Accura Healthcare of Carlisle

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or interventions for 1 of 5 residents (Resident #2) reviewed for a resident with diuretic medication usage. The facility reported a census of 78. Findings include:Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed Resident #2 utilized diuretic medications during the 7 day look back period. The MDS documented that the resident was admitted to the facility on [DATE].Review of Resident #2's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Lasix (Diuretic medication) 40mg oral tablet to give 1 tablet twice a day with a start date of 8/26/25. Review of Resident #2's Care Plan with a revision date of 4/13/26 revealed no focus, goals, or interventions for diuretic use. Interview 5/20/26 at 12:42 PM with the Minimum Data Set (MDS) Coordinator revealed that Lasix should be in the care plan. The MDS…

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, resident and staff interviews, and policy review the facility failed to to provide the necessary care and services to ensure a resident received appropriate clinical monitoring, timely medical provider notification, and consistent administration of prescribed treatments for a Urinary Tract Infection (UTI) for 1 of 1 residents reviewed for UTI (Resident #31). Specifically, facility staff failed to conduct nursing assessments across two separate antibiotic regimens, delayed follow-up with an unresponsive medical provider regarding a recurrence of symptoms, omitted a scheduled antibiotic dose without clinical justification, and failed to update the resident's care plan to reflect a suspected multidrug-resistant infection and use of antibitoics. The facility reported a census of 78 residents. Findings include: A review of all Progress Notes and clinical records from 4/1/26 to 5/20/26 established a timeline of Resident #31's antibiotic therapies for a urinary tract infection (UTI), which…

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, resident and staff interviews, and policy review the facility failed to ensure that an effective pain management regimen was consistently implemented in accordance with professional standards of practice and the comprehensive plan of care for 1 of 1 resident reviewed for pain management (Resident #64). Specifically, the facility failed to administer prescribed pain medication as ordered, resulting in a failure to meet the resident's goals for care and preferences. The facility reported a census of 78 residents. Findings include: Resident #64's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status score of 13, indicating intact cognition. The MDS revealed staff admitted him to the facility on 4/21/26. The MDS revealed he uses a wheelchair, does not walk, and depends on staff for transfers. The MDS documented diagnoses of peripheral vascular disease (a circulatory condition where narrowed blood vessels reduce blood flow to the limbs), arthritis (joint…

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 staff interview, observation, document review and facility policy review the facility failed to maintain an effective pest control program so that the facility was free from any infestation of any kind of vermin in the facility. The facility reported a census of 72 residents. Finding include:In an interview with Staff D, Licensed Practical Nurse (LPN) on 1/26/26 at 3:00 pm, she revealed there was a mice problem at the facility and in the staff break room. She further stated mice ate her snack that was in her personal locker inside the breakroom. This occurred about a week ago and the facility added mice traps and boxes at that time and the exterminator came out to the facility. The facility provided a document titled Work Orders for dates December 29, 2025 - January 29, 2026 and an entry log mouse in room [ROOM NUMBER] was documented as closed work order.During an observation of room [ROOM NUMBER] on 1/27/26 at 9:00 am, the 6-drawer clothing dresser revealed mice droppings in 4 out of 6 drawers. Drawers…

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 document review, electronic health record review (EHR), staff interviews, and policy review the facility failed to report a resident's allegation of sexual abuse (Resident #4) to the State Agency within the required timeframe for 1 of 3 residents reviewed for abuse and dignity. The facility reported a census of 72. Findings include: The Quarterly Minimum Data Set (MDS) Assessment completed on 12/4/25 revealed Resident #4 with a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. The MDS documented that Resident #4 was dependent on staff for completion of personal cares and transfers and wheelchair use. The Incident Investigative Report showed the facility submitted on online report of sexual abuse involving Resident #4 on 1/22/26 at 8:13 AM to the Iowa Department of Inspections, Appeals, and Licensing. During an interview on 1/26/26 at 1:55 PM, Staff C, Certified Nursing Assistant (CNA), stated Resident #4 reported the morning of 1/22/26 that the guy from last night needs to be fired as he raped me. Staff F, CNA, who was also present when…

