Chapters Living of Council Bluffs

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, staff interviews, family interview, provider interview and policy review the facility failed to notify the resident's representative / family / Power of Attorney (POA) and physician for change in condition when a resident had a head injury and residents had a new or worsening wound for 4 of 4 residents (Residents #2, #15, #29, #30 and #23) reviewed. The facility reported a census of 28 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented Resident #2 was at risk for developing pressure ulcers/injuries and Moisture Associated Skin Damage (MASD) present. The MDS documented admission date for Resident #2 of 11/28/25 Review of Resident #2's (Electronic Health Record) EHR dated 11/28/25 titled, Discharge Summary documented a Braden scale score of 17 with a reposition schedule at least every 2 hours. The Discharge Summary…

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, resident interviews, and staff interviews the facility failed to provide the residents with a comfortable / clean homelike environment by resident rooms found with various debris on the floor and failed to ensure resident's personal property was protected from loss or theft no personal inventory sheet was completed upon entry to the facility for 4 of 12 residents reviewed (Resident #15, #30, #38 and #11). The facility reported a census of 28 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #15 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 1/20/26 at 11:49 AM Resident #15 stated that Staff Y, Certified Nurse Assistant (CNA) was going through her bag of personal belongings with Staff EE, CNA present in the room. Resident #15 stated she told Staff J about the incident. On 1/20/26 at 11:52 AM Resident #15 stated she had 4 pairs of pants that were $25 or $30 apiece and only had 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident council meeting, resident interview, staff interviews, document review and policy review the facility failed to document grievances when residents voiced concerns, educated staff on where grievance forms could be found and when to fill grievance forms out, make prompt efforts to resolve grievances the resident may have and have grievance forms available for staff, residents and resident family members to complete for 2 of 2 residents reviewed (Resident #15 and #29). The facility reported a census of 28 residents.Findings include: On 1/27/26 at 10:25 AM at the Resident Council meeting, the residents present stated they were unaware of what grievances were, where to locate a grievance form, how to file a grievance and if the facility responded to grievances. 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #15 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 1/20/26 at 11:49 AM Resident #15 stated on 1/12/26 she sat in soiled urine and…

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

Based on personnel file review, staff interviews and policy review the facility failed to perform further background checks clearing an employee for hire that was on probation for exploitation. The facility reported a census of 28 residents. Findings include:Review of Staff A's Registered Nurse (RN) employee file revealed the following:Hired date of 9/8/2025;Single Contact License and Background Check completed on 9/4/2025 at 2:36 PM;Background Check showed further research under the criminal history section;QuickConfirm License Verification Report dated 9/4/2025 at 2:53 PM showed her RN license was on probation-RN privilege adverse action by Nebraska;QuickConfirm License Verification Report documented on 10/30/2024 action was taken against Staff's Nebraska nursing license; against privilege to practice-yesQuickConfirm License Verification Report documented Staff A was on probation from 4/18/2025-4/18/2027 in Iowa for error in prescribing, dispensing or administrating medication or sedation, against privilege to practice-noStaff A's employee file did not contain further research…

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 personnel file review, policy review, document review, and staff interviews the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment. The facility also failed to implement their abuse policies when staff reported concerns about a staff member and complete further research when Staff A's background check suggested one be completed. The facility reported a census of 28 residents.Findings include:Review of Staff A's Registered Nurse (RN) employee file revealed the following: a) hired date of [DATE]; b) Single Contact License and Background Check completed on [DATE] at 2:36 PM; c) Background Check showed further research under the criminal history section; d) QuickConfirm License Verification Report dated [DATE] at 2:53 PM showed her RN license was on probation-RN privilege adverse action by Nebraska; e) QuickConfrim License Verification Report documented on [DATE] action was taken against Staff's Nebraska nursing license; against privilege…

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, facility investigative file review, resident and staff interviews, and facility policy review the facility failed to complete a thorough investigation when it was reported Staff A signed out Resident #3's oxycodone but failed to administer the medication. The facility also failed to investigate concerns brought to them from staff members related to Staff A in September and December. The facility reported a census of 28 residents.Findings include: 1.According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of [DATE] documented Resident #3 had a Brief Interview of Mental Status (BIMS) score of 11. A BIMS score of 11 suggested mild cognitive impairment. Resident #3 did not receive a scheduled pain medication regimen; she did receive as needed (PRN) pain medications or was offered and declined. During the pain assessment Resident #3 did have pain at any time in the last 5 days occasionally. Resident #3 indicated the pain rarely the pain made it hard 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, record review, staff and family interviews, and facility policy review. The facility failed to provide oral cares for 5 of 5 residents (Resident #22, #2, #3, #29, and #30) reviewed and also failed to provide toileting and repositioning for Resident #29. The facility reported a census of 28 residents. Findings include:1.According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 10/31/2025 documented Resident #22 had a Brief Mental Status (BIMS) score of 4. A BIMS score of 4 suggested severe cognitive impairment. The MDS documented the resident required substantial/maximal assistance with oral hygiene. Resident #22 had the following diagnoses listed: multiple sclerosis, neurogenic bladder, dementia and depression. The Care Plan Focus Area with a revision date of 11/18/2020 documented Resident #22 had activities of daily living (ADL) self-care performance deficit due to her multiple sclerosis diagnoses and required the assistance of one staff for daily grooming…

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 facility document review, Facility Assessment review and staff interviews the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets by not having a staff on duty at the facility trained in cardiopulmonary resuscitation (CPR) at all times. The facility reported a census of 28 residents.Findings include: On [DATE] at 11:03 AM the DON stated there was nothing available for CPR certification on any staff at the facility. The DON explained there was no list for CPR certified staff and no way Staff O planned 24 hour CPR coverage at the facility. The DON stated Staff O thought as long as a nurse was present that nurse was CPR certified. The DON stated she expected the facility would have a list of CPR certified staff to ensure appropriate coverage. On [DATE] at 11:11 AM Staff P stated the facility did not have any CPR list when she was the interim DON from [DATE] - [DATE]. Staff P stated there was no list for CPR certified staff when she was the interim DON and CPR…

