Prestige Care Center of Fairfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interviews, the facility failed to ensure staff treated residents with dignity by not providing a meal in a timely manner for 1 of 5 residents reviewed for dignity (Resident #41) and failed to ensure the provision of a catheter dignity bag for 1 of 3 residents reviewed for catheters (Resident #42). The facility reported a census of 59 residents. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 3/16/25, listed the following diagnoses for Resident #41: anxiety, depression, and morbid obesity. A Brief Interview for Mental Status (BIMS) score as 13 out of 15, indicated intact cognition. Review of the Care Plan, dated 4/1/25, revealed a Focus area to address [name redacted] has a behavior problem false allegations regarding staff. Interventions included, in part: Caregivers to opportunities for positive interactions and attention and to stop and talk with the resident. During an interview, on 6/3/25 at 12:58 PM, Resident #41 stated Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to ensure self medication administration assessments were completed. for 2 of 2 residents reviewed for self medication safety (Resident #23 and Resident #7). The facility reported a census of 59 residents. Findings: 1. Review of the Minimum Data Set (MDS) assessment tool, dated 5/9/25, list of diagnoses for Resident #23 included heart failure, diabetes (a disorder which caused abnormalities in blood sugar), and anxiety disorder. The Brief Interview for Mental Status (BIMS) score as 13 out of 15, indicated intact cognition. Review of the Care Plan, dated 12/27/23, revealed a Focus area to address [Name redacted] is non-compliant with medication administration . Review of the June 2025 Medication Administration Record (MAR) listed metformin (a medication used to treat diabetes) 500 milligrams (mg) 2 tabs twice daily scheduled at 8:00 AM. and 8:00 PM. During an observation on 6/3/25 at 10:51 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 observation, staff interview, and clinical record review the facility failed to ensure consistent communication and clarification of resident code status, either to perform cardiopulmonary resuscitation (CPR) or Do Not Resuscitate (DNR), for 1 of 1 residents reviewed for code status (Resident #44). The facility reported a census of 59 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #44 dated [DATE], revealed the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. On [DATE] review of Resident #44's Care Plan revealed the following: I have requested that CPR (cardiopulmonary resuscitation)measures ARE to be performed (FULL CODE STATUS). The Intervention dated [DATE] revealed, Initiate CPR if you find me pulseless or breathless and continue CPR until Paramedics arrive to take over. Review of the resident's Iowa Physician Orders for Scope of Treatment (IPOST) form dated [DATE] revealed DNR…

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, clinical record review, and facility policy review the facility failed to provide privacy during an enteral tube feeding for 1 of 1 residents (Resident #53) reviewed for privacy. The facility reported a census of 59 residents. Findings include: Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severe cognitive impairment. Per the MDS. Resident #53 dependent on staff for eating and required a gastrostomy tube (tube going through abdomen into stomach to provide nutrition and hydration, commonly called a G-tube, feeding through a G tube is referred to as an enteral feeding). The MDS list of diagnoses included hemiplegia or hemiparesis (paralysis or weakness on one side of the body), traumatic brain injury, and dysphagia (difficulty swallowing). Review of the Care Plan, dated 3/19/25, revealed a Focus area to address [name redacted] requires tube feeding r/t (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 observation, interview, and clinical record review, the facility failed to ensure targeted behaviors were identified for the use of antipsychotic medication for 1 of 6 residents (Resident #11) reviewed for unnecessary medications. The facility reported a census of 59 residents. Findings include: Review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment the resident had no hallucinations or delusions, and had no physical, verbal, or other behaviors. The assessment further revealed resident took antipsychotic medication on a routine basis, with gradual dose reduction (GDR) contraindicated. Review of the Care Plan dated 5/2/24, revised 4/9/25, revealed the following: [Resident #11] uses psychotropic medications. 1/3/25 GDR (gradual dose reduction) declined for Risperidone r/t (related to) continued symptoms of mild depression 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 observation, clinical record review, policy review, and staff interviews, the facility failed to report allegations of abuse per regulatory guidelines for 3 of 3 potential incidents (involving Resident #15 & Resident #21, Resident #165 and a staff member, and Resident #61 & Resident #42) reviewed for abuse. The facility reported a census of 59 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment tool, dated 5/10/25 revealed a list of diagnoses for Resident #21 which included abnormalities of gait and mobility, abnormal posture, and adult failure to thrive. The MDS indicated the resident had a fall without injury during the review period and listed her Brief Interview for Mental Status (BIMS) score as 5 out of 15, which indicated severely impaired cognition. Review of the Care Plan, dated 5/4/23 revealed a Focus area to address [Name redacted] is at risk for falls r/t (related to) gait/balance problems. Review of an Incident Note entered on 5/15/25 at 1:08 PM revealed staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review the facility failed to ensure an ongoing discharge planning process for 1 of 1 resident reviewed for discharge (Resident #215). The facility reported a census of 59 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #215 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Care Plan for Resident #215 canceled on 4/7/25 revealed, [Resident #215] has no plans to discharge from facility. Review of Resident #215's Care Conference Review form dated 1/16/25 revealed the line titled Discharge Potential had been left blank on the form. Review of documentation emailed by the facility's Administrator on 6/11/25 at 3:30 PM revealed a Notice of Transfer or Discharge form for the resident dated 1/27/25. The form included notice to transfer/discharge the resident on 2/26/25. Per the Transfer or Discharge form, reasons 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.

