Bishop Drumm Retirement Center

Based on direct observation, clinical record review, resident and staff interview the facility failed to provide dignified grooming for residents who requested it in 1 of 15 residents surveyed (Resident #2). The facility reported a census of 124. Findings include: The quarterly Minimum Data Set (MDS) for resident #2, dated 11/27/2025, documented the following relevant diagnoses: Coronary artery disease, Diabetes Mellitus (diabetes), anxiety disorder, depression, unspecified fracture of left hip, generalized muscle weakness. The MDS also documented that the resident required assistance with personal cares, and specified the resident required substantial or maximal assistance with personal hygiene. The Care Plan for Resident #2, last revised on 02/13/2026, documented the resident requires assistance with personal cares and discussed the resident's preference for her hair to remain long, brushed daily, and that she requested to be shaved daily. This was initiated in the care plan on 02/22/2025. In a direct observation of Resident #2 on 02/10/2026 at 11:36 AM Resident #2 was noted 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 observation, clinical record review, staff interviews, and policy review, the facility failed to provide timely physician and family notification for 1 of 1 resident (#8) who experienced a change in condition or treatment. The facility reported a census of 124 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. It also revealed the resident was independent with eating, required moderate assistance with sit-to-stand and chair-to-chair and toilet transfers, and required supervision with oral and personal hygiene, moderate assistance with toileting and bathing, substantial assistance with upper body dressing, bed mobility, lying-to-sitting, sitting-to-lying, and sit-to-stand mobility, and was dependent with lower body dressing, footwear, and all other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review, the facility failed to provide assessment and interventions for 1 of 1 resident (#8) who experienced an elevated temperature and a change in mental condition. The facility reported a census of 124 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. It also revealed the resident was independent with eating, required moderate assistance with sit-to-stand and chair-to-chair and toilet transfers, and required supervision with oral and personal hygiene, moderate assistance with toileting and bathing, substantial assistance with upper body dressing, bed mobility, lying-to-sitting, sitting-to-lying, and sit-to-stand mobility, and was dependent with lower body dressing, footwear, 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, staff interview, and policy review, the facility failed to apply foot pedals to a resident's wheelchair during transport for 1 of 1 resident (#8). The facility reported a census of 124 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. It also revealed the resident was independent with eating, required moderate assistance with sit-to-stand and chair-to-chair and toilet transfers, and required supervision with oral and personal hygiene, moderate assistance with toileting and bathing, substantial assistance with upper body dressing, bed mobility, lying-to-sitting, sitting-to-lying, and sit-to-stand mobility, and was dependent with lower body dressing, footwear, and all other forms of mobility. It also indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review, the facility failed to correctly administer insulin by failing to prime a newly attached insulin pen needle before administering it for 1 of 3 residents (#14) and verifying documented open date for 2 of 3 residents (#14, #15), and attempted to administer a medication without an order for 1 of 3 residents (#8). The facility reported a census of 124 residents.Findings include:Resident #15's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of chronic kidney disease and diabetes mellitus. It indicated she required setup assistance with eating, moderate assistance with oral hygiene, was dependent with transfer mobility, and required maximal assistance with all other Activities of Daily Living (ADLs) and mobility. It also indicated she received insulin injections 7 days within the 7-day look-back…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review, the facility failed to provide an accurate health record for a change in condition for 1 of 1 resident (#8). The facility reported a census of 124 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. It also revealed the resident was independent with eating, required moderate assistance with sit-to-stand and chair-to-chair and toilet transfers, and required supervision with oral and personal hygiene, moderate assistance with toileting and bathing, substantial assistance with upper body dressing, bed mobility, lying-to-sitting, sitting-to-lying, and sit-to-stand mobility, and was dependent with lower body dressing, footwear, and all other forms of mobility. The Care Plan 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.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past surveys, and staff interview, the facility failed to correct their own deficiencies and have an effective quality assurance program in place to assist in the provision of quality of care for residents and attain substantial complaining with Federal regulation and State rule. The facility reported a census of 114 residents. Findings include: Review of the Department of Inspections Appeals and Licensing (DIAL) website under the facility's visit history revealed the facility had the following concerns identified at the current revisit and complaint survey, that were also cited at past surveys in the last two and half years. a. F686- Pressure Sores b. F658- Services to Meet Professional Standardsc. F725- Sufficient Nursing Staffingd. F880- Infection ControlThe following surveys revealed repeated deficiencies from 6/29/23 to current survey:7/21/25- Recertification, Complaint, Incident Survey: F725, F8804/3/25- Complaint, Incident: F7259/19/24- Recertification, complaint, Incident:…

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 notify the family/emergency contact when a resident had a significant change of condition for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 114 residents.Findings include: Resident #10's Quarterly Minimum Data Set (MDS) dated [DATE] assessment identified a Staff Assessment for Mental Status indicating severely impaired cognition. The MDS identified Resident #10 was dependent on staff for eating . Resident #10's MDS included diagnoses of anemia, diabetes mellitus, traumatic brain injury, malnutrition and respiratory failure. The MDS documented Resident #10 had weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician prescribed weight loss regimen. The MDS identified Resident #10 had a feeding tube and received 51% or more of the total calories through the feeding tube daily. A Progress Note dated 6/5/25 titled Dietary Note revealed Resident #10 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 clinical record review, staff interviews and policy review the facility failed to provide care and services according to accepted standards of clinical practice for 3 of 3 residents reviewed (Residents #10, #76, #15). The facility failed to obtain weekly weights per physician order for residents who have a feeding tube. The facility reported a census of 114 residents.Findings include: 1. Resident #10's Quarterly Minimum Data Set (MDS) dated [DATE] assessment identified a Staff Assessment for Mental Status indicating severely impaired cognition. The MDS identified Resident #10 was dependent on staff for eating . Resident #10's MDS included diagnoses of anemia, diabetes mellitus, traumatic brain injury, malnutrition and respiratory failure. The MDS documented Resident #10 had weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician prescribed weight loss regimen. The MDS identified Resident #10 had a feeding tube and received 51% or more of the…

