Heritage Specialty Care

Based on observation, maintenance record review, staff interviews, and facility policy review, the facility failed to provide a clean and homelike environment. The facility reported a census of 118 residents. Findings include: Observation on 8/18/25 at 8:00 am revealed a large, blackened area on the carpet in the main lobby area, located between the conference room and Administrator's office. The blackened area measured approximately 15 feet long by 6 feet wide. Observation on 8/19/25 at 8:46 am revealed the carpet at the entrance of the skilled unit coming from Station 3 had a darkened area which measured approximately 13 feet long by 3 feet in width. On 8/20/2025 at 10:25 a.m., Staff C, DON (Director of Nursing) reported when she first started in June, the facility had a resident who had a visitor who brought some things in from home, and they discovered bed bugs. They isolated the belongings, bagged them up, and treated the room. On 8/20/2025 at 11:25 am, Staff D, the Corporate Director of Facilities manager, revealed the facility had the carpet cleaned two times in the last six…

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 Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies form, the facility Quality Assurance and Performance Improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. The facility reported a census of 118 residents. Findings include:The CMS 2567, dated June 12, 2025 reflected deficiencies identified for medication administration. The current complaint survey, conducted 8/18/2025 - 8/26/2025 also identified the above concern. In an interview on 8/20/2025 at 2:00 pm, the Administrator explained the QAPI team met monthly to discuss the Performance Improvement Projects (PIP) and quarterly with the full team. Data was collected via an online program, suggestion boxes, grievance forms, and when the [State Agency] found a deficiency. The facility prioritized the issues that impinged on residents' quality of life or rights. She explained there was a PIP in place for the previous survey deficiency but they…

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 and resident interviews, observations and policy review the facility failed to administer medications as ordered for one of three residents reviewed (Resident #8). The facility reported a census of 118 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had an admission date of 8/12/25. The resident had a Brief Interview for Mental Status score of 9 out of 15, which revealed moderate cognitive impairment. The resident had diagnoses which included Non-Alzheimer's Dementia, Traumatic Brain Injury and anxiety. The resident required partial/moderate assistance with activities of daily living. Review of the Facility Incident Report dated 8/12/25 at 11:53 am revealed the following: Resident #8 received another's medication in error on 8/13/25 during morning medication pass. The Incident Report revealed the facility received a phone call from the pharmacy provider reporting they sent the wrong medications for Resident #8. The pharmacy placed…

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 and resident interviews, and clinical record review the facility failed to offer toileting assistance for one of three residents reviewed. (Resident #3). The facility reported a census of 118 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had no memory impairment, required partial assistance for transfers from one surface to another and had diagnoses including stroke and hemiplegia. The Care Plan revealed the resident had a fall risk dated 10/12/2024, and it directed staff to encourage the use of a call light and ensure it is within reach.On 7/30/2025, Staff B, CNA (Certified Nursing Assistant) reported when she arrived to work, she heard the resident calling out for assistance and rattling the bed rail. Staff B observed the resident's call light on the wall and out of reach. The resident had been incontinent of bowel and bladder. The Facility Incident Report dated 7/30/2025 included the resident reported the third shift aide failed to provide…

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, policy review, and staff interview, the facility failed to consistently monitor the functioning of the dishwasher and failed to ensure adequate kitchen sanitation for 2 of 2 kitchen observations. The facility reported a census of 118 residents. Findings include: 1. The initial kitchen tour on 5/19/25 at 10:05 a.m. revealed the following concerns: a. A fan above the hand washing sink was covered with mesh and a thick layer of dust covered the mesh and the fan blades. The fan blew toward the left hand side of the dishwasher where clean dishes emerged. b. Staff B, Dietary Staff washed dishes and when requested to test the functioning of the dishwasher she obtained a strip but then stated she did not know how to complete the test. Staff B stated she did not test the machine that morning before doing breakfast dishes. The Dietary Manager was present and could not locate a log of dishwasher function tests. c. The top of the dishwasher was covered with yellow chunks of debris. d. The fire suppression system spigots had dust particles hanging…

