Country Lane Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to follow infection prevention protocols for 2 of 3 residents (Resident #9 and Resident #14) reviewed with indwelling urinary devices. The facility reported a census of 51 residents.Findings include:1. Review of the Minimum Data Set (MDS) dated [DATE] identified Resident #9 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The list of diagnoses included diabetes mellitus, spina bifida and necrotizing fasciitis. The MDS identified Resident #9 dependent on staff assistance for toileting, showers, lower body dressing, putting on a taking off footwear. It also identified Resident #9 required partial/moderate staff assistance with upper body dressing, personal hygiene and transfers and had an ostomy (had both colostomy and urostomy). The MDS indicated Resident #9 admitted to the facility with a urostomy. Review of the Care Plan, dated 7/22/25, revealed a Focus area to address [name redacted]…

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

Based on clinical record review and staff interview, the facility failed to initiate treatment for an eye infection timely and in accordance with professional standards of practice for 1 of 5 residents reviewed. (Resident #3) The facility reported census was 53. Findings include: According to a Minimum Data Set (MDS) with a reference date of 4/29/25, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 4, indicating a severely impaired cognitive status. Resident #3's diagnosis included non-Alzheimer ' s dementia. According to a Progress Note dated 4/20/25 at 6:09 p.m. and written by Staff B, Licensed Practical Nurse (LPN), Resident #3's family summoned the nurse to assess Resident #3's right eye. The right eye was swollen, reddened and draining. Resident #3 indicated it was itchy and hurt a bit. Staff B indicated a communication note was left for the provider (nurse practitioner or physician). A Communication with Provider form was filled out by Staff B, dated 4/20/25 indicating Resident #3's right eye was swollen, reddened , with some drainage and Resident #3 was…

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, food temperatures during food services, and resident interview, the facility failed to serve food in an attractive and palatable manner for 1 of 2 meals. The facility reported census was 59. Findings include: On 2/12/25 at 12:15 p.m., a sample lunch tray provided to the State Agency. The meal consisted of a chicken patty and green beans. The chicken patty edges were hard, tough and chewy. No concerns with the green beans noted. An observation in the dining room revealed the puree green beans served to a resident appeared to be of a soup consistency. According to the Minimum Data Set (MDS) dated [DATE], Resident #7 had a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognitive status. Resident #7 was independent with transfers, mobility, dressing, toilet use and personal hygiene needs and was occasionally incontinent of bladder. Resident #7's diagnosis included congestive heart failure, diabetes mellitus and chronic obstructive pulmonary disease. During an…

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

Based on clinical record review, policy review, provider and staff interviews the facility failed to implement a physician order to change a type of wound dressing for 1 of 3 residents (Resident #6) with a wounds. The facility reported a census of 57 residents. Finding include: The Minimum Data Set (MDS) assessment, dated 9/12/24, revealed Resident #6 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating intact cognition. The MDS revealed the resident required partial/moderate assistance with rolling from left to right; sit to standing; and upper body dressing. The MDS identified the resident dependent for chair/bed to chair transfers. The MDS list of diagnoses included necrotizing fasciitis (bacterial infection that destroys tissue under the skin), diabetes mellitus, and wound infection. The MDS documented the resident had two Stage III pressure ulcers present on admission, along with surgical wounds. The Nursing Note dated 9/6/24 at 2:52 PM revealed resident arrived at facility via hospital transport accompanied by transport driver. Resident is a spina bifida…

