Autumn Lake Healthcare At Windsor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, facility policy, facility assessment, and interviews, the facility failed to ensure 5 of 5 nurse aides (NA #8, 15, 16, 17, and 18) reviewed for sufficient and competent nurse staffing, completed the minimum required 12-hours of in-service education, annually, from the last standard survey (3/12/24) through the change of ownership (11/1/25). The findings include: Review of NA #8's personnel file identified that he/she was hired in August 2021. The personnel file failed to identify documentation that the minimum required 12-hours of in-service education had been completed between the last standard survey, 3/12/24 and 1/31/26, 22 months. Review of NA #15's personnel file identified that he/she was hired in October 2018. The personnel file failed to identify documentation that the minimum required 12-hours of in-service education had been completed between the last standard survey, 3/12/24 and 12/29/25, 21 months. Review of NA #16's personnel file identified that he/she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 6 residents (Resident #16 and 110) reviewed for grievances, the facility failed to ensure the residents were treated in a respectful and dignified manner. The findings included: 1. Resident #16 was admitted to the facility in January 2026 with diagnoses that included muscle wasting and atrophy, dementia, history of falling, and congestive heart failure.The care plan dated 1/16/26 identified Resident #16 had a self-care performance deficit. Interventions included providing assistance in completing ADL tasks as needed, offer toileting every 2-3 hours while awake and staff to check for incontinence and assist with changes routinely and as needed.The resident grievance form dated 1/21/26 identified Resident #16 indicated he/she requested a blanket on 1/20/26 at 4:00 PM which was not provided until the following morning by another staff member. Resident #16 also indicated he/she requested a bedpan and was informed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #99) reviewed for resident rights, the facility failed to honor the residents request for a room change due to negative interactions with his/her roommate. Subsequently, the resident and his/her roommate had a resident-to-resident altercation. The findings include:Resident #99 was admitted to the facility in December 2022 with diagnoses that included schizoaffective disorder and dementia.The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and independent with bed mobility, transfers and ambulation.The care plan dated 10/19/25 identified Resident #99 had an actual mood problem related to dementia, schizoaffective disorder and anxiety. Interventions included monitoring mood, providing supportive psychotherapy and administering medications as ordered.Review of the grievances included a handwritten note from Resident #99 to an unidentified staff member…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #93) reviewed for abuse, the facility failed to notify the physician and the resident representative of verbal and physical abuse by Resident #41 and for 2 of 5 residents (Resident #74 and 90) reviewed for nutrition, the facility failed to notify the physician of a significant weight gain in a timely manner. The findings include: 1a. Resident #41 was admitted to the facility in September 2004 with diagnoses that included schizophrenia, dementia, and anxiety disorder. The annual MDS dated [DATE] identified Resident #41 had moderately impaired cognition. A nurse's note dated 7/7/25 at 7:34 AM by LPN #5 (11:00 PM – 7:00 AM charge nurse) identified Resident #41 was observed at 5:00 AM having a verbal altercation with his/her roommate (Resident #93). LPN #5 identified the altercation occurred without a reason, and that Resident #41 continued with behaviors despite attempts at redirection, 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 3 of 5 residents (Resident #93, 23 and 99) reviewed for abuse, the facility failed to report allegations of abuse to the state agency according to regulatory requirement and facility policy. The findings include: 1a. Resident #41 was admitted to the facility in September 2004 with diagnoses that included schizophrenia, dementia, and anxiety disorder. The annual MDS dated [DATE] identified Resident #41 had moderately impaired cognition. A nurse's note dated 7/7/25 at 7:34 AM by LPN #5 (11:00 PM – 7:00 AM charge nurse) identified Resident #41 was observed at 5:00 AM having a verbal altercation with his/her roommate. LPN #5 identified the altercation occurred without a reason, and that Resident #41 continued with behaviors despite attempts at redirection, and that Resident #41 was observed yelling at other residents in the unit hallway. The note further identified that Resident #41 was observed by 3 facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #93, 23 and 99) reviewed for abuse, the facility failed to ensure the allegations of abuse were thoroughly investigated and the residents protected from future abuse. The findings include: 1a. Resident #41 was admitted to the facility in September 2004 with diagnoses that included schizophrenia, dementia, and anxiety disorder. The annual MDS dated [DATE] identified Resident #41 had moderately impaired cognition. A nurse's note dated 7/7/25 at 7:34 AM by LPN #5 (11:00 PM – 7:00 AM charge nurse) identified Resident #41 was observed at 5:00 AM having a verbal altercation with his/her roommate. LPN #5 identified the altercation occurred without a reason, and that Resident #41 continued with behaviors despite attempts at redirection, and that Resident #41 was observed yelling at other residents in the unit hallway. The note further identified that Resident #41 was observed by 3 facility 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.