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 interview the facility failed to change oxygen tubing on 1 out of 1 concentrator for residents with physician orders for oxygen (Resident #14). The facility reported a census of 118 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #14 indicated a Brief Interview for Mental Status (BIMS) score of 15 which indicates no cognitive impairment. It further indicated diagnoses including: chronic obstructive pulmonary disease (COPD), respiratory failure, and anxiety. The MDS indicated Resident #14 required moderate assist from staff for transfers, bathing, dressing, and personal hygiene. Review of the Care Plan dated 4/22/24 revealed Resident #14 altered respiratory status and utilizes oxygen. Observed Resident #14 on 05/20/25 at 10:36 AM with oxygen on in their wheelchair at 1.5 liter per nasal cannula from a tank. The tubing did not have a label with date tubing was changed. The oxygen concentrator in residents room had a label with 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, clinical record review, menu review, and staff interview, the facility failed to ensure residents on a pureed diet received the correct portion sizes and food items in accordance with the menu for 1 of 1 meal observed. The facility reported a census of 118 residents. Findings include: The Diet Type Report listed 4 residents with an order for a pureed diet. On 5/20/25 at 10:00 a.m., Staff C, Dietary Services Manager Assistant stated he would prepare puree Salisbury steak for 6 residents but stated he would make 1 extra. Staff C placed 7 steaks, 3 slices of bread, and gravy into the food processor, ground this up, and placed it into a graduate which measured 3 cups. Staff C stated he wanted the total amount to be 5 cups so he added 3 more steaks, hot water, and 2 more sliced of bread. He then poured the mixture into the graduate which measured 6 cups. Staff C then looked at the Pureed Diet Portion Sizes/Scoops poster on the wall and stated he would use a #8 scoop (4 ounce). The Pureed Diet Portion Sizes/Scoops chart directed staff to utilize 2 #8 scoops for 6…

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, policy review, and staff interview the facility failed to follow the Center for Disease Control and Prevention (CDC) 2025 Adult Immunization Schedule for pneumococcal vaccination for 1 of 5 residents sampled (Resident #41). The facility identified a census of 118 residents. Findings include: Resident #41 Electronic Healthcare Record (EHR) Census documented admission to the facility on 1/09/23. The EHR Immunization Record documented Resident #41 received a pneumococcal 23 vaccination on 10/15/2017 at the age of 54. A Consent for Pneumococcal Vaccination signed by Resident #41 on 1/09/23 showed the Resident circled she accepted to receive the vaccination. An Order Summary Report signed by the Provider on 10/08/24 showed an active order as of 1/09/23 for a pneumococcal vaccination to be administered if applicable. A 11/30/2024 9:31 Pharmacy Consultant Review Progress Note recommended a Prevnar 20 vaccination. A 12/28/2024 4:49 PM Pharmacy Consultant Review Progress Note recommended…

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, policy review, and resident and staff interviews, the facility failed to assess and document follow up skin assessments for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 131 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnoses that included anemia, congestive heart failure, chronic kidney disease (stage 5) requiring dialysis, right femur fracture, diabetes, and depression. The MDS indicated the resident required extensive assistance with toileting, positioning, and transfers, had skin tears and was at risk for pressure ulcers. Resident #1 received antidepressant, diuretic, and antiplatelet medications during the observation period. The Care Plan initiated 1/16/25 with a revision date of 2/3/25 revealed the resident had impairment to the right upper leg related to a surgical incision with a goal of no complications related to skin impairment. Interventions included monitoring…

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, resident, and family interviews, and policy review, the facility failed to provide a safe transfer for 1 of 4 residents reviewed (Resident #10). The facility failed to utilize a gait belt during a 2 person transfer as directed by the Care Plan. The facility reported a census of 131 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS indicated the resident carried diagnoses that included non-displaced bicondylar fracture of left tibia, dementia, and Alzheimer's disease. Resident #10 was wheelchair dependent and required moderate assistance for toileting, extensive assistance for bathing, dependent on staff for personal hygiene, and maximum assistance with transfers. The resident received antianxiety, Opioid, and antiplatelet medication. Review of Resident #10's Care Plan dated 1/22/25 revealed a focus…