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, and staff interviews the facility failed to have a consistent plan and procedure for advance directives for 6 of 25 residents reviewed. (Resident #9, #17, #19, #34, #42, and #60). The facility reported a census of 56 residents. Findings include: 1. Review of facility document, Policy For Resuscitative Services/Cardiopulmonary Resuscitation (CPR), indicated on [DATE] Resident #9 signed she would like to have CPR performed in the event that her respirations or pulse would cease. Review of Resident #9's EHR (Electronic Health Record) on [DATE], failed to indicate a code status on the header of Resident #9's file. Observations on [DATE] revealed a Full Code magnet outside of Resident #9's door was placed on the right side of the door. Magnets on the right side indicated the Resident in bed B, Left side indicated bed A. Resident #9 was in bed A. Revealing the magnet was on the wrong side of the door. 2. Review of Resident #17's EHR header indicated Full Code status 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, facility provided documents, and interviews the facility failed to provide sufficient qualified nursing staff to provide nursing services that meet the residents' needs safely and in a timely manner and promotes each resident's rights, physical, mental, and psychosocial well-being The facility reported a census of 56 residents. Findings include: In an interview on 9/12/24 at 1:30 PM, Staff C, RN, indicated that during the process of admissions, when the resident comes to the facility from the hospital a packet will be sent with them. This packet includes the resident's health history, medication orders, lab orders, and any treatment or therapy orders. There have been times this packet was not available, the nurse would need to find who has it (at times has been the DON or administrative staff), if the nurse is not able to locate the packet they are to contact the hospital and get it faxed to them. Once the packet is reviewed orders are faxed to the pharmacy. The MDS nurse does the batch orders (standing orders including the resident's level of care 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 interviews, record review, and policy review, the facility failed to provide Monthly Drug Regimen Reviews for the month of July. The facility reported a census of 56 residents. Findings include: During a review of the monthly pharmacy reviews, it was revealed there were no reviews done for any residents residing in the facility for the month of July. On 9/10/24 at 4:02 p.m., the Administrator stated that there was no pharmacy review done in July. The Administrator handed an email from a Consultant Pharmacist. The Administrator stated that the pharmacist that wrote the email was not the facility's normal consultant pharmacist. An email dated 8/8/24 at 8:13 a.m., from a Consultant Pharmacist, documented that the consultant pharmacist noted that recommendations from July were not completed. The Consultant Pharmacist documented that she had re-issued any recommendations that were still relevant. This pharmacist requested that the facility let her know if there was anything she could do to assist with getting these taken care of. A Consultant Pharmacist Reports - Medication…

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

Based on observation, interview, and facility policy review, the facility failed to prevent potential for contamination when gloves were not changed at appropriate times during meal service for 1 of 1 meal services observed. The facility failed to ensure resident food had been stored at appropriate temperatures and expired food had been removed when 1 of 1 resident food refrigerators lacked a thermometer, temperature log, labels, and opened dates of food or drinks. The facility further failed to ensure dish sanitation when the dishwasher log lacked entries for safe wash and rinse temperatures and the cups used for service appeared to have a coating of white film for 1 of 1 facility dishwashers. The facility reported a census of 56 residents. Findings include: On 9/09/24 at 10:46 AM, during initial tour of the kitchen, a refrigerator/freezer kept in the dining room, contained many undated and unlabeled food and drinks. The Dietary Manager revealed this refrigerator contained resident food and drinks brought in for resident use. The Dietary Manager confirmed the resident food…