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 facility document review, staff interviews, and policy review the facility failed protect residents from further potential abuse once an allegation of sexual abuse was reported to staff, for 1 of 2 abuse allegations reviewed. An employee meeting the general description of the alleged perpetrator worked and had access to residents after the allegation was were made. The facility reported a census of 72. Findings include: During an interview on 1/28/26 at 10:00 AM, Staff H, Certified Nursing Assistant (CNA), explained Resident #4 reported to them on the morning of 1/21/26 that a black man raped me and the black girl when they asked the resident how they slept during the night. Resident #4 said this man was the one who comes in and turns the light on. After completing personal cares, Staff H stated they went to inform Staff I, Registered Nurse (RN), of the statements Resident #4 had made. During an interview on 1/28/26 at 2:00 PM, Staff I, RN acknowledged Staff H, CNA approached them the morning of 1/21/26 to report Resident #4's rape allegation. Staff I explained she then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and the Resident Assessment Instrument (RAI) Manual the facility failed to accurately complete a Minimum Data Set (MDS) assessment for four of twenty-three residents reviewed (Residents #1, #3, #6 and #32). The facility reported a census of 70 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #3 had a diagnosis of coronary artery disease. The MDS documented the resident took an anticoagulant. The Electronic Health Record (EHR)revealed that Resident #3 had diagnoses of Aortocoronary bypass graft (heart arteries blocked or narrowed) and old myocardial infarction (heart attack). The Care Plan revised 4/12/24 revealed Resident #3 had a risk of abnormal bleeding related to routine use of hematological agents (drugs used to treat disorders of the blood). The Care Plan directed staff to administer medications as ordered and monitor for side effects. The EHR revealed Clopidogrel Bisulfate (Plavix) (an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to develop a comprehensive care plan that included focus, goals, or interventions for 2 out 5 residents reviewed (Resident #5, #23). The facility reported a census of 70 residents. Findings include: 1. Review of Resident #5's Quarterly Minimum Data Set (MDS) dated [DATE] documented an admission date to the facility of 9/5/13. The MDS also documented a Brief Interview for Mental Status (BIMS) of 03 which indicated severe cognitive impairment. The MDS listed a diagnosis of Non-Alzheimer's dementia. Review of Resident #5's Electronic Health Record (EHR) document titled Care Plan last review completed date of 6/27/25 revealed no documentation of dementia diagnosis with a focus area, goals, or interventions. 2. Review of Resident #23's Quarterly MDS dated [DATE] documented an admission date to the facility of 6/8/23. The MDS listed active diagnoses of Urinary Tract Infection (UTI) (last 30 days). Review of Resident #23's…

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

Based on record review, observation, staff interview, and policy review, the facility failed to ensure staff appropriately completed a resident assessment and provide timely intervention for two residents. One resident with Lower Extremity (LE) wraps for 1 of 1 resident reviewed for edema (Resident #55) and one resident with Chronic Obstructive Pulmonary Disease (COPD) for 1 of 2 residents reviewed for oxygen (Resident #62). The facility reported a census of 70.Findings include:1. The Quarterly Minimum Data Set (MDS) for resident #55, dated 7/24/25, indicated diagnoses of hypertension, diabetes mellitus, and cerebral vascular accident.The Electronic Health Record (EHR) indicated that resident additional diagnoses of chronic peripheral venous insufficiency, localized edema and lymphedema.The EHR indicated and an active order from the primary physician for Lymphedema wraps to be worn 24 hours a day/seven days a week (24/7) and therapy to change starting 4/7/2025. The EHR also indicated that this order was discontinued 7/31/25 with a new order for compression stocking on in the morning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, and policy review, the facility failed to ensure staff secured and placed a resident's catheter bag below the level of the bladder to minimize the risk of cross-contamination and the risk of acquiring a urinary tract infection for one of two residents observed with a catheter (Residents #1). The facility reported a census of 70 residents.Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnoses of renal (kidney) insufficiency, obstructive uropathy (obstructed urine flow), and diabetes. The MDS indicated the resident had an indwelling catheter. The Care Plan revised 5/21/25 revealed Resident #1 had a suprapubic catheter and at risk for a MDRO (multi-drug resistant organism). The Care Plan directed staff to position the catheter bag and tubing below the level of the bladder. Observations revealed the following: a. On 7/28/25 at 11:30 AM, Resident #1 sat in a wheelchair with a catheter bag lying 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 clinical record review, observation, staff interview, manufacturer's instructions, and competency review the facility failed to administer insulin according to the physician's orders and per manufacturer instructions to ensure the proper amount of insulin administered for one of two residents observed who received insulin during medication pass (Resident #1). The facility reported a census of 70 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnosis of diabetes and diabetic neuropathy (nerve damage caused by diabetes, often affecting the legs and feet due to high blood sugar level). The MDS documented the resident took insulin 7 of 7 days during the look-back period.The Care Plan initiated 5/3/24 revealed Resident #1 at risk for altered blood glucose levels related to diabetes and took insulin. The Care Plan directed staff to administer medications as ordered. The Medication Administration Record for Resident # 1 listed Novolog insulin flexpen…

