Milford Center

Based on interview and record review, it was determined that for one (R1) out of three residents sampled for care plan review, the facility failed to revise the person - centered care plan interventions to address R1's refusal to obtain his daily weights. Findings include:Cross Refer F842Review of R1's clinical records revealed:10/28/25 - R1 was admitted to the facility with diagnoses including CHF (congestive heart failure).10/29/25 - R1 had a physician's order to notify provider if R1 gains more than two lbs. (pounds) in one day, or five lbs. in a week related to CHF. 10/28/25 (revised 11/4/25) - A care plan was developed for R1's risk for decreased ability to perform ADLs (Activities of Daily Living) . resistive to daily morning weights for CHF. 11/3/25 - R1's admission MDS (Minimum Data Set) assessment revealed that R1 had an intact cognition with a BIM score of 15. R1 required substantial to maximal assistance of one staff person with bed mobility including lying to sitting on side of the bed. R1 also required moderate assistance of one staff person with sit to stand or chair…

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 record review and interview, it was determined that the facility failed to maintain a complete and accurate record for one (R1) of three sampled residents. Findings include:Cross Refer F657Review of R1's clinical record revealed:12/2/25 - Review of R1's October and November 2025 TARs (Treatment Administration Record) revealed a lack of evidence that R1's daily weights were obtained and completed on October 28, 29 and 31, 2025 and from November 2 through 11, 2025. 12/3/25 10:00 AM - During an interview, E3 (Clinical Lead) confirmed the incomplete documentation. 12/3/25 4:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Clinical Lead) and E15 (Regulatory Nurse) during the Exit Conference.

Based on observation, interview, and record review, it was determined that for five (R4, R12, R38, R66 and R87) out of six residents reviewed for respiratory care, the facility failed to ensure residents' respiratory equipment (Bi-PAP mask and IVAPS mask) were stored in a protective plastic bag, the oxygen tubing was labeled and the filter on the oxygen concentrator was cleaned. Findings include:1. A review of R4's clinical record revealed: 12/16/22 – R4 was admitted to the facility. 7/8/24 – A physician's order for R4 documented to use IVAPS (Intelligent Volume-Assured Pressure Support) every night shift for bedtime and as needed for when napping. 8/1/25 – A quarterly MDS assessment documented that R4 received oxygen therapy and used a non-invasive mechanical ventilator. 8/8/25 – A care plan documented R4 as a risk for respiratory complications related to chronic respiratory failure with an intervention to use the IVAP at bedtime. 9/15/25 9:50 AM – An observation revealed that R4's IVAPS mask was sitting on top of the bedside table with no protective bag available. 9/15/25 10:28 AM…

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

Based on observation and interview, it was determined that the facility failed to ensure food and beverages were stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include:9/15/25 8:29 AM - The corners of numerous ceiling tiles in the dry food stoage room had a variety of different sized black and gray circular areas, which appeared to be mold. 9/15/25 9:17 AM - The clear plastic tubing that connected the kitchen juice machine to the beverage dispenser contained several areas of a blackish gray substance that appeared to be mold. 9/23/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 (Quality Manager) and E3 (DON) during the exit conference.

Based on interview and record review, it was determined that for one (R87) out of thirty (30) residents reviewed in the investigative sample, the facility failed to develop a care plan to address the administration of oxygen via nasal cannula and the use of an incentive spirometer. Findings include:A review of R87's clinical record revealed: 8/29/25 - R87 was admitted to the facility with diagnoses that included but not limited to, pneumonia and respiratory failure. 9/2/25 - A physician's order for R87 documented oxygen at 6L/min via nasal cannula continuously. 9/3/25 - A physician's order for R87 documented incentive spirometer - encourage patient to use as often as tolerated. 9/15/25 11:07 AM - An observation of R87's bedside table revealed an incentive spirometer. R87 stated that he is using the spirometer. 9/16/25 - 2:03 PM - A review of R87's care plan lacked evidence of a care plan addressing he administration of oxygen via nasal cannula and the use of an incentive spirometer. 9/16/25 2:25 PM - During an interview E2 ( quality manager) confirmed there wasn't a 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.

Based on observation, interview, and record review, it was determined that for one (R69) out of seven residents reviewed for ADLs, the facility failed to provide nail care for a dependent resident. Findings include:Review of R69's clinical record revealed:6/30/21 - R69 was admitted to the facility.6/11/25 - A care plan documented that R69 required assistance and was dependent for all ADLs.6/16/25 - An annual MDS assessment for R69 documented that the resident was severely cognitively impaired and required substantially maximal assistance for personal hygiene.9/15/25 9:15 AM - An observation of R69 revealed dark debris underneath each fingernail on the right and left hand. R69's fingernails were long and needed to be trimmed. 9/16/25 9:30 AM - An observation of R69 revealed dark debris underneath each fingernail on the right and left hand. R60's fingernails were long and needed to be trimmed. 9/17/25 1:03 PM - An observation of R69 revealed dark debris underneath each fingernail on the right and left hand. R60's fingernails were long and needed to be trimmed. 9/17/25 1:02 PM - During…

