Groves Center

Based on observations, record review and interviews the facility failed to ensure two residents (#36 and #11) of five observed residents received medications within the scheduled time frame and failed to ensure the physician was notified prior to the administration of late medications.Findings included: Review of the facility Medication Administration Times schedule showed daily medications were scheduled at 9:00 a.m., twice daily was scheduled for 9:00 a.m. and 5 p.m., and three times a day was scheduled for 9:00 a.m., 1:00 p.m., and 5 p.m. The time schedule revealed with meals medications were scheduled for 8:00 a.m. and 6 p.m. On 2/3/26 at 11:52 a.m. Staff B, Registered Nurse (RN) was observed in the hallway standing at the medication cart. The observation revealed Resident #36's medication profile was colored red, indicative of late medications. Staff B, RN was observed dispensing the following medications: Eliquis 2.5 milligram (mg) tablet Gabapentin 400 mg capsule Metoprolol tartrate half tablet of 25 mg's = 12.5 mg Potassium extended release 10 milliequivalents (meq)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and policy review, the facility failed to ensure a grievance was filed and investigated and resolved for one resident (#9) of seven sampled residents.Findings included: Review of Resident #9's admission record revealed an admission date of 08/18/2025. Resident #9 was admitted to the facility with diagnosis to include muscle wasting and atrophy, need for assistance with personal care, methicillin resistant staphylococcus aureus infection, and osteomyelitis.During an interview on 10/28/2025 at 12:03 p.m., Resident #9 stated, I am not happy because I have a blanket and a couple of blouses missing. The resident reported a family member came to the facility on [DATE] and the facility let them look in the laundry room for the missing items. The family member did not find the items.During an interview on 10/28/2025 at 2:15 p.m. the Social Services Director (SSD) reviewed the grievance log and stated there were no current open grievances for Resident #9. The SSD stated staff should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility did not ensure reporting of an allegation of neglect for one resident (#1) out of three residents reviewed. Findings Included: A facility policy titled Abuse Prevention Program, reviewed September 2025, showed: Policy: - The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property.These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff bum out, or resident behavior which may increase the likelihood of such events.Definitions: Neglect -Failure of the facility, its employees, or service providers to provide good and services…

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, the facility failed to thoroughly investigate an allegation of neglect, by failing to conduct interviews with all relevant staff related to a reportable event for one resident (#2) of five sampled residents. Findings included: On 10/29/25 at 2:47 p.m., a meeting was held to discuss a sample of State Agency reportable cases. The staff attendees included the Nursing Home Administrator (NHA), Regional Nurse Consultant (RNC), Director of Risk Management Consultant (DRMC), and the Senior Regional Nurse Consultant (SRNC). The NHA stated he became aware of the allegation for Resident #2 when the Department of Children and Families (DCF) agent arrived at the facility on 9/2/25. He stated DCF told him the allegation was from Resident #2's family. He was told the family said that the facility did not replace the resident's foley catheter and didn't provide catheter care. The NHA stated he was told the family believed this caused infection. The NHA stated not knowing the name of the family member. He stated he did not contact the family after 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, interview, and record review the facility failed to ensure proper catheter care was provided to include securing and changing catheter bags per physician orders, for four residents ( #15, #16, #4 and #2) of four residents sampled for catheter care. Findings included: On 10/27/25 at 4:05 p.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). He stated Certified Nursing Assistants (CNAs) and nurses cleaned the catheters. Staff A stated the staff must assess if the catheter is intact and draining and observe for urine color. Staff A said, If the line is cloudy, the nurses change it. Staff A stated if he suspected an infection, he would, call the doctor to ask for a culture.On 10/27/25 at 4:18 p.m., an observation was made of Resident #15 with a cloudy catheter drainage line.On 10/29/25 at 9:25 a.m., observed Resident #15 lying in bed, alert, with their feet raised on a pillow. The catheter drainage bag was labeled with the date 10/14/25. Observed Resident #15's catheter line was still cloudy. During the observation and interview, Staff A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure pain was managed for one resident (#12), out of three residents sampled.Findings included: On 10/28/2025 at 10:22 a.m., an interview was conducted with Resident #12. Resident #12 stated it took a couple days to get pain medication upon admission to the facility. The resident stated the staff was not ordering the medication. On 10/28/2025 at 2:51 p.m., a follow-up interview was conducted with Resident #12. The resident explained being upset about the pain and stated there was no reason she had to wait was so long to get pain medication. The resident stated the pain increased during the time she was without pain medication. Resident #12 stated when the colostomy bag breaks, the skin becomes very raw like a diaper rash. Resident #12 stated because she sat for long periods, her skin was bad. Resident #12 stated not wanting to sit on feces when left unchanged as it breaks her skin. The resident said it was upsetting and stated it felt like the skin…