Based on clinical record review, facility policy review, and staff interview, the facility failed to revise Care Plans to include significant resident information related to significant weight loss, severe allergies, wheelchair safety and change in advanced directive status for 4 of 21 residents (Resident #7, Resident #15, Resident #44, Resident #52) reviewed for Care Plans. The facility reported a census of 59 residents. Findings: 1. Review of the Minimum Data Set (MDS) assessment tool, dated 11/23/24, revealed the list of diagnoses for Resident #52 included hemiplegia (one-sided paralysis), dysphagia (difficulty swallowing), and chronic pain syndrome. The MDS stated the resident depended on staff for eating assistance and had a feeding tube. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 0 out of 15, indicating severely impaired cognition. The MDS indicated an admission date of 11/18/24. Review of the December 2024 Medication Administration Record (MAR) revealed an order with start date of 11/20/24 to check weights on admission and weekly for four…

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 resident and staff interviews, the facility failed to ensure the provision of an adequate number of baths for 2 of 2 residents reviewed for bathing assistance(Residents #5 and #43). The facility reported a census of 59 residents. Findings: 1. Review of the Minimum Data Set (MDS) assessment tool, dated 3/24/25, reveal a list of diagnoses for Resident #43 which included heart failure, depression, and obesity. The MDS indicated the resident dependent on staff for showering/bathing assistance. The Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicated intact cognition. Review of the Care Plan, dated 12/31/24, revealed the resident dependent on staff to provide a shower and requested a shower on Tuesday and a bed bath on Friday. During an interview on 6/2/25 at 1:43 PM, Resident #43 stated she received a bath on Tuesdays and Fridays. She stated last Friday (5/30/25), the staff documented in the record that she refused her bath but she did not.…

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

Based on clinical record review, policy review, and staff interview, the facility failed to assess and intervene for 2 of 2 residents (Resident #36 and #41) with high blood sugar results. The facility reported a census of 59 residents. Findings: 1. Review of the Minimum Data Set (MDS) assessment tool, dated 3/24/25, revealed a list of diagnoses for Resident #36 which included diabetes, hemiplegia (one-sided paralysis), and seizure disorder. The MDS listed a Brief Interview for Mental Status (BIMS) score as 8 out of 15, which indicated a moderate cognitive impairment. Review of the Care Plan, dated 8/30/24, revealed the resident had diabetes and directed staff to observe for signs and symptoms of hyperglycemia (high blood sugar). The June 2025 electronic Medication Administration Record (eMAR) listed an order for Lispro insulin (a type of rapid-acting insulin). The order directed staff to administer 10 units of Lispro for a blood sugar greater then 399 milligrams (mg)/deciliter (dl) and to notify the provider. Review of electronic health record (EHR) Blood Sugar Summary for 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.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to carry out interventions to prevent and treat pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident # 52). The facility reported a census of 59 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness…

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, facility policy review, resident and staff interviews, the facility failed to use Enhanced Barrier Precautions and infection control techniques during catheter care, and intervene in a timely manner reports of an indwelling catheter leaking for 1 of 1 residents (Resident #7) reviewed with an indwelling catheter. The facility reported a census of 59 residents. Findings include: Review of The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed impairment on both sides of the lower extremities. The MDS revealed resident utilized an indwelling catheter, and dependent on staff for toileting. The MDS revealed medical diagnoses for multiple sclerosis, neurogenic bladder, and urinary tract infection in the last 30 days. Review of the Care Plan, revised on 6/2/25, revealed a Focus area for Enhanced Barrier Precautions (EBP) wounds,…

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

Based on clinical record review, policy review, and staff interview, the facility failed to notify the physician and carry out interventions in a timely manner after a significant weight loss for 1 of 5 residents reviewed for weight loss (Resident #52). The facility reported a census of 59 residents. Findings: 1. Review of the Minimum Data Set (MDS) assessment tool, dated 11/23/24, listed diagnoses for Resident #52 which included hemiplegia (one-sided paralysis), dysphagia (difficulty swallowing), and chronic pain syndrome. The MDS stated the resident depended on staff for eating assistance and had a feeding tube. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 0 out of 15, indicating severely impaired cognition. Review of the December 2024 Medication Administration Record (MAR) revealed an admission date of 11/18/24 and listed an 11/20/24 order to check weights on admission and weekly for four weeks. Review of the Care Plan, dated 11/29/24 revealed entries stated the resident was at nutritional risk due to a mechanically altered diet. The Care Plan…