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 #3, 8, 74, and 107) reviewed for hospitalization, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified in accordance with regulatory requirements when the residents were transferred to the hospital. The findings include: 1. Resident #3 was admitted to the facility in June 2017 with diagnoses that included Parkinson's disease.A nurse's note dated 10/2/25 identified that at 12:20 AM Resident #3 was transferred to the hospital and was readmitted on [DATE]. A nurse's note dated 11/11/25 at 1:19 PM identified Resident #3 was transferred to the hospital and readmitted on [DATE]. A nurse's note dated 11/19/25 at 3:11 PM identified Resident #3 was transferred to the hospital and readmitted on [DATE]. 2. Resident #8 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. A nurse's note dated 9/12/25 at 4:34 PM identified Resident #8 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interview for 1 of 3 residents, (Resident #7) reviewed for Preadmission Screening and Resident Review, PASARR, the facility failed ensure a reassessment was completed following the identification of a suspected mental illness. The findings include:Resident #7 was admitted to the facility in August 2019 with diagnoses that included schizoaffective disorder and dementia.Level I PASARR dated 7/24/19, completed during hospitalization prior to admission to the facility, identified Resident #7 did not have a diagnosis of a major mental illness and no further level I screening was required unless suspected of a serious mental illness (MI) or intellectual disability (ID) and exhibits a significant change in treatment needs.Psychiatric consultations beginning 11/15/19 noted a diagnosis code for of schizoaffective disorder (F25.9) with history auditory hallucinations previously treated while hospitalized , with chronic management including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #41) reviewed for abuse, the facility failed to ensure that the resident's care plan was revised, and interventions were implemented following resident-to-resident altercations. The findings include: Resident #41 was admitted to the facility in September 2004 with diagnoses that included schizophrenia, dementia, and anxiety disorder. A physician's order dated 7/15/22 directed behavior monitoring for yelling, delusions, pacing, or weeping every shift including the behavior and number of episodes. A physician's order dated 8/16/24 directed to administer Risperdal (an anti-psychotic medication used to treat schizophrenia) 1 mg tablet every 12 hours. Review of the clinical record identified Resident #41 had a room change to Resident #93's room on 3/13/25. The annual MDS dated [DATE] identified Resident #41 had moderately impaired cognition, was always continent of bowel and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 5 residents (Residents #19) observed during medication administration, the facility failed to administer Levothyroxine according to professional standards. The findings include. Resident #19 was admitted to the facility in October 2020, diagnosis included with diagnoses that included bipolar disorder and hypothyroidism.Physician's order dated 2/7/25 directed to administer Levothyroxine 112mcg for hypothyroidism daily. The February 2026 MAR identified that between 2/1/26 - 2/19/26 the Levothyroxine was being administered daily at 6:30 AM.The clinical record identified Resident #19 was hospitalized on [DATE] and returned to the facility on 2/21/26.Physician's order dated 2/21/26 directed to administer Levothyroxine 112mcg daily, Vitamin C 500mg daily, Vitamin D 25mg daily, and Ferrous Sulfate Oral Solution 300 (60 Fe) mg/ml give 5ml daily.The February 2026 MAR identified that between 2/22/26 -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Residents #93, 57 and 4) the facility failed to provide care according to professional standards. For 1 of 5 residents (Resident #93) reviewed for abuse, the facility failed to complete an RN assessment after a witnessed resident to resident altercation. For 1 of 2 residents (Resident #57) reviewed for pressure ulcers, the facility failed to ensure that the resident's heels were offloaded per the physician's order. For 1 of 5 residents (Resident #4) reviewed for unnecessary medications, the facility failed to consult the outside cardiologist for the resident regarding his/her implanted medical device. The findings include: 1a. Resident #41 was admitted to the facility in September 2004 with diagnoses that included schizophrenia, dementia, and anxiety disorder. A physician's order dated 7/15/22 directed behavior monitoring for yelling, delusions, pacing, or weeping every shift including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #57, 90 