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, interviews and policy review the facility failed to protect residents from possible accidents and injuries for 4 of 12 residents (Residents #7, #41, #2 and #3) reviewed. The facility failed to protect residents when dependently pushed in manual wheelchairs (w/c's) without the use of footrests and using only 1 staff member with the use of dependent non-weight bearing mechanical lifts. Additionally the facility failed to protect the residents from possible scalding injuries with water temperatures above the recommended temperature range for burn prevention. The facility reported a census of 28 residents. Findings include:1. Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive deficit. The resident utilized a manual w/c with partial/moderate assistance. The document disclosed diagnoses including chronic kidney disease, nonrheumatic aortic valve stenosis, unspecified…

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 interview and facility policy review the facility failed to provide drinks to residents, during lunch service. The facility reported a census of 28 residents. Findings include:During dining room observations on 1/21/2026 at 12:05 PM observed six residents sitting at the tables with 4 residents at the assisted tables with two staff and a family member present. There were no drinks on the tables. At 12:17 PM a therapist brought Resident #40 to the dining room table, asked if she wanted a glass of water and the resident accepted it. At 12:21 PM Staff F Dietary Aide (DA) brought a drink cart down the hall from the kitchen to the dining room and began to hand out drinks to residents at the assisted tables. At 12:25 PM Staff F left the dining room with menu tickets. At 12:29 PM Staff F entered the dining room with the food cart, at 12:31 PM delivered 3 trays to residents that did not require assistance with feeding. The residents continued to not have drinks on their table. At 12:37 PM Resident #34 propelled herself from the table to the drink cart and got 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.

Based on facility document review, Facility Assessment review and staff interviews the facility failed to provide enough nursing staff to assure residents safety with transfers, provided appropriate care and resident care completed in a timely manner. The facility reported a census of 28.Findings include: Review of weekend staffing schedules for months of July, August, September, October, November, December and January revealed the following:On 7/6/25 10:00 PM - 6:00 AM 1 nurse and 1 CNAOn 7/13/25 6:00 AM - 2:00 PM 2 CNAOn 8/3/25 6:00 AM - 2:00 PM 2 CNA, 2:00 PM - 10:00 PM 2 CNAOn 9/20/25 2:00 PM - 10:00 PM 1 nurseOn 9/21/25 6:00 AM - 2:00 PM 1 nurseOn 11/18/25 6:00 AM - 2:00 PM 1 nurse, 2:00 PM - 10:00 PM 1 nurse, 10:00 PM - 6:00 AM 1 nurse and 1 CNAOn 1/4/26 6:00 AM - 2:00 PM 1 nurseOn 1/17/26 6:00 AM - 2:00 PM 1 nurse and 2 CNA, 2:00 PM - 10:00 PM 1 nurse and 3 CNA, 10:00 PM - 6:00 AM 1 nurse and 1 CNA.Review of weekday schedules Monday - Friday for months of July, August, September, October, November, December and January revealed the followingOn 7/7/25 2:00 PM - 10:00 PM 1…

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, Facility Assessment review and staff interviews the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets by not providing staff orientation for newly hired staff or agency staff. The facility reported a census of 28 residents.Findings include: On 1/12/26 at 12:00 PM AA, CNA stated she had worked at the facility for about 4 months. Staff AA stated when she started there was not an orientation check list. Staff AA stated the facility just threw her out to the floor. Staff AA stated she did not receive any training when she started. Staff AA stated she had worked as a CNA prior to working at the facility. On 1/8/26 at 5:22 PM Staff BB, CNA stated he had not received any formal training at the facility. Staff BB stated he was given to a young lady for 3 days to follow and another CNA to work with for a couple nights. Stated there was not a checklist or orientation packet when he was hired. Staff BB stated it would have been nice to have a checklist or orientation packet to ensure he knew how 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.

Based on facility document review, facility assessment review and staff interviews the facility failed to ensure a Registered Nurse (RN) was at the facility for 8 consecutive hours. The facility reported a census of 28.Findings include: Review of facility staff schedules for 7/1/25 - 1/19/26 revealed an RN was not present in the building for 8 consecutive hours on 8/23/25, 9/5/25, 9/12/25, 10/11/25, 10/25/25, 11/8/25, 11/18/25 11/22/25, 11/23/25, 12/7/25, 12/20/25, 12/21/25, 12/28/25, 1/9/26 and 1/17/26.On 1/28/26 at 10:50 PM Staff O, Certified Medication Assistant (CMA) / Certified Nurse Assistant (CNA) / Scheduler stated had worked as the scheduler for the facility since September of 2025. Staff O stated when developing a schedule she needs to make sure there is a CNA in every section GP1, GP2 and GP3. Staff O stated nurses on GP1 and GP2. Staff O stated on am shift and pm shifts. Staff O stated on the overnight shift there is only 1 nurse and 2 CNAs. Staff O acknowledged those assignments have not happened every day since she had taken over. Staff O stated there were days that…