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 reviews and interviews, the facility did not ensure providers were notified of abnormal lab results for two residents (#1 and #4) out of three residents reviewed for labs.Findings included:1.) An interview was conducted on 10/28/25 at 10:10 a.m. with a Resident Representative (RR) for Resident #1. The RR said on 9/27/25 he was at the facility with Resident #1, and she was not herself. He said she was very lethargic, wanted to sleep and was in pain. I let the nurse and Certified Nursing Assistant (CNA) know my concern. He said at one point he nor the staff could find Resident #1's assigned nurse, Staff H, Licensed Practical Nurse (LPN) for over an hour. The RR said he was trying to find the nurse because the resident's medications were late, and she was in pain. He said a CNA he talked to didn't know where the nurse was nor did the other nurse working. He said at one point the staff called Staff H to find her. He said when Staff H finally returned to the unit, she was very short and asked what he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure appropriate isolation precautions were initiated for two residents ( #10 and #9 ) of three residents sampled and failed to ensure personal protective equipment (PPE) was supplied for residents on isolation precautions for five rooms (101,409, 413, 408 and 305) out of twenty rooms observed. On 5/27/2025 at 8:32 a.m., an observation was made in front of room [ROOM NUMBER] with a blue sign outside the door and Contact Precautions was indicated for resident in bed A. There was no PPE observed outside the door. An interview was conducted with Staff B, Licensed Practical Nurse (LPN). Staff B, LPN stated the resident in bed B was on Contact Isolation for having a peripherally inserted central catheter (PICC) line. Staff B stated the PPE was located behind the door inside the residents' room. Staff B stated any resident with wounds, catheters, central lines, dialysis and catheters are placed on Contact Isolation. The Contact Isolation sign…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to ensure their pest control program was effective during two (05/27/2025 and 05/28/2025) of two days of survey. Findings included: During multiple facility tours on 05/27/2025 and 05/28/2025, observations were made of live insects in the dining hall/activity's area in 400 and 100 halls as follows: On 05/27/2025 at 06:30 a.m., a live insect was observed in the 400-hall, near the conference room. The insect was live and crawling across the floor. On 05/27/2025, at 06:48 a.m. live insects were observed in the dining hall/activity area. The insects were small flying insects observed landing on surfaces around the dining area. During this observation residents were observed in the area. On 05/28/2025 at 09:25 a.m. a live insect was observed near the 100-hall of the facility. The insect was observed crawling. There were various levels of staff near the area at the time. On 05/28/2025 at 02:29 p. m. an interview was conducted with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record and policy review, the facility failed to ensure grievances were promptly addressed and resolved to ensure complainant's satisfaction for one (#7) of seven residents reviewed. Findings included: Review of the facility's Grievance/Concern Logs for March and April 2025 revealed a grievance was filed by Resident #7's family member on 3/28/25. The log showed the concern was resolved on 3/30/25. An interview with the Nursing Home Administrator (NHA) and the Risk Management Consultant (RMC) on 5/27/25 at 2:17 p.m. revealed, Resident's bottom dentures are missing. Reviewing the grievance, the NHA stated the concern was described as Concerns because [Resident #7's] bottom dentures are missing. Certified Nursing Assistant (CNA) states that they were on side table this morning when she fed him. The facility did not designate an individual or department to handle this grievance/concern, writing looking for dentures. Staff spoke to staff (crossed out) stated they placed them in a paper towel.…