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 the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (January 1st to March 31st) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 70 residents.Findings include:The PBJ Staffing Data Report run date of 724/25 triggered for excessively low weekend staffing for the fiscal year 2nd quarter, January 1st to March 31st, 2025. In an interview with the Administrator on 7/30/25 at 8:30 am she stated the facility was not understaffed on weekends and the PBJ data submission did not include staffing agency staff that worked on weekends. The Regional Director on 7/31/25 at 1:15 pm submitted a PBJ report via email displaying the report showed no concerns. He was advised to call the help line to correct the issue with the CMS's PBJ reporting excessively low weekend staffing for the fiscal year 2nd quarter.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review the facility failed to ensure staff properly disinfected resident care devices such as a glucometer machine and a stethoscope after resident use for 1 of 2 residents observed for a blood sugar check (Resident #40) and 1 of 2 residents observed for a gastrostomy (g-tube) tube (Resident #7). The facility staff also failed to follow infection control practices in order to prevent and control the onset and spread of infection within the facility by not removing soiled gloves for 1 of 2 units. The facility reported a census of 70 residents.Findings include:1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had diagnoses of pneumonia. The MDS indicated the resident took an antibiotic. The Care Plan revised 2/19/25 revealed the resident had a tube feeding related to swallowing problem and at risk for MDRO related to an indwelling PEG (gastrostomy) (a tube in the stomach) tube. The Care Plan directed staff to use enhanced…

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, staff interview, and policy review, the facility failed to provide the necessary services to maintain personal cares of oral hygiene for 1 of 3 residents reviewed (#11). The facility reported a census of 75 residents. Findings include: On 3/31/25 at 1:42 PM, Resident #11 was observed reclined in a Geri chair (large, padded chair for individuals with limited mobility) in the television area. He was breathing through his mouth and his lips were noted to be chapped and peeling. The Quarterly Minimum Data Set (MDS) for Resident #11 dated 2/03/25 indicated a Brief Interview for Mental Status (BIMS) score of 04 out of 15 which indicated severely impaired cognition. It included diagnoses of anemia, seizure disorder, quadriplegia, a Cerebral Vascular Accident (CVA - stroke), and severe protein-calorie malnutrition. It also indicated the resident was dependent with all Activities of Daily Living (ADLs). The MDS documented that the Resident had a feeding tube for nutitional approaches for both total calories, and fluid intake. The Electronic Health 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.