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, interview and record review it was determined that for one (R69) out of seven residents reviewed for activities of daily living (ADLs), the facility failed to ensure that R69 received the treatment/services to prevent further decline in ROM. The facility lacked evidence that the palm device was applied to the left palm. Findings include:Review of R69's clinical record revealed:6/30/25 - R69 was admitted to the facility.5/7/25 10:15 AM - A physician's order documented that R69 was to have a left palm guard applied in the morning with AM care and removed with PM care. There was no stop date to this order.6/11/25 - A care plan documented that R69 required assistance and was dependent for all ADLs. In addition, R69 had a care plan with a goal to maintain skin integrity and prevent contractures with interventions that include applying a palm guard at 10:00 AM to the left hand for up to 6 hours daily as tolerated after morning care.6/16/25 - An annual MDS assessment for R69 documented that the resident was severely cognitively impaired and required substantially…

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 interview and record review it was determined that for one (R20) out of one resident reviewed for bowel and bladder, the facility failed to provide services to maintain or restore bladder continence. Findings include:Review of R20's clinical record revealed: 3/21/21 - R20 was admitted to the facility. 8/18/22 - A care plan documented that R20 was incontinent of urine and was unable to cognitively or physically participate in retraining with the following interventions: assist with perineal care as needed, monitor for signs and symptoms of infection, and provide privacy and comfort. 1/10/25 - A post voiding diary follow up assessment documented that R20 was assessed for urinary and fecal incontinence and the outcome determined R20 was a candidate for prompted voiding. The assessment lacked documentation regarding a toileting plan or update for the care plan. 5/15/25 - A quarterly MDS documented R20 had a BIMS score of 15 indicating the resident was cognitively intact. The MDS documented that R20 required supervision or minimal assistance for toileting and was occasionally…

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, interview and record review, it was determined that for one (R10) out of three residents sampled for dental services, the facility failed to assist R10 in obtaining routine dental services. Findings include:Review of R10's clinical record revealed:7/23/23 - R10 was admitted to the facility.6/27/25 - An annual MDS documented that R10 had no broken or loosely fitting dentures, no natural teeth or tooth fragments, no abnormal mouth tissue, and no obvious broken teeth.9/15/25 9:57 AM - An observation of R10 revealed loosely fitting dentures. 9/15/25 10:13 AM - An interview with FM1 (Guardian) revealed that R10 had not seen a dentist. 9/17/25 11:11 AM - An interview with E12 (Scheduler) confirmed that a dentist comes to the facility and residents also can go to outside dental providers. E12 stated, residents will request to see the dentist and will get added to the list. 9/17/25 11:44 AM - An interview with E10 (Regulatory Compliance Advisor) confirmed that R10 had not been seen by the dentist.9/23/25 2:45 PM - Findings were reviewed with E1 (NHA), E2 (Quality…

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 record review and interview, it was determined that for one (R2) out of thirty sampled residents, the facility failed to ensure the clinical record contained accurate documentation. Findings include:Review of R2's clinical record revealed:11/28/23 - R2 was admitted to the facility.9/10/25 - A review of a facility investigation documented that R2 was involved in a resident to resident altercation with R53. 9/10/25 11:06 AM- A physician's order documented that R2 was to be sent to ER for treatment and evaluation. 9/10/25 - A review of the CNA documentation record revealed that R2 was not available for all ADL tasks on the 7:00 AM to 3:00 PM shift. 9/22/25 10:20 AM - An interview with E7 (CNA) confirmed that R2 was in the facility on the date of 9/10/25 at approximately 12:15 PM and the documentation of not available was inaccurate.9/23/25 9:00 AM - An interview with E10 (Regulatory Compliance Advisor) confirmed that R2 was sent to the ER at 12:15 PM and confirmed the documentation should reflect receiving care prior to R2 leaving the facility. 9/23/25 2:45 PM - Findings were…

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 interview, record review, and review of other facility documentation as indicated, it was determined that for four (R12, R50, R6 and R413) out of ten residents reviewed for and allegation of abuse and neglect, the facility failed to have evidence of thorough investigation. 1. Review of R12's clinical record revealed: 9/25/20 - R12 was admitted to the facility. 6/6/24 - A quarterly MDS documented R12 was dependent for ADL's including toileting, dressing, and personal hygiene. 8/2024 - A review of the CNA task flow sheet for August 2024 lacked evidence that staff provided care on 8/25/24. 11/18/24 11:25 AM - A review of the facilities investigative documents for an allegation of neglect lacked evidence of direct care staff interviews for 8/25/24. The packet included the initial report to state agency, the five day follow up and a disciplinary report on alleged employee. 11/21/24 9:37 AM - An interview with E1 (NHA) and E2 (DON) confirmed that the facility lacked evidence of interviews with direct care staff. E1 was unable to provide staff interviews from the facility…