and 74) reviewed for pressure ulcers and/or nutrition, for Resident #57, reviewed for pressure ulcers, the dietitian did not complete a nutritional assessment for 1 month, until surveyor inquiry, after a new wound was identified, for Resident #90, reviewed for nutrition, the facility failed to address a significant weight loss in a timely manner and for Resident #74, reviewed for nutrition, the facility failed to obtain a reweight for 2 weeks after the resident had a significant weight gain. The findings include: 1. Resident #57 was admitted to the facility in October 2023 with diagnoses that included hypertensive urgency, muscle weakness, and bilateral osteoarthritis of the knees. The quarterly MDS dated [DATE] identified Resident #57 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required substantial assistance by staff with toileting,…

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

Based on observation, review of facility documentation, facility policy, and interviews for 1 of 4 medication carts, the facility failed to ensure shift to shift controlled drug counts were consistently completed. The findings include:Observation on 2/25/26 at 2:10 PM during the medication cart review (on the South unit) with the DNS included a review of the February 2026 controlled drugs shift count record (the on-coming and off-going nurses complete to ensure all controlled drugs are counted). The controlled drugs shift count record was missing 4 signatures on 2 shifts on 2/24/26 during the 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM shift. Interview with the DNS on 2/25/26 at 2:15 PM identified she was not aware of the missing controlled drugs shift count signatures until now. The DNS indicated it was the responsibility of all the nurses to sign the controlled drugs count record at the beginning of the shift and at the end of each shift when the controlled drugs count is completed. The DNS indicated she will provide in-service for the nursing staff.Review of the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #6) reviewed for unnecessary medications, the facility failed to ensure dental services with an oral surgeon were scheduled in timely manner. The findings include: Resident #6 was admitted to the facility in January 2022 with diagnoses that included type 2 diabetes mellitus, schizophrenia, and dementia. The physician's order dated 10/28/25 directed to arrange with outpatient oral surgeon for dental extraction. The quarterly MDS dated [DATE] identified Resident #6 had moderately impaired cognition, broken or loosely fitting full or partial denture, and obvious or likely cavity or broken natural teeth. The care plan dated 12/3/25 identified Resident #6 had oral/dental health problems related to cavities, with interventions that included coordinating arrangements for dental care, transportation as needed/as ordered, monitoring/documenting/reporting to the MD, as needed, signs and symptoms of oral/dental problems…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews 2 residents (Resident #57 and 90) who were reviewed for wounds, the facility failed to implement enhanced barrier precautions (EBP) as per facility policy and professional standards. The findings include: Resident #57 was admitted to the facility in October 2023 with diagnoses that included hypertensive urgency, muscle weakness, and bilateral osteoarthritis of the knees. The quarterly MDS dated [DATE] identified Resident #57 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required substantial assistance by staff with toileting, dressing, and transfers. A weekly wound assessment note dated 1/21/26 identified that Resident #57 was found to have a new facility acquired stage 3 pressure ulcer on the plantar surface of the left foot which measured 1.6 cm x 1.1 cm by 0.2 cm. A telemedicine initial wound care note dated 1/21/26 by MD #2 (Wound care physician) identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 2 of 5 residents (Residents #4 and 6) reviewed for immunizations, the facility failed to ensure the pneumococcal vaccine was administered in a timely manner. The findings include: 1. Resident #4 was admitted to the facility in April 2023 with diagnoses that included heart failure, dementia, and hypertension. The quarterly MDS dated [DATE] identified Resident #4 had severely impaired cognition and was not up to date on the pneumococcal vaccination; it was offered and declined. Review of Resident #4's Immunization Report identified Pneumococcal-Historical Type Unknown was administered on 3/20/24. The Resident Pneumonia Vaccine Education Document Form signed and dated 2/5/26 identified Resident #4 agreed to receive the Pneumococcal Conjugate Vaccine (PCV 20). 