Based on observations, clinical record review, staff interview, and policy review, the facility failed to provide treatment and services to prevent the development of a pressure ulcer for 2 of 3 residents reviewed (#4 & #11). The facility reported a census of 75 residents. Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue…

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, clinical record review, staff interview, and policy review, the facility failed to use ordered Durable Medical Equipment (DME) to prevent a further decrease in Range-of-Motion (ROM) for 2 of 3 residents reviewed. (provide treatment and services to prevent the development of a pressure ulcer for 2 of 3 residents reviewed (#4 & #11). The facility reported a census of 75 residents. Findings include: 1. On 3/31/25 at 1:42 PM, Resident #11 was observed in a Geri chair (large, padded chair for individuals with limited mobility) in the television area without any DME. His hands were noted to be limited in range-of-motion. At 1:58 PM, a review of his Electronic Health Record (EHR) revealed a physician's order dated 3/01/25 for resident to wear palm [NAME] (DME used to prevent contractures <shortened or tightened muscle, tendon, or joint that causes limited movement> and protect skin for people with limited ROM) at all times. [NAME] may be removed if resident complains of (c/o) pain. May remove 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 observations, clinical record review, staff interview, and policy review, the facility failed to don appropriate Personal Protective Equipment (PPE) when providing direct resident care for 2 of 2 residents who were on Enhanced Barrier Precautions (EBP) (#11 & #15). The facility reported a census of 75 residents. Findings include: 1. On 4/01/25 at 7:28 AM, Staff D, Certified Nurse Aide (CNA), Staff E, CNA, and Staff G, CNA entered Resident #15's room without any PPE. An Enhanced Barrier Precaution sign was observed attached to the resident's door in both English and Spanish. The sign indicated staff were to wear gloves and a gown for the following activities: a) Dressing b) bathing/showering c) transferring d) changing linens e) providing hygiene f) changing briefs or assisting with toileting g) device care use: central line, urinary catheter, feeding tube, tracheostomy h) wound care: any skin opening requiring a dressing The Significant Change Minimum Data Set (MDS) dated [DATE] for Resident #15…

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 clinical record review, policy review, and staff interview, the facility failed to ensure staff treated residents with dignity and respect for 3 of 7 residents reviewed for resident rights (Resident #2, #7 and Resident #8). The facility reported a census of 75 residents. Findings include: 1. The Significant Change Minimum Data Set (MDS) assessment tool, dated 12/29/24, listed diagnoses for Resident #2 which included paraplegia (paralysis in the lower portion of the body), anxiety, and depression, and stated the resident was dependent on staff for bathing. The MDS listed her Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated intact cognition. A Care Plan entry, dated 12/2/24, stated the resident had a history of a traumatic life event and directed staff to provide a calming environment through country music, pet visits, and TV. An untitled, undated facility investigation stated on 2/16/25, Resident #2 reported that Staff C Certified Nursing Assistant (CNA) accidentally hurt her arm by lifting it too high to wash under her arms and Staff C called…

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 clinical record review, policy review, and staff interview, the facility failed to carry out a medication intervention for 1 of 3 residents reviewed for a change in condition (Resident #1). The facility reported a census of 75 residents. Findings includes: The Minimum Data Set (MDS) assessment tool, dated 1/6/25, listed diagnoses for Resident #1 which included hemiplegia (one-sided weakness), diabetes, and anxiety. The MDS listed her cognition as severely impaired. The facility policy Medications Ordering and Receiving from Pharmacy, revised January 2018, did not address how staff should obtain medications needed for new orders. A 4/15/24 Care Plan entry directed staff to administer psychotropic medications as ordered by the physician. The February 2025 Treatment Administration Record (TAR) listed a 2/21/25 6:00 p.m. order for lorazepam(a medication used for anxiety) 2 milligrams (mg)/milliliter (ml) oral concentrate, give 0.25 ml every 6 hours for anxiety/agitation. The 6:00 p.m. dose on 2/21/25 and the 12:00 a.m. dose on 2/22/25 lacked checks to indicate staff…

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

Based on observations, staff interviews, and policy review, the facility failed to properly secure medications from unauthorized access for one of one medication cart observed. The facility reported a census of 73 residents. Findings include: On 1/13/25 at 3:31 PM, an observation revealed an unattended, unlocked medication cart in a resident hall. There were no staff members present. Staff A, Licensed Practical Nurse (LPN), exited a resident's room and came to the medication cart. She locked the medication cart and stated the medication cart should not have been unlocked. A policy titled Medication Storage in the Facility revised 11/2018 indicated medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. On 1/15/25 at 9:33 AM, the Director of Nursing (DON) stated staff should ensure the medication cart is locked if they are leaving the cart.