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

Based on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during surveys completed in the last six months. The facility reported a census of 56 residents. Findings include: Review of the facility's CMS-2567 form from a recertification survey which occurred 4/29/24 to 5/02/24 revealed the facility received non-harm level citations for the following areas: resident rights/dignity, reasonable accommodation of needs, services provided meet professional standards, bowel/bladder incontinence, or catheter, sufficient nursing staff, psychotropic drug use, food procurement/storage/service/sanitation, and QAPI program/plan. The facility's current recertification survey, entrance date 9/09/24, resulted in multiple repeated non-harm level deficient practices for the following areas:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and clinical record review, the facility failed to ensure resident choice of caregivers had been respected for 1 of 3 residents (Resident #18) reviewed for dignity, when a caregiver continued to assist with cares following resident request otherwise. The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition and intermittent behavior that included rejection of care. Diagnoses included anxiety disorder, depression, and neuropathy. The Care Plan, revised 7/25/24, revealed Resident #18 had a self-care deficit and required one person staff assistance for bed mobility, dressing, transfers, and toileting. The Care Plan informed that Resident #18 would refuse a gait belt at times but lacked indication for refusal of cares or preferences with caregivers. Review of Nursing Progress Notes, revealed the following entries:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, clinical record review, and facility policy review, the facility failed to ensure accessibility of a hand washing sink and working overhead lamp in resident room for 1 of 2 residents (Resident #18) reviewed for choices. The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. MDS revealed Resident #18 had moderate hearing difficulty and limited vision. Diagnoses included anxiety disorder, depression, and neuropathy. The Care Plan, revised 7/25/24, revealed Resident #18 had a self-care deficit and required one person staff assistance for bed mobility, dressing, transfers, and toileting. On 9/09/24 at 1:30 PM, Resident #18 reported an inability to get their wheelchair into the bathroom to reach or access the sink. Resident #18 reported over-bed lamp had a difficult pull string and light often did not work.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure basic nursing principles were followed for 2 of 24 residents reviewed (Resident #9 and Resident #20). The facility readmitted Resident #9 from a hospital stay and did not ensure that the primary provider was aware of her readmission therefore this resident did not receive a number of her medications. The facility obtained an order of liquid morphine (narcotic) for Resident #20 who was on Hospice Care and actively dying. The facility did not obtain a bottle of liquid morphine for Resident #20 and gave her the medication from another resident's bottle. The facility reported a census of 56 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had diagnoses of anemia, heart failure, depression, hypertension (high blood pressure), stage 4 chronic kidney disease, type 2 diabetes with diabetic chronic kidney disease, seizure disorder, and a history of stroke. Review of Resident #9'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 interview, clinical record review, and facility policy review, the facility failed to follow Provider's orders for indwelling catheter balloon size for 1 of 2 resident (Resident #43) reviewed for bowel and bladder incontinence. The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS) dated , 8/13/24, revealed Resident #43 utilized an indwelling catheter and had diagnoses of Neurogenic bladder and urinary retention. The Care Plan, dated 5/14/24, revealed Resident #43 had an indwelling catheter, placed on 5/11/24, with goal that catheter will be managed appropriately and not exhibit signs of infection or urethral trauma. Interventions included: use of a 16 French (size) catheter with 10 milliliter (mL) balloon and to change catheter as ordered by Provider. Review of a telephone order, dated 5/14/24, and signed by Provider on 5/17/24, revealed an order for indwelling (Foley) catheter size 16 French with 10 mL balloon, changed every 30 days, for diagnosis of urinary retention. The Medication/Treatment Administration Record (MAR/TAR), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a Gradual Dose Reduction (GDR) was trialed for 1 of 5 residents reviewed (Resident #38). A Consultant Pharmacist recommended a GDR for Duloxetine (antidepressant medication)from 40 mg (milligrams) to 30 mg for Resident #38 in November of 2023. The primary provider for Resident #38 agreed to the GDR in January of 2024. The Duloxetine was not decreased per the recommendation and approval of the provider. The facility reported a census of 56 residents. Findings include: A Minimum Data Set for Resident #38, dated 4/8/24, documented a Brief Interview for Mental Status was scored at a 13 out of 15, which indicated intact cognition. It documented the resident was taking antidepressant medication. It documented that diagnoses for this resident included depression and anxiety. A Minimum Data Set, dated [DATE], documented a Brief Interview for Mental Status was scored at 13 out of 15 which indicated intact cognition. A Pharmacist's Report…

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

Based on facility document review, staff interview and facility policy review, the facility failed to ensure a process in place to allow consistent access to resident funds outside of business hours for five of five residents who participated in the trust fund (Resident #11, #12, #27, #28, and #40). The facility reported a census of 58 residents. Findings include: Review of a document provided by the facility titled Residents who use the trust, undated, revealed the following residents utilized the trust fund: Resident #11, Resident #12, Resident #27, Resident #28, and Resident #40. On 5/1/24 at 3:12 PM, the facility's Business Office Manager (BOM) and Administrator queried as to how residents accessed their personal funds. The BOM responded if residents asked, she would give it to them. The Administrator acknowledged money had not been available 24 hours and would be moving forward. The Administrator further explained the facility had done some weekends, not really consistently, and there had been some access but not consistently. The Facility Policy titled Protection of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, clinical record review, and the facility policy, the facility failed to provide adequate staffing to prevent a fall with injury; answer call lights in a timely manner; provide feeding and bathing assistance; and provide a bed pan to a resident before an incontinent accident for 6 of 19 residents (Residents #10, #12, #19, #28, #46, #207). The facility census 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The MDS revealed Resident #19 used a wheelchair and dependent with toilet transfer and transfer to the chair/bed to chair. The Care Plan revealed a focus area dated 3/10/22 for required assistance with ADLs (activities of daily living) due to recent right shoulder surgery with need for immobilizer. The interventions revised on 2/15/24 revealed resident utilized an sit to…

