Kingsley Specialty Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Electronic Health Record (EHR) review, policy review, resident interviews and staff interviews the facility failed to provide dignity and respect to 1 of 8 residents reviewed (Resident #7). The facility reported a census of 31 residents.Finding include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS also documented diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, unsteadiness on feet and generalized muscle weakness. The MDS indicated Resident #7 required substantial / maximal assistance for transfers on and off the toilet and Resident #7 was completely dependent on staff for toileting hygiene.An observation on 8/4/25 at 1:15 PM revealed Staff A, Non Certified Aide (NA) entered Resident #7's room and shut the call light off. Resident #7 stated to Staff A he needed to go to the bathroom. Staff A told Resident #7 she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy and interviews the facility failed to permit a resident to return to the facility after hospitalization for 1 of 1 residents reviewed (Resident #39). The facility reported a census of 31 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #39 documented a discharge assessment with return anticipated for an unplanned short-term general hospital stay.The Clinical Progress Notes for Resident #39 showed on 3/10/25 at 9:01 PM showed the resident admitted to the hospital. The notes showed no documentation for readmission.In an interview on 8/4/25 at 1:32 PM, the locally assigned Office of the State Long-Term Care Ombudsman (OSLTCO) reported on March 7, 2025 the facility's Business Office Manager (BOM) called to discuss Resident #39's Medicare coverage ended and that he owed a substantial outstanding balance. The BOM reported Resident #32 wanted to remain at the facility until he had the strength to go home, but refused to pay. 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 Medication Administration Record (MAR) - Treatment Administration record (TAR), Electronic Health Records (EHR) review, resident interviews and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the MDS by not accurately assessing the use of insulin for 1 of 10 residents reviewed (Resident #7). The facility reported a census of 31 residents. Finding include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. On 8/4/25 at 1:21 PM Resident #7 stated he was not on insulin. Review of Resident #7's MDS dated [DATE] documented 7 days insulin injections were received during the last 7 days and no order for insulin.Review of Resident #7's EHR titled, Orders documented no current order for insulin.Review of Resident #7's EHR titled, Orders documented basaglar kwik pen started 2/3/23 and discontinued 3/22/24 and insulin…

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

Based on observation, Electronic Health Record (EHR) review, staff interview, policy, and Medication Administration Records - Treatment Administration Records (MAR-TAR) review the facility failed to provide needed services in accordance with professional standards by administering a medication that should have been held related to parameters for 1 of 3 residents (Resident #8). The facility reported a census of 31 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #8, dated 7/7/25 did not document a Brief Interview for Mental Status (BIMS). Review of EHR titled, Progress Notes dated 8/5/25 revealed a BIMS evaluation with a BIMS of 15 documented. The MDS documented diagnoses of essential hypertension and unspecified hypotension. An observation on 8/6/25 at 7:24 AM with Staff D, MDS Coordinator / Infection Preventionist (IP) / Registered Nurse (RN) present of Staff E, Registered Nurse (RN) prepare medications for Resident #8, blood pressure obtained 140/70, midodrine 10mg removed from the drawer, midodrine reviewed with the MAR, midodrine 10mg removed from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review and staff interviews the facility failed to provide 2 of 37 medications as ordered resulting in a medication error rate of 5.41. The facility reported a census of 31 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #8, dated 7/7/25 did not document a Brief Interview for Mental Status (BIMS). Review of EHR titled, Progress Notes dated 8/5/25 revealed a BIMS evaluation with a BIMS of 15 documented. The MDS documented diagnoses of essential hypertension and unspecified hypotension. An observation on 8/6/25 at 7:24 AM with Staff D, MDS Coordinator / Infection Preventionist (IP) / Registered Nurse (RN) present of Staff E, Registered nurse (RN) prepare medications for Resident #8, blood pressure obtained 140/70, midodrine 10mg removed from the drawer, midodrine reviewed with the MAR, midodrine 10mg removed from the bubble pack, the rest of Resident #8's medications removed from bubble pack, Staff E knocked on Resident #8's door, Staff E…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene after resident care for 2 of 2 residents reviewed (Resident #8 and #26). The facility reported a census of 31 residents.Findings include: 1. Observation on 08/06/2025 at 8:02 AM showed Staff K, Certified Nursing Assistant, (CNA) and Staff C, CNA performed hand hygiene, donned personal protective equipment (PPE) of a gown and gloves then provided care for a catheter and bowel movement incontinence. When finished Staff K removed the soiled gown and gloves, used the left hand to hold the trash receptacle, then used the right hand to place soiled PPE into the trash. Staff K next placed her right hand on top of the soiled PPE, and pushed the soiled PPE down further into the trash receptacle. Without performing hand hygiene Staff K arranged the resident’s sheet and bedside table. In an interview on 8/7/25 at 3:34 PM, the Administrator reported she expected staff to complete hand hygiene…

