Carrollton Manor, Incorporated

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and policy review, the facility failed to provide evidence that residents and/or their representatives were informed of the risks, benefits, and available treatment options before restraints were initiated for two of seven residents reviewed for restraints (Resident (R) 21 and R56) and before psychotropic medications were initiated for four of five residents reviewed for unnecessary medication (R33, R12, R38, and R70) from a total sample of 34 residents. This deficient practice could result in residents being restrained or receiving medications without clinical necessity. Findings include: 1. Review of R21's admission Record, located under the Profile tab of her electronic medical record (EMR), revealed she was admitted to the facility on [DATE] and had diagnoses of Alzheimer's disease with behavioral disturbance, restlessness, and agitation. Review of R21's admission Packet dated 11/12/24 and provided on paper by the Director of nursing (DON) revealed 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, document review, staff interviews, policy review, and Centers for Medicare and Medicaid (CMS) guidance review, the facility failed to ensure two of three residents (R) (R24 and R90) who were reviewed for Beneficiary Notices received a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). This deficient practice had the potential for residents and/or their representatives not to be fully informed of the out-of-pocket costs associated with continuing to receive therapy after a Medicare Part A service ended. Findings Include:1. Review of R24's admission Record from the facility electronic medical record (EMR) Profile tab revealed a facility admission date of 09/17/2024, and readmission on [DATE], with medical diagnoses that included spinal stenosis, peripheral vascular disease (PVD), low back pain, altered mental status, acute pulmonary edema, and acute respiratory failure. Review of the facility provided Notice of Medicare Non-Coverage (NOMNC) revealed…

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, interviews, and policy review, the facility failed to ensure incidents of potential resident-to-resident abuse were identified, reported, and investigated per the facility's policy for three of 11 residents (R75, R19, R101) reviewed for abuse. These failures placed the residents at risk for physical and/or psychosocial harm related to continued abuse. Cross Reference F600, F609, and F865.Findings include:1A. Review of R75's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she was admitted on [DATE] and had a diagnosis of dementia with psychotic disturbance. Review of R75's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/19/26 and located under the MDS tab of the EMR revealed a score of three out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. Review of R75's EMR under the Progress Note tab revealed a General Nurses Note dated 03/04/26 that documented, Spoke with [R75's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of record review, document review, interviews, and policy review, the facility failed to ensure timely reporting of allegations of abuse related to three Residents (Resident (R) 101, R75, and R19) out of eleven residents reviewed for abuse. The facility's failure to ensure potential abuse was reported timely created the potential for ongoing abuse of residents in the facility. A total of 34 residents were reviewed in the sample. Cross reference F600 Findings include:1. Review of R101's admission Record, located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease. R101 was discharged from the facility on a psychiatric hold on 04/06/26 and was not residing in the facility at the time of the survey. A. Review of R101's Progress Notes, dated 09/20/25 and found in the EMR under the Notes tab, revealed, Resident [R101] started arguing with her [unidentified] roommate. She was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement care plans for four residents (Resident (R)2, R5, R24, and R70) of 34 sampled residents. Specifically, care plans were not developed for residents' use of bed rails or oxygen, and resident-to-resident abuse interventions were not included in their comprehensive care plan. This failure had the potential to affect the accuracy and complexity of resident care. Findings include:1. Review of R2's admission Record from the facility's electronic medical record (EMR) Profile tab revealed a facility admission date of 10/10/2025 with medical diagnoses that included pneumonia, asthma, protein-calorie malnutrition, chronic respiratory failure, and chronic kidney disease (CKD). During an observation on 04/21/2026 at 12:18 PM, R2's bed had bilateral upper bed rails (towards the head of the bed). During an observation on 04/22/2026 at 9:25 AM, R2 was in bed with bilateral upper rails. Review of R2's EMR Care…

