition, dysphagia (difficulty swallowing), and gastro-esophageal reflux disease. The admission Minimum Data Set assessment dated [DATE] identified Resident #22 was cognitively intact and required setup assistance with eating, limited assistance with transfers, and extensive assistance for bed mobility. Review of the clinical record identified Resident #22 weighed 116.2 pounds on 7/3/23, 145.4 pounds on 8/3/23, and 111.4 pounds on 8/16/23 and 8/17/23. A physician's order dated 7/6/23 directed to weigh Resident #22 monthly, compare weight to the previous month, reweigh as needed, and update physician with any significant change. Review of the hospital Discharge summary dated [DATE] identified Resident…

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

Based on staff interviews and review of Payroll Based Journal (PBJ) submissions for Quarter 4 of 2023, Quarter 3 of 2023, Quarter 2 of 2023, and Quarter 1 of 2023, the facility failed to to ensure the required number of Registered Nurse hours . The findings include: The PBJ submissions for Quarter 4 of 2023 (July 1 through September 30), Quarter 3 of 2023 (April 1 through June 30), Quarter 2 of 2023 (January 1 through March 31), and Quarter 1 of 2023 (October 1 through December 31, 2022) identified identified that the facility had no RN hours reported. On 4/29/24 at 12:21 PM, an interview with the Administrator indicated the facility was not operational from 10/24/22 through 3/15/23, which corresponds with quarters 1 and 2 of 2023. Additionally, the Administrator identified the facility had adopted a new payroll system as of January 2023 and has been working with the software vendor who oversees the system to identify why payroll data has not been submitted automatically. The Administrator further identified that prior to January 2023, PBJ data was entered manually. Although, 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 staff interviews and review of Payroll Based Journal (PBJ) submissions for Quarter 4 of 2023, Quarter 3 of 2023, Quarter 2 of 2023, and Quarter 1 of 2023, the facility failed to ensure that PBJ data was complete and accurate. The findings include: The PBJ submissions for Quarter 4 of 2023 (July 1 through September 30), Quarter 3 of 2023 (April 1 through June 30), Quarter 2 of 2023 (January 1 through March 31), and Quarter 1 of 2023 (October 1 through December 31, 2022) identified the facility failed to have licensed nursing coverage 24 hours/day, noted excessively low weekend staffing, and had no RN hours. On 4/29/24 at 12:21 PM, an interview with the Administrator indicated the PBJ data was not accurate. The Administrator indicated she had to call Centers for Medicare and Medicaid Services ( CMS) to understand the issue that was occurring when she found out the facility had triggered PBJ staffing. The Administrator indicated the facility was not operational from 10/24/22 through 3/15/23, which corresponds with quarters 1 and 2 of 2023. Additionally, the Administrator…

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

Based on observations, Review of Resident Council Meetings, facility documentation, and interviews, the facility failed to follow up on resident concerns in Resident Council Meetings timely. The findings include: On 4/24/24 at 10:00 AM during the Resident Council meeting, Resident's # 1, 7, 13 and 17 reported that their bedrooms were cold and drafty. The residents indicated that they had complained about room temperatures often to the Administration and had also brought the concern up in Resident Council Meetings with no resolution. Review of the Resident Council Meeting Minutes from 1/31/24 identified Resident #1 had complained about a draft coming through his/her bedroom window. There were handwritten notes on the meeting minutes stating maintenance was notified and was addressing the issue. Further review of the Resident Council Meeting Minutes from 2/29/24 identified Resident #1 and Resident #7 complained about drafts coming through their bedroom windows. There were handwritten notes on the meeting minutes stating that maintenance was notified and was addressing the issue.…