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

Based on observation, clinical record review, staff interview, and policy review the facility failed to provide appropriate suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) care for 1 of 3 residents (Resident #15) reviewed. The facility reported a census of 114 residents.Findings include:The Quarterly Minimum Data Set (MDS) for Resident #15, dated 7/24/25, included diagnoses of Muscular Dystrophy, respiratory failure, dysphagia (difficulty swallowing food or liquids), and malnutrition. The MDS identified the resident was dependent on staff for eating, toilet hygiene. and transfers. The MDS indicated the resident had a suprapubic catheter and a tracheostomy (opening with tube into the windpipe to maintain an airway for breathing). The MDS indicated the resident had a BIMS score of 12, indicating mild cognitive impairment. Observation on 9/15/25 at 2 PM, Staff A, Registered Nurse with the same pair of gloves on completed the 2 wound treatments, removing the old dressings, cleansing the wounds, and applying new dressings on Resident #15. Staff A then…

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

Based on observation, clinical record review, staff interview, and policy review the facility failed to flush an enteral gastrostomy tube (g-tube) (tube surgically inserted into the stomach to provide nutrition and medication) per facility policy prior to and after administering medication thru the g-tube for 1 of 3 resident (Resident #15) reviewed. The facility reported a census of 114 residents. Findings include:The Quarterly Minimum Data Set (MDS) for Resident #15, dated 7/24/25, included diagnoses of Muscular Dystrophy, respiratory failure, dysphagia (difficulty swallowing food or liquids), and malnutrition. The MDS identified the resident had a g-tube and was dependent on staff for eating, toilet hygiene. and transfers. The MDS indicated the resident had a suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) and a tracheostomy (opening with tube into the windpipe to maintain an airway for breathing). The MDS indicated the resident had a BIMS score of 12, indicating mild cognitive impairment.Observation on 9/15/25 at 2:30 PM, Staff A, Registered…

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 minutes review, resident and staff interviews, record review, and policy review the facility failed to answer call lights in a timely manner (15 minutes or less) for 3 of 3 residents (Residents #26, #39, and #79) reviewed and failed to ensure the call light was within reach for 2 of 5 residents (Residents #1 and #15) reviewed. The facility reported a census of 114 residents. Findings include:1.Review of Resident Council Minutes for August 2025 documented the residents in attendance expressed continued concerns regarding the length of time it takes staff to respond to call lights. Interview on 9/8/25 at 2 PM, Resident #79, with a Brief Interview for Mental Status (BIMS) score of 15 (indicating cognitively intact) stated the call light response time had not gotten any better, that it still takes quite a while. During the same interview, Resident #26 with a BIMS score of 14 (indicating cognitively intact) agreed that the call light response time had not gotten any better. Interview on 9/8/25 at 2:15 PM, Resident #39, with a BIMS score of 15, stated the call…

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

Based on observations, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 1 of 5 residents reviewed (Resident #15). The facility failed to ensure use of enhanced barrier precautions (EBP)when required and failed to complete hand hygiene and change gloves when completing treatments. The facility reported a census of 114 residents. Findings include:1.The Quarterly Minimum Data Set (MDS) for Resident #15, dated 7/24/25, included diagnoses of Muscular Dystrophy, respiratory failure, dysphagia (difficulty swallowing food or liquids), and malnutrition. The MDS identified the resident was dependent on staff for eating, toilet hygiene. and transfers. The MDS indicated the resident had a gastrointestinal feeding tube (g-tube) (tube into the stomach to provide liquid nutrition) a suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) and a tracheostomy (opening with tube into the windpipe to maintain an airway for breathing). The MDS indicated the resident had a BIMS score of 12, indicating…

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 document an accurate code status for one of thirty-two residents sampled for advanced directives (Resident #11). The facility reported a census of 107 residents.Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had diagnoses that included a myocardial infarction (heart attack), cancer, renal insufficiency, diabetes, and chronic myeloid leukemia. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The Care Plan initiated/revised [DATE] revealed Resident #11 desired to have limited end of life treatment for a DNR (Do Not Resuscitate) status. The staff directives included to review the advanced directives with the resident on a quarterly basis or as needed (PRN).The Electronic Medical Record (EHR) physician's orders revealed Resident #11's code status as a DNR. The order was created on [DATE] by the Director…

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 work orders, resident and staff interviews, and policy review, the facility failed to provide a safe, clean, comfortable and homelike environment. The facility identified a census of 107 residents.Findings include:Observations revealed the following: a. On 7/14/25 at 3:00 PM, the door to resident's room [ROOM NUMBER] and room [ROOM NUMBER] would not close even though the surveyor pulled on the door repeatedly in attempt to close the door to the room. b. On 7/16/25 at 12:30 PM, room [ROOM NUMBER] had a board for the window sill lying on the floor by the resident's bed.c. On 7/17/25 at 8:50 AM, the door to resident's room [ROOM NUMBER] and room [ROOM NUMBER] sprung open several times as the surveyor and staff attempted to close the door. room [ROOM NUMBER] continued to have a board for the window sill lying on the floor by the wall and bed. The platform (by the window) for the window sill had hard, dried glue and a rough surface. The bathroom call light in room [ROOM NUMBER] was 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, facility record review and staff interview, the facility failed to provide notification to the Long Term Care (LTC) Ombudsman for 1 of 3 (Resident #1) reviewed. The facility reported a census of 107 residents. Findings include: Record review of Resident #1 Census in her clinical record documented she discharged to the hospital on 2/13/25 and returned to the facility on 3/4/25. She discharged to the hospital again on 5/30/25 and returned to the facility on 6/4/25. A Progress Note on 2/13/25 at 2:02 PM, documented Resident #1 had been sent out to the hospital at 1:35 PM. A Progress Note on 2/27/25 at 4:25 PM documented Resident #1 returned to the facility at 3:30 PM A Progress Note on 5/30/25 at 12:02 PM documented Resident #1's spouse called and informed the facility Resident #1 had been admitted to the hospital. A Progress Noted on 6/4/25 at 5:35 PM documented Resident #1 returned to the facility. The Admit/Discharge To/From Report dated 4/21/25 for hospitalized and discharged residents from 2/1/25 to 2/28/25 provided to the LTC Ombudsman revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 23 residents sampled (Resident #100 and #62). The facility reported a census of 107 residents.Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE], indicated that Resident #100 had a Cerebrovascular Accident (CVA), Non-Alzheimer's dementia and aphasia following cerebral infarction. The MDS dated [DATE], indicated that Resident #100 did not trigger for behavioral symptoms.The resident's Care Plan with date initiated 2/29/20 indicates Resident #100 had a tendency to sit down on the floor which is a cultural lifestyle. It lacked documentation of her crawling on the floor, wandering and going into other resident's rooms. It also lacked specific interventions for staff when these behaviors occur.The Progress Note on 7/4/25 at 10:38 AM for Resident #100 revealed that she was found crawling on the floor and went into another…