2. Resident #6 was admitted to the facility in January 2022 with diagnoses that included dementia, type 2 diabetes mellitus, and COPD. The annual MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #4, 6, 8, and 99) reviewed for immunizations, the facility failed to ensure Covid-19 booster vaccines were administered in a timely manner. The findings include: 1. Resident #4 was admitted to the facility in April 2023 with diagnoses that included heart failure, dementia, and hypertension. The quarterly MDS dated [DATE] identified Resident #4 had severely impaired cognition and was not up to date on the Covid-19 vaccination. Review of Resident #4's Immunization Report identified the most recent SARS-COV-2 COVID-19 vaccine had been administered on 1/26/24. The Resident Covid Vaccine Education Document Form signed and dated 2/5/26 identified Resident #4 agreed to receive the Covid-19 booster vaccine. 2. Resident #6 was admitted to the facility in January 2022 with diagnoses that included dementia, type 2 diabetes mellitus, and COPD. The annual MDS dated [DATE] identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who required set-up assistance from staff with personal hygiene and toileting, the facility failed to ensure a staff member did not verbalize profanity towards the resident. The findings include: Resident #1's diagnoses included vascular dementia, anxiety, depression, and coronary vascular accident with right sided weakness. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was oriented to person, place, time, and situation, required supervision from staff for toileting, personal hygiene, bed mobility, transfers and self-propelled while in a wheelchair. The Resident Care Plan dated 5/9/25 identified Resident #1 had a self-care deficit and was hard of hearing. Interventions directed to assist with care as needed, ensure resident was aware of staff presence before providing care, and use facial expressions to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 6 sampled residents (Resident #30) reviewed for non-pressure skin conditions, the facility failed to ensure the physician was notified of a newly identified non-pressure skin condition(s) in a timely manner. The findings include: Resident #30 diagnoses included muscle weakness and seborrheic dermatitis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 had moderate cognitive impairment, required partial to moderate assistance with bed mobility, transfers, one person assist with locomotion with the use of a wheelchair and had no unhealed pressure or non-pressure skin injuries. The Resident Care Plan (RCP) dated 11/5/23 identified Resident #30 had the potential for skin integrity issues related to fragile skin, incontinent episodes of bowel and bladder, seborrheic dermatitis, and limited mobility. Interventions directed to keep skin clean and dry, use lotion on dry scaly skin and use…

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

Based on observations, facility documentation and interviews, the facility failed to ensure that foods were stored and prepared under sanitary conditions. The findings included: During tour and observation of the kitchen with the [NAME] #2 on 2/25/24 at 10:20 AM revealed the following: 1. Tray with clean coffee mugs to be used for lunch was on the counter next to the hand washing sink and above the sink divider. Above the tray with cups was a single electric outlet covered with dust and caked in dirt. The wall behind the electrical outlet was dirty and damaged with a hole above the outlet. The conduit was rusty, with marred and/or chipped paint and with grime or dust. There was a rust-colored liquid dripping on the conduit. On the side of the sink and above the conduit was a soap dispenser that was dripping down after use. The hand sink had dry grime on the upper part and soiled wet cloth was stored on the side. Cook #2 identified at the time of observation that coffee mugs should be stored away from the handwashing sink to prevent any possible splatter. 2. The metal shelves storing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interviews for 4 of 5 residents, (Resident 23, #28, #49 and #498) reviewed for quarterly social service review, the facility failed to conduct quarterly social service visits timely. The findings include: 1. Resident #23 ' s diagnoses included Respiratory Failure, Essential Hypertension, and Alcoholic Cirrhosis of liver with ascites. A physician's order dated 9/25/21 directed to monitor symptoms and signs such as malaise, dizziness, diarrhea, sore throat, oxygen desaturation, loss of appetite, or mental status changes. Particular attention should be made to identify sudden changes in behavior and temperature greater than 100 degrees F every day/shift. The Resident Care Plan dated 10/22/21 with a revision date of 5/3/22 identified Resident #23 had a BIMS less than 13. Interventions included social services to provide emotional support, assessment, and intervention as needed. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy for 1 of 3 bathrooms, the facility failed to ensure resident care equipment was stored in a sanitary manner according to infection control practices and for 1 of 6 sampled residents (Resident #30) reviewed for non-pressure skin conditions, the facility failed to ensure wound care was performed in accordance with infection control standards regarding hand hygiene. The findings included: 1. Observation on 2/25/24 at 11:29 AM of resident's bathroom of rooms [ROOM NUMBERS] on North Wing identified two sets of gray color wash basins stacked on top of each other and stored on the floor under the sink by to the garbage container. One wash basin had a small amount of soapy liquid. All four wash basins were uncovered and without resident name. Further observation identified a grey color bedpan stored on the floor by the toilet. The bedpan had some light color dried debris inside, was uncovered and without resident name on it. Four residents shared this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records, facility documentation, facility policy and interviews for 1 of 10 sampled residents (Resident #26) reviewed for abuse, the facility failed to ensure the comprehensive care plan was revised to reduce the risk of further physical mistreatment following a resident-to-resident physical altercation where Resident #70 was the victim. For 2 of 6 residents, (Resident #30 and #42), the facility failed to revise the care plan following a newly developed non pressure injury For Resident #43, the facility failed to ensure the care plan was revised in atimely manner following an allegation of abuse. The findings include: 1. Resident #26's diagnoses included borderline personality disorder and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #26 as cognitively intact, did not express any indicators of psychosis, required one person assist with bed mobility, transfers and was independent with locomotion with the use of a wheelchair. The RCP dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident # 78) reviewed for discharge, the facility failed to ensure that other state agencies were notified of the resident's decision to (Leave Against Medical Advice). The finding included: Resident # 78's diagnoses included schizoaffective disorder, nutritional deficiency, and repeated falls. The admission MDS assessment dated [DATE] identified Resident # 78 had intact cognition, used a rolling walker for mobility, and noted frequently incontinent of bowel and bladder. The care plan dated 3/25/24 identified a concern with Resident #78's desire for long term care Intervention included: to evaluate motivation of the resident to remain in facility long term care, to discuss feelings and concerns with her/his expressed desire for long term care, and to monitor for and address episodes of anxiety, fear, and distress. The Advanced Practiced Registered Nurse (APRN) assessment dated [DATE] identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, review of facility documentation, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #46) reviewed for Activities of Daily Living (ADL). The facility failed to follow the resident plan of care. The findings include: Resident #46 's diagnoses included vascular dementia, malnutrition, and feeding difficulties. The physician's orders dated 10/18/23 directed ADL care as total assist at bed level and extensive assistance for feeding. The care plan with revision date of 11/26/23 identified Resident #46 has an ADL self-care performance deficit related diagnosis of dementia, occasional back pain, weakness, abnormal posture, and feeding difficulties. Resident #46 's goals for this focus included: will maintain current level of function in transfers, eating, dressing, toilet use, and personal hygiene through the next review date. Interventions dated 3/9/23 with a revision date of 11/26/23 included total assistance with ADLs at bed level, extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy and interview for 1 of 3 sampled residents ( Resident # 51) at risk for pressure ulcer development, the facility failed to perform a weekly skin assessments as directed in the plan of care. The finding include: Resident #51's diagnoses included generalized muscle weakness, orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down), and high cholesterol. The care plan revises dated 12/26/23 identified Resident #51 had a reopened area to coccyx, start date of 11/24/23 with the goal to include area to sacrum will be resolved without complications by next review, resolved on 12/26/23. The care plan failed to identify the new