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, staff and family interviews, and policy review the facility failed to complete pain assessments as directed, update Narcotic Records with changes in medication prescriptions, and complete follow up assessments when pain interventions were ineffective for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 131 residents. Findings include: Resident #10 was admitted to Heritage Specialty Care on 1/22/25 for aftercare following a left tibial plateau fracture sustained sometime in the 3 weeks prior to her hospitalization from multiple falls at home. The resident was moved from the Rehab Unit to the Chronic Confusion or Dementing Illness (CCDI) Unit on 2/13/25 due to exit seeking and wandering behaviors. The resident was admitted to hospice care on 2/21/25 for vascular dementia. The admission Minimum Data Set (MDS) dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. 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 reviews, interviews, policy reviews, and observations the facility failed to maintain a clean, homelike, and safe environment. The facility reported a census of 134 residents. Observations on 2/3/25 at 9:05 am with Staff A-LPN revealed the following: a. Observation at 9:10 am revealed 15 4-person tables and 1-6 person table with black metal bases, each table base revealed dust accumulation and dried food particles splattered on the bases of each table. b. Observation at 9:20 am revealed at the entrance of the skilled unit across from the nurses station, the base of the North pillar had exposed insulation material with approximately 1/2 of the original wood covering noted to be missing. c. Observation at 9:30 am revealed the bottom of the wall directly next to the janitors closet on 3-B Hall revealed a hole in the wall behind and directly above the rubber baseboard. The hole measured approximately 12 inches long and 6 inches high. Staff B states this is probably the result of a resident driving 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 and resident interviews, observations, and policy review, the facility failed to follow physician's orders for wound treatments for 1 of 4 residents reviewed (Resident #4). The facility reported a census of 134 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #4 had diagnoses which included non-pressure chronic lower leg ulcers, diabetes, renal insufficiency, stroke, and heart failure. According to the Brief Interview for Mental Status (MDS) score, the resident had a score of 15, which indicted the resident had intact cognitive ability. The MDS indicated the resident received daily dressing changes. Review of Resident #4's Care Plan dated 1/20/25, informed staff the resident had impaired skin to both lower extremities with open wounds. The Care Plan directed the staff to monitor and document location, size, and treatment of skin injury. Observation on 2/4/25 at 10:00 am revealed the resident sitting in a recliner as Staff A-LPN…

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 and resident interviews, and observations the facility failed to send a resident's medications for an off campus appointment for 1 of 8 residents reviewed (Resident #2). The facility reported a census of 144 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had diagnoses which include debility, cardiac respiratory condition, heart failure, renal failure, diabetes, and Chronic Obstruction Pulmonary Disease. The resident had a Brief Interview for Mental Status score of 14 which indicated she was alert and oriented. The resident required partial assistance of 1 staff for transfers and ambulation, and substantial assistance for dressing. Review of the Care Plan dated 12/22/2023 informed the staff the resident had diabetes mellitus and to administer the diabetic medications according to the physician's orders. Review of a Physician's Order dated 7/18/24 directed staff to administer Insulin Aspart Solution 4 units subcutaneous three…

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 and resident interviews and observations, the facility failed to provide adequate oxygen services for 1 of 8 residents reviewed (Resident #2). The facility reports a census of 144 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had diagnoses which include debility, cardiac respiratory condition, heart failure, renal failure, diabetes, and Chronic Obstruction Pulmonary Disease. The resident had a Brief Interview for Mental Status score of 14 which indicated she was alert and oriented. The resident required partial assistance of 1 staff for transfers and ambulation, and substantial assistance for dressing. The resident utilized oxygen therapy. Review of the Care Plan dated 12/22/2023 informed the staff the resident utilizes oxygen therapy related to ineffective air exchange. The Care Plan directed the staff to administer oxygen to the resident as ordered. During an interview with Resident #2 on 11/19/24 at 8:30 am, the 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 clinical record review, staff and resident interviews, and observations the facility failed to follow a physician's order for wound treatment for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 143 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #4 had diagnoses which included Non-traumatic brain dysfunction, Parkinson's, dementia, chronic pain, and a history of falls. The resident could ambulate independently in her room with the aide of a wheeled walker. The resident had a Brief Interview for Mental Status score of 11 which indicated moderate cognitive impairment. The MDS indicated the resident had 1 fall since the prior assessment completed on 7/5/24 which resulted in skin tears. Review of the Care Plan dated 8/19/24, the family reported the resident had a fall in her room but had the ability at that time to get herself up from the floor. The Care Plan directed the staff to remind the resident to use the call light to ask 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 clinical record review, staff and resident interviews, and observations the facility failed to answer resident call lights within 15 minutes of activation for 2 of 6 residents reviewed (Residents #4 and #10). The facility reported a census of 143 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #4 had diagnoses which included Non-traumatic brain dysfunction, Parkinson's, dementia, chronic pain, and a history of falls. The resident could ambulate independently in her room with the aide of a wheeled walker. The resident had a Brief Interview for Mental Status score of 11 which indicated moderate cognitive impairment. Review of the Care Plan dated 8/19/24 the family reported the resident had a fall in her room and had the ability at that time to get herself up from the floor. The Care Plan directed the staff to remind the resident to use the call light to ask for assistance. Observation on 10/14/24 at 10:45 am revealed Resident #4 sitting on her bed, the room…

