Vero Beach Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents who were trauma survivors had triggers identified and implemented in the care plan in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 sampled resident review for Post Traumatic Stress Disorder (PTSD), Resident #7. The findings included: Review of Resident #7's records revealed Resident #7 was admitted to the facility on [DATE] and readmitted [DATE] from the hospital, with diagnoses that included PTSD (Post Traumatic Stress Disorder), Major Depressive Disorder, Generalized Anxiety, Insomnia, Type II Diabetes, Coronary Artery Disease, Alcoholic Cardiomyopathy, Migraines, Muscle Weakness and Chronic Obstructive Disease. (COPD). Review of Resident #7 MDS (Minimum Data Set) Medicare 5-day assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognition impairment.Review of the resident's care plan documented 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 adequate monitoring of side effects and behaviors for residents receiving psychotropic medications for 1 of 5 sampled residents reviewed for unnecessary medications, Residents #9. The finding included:Review of the facility's policy titled, Medication Utilization and Prescribing - Clinical Protocol, with a revised date of 01/2024, included in part the following: The physician and staff will identify situations in which a resident is taking medications associated with potentially significant medication-related problems such as allergies, drug-drug interactions, drug-food interactions and adverse drug reactions. The physician and IDT (Interdisciplinary Team) will identify significant factors that may affect medication effectiveness and medication related problems. Risks and benefits of utilization of psychotropic mediations will be reviewed with resident and/or responsible party prior to initiation or increased dose as indicated. Record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and clinical and administrative record review, the facility failed to ensure 1 of 8 sampled residents, Resident #5, was assessed by the interdisciplinary team and established a plan of care for self-administration of medication before the resident participated in the practice. The findings included: An observation was conducted on 05/19/25 at 10:50 AM with Resident #5. Upon speaking with the resident, the surveyor noticed that there were approximately 10 bottles of pills and liquid supplements neatly stored on the resident's night stand. The bottles were noted to be open. Photographic Evidence Obtained. The following supplements were stored on the night stand: 1. Two (2) bottles of 32 ounces of MCT oil weight management 2. Two (2) bottles of Nugenix Thermo X 3. One (1) bottle of weight loss probiotics 4. One (1) bottle of Veggies capsule 5. One (1) bottle of Testerone Booster 6. One (1) bottle of Fruit Dietary Supplement 7. One (1) bottle of Nugenix Ultimate Testerone Booster 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 interview, clinical and administrative record review, the facility failed to honor the resident's bath preference and ensure the resident consistently received his bath preference for 1 of 8 sampled resident, Resident #4. The findings included: During the observational tour of the facility on 05/19/25 at 11:30 AM, the surveyor approached Resident #4, who was sitting in his wheelchair in front of his room. The resident voiced his dissatisfaction that they forget about us in room [room number]. The housekeeping aide was observed in the room at this time mopping the floor. The resident stated, I haven't got my medications yet and has gone about 3 weeks without a shower. They don't ever change my linen. I told them my toilet is leaking, and they don't do anything about it. The resident stated that they will wash him in his private area, but he wants a shower. He stated also that he has said he prefers to wear the pull up type of incontinent briefs but some of the aides keep putting the ones with the tabs…

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, clinical and administrative record review and interview, the facility failed to ensure the residents received the necessary care and services for skin assessments and timely medication administration, as evidenced by the facility's consistent failure to respond in a timely manner fo residents who developed new skin issues and failed to ensure that residents received their prescribed medications in a timely manner, for 3 of 8 sampled residents, Residents # 1, # 4 and # 6. The findings included: 1. Record review revealed Resident #1 was readmitted to the facility on [DATE] with pertinent diagnosis which includes, Diabetes Mellitus, Cerebrovascular disease, Chronic Kidney disease, Stage 3, Essential Hypertension, and Blind Left eye. Review of the resident's plan of care identified a concern initiated on 02/24/25, The resident has a Skin Impairment: eczema. Interventions included: Encourage and assist resident to Off Load Heels as ordered Monitor the Resident's changes in skin condition, and…