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, interviews, and policy review, the facility failed to ensure an ongoing program of activities was provided for one of five residents reviewed for activities (Resident (R) 28), who was bedbound. This failure placed R28 at risk for isolation or lack of sensory stimulation.Findings include:Review of R28's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including vascular dementia and anoxic brain damage. During an observation on 04/21/26 at 11:11 AM in R28's room, she was observed lying in bed. R28 was not responsive to questions or verbal/tactile stimuli. R28's eyes remained closed and she was not observed to move on her own. There was no radio in her room, and the TV was not on. During an observation on 04/22/26 from 10:22 AM to 11:47 AM in R28's room, she was lying in bed with her eyes closed and was unresponsive to verbal or tactile stimuli. The TV was on; however, there was no volume. During 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 record review, observations, staff interviews, review of the Food and Drug Administration (FDA) guidance, and facility policy review, the facility failed to ensure assessments, including alternatives to rail usage, were attempted prior to the installation and use of bed rails for six 34 sampled residents (Resident (R) 2, R5, R24, R28, R33, and R57). This failure had the potential to increase accidental entrapment or injury.Findings include:1. Review of R2's admission Record from the facility electronic medical record (EMR) Profile tab revealed a facility admission date of 10/10/25 with medical diagnoses that included pneumonia, asthma, protein calorie malnutrition, chronic respiratory failure, and chronic kidney disease (CKD). During an observation on 04/21/26 at 12:18 PM, R2's bed had bilateral upper (towards the head of the bed) bed rails. During an observation on 04/22/26 at 9:25 AM, R2 was in bed with bilateral upper rails. Review of R2's EMR Assessment tab, Progress Notes tab, and Miscellaneous tab…

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, staff interviews, and policy review, the facility failed to provide medically-related social services to address potential psychosocial concerns and evaluate the ability to consent in sexual activities for two of three residents (Resident (R) 75 and R19) reviewed for behavioral and emotional needs. These failures had the potential to contribute to ongoing psychosocial distress following an incident of potential sexual abuse.Findings include:1. Review of R75's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she was admitted on [DATE] and had a diagnosis of dementia with psychotic disturbance. Review of R75's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/19/26 and located under the MDS tab of the EMR revealed a score of three out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. Review of R75's EMR under the Progress Note tab revealed a General Nurses Note dated 03/04/26…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to ensure a medication error rate was less than five percent during medication administration review. Five errors were identified from 31 opportunities involving three residents (R) (R39, R46, and R49), resulting in a 16.13 percent medication error rate. The deficient practice placed residents at risk for inaccurate dosing and adverse clinical outcomes. Findings include:1. Review of R39's admission Record, dated [DATE] and located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included hypertension. Review of R39's Physician's Order Report, dated [DATE] and located in the EMR under the Orders Tab, revealed an order dated [DATE] for the resident to receive ferrous sulfate (iron supplement) 325 milligrams (mg) one time per day and an order dated [DATE] for the resident to receive amlodipine (a blood pressure reducing medication) 2.5 mg…

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, observation, staff interviews, and policy review, the facility failed to ensure proper storage of refrigerated medications in one of two medication storage rooms in the facility. The facility's failure to ensure medication was appropriately stored created the potential for residents to receive inactive/ineffective medication. Findings include:On 04/25/2026 at 12:00 PM, the facility's main medication storage room was observed with Licensed Practical Nurse (LPN) 2, who served as Unit Manager. The refrigerator in the medication room was used to store multiple residents' medications, including insulin, suppositories, eye drops, and vaccine vials. The facility's temperature monitoring form dated 04/01/2026 through 04/25/2026 was in a book next to the refrigerator; however, temperature entries were missing over multiple days. At the time of observation, the refrigerator temperature was 34 degrees Fahrenheit, cooler than indicated by the facility's policy. Review of the facility's Medication Refrigerator Temperature Log for the refrigerator in the main medication…

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, staff interviews, and review of the facility's policies, the facility failed to appropriately store medications in three of three medication storage carts (200-300 Hall cart, 400 Hall cart, and 500 Hall cart). Findings include: Review of the undated facility policy titled, Medication Labeling and Storage, noted: Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation. Medication Storage: 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. [sic] During a medication storage observation of the 500 Hall medication cart, on 4/23/25 at 2:40 p.m., with Licensed Practical Nurse (LPN) CC, the second 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 observations, staff interviews, record review, and review of the facilities policy, the facility failed to accommodate resident's food allergies, intolerances, and preferences for seven (7) residents that had been identified to have a latex allergy to include sampled residents. [Residents (R) #7, R#13, R#27, R#39, R#49, R#51and R#247]. Specifically, the facility failed to provide an appropriate alternative as evident by dietary staff plating food from the tray line using their hands donning latex gloves. The deficient practice had the potential to affect all residents who receive an oral diet from the kitchen. Findings include: Review of the facility policy titled, Food Allergies, undated, revealed: Procedure 4, The facility must determine a practice for patient/resident identification for food allergy. The policy does not specifically identify latex allergies. Review of the facility policy titled, Bare Hand Contact with Food and Use of Plastic Gloves, not dated, revealed, Procedure 2, staff will use…