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, document review, and staff interview, the facility failed to maintain a clean, homelike environment. The facility reported a census of 140 residents. Findings include: 1. A Brief Interview for Mental Status (BIMS) score Evaluation Scoring Report provided by the facility on 8/19/24 detailed Resident #61 and Resident #71 with BIMS scores of 15 out of 15 indicating intact cognition. On 8/19/24 at 2:15 PM Resident #61 reported his room just got cleaned today because the State was here. He reported it had been approximately three weeks since his floors has been cleaned in the room. The rooms are just plain dirty. Resident #61's roommate also chimed in and said, everything he is saying is true. Observation at this time reveal a black built up substance splattered across the floor in front of the bedside stand and the bed. The black substance could be scraped up off the floor but did not come up easily. The Surveyor noted a housekeeper had her cart parked in front of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, resident and staff interviews, the facility failed to follow physician orders for 1 of 1 resident's reviewed for catheter care (Resident #71). The facility identified a census of 140 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS documented Resident #71 as dependent upon staff for toileting and utilized an indwelling urinary catheter for diagnosis of neurogenic bladder. The Care Plan dated 7/08/24 detailed the use of a urinary catheter. The Care Plan lacked direction to the staff on changing the urinary catheter per the physician orders. During an interview on 8/20/24 at 7:28 AM Resident #71 reported his catheter had not been changed in at least four weeks. He had brought it to Staff F, License Practical Nurse (LPN) attention, but she no longer worked at the facility. Observation at this time revealed 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 observations, interviews, and record reviews, the facility failed to do weekly measurements and assessments on 1 of 2 residents with pressure ulcers (Resident #37). Resident #37 did not receive the weekly assessments between 7/10/24 when he was seen at a wound clinic to 8/20/24 when an assessment was done at the facility. The facility reported a census of 140 residents. Findings include: Staging of a PU/PI is performed to indicate the characteristics and extent of tissue injury, and should be conducted according to professional standards of practice. Determining whether damage to the skin and underlying tissue is a PI or PU depends on the staging of the damaged tissue. See stages below. NOTE: Regardless of the staging system or wound definitions used by the facility, the facility is responsible for completing the MDS utilizing the staging guidelines found in the RAI Manual. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents were smoking in approved areas for 1 of 1 resident reviewed (Resident #184). Resident #184 was observed smoking on facility grounds. The facility was a smoke free campus. The facility reported a census of 140 residents. Findings include: Resident #184 did not have a current MDS as she readmitted to the facility on [DATE]. A Care Plan initiated on 8/8/24, directed staff that this resident used tobacco. The goal was that Resident #184 would adhere to the tobacco/smoking policies of the facility. A Smoking Evaluation was to be done upon admission and as needed. Resident #184 was to be educated on the facility's tobacco / smoking policy(s). On 8/19/24 at 3:34 p.m., Resident #184 wheeled herself down the hall in her wheelchair carrying a pack of cigarettes. Resident #184 stated she does smoke. She said she could smoke whenever she wanted. Resident #184 stated she had asked staff before and they have said they were too busy…