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, interviews and record review, the facility failed to have pain medication available per physician orders for one resident (#5) out of three residents sampled. Findings Included: On 5/27/2025 at 1:49 p.m., an interview was conducted with Resident #5 with Staff A, Registered Dietician, for interpretation. Resident #5 stated getting her pain medication was an issue the last month and stated she went without getting her pain medication. A record review of Resident #5's Medication Administration Record (MAR) for the month of April 2025 showed a missed dose of Oxycodone HCL oral tablet 10 milligrams (mg) by mouth one time a day for non- acute pain on 4/26/2025. A record review of Resident #5's admission Record showed an original admit date of 02/14/2024 with a readmission date of 5/01/2025 with diagnoses included but not limited to spinal stenosis cervical region, neuralgia and neuritis unspecified, monoarthritis not elsewhere classified unspecified site and pain unspecified. A record review of Resident #5's Controlled Drug Declining Inventory Sheet with a 4/16/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to provide incontinence care for four ( #4, #5 #8 and #11) out of four residents sampled. Findings Included: During an interview on 05/27/2025 at 12:46 p.m., Resident #4 stated a few months ago she put her call light on, and a male staff member came into her room told her that he was not her aide and that he was going to get her aide. She stated he turned off her light and no one ever came back. She stated she had to wait for the next shift to come in and change her wet brief. She spoke with the facility at the time of the incident and told them that staff do not come into her room at night and they do not offer to change her. She reported she was told that this would change, and staff would come and check on her during the night. Resident #4 stated this has not happened. Staff still do not come into the room during the night and offer or check to see if she needs incontinent care. She stated she waits for the morning shift to be changed out…

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 the facility failed to provide privacy and confidentiality for three (#1, #4, #7) of seven sampled residents related to placing items in the trash can with resident identifiable information and leaving the medication cart unattended with resident information present and accessible in paper and electronic format. Findings included: On 10/01/2024 beginning at 9:42 a.m., Staff A, Registered Nurse (RN) entered Resident #1's room and detached the feeding tube from the (gastrostomy) g-tube site. She placed the used tube feeding bottle with resident information into the unsecured, publicly accessible trash can. Staff A, RN then went over to Resident #1's roommate, Resident #7, detached the feeding tube from the g-tube site and placed Resident #7's used tube feeding bottle with resident information into the unsecured, publicly accessible trash can. Staff A, RN left the room and opened the computer on the medication cart. Staff A, RN went to the supply room and left the computer open with Resident #4's information on the screen and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross reference F695 and F880 Based on interview and record review the facility failed to provide care consistent with the comprehensive person-centered care plan for two (#1 and #6) of three sampled residents with tracheostomies. Findings included: 1. Review of Resident #1's admission record showed an admission date of 06/26/2024 and readmission date of 08/21/2024. The admission record showed diagnoses to include anoxic brain damage, respiratory disorders, acute and chronic respiratory failure, bell's palsy, metabolic encephalopathy, muscle wasting and atrophy, acute kidney failure, myocardial infarction, acute and subacute hepatic failure, hypokalemia, obstructive and reflux uropathy, protein-calorie malnutrition, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/09/2024, showed a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The resident was rarely or never understood, was dependent on staff for bathing and toileting, 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.

Cross reference F656 and F880 Based on observation, interview, and record review the facility failed to provide tracheostomy (trach) and suctioning care consistent with professional standards of practice and the resident's comprehensive person-centered care plan for one of three sampled residents (#1). Findings included: On 10/01/2024 beginning at 9:42 a.m., Staff A, Registered Nurse (RN) entered Resident #1's room without a gown on and put on gloves. Resident #1 was lying in bed, had a trach with humidifier mask in place, and oxygen attached. Staff A, RN detached the feeding tube from the (gastrostomy) g-tube site for Resident #1 Staff A, RN removed her gloves and did not perform hand hygiene. She applied new gloves and went to Resident #1's roommate (Resident #7) and detached Resident #7's feeding tube from the g-tube site. She removed her gloves, did not perform hand hygiene, and exited the room. Staff A, RN went to the medication cart and started to open it. Staff A, RN then stopped and went into the resident room across from Resident #1 and #7 and washed her hands. Staff A then…