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

Based on observations, menu review, policy review, and staff interviews, the facility failed to ensure 18 of 18 residents receiving a mechanical soft diet received the correct meal portion and failed to ensure 6 of 6 residents receiving a pureed diet received food in accordance to the menu. The facility reported a census of 58 residents. Findings include: The Week 2 Tuesday Menu directed staff to serve residents receiving a mechanical soft diet 1 serving of beans and ground franks, soft garlic bread, and 4 ounces of vegetables. The menu directed staff to serve residents receiving a pureed diet 1 serving of pureed beans and franks, 1 serving of pureed garlic bread, and 1 serving of pureed vegetables. On 4/30/24 at 9:45 a.m., the Dietary Manager cut 19 hot dogs into chunks and processed them to a ground consistency. She then measured the volume as 8 cups and walked over to a chart on the wall and stated she would use a #10 scoop. She transferred the hot dogs into a pan and added 19 scoops of baked beans. She did not then measure the total volume of the hot dogs and the beans. The noon…

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, facility document review, policy review, and staff interviews, the facility failed to maintain adequate kitchen sanitation and failed to follow infection control measures to prevent cross contamination during food service for 1 of 1 meal observed. The facility reported a census of 58 residents. Findings: The initial kitchen tour on 4/29/24 at 9:30 a.m., revealed the following concerns: a. Staff B Dietary Aide washed dishes using the dish washing machine. Upon request, Staff A [NAME] ran the machine again. The wash temperature gauge on the side of the machine read 108 degrees Fahrenheit. Staff A then ran the machine a second time and the wash temperature gauge read 108 degrees Fahrenheit. A sign on the side of the machine stated the minimum wash temperature should reach 155 degrees Fahrenheit. The Dietary Manager stated the facility did not have any strips to test the functioning of the machine and stated she could not remember the last time they had the strips. b. The water in the hand washing sink cold to the touch. Staff A stated this just started today 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 observations, staff interview, and clinical record review, the facility failed to ensure a dignified dining experience when a resident was not provided assistance timely during two meal observations and was not assisted timely after the resident spilled water on themselves for one of two residents reviewed for dignity (Resident #12). The facility reported a census of 58 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 3/28/24 revealed the resident scored 2 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The MDS documented the resident independent for eating. The Dietary assessment dated [DATE], noted to be the same day as the resident's MDS, revealed the resident required set up assist and encouragement/cues. The Comments section documented, she is able to feed herself after set-up and utilizes weighted silverware; staff may provide occasional PRN (as needed) assist. Observation of Resident #12…

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

Based on observation, clinical record review, policy review, resident interview and staff interview, the facility failed to individualize the physical space of a resident's bathroom in order to ensure the resident maintained independent functioning, dignity, and well-being for 1 of 1 residents reviewed for accommodation of needs (Resident #16). The facility reported a census of 58 residents. Findings: The Minimum Data Set (MDS) assessment tool, dated 2/13/24, listed diagnoses for Resident #16 which included acquired absence of the left leg above the knee, pain in the right shoulder, and chronic obstructive pulmonary disease. The MDS stated the resident required supervision or touching assistance for oral hygiene and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15 indicating intact cognition. A 4/19/21 Care Plan entry stated the resident able to complete oral hygiene independently and took care of his dentures himself. The resident's Census List stated he moved to his current room on 12/5/23. A 12/7/23 Interdisciplinary Team (IDT) Resident 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 resident interview, staff interviews, clinical record review, and the facility policy, the facility failed to supply the resident with a menu that provided him options for the meals for 1 of 3 residents reviewed for choices (Resident #10). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed resident needed set up and clean up assistance only for eating. The Care Plan revealed a focus area revised on 3/29/24 for a nutritional problem related to his multiple sclerosis, paraplegia, osteoarthritis, diabetes mellitus, vitamin D deficiency, depression, urinary incontinence, hypertension, and obesity. The interventions revised on 11/10/23 revealed a general with ground meat and thin liquid diet and honored food preferences/special requests as able. The Physician Orders revealed a regular/general…