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

Based on observation and interview, the facility failed to ensure all medications and/or supplements were not stored at the residents' bedside but were safely secured in locked compartments for 1 of 8 sampled residents, Resident #5. The findings included: An interview was conducted on 05/19/25 at 10:50 AM with Resident #5. Upon speaking with the resident, the surveyor observed there were approximately 10 bottles of pills and liquid supplements neatly stored unsecured on top of the resident's bedside night stand. Photographic Evidence Obtained. The following supplemental pills were stored on the night stand and clearly visible upon entering the resident's side of the room: 1. Two (2) bottles of 32 ounces of MCT oil weight management 2. Two (2) bottles of Nugenix Thermo X - 60 capsules bottles 3. One (1) bottle of weight loss probiotics 4. One (1) bottle of Veggies capsule 5. One (1) bottle of Testerone Booster 6. One (1) bottle of Fruit Dietary Supplement 7. One (1) bottle of Nugenix Ultimate Testerone Booster. An interview was conducted with the resident at this time revealed 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, record review and interview, the facility failed to provide necessary care and services to prevent, identify and properly assess wounds, for 1 of 2 sampled residents reviewed for wounds (Resident #3), as evidenced by the facility failed to identify the blister or subsequent open wound to the resident's right foot, prior to surveyor intervention; the wound care nurse failed to properly assess the wound, documenting erroneous measurements and staff nurses failed to capture the wound during skin check assessment completed on 02/11/25, the day prior to the surveyor's observation. The findings included: Observation of wound care conducted on 02/12/25 at 10:20 AM revealed the Wound Care Nurse (WCN) performed wound care for Resident #3's left foot. At the end of the treatment, the surveyor asked the reason why the offloading boot was only applied to the left leg, as the resident was severely contracted on both legs. The WCN responded that the resident prefers to lay on the left side and that is where the wound is located, so an offloading boot is not necessary to 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 observation, record review and interview, the facility failed to provide necessary care and services to prevent and promote healing of pressure ulcers, for 2 of 2 sampled residents reviewed for pressure wounds, Resident #3 and Resident #1. The findings included: Review of the policy, titled, Wound Care and Treatment, revised 01/2024, documented, in part: Standard: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Guideline: Only staff trained to complete physician orders will complete wound care and treatments as prescribed. Procedure: Preparation 1. Verify that there is a physician's order for this procedure . 4. Assess residents pain level as needed. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure . 12. Assess residents tolerance of wound care throughout the procedure. 16. Reposition the bed covers. Make the resident comfortable. Use supportive devices as instructed. Documentation: 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 observations, interviews and record reviews, the facility failed to provide maintenance and housekeeping services to maintain a clean, comfortable and homelike environment on 4 of 5 units and in common areas. The findings included: During an environmental tour of the facility on 09/12/24 at 4:25 PM with the Maintenance Director, the following was observed: a. In room [ROOM NUMBER], there were two picture hanging hooks protruding from the wall with sharp points on them by the head of the bed. b. In room [ROOM NUMBER], there was an accumulation of residue on the exterior of the wall mounted air conditioning unit and an accumulation of debris inside of the vents of the unit. c. In room [ROOM NUMBER], there were multiple holes in the wall from where the chair rail once was. d. In room [ROOM NUMBER], the wall by the wall mounted air conditioning unit was in disrepair. e. In room [ROOM NUMBER], the bed frame was in disrepair and showed signs of wear. f. In room [ROOM NUMBER], there was residue and debris on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sufficient staffing as evidence by falls and a consistent stale urine odor on 1 of 5 units ([NAME]); lack of ADL care for 1 of 5 sampled residents (Resident #44); lack of Hospice coordination for 2 of 2 sampled residents (Resident #25 and #87); and voiced complaints by residents, families, staff, and resident council. The findings included: 1) Resident #128, who was admitted to the facility on [DATE], sustained eleven falls while residing on the [NAME] unit. Review of these falls lacked evidence the facility followed their fall prevention policy. (Refer to F689 for details). Review of the fall log from 07/01/24 through the survey date of 09/13/24 revealed the facility had 38 falls, 10 of which were on the [NAME] unit. Upon entering the [NAME] unit on all five days of the survey (09/09/24 - 09/13/24) a constant urine odor was noted throughout. Although a specific resident was not identified during the survey, the odors remained. 2)…