Based on observations and staff interviews, the facility failed to properly protect resident information from unauthorized access for one of one laptop reviewed. The facility reported a census of 73 residents. Findings include: On 1/13/25 at 3:31 PM, an observation revealed an opened laptop with Resident #11's Electronic Health Record (EHR) viewable. There were no staff members present. Staff A, Licensed Practical Nurse (LPN), exited a resident's room and came to the medication cart. She exited the resident's EHR and accessed a screen that displayed 16 residents' EHR information. At 3:33 PM, Resident #10 activated her call light and called out for help. Staff A walked into the resident's room. The laptop was observed opened with 16 residents' EHR information viewable. At 3:37 PM, Staff A returned to the medication cart and stated the EHR information should not be unlocked. On 1/14/25 at 6:48 AM, an observation revealed an opened laptop with Resident #2's EHR viewable. Another staff member locked the drawer. On 1/15/25 at 7:51 AM, the Administrator emailed the facility didn't have 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, staff interview, and policy review, the facility failed to implement infection control policies to prevent cross-contamination. The facility reported a census of 73 residents. Findings include: 1. On 1/13/25 at 1:21 pm, Staff D, Housekeeping Aide (HA) and Staff E, Certified Nurse Aide (CNA) stated purple-top sanitizing wipes (saniwipes) were used to clean Personal Protective Equipment (PPE) goggles for use in Covid+ resident rooms but were not able to locate the wipes. At 1:25 pm, the PPE bin at the north end of hall 200 contained only goggles for eye protection but did not contain any saniwipes for shared equipment. At 1:45 pm, Staff F, Registered Nurse (RN) stated PPE goggles are for individual residents but for multiple staff. He also stated the goggles get cleaned with saniwipes after use. At 1:45 pm, Staff E, CNA and Staff G, CNA used an EZ Stand (mechanical device used for standing assistance) to transfer Resident #2. There were no saniwipes available to clean the EZ Stand. At 1:53…

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 resident observations, record review, staff interview, and policy review, the facility failed to treat residents with dignity by failing to provide an alternate method of obtaining toileting assistance which resulted in the resident walking to the unit hallway intersection and yelling for help to be changed. Dignity was reviewed for eleven residents, concerns were found for Resident#8. The facility reported a census of 73. Findings include: On 1/14/25 at 7:16 AM, an Environmental Services (EVS) staff member was observed leaving the south hall of the Chronic Confusion Dementing Illness (CCDI) unit. At 7:22 AM, Resident #8 walked to her room doorway and asked to be changed. The resident was instructed to follow her normal method of contacting staff for assistance as the surveyor was not authorized to help. At 7:26 AM, the resident ambulated with her walker to the south hall main corridor intersection and yelled down the hall for someone to change her. At 7:30 AM, another EVS staff member entered the south hall and got the wet floor sign. At 7:32 AM, Staff B, Certified Nursing…

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

Based on document review, and staff interview the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 9 of 32 days reviewed (July 28th through August 28th 2024). The facility reported a census of 71 residents. Findings include: Review of untitled documents of the facility's daily staffing schedule provided by the facility revealed there was no RN coverage 7/30/24, 7/31/24, 8/5/24, 8/12/24, 8/14/24, and 8/15/24. These documents further revealed there was only 4 hours of RN coverage 8/19/24, 8/20/24, and 8/21/24. During an interview 8/28/24 at 9:02 AM with Staff A Certified Nurse Aide (CNA) revealed that the facility did not have 8 hour RN coverage every day. Staff A further revealed they cannot count management towards the 8 hours RN coverage, and that the facility did not have enough RN coverage for the schedule. During an interview 8/28/24 at 9:06 AM with the Administrator revealed that the facility did not have 8 hour RN coverage for the days reviewed. The administrator further revealed that the facility does not have a policy…