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 record review and interview, it was determined that for one (R6) out of forty-six (46) residents in the investigative sample, the facility failed to ensure the clinical record contained accurate documentation. Findings include: 1 A. Cross refer F686. Review of R6's clinical record revealed: 3/25/22 - R6 was admitted to the facility. 7/3/24 - R6's physicians orders documented to cleanse right heel with wound cleanser, apply Medi-honey and cover with Optifoam every other day until healed. 7/12/24 - The treatment administration record (TAR) documented that E24 (LPN) had administered the treatment to R6's right heel. 7/16/24 - A facility investigative report revealed that the wound dressing to R6's right heel was dated 7/8/24, even after 8 days had passed. 7/16/24 - A statement by E24 documented that the TAR was signed off prior to the treatment being completed to R6's right heel and then forgot to go back and complete the treatment later. 11/20/24 9:44 AM - An interview with E2 (DON) confirmed that E24 signed the TAR off as completed and the treatment was not done. The…

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

Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include: 1. 11/12/24 8:43 AM During a tour of the kitchen, the surveyor observed E29 (Dietary Manager) test the sanitizer level of the solution in two red sanitizing buckets. When E29 tested the sanitizing solution, the test strips from each of the buckets indicated that the level of chemical concentration in the buckets was not at a sufficient level to provide proper sanitization. 2. 11/12/24 9:14 AM - Observation of the ceiling in the main kitchen area and the dry storage room adjacent to the main kitchen revealed patches of dark spotted staining, which appeared to be mold or mildew in the corners of several ceiling tiles. 3. 11/12/24 9:26 AM - The bottom of the door to the walk-in-freezer was damaged resulting in a poorly functioning seal and significant build-up of ice along the interior edge of the door. 4. 11/12/24 12:04 PM - A black substance and a significant amount of dust was…

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

Based on record review and interview, it was determined that for six (R5, R61, R65, R83, R89, and R91) out of thirty-one sampled residents, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings and to ensure that care plan meetings occurred every three months. For R33, R34 and R38 the facility failed to revise the care plan to reflect resident's current needs. Findings include: 1. Review of R89's clinical record revealed: 2/12/24 - R89 was admitted to the facility with a BIM's of 13 which indicated that R89 was cognitively intact. 8/14/24 - R89's quarterly MDS assesment documented that her BIMs was not assessed, but R89 had disorganized thinking. 8/30/24 11:21 AM - A care plan evaluation progress note included that the social worker, medical staff and resident representative were aware of a room change. Review of the resident record revealed that the facility lacked evidence of a quarterly care plan meeting. 10/3/24 - R89's discharge MDS assessment documented that her BIMs was not assessed, but R89 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 interview and record review it was determined that for four (R6, R43, R89 and R91) out of four residents reviewed for urinary incontinence, the facility failed to assess and provide care and services to maintain/restore bowel and bladder continence. Findings include: A facility policy titled Continence Management (effective 6/1/96 last revised 6/15/22) included: Patients will be assessed for the need for continence management as part of the nursing assessment process. A urinary incontinence assessment and or bowel incontinence assessment will be completed upon admission or re-admission and with a change in condition or change in continence status. Continence status will be reviewed quarterly as part of the care planning process. Identify patient's incontinence management by conducting a nursing assessment. Assess components include but are not limited to .voiding patterns. Cross refer to F689 1. Review of R89's clinical record revealed: 2/12/24 - R89 was admitted to the facility with dementia. 2/12/24…

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 interview and record review, it was determined that for one (R38) out of two residents reviewed for dialysis, the facility failed to ensure that the provider was consulted when R38 refused dialysis services. Findings include: Review of R38's clinical record revealed: 8/23/22 - R38 was admitted to the facility. 6/1/14 - A quarterly MDS documented R38 was receiving dialysis as a special treatment. 7/8/24 11:17 AM - A progress note documented that R38 refused dialysis today and the Unit Manager (UM) was made aware. 11/15/24 2:31 PM - In an interview, E11 (RN) stated that the expectation if a resident refused dialysis would be to notify the provider and notify the family. E11 stated she would provide education to the resident and encourage them to attend dialysis. 11/15/24 2:43 PM - In an interview, E12 (UM) stated that expectation of a resident missing dialysis would be that the nurse responsible for the resident would notify the provider. E12 stated she was aware of R38 missing dialysis on 7/8/24 and that the provider was already aware of R38's behavior of refusing dialysis.…

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 interview, record review and review of other facility documentation, it was determined that for one (R50) out of one reviewed for grievances, the facility failed to ensure that resident concerns received by the facility included prompt efforts to resolve the resident's problems. Findings include: Review of R50's clinical record revealed: 12/19/23 - R50 was admitted to the facility. 5/2024 - A grievance/concern log revealed an entry for 5/17/24 for R50 stated a clinical concern and DON/UM were responsible to investigate. 5/17/24 - A grievance report documented that R50 had concerns that staff did not provide care during the 7:00 AM to 3:00 PM shift on 5/8/24. The report was initially accepted by E4 (SW). The follow up section of the grievance report was blank. 5/17/24 - A grievance report documented that R50 had concerns that staff did not address R50's immediate needs during the 7:00 AM to 3:00 PM shift on this date. This report was completed by E4 (SW). The follow up section was blank. 11/21/24 9:37 AM - An interview with E4 (SW) revealed that E4 was the grievance officer.…