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

Based on observations, interviews and record reviews, the facility failed to provide food prepared, stored and served in a sanitary manner and in accordance with professional standards for food safety. The findings included: 1). During the initial kitchen tour, on 09/09/24 at 8:43 AM, accompanied by the Dietary Manager, the following were noted: a. The hand washing sink and the baseboard by the food assembly area were not secured to the wall. b. Cleaned and sanitized utensils (knives, forks and spoons) were not inverted while being stored and were stored directly underneath the hand washing sink. c. The floor paint was noted to be peeling throughout the kitchen. d. There was an accumulation of debris and residue on blade and mechanism of the counter mounted can opener. e. The shelving underneath the hot holding unit was damaged and rusted. f. There was an accumulation of dust on the air conditioning vents in the ceiling throughout the kitchen. g. The oven mitts were noted to be torn and uncleanable. h. In the walk in cooler, there were packages of raw beef stored directly over a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to follow infection control standards to ensure appropriate treatment for a rash outbreak on 1 of 5 units ([NAME] Unit) affecting sampled Residents #25, #30, #32, #33, #40, #42, #56, #73, #87, #93, #99, #109, #123, and #133; failed to report a rash outbreak to the Florida Department of Health (DOH); and failed to follow Enhanced Barrier Precautions (EBP) for 1 of 3 sampled residents with an indwelling urinary device for Resident #112. The findings included: 1. On 09/12/24 at 3:20 PM, a call from the Florida DOH revealed they had received a report of numerous residents on the [NAME] unit that had had a rash that was not identified, not reported to the DOH, and or that the facility was hiding as dermatitis (inflammation of the skin). On 09/13/24, the Director of Nursing (DON) was asked to provide a list of residents that have had any type of rash since 07/01/24 to the present time. The DON provided a list of ten residents, all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], [NAME] Based on observations, interviews and record reviews, the facility failed to provide a safe, sanitary and comfortable environment for residents, staff and the public, in the common areas on 4 of 5 units ([NAME], Canterbury, [NAME], and [NAME]). The findings included: 1. There was an accumulation of dust and mold-like substance in the air condition vents and ducts on the [NAME] Unit, the Canterbury Unit, the [NAME] Unit and the [NAME] Unit, as well as the common areas and dining areas of the units. 2. In the Shower room on Canterbury unit, there was a large puddle of water on the floor at the commode, the toilet was running, the wall under the shower on the left side of the room was damaged, there was an accumulation of dust on the inside of the air conditioning vent and duct. 3. In the soiled utility room on the Canterbury unit, the wall was damaged inside of entrance to the room, and there was a sink filled with standing dirty water. 4. The wall in the employee bathroom of the [NAME]…

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 interview, the facility failed to honor resident's choice to sleep in and utilize a reclining chair for 1 of 7 reviewed for choices, Resident #138. The findings included: Review of Resident #138 medical records revealed the resident had multiple admissions with the latest admission on [DATE]. He has diagnoses that included Lymphedema, Chronic Systolic Congestive Heart Failure, Venous Insufficiency, Chronic Kidney Disease, Anxiety Disorder, Depression, Dyspnea, and Severe Morbid Obesity. His MDS (Minimum Data Set) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicting cognition is intact. Review of the physician Progress Notes on 09/12/24, with a service date of 09/10/24, revealed the physician documented the resident is not being compliant with elevating his legs during the day, but he is wearing compressive ACE wraps. He documented he has given up on trying to get a recliner chair for his room which would assist in elevating his legs. He was trying to…