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, resident representative interview, staff interviews and facility policy review, the facility failed to conduct resident care conferences and offer the resident's Legal Guardian (an individual appointed by the court to make decisions for another person, known as the protected person, who is unable to care for themselves due to physical or cognitive limitations) to participation in their plan of care for 1 of 1 residents reviewed (Resident #3) . The facility reported a census of 107 residents. Findings include: Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10 out 15 indicating moderate cognitive impairment. The MDS included diagnoses of dementia, hemiplegia, malnutrition and depression. The MDS documented the resident has a legal guardian. On 7/15/2025 at 9:48 AM the Legal Guardian reported she is court appointed legal guardian for Resident #3. She reported she had not been invited to a care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident and staff interviews, and policy review the facility failed to report a resident's change in condition, and failed to assess and document a skin assessments for one of three residents reviewed (Resident #5). The facility reported a census of 107 residents.Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had diagnoses of osteomyelitis to the left ankle and foot, diabetes, and renal insufficiency. The Care Plan created on 5/14/25 revealed Resident #5 had a break in skin integrity on the left third toe due to an amputation. The Care Plan directed staff to provide treatment as ordered. The Care Plan lacked information about a wound or area of concern on her bottom. An admission assessment dated [DATE] revealed the resident had a toe amputation. Section B of the assessment revealed the resident had bruises to her hands that were present on admission. The resident had no other skin abnormalities documented. 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 Resident council minutes, family interview, resident interview, and staff interview the facility failed to answer call lights in a timely manner (15 minutes or less) for 3 of 4 units (North, South and North East). The facility reported a census of 107 Residents. Findings include:Review of Resident Council Minutes for April, May and June of 2025 documented the residents in attendance each month expressed concerns regarding the length of time it takes staff to respond to call lights. During an interview on 7/14/25 at 1:53 PM, Resident #79, with a Brief Interview for Mental Status (BIMS) of 15 (indicating cognitively intact) explained it takes at least 20-30 minutes to get staff to respond to call lights. During the same interview, Resident #26 with a BIMS of 14 (indicating cognitively intact) agreed that it takes a long time to get call lights answered. During an interview on 7/14/25 at 3:08 PM, Resident #5 with a BIMS of 15, explained it takes a long time to get staff to respond to her call light. She explained she turned her call light on at 1:00 PM and no staff came in 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 observation, staff interview, and policy review, the facility failed to follow infection control practices for a resident with a feeding tube for 1 of 3 residents reviewed for medication review (Resident #79). The facility also failed to follow infection control practices for a resident with a catheter for 1 of 1 resident reviewed for catheter care (Resident #19). The facility reported a census of 107 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE], indicated that Resident #79 had hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, aphasia following cerebral infarction and a feeding tube. The Care Plan for Resident #79, with a target date of 7/18/25, indicated a feeding tube related to dysphagia secondary to Cerebral Vascular Accident (CVA) requiring Enhanced Barrier Precautions (EBP). During an observation on 7/15/25 at 12:34 PM, Staff A, RN gave medications to Resident #79. Staff A, RN donned gloves and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, hospital record review, staff and physician interview, the facility failed to promptly notify a medical provider in a timely manner of a change of condition for 1 of 4 residents reviewed (Resident #2). Resident #2 was exhibiting symptoms of hyperglycemia (high blood sugar) two days prior to physician notification and had an elevated heart rate for several days prior. The resident was hospitalized with diagnoses including sepsis (infection in the bloodstream) and diabetic ketoacidosis (also known as DKA, a serious complication of diabetes causing a buildup of ketones and a significant rise of blood sugar). The facility reported a census of 117 residents. Findings include: The Quarterly Minimum Data Set (MDS) of Resident #2, dated 4/3/25 coded the resident to be non verbal and could sometimes make herself understood. The MDS documented diagnoses that included anemia, hypertension, diabetes, aphasia (a communication disorder that impairs a person's ability to process language…

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

Based on observations, clinical record review, staff interview and facility policy review, the facility failed to provide adequate supervision and follow the care plan for 1 of 3 residents reviewed, resulting in Resident #3 suffering a fall. The facility reported a census of 117 residents. Findings include: The Quarterly Minimum Data Set (MDS) Assessment of Resident #3 dated 3/22/25 identified a Brief Interview for Mental Status Score of 5, which indicated severe cognitive impairment. The MDS documented diagnoses which included humerus fracture, non Alzheimer's dementia, and anxiety disorder. The MDS revealed the resident had an impairment to one upper extremity, and used a walker for a mobility device. The MDS documented that the resident required substantial/maximal assistance with the following activities; toilet transfer, chair/bed-to-chair transfer, sit to stand, lying to sitting on side of bed, sit to lying, and roll left and right in bed. The MDS documented the resident had had one fall with no injury and one fall with injury since the prior MDS assessment. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, electronic health record (EHR) review, resident interview and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 6 resident reviewed (Resident #5, #6, #7 and #11). The facility reported a census of 117 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) of 10 which indicated moderate cognitive impairment. The MDS documented diagnosis of wedge compression fracture of fourth lumbar vertebra, with subsequent encounter for fracture with routine healing. Review of Resident #6's EHR titled, Care Plan documented Resident #6 was unable to get out of bed and was on strict bedrest for at least 3 months. On 4/1/25 at 3:42 PM Resident #6 stated the staff rarely come promptly. Resident #6 explained it took about 15 or 20 minutes for the staff to answer the call lights frequently. Resident #6 stated her call…