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 of facility policy and interviews for 1 of 1 resident (Resident # 39), the facility failed to ensure the resident's Advanced Directive was reviewed with the responsible party timely. The finding include: Resident #39's diagnosis included cerebral infarction and Alzheimer's disease. A physician's order dated 10/10 2023 directed to provide Full code status for Advanced Directives. A progress note dated 10/11/2023 at 5:11 AM indicated in part Resident #27 had a Conservator of Person (COP) and the code status was to be determined (TBD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #27 had some difficulty in daily decision making in new situations only. On 4/22/2024 at 1:20 PM an interview and record review with Registered Nurse (RN #1) indicated not finding the advanced directives sheet for Resident #39. However, RN # 1 did indicate seeing the resident's Advanced Directives in the past and s/he would investigate the matter right away. An interview…

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 1 of 2 residents (Resident #44) reviewed for hospitalization, the facility failed provide notification of transfer/discharge to the Regional Ombudsman's Office timely. The findings include: Resident #44's diagnoses included acute respiratory failure with hypoxia, hypertension, and heart disease. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 as severely cognitively impaired, required substantial assistance for bed mobility and personal hygiene, and was dependent on staff for transfers. Review of the clinical record identified Resident #44 was transferred to and admitted to an acute care facility on [DATE] and returned to the facility on [DATE]. Resident #44 was also transferred to and admitted to an acute care facility again on [DATE]. The resident expired in the hospital on [DATE]. However, review of the clinical record failed to identify documentation and the Regional Ombudsman's Office…

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 policy and interviews for 1 of 2 residents (Resident #44) reviewed for hospitalization, the facility failed to provide evidence that the resident and or responsibly party was made aware of the facility bed hold notice upon hospitalization. The findings include: Resident #44's diagnoses included acute respiratory failure with hypoxia, hypertension, and heart disease. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #44 as severely cognitively impaired, required substantial assistance for bed mobility and personal hygiene, and was dependent on staff for transfers. Review of the clinical record identified Resident #44 was transferred to and admitted to an acute care facility on [DATE] and returned to the facility on [DATE]. Resident #44 was also transferred to and admitted to an acute care facility on [DATE]. The resident expired in the hospital on [DATE]. Review of the clinical record failed to identify evidence the resident/responsible…

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, and interview for 2 of 3 residents (Resident #1 and Resident #35) reviewed for Resident Assessments, the facility failed to complete and transmit the annual Minimum Data Set (MDS) assessments timely. The findings include: 1. Resident #1's diagnoses included diabetes mellitus, hypertension, and anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and required supervision for bed mobility, transfers, and ambulation. Additionally, the MDS signature page identified that section Z was not signed. Review of the facility's electronic health record identified the annual MDS dated [DATE] was in progress and had not yet been signed or transmitted. 2. Resident #35's diagnoses included dementia without behavioral disturbances, hypertension, and dysphagia. The annual MDS dated [DATE] identified Resident #35 was severely cognitively impaired and required supervision for bed mobility and was dependent for transfers.…

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 sampled residents (Resident #26) who were reviewed for unnecessary medications, the facility failed to review or discontinue the use of a PRN (as needed) psychotropic medication. The findings include: Resident #26's diagnoses included diabetes mellitus type II and vascular dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was severely cognitively impaired, required total assist of two for bed mobility, transfers, toileting and received psychotropic medication. The Resident Care Plan dated 11/7/23 identified Resident #26 had a diagnosis of depression and was prescribed psychotropic medication. Interventions directed to provide psychiatric consultation as needed and monitor for side effects of medications. The physician's orders dated 2/5/24 directed Trazadone 25MG every (6) hours when needed for 14 days for agitation and restlessness with no date of discontinuation. 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 the 1 of 1 sampled resident (Resident #45) reviewed for death, the facility failed to ensure the resident's death certificate was in the clinical record. The findings include: Resident #45's diagnoses included dementia without behavioral disturbances, hypertension, and hypothyroidism. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 was moderately cognitively impaired and required supervision for eating, substantial assistance for bed mobility, was dependent for transfers. The Medication Administration Record for Resident #45 dated [DATE] through [DATE] identified Resident #45 had a code status of Do Not Resuscitate, Do Not Intubate, palliative care. The Resident Care Plan dated [DATE] identified Resident #45 was comfort measures only. Interventions included having staff ensure the resident was comfortable during bathing, repositioning, dressing, and during linen changes. Pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #4, 8, and 230), the facility failed to ensure the physician's orders were reviewed and signed according to established timeframes. The findings include: 1. Resident #4 was admitted to the facility in April 2020 with diagnoses that included diabetic, heart failure, and seizures. The quarterly MDS dated [DATE] identified Resident #8 had severely impaired cognition and required total assistance for all activities of daily living. Review of the clinical record failed to reflect that the monthly physician's orders were signed by the physician since 8/12/21, 4 months. Further, physician orders for September through December 2021 were not available in the paper clinical record. 2. Resident #8 was admitted to the facility in August 2019 with diagnosis that included dementia, chronic kidney disease, and heart failure. The annual MDS dated [DATE] identified Resident #8 was severely impaired cognition…