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 interview and record review, it was determined that for one (R261) out of four residents reviewed for allegation of neglect, the facility failed to immediately report an allegation of neglect within the required timeframe. A five day follow-up report wasn't submitted following the allegation until fifteen days later. Findings include Review of R261's clinical record revealed: 7/30/22 - R261 was admitted to the facility. 6/9/24 - A facility incident report documented, E9 (CNA) alleged E10 (LPN) was neglectful by not responding to the needs of R261 in a timely manner and reported the allegation to E2 (DON). 6/17/24 - An incident report was submitted to the state agency for an allegation of neglect for R261, eight days after the allegation. 7/2/24 - The five day follow up report for R261 was submitted to the state agency for the allegation of neglect on day fifteen. 11/22/24 9:37 AM - During an interview, E2 (DON) confirmed the allegation of neglect was reported late, eight days after the allegation. 11/25/24 1:00 PM - Findings were reviewed with E1 (NHA) and E2 during 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 interview and record review, it was determined that for two (R38 and R66) out of two residents reviewed for PASARR, the facility failed to ensure that a referral for PASARR screening was completed. Findings include: 1. Review of R38's clinical record revealed: 8/23/22 - R38 was admitted to the facility with diagnosis including bipolar disorder. 7/2/24 - A discharge summary [hospital] revealed that R38 was admitted related to dementia with behaviors. The summary revealed that R38 was having aggressive behaviors while at the dialysis center for treatment and transferred to the emergency department for treatment. 7/15/24 - A psychology progress note revealed that R38 had a new diagnosis of unspecified mood disorder and adjustment disorder with depressed mood. The facility lacked evidence that a referral was made to the State PASARR authority. 11/18/24 10:05 AM - An interview with E4 (SW) confirmed that R38 had not had an update sent to PASARR and confirmed she would send the update now. 2. Review of R66's clinical record revealed: 6/17/21 - R66 was admitted to the facility…

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, interview and record review it was determined that for three (R6, R12, and R34) out of twelve residents reviewed for activities of daily living (ADL's), the facility failed to provide care and services for dependent residents. Findings include: 1. Cross refer to F656 Review of R33's clinical record revealed: 8/5/22 - R33 was admitted to the facility with dementia. 8/5/22 - R33's care plan included that the resident requires assistance/dependent for ADL care. 6/4/24 - R33's care plan included being resistive to care and refusing medication. The care plan did not include refusal of nail care. 7/5/24 - A significant change MDS documented that R33 required partial/moderate assist for hygeine and bathing and had no rejection of care. Observations on 11/12/24 at 2:42 PM; 11/15/24 at 10:20 AM; 11/22/24 at 10:52 AM; and 11/22/24 at 10:56 AM revealed R33 had black debris underneath all of her nails. 11/22/24 - During an observation and interview, E30 (CNA) stated that it was the responsibility of the CNA's to provide nail care. E30 confirmed that R33 had black debris…

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 interview and record review, it was determined that for two (R6 and R5) out of four residents reviewed for pressure ulcers, the facility failed to provided necessary treatment to promote healing of a current pressure ulcer. Cross refer to F842 1. Review of R6's clinical record revealed: 3/25/22 - R6 was admitted to the facility. 3/16/23 - A care plan for R6 was initiated for having skin breakdown related to decreased activity, reluctance to offload heels in bed, impaired cognition and comorbidities. Interventions included but not limited to providing preventative skin care as ordered, encouraging resident to turn and reposition and to check skin every two hours. 7/7/24 - A care plan for R6 was initiated for having a documented pressure ulcer. Interventions included to complete a mini nutritional evaluation and to educate the resident or representative on the importance of keeping skin clean and moisturized. 7/28/24 - A quarterly MDS assessment revealed that R6 required supervision or touching assistance of one person for sitting to lying and lying to sitting. R6 required…

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 record review and interview, it was determined that for one (R89) out of five residents reviewed for unnecessary medications, the facility lacked evidence of side effect monitoring for psychotropic medications. Findings include: Review of R89's clinical record revealed: 2/12/24 - R89 was admitted to the facility with the following diagnoses, but not limited to, including major depressive disorder, adjustment disorder with mixed anxiety and depressed moods, unspecified dementia with psychotic behaviors, and unspecified dementia with other behaviorial disturbances. 10/31/24 - A physician's order was written for Ativan 0.5 mg three times a day for anxiety. 11/2024 - A review of the November MAR lacked evidence of monitoring for side effects related to psychotropic medications. 11/15/24 2:43 PM - An interview with E12 (UM) confirmed that R89 did not have an order to monitor for side effects related to psychotropic medications. 11/25/24 1:00 PM - Findings were reviewed with E1 (NHA) and E2 during the exit conference.