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 Electronic Health Records (EHR), resident interview, resident council documentation, and observations the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 18 residents reviewed (Resident #2, #35, #38, and #41). The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #35 documented a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. The MDS documented the resident required partial/moderate assistance with toileting hygiene. On 8/25/24 at 2:04 PM Resident #35 stated it takes a while for staff to answer her call light. Resident #35 stated she had turned the call light on while in the bathroom and had to wait for longer than a half an hour. Resident #35 stated at that time she just did the best she could and completed the peri care herself and transferred herself back to the wheelchair. 2. The Minimum Data Set (MDS) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Staff interview, and infection control policy the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during cares for 2 of 3 residents reviewed for infection control (Residents # 2, and #7). The facility further failed to properly wear proper personal protective equipment (PPE) while caring for 2 of 2 Residents reviewed with a positive Covid diagnosis. (Resident #49 and #60) The facility reported a census of 71 residents. Findings include: 1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS further revealed diagnosis of paraplegia, and chronic obstructive pulmonary disease. Review of Resident#2's Electronic Health Record (EHR) document titled, Physician's orders, revealed a physician order dated 5/29/24 documenting EBP every day and night shift related to risk for Multi-Drug Resistant Organisms (MDRO). Resident#2's 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 document review, observations, resident interview, and staff interview the facility failed to provide dignity by leaving a catheter bag uncovered for 1 of 8 residents reviewed (Resident #2). The facility reported a census of 71 residents. Findings include: Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS further revealed diagnosis of paraplegia, and chronic obstructive pulmonary disease. Observation 8/25/24 at 1:42 PM Resident #2's Catheter bag was noted to not have a privacy cover. Interview 8/25/24 at 1:42 PM Resident #2 revealed the facility never puts a cover on the drainage bag. During a follow up observation 8/26/24 at 2:07 PM Resident #2's catheter bag was observed with no dignity cover. During a follow up interview 8/26/24 at 2:10 PM Resident #2 revealed that the urinary drainage bag had a cover, but it went missing a long time ago. Resident #2 further revealed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Medication Administration Record (MAR)- Treatment Administration Record (TAR), resident interview and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the MDS by not accurately assessing need for restrains and utilization of catheter for 2 of 18 residents reviewed (Resident #2 and #38). The facility reported a census of 71 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #38 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 8/26/24 at 8:11 AM Resident #38 stated he had not had a catheter in about 2 years and had not had a catheter at this facility. Review of Resident #38's MDS dated [DATE] documented indwelling catheter present. Review of Resident #38's MAR-TAR documented no physician's order for catheter. Review of Resident #38's care plan documented no care plan for indwelling catheter. On 8/27/24 at 4:59 PM the DON stated Resident #38…

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 electronic record review (EHR), staff interviews, and policy review the facility failed to implement a comprehensive care plan when staff left a resident that had a care plan of supervision with meals unsupervised during meals for 1 of 5 residents reviewed (Resident #60). The facility reported a census of 71 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #60 documented a Brief Interview for Mental Status (BIMS) of 9 which indicated moderate cognitive impairment. Review of Resident #60's Care Plans documented an intervention that Resident #60 could eat independently in the dining room with supervision, after setup. Observation on 8/25/24 at 1:30 PM of Staff G, Certified Nursing Assistant (CNA) delivered Resident #60's lunch tray into her room, opened the styrofoam tray, removed plastic wrap from drinks, and handed Resident #60 utensils. Staff G left the room and closed Resident #60's door. Resident #60 began to eat her pie. On 8/26/24 at 1:45 PM Staff F, CNA 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, staff interview, and policy review the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not verifying gastrostomy tube (feeding tube) is functioning properly before beginning a feeding for 1 of 1 residents (Resident #7) reviewed. The facility reported a census of 71 residents. Findings include: Review of Resident #7's Minimum Data Set (MDS) dated [DATE] revealed diagnosis of traumatic brain dysfunction, pneumonia, malnutrition, and artificial openings of the gastrointestinal tract. Review of Resident #7's Electronic Health Record (EHR) page titled, Physician's Orders, revealed a physician order dated 1/30/24 documenting to check placement and residual prior to administering medications via Percutaneous Endoscopic Gastrostomy (PEG) tube. Observation 8/27/24 at 12:24 PM Staff C Licensed Practical Nurse (LPN) proceeded to access Resident #7's PEG tube to administer medications. Staff C then administered a flush and medications without…