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

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure that proper sanitation and food handling practices to prevent the outbreak of foodborne illness were followed and safe food handling for the prevention of foodborne illnesses throughout the facility's food handling processes, and failed to ensure proper hand hygiene or donning (putting on) of a protective apron during meal service tray line. Specifically, two freezers, one walk in refrigerator, three juice coolers, and one front and back ice cream cooler failed to have documentation verifying the temperatures of each. The deficient practice had the potential to affect all residents who receive an oral diet from the kitchen. Findings include: Review of the facility policy for reference cold and warm temperatures was requested, however the facility failed to provide the requested policy. Review of the facility policy titled, Employee Hygiene for Food Safety, not dated, revealed all food and nutrition service employees will practice personal hygiene and safe food handling…

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, staff interviews, and review of the facility's policies, the facility failed to provide services that meet professional standards for one of six residents observed for medication administration (Resident #41). Specifically, blood pressure monitoring was not provided following physician's orders before administering a medication. Findings include: Review of the undated facility policy titled, Administering Medications, noted: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. [sic] Review of the medical…

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, resident family and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, the facility failed to report an incident of sexual abuse for one of three sampled residents (R) (R1). This failure had the potential for abuse to other residents by staff. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating states under Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under Policy Interpretation and Implementation, Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect,…

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 interviews and policy reviews, the facility failed to maintain an effective infection control program related to the unsanitary conditions for three out of three medication carts, failed to ensure that a blood pressure cuff was properly disinfected after each resident use, failed to use barriers with multi-use medications, failed to wash and/or sanitize hands while administering medications to prevent possible cross-contamination, and failed to transport soiled linen in a covered container. The facility census was 93. Findings included: Review of facility policy titled Storage of Medications revised November 2020, revealed number three listed under Policy Interpretation and Implementation states: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment. Revised September 2022 revealed Number one C. (1) states non-Critical resident-care items include bedpans, blood pressure cuffs, crutches,…

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 policy review, the facility failed to ensure a safe environment related to unsafe employee smoking practices on facility grounds. Findings include: 1. A review of the policy titled Smoking Policy - Employees with a date of 2001 and a revision date of May 2019 revealed the policy statement of: It is the policy of this facility to provide our employees with as near a smoke-free environment as possible and to ensure safe smoking practices for those who smoke. The policy Interpretation and Implementation section revealed line numbered 1. Employee smoking is permitted only in places where it is designated. Smoking is prohibited in all other areas. The section titled Visitors revealed line numbered 2. Visitors are not permitted to smoke in any area that is not designated as a smoking area. On 3/1/23 at 1:20 p.m. observation of an area located outside of the dining area revealed two picnic tables on a grass area. Observation of the area around the tables revealed dry grass and dry, brown leaves covering the ground. Observation revealed one dark brown…

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, staff interviews, record reviews, and review of facility policy 'Resident Hydration and Prevention of Dehydration', the facility failed to ensure adequate hydration was provided to three of 40 sampled residents (R) (R#48, R#67, and R#285) and follow the fluid restriction for one of 40 sampled residents (R#26). Findings included: A review of facility policy 'Resident Hydration and Prevention of Dehydration' last revised October 2017 revealed 'This facility will strive to provide adequate hydration and to prevent and treat dehydration. Policy Interpretation and Implementation: Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current standards of practice. Physician orders to limit fluids will take priority over calculated fluid needs. The dietitian may refer calculated needs to the physician if restrictions potentially increase risk for dehydration. The dietitian and nursing staff will educate the resident and family…