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 interview, and facility policy review the facility failed to ensure consistent completion of post dialysis assessments for 1 of 1 residents reviewed (Resident #44) for dialysis. The facility reported a census of 59 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #44 dated 5/1/25 revealed the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated a moderate cognitive impairment. Per this assessment, the resident received dialysis while resided in facility. Review of Resident #44's Care Plan dated 4/26/24, revised 12/5/24, revealed the following: [Resident #44] is at risk for complication related to receiving dialysis for diagnosis of ESRD (End Stage Renal Disease). Receiving dialysis on M-W-F (Monday-Wednesday-Friday). Review of the resident's pre and post dialysis assessments from 5/28/25 to current revealed the following: Although the resident had a pre dialysis completed on the following dates, the resident lacked completion of a post dialysis assessment on…

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

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to ensure the provision of therapy services for 1 of 2 residents reviewed for specialized services (Resident #23). The facility reported a census of 59 residents. Findings: Review of the Minimum Data Set (MDS) assessment tool, dated 5/9/25,revealed a list of diagnoses for Resident #23 which included heart failure, diabetes (a disorder which caused abnormalities in blood sugar), and anxiety disorder. The Brief Interview for Mental Status(BIMS) score as 13 out of 15, indicated intact cognition. During an interview on 6/3/25 at 10:51 AM, Resident #23 stated she would like to receive therapy services to become more mobile. Review of a 7/29/24 Social Service note, written by Staff G, former Social Services Director, stated the resident wanted physical therapy but did not have a payor source. The note stated the social worker would check on different options. The resident's clinical record lacked documentation regarding follow-up to the resident's wish for therapy between 7/29/24 and 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 review of the Resident Matrix, the facility policy, the Facility Assessment, and staff interview the facility failed to ensure the Facility Assessment identified and addressed the specialized staff training and supply needs for residents in the facility who currently receive hemodialysis (treatment to filter waste and excess fluids from the blood and kidneys) and receive nutrition, hydration and mediations through the use of an enteral tube (a tube surgically inserted through the abdomen into the stomach, specifically a gastrostomy tube or G-tube). The facility reported a census of 59 residents. Findings include: Review of the facilities Resident Matrix, dated 6/2/25, revealed the facility identified a total of 3 residents received hemodialysis (Residents #29, #44 and #37) and 2 residents received nutrition, hydration and medications through the use of a G-tube (Residents #52 and #53). The Resident Matrix identified none of the 5 residents as new admissions due to dates of admission greater than 30 days past. Review of the Facility Assessment, dated 5/16/25, revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment in the resident's room when a pervasive urine odor present in the resident's room for one of one resident reviewed for environment (Resident #9). The facility reported a census of 59 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 revealed the resident scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident was frequently incontinent of urine. The Care Plan dated 6/5/25 revealed, The resident is non compliant with hygiene needs r/t (related to) not wanting to wear incontinent product even though incontinent of urine. Doesn't always take snack when offered as ordered for blood sugar control. Observation on 6/03/25 at 9:12 AM revealed when entered Resident #9's room, immediately noted a strong urine odor present. Observation on 6/5/25 at 9:35 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 §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation Based on clinical record review, facility policy and staff interview, the facility failed to complete shift change controlled substance counts with the required two licensed nurses per facility policy. The facility reported census was 65. Findings include: According to Controlled Substance Administration and Accountability policy: 9. Inventory Verification b. Two licensed nurses account for all controlled substance and access keys at the end of each shift. In an interview on 8/19/24 at 2:15 p.m. Staff C, Certified Medication Aide, stated she worked 2:00 p.m. to 10:00 p.m. on 7/9/24 and was responsible for passing medications on [NAME] hall. Staff C stated at 2:00 p.m. she completed the narcotic count with Staff G, Registered Nurse, and all narcotics were accounted for and the medication cart keys were passed on to Staff C. Staff C stated at the end of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. Based on clinical record review, facility policy and staff interview, the facility failed to ensure custody of medication cart keys were only accessible to authorized personnel. The facility reported census was 65. Findings include: According to Controlled Substance Administration and Accountability policy: 9. Inventory Verification b. Two licensed nurses account for all controlled substance and access keys at the end of each shift. In an interview on 8/19/24 at 2:15 p.m. Staff C, Certified Medication Aide, stated she worked 2:00 p.m. to 10:00 p.m. on 7/9/24 and was responsible for passing medications on [NAME] hall. Staff C stated at 2:00 p.m. she completed the narcotic count with Staff G, Registered Nurse, and all narcotics were accounted for and the medication cart keys were passed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and the facility policy, the facility failed to accurately code antiplatelet medication, insulin, and hospice services for 4 of 23 residents reviewed for Minimum Data Set (MDS) assessment (Residents #21, #22, #25, and #34). The facility reported a census of 61 residents. Findings include: 1. Resident #34's MDS assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included a medical diagnosis of diabetes mellitus (DM). The MDS reflected Resident #34 received insulin 7 out of 7 days in the lookback period. The Care Plan Focus dated 10/20/23 indicated Resident #34 had type II DM and used insulin glargine. The interventions dated 10/20/23 directed to give diabetes medication as ordered by the doctor. The EMR (Electronic Medical Record) revealed the medical diagnosis for type II DM without complications. The Clinical Physician Orders reviewed on 6/27/24 included an order dated 10/19/23 for Insulin Glargine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident had a comprehensive individualized care plan that accurately reflected the resident's plan of care for 4 of 23 residents reviewed (Residents #22, #25, #28, and #60). The review of the 4 residents Care Plans failed to address diabetes, a peripherally inserted central catheter (PICC), use of antibiotics, wounds, hospice level of care, and use of oxygen therapy. The facility reported a census of 61 residents. Findings include: 1. Resident #25's MDS assessment dated [DATE] identified a BIMS score of 11, indicating moderately impaired cognition. The MDS included a diagnosis of diabetes mellitus. Resident #25's Medical Diagnoses reviewed 6/25/24 listed a diagnosis added in 2022 of type 2 diabetes mellitus without complications. The Care Plan Focus revised 3/20/23, indicated Resident #25 had a potential of alteration in nutritional status related to stroke (CVA), weakness, depression, and needed a mechanically altered diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and facility policy review, the facility failed to have enough staff in the dining room during lunch to assist residents with eating and help a resident out of the dining room to the bathroom. This resulted in an incontinent episode in the dining room for 4 of 10 residents reviewed for insufficient staffing (Residents #17, #33, #41, and #45). The facility reported a census of 61 residents. Findings include: 1. Resident #17's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Resident #17 required total assistance with toilet hygiene and needed supervision/touching assistance with toilet transfers. The MDS included a diagnosis of non Alzheimer's dementia. The Care Plan Focus dated 2/5/24 reflected Resident #17 had a risk related to gait/balance problems, incontinence, poor communication/comprehension, and vision/hearing problems. The Interventions dated 2/5/24…