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, Electronic Health Record review (EHR), resident interviews and staff interviews the facility failed to maintain an effective pest control program so that the facility was free of pest and rodents for 2 of 3 residents reviewed (Resident #1 and #10). The facility reported a census of 117 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. On 4/1/25 at 3:17 PM Resident #1 stated she had seen a mouse in her room. Resident #1 explained there was only 1 that had been in the facility but had been around for the last 4 months. Resident #1 stated the traps in her room were set and got set off but, no mouse on the trap. Resident #1 revealed she had bought sticky traps and the traps disappeared. Resident #1 said she did not know what happened to them. Resident #1 said she told Staff F, Director of Maintenance and facilities about the mouse and he said he would call…

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 policy review, the facility failed to treat residents with dignity by staff arguing with each other in front of 9 residents. The facility reported a census of 120. Findings include: 1) On 9/19/24 at 7:55 AM, Staff H, Dietary Attendant and Staff I, Culinary Support argued in the large dining room with 9 residents present. While standing 30 feet outside the large dining room door, the surveyor heard someone yell I don't care. Upon entering the dining room doorway, 1 of the 9 residents in the dining room watched as Staff H walked from the left side of the dining room to the right side and yelled I have to do everything around here. at Staff I. Staff H threw some cloth napkins in a bin on the table near the kitchen entrance and yelled You don't ever help at Staff I. Staff I made an inaudible comment and Staff H yelled I bet you do then grabbed the tray cart and left the dining room. At 2:25 PM, the Director of Dietary stated staff should never have any argument in the dining room. It is not necessary. A policy titled Dignity revised 2/2021…

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 policy review, the facility failed to secure Electronic Health Record information for 16 residents. The facility reported a census of 120. Findings include: 1) On 9/17/24 at 8:15 PM, a northeast hall report sheet with 21 residents' information was observed laying face up on a medication cart. At 8:17 PM, the Director of Nursing (DON) stated the resident's information (NE report sheet) is usually under the binder and should not be face up on top of the cart. A policy titled Confidentiality of Information and Personal Privacy revised 10/2017 indicated the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to implement infection control practices to minimize cross-contamination for 9 of 9 resident staff interactions reviewed for infection control observations (#31, 52, 61, 63,64,113, 114, and 324). The facility reported a census of 120. Findings include: 1) On 9/18/24 at 8:34 AM, Staff D, Certified Nurse Aide (CNA) and Staff E, Certified Nurse Aide (CNA) transferred Resident #31 from her bed to her wheelchair. Staff D hung the resident's indwelling catheter bag on the spreader bar (center bar between grip handles) above the resident's bladder. The Minimum Data Set (MDS) dated [DATE] indicated Resident #31 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated completely intact cognition. It included diagnoses of Heart Failure, peripheral vascular disease, kidney disease, obstructive uropathy (blocked urine flow), anemia, and Atrial Fibrillation (irregular heartbeat). It revealed the resident…

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

Based on observations, resident, family, and staff interviews, record review, facility assessment, and policy review, the facility failed to provide sufficient staff to meet the residents' needs for cares and answer call lights timely for 2 of 3 nursing units. The facility reported a census of 116 residents. Findings include: Observations revealed the following: a.On 6/20/24 at 11:55 AM, no staff in the dining room with resident. Residents seated at two assistive table. A family member assisted a resident with feeding. At 12:02 PM, a staff person brought one of the residents at the assistive table a tray of food and began to assist the resident with eating. The staff member then assisted three residents, spooning food into their mouths and provided beverages. The staff member sat on a stool and wheeled around the table, and fed the residents. At 12:27 PM, the Administrator, Director of Nursing (DON), and Social Worker passed meal trays and answered call lights on the [NAME] halls. On the [NAME] (200) halls: b.On 6/24/24 8:00 AM 4 call lights on. On 6/24/24/ 8:24 AM all call lights…