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

Based on interviews and record reviews, the facility failed to promptly act on and resolve grievances voiced by residents and the Resident Council, for 8 of the residents interviewed, including Residents #113, #85, #143, #13, #122, #27, #95, and #60. Four of 4 residents in the Resident Council meeeting voiced food concerns that included Residents #85, #113, #116 and #135. The census at the time of the survey was 146. The findings included: Record review of Resident #113's most recent Minimum Data Set (MDS) assessment documented Resident #113, with a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. An interview was conducted on 09/09/24 at 10:17 AM with Resident #113, the Resident Council President, who when asked of any grievances that had not been resolved by the facility, replied that grievances related to food were ongoing and had not been resolved. During the interview, Resident #113 granted permission to this Surveyor to review Resident Council Meeting Minutes and Food Committee Meeting minutes. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to ensure 1 of 1 sampled resident was free from physical restraint, Resident #128. The findings included: Review of the policy, titles, Identifying Seclusion and Unauthorized Restraint, revised 06/2023, documented, in part, As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify involuntary seclusion and/or unauthorized restraint of residents. Unauthorized Physical Restraints: 1. Residents are free from the use of any physical restraints not required to treat their medical condition. 2. Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: a. Is attached or adjacent to a resident's body; b. Cannot be removed easily by the resident (in the same manner as it was applied by the staff); and c. Restricts the resident's freedom of movement or normal access to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure accurate assessments for 2 of 42 sampled resident records reviewed, Residents #48 and #60, as evidenced for Resident #48 related to visual impairment and Resident #60 for use of antianxiety medications. The findings included: 1. Review of Resident #48 medical records revealed Resident #48 was admitted to the facility on [DATE] with diagnoses tha included Heart Failure, Hypertension, Diabetes Mellitus, and Major Depressive Disorder. Review of the resident's care plan initiated and revised on 03/10/23 documented the resident is at risk for complications and impaired visual function related to dry eyes syndrome and complications of Diabetes. The interventions included to observe for and report to the nurse any complaints of eye discomfort / pain, any noted problems with or any complaints of change in eyesight. To report and document as needed (PRN) any signs or symptoms of acute eye problems: Change in ability to perform ADLs [Activity…

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 reviews, the facility failed to develop and implement care plans for 1 of 3 sampled residents related to behaviors reviewed for catheter, Resident #91, and the facility failed to develop and implement care plans to accurately account for vision deficit for 1 of 2 sampled residents reviewed for vision, Resident #48. The findings included: 1. Record review revealed Resident #91 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. Resident #91's diagnoses at the time of the assessment included: Heart Failure, Hypertension, Obstructive Uropathy, Diabetes Mellitus, Hemiplegia, History of cerebral infarction, Retention of urine, and Adult failure to thrive. Resident #91 was not interviewable. Review of Resident #91's orders included: On 01/06/24, Indwelling Urinary…