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 Cross reference F656 and F695 Based on observation, interview, and record review the facility failed to follow standard and enhanced barrier precautions when performing resident care for one (#1, #7) of seven sampled residents. Findings included: On 10/01/2024 beginning at 9:42 a.m., Staff A, Registered Nurse (RN) entered Resident #1's room without a gown on and put on gloves. Resident #1 was lying in bed, had a trach with humidifier mask in place, and oxygen attached. Staff A, RN detached the feeding tube from the (gastrostomy) g-tube site for Resident #1 Staff A, RN removed her gloves and did not perform hand hygiene. She applied new gloves and went to Resident #1's roommate (Resident #7) and detached Resident #7's feeding tube from the g-tube site. She removed her gloves, did not perform hand hygiene, and exited the room. Staff A, RN went to the medication cart and started to open it. Staff A, RN then stopped and went into the resident room across from Resident #1 and #7 and washed her hands. Staff A then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations interviews and facility records review, the facility failed to ensure hot water temperatures were maintained at comfortable levels in one hall (Hall 100) of four halls for four days (1/8/24, 1/9/24, 1/10/24 and 1/11/24) of a five day survey. Findings included: On 01/08/24 at 10:17 a.m., the residents in Rooms 101, 103, 105 and 106 reported Hall 100 has had water issues for an unknown period of time. They reported the water was cold and this had been going on for a long time. A resident in room [ROOM NUMBER] stated it had been probably three to six months. The residents stated the CNAs (certified nursing assistants) knew of the problem. The resident in room [ROOM NUMBER] stated a grievance was filed during a Resident Council meeting. The resident stated the CNAs complained about cold water when giving residents showers. Review of the Grievance Logs August 2023 to January 8, 2024 revealed no grievances were filed from Resident Council meetings. Review of a facility documentation titled,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations interviews and record review, the facility failed to ensure hand splints were applied and range of motion (ROM) was provided for one resident (#8) of two residents sampled for limited range of motion. Findings included: Review of the admission Record revealed Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include contracture of right wrist, contracture of left wrist, contracture of left and right elbow, stiffness of shoulder and quadriplegia. Review of Resident #8's care plan showed a focus of ADL (activities of daily living): The Resident has an ADL Self Care Performance Deficit, initiated 5/25/22. Goals showed as PT (physical therapy) is ordered and goals are established per the PT plan of care (see PT POC), OT (occupational therapy) is ordered and goals are established per the OT plan of care (see OT POC) and ST (speech therapy) is ordered and goals are established per the ST plan of care (see ST POC) all with a target date 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 observation, staff interview and record review the facility nursing staff failed to accurately conduct assessments from 1/1/24 to 1/11/24 following a fall, identify a change in condition of a swollen right shoulder and provide treatment and care in accordance with standards of practice for one resident (#207) of forty two residents sampled. Findings included: Review of the admission Record for Resident #207 revealed an original admission date of 12/4/23 and a readmission date on 12/26/23 with diagnoses to include repeated falls, pain in right arm, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified lack of coordination, difficulty in walking, and unsteadiness on feet. Review of The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities (https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html#:~:text=1.-,Evaluate%20and%20Monitor%20Resident%20for%2072%20Hours%20After%20the%20Fall,provide%20immediate%20treatment%20if%20necessary) showed: Chapter 2. Fall Response…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure post dialysis care was completed per physician orders for one resident (#12) of five dialysis residents sampled. Findings included: On 01/08/24 at 9:52 a.m. Resident #12 was observed in her room. Resident #12 was noted with an undated dressing on her left arm. The dressing around the left upper arm area was observed with blood. Resident #12 stated she did not know she had been bleeding and did not know the cause. (Photographic Evidence Obtained) Review of the admission Record revealed Resident #12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include end stage renal disease and legal blindness. Review of a Minimum Data Set (MDS), dated [DATE], showed Resident #12 had a Brief Interview for Mental Status (BIMS) of 14, indicating intact mental cognition. Review of Resident #12's physician orders, dated 01/12/24, showed: *Resident to have dialysis on days: [dialysis center name], 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of facility policy, the facility failed to provide ongoing monitoring for complications before and after dialysis treatments for 2 (Resident #92 and Resident #35) of 2 resident sampled for dialysis care. Findings included: A review of Resident #92's Medical Record revealed that Resident #92 was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (ESRD). A review of Resident #92's Physician's Orders revealed an order, dated 04/19/2020, for Dialysis on Monday, Wednesday, and Friday with a chair time of 04:30 AM. A review of Resident #92's Care Plan revealed a problem, revised on 01/06/2020, that Resident #92 had actual risk for impaired renal function related to end-stage renal failure. Interventions included dialysis treatment on Monday, Wednesday, and Friday, observe dialysis catheter site for signs and symptoms of bleeding, and protect shunt site from injury. A review of Resident #92's Dialysis Communication Forms for the dates…