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 record review, policy review, and staff interview, the facility failed to have an effective quality assurance (QA) program in place to assist in the provision of quality care for residents and attain substantial compliance with Federal regulations and State rules. The facility identified a census of 116 residents. Findings include: Review of the Department of Inspections, Appeals and Licensing (DIAL) website under the facility's visit history revealed repeated deficient practices identified during the facility's annual survey 2/24/21 and 6/29/23, and complaint investigations completed 10/9/23, 2/27/24, and the current complaint investigations. The repeat deficiencies cited included: F725 cited 6/29/23, 10/9/23, and during the current survey F686 cited 2/24/21, 2/27/24, and during the current survey. A Quality Assurance and Performance Improvement (QAPI)) change process implemented 10/24/22 revealed the QAPI as a systematic approach for performance improvement activities to ensure changes are effective and improvements are sustained. Performance improvement is 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 observations, clinical record review, staff interviews facility policy review the facility failed to ensure the dignity of 1 of 3 residents (#3) was respected while she sat in the commons area with peers. The facility reported a census of 110 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 4/2/24 documented Resident #3 has severely impaired cognitive skills for daily decision making. Resident #3's preferred language was Spanish and wanted or needed an interpreter to communicate with a doctor or health care staff. The MDS documented no rejection of care during the 7-day review period and utilized a wheelchair. The MDS indicated she was always incontinent of bowel and bladder. The following diagnoses were listed for Resident #3: stroke, hypertension (high blood pressure), diabetes mellitus, aphasia (trouble speaking), and atrial fibrillation. The Care Plan focus area with an initiation date of 1/13/2020 documented Resident #3 had a communication problem related to a language barrier, stroke with residual aphasia 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 record review, staff and hospital staff interviews, and policy review the facility failed to initiate 2 of 3 resident's (Resident #1 & #2) physician's orders. Resident #1 was seen by the wound physician weekly with recommendations that were not initiated. Resident #2 was a newly admitted resident to the facility. The facility failed to administer his medications as ordered. The facility reported a census of 110 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment tool with a reference date of 1/22/24 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 suggested no cognitive impairment. The MDS documented she had a one Stage 2 pressure ulcer that was present upon admission. The MDS listed the following diagnoses for Resident #1: metabolic encephalophy, atrial fibrillation, and type 2 diabetes mellitus. The Care Plan focus area with an initiation date of 1/26/24 documented she was admitted to the facility with pressure ulcers to her right buttocks and sacrum. The care plan directed staff to consult 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 observations, record review, staff interviews, and policy review the facility failed to ensure 1 of 3 residents (Resident #3) received assistance with their activities of daily living (ADLS). The facility reported a census of 110 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 4/2/24 documented Resident #3 has severely impaired cognitive skills for daily decision making. Resident #3's preferred language was Spanish and wanted or needed an interpreter to communicate with a doctor or health care staff. The MDS documented no rejection of care during the 7-day review period and utilized a wheelchair. The MDS indicated she was always incontinent of bowel and bladder. The following diagnoses were listed for Resident #3: stroke, hypertension (high blood pressure), diabetes mellitus, aphasia (trouble speaking), and atrial fibrillation. The Care Plan focus area with an initiation date of 1/13/2020 documented Resident #3 had a communication problem related to a language barrier, stroke with residual aphasia and confusion. 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, clinical record review, staff interview and facility policy review the facility failed to implement a comprehensive care plan for 1 of 3 residents (Resident #5) reviewed for elopement. The facility reported a census of 110 residents. Findings include: The admission Minimum Data Set (MDS) assessment tool with a reference date of 2/13/24 documented Resident #5 had a Brief Interview of Mental Status (BIMS) score of 4. A BIMS score of 4 suggested severe cognitive impairment. The MDS documented he had an admission date of 2/9/24. Resident #5 exhibited wandering behavior daily during the review period. He needed partial assistance from another person for indoor mobility, had impairment to both of lower extremities and utilized a walker. Resident #5 required supervision or touching assistance to walk 50 feet with two turns. The MDS documented he had the following diagnoses: metabolic encephalopathy, diabetes mellitus, dementia, anxiety, and chronic obstructive pulmonary disease. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice regarding signing out ointment treatments as being completed and initiating physician's orders for 2 or 3 residents reviewed (Resident #4 and #11). The facility reported a census of 110. Findings include: 1) The annual Minimum Data Set (MDS) assessment tool with a reference date of 1/7/24 documented Resident #4 had a Brief Interview of Mental Status (BIMS) score of 2. A BIMS score of 2 suggested severe cognitive impairment. The MDS listed the following diagnoses: dementia, hypertension, peripheral vascular disease, and benign prostatic hyperplasia. The Care Plan focus area with an initiation date of 1/12/24 documented Resident #4 had a communication problem related to confusion, short-term memory and dementia. The care plan directed staff to monitor for presence or absence of symptoms such as fever, cough and shortness…

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 facility policy review the facility failed to ensure 1 of 3 residents (Resident #5) was assessed for an elopement risk after he left the building on 2/13/24. The facility reported a census of 110 residents. Findings include: The admission Minimum Data Set (MDS) assessment tool with a reference date of 2/13/24 documented Resident #5 had a Brief Interview of Mental Status (BIMS) score of 4. A BIMS score of 4 suggested severe cognitive impairment. The MDS documented he had an admission date of 2/9/24. Resident #5 exhibited wandering behavior daily during the review period. He needed partial assistance from another person for indoor mobility, had impairment to both of lower extremities and utilized a walker. Resident #5 required supervision or touching assistance to walk 50 feet with two turns. The MDS documented he had the following diagnoses: metabolic encephalopathy, diabetes mellitus, dementia, anxiety, and chronic obstructive pulmonary disease.…

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 interviews and facility policy review the facility failed to ensure Resident #6, #7, and #8 medical record contained bath records and Resident #11 medical record contained completed skin assessments. The facility reported a census of 110 residents. Findings include: 1) According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 12/6/23 Resident #6 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented Resident #6 was dependent on staff for showering/bathing. The MDS documented the following diagnoses: heart failure, renal failure, diabetes mellitus, depression, chronic pain and COVID-19. The Care Plan focus area with an initiation date of 3/2/22 documented Resident #6 had activities of daily living (ADL) self-care performance deficit related to weakness, fatigue, and impairment balance. The care plan documented staff were to provide her with a sponge bath when a full bath or shower cannot be tolerated. Record review of Resident #6's…

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

Based on observations, clinical record review, staff interviews and facility policy review the facility failed to follow infection control practices while completing incontinent cares for 1 of 3 residents (Resident #14). The facility reported a census of 110 residents. Findings include: The quarterly Minimum Data Set (MDS) with a reference date of 12/15/23 documented Resident #14 had a Brief Interview of Mental Status (BIMS) score of 8. A BIMS score of 8 suggested mild cognitive impairment. The MDS documented the resident always incontinent of urine and bowel. The MDS documented the following diagnoses for Resident #14: dementia, coronary artery disease, depression, and COVID-19. The Care Plan focus area with an initiation date of 3/20/2020 documented she had activities of daily living (ADL) self care performance deficit related to dementia, impaired balance, limited mobility and weakness. The care plan documented she required assistance from staff with personal hygiene care. Staff directed to ask Resident #14 routinely and as needed if she needs to use the restroom to prevent…

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, resident, and family interview, along with facility policy, the facility failed to assure residents were treated with respect and dignity for which residents were exposed to social media for 4 of 6 residents reviewed (Resident #4, #5, #6, and #7). The facility reported a census of 108 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required dependent assistance with all aspects of activities of daily living, sometimes makes self understood and sometimes understands others, has verbal behaviors (threatening, screaming, cursing at others) for which occurred 4-6 days a week, and frequently incontinent of bowel and bladder. The resident's diagnoses included senile degeneration of brain, anemia and heart failure. The Care Plan included Resident #4 showed recent allegation of being exposed to (social media)…