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

Based on observations, review of the clinical records, facility policies, facility documentation and interviews, the facility lacked effective administration to maintain the highest practicable physical, mental and psychosocial well-being of the residents. The findings include: The Administrator failed to: 1. Ensure the physician signed and dated orders and progress notes as required. 2. Ensure MDS assessments were completed according to established timeframes. 3. Ensure staff developed resident centered comprehensive care plans. 4. Ensure sufficient nurse staffing, licensed nurse and nurse aide competencies and annual nurse aide performance reviews. 5. Ensure a facility assessment was developed and implemented. 6. Ensure an infection control and prevention program was maintained, including an antibiotic stewardship program and clear immunization documentation. 7. Ensure covid testing of staff and residents was completed according to requirements, that covid vaccines were given as required and that documentation was comprehensive to reflect such.

Based on review of facility documentation and interviews, the facility failed to demonstrate an active (engaged and involved) governing body responsible for establishing and implementing policies regarding the management of the facility. The findings include: The Governing body failed to ensure the following; a. Development, implementation and annual review of an effective and comprehensive QAPI program. b. An identified frequency that the administrator reported to the Governing Body, how this communication would be done, how the Governing Body was to respond, as well as what specific types of problems and information (i.e., survey results, allegations of abuse or neglect, complaints, etc.) are reported or not reported directly to the Governing Body. c. Oversight and involvement in the Facility Assessment. d. Documentation that the Governing Body appointed the current Administrator. Interview with the Administrator on 12/28/21 at 12:30 PM identified that although the above information was requested, the information was not provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, facility documentation, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The findings include: A review of the facility infection control program identified the following: Review of the Infection Control Long Term Policy and Procedure manual identified it was last updated 5/2017. The facility lacked a measured trackable system for preventing, identifying, reporting, investigating, and controlling new and existing infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement before spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. The facility lacked tracking of multidrug resistant organisms (MDRO). 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 records, facility documentation, and interviews, the facility failed to ensure an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. A review of the facility infection control program identified no tracking of antibiotic use or evidence of practice utilizing the principles of antibiotic stewardship that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use and implement a facility-wide system to monitor the use of antibiotics. A review of Quarterly Nursing Department quality assurance performance standards (QAPI) Medical Staff Review dated 4/2021 through 9/2021 did not include any tracking of antibiotic and outcomes. An interview on 12/21/21 at 11:28 AM with LPN #3 identified she worked at the facility for four years. When there is a suspected infection, the doctor is notified for an order for antibiotics and a culture. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and interview for 1 resident (Resident #230) reviewed for notification of change, the facility failed to ensure the physician and POA were notified timely with a change in condition from hospice services. The findings include: Resident #230 was admitted to the facility in April 2019 with diagnoses that included heart failure, and dementia. Although requested, the MDS prior to 6/11/21 was not provided. Review of the clinical record failed to reflect nurses notes dated 6/1/21 - 6/18/21. Review of nurses notes dated 6/18/21 - 8/1/21 failed to reflect the status of Resident #230's condition related to hospice care or that the physician or resident representative were notified in the discontinuation of