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, record reviews, and interviews the facility failed to ensure medications were stored appropriately in three of four medication carts and one of two medication preparation rooms. Findings included: On 1/26/22 at 11:14 a.m., an observation of the 100-hall medication cart was unlocked and left unattended. Staff Member L, Registered Nurse (RN) came out of room [ROOM NUMBER], on 1/26/22 at 11:17 a.m., and confirmed that the cart was unlocked and should have been locked. Photographic evidence was obtained. On 1/27/21 at 10:39 a.m. an observation of the 400-hall medication cart was conducted with Staff Member U, Registered Nurse (RN). The observation revealed an unopened bottle of Novolog, which the label indicated had been delivered on 1/24/22. The staff member stated the bottle was ok to be in the cart, then stated. no that it should be in the refrigerator. On 1/27/21 at 10:45 a.m., an observation of the 100-hall medication cart was conducted with Staff Member T, RN. The observation revealed 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 interviews and record reviews, the facility failed to conduct ongoing COVID-19 outbreak testing in accordance with testing frequency parameters for four (Resident #68, Resident #30, Resident #13, and Resident #79) of five residents sampled for COVID-19 testing requirements. Findings included: A request was made on 01/26/2022 at 04:30 PM to review the last COVID-19 testing results for Resident #68, Resident #30, Resident #13, and Resident #79 to the facility's Director of Nursing (DON). A review of Resident #68's COVID-19 test results revealed the last testing conducted on 01/17/2022 with a negative result. A review of Resident #30's COVID-19 test results revealed the last testing conducted on 01/17/2022 with a negative result. A review of Resident #13's COVID-19 test results revealed the last testing conducted on 01/17/2022 with a negative result. A review of Resident #79's COVID-19 test results revealed the last testing conducted on 01/17/2022 with a negative result. An interview was conducted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure one (#63) out of thirty-seven sampled residents had the right to be treated with dignity and respect related to staff restricting the residents' ability to self-propel in a wheelchair. Findings include An observation on 1/24/22 at 10:36 a.m., revealed Resident #63 sitting in a wheelchair at the end of the 100-hallway. The resident attempted to self-propel the wheelchair into room [ROOM NUMBER], which was not where the resident resided. Staff Member A, Certified Nursing Assistant (CNA) directed the resident back into the hallway and locked both wheels of the chair as it was parked between rooms [ROOM NUMBERS] at the end of the hallway. During an interview, at 10:40 a.m. on 1/24/22, Staff A confirmed locking both wheels of Resident #63's wheelchair. The CNA stated she does that because the resident attempts to stand up. On 1/24/22 at 10:44 a.m., Staff Member E, Licensed Practical Nurse (LPN), stated that staff does lock 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 record reviews, interviews, and review of facility policy, the facility failed to provide written notification of Transfer/Discharge to Resident Representatives and failed to notify the Office of the State Long-Term Care Ombudsman of a resident transfer for two (Resident #56 and Resident #200) of four residents sampled for hospitalizations. Findings included: A review of Resident #56's Medical Record revealed that Resident #56 was admitted to the facility on [DATE] with diagnoses of dementia, acute osteomyelitis of right ankle and foot, non-pressure chronic ulcer of the right heel and midfoot with necrosis of muscle. A review of Resident #56's Medical Record also revealed that Resident #56 was transferred to the hospital on [DATE] and 12/27/2021 during a visit with the wound care physician due to wound infections. A review of Resident #56's Nursing Home Transfer and Discharge Notice dated on 11/29/2021 revealed a reason for discharge/transfer listed as needs cannot be met in this facility. The Nursing…

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 reviews, interviews, and review of facility policy, the facility failed to provide written notification of the Bed Hold Policy to Resident Representatives for for one (Resident #56) of four residents sampled for hospitalizations. Findings included: A review of Resident #56's Medical Record revealed that Resident #56 was admitted to the facility on [DATE] with diagnoses of dementia, acute osteomyelitis of right ankle and foot, non-pressure chronic ulcer of the right heel and midfoot with necrosis of muscle. A review of Resident #56's Medical Record also revealed that Resident #56 was transferred to the hospital on [DATE] and 12/27/2021 during a visit with the wound care physician due to wound infections. A request for documents was made on 01/26/2022 at 04:30 PM for Resident #56's Bed Hold and In-House Transfer Policy for the hospital admissions on 11/29/2021 and 12/27/2021 to the facility's Director of Nursing (DON). A review of Resident #56's Bed Hold and In-House Transfer Policy on 01/27/2022…