Based on record review and interview, it was determined, for one (R50) out of four residents sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner of laboratory results. Findings include: Review of R50's clinical record revealed: 12/29/23 - R50 was admitted to the facility. 10/31/24 - A provider (E18 NP) encounter note documented R50 was having malodorus urine with cloudy urine noted in foley tubing. E18 ordered a urine analysis (UA) and culture sensitivity (C & S). 11/1/24 5:06 PM - A review of lab results revealed that R50 was positive for a urinary tract infection. The culture was still pending at this time. 11/3/24 (Sunday) 4:18 PM - A review of lab results revealed the urine sample from R50 was positive for growth. 11/4/24 (Monday) 9:00 PM - A physician's order was written for Ciprofloxacin (anitibiotic) 500 mg give one tablet by mouth every twleve hours for urinary tract infection for seven days. 11/19/24 9:12 AM - An interview with E17 (RN) stated if lab results post during the weekend the nurse on duty is expected to review…

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

Based on observation, interview and record review, it was determined that for one (R13) out of three residents sampled for dental services, the facility failed to assist the resident in obtaining routine dental services. Findings include: Review of R13's clincal record revealed: 8/19/21 - R13 was admitted to the facility. 4/21/24 - A significant change MDS documented that R13 had no natural teeth or tooth fragments, no abnormal mouth tisssue, and no obvious broken teeth. 11/12/24 2:58 PM - An interview with R13 revealed that R13 has several missing teeth. R13 stated that she only has approximately five teeth left. R13 stated she has not seen a dentist or has been offered dental services by the facility. 11/13/24 2:45 PM - An interview with E22 (CNA) confirmed that a dentist comes to the facility and residents also can go to outside dental providers. E22 stated that residents will request to see the dentist and will get added to the list. 11/13/24 3:02 PM - An interview with E23 (Unit Clerk) confirmed that there is a list of residents for the dentist to see. E23 stated she will call…

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 interview and record review, it was determined that for three (R1, R3 and R5) out of three sampled residents reviewed for pressure ulcer (PU), the facility failed to ensure monitoring for the development of new pressure ulcers and monitoring of existing pressure ulcers was completed. Findings include: The facility policy on skin and integrity and wound management last updated 5/1/24 directed staff to Complete comprehensive evaluation of patient upon admission/readmission. Complete risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition. Perform and document skin inspection on all newly admitted /readmitted patients, weekly thereafter and with any significant change in condition. Complete wound evaluation upon admission/readmission, new in-house acquired, weekly and with unanticipated decline in wounds. 1. Review of R1's clinical record revealed: 3/27/24 - R1 was admitted to the facility. 3/27/24 3:21 PM - An admission note written by E4 (interim ADON) documented, .Other skin issue. Location: Left heel. Other…

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

Based on record review and interview, it was determined that for one (R1) out of three residents reviewed for pressure ulcers the facility failed to implement the grievance process. Findings include: The facility policy on grievances last updated, 1/8/24 indicated, Upon receipt of a grievance/concern the grievance form will be initiated by the staff member receiving the concern. Review of R1's clinical record revealed: 3/27/24 - R1 was admitted to the facility. 4/3/24 - An admission MDS assessment documented R1 as cognitively intact with no behaviors. During an interview on 5/17/24 at 9:33 AM, FM1 stated, On April 26th two CNA's went in [R1's] room and said his vibe was off and the woman told him we are not having any of that now. She went to change him but needed supplies and left the room. The other CNA was sitting in the chair began standing, chanting and naming Jesus Christ and The blood of Jesus. [R1] was very upset and when he asked who was the supervisor she said she didn't know. I called the nursing home. I got the names of these two staff members, E8 (CNA) and E9 (CNA),…

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 record review and interview it was determined that for one (R1) out of three residents reviewed for pressure ulcers the facility failed to accurately completed the admission MDS assessment. Findings include: Cross refer F686: Review of R1's clinical record revealed: 3/27/24 - R1 was admitted to the facility. 3/27/24 3:21 PM - An admission note written by E4 (interim ADON) documented, .Other skin issue. Location: Left heel. Other skin issue description: Dry scaly; covered with pad .Other skin issue. Location: Right heel. Other skin issue description: Dry scaly; covered with pad. Pressure reducing device to bed. 4/3/24 An admission MDS assessment documented, that R1 was at risk for pressure ulcer development but had no unhealed pressure ulcers. 4/10/24 - A wound evaluation documented R1 as having an unstageable pressure ulcer to the right heel that was present on admission. During an interview on 5/22/24 at 1:50 PM E7 (RN) confirmed the findings, and stated, He came in with pressure ulcers but I didn't know that. I knew he came in with something on his heel. Findings were…

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 interview, record review and review of other related documentation, it was determined that for one (R1) out of three residents reviewed for discharge, the facility failed to implement a discharge planning process that included education/training on mechanical lift transfers and pressure ulcer care to R1's caregiver because R1 was unable to perform these task independently. Findings include: The facility policy on discharge and transfer last updated, 11/15/22 indicated, The registered nurse is ultimately responsible to ensure that there is a safe and coordinated discharge and transfer plan in place for the patient .The inter-professional care team will provide sufficient preparation and orientation to the patient prior to transfer or discharge. 1. Review of R1's clinical record revealed: 3/27/24 - R1 was admitted to the facility. 3/29/24 3:16 PM - The post admission Pt/Family conference to review the baseline care plans documented, Patient's stay is expected to be short term. Expectations and goals of care related to transitioning back to the community discussed. Home Health…