hospice. Review of the Long Term Status Form dated 6/11/21 indicated Resident #230 was taken off of hospice services and benefits. Although the form required a signature of the resident or resident representative, the form was signed by the facility nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, facility policy, and interview, the facility failed to ensure the resident rooms were homelike. The findings include: Interview and tour with the Director of Maintenance (DOM) on 12/20/21 at 1:20 PM identified the following: room [ROOM NUMBER]A had scuff marks and torn wallpaper on wall as you enter at the foot of bed 1, and bed 1 privacy curtain had multiple brown substance stains. The DOM was not able to identify substance and had privacy curtain removed. room [ROOM NUMBER] had a 6 inch long by 3 inch wide hole in the wall approximately 8 inches up from the floor. room [ROOM NUMBER] had multiple areas of torn wallpaper. room [ROOM NUMBER]'s bathroom call bell was a piece of cloth tied to a chain hanging on floor. Additionally, there was torn wallpaper on wall. The DOM during tour indicated he was aware of the areas noted and there was not a maintenance log book at the nurses station but he plans on making a maintenance book for staff to write in and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 9 residents (Residents #4, 230, 2, 3, 6, 7, 9, 19, and 27) reviewed resident assessment, the facility failed to complete quarterly MDS assessments according to established timeframes. The findings include: 1. Resident #4 was admitted to the facility in [DATE] with diagnoses that included diabetes, heart failure, and seizures. Review on [DATE] identified the quarterly MDS dated [DATE] had not been completed or transmitted. 2. Resident #230 was admitted to the facility in [DATE] with diagnosis that included dementia and heart failure. Review of the record on [DATE] identified the quarterly MDS dated [DATE] had not been completed or transmitted. 3. Resident #2 was admitted on [DATE]. A quarterly assessment was completed on [DATE]. On [DATE] Resident #2's quarterly assessment was in progress but was not completed nor submitted. 4. Resident #3 was admitted on [DATE]. A quarterly assessment was completed on [DATE]. 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, facility documentation, facility policy, and interviews for 9 residents (Residents #4, 230, 2, 3, 6, 7, 9, 19, and 27) reviewed resident assessment, the facility failed to transmit MDS assessments according to established timeframes. The findings include: 1. Resident #4 was admitted to the facility in [DATE] with diagnoses that included diabetes, heart failure, and seizures. Review on [DATE] identified the quarterly MDS dated [DATE] had not been completed or transmitted. 2. Resident #230 was admitted to the facility in [DATE] with diagnosis that included dementia and heart failure. Review of the record on [DATE] identified the quarterly MDS dated [DATE] had not been completed or transmitted. 3. Resident #2 was admitted on [DATE]. A quarterly assessment was completed on [DATE]. On [DATE] Resident #2's quarterly assessment was in progress but was not completed nor submitted. 4. Resident #3 was admitted on [DATE]. A quarterly assessment was completed on [DATE]. On [DATE]…

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

Based on review of facility documentation and staff interviews the facility failed to ensure sufficient staffing on 12/22/21 which resulted in the DNS having to work 3 consecutive shifts. The findings include: Interview with the Administrator on 12/23/21 at 10:00 AM identified the DNS worked 12/22 the day shift and evening shift, and stayed to work the 3rd shift (11-7) because the RN scheduled to relieve her did not show up. The Administrator also stated that the DNS called her at the end of the 2nd shift on 12/22/21 and informed her of the situation. The Administrator then called the scheduler to try to call other staff to come in and relieve the DNS, who had already worked 16 hours (7-3 and 3-11 shifts). The Administrator stated that the scheduler and the DNS were not able to find a replacement to relieve the DNS, so the DNS stayed and worked the 11-7 shift. The Administrator further stated that staff can work 2 shifts (16 hours) but not more than that. Interview with the Scheduler on 12/23/21 at 10:20 AM identified that DNS called her on the night of 12/22/21 before midnight 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.