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 assessment review, facility document review and staff interviews the facility failed to complete an employee performance review at least once every 12 months. The facility reported a census of 28 residents. Findings include: On 1/21/26 at 7:52 AM Staff R, Certified Nurse Assistant (CNA) stated she had never had a performance evaluation since working at the facility. Staff R explained she had worked at the facility since 12/23.On 1/28/26 at 4:19 PM Staff N, CNA / Interim Social Services Director stated she had gotten evaluations when the previous owners ran the facility. Staff N stated she had not had an evaluation in over a year. On 1/28/26 at 4:28 PM Staff J, Registered Nurse (RN) had worked at the facility for 6 years. Staff J stated he had not had any performance evaluations in the last year. Staff J stated had not had a performance evaluation since 2021. Review of Personnel File for Staff J documented no performance evaluations.Review of document titled, Facility Assessment documented employees are provided with an annual performance appraisal and potential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and facility policy review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services. Areas identified for failure for employment of nutritional management staff with competencies included food preparation, meal delivery not including licensed nurses, nurse aides or paid feeding assistants involved with assisting residents with eating, meal service delivery in a timely manner to maintain food safety and temperature and within 45 minutes or less of resident request and facility's scheduled time for meals. Findings include: During continuous dining room observation on 1/20/2026 at 11:50 AM Resident#9 and #17 stated all the meals are always late. They indicated breakfast was not served until 9:00 AM today. Both residents stated breakfast is the worst because residents can not get their meals until everyone is at the assisted table with staff present. They stated it's not the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility document review, staff interviews, and facility policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs of residents by not following the approved menu for a meal. The facility reported a census of 28 residents.Findings include:Observation on 1/21/26 at 10:34 AM Staff V Cook/Dietary Manager, prepared 3 puree meals. The staff completed the puree process for egg noodles, Chicken [NAME] and vegetables following the menu. Following completion of the modification of the Chicken [NAME] and noodles, the staff added additional [NAME] sauce to the top to prevent drying out of the modification. The 2 plates required for the nursing facility were covered with plastic and placed on the warming shelf. Continuous observation of the meal service on 1/21/26 beginning at 12:02 PM noted the following:Staff V re-warmed the pureed plates from 147 degrees to 167 degrees in the microwave and set on the delivery cart.Staff V prepared 3 mechanical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews and policy review the facility failed to provide food at an appetizing temperature to 6 of 20 residents reviewed (Resident #17, #42, #36, #44, #3 and #15). The facility reported a census of 28 residents.Findings include:1. Resident #17's MDS dated [DATE] revealed a BIMS score of 12/15 indicating moderate cognitive impairment. The document disclosed the resident was independent with eating. On 1/20/26 at 10:45 AM the resident stated the food was not hot when it was supposed to be hot. The resident stated she did tell undisclosed staff that the food was not hot and was told to be grateful she got food. The resident stated she ate in the dining room. 2. Resident #42's MDS dated [DATE] revealed a BIMS score 12/15 indicating moderate cognitive deficit. The document disclosed the resident was independent with eating. On 1/20/26 at 12:49 PM Resident #42 stated she ate in her room and had room trays. The resident stated her food had been cold when her trays…

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 policy review the facility failed to prepare, serve and distribute food in accordance with food service safety for 3 of 8 residents (Resident #3, #9, #15) reviewed, as well as general practices for mealtime service. The facility reported a census of 28 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. On 1/22/26 at 9:26 AM an observation of Resident #3's breakfast tray delivered to the room. On 1/22/26 at 9:26 AM Resident #3 acknowledged her food was just dropped off. Resident #3 stated 9:30 AM does feel a little late for breakfast but the breakfast meal has come much later. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 1/20/26 at 11:29 AM Resident #9 stated you never know when the meal will be served. Resident #9 stated she…

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 and staff interviews the facility failed to properly dispose of room trays with left-over food and beverages in a timely manner. The facility further failed to dispose of garbage and waste properly. The facility reported a census of 28 residents. Findings include:On 1/21/2026 at 7:00 AM outside room GP10 observed a cart with room trays, plates, and cups on it. Breakfast had not been served prior to this. The Minimum Data Set (MDS) Coordinator/Infection Preventionist observed the surveyor in front the cart and removed it from the hall at 7:05 AM. At 9:06 AM in a cubie across from the Clinical Office observed three meal trays that contained what looked like an uncovered bowl of vegetable soup, cup of brown liquid, uncovered ice cream cups, two plates with sloppy joe sandwiches on them (from 1/20/2026 lunch meal), carrots, green beans, opened fruit cup and silverware. At 9:45 AM the food trays remained in the cubie across from the clinical office. At 10:30 AM the trays had been moved to a cart and placed in front of the nurse's station (main) by the Long-Term 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 clinical record review, staff interview, policy review and facility document review the facility failed to provide complete and accurate records when inventory lists were not completed, failed to accurately document administration of medication, documented treatments completed before doing them, failed to lock or close a laptop leaving confidential health information accessible, and documented refrigerator temperatures falsely for 7 of 12 resident reviewed (Resident #3, #15, #11, #44, #21, #3 and #11). The facility reported a census of 28 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. The MDS revealed Resident #3 had diagnoses of pressure ulcer of sacral region stage 4, pressure ulcer of right buttocks stage 4 and pressure ulcer of left buttocks stage 4. Review of Resident #3's Medication Administration Record (MAR) documented a physician's order with a start date…

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, facility policy review, and staff interviews the facility failed to ensure staff utilized consistent infection controls techniques as evidenced by a failure to complete hand hygiene during resident cares, remove personal protective equipment prior to exiting a residents room, sanitize shared resident equipment after use, and ensure catheter tubing, and oxygen tube secured in a position to not fall on the floor for 6 of 12 residents (Resident's #2, #22, #23, #11, #3 and #17) in the sample, and failed to review the infection control policy at least annually. The facility reported a census of 28 residents.Findings include:1. Review of the Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated intact cognition. Review of Resident #2 Physician orders revealed the following orders: a. Cleanse, dry, paint with betadine and cover with Mepilex Foam dressing to right heel. One time a day for DTI (deep tissue injury).…