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

Based on clinical record review, staff interview, and policy review, the facility failed to notify 1 of 3 Medicare Part A beneficiaries of coverage ending (Resident#8). The facility reported a census of 58 residents. Findings: The Beneficiary Notice-Residents discharged With the Last Six Months form, collected upon survey entrance, stated Resident #8 discharged from Medicare Part A on 1/19/24. Via email correspondence on 5/2/24 at 8:44 a.m., the Assistant Director of Nursing (ADON) stated the facility could not locate a discharge notice provided to Resident #8. She stated at the time of her discharge, the facility had a different Social Services Director. The facility policy Beneficiary Notices: Skilled Nursing Facility (SNF) Advanced Beneficiaries Notice (ABN) and Notice of Medicare Non-coverage (NOMNOC), effective 4/15/18, stated the facility would notify beneficiaries when their skilled nursing services and/or therapy services would end and their right to request an appeal.

Based on personnel record review, staff interview, and facility policy review the facility failed to ensure staff's background checks completed prior to hire date for 1 of 5 staff; and failed to ensure the dependent adult abuse mandatory reporter training current for 1 of 5 staff reviewed (Staff C, and Staff D). The facility reported a census of 58 residents. Findings include: According to Staff C, RN (Registered Nurse) personnel file her date of hire was 10/26/23 and the Single Contract Repository (SING) completed on 4/29/24 at 2:57 PM. Staff D, CNA (Certified Nurse Aide), personnel file lacked documentation of the dependent adult abuse mandatory reporter training. Staff D date of hire was 11/8/22. During an interview on 5/2/24 at 2:22 PM, the Administrator queried on the expectations of the dependent adult abuse mandatory reporter being completed and he stated it needed to be current. The Administrator asked the expectations on background checks and he stated they needed done prior to the staff member being hired. The Facility Abuse Policy (no date indicated) revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, the facility failed to ensure accurate Minimum Data Set (MDS) coding for 3 of 7 residents reviewed for medications (Residents #3, #18, #46) and for 1 of 1 residents reviewed with a catheter (Resident#11). The facility reported a census of 58 residents. Findings include: 1. The MDS assessment tool, dated 2/29/24, stated Resident #3 received an anticoagulant (a medication used to prevent blood clots). The February 2024 Medication Administration Record lacked documentation the resident received an anticoagulant. 2. The MDS assessment tool, dated 3/20/24, stated Resident #46 received an anticoagulant. The March 2024 Medication Administration Record lacked documentation the resident received an anticoagulant. On 5/2/24 at 12:37 p.m., the Assistant Director of Nursing (ADON) stated MDS coding should be accurate. She stated her trainer directed her to code medications such as aspirin as an anticoagulant. On 5/2/24 at 4:03 p.m., the ADON stated 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 observations, staff interviews, clinical record review, and facility policy review the facility failed to ensure medications were administered per physician order, failed to ensure parameters present for insulin administration for when to hold scheduled insulin dosage, failed to ensure medication dosages consistently included as part of medication orders, and failed to ensure rinse and spit following administration of a steroid inhaler for three of five residents reviewed for professional standards (Resident #11, Resident #18, Resident #50). The facility reported a census of 58 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 3/21/24 revealed the resident scored 06 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment the resident received insulin injections for 7 of the past 7 days. Review of the Care Plan dated 1/24/21, revised 4/23/24, revealed the following: Resident #11 is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, resident interviews, clinical record review, and facility policy review the facility failed to ensure activities of daily living (ADL) including eating assistance, nail care, shaving, and showers consistently completed for three of four residents reviewed for ADLs (Resident #12, #28, and #29). The facility reported a census of 58 residents. Findings include: 1. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #29 dated 2/2/24 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, self care for shower/bathing marked not applicable. The Care Plan dated 1/6/22 revised 4/29/24 revealed, Resident #29 has a self-care deficit due to impaired mobility with dx (diagnosis) of quadriplegia, protein calorie malnutrition/severe, anemia, hypotension, polyneuropathy, neurogenic bladder & bowel, vertigo, R) BKA (below knee amputation), insomnia, muscle spasms to 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 observations, staff interviews, clinical record review and facility policy review the facility failed to ensure catheter tubing remained off the floor, failed to accurately assess a resident for the presence of a catheter, and failed to ensure timely orders for an indwelling catheter for two of two residents reviewed for catheters (Resident #11, Resident #19). The facility reported a census of 58 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 3/21/24 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The assessment further revealed Resident #11 was always incontinent for urinary continence and did not have an indwelling catheter. The admission assessment dated [DATE] revealed per the urinary continence section that Resident #11 always continent. The option for an indwelling catheter was not selected. The Narrative Notes section at the bottom of the assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, and the facility policy, the facility failed to ensure the resident didn't have two active orders for the same opioid medication for 1 of 1 residents reviewed for pain (Resident #208). The facility reported a census of 58 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #209 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed diagnosis for multiple sclerosis. The MDS revealed one Stage 2 pressure ulcer, one Stage 3 pressure ulcer, and one Stage 4 pressure ulcer present on admission. The MDS revealed resident took opioids. The Care Plan revealed a focus area dated 4/12/24 for multiple sclerosis and at risk for a decline in current activities of daily living (ADL) self-performance level and injuries due to increased weakness, pain, fatigue, and impaired coordination. The Care Plan revealed a focus area dated 4/23/24 for Stage 4 pressure ulcer…