Based on review of facility documentation and staff interviews, the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for the residents', and failed to ensure nurse aides demonstrated competency in skills and techniques necessary to care for residents'. The findings include: Interview with the DNS on 12/22/21 at 1:00 PM identified that training and competencies are required to be done annually. The DNS indicated that she is not able to locate or provide verification or documentation that competencies, nursing staff education was done for the past year. The DNS also indicated when she first started working in the facility, the facility did not have a staff development coordinator/nurse, who is responsible to perform monitoring and tracking staff education and competencies. Interview with Administrator on12/23/21 at 11:00 AM identified that she is not able to locate nurse competencies, education, /training or performance evaluations.

Based on review of facility documentation, facility policy and staff interviews, the facility failed to ensure nurse aide competencies were completed per established guidelines. The findings include: Interview with DNS on 12/22/21 at 1:00 PM identified that nurse aide trainings, performance evaluations and competencies are required to be done annually, however, she was not able to locate or provide verification or documentations that the competencies, education, or performance evaluations had been done. The DNS also indicated that there was no competencies done, when she first started in the facility, because the facility did not have a staff development coordinator. The DNS also mentioned that the SDC is responsible to perform, monitor and track staff education and competencies. Interview with Administrator on 12/23/21 at 11:00 AM identified that she is not able to locate nurse aide competencies, educations/trainings, or performance evaluations. The facility failed to provide verification and documentation of nursing competencies and performance evaluations despite multiple…

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

Based on review of facility documentation, facility policy and staff interviews, the facility failed to ensure nurse aide performance reviews at least once every 12 months per established guidelines. The findings include: Interview with DNS on 12/22/21 at 1:00 PM identified that nurse aide trainings, performance reviews and competencies are required to be done annually, however, she was not able to locate or provide verification or documentations that the performance reviews had been done. The DNS also indicated that there was no competencies done, when she first started in the facility, because the facility did not have a staff development coordinator. The DNS also mentioned that the SDC is responsible to perform, monitor and track staff education and competencies. Interview with Administrator on 12/23/21 at 11:00 AM identified that she is not able to locate nurse aide competencies, educations/trainings, or performance evaluations. The facility failed to provide verification and documentation of nursing competencies and performance evaluations despite multiple requests.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and interviews the facility failed to ensure the safe storage of a prescribed medication. The findings include: Observation of LPN #2's medication cart on [DATE] at 12:00 PM identified in the top first drawer, three (3) un-identified tablets were located in between medication bottles in open view. Interview and medication review with LPN #2 on [DATE] at 12:05 PM identified the 3 unknown medications to be: a. Remeron 7.5mg b. Vitamin B12 500mg c. Vitamin D 1000mg LPN #2 identified medication should be stored in their respective bottles/containers with proper labeling. Any medications that are found not inside their respective bottles/containers must be wasted with another nurse for proper medication disposal. LPN #2 identified staff should clean their medication carts at the end of each shift and ensure no loose medication are identified within the cart. Observation of LPN #3's medication cart on [DATE] at 12:20 PM identified in the top first drawer, three (3)…