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 interviews, resident council minutes, facility call light audits, facility assessment, policy review, and staff interviews the facility failed to provide sufficient staff to meet the residents' needs and answer call lights timely (within 15 minutes per regulatory standards) for 5 of 5 residents interviewed, and 3 of 3 nursing units reviewed. The facility reported a census of 104 residents. Findings include: During confidential resident interviews starting on 9/27/23 at 1:45 PM to 9/30/23 at 6:45 PM, 5 of 5 interviewable residents who had a Brief Interview for Mental Status (BIMS) score of 12-15 reported concerns about call light response times. One resident reported it took a long time for staff to answer her light, and when staff came, the staff person told her they would be back but didn't return for an hour. The resident reported she had waited up to 4 hours for someone to answer her call light. Staff response times were worse on the night shift. The resident had a clock the wall in her room…

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

Based on facility record review, review of 2567's, and staff interviews, the facility failed to effectively address repeat deficiencies cited during prior surveys, and failed to implement an effective, comprehensive Quality Assurance Performance Improvement (QAPI) program that focused on indicators of the outcomes of care and quality of life. The facility identified a census of 104 residents. Findings include: Review of facility records revealed repeated deficient practices identified during the facility's recertification surveys completed 6/29/23, complaint and facility reported incident (FRI) 8/8/23, and during the current complaint, FRI, and recertification survey revisit investigations. During an interview on 10/9/23 at 2:30 PM, the Executive Director (ED), reported issues brought to the QA (Quality Assurance) committee for discussion, then the committee decided if they needed to work on the issue. The ED stated concerns also brought up during the monthly Resident Council meeting and he determined if QAPI needed. The ED stated the QA committed prioritize the concerns that were…

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 facility policy review, the facility failed to provide a safe and sanitary environment to help prevent cross contamination and potential exposure to pathogens. The facility failed to follow hand hygiene, change gloves when contaminated, and follow disinfecting practices consistent with accepted standards of practice for 1 of 3 residents reviewed (Resident #8) during a dressing change. The facility staff also failed to transport soiled linens in a manner to prevent cross-contamination for 1 of 3 units observed. The facility reported a census of 104 residents. Findings include: 1. Resident #8's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had diagnosis of diabetes, wound infection, and a Stage 4 pressure ulcer to her left buttock. The MDS indicated the resident required extensive assistance of two persons for bed mobility and total dependence of two persons for transfers. The MDS documented the resident took an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, and policy review the facility staff failed to transfer a resident as directed by the resident's care plan for one of three residents reviewed for transfers (Resident #4), and failed to transfer a resident appropriately and safely using a gait belt for one of three residents reviewed for transfers (Resident #9). The facility reported a census of 104 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had diagnosis of vascular dementia, diabetes, and glaucoma. The MDS assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated severely impaired cognition. The MDS indicated the resident required assistance of two persons for transfers. The MDS revealed the resident had a history of falls. The Care Plan updated 4/28/23 revealed the resident had risk for ADL self-performance decline due to weakness, cognitive impairment secondary to vascular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to provide incontinence care in a manner to prevent cross contamination for one of three residents observed for incontinence care (Resident #9), and for one of three residents observed for catheter and nephrostomy care (Resident #10). The facility reported a census of 104 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had diagnoses of Non-Alzheimer's dementia. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated severely impaired cognition. The MDS documented the resident required limited assistance of one for transfers and extensive assistance of one for toileting. The resident had bowel and bladder incontinence. The Care Plan revised 3/13/23 revealed Resident #9 had incontinence and a risk for falls due to confusion and gait/balance problems. The directives for staff included…

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, resident interviews, staff interviews, pharmacist interviews and facility policy review the facility failed to follow physician orders for 4 of 4 residents reviewed with medication errors reported (Resident #1, #2, #3, and #4). The facility administered morphine sulfate (a narcotic medication) extended release 90 mg (milligrams) crushed and sublingually to Resident #1, and administered 16 mg of Dexamethasone (steroid) instead of 4 mg as ordered to Resident #2. Additionally, Resident #3 received a narcotic medication on an as needed dose without an order and Resident #4 received another resident's medicated eye drops. The facility reported a census of 108 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 13 out of 15 points and had the following diagnoses: cancer, deep vein thrombosis and diabetes mellitus. The MDS also identified Resident #1 required only 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, family and staff interviews, the facility failed to answer call lights in a timely manner for 5 of 5 residents reviewed for call lights (Residents #6, #7, #8, #9 and #10). The facility reported a census of 108 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #6 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 out of 15 points. The MDS also identified Resident #6 with the following diagnoses: cerebral palsy, anxiety disorder and respiratory failure. The MDS also identified Resident #6 required extensive staff assistance with bed mobility, transfers and bathing and required one person assist with dressing and toileting. The Care Plan dated 8/30/21 identified Resident #6 with the problem of ADL (Activities of Daily Living) self care performance deficit and had documentation of the following: -Prefers to be out of bed between 7:00 AM to 8:00 AM daily -Provide assist of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, resident and staff interview, and facility policy review, the facility failed to document adequate assessments after medication errors for 2 of 4 residents reviewed (Resident #1 and #4). The facility reported a census of 108 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 13 out of 15 points. The MDS documented the resident had the following diagnoses: cancer, deep vein thrombosis and diabetes mellitus. The MDS also identified Resident #1 required only staff supervision for most activities of daily living (ADL). The MDS identified Resident #1 complained of pain occasionally and the worst he rated the pain level was 9 out of 10. The MDS documented the resident received opioids on 6 of the 7 days of the assessment period. The Care Plan dated 7/5/23 for Resident #1 documented the resident has altered respiratory status and directed staff as follows:…