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, record reviews, and review of the facility policy titled Dignity, the facility failed to ensure that 12 of 24 sampled residents (R) (R#48, R#58, R#26, R#69, R#440, R#29, R#51, R#38, R#54, R#33, R#18, and R#67) were treated in a dignified manner related to (1) placing medical instruction signage in an area easily viewed by other residents/visitors for R#48, R#58, R#26, R#69, R#440, R#29, R#51, R#38, R#54, R#33, and R#18; and (2) an uncovered catheter bag for R#67. Findings Included: 1. A Review of the policy titled Dignity dated 2001 and revised 2/21/22 revealed the policy statement to be: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy interpretation and implementation section line numbered 10.b. Signs indicating the resident's clinical status or care needs are not openly posted in the resident's room unless specifically requested by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of facility policy titled admission Criteria the facility failed to conduct a Level II Preadmission Screening and Resident Review (PASARR) screening for one of 40 sampled residents (R) (R#39) following a new diagnosis of major depressive disorder and mild intellectual disabilities. Findings included: Review of facility policy 'admission Criteria' revealed: All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. g. Residents will be evaluated at least quarterly for mental status or new diagnosis of mental disorder. A review of the clinical record revealed that R#39 was admitted to the facility 11/30/16 with diagnoses including but not limited to obesity, hyperlipidemia, and hypertension. On 2/19/20 diagnoses of mild intellectual disabilities and major depressive disorder were added. Review of quarterly…

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, staff interviews, and review of facility policy 'Care Plan, Comprehensive Person-Centered', the facility failed to develop a person-centered comprehensive care plan related to nutrition/hydration needs for one of 40 sampled residents (R) (R#74). Findings included: Review of facility policy 'Care Plans, Comprehensive Person-Centered' last revised March 2022 revealed 'A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS (Minimum Data Set) assessment (Admission, Annual or Significant Change in status), and no more than 21 days after admission. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A review of the clinical record…

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 staff interviews, the facility failed to document weekly skin assessments in accordance with Physician orders for one of 40 sampled residents (R) (R#77). Findings included: A review of the clinical record revealed R#77 was admitted to the facility 6/22/22 with diagnoses including but not limited to frontotemporal neurocognitive disorder, dementia, and atrial fibrillation. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 99, indicating severe cognitive decline. A review of R#77's Physician orders dated March 2023 revealed an order for weekly skin assessments every Sunday on night shift. Further observation of February and March 2023 orders did not reveal orders for a treatment to the right elbow. During review of R#77's skin assessments the last skin assessment was performed 2/13/23. This skin assessment did not document any skin conditions. During observation on 2/28/23 at 2:20 p.m. R#77 was observed 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 reviews, the facility failed to ensure the safety for one of 40 sampled residents (R) (R#28) related to ensuring safe smoking practices. Findings include: A review of the policy titled Smoking Policy Update dated 5/13/13 revealed a statement of: (The facility) will become a smoke-free facility. Effective date for clients in our facility to be smoke free will be June 15, 2013. For all new clients, the policy will be effectively immediately. The policy was signed by the Administrator. A review of the clinical record revealed that R#28 was a [AGE] year-old male admitted on [DATE] with diagnosis including unspecified vascular injury of the head and vascular dementia. On 2/28/23 at 10:46 a.m. and 3/1/23 at 9:20 a.m. interviews with R#28 revealed he is allowed to go outside to smoke when his family visits and accompanies him outside. He revealed he normally goes to the parking lot or to an area just outside of the building and smokes with his family but did not go to the employee…

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, staff interview, and review of the policy titled Psychotropic Medication Use, the facility failed to ensure that psychotropic medications/antianxiety medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for two of five residents (R) (R#66 and R#77) reviewed for unnecessary medications. Findings included: Review of the policy titled Psychotropic Medication Use dated 2001 and revised July 2022 revealed the policy statement of: Residents will not receive medications that are not clinically indicated to treat a specific condition. The Policy and Interpretation and Implementation section revealed line numbered 12a.: As needed (PRN) orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN…

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 review of the policies titled, Storage of Medications, the facility failed to ensure that one of three medication carts (400 Hall Medication Cart) was locked and secured when the carts were out of view of the nurse. The Deficient practice had the potential to allow unauthorized staff, visitors, and residents access to unsecured medications. Findings included: Review of the policy titled Storage of Medications dated November 2020 revealed the policy heading for the facility is to store all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and implementation number 6 stated: Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. potentially available to others. An observation on 3/1/23 at 2:00 a.m. on the 400 Hall revealed that one medication cart located in the hallway outside resident rooms to be unlocked two times as the nurse left the cart unattended…

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.