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, and staff interviews the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), Form CMS-10055 for 3/3 residents reviewed (Resident #50, #51, #52). The facility reported a census of 28. Findings include: 1. Resident #50 signed a Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123-NOMNC approved 12/31/11, on 10/17/25 indicating coverage of his skilled nursing services would end on 10/21/25. The facility failed to provide the SNF ABN, CMS Form-10055, for the resident to complete. The facility failed to utilize a current Center for Medicare Services (CMS) NOMNC Form CMS-10124-DENC expiration 11/30/27.2. Resident #51 signed a NOMNC, Form CMS 10123-NOMNC approved 12/31/11, on 10/17/25 indicating coverage of his skilled nursing services would end on 10/19/25. The facility failed to provide the SNF ABN, CMS Form-10055, for the resident to complete. The facility failed to utilize a current Center for Medicare Services (CMS) NOMNC Form CMS-10124-DENC expiration 11/30/27.3. Resident #52 signed a NOMNC, Form CMS…

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 facility policy review the facility failed to ensure 3 of 5 residents (Resident #3, 11, and 32) reviewed were free from exploitation. The facility reported a census of 28 residents. Findings include:1.According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 11/7/2025 documented Resident #3 had a Brief Interview of Mental Status (BIMS) score of 11. A BIMS score of 11 suggested mild cognitive impairment. Resident #3 did not receive a scheduled pain medication regimen; she did receive as needed (PRN) pain medications or was offered and declined. During the pain assessment Resident #3 did have pain at any time in the last 5 days occasionally. Resident #3 indicated the pain rarely the pain made it hard for her to sleep nor did it limit her day-to-day activities. The MDS documented Resident #3 rated her pain at a 4 out of 10 (zero being no pain and ten as the worst pain you can imagine). The MDS documented Resident #3…

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, document review, staff interview, and policy review the facility failed to obtain bed hold notifications for 2 of 3 residents (Resident #5 and #29) reviewed. The facility reported a census of 28 residents.Findings include: 1.According to the discharge-return anticipated Minimum Data Set (MDS) assessment tool with a reference date of 8/13/2025 documented Resident #5 was discharged to a short-term general hospital on 8/13/2025. Record review revealed the following progress note:a) On 8/13/2025 at 12:45 PM shortly after he was assisted to recliner for therapy, resident experienced hypotension, increased weakness, dizziness, nausea and requested to go back to hospital,b) On 8/13/2025 at 4:54 PM resident was admitted to the hospital due to declining renal function. Record review revealed it lacked a bed hold form completed by Resident #5 and/or his representative. On 1/23/2025 at 10:39 AM via email communication the Administrator acknowledged facility was unable to locate 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 and staff interviews the facility failed to accurately code the type of assessment for 1 of 2 discharge Minimum Data Set (MDS) assessments (a federally mandated, standardized, comprehensive clinical assessment tool used in nursing homes to evaluate functional, medical, and psychological status, it identifies resident problems, strengths, and preferences to guide care planning and determine reimbursement) (Resident #5). The facility also failed to accurately code medications taken when reviewing unnecessary medications for 2 of 3 residents (Resident #5 and #23). The facility reported a census of 28 residents.Findings include: 1. The MDS Entry assessment dated [DATE] for Resident #5 documented this was not the first assessment since his most recent reentry to the facility. The MDS admission assessment dated [DATE] for Resident #5 documented this was the first assessment since his most recent reentry to the facility. The MDS Discharge assessment dated [DATE] for Resident #5…

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, interviews, and policy review the facility failed to develop and implement a Baseline Care Plan for 2 of 10 residents (Residents #17, #42) reviewed. The facility failed to develop and involve the resident and/or resident representative in the development of the Baseline Care Plan within 48 hours of admission. The facility reported a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #17 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderate cognitive impairment. The document disclosed diagnoses of atrial fibrillation (A-fib), heart failure, Non-Alzheimer's Dementia and Chronic Obstructive Pulmonary Disease (COPD). The resident utilized oxygen while a resident. The Care Plan dated 1/20/26 revealed a focus area related to oxygen therapy revised 1/20/26 with staff interventions of providing medications as ordered, oxygen as ordered by the physician, and monitor/document/report signs and symptoms 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 observations, record review, interviews and policy review the facility failed to provide resident centered activities that incorporated the resident's interests, hobbies to maintain and/or improve a resident's physical, mental and psychosocial well-being and independence for 1/10 residents (Resident #21) reviewed. The facility failed to create opportunities for the resident to have a meaningful life by supporting her domain of wellness (autonomy, connectedness, joy and meaning). The facility reported a census of 28.Findings include:Resident #21's MDS dated [DATE] Significant Change export ready revealed a BIMS score of 8/15 indicating moderate cognitive impairment. The document disclosed the resident did not have a catheter, was incontinent of bowel and bladder, and dependent for bed mobility and transfers. The document indicated the resident's diagnoses included heart failure, atrial fibrillation (A-fib) and impaired brain function. The MDS revealed the resident had (1) Stage 2 pressure ulcer, partial…

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, provider interview, resident and family interview, staff interviews, and policy review the facility failed to appropriately assess a resident with a head injury and appropriately complete assessments / provide interventions for a diabetic ulcer for 2 of 8 residents (Resident #15, and #30). The facility reported a census of 28 residents.Findings include:1.The MDS dated [DATE] documented Resident #15 had a BIMS of 15 indicating no cognitive impairment. On 1/20/26 at 11:49 AM Resident #15 stated she told Staff P RN / Assistant Director of Nursing (ADON) about the sore on her foot and she did nothing about it. Resident #15 stated Staff J, RN was the nurse that finally did something about it. Review of Resident #15's (Treatment Administration Record) TAR documented a physician's order with a start date of 1/15/26 to cleanse 2nd toe on left foot with wound cleanser, pat dry, apply Triple Antibiotic Ointment (TAO) and cover with band aid daily.Review of Resident #15's (Electronic Health…