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 interview and record review, it was determined that for three (R1, R2, and R3) out of three residents reviewed for Advance Directives, the facility failed to provide evidence that R1, R2 and R3 were offered an opportunity to formulate an Advance Directive. Findings include: A facility policy dated 6/1/96, revised 1/8/24, and titled, Health Care Decision Making, documented, .It is the right of all patients/residents to participate in their own health care decision-making including the right to decide whether they wish to request, accept, refuse or discontinue treatment, and to formulate or not and advance directive. 1. Review of R1's clinical records revealed: 2/14/24 - R1 was admitted to the facility with diagnoses including but not limited to insulin dependent diabetes and hyperglycemia. 2/23/24 1:04 PM - A review of R1's clinical lacked evidence that R1 was offered or provided an opportunity to formulate an Advance Directive. 2/23/24 1:15 PM - During a phone interview with F1 (Family) it was stated, Advance Directive or Code Status was not discussed during 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.

Based on record review and interview it was determined that for one (R16) out of three residents reviewed for falls, the facility failed to ensure accuracy of the MDS assessment. Findings include: Review of R16's clinical record revealed: 3/25/21 - R16 was admitted to the facility. 2/15/24 - A nursing progress note documented that R16 had a fall without any injury. 3/8/24 - An annual MDS assessment for R16 documented, Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent? The facility answered No. 4/22/24 3:26 PM - During an interview E17 (MDS coordinator) confirmed that the MDS should have documented yes for the question related to any falls since admission because the resident has a history of falls and she fell on 2/15/24. E17 stated we can go in and fix that. These findings were reviewed during the exit conference on 4/22/24 at 3:40 PM with E1 (NHA), E2 (DON) and E16 (Regional Nurse Consultant).

Based on observation and interview, it was determined that for one (R17) out of one resident reviewed for ADLs, the facility failed to ensure ADLs were provided to dependent residents. Findings include: Review of R17's record revealed: 3/7/24 - R17 was admitted to the facility. 3/13/24 - An admission MDS revealed that R17 is cognitively intact. R17 required substantial or maximum assist by one person for toileting, shower/bath, hygiene, and rolling side to side. The MDS revealed that R17 had an indwelling catheter in place and was always incontinent of bowel. 4/16/24 7:00 AM to 3:00 PM - A review of R17's CNA task flow sheet revealed that E15 (CNA) documented R17 as dependent response not required for bowel continence. The task sheet also revealed that R17 did not receive assistance with dressing, hygiene, or toileting. 4/16/24 - A facility incident report revealed that R17 reported he was not provided care on 4/16/24 during the day shift. 4/16/24 5:14 PM - A facility investigative packet revealed that E15 confirmed that care was not completed for R17 on 4/16/24 due to [R17] stated…

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 interview and record review, it was determined that for one (R1) out of three residents reviewed for hydration, the facility failed to ensure a resident at risk for dehydration R1 was monitored for hydration. Findings include: A facility policy dated 1/1/04, revised 2/1/23, and titled, Nutrition/Hydration Care and Services, documented, Maintain fluid and hydration balance at risk for dehydration . Review of R1's clinical records revealed: 2/14/24 9:11 PM - R1 was admitted to the facility with diagnoses including insulin dependent diabetes mellitus with hyperglycemia, obstructive uropathy, and acute kidney injury. R1 had a urinary catheter. R1's medications included Lasix (diuretic) daily for fluid management, and Keflex (antibiotic) four times a day for seven days for sepsis. R1's clinical record documented, .is a brittle diabetic . 2/15/24 6:51 AM - R1's laboratory results in the facility revealed a potassium level of 4.7 (normal range 3.6 - 5.2), BUN level of 39 (normal level 6-24), and Creatinine level of 1 (normal level 0.7-1.3). 2/15/24 10:38 AM - R1's nutritional…

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 interview and record review, it was determined that for one (R1) out of three residents reviewed for physician's services, the facility failed to ensure that R1's order for insulin was accurately reviewed and documented to ensure that R1 received the insulin as ordered. Findings include: Cross refer F760. Review of R1's records revealed: 2/14/24 9:11 PM - R1 was admitted to the facility with diagnoses including but not limited to insulin dependent diabetes mellitus with hyperglycemia. 2/14/24 - R1's hospital physician's discharge orders included, insulin lispro (insulin lispro 100 units/ml injectable solution) via continuous insulin pump per current pump settings. 2/15/24 - E5's (NP) documentation included, .Patient (R1) to continue on insulin .I reviewed external hospital notes/discharge summary . 2/16/24 - E5's (NP) documentation included, .Patient (R1) to continue insulin . 2/19/24 6:40 AM - R1's clinical records documented that R1 was observed with medical status changes including respiratory distress. R1's blood sugar, was greater than 500, and the glucometer read HI.…

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 interview and review of facility documentation, it was determined that the facility failed to ensure that a performance review was completed at least every 12 months for five (E16, E17, E18, E19 and E20) out of five sampled employees. Findings include: 2/27/24 9:30 AM - Review of the staff training hours documentation revealed the following: 1. E16 (CNA) had a hire date of 9/24/13. A record review revealed that the last annual performance was completed on 3/11/21. There was a lack of evidence of a performance evaluation from the past year. 2. E17 (CNA) had a hire date of 8/20/18. A record review revealed a lack of evidence of a performance evaluation from the past year. 3. E18 (CNA) had a hire dated of 9/2/20. A record review revealed a lack of evidence of a performance evaluation from the past year. 4. E19 (CNA) had a hire date of 8/19/19. A record review revealed that the last annual performance was completed on 3/5/21. There was a lack of evidence of a performance evaluation from the past year. 5. E20 (CNA) had a hire date of 9/8/21. A record review revealed a lack 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.