wound to the right buttock. The quarterly MDS assessment dated [DATE] indicated Resident #51 was severely cognitively impaired and required maximal assistance for eating and oral hygiene and was dependent on toileting, dressing and personal hygiene. The MDS further indicated Resident #51 was at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 4 residents (Resident # 275) reviewed for abuse, the facility failed to assist implement a bowel retraining program when the resident was identified as a good candidate for retraining. The findings include: Resident #275's diagnoses included Alzheimer's disease, dementia, and irritable bowel syndrome without diarrhea. A physician's order dated 3/8/24 directed to monitor bowel patterns every shift for 3 days. The facility's Bladder and Bowel Program Screener dated 3/8/24 identified Resident #275 was incontinent of stool 1-3 times a week categorized as a 'good candidate for retraining'. The admission MDS assessment dated [DATE] identified Resident #275 had moderately impaired cognition, was frequently incontinent of bowel and bladder, utilized a walker for mobility, and required substantial/maximal assistance with toileting, helper performs more than half of the effort and noted difficulty hearing. Additionally, the assessment notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, review of facility policy and staff interviews for 1 of 1 resident, (Resident #20), reviewed for specialized treatment, the facility failed to ensure that the specialized treatment communication log was consistently completed before the resident left for the specialized treatments. The findings include: Resident #20 was admitted on [DATE] to the facility. The resident diagnoses included. dementia, end-stage kidney disease requiring specialized treatment. The clinical record also noted the utilization of an acquired arteriovenous (AV) fistula on the left arm, which is a surgically created connection of a vein and artery that is used to connect the specialized machine. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 had severe cognitive impairment and required partial to moderate assistance with eating, toileting, and personal hygiene. A care plan dated 2/6/24 identified Resident #20 received specialized treatment on Mondays, Wednesdays, 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, and interviews for 1 of 3 residents (Resident #7) reviewed for dental, the facility failed to arrange dental appointment and assist with transportation timely. The findings include: Resident #7 's diagnoses included, Immuno- compromised, Stage 3 chronic kidney disease and schizophrenia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was cognitively intact and independent in ADL. The MDS further identified Resident #7 experiences mouth or facial pain, discomfort, or difficulty with chewing. The care plan dated 2/9/24 indicated Resident #7 has oral/dental health problems related to partially edentulous, no upper teeth. Interventions include coordinating arrangements for dental care, transportation as needed and as ordered. A physician's order dated 11/4/22 directed to monitoring pain using verbal/non-verbal cues. A nurse's note dated 2/17/24 at 10:09 AM identified Resident # 7 complained of pain to right lower back…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews for 1 of 2 residents (Resident #248) reviewed for food quality, the facility failed to ensure a resident with a severe seafood allergy did not receive fish during a meal. The findings include: Resident #248's diagnosis included congestive heart failure and respiratory failure. A physician's order dated 2/16/24 directing to provide an Epi-Pen 2 Pak Injectable solution (epinephrine) auto injector 0.3mg/0.3 ml inject 3 ml intramuscularly as needed for anaphylaxis. The care plan dated 2/16/24 indicated resident #248 could self-administer an Epi-pen to treat a severe or life-threatening allergic reaction with interventions that included to assist reside to secure medication after administration as needed, educate on proper storage of the drug to prevent unauthorized access and side effects of medication as needed. A nurses note dated 2/16/2024 at 6:56 PM indicated Resident #248 had an allergy to any seafood which caused an anaphylactic reaction was given 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 review, facility policy and interviews for 1 of 6 sampled residents (Resident #30) reviewed for non-pressure skin conditions, the facility failed to ensure a complete and accurate clinical record for a resident with newly identified non- pressure wound(s). The findings include: Resident #30's diagnoses included muscle weakness and seborrheic dermatitis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 as moderately cognitively impaired, required partial to moderate assistance with bed mobility and transfers. The resident also required one person assist with locomotion with the use of a wheelchair and had no unhealed pressure or non-pressure skin injuries. The Resident Care Plan (RCP) dated 11/5/23 identified Resident #30 had the potential for skin integrity issues related to fragile skin, incontinent episodes of bowel and bladder, seborrheic dermatitis, and limited mobility. Interventions included keeping skin clean and dry, using lotion on dry scaly…