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

Based on review of facility documentation and interview the facility failed to ensure a facility assessment was completed and updated per established requirements. The findings include: Interview with Administrator on 12/23/21 at 10:40 AM identified that she is not able to locate the facility assessment and is not aware if and when it was updated or reviewed. The Administrator stated that she is aware that the facility assessment is to be reviewed annually. Although requested, a facility assessment was not provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, facility documentation and interviews for 3 of 5 residents (Resident #8, 14 and 114) reviewed for immunizations, the facility failed to maintain documentation of education for pneumococcal vaccines regarding the benefits and potential side effects of the immunization to the resident/ resident representative, failed to maintain a measured means of monitoring the status of the pneumococcal immunization for residents who received the vaccination in the past, the type of vaccination received (23-valent pneumococcal polysaccharide vaccine (PPSV23) and 13-valent pneumococcal conjugate vaccine (PCV13) or those that may have refused. Additionally, for Resident #124, the facility failed to identify the residents pneumococcal vaccination status and offer education upon admission. The findings include: 1. Resident #8 was admitted on [DATE]. A review of Resident #8's immunization record identified the administration of the pneumococcal vaccine 10/1/02 without identifying the type…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation and interviews for 1 resident (Resident #15) reviewed for infection control, the facility failed to ensure written notification was provided to the responsible party following a newly identified resident case of Covid 19. The findings include: Resident #15 was admitted on [DATE] with diagnoses that included heart failure, atrial fibrillation and stage # kidney disease. The admission MDS dated [DATE] identified Resident #15 had moderate cognitive impairment and required supervision with personal care. Inter - agency patient referral report dated 11/3/21 identified Resident #15 was transferred to an outside community hospital after experiencing chest pain with audible wheezing. Nursing progress note dated 11/5/21 identified on 11/4/21 the facility was in receipt of Resident #15's Covid test dated 11/1/21, and that the results were positive. The Administrator, Medical Director, residents, families were notified as was the epidemiologist and staff at 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 records, facility documentation and interviews, the facility failed to ensure Covid testing was completed, according to established requirements, to include testing of 'exempt staff, ' conducted at least weekly or more based on community spread, on a consistent basis and following a newly identified resident case of Covid. The findings include: 1. A review of the facility Binex (rapid testing) identified two 'exempt' employees (RN #2 and Accounts Receivable Staff #1) had not been tested at least weekly from 9/27/21 to 12/20/21, and the testing had not increased to twice weekly when the positivity rate in the community was high on a consistent basis. Binex Rapid Testing Log noted RN #2 tested on four occasions between 9/28/21 and 12/21/21. Binex Rapid Testing Log noted Accounts Receivable Staff #1 tested on five occasions between 9/28/21 and 11/5/21, weekly from 11/5/21 to 12/2/21, 12/16/21 and 12/20/21. Both exemptions failed to include documented approval. One exempt staff…

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 and interviews, the facility failed to ensure Covid vaccines were offered and administered to staff as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). The findings include: Review of the employee vaccination log dated 9/27/21 through 12/20/21 identified the following: No documented vaccination status for twenty-three of ninety-eight staff with 8 currently employed and no documented attestation verifying vaccination status for six of ninety-eight staff. Staff Vaccination Log did not include a complete list of contracted staff such as lab personnel and x-ray staff. Covid authentication cards for two nurse aides noted the first dose was administered after 9/27/21. (NA #2) had a documented first dose on 10/7/21 and remained in the facility. One previously employed nurse aide, (NA #10) had a documented first dose on 10/20/21 and worked until 11/17/21. Two 'exempt' employees did not include documented approval. One exempt staff (RN #2) provided direct care and had…

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

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 #13) reviewed for abuse, the facility failed to ensure the state agency was notified of a large bruise of unknown origin. The findings include: Resident #13 was admitted to the facility in July 2018 with diagnoses that included dementia, iron deficiency anemia, and diabetes. The quarterly MDS dated [DATE] identified Resident #13 had severely impaired cognition, was totally dependent on staff for activities of daily living. Although requested, the MDS for July 2021was not provided. The care plan dated 7/6//21 identified at risk for bleeding due to on aspirin therapy. Interventions directed to monitor for signs of active bleeding, purpura, ecchymotic areas, and hematomas. A physician's order dated 8/5/21 directed to transfer Resident #13 out of bed to an adaptive wheelchair with the assistance of 2 staff and a rolling walker. Further, place a hoyer pad in the wheelchair as the resident may…