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 record review, the facility failed to ensure they followed the for residents who received a pureed diet. The meal lacked pureed cornbread as directed on the menu for one of one observation of the puree process. The facility reported a census of 61 residents. Findings include: The Week 4 Wednesday Diet Spreadsheet directed the following meal for pureed: a. 1 serving of puree barbecue pork b. 1 serving puree potato salad c. 1 serving puree creamy coleslaw d. 1 serving puree cornbread/margarine e. #8 scoop cinnamon applesauce f. 6 fluid ounces coffee or hot tea g. 8 fluid ounces milk On 6/26/26 at 11:08 AM observed Staff H, Cook, prepare the pureed pork, potato salad, and coleslaw. Staff H failed to puree cornbread as directed in the menu. The Diet Type Report sheet reviewed on 6/26/24 listed five residents had a pureed diet with one additional resident who requested a pureed diet. On 6/27/24 at 1:25 PM, the Dietary Manager explained the might have missed the cornbread the day before, and acknowledged the meal should have cornbread. The Food…

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 record review, the facility failed to maintain the kitchen in a sanitary manner. In addition, the facility failed to test the low temperature dish machine temperature and chemical level. The facility reported a census of 61 residents. Findings include: On 6/24/24 at approximately 10:40 AM during the initial tour of the kitchen revealed the following: a. Bins of cornstarch and sugar contained scoops stored inside of the bin in the product. b. Observation of the chest freezer revealed two bags of hamburger in bags that had openings and exposed to air. A few loose tater tots observed in one storage compartment inside of the chest freezer. c. Loose debris observed on the bottom level inside of the bread refrigerator. d. One open and undated container of cultured sour cream observed in Refrigerator 5. When asked when the sour cream got open, the Dietary Manager responded probably over the weekend, and acknowledged they should have dated the sour cream. On 6/24/24 at 11:35 AM when questioned about testing the dishwasher, the Dietary manager…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and the facility policy, the facility failed to give the resident meal choices prior to the meals for 1 of 1 resident reviewed for choices (Resident #58). The facility reported a census of 61 residents. Findings include: Resident #58's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included a diagnosis of Stage 4 chronic kidney disease. During an interview on 6/25/24 at 11:16 AM, Resident #58 described the quality of the food as not good. During an interview on 6/25/24 at 11:27 AM, Resident #58 stated the staff brought her meals without letting her pick what she wanted. She heard other people got choices. She states no one came around and told her what the meals are and they didn't give her a menu. Resident #58 stated if she didn't like the food, she just wouldn't eat it. On 6/27/24 at 8:14 AM, Resident #58 stated they just brought her breakfast. She repeated they just…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review, the facility failed to notify the Ombudsman of a resident's hospitalization for 1 of 2 residents reviewed for hospitalization (Resident #28). The facility reported a census of 61 residents. Findings include: Resident #28's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The Progress Note dated 3/11/24 at 1:40 PM indicated someone called the nurse to Resident #28's room for a need to transfer to hospital. The facility's provider saw resident that afternoon with new orders (N.O.) to send to them to the emergency room (ER). The nurse called report called to the ER nursing staff and completed a situation, background, assessment, recommendation (SBAR) assessment, transfer assessment and sent them with Resident #28. The Nursing Note dated 3/12/24 at 4:38 PM reflected, Resident #28 returned to the facility around 4:00 PM. The March 2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and the facility policy, the facility failed to follow the special recommendations as directed by the Preadmission Assessment Screening and Resident Review (PASRR) Level II for 1 of 2 residents reviewed (Resident #34). In addition, the facility failed to submit the PASRR level II in a timely manner for 2 of 2 residents reviewed (Residents #2 and #34). The Level II Special Recommendations directed the facility to designate a Power of Attorney (POA) for Resident #34. The facility reported a census of 61 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS included diagnoses of anxiety, depression, and post traumatic stress disorder (PTSD). The MDS revealed resident took antianxiety and antidepressant medications during the 7 day lookback period. The Care Plan Focus dated [DATE] indicated PASRR identified Resident #2 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 interviews, record review, and facility policy review, the facility failed to ensure a resident received their medication. In addition, the facility failed to ensure the Certified Medication Aide (CMA) administered a resident's medication under their name and did not hold the medication cup in their hand in their shirt pocket prior to administration to the resident for 2 of 2 residents reviewed for professional standards (Residents #33 and #45). The facility reported a census of 61 residents. Findings include: 1. Resident #33's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The Clinical Physician Orders reviewed on 6/27/24 listed the following medication orders of white pills: a. tramadol (pain medication) 50 milligrams (mg) 2 tablets b. gabapentin (pain medication) 600 mg 1 tablet c. meclizine (medication for dizziness) chewable 25 mg 1 tablet d. buspirone HCl (hydrochloride) (antianxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow-up after a resident had documentation of no bowel movement from 6/17/24 through 6/23/24. In addition, the facility failed to perform adequate assessment of a non pressure wound for two of three residents reviewed for assessment and intervention (Residents #3 and #51). The facility reported a census of 61 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status score of 11, indicating moderately impaired cognition. The MDS listed Resident #3 had frequently incontinence of bowel without constipation. The Clinical Physician Orders reviewed on 6/25/24 included an order dated 4/19/23 for Dulcolax (bisacodyl) rectal suppository 10 MG. Insert 1 suppository rectally every 24 hours as needed for constipation. The Physician order dated 4/19/23 revealed, Milk of Magnesia Oral Suspension (Magnesium Hydroxide) with directions to give 30 ml orally every 24 hours…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to keep a resident free from injury while repositioning them in bed for 1 of 3 residents reviewed for accidents (Resident #22). This resulted in Resident #22's head hitting the bed rail. The incident caused a bruise to Resident #22's forehead. The facility reported a census of 61 residents. Findings include: Resident #22's MDS assessment dated [DATE] identified an incomplete BIMS exam due others rarely or never understanding her. The MDS included a diagnosis of Alzheimer's disease with late onset. The Care Plan Focus dated 2/15/23 indicated Resident #22 had a potential for impaired skin integrity related to fragile skin. The Interventions dated 2/15/23 directed to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. The Incident Report #1542 dated 6/5/24 at 11:39 AM reflected as a Certified Nurse Aide (CNA) changed Resident #22. They rolled her to the left…