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, record reviews, and interviews the facility failed to maintain and store respiratory equipment in a sanitary manner for one (#57) out of 7 residents who utilized a continuous positive airway pressure (CPAP). Findings included: Resident #57 was admitted on [DATE]. A review of the resident's Order Listing Report included an order, dated 1/20/22, Empty and Rinse CPAP humidifier chamber every a.m. (QAM) and allow to dry every day shift. Every day shift for Acute and Chronic Respiratory Failure with Hypercapnia. An observation was conducted, on 1/25/22 at 9:02 a.m., of Resident #57's continuous positive airway pressure (CPAP) machine in the bottom drawer of the bedside dresser. The observation revealed the tubing from the machine was lying out of the drawer, on the floor then looped back into the drawer with the uncovered mask lying on the other items in the drawer. The resident reported taking the mask off, the aides put it the drawer, and that staff fill it (humidifer) with water. On 1/26/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of facility policy, the facility failed to act upon a pharmacy recommendation in a timely manner for one (Resident #59) of six residents sampled for unnecessary medications. Findings included: A review of Resident #59's Medical Record revealed that Resident #59 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #59's Physician's Orders revealed an order, dated 01/19/2022, for Fludrocortisone Acetate 0.1 milligrams (mg) by mouth one time a day for orthostatic hypotension. A review of Resident #59's Medication Regimen Review, dated 11/05/2021, revealed a recommendation from the Consultant Pharmacist (CP) to Resident #59's Attending Physician to indicate a diagnosis to be added to the Medication Administration Record for fludrocortisone. No response was recorded by Resident #59's Attending Physician for the recommendation. A review of Resident #59's Medication Regimen Review, dated 01/10/2022, revealed a recommendation from 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 interviews and record reviews, the facility failed to ensure proper monitoring for psychotropic medication use was consistently implemented for two (Resident #59 and Resident #68) of six residents sampled for unnecessary medications. Findings included: A review of Resident #59's Medical Record revealed that Resident #59 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #59's Physician's Orders revealed the following orders: - An order dated 01/15/2022 for Olanzapine 2.5 milligrams (mg) by mouth one time daily and 5 mg by mouth at bedtime for mood disorder. - An order dated 01/04/2022 for behavioral monitoring of antipsychotic medication use every shift. - An order dated 01/04/2022 for side effect monitoring of antipsychotic medication use every shift. A review of Resident #59's Care Plan revealed a problem revised on 01/04/2022 that Resident #59 used psychotropic medications. Interventions included to administer medications as ordered, observe/document for side…

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

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and three errors were identified for two (#74 and #15) of four residents observed. These errors constituted a 12.00% medication error rate. Findings included: 1. On 1/25/22 at 8:20 a.m., an observation of medication administration with Staff Member T, Registered Nurse (RN) was conducted with Resident #74. Staff T was observed dispensing the following medications: - Enteric coated Aspirin 81 milligram (mg) tablet orally - Calcium Carbonate 2 tablets orally - Vitamin D 25 microgram (mcg) tablet orally - Metformin 1000 mg tablet orally - Repaglinde 2 mg tablet orally - Memantine 5 mg tablet orally - Losartan 50 mg tablet orally - Celecoxib 400 mg tablet orally - Levemir 10 units subcutaneously - Sertraline 50 mg tablet orally During dispensing of the medication, Staff Member T stated she had previously checked for Resident #74's Levemir in the refrigerator in the medication room 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 and interview, the facility failed to ensure that the call light was functioning properly for Resident's #17 and #89 during 4 of 4 days of survey. Findings included: Resident #89's admission Record revealed she was admitted to the facility on [DATE] with a primary diagnosis of muscle wasting atrophy. A review of the Minimum Data Set (MDS) assessment Section G: Functional Status, dated 01/11/22, indicated that the resident had extensive limitation and required the assistance of at minimum one person for Activities of Daily Living (ADL's). A review of the Care Plan with a revision date of 08/05/21, revealed that Resident #89 had an ADL self-care performance deficit related to the following: weakness, incontinence, impaired mobility, balance and cognition. Interventions included call bell within reach while in room/bathroom/ shower room and remind to use. Resident #17's admission Record revealed she was admitted to the facility on [DATE] with a primary diagnosis of encephalopathy. A review of…

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