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 interview, the facility failed to revise care plans for 2 of 9 sampled residents reviewed for nutrition and or medication use, Residents #81 and #79, as evidenced by the care plan for Resident #81 lacked information related to being aggressive toward others, and the care plan for Resident #79 noted the resident had a fluid restriction order that had been discontinued. The findings included: 1. Review of the record revealed Resident #81 was admitted to the facility on [DATE]. Further review revealed the resident was moved to different rooms on 04/20/24 and 09/04/24 after a resident-to-resident altercation. Review of the current care plans lacked any documentation related to physical aggression or any resident-to-resident events or conflicts. During an interview on 09/12/24 at 2:01 PM, the Director of Nursing (DON) agreed Resident #81 had had two resident-to-resident events and was surprised this was not noted in any of the care plans. During an interview on 09/12/24 at 2:32 PM, 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 interview, the facility failed to provide services of peri care and failed to get a resident out of bed as requested for 1 of 1 sampled resident, Resident #44, reviewed for Activities of Daily Living (ADLs). The findings included: Clinical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnosis that included: medically complex conditions. The admission Minimum Data Set (MDS) assessment, reference date 09/03/24, recorded a Brief Interview for Mental Status score of 14, indicating Resident #44 was cognitively intact. This MDS evidenced Resident #44 exhibited moods that included: Feeling down, depressed, or hopeless. Poor appetite or overeating. Feeling bad for herself - or that she is a failure or have let herself or her family down. This MDS also documented Resident #44 required substantial / maximal assistance with toileting hygiene, shower / bath self, and lower body dressing, and required partial / moderate assistance with upper body dressing. Additional review of 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 observation, record review, interview, and Hospice Agreement review, the facility failed to ensure coordination of care and services for 2 of 2 sampled residents, as evidenced by the lack of orders for Hospice services and oxygen use for Resident #25; and failure to coordinate the provision of an offloading boot, lack of Certificate of Terminal Illness (CTI) paperwork, and lack of current Hospice notes for Resident #87. The findings included: Review of the Hospice Agreement effective 01/15/24 documented, 6a. Patient admission Process: 1. ii. 3. Hospice shall notify Home, as appropriate, of patients being admitted to service, the day of the referral. Hospice shall provide copies of the Initial Hospice admission paperwork. 8. Coordination, Supervision and Evaluation of the Care/Service: . b. Home Responsibilities . iv. Home shall assist the Hospice in the coordination of patient care from admission up through and including discharge from service. 1) Review of the record revealed Resident #25 was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to follow their fall prevention policy for initiating new interventions, updating care plans, and ensuring supervision to prevent falls for 1 of 4 sampled residents reviewed for accidents (Resident #128). The findings included: Review of the policy Falls - Managing, Preventing, and Documentation revised 01/2024 documented, Standard: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Guideline: The resident's plan of care will be developed and followed accordingly to prevent or minimize the risk of falls or fall related injuries. Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to secure medication storage on 2 of 5 units, as evidenced by leaving the medication and treatment carts unlocked and unattended on the [NAME] Unit, the designated memory care unit, and a random observation of non-secured ointments on the [NAME] Unit. The findings included: 1) An observation on 09/09/24 at 11:43 AM revealed the medication cart was positioned against the wall in the common area of the [NAME] unit, unlocked with at least three bubble pack medication cards with pills in at least one pack, noted on top of the cart. Staff K, Licensed Practical Nurse (LPN) was noted at the desk on the other side of the common area, working on the computer. The LPN retrieved the bubble pack medication from the medication cart, but left the medication cart unlocked (Photographic Evidence Obtained). During the continued observation on 09/09/24 at 12:01 PM, both the medication cart and the treatment cart remained unlocked in the common area. Although three staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure complete and current medical records for 3 of 42 sampled residents (Resident #5, #26 and #81). The findings included: Review of the policy Documentation revised 01/2024 documented, Procedure: . 2. The following information is to be documented in the resident medical record: . c) Treatments or services performed; 1) During an observation on 09/09/24 at 10:41 AM, Resident #5 was noted with thick elongated toenails. The resident reported he had not been seen by a podiatrist. Review of the record revealed Resident #5 was admitted to the facility on [DATE]. Review of the electronic medical record lacked any documented podiatry services. During an interview on 09/12/24 at 4:44 PM, when asked about podiatry services for Resident #5, the Social Services Director (SSD) stated the resident had been seen by the podiatrist. When asked to locate and provide evidence of the services, the SSD was unable to locate any documented podiatry service…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the client's Arbitration agreement and interview, the facility failed to ensure the arbitration agreement is explained to the resident or representative in a manner they understand, and had a signature from the resident if they agreed to the arbitration agreement, for 2 of 3 residents reviewed for Arbitration (Resident #149 and Resident #143). The findings included: During the initial entrance conference on 09/09/24 at 9:17 AM, the surveyor requested a list of residents who currently reside in the facility and entered into a binding arbitration agreement. On 09/11/24 Surveyor was given a list of residents that have a Y or a N next to their name. Surveyor chose three residents that were recently admitted to the facility with a high BIMS (Brief Interview for Mental Status) to interview. A review of Resident #149 medical records revealed this resident is on the Rehab unit (SSU) and admitted to the facility on [DATE]. Her 5-day Medicare MDS (Minimum Data Set) documents her BIMS (Brief Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to maintain a functioning call system for 1 of 26 sampled residents, Resident #27; and failed to maintain a call light in a manner to be accessible to the resident for 1 of 26 sampled residents, Resident #95. The findings included: 1. Record review revealed Resident #27 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitive was intact. During an interview with Resident #27, on 09/10/24 at 9:20 AM, and the surveyor requested Resident #27 to initiate the call system by pressing a button at the end of the call light cord. Resident #27 pressed the button and there was no light over the door to indicate that the resident had initiated the call light and no signal at the nurse' station to indicate that Resident #27 had initiated the call light. At the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to provide a safe, clean comfortable homelike environment for the residents. The findings included: A tour of the facility, including resident rooms, was conducted on 07/08/24 at 9:30 AM and a second tour was conducted on 07/10/24 on 12:00 PM, with the Maintenance Director and the Housekeeping Manager. They both acknowledged the following concerns that were identified had during tour: Photographic Evidence Obtained. a. room [ROOM NUMBER] A - The wheelchair arm rests, seat and back of chair were torn. b. room [ROOM NUMBER] - The floor was very dirty with debris that included the corners of the room. room [ROOM NUMBER] - The resident in bed-A stated on 07/08/24 at 9:55 AM that there had been an Ibuprofen pill on the floor that gets pushed around, which has been there a month, and it just gets moved around when they clean and mop. She said they don't clean the toilet and it is filthy with dried up bowel movement. She stataed she has told…