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 interview, clinical record review, and facility policy review, the facility failed to follow the physician's order for continuous administration of oxygen for 1 of 3 residents reviewed (Resident #12) for respiratory care. The facility reported a census of 61 residents. Findings include: Resident #12's Minimum Data Set (MDS), dated [DATE], reflected she had severely impaired cognition. Resident #12 had shortness of breath at rest, while lying flat, and with exertion. The MDS included diagnoses of ventricular tachycardia (abnormal heart rate), atrial fibrillation (abnormal heart rate affecting breathing), heart failure, cerebrovascular accident (CVA), and non Alzheimer's dementia. The MDS indicated Resident #12 used oxygen therapy during the 7-day lookback period. The Care Plan initiated 6/6/24 included the following Focuses a. Resident #12 had an altered cardiovascular status related to atrial fibrillation and myocardial infarct (MI or heart attack). - The Interventions instructed 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, staff interview, and facility policy review, the facility failed to serve mandarin oranges at the appropriate temperature; they failed to serve the room trays at the appropriate temperature; and touched food on a plate with gloves and did not remove the gloves after handling the food or wash their hands. The facility reported a census of 60 residents. Finding include: During an observation on 5/22/24 at 12:05 PM, Staff A, [NAME] checked the temperatures of the lunch food prior to service revealed the following: a. broccoli 168.5 degrees F (Fahrenheit) b. pork loin 166.2 degrees F c. potatoes 147.4 F degrees F d. mandarin oranges 42 degrees F During an observation on 5/22/24 at 12:10 PM, lunch meal service began. Staff A wore gloves during meal service. During an observation on 5/22/24 at 12:19 PM, Staff A moved over the resident's broccoli and potatoes using her gloved hand on the plate, and didn't remove gloves after touching the food on the plate. During an observation on 5/22/24 at 12:23 PM, Staff A put potatoes on the plate and then used her hand to push…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to notify the physician when a resident's blood glucose over 450 mg/dl (milligrams/deciliter) for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 60 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated cognition moderately impaired. The MDS revealed a diagnosis of Type II DM (diabetes mellitus) without complications. The MDS revealed the resident received insulin 7 out of 7 days. The Care Plan revealed the focus area for Type II DM and currently took Humalog and Tresiba dated 11/3/23. The interventions dated 11/3/23 revealed monitor, document, and report signs and symptoms of hyperglycemia such as increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to answer a call light in less than 15 minutes for 1 of 3 residents reviewed for insufficient number of staff (Resident #1). The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the resident used a walker and wheelchair for mobility. The MDS revealed the resident needed partial/moderate assistance with toileting hygiene and toilet transferring. The MDS revealed a diagnosis of cerebral palsy. The Care Plan revealed a focus area for risk for falls related to gait and balance problems dated 9/28/23. The interventions dated 9/28/23 revealed making sure call light within reach and encourage to use it for assistance when needed and prompt response to all requests for assistance. During an observation on 5/20/24 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 observation, interview, record review, and the facility policy the facility failed to report an allegation of resident to resident sexual abuse in a timely manner and failed to report facial bruising of an unknown origin for 3 of 3 residents reviewed for abuse reporting (Residents #1, #2, and #3). The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated moderate impaired cognition. The MDS revealed medical diagnosis of coronary artery disease, hypertension, and heart failure. The MDS revealed the resident didn't take an anticoagulant (blood thinner) medication. The MDS documented the resident dependent with toileting, showering, and lower body dressing and required substantial/maximal assistance with upper body dressing and personal hygiene. The MDS revealed no falls since last assessment. Review of the Self Report list dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and the facility policy the facility failed to thoroughly investigate facial bruising of unknown origin for 1 of 3 resident reviewed for inadequate nursing supervision. The facility reported a census of 66 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated moderate impaired cognition. The MDS revealed medical diagnosis of coronary artery disease, hypertension, and heart failure. The MDS revealed the resident didn't take an anticoagulant (blood thinner) medication. The MDS documented the resident dependent with toileting, showering, and lower body dressing and required substantial/maximal assistance with upper body dressing and personal hygiene. The MDS revealed no falls since last assessment. The Progress Note dated 12/2/23 at 10:28 AM revealed when started peri cares before breakfast, staff observed a purple…