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 interview for 1 of 2 residents (Resident #13) reviewed for abuse, the facility failed to conduct a thorough investigation into an injury of unknown origin. The findings include: Resident #13 was admitted to the facility in July 2018 with diagnoses that included dementia, iron deficiency anemia, and diabetes. The quarterly MDS dated [DATE] identified Resident #13 had severely impaired cognition, was totally dependent on staff for activities of daily living. Although requested, the MDS for July 2021was not provided. The care plan dated 7/6//21 identified at risk for bleeding due to on aspirin therapy. Interventions directed to monitor for signs of active bleeding, purpura, ecchymotic areas, and hematomas. A physician's order dated 8/5/21 directed to transfer Resident #13 out of bed to an adaptive wheelchair with the assistance of 2 staff and a rolling walker. Further, place a hoyer pad in the wheelchair as the resident may be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and staff interviews for 1 of 2 residents (Resident #30) reviewed for closed records, the facility failed to maintain discharge documentation including a discharge summary and plan of care. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included PVD, HTN, dementia. The care plan dated 10/4/21 identified the resident was admitted for respite care with interventions that included to provide appropriate respite care, psychosocial support and therapeutic activities. A nurse's note dated 10/4/21 at 4:00 PM identified that at 1:45 PM Resident #30 was admitted for respite care for 7 days. The admission MDS dated [DATE] identified Resident #30 had moderately impaired cognition, was continent of bowel and bladder and required supervision with ADL's. A Social work noted dated 10/11/21 at 7:59 PM identified that Resident #30 is scheduled to be discharged home to previous living arrangements. It further identified that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #4, 8, 13 and 230), the facility failed to develop a comprehensive care plan according to established timeframes. The findings include: 1. Resident # 4 was admitted to the facility in April 2020 with diagnoses that included diabetes, heart failure, and seizures. The quarterly MDS dated [DATE] identified Resident #4 had severely impaired cognition, and was totally dependent for activities of daily living. Review of the clinical record identified the last interdisciplinary care plan conference was held on 8/3/21, over 4 months ago. Although requested, the Administrator and DNS could not provide a documentation that a comprehensive care plan had been developed for Resident #4. Further, the nurse aide care card was last revised on 2/9/21, 10 months prior. 2. Resident #8 was admitted to the facility in August 2019 with diagnoses that included dementia, heart failure and chronic kidney disease. 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 1 residents (Resident #13) reviewed for Quality of Care, the facility failed to ensure a RN assessment when the resident had a change of condition. The findings include: Resident #13 was admitted to the facility in July 2018 with diagnoses that included dementia, iron deficiency anemia, and diabetes. The quarterly MDS dated [DATE] identified Resident #13 had severely impaired cognition and was totally dependent on staff for activities of daily living. The care plan dated 4/13/21 identified Resident #13 was at risk for bleeding due to aspirin therapy. Interventions included to monitor for signs of active bleeding, purpura, ecchymosis and hematomas. A physician's order dated 8/5/21 directed to transfer the resident out of bed to the adaptive wheelchair with the assistance of 2 staff with a rolling walker and place a hoyer pad in wheelchair as the resident may be transferred via the hoyer lift back to bed as needed.…

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

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #13), the facility failed to ensure the annual history and physical was completed timely. The findings include: Resident #13 was admitted to the facility in July 2018 with diagnoses that included Alzheimer's Disease, auditory and visual hallucinations, and diabetes. Review of the clinical record identified the last History and Physical was done 1/16/2020 (1 year and 11 months ago). Interview and review of the clinical record with MD #1 on 12/23/21 at 12:28 PM identified he tries to keep track of the annual history and physicals that need to be done for his residents and indicated he was responsible to make sure the history and physicals were done on time. MD #1 noted the history and physicals need to be done annually for all residents. MD #1 indicated the last annual history and physical in Resident #13's chart was done January 2020 and indicated he did not start seeing resident until March 2021. MD #1 indicated the prior physician, MD #2, was responsible to do…

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 and interview the facility failed to discard foods or products on or before expiration date and label food items stored on shelves and in refrigerator. The findings include: 1. Observation on 12/14/21 at 11:00 AM identified a large can of sausage gravy had a heavy concentration of dust, with dents and noted discoloration. Several items were expired including two cases of pureed [NAME] vegetables (11/17/20), powdered milk (2/22/19) and oatmeal (1/2021). Interview with the Food Services Director, in the presence of the Administrator, on 12/14/21 at 11:15 AM identified the dented can and expired food products were part of the 3-day emergency food supply. The Food Service Director indicated it was his responsibility to ensure the products were rotated and maintained and indicated he had been off and had returned 5 days ago. Interview on 12/14/21 at 12:40 PM with the Administrator indicated it is her expectation that foods are rotated and that the three day emergency supply is maintained. 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.