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, resident, and staff interviews, the facility failed to keep a comfortable temperature in one of the facilites dining rooms. Temperatures were outside the regulation of 71 to 81 degrees. The facility reported a census of 110 residents. Findings include: During an observation of the dining room on 6/20/23 at 2:00 PM, the infrared thermometer reading recorded a temperature of 85 Farenheit (F) degrees. On 6/22/23 at 3:00 PM, observed the temperature at 90 F degrees. During an interview on 6/20/23 at 2:30 PM with Staff G, revealed the temperatures were too warm for the staff to work in the dining room for some time now and she overheard residents complain about the warm temperatures. She further stated the air conditioning had not been working properly since August of 2022. During an interview with the Director of Facilities on 6/20/23, he reported the air conditioning system was not working properly since last August and it was in the works to replace the system in the near future. In an interview on 6/21/23 at 11:30 AM Resident #49 stated she felt the temperature…

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 record review, staff interviews, and facility policy review the facility failed to provide routine bathing per residents wishes for 5 of 5 residents (Resident #1, #86, #33, #59, and #88) reviewed for bathing. The facility reported a census of 110 residents: Findings include: 1. The Minimum Data Set (MDS) for Resident #1 dated 4/13/23 documented a Brief Interview of Mental Status (BIMS) of 13 out of 15 indicating no cognitive impairment. The MDS also documented he is physical dependent on staff for bathing. Record review of a document titled, Documentation Survey Report v2 for April 2023 documented Resident #1 received one (1) bath for the month. Record review of a document titled, Documentation Survey Report v2 for June 2023 documented Resident #1 received one (1) bath for the month. 2. The MDS dated [DATE] for Resident #86 documented a BIMS of 13 out of 15 indicating no cognitive impairment. The MDS also documented he is physical dependent on staff for bathing. Record review of a document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to repair their roof after damage was caused from the Derecho (August 10, 2020). The facility has received multiple bids for a new roof once damage was identified without accepting offers. Observations of damage to the building have caused the ceiling of the activity room to fall, the main dining room to have wet ceiling tiles and the nurses station to bow. A strong, musty, damp odor was smelled throughout the facility. Dried water marks were identified throughout the facility walls. Throughout the 100 and 200 hallways and resident room areas the air vents, ceiling tiles, drop ceiling frame, fire sprinkler system, air conditioner unit duct work and cupboards, a black substance had been identified. The facility reported a census of 110 residents. Findings include: During an observation on 6/20/23 at 12:09 PM, it was revealed that several ceiling tiles throughout the building had active, damp water damage and in the lights on 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 observations, resident and staff interview, and facility policy review, the facility failed to serve all foods at palatable temperatures for 1 of 3 meal services observed. The facility reported a census of 110 residents. Findings include: 1. During confidential resident interviews starting on 6/19/23 at 1:00 PM to 6/21/23 at 8:30 AM, 4 of 6 residents reported food temperatures often not hot when meals served. One resident reported her breakfast of sausage, biscuits, and eggs were cold and it was common for her food to be cold. Two residents reported breakfast food not hot but edible on 6/21/23. Another resident reported vegetables were cold on meal tray during lunch on 6/19/23. Observations on 6/21/23 revealed the following: a. At 7:35 AM, dietary staff wheeled a cart with meal trays to the North 200 hallway. b. At 7:52 AM, the cart with meal trays sat in the middle of the North 200 hall and a CNA delivered a meal tray to a resident. c. At 8:01 AM, three meal trays and a test tray remained on the cart parked in the North 200 hall. d. At 8:06 AM, the CNA took the last meal…

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 interviews, and facility policy review the facility failed to have an effective antibiotic stewardship program to monitor infections in the facility and use of antibiotics. The facility reported a census of 110 residents. Findings include: Review of the facilities May 2023 antibiotic tracking logs lacked documentation and evaluation of type of symptoms for antibiotic use and if the facility obtained labs to ensure appropriate for treatment. During an interview on 6/20/23 at 1:19 PM with the facilies Infection Preventionist (IP) revealed she does not have antibiotic tracking logs for March and April 2023. During interview with the facilities IP on 06/20/23 at 1:10 PM revealed she has recently started in the position and does not currently have her Infection Preventionist certificate but is serving as the IP. She revealed she has not had formal training for tracking antibiotics. Review of the facilities policy titled, Infection Surveillance, titled 5/22/23 instructed the following: The facility will collect data to properly identify possible…

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 record review, staff, resident and volunteer interviews and review of facility policy, the facility failed to provide care for 2 of 26 residents reviewed (Resident #7 and #19) in a manner to promote dignity and respect. The facility reported a census of 110 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #7 dated 4/12/23 assessment identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #7 's MDS included diagnoses of cerebral palsy, anxiety disorder, and depression. A facility grievance report dated 5/1/23 revealed Resident #7 made a formal complaint that she did not get her shower on 4/30/23 and that she was embarrassed as she went to a doctor's appointment on the morning of 5/1/23 without being clean. The report documented the concern was referred to nursing and the Assistant Director of Nursing was informed of the concern. The report lacked any documented resolutions. On 06/19/23 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.

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 accurately document advance directives for 1 of 7 residents (Resident #108) reviewed. The facility reported a census of 110 residents. Findings include: Review of the hospice service hard chart revealed Resident #108's Iowa Physician Orders for Scope of Treatment (IPOST), documented a Do Not Attempt Resuscitation (DNR) choice for the Cardiopulmonary Resuscitation (CPR) category. The IPOST was signed and dated on [DATE] by Resident #108 and the physician or physician's care team. On [DATE] at 10:35 AM Facility electronic record review and IPOST binder revealed Resident #108's IPOST was signed and dated on [DATE] by the Resident and the physician or physician's care team. Facility did not update the electronic chart and the IPOST binder with the latest changes in code status. During an interview on [DATE] at 1100 Staff B confirmed Resident #108 was considered full code after verifying in the IPOST binder and 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 clinical record review, staff interview, and facility policy review the facility failed to develop a comprehensive care plan for one of twenty-six residents reviewed (Resident #11). The facility reported a census of 110 residents. Findings include: The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had diagnoses of anemia, Alzheimer's disease, and dementia. The MDS documented the resident took an antidepressant and anticoagulant medications for seven of seven days during the look-back period. The Medication Administration Record and Physician's Orders for Resident #11 revealed apixaban (an anticoagulant) twice a day for atrial fibrillation started 1/13/23. The Care Plan revised 2/22/22 revealed the resident had an ADL (activities of daily living) self care performance deficit related to cognitive decline, weakness, and a fractured right distal femur diaphysis (shaft of the long bone). The Care Plan revised 3/30/22 revealed Resident #11 took psychoactive medications…