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 interviews, and observation the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by pushing enteral flushes with a piston syringe into the enteral tube for 1 of 1 residents (Resident #44). The facility reported a census of 28 residents. Findings include: Review of Resident #44's Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was admitted to the facility from another nursing home on 1/15/2026. The MDS then revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS further revealed Resident #44 utilized a feeding tube while at the facility.Review of Resident #44's Electronic Health Record (EHR) page titled, Clinical Physician's Orders revealed an order to flush Resident #44's tube with 25 milliliters of water twice a day starting 1/15/2026. Observation on 1/21/2026 at 10:45 AM Staff A Registered Nurse (RN) completed hand hygiene, donned gown, gloves, and goggles. Staff A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, electronic medical record (EMR) reviews, resident and staff interviews, and policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 1 residents (Resident #17) reviewed, requiring the use of oxygen. The facility reported a census of 28 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #17 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderate cognitive impairment. The document disclosed diagnoses of atrial fibrillation (A-fib), heart failure, Non-Alzheimer's Dementia and Chronic Obstructive Pulmonary Disease (COPD). The resident utilized oxygen while a resident. The Care Plan dated 1/20/26 revealed a focus area related to oxygen therapy revised 1/20/26 with staff interventions of providing medications as ordered, oxygen as ordered by the physician, and monitor/document/report signs and symptoms of respiratory distress dated 1/20/26. Resident #17's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and policy review the facility failed to prepare and serve food in a form designed to meet individual needs and according to their assessments and Care Plans for 3 of 5 residents (Residents #3, #13, #23) reviewed. The facility failed to prepare and serve 3 meals according to the residents' prescribed diet orders. The facility reported a census of 28 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment. The document disclosed the resident received a mechanically altered diet during the last 7 days of the assessment period. The resident's Care Plan dated 8/21/25 revealed a focus area of nutritional problems or potential nutritional problems related to needing a mechanical soft diet with increased protein revised 5/19/25. Interventions for staff included downgrading to mechanical soft due to a resident request related…

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 reviews, family and staff interviews and policy review the facility failed to provide therapeutic diets as prescribed by the primary care provider for 3 of 6 residents (Resident #23, #33, #42,) reviewed. The facility failed to follow physician orders for consistent carbohydrate (CCHO) and renal diets. The facility reported a census of 28.Findings include: Findings include:1. Resident #23's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment. The document disclosed resident diagnoses including diabetes mellitus, high cholesterol, and Alzheimer's. The document included the resident consumed a therapeutic diet during the last 7 days of the assessment period. The resident's Care Plan dated 1/8/26 included a focus area related to a nutritional problem or potential nutritional problem related to diabetes mellitus and dementia revised 2/28/25. Interventions for staff included explaining 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 record reviews, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards by not following physician orders for 3 of 3 residents (Resident #1, #2, #4, #3). The facility reported a census of 19 residents.Findings include: 1. The Minimum Data Set (MDS) for Resident #1 dated 11/3/25 provided a Brief Interview for Mental Status (BIMS) score of 6/15 indicating severe cognitive impairment. The document revealed the resident had diagnoses of atrial fibrillation (A-fib), heart failure, hypertension (HTN), urinary tract infection (UTI) - last 30 days and respiratory failure. The document disclosed Resident #1 had an indwelling catheter and took anticoagulant, diuretic, opioid, hypoglycemic and anticonvulsant medications. Resident #1's Medication Administration Record (MAR) 11/25 revealed the following entries: 11/1/25 No data for Olmesartan Medoxomil Tablet 20 mg; 1 tablet in the morning for HTN order date 10/31 and discharge (D/C) date…

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 interview, and policy review the facility failed to provide a professional standard of quality of care by not completing catheter cares for 3 of 3 residents reviewed (Resident #1, #2, #3). The facility reported a census of 19 residents. Findings include:1. The Minimum Data Set (MDS) for Resident #1 dated 11/3/25 provided a Brief Interview for Mental Status (BIMS) score of 6/15 indicating severe cognitive impairment. The document revealed the resident had diagnoses of atrial fibrillation (A-fib), heart failure, hypertension (HTN), urinary tract infection (UTI) - last 30 days and respiratory failure. The document disclosed Resident #1 had an indwelling catheter and took anticoagulant, diuretic, opioid, hypoglycemic and anticonvulsant medications. Resident #1's Care Plan revised 11/4/25 provided a focus area of indwelling catheter revised on 11/4/25 with interventions of Enhanced Barrier Precautions initiated on 10/25/25 and monitor/record/report signs/symptoms…

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, Electronic Health Record (EHR) reviews, staff interviews, and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during resident cares for 2 of 3 residents (Resident #2, #3). The facility failed to utilize Enhanced Barrier Precautions (EBP) and complete hand hygiene. The facility reported a census of 19. Findings include:1. The MDS for Resident #2 dated 10/31/25 provided a BIMS score of 4/15 indicating severe cognitive impairment. The document revealed the resident had diagnoses of coronary artery disease (CAD), HTN, neurogenic bladder, Non-Alzheimer's Dementia and depression. The document disclosed Resident #2 had an indwelling catheter and took antidepressant and anticonvulsant medications.The Care Plan updated 10/9/25 revealed a focus area for suprapubic catheter due to neurogenic bladder initiated on 1/12/23 and revised on 10/9/25 with UTI on 10/7 with antibiotics as ordered. Interventions included catheter care every shift initiated 11/2/20, monitor/record/report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interview, and facility policy review the facility failed to provide the appropriate interventions to prevent falls for 2 or 3 residents (Resident #1, #9, and #10). The facility also failed to complete neurological assessments after 2 of 4 residents (Resident #4 and #10) after they experienced an unwitnessed fall. The facility reported a census of 26 residents. Findings include: 1. According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 12/22/2024 Resident #1 had a Brief Interview of Mental Status (BIMS) score of 2. A BIMS score of 2 suggested severe cognitive impairment. Resident #1 utilized a walker and wheelchair for mobility. He required partial/moderate assistance for sitting to lying, lying to sitting, sitting to standing, chair/bed to chair transfer, and toilet transfer. The MDS documented he had a fall in the last month prior to admission/entry, in the last 2-6 months prior to admission/entry, and has had a fall…