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 revise and update care plans to include appropriate interventions for residents to prevent repeated fall and injuries for 3 out of 3 residents reviewed (Resident #1, #2 and #3). The facility reported a census of 34 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of neurological disorder, dysphagia, and stroke. The MDS showed Resident #2 ' s cognitive skills for daily decision making as moderately impaired. Review of the facility Incident Reports from a look back period starting on admission [DATE] through 12/31/24 showed Resident #2 fell four times. The Incidents Reports for Resident #2 showed the following falls: a. On 11/8/24 at 11:00 PM- resident found with his back on the floor. b. On 11/9/24 at 4:53 PM- resident found sitting on the floor. c. On 11/25/24 at 10:47 PM- resident found on the floor sitting on both knees. d. On 12/7/24 at 9:47 AM-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interviews, and facility record review, the facility failed to provide adequate fall interventions and communicate inventions via the care plan to prevent falls that resulted in injury for 1 of 3 residents reviewed (Residents #1). The facility reported a total census of 34 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented the initial reentry to the facility from a short term general hospital stay. The Clinical assessment dated [DATE] for Resident #1 showed the Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. On 10/14/24 reassessment of the BIMS showed a score of 1 which indicated severe cognitive impairment. The Medical Diagnosis for Resident #1 showed diagnoses of dementia, blindness, cerebral infarction, and heart failure. The Fall Risk Evaluation dated 10/8/24 for Resident #1 showed the fall risk score of 13, which indicated a high risk of falling.…

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

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report from Fiscal Quarter 3, 2024 (April 1- June 30) review, facility staffing review, and staff interviews, the facility failed to meet staffing requirements in three metrics. The facility reported a census of 33 residents. Findings include: The PBJ Staffing Data Report with a run date of 9/4/24 triggered no data submitted for the quarter, excessively low weekend staffing, and failed to have licensed nursing coverage 24 hours a day for four or more days within the quarter and less than 24 hours per day licensed nursing coverage. Review of staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. The Reporting Direct-Care Staffing Information (Payroll-Based Journal) policy directed staff to electronically report staff and census information to CMS in compliance with 6106 of the Affordable Care Act. In an interview on 9/13/24 at 3:23 PM, the Administrator reported knowledge of the requirement of submitting staffing data to CMS. 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, infection control policy and staff interview, the facility failed to initiate a legionella water program for the facility. The facility reported a total census of 33 residents. Findings include: 1. Interview on 9/12/24 at 10:24 a.m., with Staff A, Maintenance Director revealed Staff B, Administrator was in charge of the Legionella water program. He did not do any testing or monitoring of the program. Interview on 9/12/24 at 10:26 a.m., with Staff C, Registered Nurse, Infection Preventionist revealed she did not know who was in charge of the Legionella water program for the facility. Interview on 9/12/24 at 10:38 a.m., with Staff B, Administrator revealed Staff B and Staff A were in charge of the Legionella water program for the facility. Staff B could not give specifics on when the testing was done but the facility planned to educate the facility staff on the program this month. Staff B revealed the facility had a 20 page plan and would have to review the plan in order to be able to explain the plan. Staff B was unable to explain what the facility was currently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 4 of 4 residents reviewed (Residents #7, #18, #32 and #36). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of cancer, hypertension, anxiety and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of Resident #7's Census tab revealed the following information: a. 8/29/24- hospital unpaid leave b. 9/1/24- active c. 5/8/24- hospital unpaid leave d. 5/9/24- active Review of bed hold dated 8/23/23 revealed son had been contacted via phone for bed hold authorization but was not sent to representative for signature. Review of bed hold dated 5/9/24 revealed verbal confirmation but lacked a contact and lacked…