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 2. The MDS assessment dated [DATE] revealed Resident #13 scored a 6 out of 15 on the BIMS exam, which indicated cognition severely impaired. The MDS revealed the resident received an antidepressant. The MDS revealed a diagnosis of depression. The Care Plan revealed a focus area revised on 10/27/23 for a diagnosis of depression and resident received medication for the disease process. The interventions dated 2/3/22 revealed administration of an antidepressant medication as ordered by the primary care provider (PCP). The interventions dated 1/22/24 revealed antidepressant medication decreased by PCP/GDR (gradual dose reduction); observe for signs/symptoms of increased depression and notify PCP as needed. The Physician Orders revealed the following orders: a. Duloxetine 20 mg (milligram)- give 2 tablets- ordered on 5/8/23 and discontinued on 1/20/24 b. Duloxetine 30 mg- give 1 tablet- ordered on 1/23/24 The Pharmacist's Recommendation to Prescriber dated 11/2/24 revealed Resident #13 took Duloxetine 40 mg once…

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

Based on clinical record review, policy review, resident interviews and staff interviews, the facility failed to offer bedtime snacks to 2 of 2 residents who desired bedtime snacks (Residents #28 and #46). The facility reported a census of 58 residents. Findings include: 1. The 2/21/24 Minimum Data Set (MDS) assessment tool, dated 2/21/24, listed diagnoses for Resident #28 which included depression, diabetes, and non-Alzheimer's dementia. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. On 4/29/24 at approximately 1:00 p.m., Resident #28 stated staff did not offer him bedtime snacks. He stated he would like staff to offer him a snack. The Documentation Survey Report for April 2024 listed an entry for Snacks at 7:00 p.m. The following dates were blank or stated NA-Not Applicable and lacked documentation staff offered the resident a snack: 4/7/24, 4/8/24, 4/9/24, 4/11/24, 4/13/24, 4/15/24, 4/16/24, 4/18/24, 4/19/24, 4/20/24, 4/21/24, 4/24/24, 4/25/24, 4/26/24, 4/29/24, 4/30/24. 2. The MDS assessment tool, 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 observations and provider interview, the facility failed to pay it's waste management providers resulting in delayed and absent pick up. The facility reported census was 50 residents. Findings include: During an observation on 3/12/24 at 12:30 p.m. there were four full dumpster's of waste sitting on the facility premises. Three containers belonged to Provider A and one container belonged to Provider C. During an observation on 3/18/24 at 11:55 a.m. three dumpster's belonging to Provider A remain full with yellow tape wrapped around them. Provider C's dumpster had been emptied and an additional dumpster was now on the property. In an interview on 3/13/24 at 3:33 p.m. Provider B, owner/operator, stated the facility had been using multiple waste management companies due to failing to pay for services timely and in full. Provider B stated he was the third waste management provider he knows of and stopped picking up his dumpster's in November 2023 due to nonpayment. In an interview on 3/7/24 at 3:51 p.m. Provider A, owner/operator, stated he had been providing waste pick up…