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 interview, the facility failed to ensure nursing staff followed physician orders for blood pressure medication perimeters for 1 of 5 sampled residents (Resident #2) reviewed for medications; and failed to follow physician orders for a wound vac for 1 of 1 sampled resident reviewed for a wound vac (Resident #4) The findings included: 1. Record review for Resident #2 revealed Resident #2 was admitted to the facility on [DATE] with diagnoses to include Hypertension (high blood pressure), Orthostatic Hypotention, Atrial Fibrillation, and History of Falling, Review of the physician orders revealed the following orders: a) Dilltiazem HCl Oral Tablet 30 MG to give 0.5 tablet by mouth every 6 hours for Hypertension. Hold if SBP(Systolic Blood Pressure) is less than 105 or HR (Heart Rate) is less than 60 (0000-midnight, 6:00 AM, 12:00 PM, and 6:00 PM). b) Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day for Hypertension. Hold for SBP [Systolic…

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, the facility failed to ensure interdisciplinary team (IDT) participation in care planning process for 7 of 32 sampled residents, to include food and nutrition services, activities, and therapy, as applicable involving Residents #6, #22, #41, #106, #111, #5, and #8. The findings included: On 07/13/23 during the afternoon, Staff B, Minimum Data Set (MDS) Coordinator, provided requested evidence of interdisciplinary team (IDT) participation in the care planning process for numerous resident's in the survey sample, as the electronic medical record lacked current participation records. An overview of the provided Quality Resident Review Worksheet & Attendance Records, the forms utilized by the facility to document participation in the care planning process, revealed numerous blanks where the signatures of dietary, activities and therapy staff were to be recorded. The MDS Coordinator confirmed the Registered Dietician was only in the building once weekly, and also agreed someone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to speak to 4 of 32 sampled residents in a dignified manner, related to toileting and care, use of cell phones by staff during care, and staff speaking in foreign language during care, Residents #21, #22, #41, and #109. The findings included: 1. Review of the record revealed Resident #21 was admitted to the facility on [DATE], and moved to her current room on 07/19/22. Review of the current Minimum Data Set (MDS) assessment, dated 04/30/23, documented Resident #21 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident did not exhibit any behaviors, and needed the extensive to total assistance from staff for all Activities of Daily Living (ADLs), except eating. This MDS documented locomotion on the unit only occurred once or twice during the seven-day look back period. During an interview on 07/10/23 at 11:04 AM, Resident #21…

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, the facility failed to ensure baths and showers for 2 of 5 sampled residents were provided as per facility schedule and resident request, Resident #22 and #100. The findings included: 1. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE], documented the resident had a BIMS score of 10, on a 0 to 15 scale, indicating he had some cognitive impairment. This MDS documented the resident had no behaviors, and that he needed the total assistance of one person for bathing. This MDS also documented it was very important for the resident to choose between a bath and a shower. During an interview on 07/10/23 at 3:12 PM, Resident #22 and his wife were discussing their concerns with the slow or no response by staff, resulting in the resident having incontinent episodes. The resident's wife stated, They don't like giving showers. You have to beg for them. You always get the yes, yes, yes, but nothing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services to maintain a clean, comfortable and homelike environment for 3 of 5 units (Units 100, 200, and 500); and failed to maintain the residents' call lights to be accessible to the residents, for 4 of 53 sampled residents reviewed, Residents #64, #46, #4 and #85. The findings included: 1. Observations on 07/13/23 at approximately 1:00 PM, accompanied with the Director of Maintenance, revealed the following: In room [ROOM NUMBER], the room floors were dirty, the bed linens on the window-bed were stained, there was no toilet seat on the commode, there was an accumulation of trash on the floor, and the commode was not in proper working order. As reported by the residents, the toilet would 'fill up with water and then go down really slow'. In room [ROOM NUMBER], the privacy curtain between the beds was stained, there was an accumulation of residue and debris on the floor and the sink in the shared…