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 review of the facility's assessment and staff interview the facility failed to update the Facility Assessment. The facility reported a census of 26 residents. Findings include: On 6/5/2025 at 12:48 PM the Administrator provided the Facility Assessment. The document was dated 7/2023 through 6/2024 with the previous facility name attached to it. On 6/10/2025 at 2:08 PM the CEO currently working as the Administrator stated the Executive Director or Administrator usually updates the Facility Assessment. He indicated they could not find and updated assessment and they have not updated once since they took over in February. On 6/10/2025 at 3:25 PM the Skilled Unit Manager/Assistant Director of Nursing (ADON) indicated she was unable to get in to the program the previous owners used to obtain policies. She went through the binders they have and could not find a policy the facility would follow in regards to the Facility Assistant. On 6/10/2025 at 3:58 PM corporate staff were asked to provide policies they would be implementing at the facility since taking over the facility. A list…

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 reviews, staff interviews, and policy review the facility failed to employ a qualified person to serve as the Infection Preventionist (IP) for the facility. The facility reported a census of 26 residents. Findings include: The facility provided a document from their previous owners, titled Infection Preventionist that documented the facility will employ one or more individuals with responsibility for implementing the facility's infection prevention and control program. The facility will designate a qualified individual as Infection Preventionist (IP) whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control program and antibiotic stewardship program. The facility will ensure the IP works at least part-time at the facility, is adequately qualified and completed a specialized training in infection prevention and control through accredited continuing education. On 6/5/2025 at 11:50 PM the Minimum Data Set (MDS) Coordinator stated she is the facility's IP. When asked if she is certified she stated she is going…

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, family and staff interviews, the facility failed to maintain a clean environment for residents. The facility reported a census of 26 residents. Findings include: Observations on 6/3/2025 at 10:30 AM the area between the set of exit doors by room [ROOM NUMBER], revealed multiple dead June bugs on the floor. Continued observations on 6/4/2025, 6/5/2025, and 6/10/2025 revealed the area to still have multiple dead June bugs on the floor. On 6/4/2025 at 10:15 AM a family member of Resident #4, stated housekeeping has not been in her room since she has been admitted . One family member stated she has been picking up the debris on the floor in her mother's room and bathroom. On 6/4/25 at 10:45 AM the Director of Nursing was made aware of Resident #4's concern about the lack of cleaning to her room. On 6/5/2025 during a follow-up interview with Resident #4 and her family, they were informed the DON was made aware of their housekeeping concerns. The family indicated housekeeping still had not been…

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, facility investigative file review, staff and family interviews the facility failed to report to the State Agency, when Resident #3 reported staff were rude to her and threw her call light out of reach. The investigation included three resident reviews. The facility reported a census of 26 residents. Findings include: According to an admission Minimum Data Set (MDS) reference tool with an assessment date of 3/14/2025 Resident #3 had a Brief Interview of Mental Status score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented Resident #3 required substantial/maximal assistance of staff for toileting hygiene and was dependent on staff for transfers to the toilet. The MDS indicated she was occasionally incontinent of urine and frequently incontinent of bowel. The following diagnoses were listed for Resident #3: stroke, atrial fibrillation, coronary artery disease, heart failure, thyroid disorder, and sleep apnea. The Care Plan focus area with an initiation date of 3/10/2025 documented Resident #3 needed assistance with Activities 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 record review, facility investigative file review, staff and family interviews the facility failed to thoroughly investigate when Resident #3 reported staff was rude to her and removed her call light out of reach. The facility also failed to complete a thorough investigation when Resident #4 reported staff were mean to her. Three residents were reviewed related to this investigation. The facility reported a census of 26 residents. Findings include: 1. According to an admission Minimum Data Set (MDS) reference tool with an assessment date of 3/14/2025 Resident #3 had a Brief Interview of Mental Status score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented Resident #3 required substantial/maximal assistance of staff for toileting hygiene and was dependent on staff for transfers to the toilet. The MDS indicated she was occasionally incontinent of urine and frequently incontinent of bowel. The following diagnoses were listed for Resident #3: stroke, atrial fibrillation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interview the facility failed to complete a comprehensive Care Plan for 2 of 7 residents (Residents #5 and #9) after their admission. The facility reported a census of 26 residents. Findings include 1. According the 5-day Minimum Data Set (MDS) assessment tool with a reference date of 4/15/2025 documented Resident #5 had a BIMS score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented she was admitted to the facility on [DATE]. The MDS documented she was at risk for developing pressure ulcers/pressure injuries and had 3 unhealed stage 4 pressure ulcers, present upon admission. The following treatments were listed for Resident #5: pressure reducing device for chair and bed, and pressure ulcer/injury care. The MDS listed the following diagnoses for Resident #5: pressure ulcer of sacral region stage 4, anemia, renal failure, stroke, sepsis, atrial fibrillation, pressure ulcer of right and left buttock stage 4, adult failure to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interview the facility failed to update 3 of 3 resident's Care Plans (Resident #1, #9 and #10) after they experienced a fall. The facility also failed to update 1 of 3 resident's (Resident #9) Care Plan when he developed a new pressure ulcer. The facility reported a census of 26 residents. Findings include: 1. According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 12/22/2024 Resident #1 had a Brief Interview of Mental Status (BIMS) score of 2. A BIMS score of 2 suggested severe cognitive impairment. Resident #1 utilized a walker and wheelchair for mobility. He required partial/moderate assistance for sitting to lying, lying to sitting, sitting to standing, chair/bed to chair transfer, and toilet transfer. The MDS documented he had a fall in the last month prior to admission/entry, in the last 2-6 months prior to admission/entry, and had a fall since admission/entry with no injuries. The Care Plan focus area with 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.