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

Based on observation, review of facility documentation, facility policy review and interviews for one of three nursing units ( South Unit) review of the Controlled Drug Count Record Sheet (CDCRS) for reconciliation, the facility failed to consistently reconcile or sign off on the CDCRS for controlled medications every shift. The findings included: Observation by the surveyor on 12/1/2021 at 8:15 AM on the South Unit during medication administration by RN #1 identified after RN # 1 signed out a narcotic. Surveyor reviewed of the Controlled Drug -Count Record Sheet, for November 2021 identified 2 out of 28 occasions where the licensed staff nurses failed to sign or initial the Controlled Drug Count Record as an oncoming or an off going nurse. Further observation of the December 1, 2021, Controlled Drug -Count Record Sheet with RN #1 identified a blank space for count for 11-7 A.M. shift. RN #1 indicated she forgot to sign and immediately initial the 11-7 AM 12/1/21 Controlled Drug -Count Record Sheet. Interview with RN #1 on 12/1/21 at 8:25 AM identified that she always signs the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy and interviews for one of three residents reviewed for accidents (Resident #341) failed to develop a comprehensive plan of care for the resident's Leave of Absence (LOA) and for one of three residents reviewed for Activities of Daily Living (ADL) (Resident #11), the facility failed to develop and implement a comprehensive care plan consistent with resident's participation in treatment. The findings included: 1.Resident #341 was admitted to the facility on [DATE] with diagnoses that included viral meningitis and hearing loss. An admission MDS assessment dated [DATE] identified the resident as cognitively intact, clear speech, without behaviors. and independent for all activities of daily living. The physician's admission orders dated 10/29/21 directed (resident) may go independent Leave of Absence (LOA). A second physician's order dated 10/29/21 directed (resident) may go on LOA with wife or son for three hours. The nurse's progress notes dated 10/31/21 at 12:20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and interviews for one of three residents (Resident #3) reviewed for ADL, the facility failed to provide care per resident's preferences. The findings include: Resident #3's diagnoses included cerebral infarction, sickle-cell, hemiplegia and hemiparesis and paralytic syndrome. The quarterly MDS assessment dated [DATE] identified Resident #3 was severely cognitively impaired and required extensive assistance with two or more people for physical assist and the resident was identified to have a tracheostomy. The care plan identified 11/2021 identified the resident has an ADL self-care performance deficit related to bedfast, deteriorating physical condition, limited mobility and stroke. Resident requires caregiver to be able to assist resident to perform grooming, dressing and bathing. Interventions include resident in dependent on staff for foley care and ostomy management. Wheelchair positioning plan 24 hours. Out of bed to specialized wheelchair…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and interviews for one resident (Resident #3) reviewed for respiratory care, the facility failed obtain active physician's order for the resident's tracheostomy. The findings include: Resident #3's diagnoses included cerebral infarction, sickle-cell, hemiplegia and hemiparesis and paralytic syndrome. The quarterly MDS assessment dated [DATE] identified Resident #3 was severely cognitively impaired and required extensive assistance with two or more people for physical assist and indicated the resident was noted utilizing a tracheostomy. The hospitalization Intra- Agency Discharge summary dated [DATE] at 12:30PM identified Resident #3's tracheostomy was originally a #8 Shiley but was subsequently changed at the hospital to a #7 Portex. Interview with RN #2 on 11/30/21 at 11:30AM identified she was unable to verify the size and type of the tracheostomy. RN #2 identified RN #4 would know the correct size and type. Interview with RN #4 on 11/30/21 at…

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