Based on interview and record review, it was determined that for one (R1) out of three residents reviewed for pharmacy services, the facility failed to ensure that R1's order for insulin was accurately and comprehensively reviewed to ensure that R1 received the insulin as ordered. A facility document dated 10/1/17, revised on 2/13/18, 10/1/18, and 11/8/23, and titled, admission Medication Regimen Review, documented, The Consultant Pharmacist will conduct a comprehensive review of each patient's medication therapy .this will include but not limited to current medication regimen, medication history, admission, and discharge information . Review of R1's records revealed: 2/14/24 9:11 PM - R1 was admitted to the facility with diagnoses including insulin dependent diabetes mellitus with hyperglycemia. R1's hospital physician's discharge orders included, insulin lispro (insulin lispro 100 units/ml injectable solution) via continuous insulin pump per current pump settings. 2/16/24 9:41 AM - R1's Pharmacist Medication Regimen Review documented, No irregularities. 2/19/24 6:40 AM - R1's…

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 interview and review of facility documentation, it was determined that the facility failed to ensure that the required training on effective communications for direct care staff was completed for two (E10 and E21) out of four sampled employees. Findings include: 2/27/24 10:00 AM - Review of the employee training records revealed a lack of evidence of effective communications for direct care staff training of the following staff: 4/24/23 - E10's first day in the facility assigned as Agency LPN. 9/20/21 - E23's first day in the facility hired for the RN (Registered Nurse) position. 2/27/24 2:00 - Findings were comfirmed by E1 (NHA) during an interview. 2/27/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (RRM) during the exit conference.

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training on resident rights was completed for three (E10, E21 and E22) out of four sampled employees. Findings include: 2/27/24 10:00 AM - Review of the employee training records revealed a lack of evidence of resident rights training of the following staff: 4/24/23 - E10's first day in the facility assigned as Agency LPN. 2/25/82 - E21's first day in the facility hired for the CNA (Certified Nurse Assistant) position. 9/26/23 - E22's first day in the facility assigned as Agency LPN. 2/27/24 2:00 - Findings were comfirmed by E1 (NHA) during an interview. 2/27/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (RRM) during the exit conference.

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training on abuse, neglect and exploitation was completed for three (E10, E21 and E22) out of four sampled employees. Findings include: 2/27/24 10:00 AM - Review of the employee training records revealed a lack of evidence of Abuse, Neglect and Exploitation training of the following staff: 4/24/23 - E10's first day in the facility assigned as Agency LPN. 2/25/82 - E21's first day in the facility hired for the CNA (Certified Nurse Assistant) position. 9/26/23 - E22's first day in the facility assigned as Agency LPN. 2/27/24 2:00 PM - Findings were comfirmed by E1 (NHA) during an interview. 2/27/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (RRM) during the exit conference.

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training on QAPI (quality assurance and performance improvement) was completed for two (E10 and E23) out of four sampled employees. Findings include: 2/27/24 10:00 AM - Review of the employee training records revealed a lack of evidence of QAPI training of the following staff: 4/24/23 - E10's first day in the facility assigned as Agency LPN. 9/20/21 - E23's first day in the facility hired for the Registered Nurse (RN) position. 2/27/24 2:00 PM - Findings were comfirmed by E1 (NHA) during an interview. 2/27/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (RRM) during the exit conference.

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training on infection control program was completed for one (E10) out of four sampled employees. Findings include: 4/24/23 - E10's first day in the facility assigned as Agency LPN. 2/27/24 10:00 AM - Review of E10's employee training records revealed a lack of evidence of infection control program training. 2/27/24 2:00 - Findings were comfirmed by E1 (NHA) during an interview. 2/27/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (RRM) during the exit conference.

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the required yearly training on compliance and ethics program was completed for three (E10, E21 and E22) out of four sampled employees. Findings include: 2/27/24 10:00 AM - Review of the employee training records revealed a lack of evidence of compliance and ethics program training of the following staff: 4/24/23 - E10's first day in the facility assigned as Agency LPN. 2/25/82 - E21's first day in the facility hired for the CNA (Certified Nurse Assistant) position. 9/26/23 - E22's first day in the facility assigned as Agency LPN. 2/27/24 2:00 - Findings were comfirmed by E1 (NHA) during an interview. 2/27/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (RRM) during the exit conference.