Based on record review, resident and staff interviews the facility failed to ensure 2 of 3 resident's (Resident #2 and #5) treatment orders were signed out as being completed. The facility reported a census of 26 residents. Findings include: 1. According to the Significant Change Minimum Data Set (MDS) assessment tool with a reference date of 2/25/2025 Resident #2 had a Brief Interview of Mental Status (BIMS) score of 8. A BIMS score of 8 suggested no mild cognitive impairment. The MDS documented he was at risk for developing pressure ulcers/pressure injuries and had one unhealed stage 1 pressure ulcer/pressure injury. The MDS documented the following treatments: pressure reducing device for his chair and bed, and applications of ointments/medications other than to his feet. The MDS listed the following diagnoses for Resident #5: stroke, renal insufficiency, depression and obesity. The Care Plan focus area with an initiation date of 2/11/2025 documented Resident #2 had a pressure injury to his right and left lateral malleolus related to immobility. The care plan directed staff to…

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

Based on resident council notes, facility assessment review, resident and staff interview the facility failed to provide sufficient staff for safe transfers and assisting residents timely when needed. The facility reported a census of 26 residents. Findings include: Review of April 2025 Resident Council Notes revealed a resident indicated it would be nice if they could have more Certified Nursing Assistants (CNAs) on the overnight shift. Review of the facility assessment dated 7/2023 through 6/2024 documented 1 Licensed Practical Nurse (LPN)/Registered Nurse (RN) to 15 residents ratio on the day shift, 1 LPN to 30 residents on the overnight shift, 1 Certified Nursing Assistant (CNA) to 10 residents ratio on the day and evening shifts, and 1 CNA to 15 residents ration on the overnight shift. If the census is 30 or above, 1 Certified Medication Aide (CMA) works day shift, 8 hours. On 6/4/2025 at 10:00 AM Resident #7 stated staffing can be iffy at times. She reported she has had to weight for 40 minutes for help. She has been fighting a Urinary Tract Infection (UTI) and can't hold her…

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 view, resident and staff interviews the facility failed to ensure 3 of 10 resident's (Resident #7, #8, and #10) records were complete and accurate. The facility reported a census of 26 residents. Findings include: 1. According to the 5-day Minimum Data Set (MDS) assessment tool with a reference date of 5/16/2025, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 10. A BIMS score of 10 suggested no cognitive impairment. The MDS documented she was dependent on staff to shower or bathe self. The following diagnoses were listed for Resident #7: urinary tract infection (UTI), hypertension, anxiety, depression, and obesity. The Care Plan focus area with an initiation date of 5/12/2025 documented Resident #7 required assistance with Activities of Daily Living (ADLs). The care plan documented she required the assistance of one staff for bathing and tub/shower transfers. Record review of Resident #7's bathing record, revealed only two showers were documented as being completed in the last 30 days. A shower was documented as being given on 5/24/2025 and…

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

Based on observation, interview and policy review, the facility failed to ensure that proper infection control measured were used during food service. While preparing the lunch meal Staff F applied disposable gloves, then touched several surfaces before touching food. The facility reported a census of 22 residents. Findings include: On 1/7/24 at 11:15 AM Staff F, Culinary Supervisor (CS), prepared some grilled cheese sandwiches. He donned disposable gloves, grabbed the bag of bread, touched the counter, then reached into the bag and grabbed a piece of bread. He held the bread with the same gloved hand, buttered it with the other and placed it on the grill. He repeated the process two more times to make 3 sandwiches. Staff F then used the same gloved hand, reached into a container of sliced cheese, grabbed 6 slices of cheese, placed two slices on each piece of bread. He then buttered three more pieces of bread with the same gloved hands put the bread on top. On 1/08/25 at 6:27 AM, The Dietary Manager (DM) said that staff were taught not to use gloves unless they absolutely needed…

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 personnel file review, staff interview, and policy review the facility failed to ensure that all staff completed the required Dependent Adult Mandatory Reporter Training for 1 of 5 staff reviewed. The facility reported a census of 22 residents. Findings include: A review of the personal file for Staff E, Certified Nurse Aide (CNA), reveled that as of [DATE], Staff E last completed the Dependent Adult Mandatory Reporter (DAMR) training, on [DATE]. The certificate indicated that after 3 years, the training should have been renewed. The file included a certification for DAMR training dated [DATE]. On [DATE] at 3:22 PM The Administrator acknowledged that when the personal file was requested by the survey team on [DATE], they discovered that Staff E had an expired DAMR training certificate. Staff E then completed the training. Going forward, they plan to have the business office establish a spreadsheet to monitor trainings so they can notify staff when an expiration date would be coming up. According to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health record review (EHR), resident interviews, staff interviews and policy review the facility failed to provide dignity and respect during personal cares to 2 of 22 residents reviewed (Resident #8 and #175). The facility reported a census of 22 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. On 1/8/25 at 9:30 AM Staff G Certified Nurse Assistant (CNA) stated residents at the facility had told her about negative statements and care that Staff H had given. Staff G stated Resident #8 told her a couple days ago she was having a hard time standing up off the toilet. Staff G stated Resident #8 told her Staff H said she could not sit here and babysit you guys. Staff G stated Resident #8 was talking about the incident in the dining room. Staff G stated another resident that sat at the dining room table stated they could hear Staff H telling her that in…