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 document review, the facility failed to initiate a new wound care physician order in a timely manner for 1 of 3 sampled residents reviewed for facility-acquired pressure ulcers, Resident #33. The findings included: The policy, titled, Prevention of Pressure Ulcers/ Injuries and revised on 07/17, documented, in part: Review the interventions and strategies for effectiveness on an ongoing basis. Resident #33 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Type 2 diabetes, history of falls, Atrial Fibrillation, Tremors, Glaucoma, Hyperlipidemia, and muscle wasting with atrophy. The record documented the resident had a BIMS (Brief Interview for Mental Status) score of 3 of 15, which indicated severe cognitive impairment. On 07/10/23 at 11:53 AM, a telephone interview was conducted with the spouse of Resident #33 to review his care at the facility. She stated her husband has a pressure ulcer on his left heel and she was the one who identified it. She 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician dietary orders and recommendations for obtaining weights for 3 of 5 sampled residents reviewed for nutrition, Residents #120, #111 and #123, that resulted in significant weight loss for Residents #111 and #123. The findings included: The facility's policy, titled, 'Weight Assessment and Intervention', revised September 2022, documented, in part: Weight Assessment 1. The nursing staff will measure resident weight on admission. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Any weight change of 5% or more since the last weight assessment will be retaken as soon as practical usually within the next day for confirmation. If the weight is verified, nursing will communicate with the Dietitian. 3. The Dietitian will review the Weight Record to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to respond to 1 of 1 sampled residents reviewed for vocalization of significant pain which resulted in harm, Resident #36. The findings included: The facility policy, titled, Pain Assessment and Management, documents in part: 2) Pain management is defined as the process for alleviating the resident's pain to a level that is acceptable to the resident and is based on his or clinical condition and established treatment goals. 3)d address the underlying cause of the pain Resident #36 was admitted to the facility on [DATE] with documented diagnosis to include Dementia, unspecified severity with other behavioral disturbance, history of falling, Osteoarthritis, personal history of Covid 19, and Dysphagia. The resident had a BIMS (Brief Interview for Mental Status) score of 3 of 15, which indicates severe cognitive impairment. Record review of the nursing progress notes for Resident #36 documented on 03/10/23 at 1:03 PM that the resident 'has been in bed all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care and services for 1 of 1 sample resident receiving dialysis, as evidenced by a lack of consistent documentation of coordination between the nursing and dialysis facility; failure to ensure documented pre and post weights to monitor for fluid overload; and failure to inform the physician and/or family of the resident's refusal of dialysis services, Resident #6. The findings included: Review of the record revealed Resident #6 was admitted to the facility on [DATE]. Resident #6 received dialysis services from an outside facility every Monday, Wednesday, and Friday. Dialysis treatment records were noted as part of the record to ensure communication between the two facilities. Review of the record lacked any communication documentation from the dialysis facility for the month of June 2023, and only included one note dated 07/10/23 for the month of July 2023. On 07/12/23 at 1:30 PM, Staff R, Unit Manager, explained the documented communication…

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 follow physician orders for 2 of 2 sampled residents with physician ordered fluid restrictions, Residents #22 and 120. The findings included: The facility's policy, titled, 'Fluid Restrictions' documented, in part: Policy Interpretation and Implementation 1). When a physician prescribes a fluid restriction, a communication form notifying the Fod and Nutrition Services department will be completed. 2). If the resident is receiving liquid nourishments for nutritional support. 3). If no clarification of liquid nourishment provided is obtained the liquid nourishment shall be included in the total fluids administered. 4). Water pitchers will be removed from the resident's room. Beverage preferences will be obtained by Food and Nutrition Services designee if possible and reflected on the resident's meal ticket/tray card. 5). Jell-O, ice cream, soup and anything at room temperature that becomes liquid, will be calculated and included in 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.