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

Based on observation, record review, and staff and Fire Marshall interviews, the facility failed to follow Life Safety Code regulations (mandated by the Fire Marshall) when they applied a combination lock to 1 of their fire exit/egress doors on 10/3/23, without consultation with or authorization from the State Fire Marshall. The lock prevented the fire exit door from opening unless a code was entered, the lock remained on the door through 10/26/23 and was a direct violation of Life Safety Code regulations. The facility reported a census of 68 residents. Findings include Observation on 10/25/23 at 10:37 a.m. with Staff J, Dietary Manager, revealed an illuminated Exit sign mounted from the ceiling above the Employee Entrance door located on the north side of the facility, a security code key pad mounted to the wall on the right side of the door, a 4 digit code followed by the # sign entered on the key pad required to de-activate the alarm for 3 minutes when the door was opened. If someone opened the door again after it was closed in that 3 minute period, the alarm automatically…

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 resident and staff interviews, the facility failed to ensure all residents received the correct medications, as ordered and directed by their physicians, for 1 of 9 residents reviewed (Resident #2). The medication administered to Resident #2 in error were intended for Resident #3, and resulted in a delay of analgesic medication administration for Resident #3. The facility reported a census of 68 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) Assessment tool dated 9/5/23 revealed Resident #2 had diagnoses that included arthritis, tension headaches and right upper quadrant pain (of abdomen), scored 10 out of 15 points on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated minimal cognitive impairment without symptoms of delirium present. The MDS documented that the resident was always able to make herself understood and understood others. The MDS revealed the resident had experienced occasional pain during the 5 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident and staff interview, clinical record review the facility failed to completed accurate MDS's for 4 out of 4 resident reviewed Resident (# 14, 23, 31 and 37). The facility reported a census of 64 residents. Findings included: 1. Resident # 23's Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses of fusion of the spine, cervical region and muscle weakness. The Nurses Note for Resident # 23 dated 11/21/2022 at 3:26 AM, read contacted 911 for transport to emergency room (ER). The Nurses Note dated 11/21/2022 at 9:04 AM, read ER nurse stated resident to be admitted for observation. The MDS Tracking for Resident # 23 failed to show a discharge return anticipated MDS dated [DATE] and failed to show a entry MDS dated [DATE]. 2. The MDS for Resident # 14 dated 3/3/23, listed diagnoses of saddle embolus(a blood clot, air bubble, piece of fatty deposit, or other object which has been carried in the bloodstream to lodge in a vessel) of pulmonary artery (rare type of acute pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to maintain the integrity of a resident's liquid Morphine (a narcotic pain medication) and handle the medication per accepted standards, failed to prime an insulin pen prior to insulin administration, and failed to implement a gradual dose reduction per physician orders for four of nineteen residents reviewed for standards of practice (Resident #21, Resident #27, Resident #31, Resident #64). The facility reported a census of 64 residents. Findings include: 1.The Minimum Data Set (MDS) assessment for Resident #64 dated 9/2/22 revealed the resident was rarely to never understood. The Physician Order dated 6/2/22 discontinued on 10/15/22 documented, Morphine Sulfate (Concentrate) Solution 20 MG/ML (milligram per milliliter) Give 5 mg by mouth every 4 hours as needed for pain/ shortness of breath. a. Review of a Self Report summary dated 9/7/22 documented, in part, the following: On 09/07/2022 during 0600 (6:00 AM) the change of shift…