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, staff interview, resident interview, review of Steamtable Temperature logs, review of Resident Council Meeting Minutes and facility policy review the facility failed to maintain hot food served at a temperature greater than 140 degrees during a meal service. The facility identified a census of 65 Findings include: An observation and interview on 5.2.24 at 12:58 p.m. revealed Staff A, [NAME] as she tempted the food at the immediate end of the food service with the results as follows: a. Taco casserole - 135 degrees Fahrenheit (F) b. [NAME] - 137 F c. Mashed potatoes - 120 F. As the staff member took this temp she confirmed the temperature as low because there had been no room on steam table so she positioned the serving pan on top of the table and not around the heating elements. d. Chicken strips - 164 e. Hamburger patty - 151 Staff A reported she had been required to maintain food temps at 140 to 165 degrees F for hot food. Review of the facilities Steamtable Temperatures logs revealed the facility staff failed to check the food temperatures 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 observation, clinical record review, staff interview, resident interview, a volunteer ombudsman interview, review of the facilities Employer Handbook and review of the facilities Residents' [NAME] of Rights the facility failed to treat 1 of 3 residents with dignity and respect while preserving her rights. (Resident #1) The facility identified a census of 65 residents, Findings include: During an interview 5.2.24 at approximately. 3:30 p.m. the facilities Volunteer Ombudsman voiced a concern related to the facilities refusal to allow Resident #1 to have vaped an electronic nicotine device because the facility had allegedly being a non-smoking facility minus 2 residents that were grandfathered in at the time of the policy change. The Ombudsman confirmed staff as able to have smoked. The Ombudsman indicated not to long ago (a few weeks) he drove by the facility around 7:30 p.m. and observed several staff smoking in the designated resident smoking area to the South side of the building. An observation at…

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

Based on observation, clinical record review, resident interview, staff interview and review of Resident Council Meeting Minutes the facility failed to follow physician orders for 1 of 3 residents reviewed with an acute and chronic illness. (Resident #4) The facility identified a census of 65 residents. Findings include: 1. A Medication Administration Record (MAR) form dated 5.1.24 thru 5.31.24 for Resident #4 directed the facility staff to have administered Lispro insulin (short acting insulin) 3 units subcutaneously (SQ) with meals and to hold if blood sugars registered less than 90 related to Diabetes Mellitus (DM) due to an underlying condition with hyperglycemia. That order had been in addition to a sliding scale of Lispro insulin. (started 3.25.24 at 6 p.m.) The resident's Lispro sliding scale went as follows with a Physician's directive to have been administered with meals. (started 3.20.24 at 6 p.m.) A blood sugar of 0-150 = no units of Lispro insulin 151-200 = 2 units. 201-250 = 4 251-300 = 6 301-350 = 8 351-400 = 10 An observation 5.3.24 at 9:14 a.m. revealed Staff H,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility policy review, the facility failed to properly destroy Resident #6's narcotic (pain) medication when the resident was discharge to the hospital on 6/11/2023, and then passed away while at the hospital. The facility identified a census of 67 residents. Findings include: 1. Resident #6' s Minimum Data Set (MDS) dated [DATE], documented an admission date of 12/24/2020 and revealed memory problems with moderately impaired decision making abilities and an opiod (pain medication) was used in the last 7 days of the look back period. Resident was discharged to hospital on 6/11/2023 with return anticipated. Diagnosis include Diabetes Mellitus, Anxiety and Pain. A Physician Order Sheet signed and dated by the Physician on 4/7/2023, documented Tramadol HCL tablet 50 milligrams, give 1 tablet by mouth every 12 hours for pain. A documented titled Controlled Drug/Receipt/Record/Disposition Form dated 5/30/23, identified that 30 Tramadol HCL tablets were delivered…

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.