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, document review, resident and staff interviews, the facility failed to honor resident choice of meal items for 1 of 1 resident sampled (Resident #113). The facility identified a census of 140 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS identified Resident #113 with a significant weight gain and a diagnosis of lupus, anemia, and end stage renal disease. During an interview on 8/20/24 at 8:49 AM Resident #113 reported she has chosen to eat a vegetarian diet and the staff are not supporting her choice of diet. They served her an Italian club sandwich the other day with meat sauce. Other days they served her a hot dog or a hamburger. She related her physician ordered diet is a low sodium diet, but she has made it clear to the staff that she doesn't want to eat meat as she isn't digesting the meat well. On 8/21/24 at 7:45 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility to follow Physician Orders for one of three residents reviewed (Resident #10). The facility reported a census of 139. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 11/16/2023 revealed Resident #10 with no cognitive impairment, relied on staff assistance for transfers from one surface to another and had a history of falls. The resident had diagnoses including closed fractures of the right tibia and left femur, diabetes and congestive heart failure. The Care Plan directed staff to transfer the resident using a Hoyer mechanical lift with two person assistance. The resident admitted to the facility 11/12/2023 from the hospital. The resident's Discharge Instructions included a scheduled follow-up appointment for the resident to see the Orthopedic Physician on Friday, 11/17/2023 at 1:00 p.m. The resident's Progress Notes dated 11/17/2023 failed to reveal staff sent the resident to the scheduled physician visit. On 11/30/2023 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations and staff interviews, the facility failed to adequately provide supervision to keep two of three residents reviewed free from a resident to resident altercation. (Residents #7 and #8). The facility reported a census of 139 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #8 failed to complete the Brief Interview for Mental Status (BIMS) indicating cognitive impairment and ambulated with supervision. The MDS reported the resident had no behaviors during the look back period and had diagnoses including dementia and hypertension. On 11/20/2023 the Care Plan added: observe for the potential that the resident may try to redirect other residents himself and remind him to allow staff to do so. On 11/26/23 the Care Plan documented the resident struck another resident in his room. On 11/29/2023 the Care Plan indicated staff applied a stop sign across resident's door. It also directed staff to redirect other residents away from his room…

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

Based on record review and staff interview the facility failed to have a properly certified nutrition professional and/or director who met the required qualifications in the time frame allowed. The facility reported a census of 138 residents. Findings Include: A document titled Continuing Education from a local college with a transaction date of 10/30/23 documented Staff H, Food Service Director, was enrolled in a Dietary Manager certification program beginning 1/08/2024. During an interview with Staff H on 10/30/23 at 9:49 AM he indicated he did not have a current Dietary Manager certification, had enrolled in the Certified Dietary Manager (CDM) course, and would start his training in January. He stated the Dietician came to the facility one day per week. An interview with the Administrator on 11/2/23 at 8:02 AM confirmed he was aware Staff H did not have a current CDM and was enrolled in the course beginning in January.

Based on observation, facility policy review, and staff interview the facility failed to prepare foods under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 138 residents. Findings Include: 1. The initial kitchen observation on 10/30/23 at 9:24 AM revealed the following: a. The Handwashing sink did not have paper towels, and the sink basin contained a wet wash rag, a wrapper, and a Styrofoam cup. b. The food preparation area lacked filled sanitizer buckets. Food was wiped from surfaces with dry rags. A green food product was noted under breadstick pans placed on the surface after they were cleaned. c. The dishwasher chemical did not read on the test strip. Staff H, Food Service Director, was not able to determine how long the chemical had been missing from the cycle. The temperature gauge read between 148 and 150 degrees. d. Staff I, Cook, wore gloves to fill a water pitcher at the dishwashing sink, lifted a lid and used a utensil to stir food, touched pans of bread, and wiped a food service area without proper hand hygiene. 2. The second…

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, staff interviews and the facility's Quality Assurance Performance Improvement (QAPI) Plan the facility failed to implement a successful QAPI program for six repeated citations. The facility reported a census of 138 residents. Findings Include: 1. Review of the Statements of Deficiencies and Plan of Correction dated 5/6/22, identified the following deficiencies: F550 - Dignity. F698 - Dialysis. F812 - Kitchen Cleanliness F880 - Infection Control. The Plan of Correction reflected the QAPI to monitor for compliance and address addition intervention as indicated. 2. The Statements of Deficiencies and Plan of Correction dated 10/5/22, identified deficiencies as follows: F677 - Activities of Daily Living (ADL). F812 - Kitchen Cleanliness. F880 - Infection Control. The Plan of Correction identified the QAPI team to monitor for compliance. 3. The Statements of Deficiencies and Plan of Correction dated 11/30/22, identified deficiencies as follows: F658 - Professional Standards. F865 - QAPI Program. The Plan of Correction identified the QAPI team to monitor 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 clinical record review, observations, staff interviews, and policy review, the facility failed to provide privacy and dignity with dressing (Resident #55) and failed to ensure privacy of a urinary bag by omitting a dignity cover (Resident #4) for 2 out of 5 residents reviewed for dignity. The facility reported a census of 138 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE] for Resident #55, revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicative of moderate cognitive impairment. The MDS documented the following active diagnoses: medically complex conditions, Alzheimer's Disease, dementia, Diabetes Mellitus with polyneuropathy, bilateral primary Osteoarthritis of the knee, abnormalities of gait and mobility, and unsteadiness on feet. The MDS revealed Resident #55 required limited assistance of one staff for dressing, personal hygiene, toileting, and transferring. The Care Plan, revised on 9/29/23, identified a focus area for Activities of Daily Living…