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) review, and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing the use of insulin for 1 of 10 residents reviewed (Resident #15). The facility reported a census of 22 residents. Finding include: The MDS dated [DATE] for Resident #15 documented a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. Review of Resident #15's Medication Administration Record (MAR) revealed a physician's order for Trulicity Subcutaneous Solution (glucagon like peptide) to inject 0.5mL subcutaneous in the morning every Monday. The MAR did not include an order for insulin. Review of Resident #15's MDS dated [DATE] documented insulin injections were given once in the last 7 days. Resident #15's MDS also documented orders for insulin were changed by the physician once during the last 7 days or since admission/entry or reentry…

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 interviews and policy review the facility failed to follow professional standards of quality for 2 of 4 residents reviewed. Resident #172 had a low blood glucose reading, staff failed to document the reading and failed to follow up with a second check. Resident #9 had low blood pressure readings and staff failed to establish parameters to determine when to hold his hypertension medication. The facility reported a census of 22 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #172 had a Brief Interview for Mental Status score of 14 (intact cognitive ability). She was totally dependent on staff for toileting hygiene, showers, and partial assistance with sit to stand and transfers. She was on pain medications, the MDS showed that she was not assessed for frequency or intensity. A Baseline Care Plan Summary, dated 12/3/24, showed that Resident #172 was admitted for skilled care after a hospitalization for extradural and subdural…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with facility staff and healthcare services, policy and record review the facility failed to ensure that follow up services and appointments were established before discharge for 1 of 3 residents reviewed. Resident #173 was discharged to a hotel without securing home health services or follow up appointments with the doctor. The facility reported a census of 22 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #173 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required partial assistance with showers or bath, supervision or touch assistance with toileting hygiene, dressing and applying footwear and transfers. The diagnosis for Resident #173 included orthostatic hypotension, type 2 diabetes mellitus and chronic kidney disease. The admission Note dated 12/3/24 at 12:32 PM, showed that Resident #173 was admitted to the facility for Physical Therapy and Occupational Therapy (PT/OT), and orthostatic hypotension…

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 interviews, clinical record review and policy review the facility failed to assess pain and failed to complete vitals and complete a comprehensive assessment prior to transfer out for 1 of 4 residents reviewed. Resident #171 experienced severe pain related to a fracture and staff failed to assess pain levels, administer pain medication and notify the physician per the plan of care. The facility reported a census of 22 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #171 documented a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented the resident received scheduled and PRN (as needed) pain medications and experienced pain frequently. The MDS documented the resident limited participation in therapy and day to day activities frequently. She rated her pain at an 8 on a scale of 0-10 with 10 being the worse. The MDS listed diagnosis of lumbar vertebrae fractures and other multiple trauma, and arthritis. The 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 clinical record review, observations, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when providing personal care and providing catheter care to a resident that was on Enhanced Barrier Precautions (EBP) for 2 of 3 residents reviewed (Resident #2 and #180). The facility reported a census of 22 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #2 documented a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The MDS documented the utilization of an indwelling catheter. Review of Resident #2's Medication Administration Record revealed a physician's order to change 16 FR 10cc monthly and change drainage bag at bedtime every 30 days for infection control. Review of Resident #2's MDS dated [DATE] documented utilization of indwelling catheter. On 1/7/25 at 10:09 AM Staff K, Certified Nurse Assistant (CNA) entered Resident #2's room applied gown, rolled sleeves up on gown,…

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 appropriately implement interventions to protect 1 out of 2 female residents from possible sexual abuse. The facility further failed to appropriately implement interventions to protect 1 out of 1 male residents from possible physical abuse by Resident #182. The facility reported a census of 25 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #182 documented diagnoses of Alzheimer's Disease, asthma, and renal insufficiency. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of Progress Notes revealed the following: a. 4/22/23 at 4:21 a.m., staff to visually observe resident that not attempting to touch, inappropriately touch other resident's every 4 hours, sleeping. b. 4/23/23 at 3:18 p.m., patient keeps looking for an exit. When staff assist with keeping patient in facility patient becomes combative and physically abusive.…

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 complete a thorough investigation for possible abuse by not interviewing all the witnesses for 2 of 3 incidents reviewed against 2 residents (Resident #183 and #184). The facility reported a census of 25 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #183 had a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. The MDS documented diagnoses of Non-Alzheimer's Dementia, seizure disorder, anxiety disorder, and pulmonary hypertension. Review of the facility provided investigation dated 4/29/23 revealed Resident #182 wheeled down a residential hallway in the facility and placed his hands on Resident #183's chest. This investigation further revealed there were no statements from any witnesses for the incident dated 4/29/23. Review of the clinical record lacked documentation of the incident dated 4/29/23. 2. The MDS dated [DATE] revealed Resident #184 had 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 document review, policy review, and staff interview the facility failed to provide treatment or services to a resident that had decreased range of motion to prevent further decrease in range of motion for 1 of 12 residents reviewed (Resident #22). The facility reported a census of 25 residents. Findings include: The MDS dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. The MDS documented a diagnosis of non-traumatic intracerebral hemorrhage in the hemisphere, subcortical. On 1/7/24 at 3:33 PM Resident #22 stated he only had only one treatment with any sort of therapy. Resident #22 stated no other treatments had been completed. Resident #22 stated he would like to have more therapy. Resident #22 stated he did not know who to tell he wanted more. Review of Resident #22's electronic health record (EHR) revealed no documentation of restorative programs in Progress Notes or in the task portion. On 1/9/24 at 4:21 PM Staff A…

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