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

Based on record review, staff interviews, facility policy review, and Centers for Disease Control information the facility failed to follow proper infection control practices to mitigate the risk for the spread of infectious disease. The facility reported a resident census of 50 residents. Findings include: According to an infection control log for January 2024, the facility had a COVID outbreak beginning on 1/7/24 and ending on 1/21/24 involving 27 residents. During that time frame 13 staff tested positive for COVID 19 and 11 staff were permitted to work prior to conventional return to work criteria being met. The following website for the Centers for Disease Control (CDC) https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assessment-hcp.html included updated guidance as of September 23, 2022. The Interim Guidance for Managing Healthcare Personnel with a respiratory disease called coronavirus disease 19 (COVID-19) (SARS-CoV-2) Infection or Exposure to SARS-CoV-2 included the following return to work criteria; a. Healthcare Personnel (HCP) who were asymptomatic throughout…

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, food temperatures during food services, and resident interviews, the facility failed to serve food within appropriate temperature ranges, with consistently adequate flavoring and in an attractive and palatable manner throughout 4 observed meals. Facility reported census was 50 residents. Findings include: During an observation on 3/18/24 at 11:55 a.m. a sample tray was provided which included baked ziti pasta, garlic toast, salad, and fruit cocktail. The food was good but slightly cool. The food had good flavoring and seasoning. There was only one entree with no alternative option prepared. In an interview on 3/18/24 at 11:55 a.m. Staff G, cook, stated the menu was for spaghetti, but the food order had not arrived so she substituted with ziti pasta instead. According to the week 4 menu, mandarin oranges were on the menu and not served. In an interview on 3/18/24 at 12:30 p.m. Resident #13 was sitting in the dining room with several peers eating lunch. Resident #13 was asked about meals and he stated they were good enough to keep you from starving, but they are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure residents treated in a dignified manner and value the resident's right to choose to stay in bed for breakfast and still be allowed to go outside and smoke for 1 of 3 residents reviewed for resident's rights (Resident #8). The facility reported a census of 60. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the resident required extensive assistance with two plus person assist for bed mobility and transfers and needed extensive assistance with one person physical assist for locomotion off the unit. The Care Plan identified a focus area dated 10/9/23 as follows: the resident preferred to smoke while at the facility and currently did not want a smoking cessation program. During an interview on 10/9/23 at 12:33 PM, Staff C, Certified Nurse Aide (CNA)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to update the Care Plan and fall interventions for 3 of 3 residents reviewed for falls (Resident #2, Resident #4, and Resident #5). The facility reported a census of 60. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) exam which indicated severely impaired cognition. The MDS revealed the resident required extensive assistance with 2 plus person physical assist for bed mobility, transfers, dressing, and toilet use. The MDS documented the resident required total dependence with bathing self performance and the bathing support provided required 2 plus person physical assistance. The MDS revealed since last prior assessment 2 or more falls with no injury and 2 or more falls with injury without major injury occurred. The Care Plan revealed a focus area initiated on 6/20/23 for risk of falls related to impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and the facility policy review, the facility failed to adequately supervise a resident in a shower chair after transferred to his room which lead to the resident falling out of the shower chair for 1 of 3 residents reviewed for falls (Resident #2). The facility reported a census of 60. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #2 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated severely impaired cognition. The MDS revealed the resident required extensive assistance with 2 plus person physical assist for bed mobility, transfers, dressing, and toilet use. The MDS revealed resident total dependence with bathing self performance and the bathing support provided required 2 plus person physical assistance. The MDS indicated since last prior assessment 2 or more falls with no injury and 2 or more falls with injury without major injury. The MDS documented the resident had diagnoses…

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 and staff interviews, the facility failed to provide incontinence cares for 1 of 4 residents reviewed who were unable to carry out the activity independently. (Resident #3) The facility reported census was 53. Findings include: According to the Quarterly Minimum Data Set (MDS) with an assessment reference date of 5/11/23, Resident #3 had long- and short-term memory deficits and a severely impaired cognitive status. Resident #3 required extensive assistance of two staff with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #3 was coded as always incontinent of bowel and bladder. Resident #3's diagnosis included Alzheimer's, Non-Alzheimer's Dementia, diabetes mellitus, seizure disorder and schizophrenia. Resident #3's Plan Of Care indicated a problem with self care deficit and need for physical assistance with toileting with interventions which included assistance of two to toilet and provide peri cares after each incontinent episode. In an interview on 7/24/23 at 1:04 p.m. Staff B, Certified Nurse Aide (CNA),…

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.