Based on record review and interview, it was determined that for four (E16, E17, E18 and E20) out of five sample Certified Nursing Assistants (CNAs) reviewed, the facility failed to ensure that these employees had the mandatory twelve hours of annual in-service training. Findings include: 2/27/24 9:30 AM - Review of the staff training hours documentation revealed the following: E16 (CNA) with a hire date of 9/24/13 had only 8.4 hours of training; E17 (CNA) with a hire date of 8/20/18 had only 3.10 hours of training; E18 (CNA) with a hire date of 7/5/22 had only 4.5 hours of training; E20\(CNA) with a hire date of 9/8/21 had only 4.56 hours of training. The facility lacked evidence that these employees completed the mandatory twelve hours of annual in-service training. 2/27/23 1:45 PM - In an interview, E1 confirmed that the facility has no additional information regarding the training and that it was not completed by E16, E17, E18 and E20. E1 stated that those were the only training records that the facility has on file. E1 further confirmed that the facility has no other additional…

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

Based on observation and interview, it was determined that for one unit out of three units, the facility failed to maintain a clean, comfortable, and homelike environment. The facility failed to provide acceptable water temperatures to provide bathing. Additionally the facility failed to provide adequate lighting in a resident room. Findings include: 1. 12/12/23 9:32 AM - During an observation and interview, R379 stated that the water did not get hot. The surveyor tested the water temperature with her hands and the water was ice cold. The faucet was on for five minutes and did not warm up. 12/12/23 10:46 AM - During an interview, R12 stated that there was not any hot water this morning. 12/12/23 10:52 AM - During an interview, E12 (Maintenance Director) stated, the mixing valve was out since last night. The man is here working on it. The surveyor inquired how did the residents receive care without hot water, and he replied, there was still some warm water available this morning, (and) that it should be fixed soon. E12 stated that they were still adjusting the mixing valve. E12…

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 record review and interviews, it was determined that for one (R107) out of five residents sampled for medication review. The facility failed to notify R107's representative of a change to R107's treatment plan involving medication. Findings include: Review of R107's clinical record revealed: 10/14/22 - R107 was admitted to the facility with a diagnoses of but not limited to anxiety disorder. 10/20/23 - An annual MDS documented R107 as severly cognitively impaired. 12/17/23 - A physician's order to discontinue lorazepam 1 mg one time a day for anxiety. 1/3/24 10:35 AM - During an interview with FM2, it was revealed that the facility did not notify the family regarding the change to R107's medication treatment plan. 1/5/24 1:20 PM - During an interview via telephone with E33 (Psychiatric Nurse Practitioner), it was confirmed that she had discontinued the aforementioned medication without notifying FM2. 1/5/24 2:10 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for one (R107) out of five residents for medication review, the facility discontinued R107's routine anti-anxiety medication in error. In addition, it was determined that for one (R114) out of two residents reviewed for Urinary Cather/UTI, the facility failed to follow the plan of care. Findings include: 1. Review of R107's clinical record revealed: 10/14/22 - R107 was admitted to the facility with a diagnosis that included but was not limited to anxiety disorder. 10/25/23 - A physician order documented lorazepam 1 mg to be given one time a day for anxiety. 11/3/23 (revision date) - A care plan documented R107 has anxiety, depression with behaviors. 12/17/23 - A physicians order documented to discontinue routine lorazepam 1mg one time a day for anxiety. 12/21/23 - A NP progress note for R107 documented agitation .spouse is requesting that he continue on his previous dose of lorazepam. 1/4/24 9:45 AM - During an interview E4 (NP) stated that R107 was experiencing increased agitation. 1/4/24 1:20 PM - During an interview via…

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 record review and interview, it was determined that for three (E8, E10 and E11) out of five Certified Nursing Assistants (CNA) reviewed, the facility failed to ensure that these employees had the mandatory twelve hours of annual in-service training. Findings include: 12/15/23 approximately 12:15 PM - The surveyor received documentation regarding staff training hours. Review of this documentation revealed the following: E8 (CNA) with a hire date of 11/8/22 had only 4 hours of training; E10 (CNA) with a hire date of 8/9/22 had only 2 hours of training; E11 (CNA) with a hire date of 7/5/22 had only 4.45 hours of training. The facility lacked evidence that these employees completed the mandatory twelve hours of annual in-service training. 12/19/23 approximately 12:00 PM - During an interview, E1 (NHA) and E2 (DON) stated they will review additional records to provide confirmation of training's. 12/19/23 2:41 PM - In an email correspondence, E1 confirmed that the facility has no additional information regarding the training and that it was not completed by E8, E10 and E11.…

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 and interview, it was determined that the facility failed to prevent the occurrence of mold in high moisture areas and maintain food storage areas in a clean and safe condition. Findings include: 8/30/23 9:38 AM - The surveyor observed the bottoms of all of the shelving and several of the tops of the shelving in the walk-in refrigerator were covered with numerous areas of small to medium black spots, which appeared to be mold. 8/30/23 9:52 AM - One of the seams in the metal floor if the walk-in refrigerator was not sealed tightly leaving a space for rodents and other pests to access the refrigerator and allowing debris to accumulate preventing proper sanitation of the area. The upper edge of the floor seam showed a large area of heavy rust staining indicating prolonged contact with water. 8/30/23 3:07 PM - Findings were reviewed with E1 (Corporate), E2 (Senior Market DON) and E3 (DON) during the exit conference.