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 revise a Care Plan for 1 of 2 residents reviewed (Residents #55) with a catheter. The facility reported a census of 110 residents. Findings include: Resident #55 's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. The MDS identified the resident required extensive assistance of two persons with bed mobility and toileting. The MDS identified the resident was dependent on two persons with transfers. The MDS indicated Resident #55 walking in the room or hallway did not occur in the seven day look back period. The MDS indicated the resident had an indwelling catheter and stage 4 pressure ulcer (full tissue thickness loss with exposed bone, tendon or muscle). The MDS included diagnoses of heart failure, anemia, hip fracture, abnormal posture and need for assistance with personal care. A Physician Order…

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 and resident interviews, and facility policy review the facility failed to provide the appropriate level of transfer assistance and also failed to stay with the resident while on the toilet as directed by the care plan for 1 of 1 resident reviewed (Resident #19) for toileting transfers. The facility reported a census of 110 residents. Findings include: 1. Resident #19's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS identified the resident required extensive assistance of one person with bed mobility and toilet use and extensive assistance of two persons with transfers. The MDS indicated Resident #19 walking in the room or hallway did not occur in the seven day look back period. The MDS identified the resident used a wheelchair for locomotion. The MDS included diagnoses of multiple sclerosis, depression, thyroid disorder and osteoporosis. 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 clinical record review, resident and staff interviews, and review of facility policy, the facility failed to provide a restorative program to residents with mobility and range of motion concerns for 2 of 2 residents reviewed (Resident #6 and #7). The facility reported a census of 110 residents Findings include: 1. Resident #6's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS identified the resident required extensive assistance of two persons with toilet use and dependent of two persons for transfers. The MDS indicated the resident required extensive assist of one person for bed mobility and dressing. The MDS indicated Resident #6 walking in the room or hallway did not occur in the seven day look back period. The MDS indicated the resident required a wheelchair for locomotion. The MDS indicated the resident had impairment in range of motion (ROM) to upper extremity on one side and lower extremity on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to ensure complete and appropriate incontinence care provided for three of four residents observed for incontinence care (Resident #11, #18, and #19). The facility reported a census of 110 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had diagnoses of anemia, Alzheimer's disease, and dementia. The MDS revealed the resident had short-term and long-term memory impaired, and severely impaired decision making skills. The MDS indicated the resident always had bowel and bladder incontinence, and required extensive assistance of two staff for bed mobility and toileting. The Care Plan revised 2/22/22 revealed the resident had an ADL (activities of daily living) self care performance deficit related to cognitive decline, weakness, and a fractured right distal femur diaphysis (shaft of the long bone). The Care Plan also 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.

Based on clinical record review, facility policy review and resident and staff interviews the facility failed to provide sufficient staff to meet the needs for 1 of 5 residents reviewed (Resident #7) for call lights. The facility reported a census of 110 residents. Findings include: The Minimum Data Set (MDS) for Resident #7 dated 4/12/23 identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #7's MDS included diagnoses of cerebral palsy, anxiety disorder, and depression. The facility Grievance Report dated 5/1/23 revealed Resident #7 complained on 4/29/23 that her call light was on from 2:15 PM to 4:30 PM without being answered. The report documented the concern was referred to nursing and the Assistant Director of Nursing was informed of the concern. The report lacked any documented resolutions. On 6/19/23 at 11:24 AM the resident reported there was not enough staff. Resident #7 reported she put her call light on that morning at 7:30 AM and it did not get answered until 9:00 AM. She reported she watched the clock on 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 clinical record review, facility policy review, and staff interviews the facility failed to complete Monthly Medication Regimen Review (MRR) by a licensed pharmacist for 3 of 5 residents reviewed (Resident #1, #11, and #14). The facility reported a census of 110. Findings include: 1. The Minimum Data Set (MDS) for Resident #14 dated 4/30/23 documented a Brief Interview of Mental Status (BIMS) of 9 out of 15 indicating moderate cognitive impairment. The MDS documented diagnosis of major depressive disorder, anxiety, and unspecified dementia. Review of facility binder titled, Pharmacy, revealed no MRR's completed for Resident #14 for the months of July 2022, August 2022, September 2022, October 2022, February 2023, and March 2023. Review of policy titled, Medication Therapy revised on April 2007 provided by the Director of Nursing (DON) documented the following: The consultant pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when 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, clinical record review, staff interviews, and facility policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow hand hygiene, gloving and disinfecting practices consistent with accepted standards of practice for 5 of 5 residents reviewed (Resident #55, #65, #18, #45, and #11) during incontinence and catheter care. The facility failed to change gloves when contaminated while providing incontinence cares for 3 of 4 residents observed for cares (Resident #11, #18, and #19). The facility failed to disinfect the floor in a resident's room after contaminated with a soiled washcloth used during resident cares. The facility failed to sanitize hands before, during and after resident cares. The facility staff also failed to properly store a basin used for resident care to prevent cross contamination and potential exposure to pathogens. The facility reported 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 clinical record review, staff interviews, and facility policy review the facility failed to ensure 2 of 5 residents (Resident #78 and 34) received education on the influenza vaccination prior to refusal. The facility reported a census of 110 residents. Findings include: 1. Record review of a Resident #78 Electronic Health Record (EHR) Immunizations documented she refused the influenza vaccine. Record review of Resident #78 Progress Notes since September 2022, lacked documentation of education provided to her regarding the influenza vaccination. 2. Record review of Resident #34 Immunizations documented she refused the influenza vaccination. Record review of Resident #34 Progress Notes since September 2022, lacked documentation of education provided to her regarding the influenza vaccination. During an interview with the facilities Infection Preventionist (IP) on 6/20/23 at 1:19 PM revealed she does not have documentation of Resident #78 and Resident #34 receiving education of the influenza vaccination. During an interview on 06/22/23 at 3:27 PM with the facilities Director…

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.