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, resident, family and staff interviews the facility failed to assist a resident to shave and failed to provide appropriate peri-care for 1 of 4 residents reviewed for activities of daily living (ADLs) (Resident #25). The facility identified a census of 138 residents. Findings Include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive loss. The resident required extensive assistance of two staff for bed mobility, transfer, dressing, toileting and personal hygiene. The MDS documented Resident #25 as frequently incontinence of bowel and bladder. The MDS listed a diagnosis of Non-Alzheimer's Dementia. The ADL Care Plan revised 3/15/23 detailed Resident #25 required assistance for ADL's and mobility. The Care Plan lacked intervention or direction to the staff on shaving Resident #25. The Care Plan directed the staff to provide a check and change before 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 clinical record review, staff and resident interviews, and observations the facility failed to keep 5 of 5 resident showers free of black substance. The facility reported a census of 152 residents. Findings include: Tour of Station 1, Station 2, and Station 3 shower rooms on 8/7/23 at 2:30 pm with Staff P-Assistant Housekeeping Supervisor revealed the following: a. Station 3-A Hall shower floor noted to have a black substance around the perimeter of the shower floor. Staff P stated it was an ongoing problem but does appear to need re-caulked. b. Station 1 shower room located directly across from room [ROOM NUMBER] noted to have black substance around the perimeter of the shower floor. c. Station 1 shower room located directly across from Room B-10 noted to have black substance around the perimeter of the shower floor. d. Station 2 shower room located directly across from room [ROOM NUMBER] noted to have black substance around the perimeter of the shower floor. e. Station 2 shower room located directly…

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 and resident interviews, observations, and facility policy review the facility failed to maintain Individual Narcotic Records which matched documentation in the residents' Medication Administration Records for 4 of 4 residents reviewed (Resident #25, #28, #29, #35). The facility reported a census of 152 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 revealed the resident had a (Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognitive ability. A Discharge summary dated [DATE] revealed the resident had an order for Oxycodone 5 milligrams 1 tablet every 6 hours for pain upon discharge from a local hospital. Noted directly under the Oxycodone order was a hand written verbal order by Staff N-RN directing the staff to discontinue the Oxycodone. Review of Resident #25's facility Physician Orders failed to include an order for Oxycodone 5 milligrams as needed for pain.…

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, staff and resident interviews, and observations the facility failed to complete a shift to shift narcotic count to ensure an accurate narcotic medication count. The facility reported a census of 152. Findings include: Observation on 8/9/23 at 10:15 am revealed Staff R-Agency RN counting medications with Staff N-RN on Station 4. Staff R had an incorrect narcotic count for Resident #36. Staff R-RN picked up a pen and signed out the resident's Hydrocodone tablet that she gave at an earlier time that morning. Staff R stated she didn't have time to sign out the narcotic medication earlier when she gave it so she is signing it off now. Observation of the July 2023 Controlled-Drug Count Records sheets for Station 2 revealed the staff failed to count narcotic medications with the on coming/off going staff 31 times from 7/1-7/22/23. Observations of the July 2023 Controlled Drug-Count Records sheets for Station 3-B Hall revealed the staff failed to count narcotic medications with the on coming/off going staff 24 times from 7/1-7/31/23. Observations of the July…

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, staff and resident interviews, observations, and policy review the facility failed to maintain the kitchen in a clean and sanitary manner. The facility reported a census of 152. Findings include: Observations revealed on 8/16/23 at 11:10 am an August 2023 Cleaning Schedule without any signatures on the form. Staff S-Traveling Dietary Manager admitted things are not getting cleaned as they should, stating we have a lot of work to do in regards to training the staff on cleaning responsibilities. The cleaning schedule assigns the day and evening cooks and dietary aides to tasks they are responsible to clean. During a tour of the main kitchen on 8/16/23 at 11:10 am with Staff S-Travel Dietary Manager revealed a microwave with dried food and dried liquids inside of the microwave and food on the top and sides of the Robo Coupe food processor. During an interview with Staff L-Traveling Administrator on 8/8/23 at 7:30 am, Staff L stated the facility has not had a full time Dietary Manager since mid July. They have utilized Dietary Managers from other 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.