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, resident council notes, test tray tasting and staff interview, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 64. Findings include: Continuous observation on 3/15/23 beginning at 11:21 am, Staff M, Cook, began to prepare for meal service. The temperatures for the food when placed on the steam table were as follows: Apple brats: 210 degrees Cauliflower: 169 degrees Sweet potato puffs: 169 degrees Cheese sauce: 177 degrees Cauliflower, puree texture: 148 degrees Sweet potato, puree texture: 165 degrees Apple brats, puree texture: 165 degrees Apple brats, chopped texture: 201 degrees Food was divided between two steam tables. Table 1 was in the first floor dining room. This table was used to serve residents of the first floor. Table 2 was kept in the main kitchen. Table 2 was used to make food trays for residents of the second floor. Trays were first made for the residents on [NAME] unit on 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy review the facility failed to notify the resident representative when the resident had a condition change and the facility sent the resident to the hospital for 1 out of 4 (Resident 164). The facility reported a census of 64 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), anemia, and diabetes mellitus. The Brief Interview of Mental States score reflected a 15 (intact cognition). The MDS reflected the resident able to understand and make his needs known. The Nursing Note dated 8/16/2022, at 12:57 PM, read the Primary Care Provider (PCP) ordered Resident # 164 transferred to the emergency room (ER) related to his low Oxygen saturation, shortness of breath (SOB), left lower leg red and swollen. The note read the wife aware of the transfer. The note continued to list Resident # 164's diagnoses of COPD, CHF, Hypoxia,…

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, and facility policy, the facility failed to provide documentation to show verification of licensure for a Certified Nurses Aide/Certified Medication Aid (CNA/CMA) for one of two CNA human resources records reviewed. The facility reported a census of 64 residents. Findings included: 1. A review of the human resources record for Staff C, CNA/CMA revealed a hire date of 2/13/23 and revealed the following: a. SING (single contact repository which expedites the process of checking backgrounds of potential employees) check had no documentation to show verification of CNA licensure. b. No documentation to show verification of CNA licensure through the DCW (direct care worker) registry. In an interview on 3/16/23 2:25 PM, the Business Office Manager (since July 2022) reported she also had been responsible for the completion of the hiring process and HR (human resources) record documentation. She reviewed the HR file for Staff C and verified she could not find documentation of checking for CNA licensure verification and admitted she forgot to run…

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, and facility policy the facility failed to provide documentation of completion of dependent adult abuse mandatory reporter training had been completed for one of two nurses' HR (human resources) records reviewed. The facility reported a census of 64 residents. Findings included: 1. A review of the HR record for Staff N, RN revealed a hire date of 7/14/22 and had no documentation to show she completed the dependent adult abuse mandatory reporter training within 6 months of her hire date. In an interview on 3/16/23 2:25 PM, the business office manager (since July 2022) reported she also had been responsible for the completion of the hiring process and HR (human resources) record documentation. She reviewed the HR file for Staff N, RN and could not locate certificate of completion of dependent adult abuse mandatory training. She verified Staff N had been hired 7/14/22, she should have provided a copy of certificate of completion upon hire and admitted she forgot to follow-up and check. She also reported this should have been completed January…

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 interview, record review, and facility policy review the facility failed to ensure two allegations of staff tampering with Morphine, a narcotic pain medication, had been reported to the State Agency and/or reported to the State Agency in a timely manner per accepted regulatory timeframes upon review of the contents of one of three Facility Reported Incident (FRI) files which involved Resident #64. The facility reported a census of 64 residents. Findings include: 1. Review of a Self Report summary dated 9/7/22 documented, in part, the following: On 09/07/2022 during 0600 (6:00 AM) the change of shift narcotic count between [Staff F, Registered Nurse (RN)] and [Staff G, Certified Medication Aide (CMA)], Staff G questioned the remaining doses of Morphine Sulfate Solution in the bottle for [Resident #64]. [Staff G] states she witnessed [Staff F] going over to the kitchenette sink, turning the faucet on, letting water run into the bottle and returning to the medication cart stating there, now the count is right. [Staff G] reported to her Charge Nurse-[Staff O, Licensed Practical…

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 interview, record review, and facility policy review the facility failed to ensure an allegation of tampering with a resident's Morphine, a narcotic pain medication, had been thoroughly investigated upon review of documentation contained in one of three Facility Reported Incident files. The facility reported a census of 64 residents. Findings include: Review of a Complaint Hotline Compliance Report with a date and time of call documented as 9/15/22 at 12:53 PM contained inside a Facility Reported Incident folder pertaining to a separate incident documented the following: Summary of Complaint: The caller states they are calling to make a report their [family member] witnessed [Staff J] licking morphine from her fingers. They state that she is extremely upset about this but doesn't know who to talk to about it. The caller feels this needs to be investigated. 4:55pm EST: Per Admin request [initials redacted] called the caller to verify identify of accused person. The caller verified that it was not [Staff J], but instead it was [Staff K] [Job Title Redacted] that was witnessed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility failed to update care plans for three of four residents reviewed (Residents #29 #39, #56) The facility reported a census of 64 residents. Findings included: 1. The Minimum Data Set, dated identified Resident #29 as severely cognitively impaired with a BIMS of 0 and with the following diagnoses: Hypertension, Renal Insufficiency and diabetes Mellitus. It also identified the resident required extensive staff assistance with bed mobility, toileting and bathing and totally dependent on staff for personal hygiene. A review of the undated care plan did not identify the resident with the problem of risk of elopement. During an observation on 3/14/23 at 7:43 AM, the resident self-propelled in her wheelchair out through side door and the alarm sounded. She had pushed herself out through the first door and had her hand on the safety bar of the second door which led immediately outside. The surveyor had to flag down staff to assist the resident. Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview and staff interview, the facility failed to transcribe the order for continuous oxygen to the Treatment Administration Record and to the care plan for one of two residents reviewed with oxygen (Resident #39) The facility reported a census of 64 residents. Findings included: 1. The Minimum Data Set, dated [DATE] identified Resident #39 as moderately cognitively impaired with a BIMS (brief interview for mental status) of 10 and with the following diagnoses: Pneumonia, Coronary Artery Disease and Heart Failure. It also identified the resident required extensive staff assistance with repositioning and personal hygiene and totally dependent on staff for locomotion on and off the unit, dressing, toileting and bathing. It also identified the resident to occasionally incontinent of bowel. A review of the physician orders revealed the following: 1/12/23 02 2 liters per nasal cannula continuously, humidified air (resident admitted [DATE]) An observation on 3/13/23 at…

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

Based on observation, interview, and record review, the facility failed to maintain an accurate, complete Controlled Substance Shift Count & Usage Record sheets to account for all doses of Morphine for one of three residents reviewed for narcotic records (Resident #64). The facility reported a census of 64 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #64 dated 9/2/22 revealed the resident was rarely to never understood. The Physician Order dated 6/2/22 discontinued on 10/15/22 documented, Morphine Sulfate (Concentrate) Solution 20 MG/ML (milligram per milliliter) Give 5 mg by mouth every 4 hours as needed for pain/ shortness of breath. Review of the September 2022 Medication Administration Record (MAR) for Resident #64 documented doses of PRN (as needed) Morphine had been administered on 9/6/22 on the following dates and times: 7:30 AM and 4:40 PM. No other doses had been administered on that day. No doses of PRN Morphine had been documented on the MAR for 9/7/23. Review of two Controlled Substance Shift Count and Usage Records for Resident #64,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and policy review, the facility failed to ensure that psychotropic medications were used only to treat a specific, diagnosed and documented condition for 1 of 5 (Resident #31) residents reviewed for unnecessary medications. Findings include: The Minimum Data Set (MDS) dated [DATE] identified the presence of short and long-term memory impairment. The MDS documented the resident exhibited no wandering behavior during the 7-day look back period. The MDS documented diagnoses that included dementia and depression. The Care Plan, reviewed 3/10/23, identified the resident had impaired thought process due to dementia. It directed staff to cue, orient and supervise the Resident as needed. The Care Plan failed to reflect the resident having anxiety. The Medication Order dated 1/25/23 docuemented a verbal order for Sertraline, an antidepressant medication, to be given one time a day for anxiety. The order was transcribed by Staff P, Licensed Practical Nurse (LPN). The Active…

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 utilize proper infection control practices while providing incontinence care for one of five residents observed (Resident #39). The facility reported a census of 64 residents. Findings included: 1. The Minimum Data Set, dated [DATE] identified Resident #39 as moderately cognitively impaired with a BIMS (brief interview for mental status) of 10 and with the following diagnoses: Pneumonia, Coronary Artery Disease and Heart Failure. It also identified the resident required extensive staff assistance with repositioning and personal hygiene and totally dependent on staff for locomotion on and off the unit, dressing, toileting and bathing. It also identified the resident to be occasionally incontinent of bowel. During an observation of incontinence cares that began at 3/15/23 at 8:10 AM, Staff C, Certified Nurse Aide (CNA) and Staff H, CNA both entered the room, closed the door, used alcohol hand rub and donned gloves. At 8:11 AM Staff C…

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.