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

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of residents. Findings include: An initial kitchen tour conducted on 9/9/24 at 10:17 a.m., revealed the following observations: The dry storage area revealed the following items ready for service: a. A bottle of kiwi-lime sauce with an expiration date of 8/15/24. b. A bottle of mango sauce with an expiration date of 6/8/24. c. Two packages of tortilla shells with an expiration date of 9/6/24. d. Twenty one packages of tortilla shells with an expiration date of 8/4/24. The kitchen fridge revealed the following items ready for service: a. Two gallons of white milk open with no open date. b. One gallon of chocolate milk open with no open date. c. Thickened water, open, with no open date. d. Thickened apple juice, open, with no open date. e. A gallon of orange juice unlabeled, with no open date. A container of food thickener open with no open date and scoop inside of the container with lid on. Review…

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

Based on observations, staff interviews and facility policy review the facility failed to maintain a clean, orderly and homelike environment for the residents and public by having boxes stacked around the nurses station and having 2 wheelchairs parked in the hallway blocking an emergency door. The facility identified a census of 33. Findings include: 1. Observation on 9/9/24 at 11:40 a.m., of 16 boxes stacked along the wall by the nurses station. 2. Observation on 9/9/24 at 11:50 a.m., of two wheelchairs sitting at the end of the 300 hallway next to each other blocking the exit door. 3. Observation on 9/9/24 at 12:13 p.m., of 16 boxes still stacked along the wall by the nurses station. 4. Observation on 9/9/24 at 1:57 p.m., of 14 boxes still stacked along the wall around nurses station and 2 wheel chairs sitting at the end of the 300 hallway next to each other blocking the exit door. 5. Observation on 9/12/24 at 12:16 p.m., of 26 boxes stacked along the wall sitting around the nurses station and 4 boxes stacked next to the nurses station. Review of facility provided policy titled…

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 interviews, and staff interviews the facility failed to respect each resident's dignity throughout all care and services provided (Resident #32). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #32 documented diagnosis of renal insufficiency, Diabetes Melltuis and peripheral vascular disease. The MDS showed a BIMs score of 15, indicating no cognitive impairment. The Care Plan for Resident #32 showed the presence of a urinary catheter. The interventions included changing the catheter as needed. In an interview on 9/10/24 at 9:58 AM, Resident #32 reported an incident that occurred in July that he reported a catheter leak to a nurse. The resident stated, the nurse was more worried about leaving in time for her shift to be over than taking care of my catheter. No one did anything. I sat the whole night with a leaking catheter. I was soaked and smelled of urine. I was upset and embarrassed. I filed 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, family interviews and facility policy review the facility failed to notify the resident's representative of hospitalization of 1 of 3 residents reviewed (Resident #7). The facility reported a census of 33. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of cancer, hypertension, anxiety and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of Resident #7's Census tab revealed the following information: a. 8/29/24- hospital unpaid leave. b. 9/1/24- active. Review of bed hold dated 8/23/23 revealed son had been contacted for bed hold authorization. Review of Progress Notes lacked documentation son had been contacted and signed bed hold authorization. During interview on 9/11/24 at 10:11 a.m., Resident #7's son was asked to confirm confirmation of authorizing a bed hold for Resident #7's hospitalization. Resident #7's son revealed he had never…

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 interview the facility failed to develop care plans to address usage of high risk medications and side effects to watch for 2 out of 5 sampled residents reviewed for comprehensive care plans (Resident #4 and #35). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of hypertension, depression, bipolar disorder and diabetes mellitus. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #4's September Medication Administration Record (MAR) revealed current orders for the following medications: a. Latuda tablet daily (antipsychotic medication) with a start date of 8/21/23. b. Nucynta Tablet four times daily (opioid medication) with a start date of 9/13/23. Review of Resident #4's current medication orders revealed orders for the following medications: a. Latuda daily with a start date of 8/21/23. b.…

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 and staff interviews the facility failed to provide professional standards of care by not initiating physical therapy as ordered for 1 of 12 residents reviewed (Resident #9). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented diagnoses of cancer, renal insufficiency, and Parkinson's Disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. In an interview on 9/9/24 at 11:59 AM, Resident #9 reported the physician ordered physical therapy for shoulder pain, but therapy wasn't initiated. Review of the electronic Physician Orders showed the facility lacked an order for physical therapy. Review of the written Physician Orders showed physical therapy ordered on 7/18/24 related to shoulder pain. Review of Resident #9's chart on 9/10/24 at 8:46 AM revealed no further documentation found relating to physical therapy. In an interview on 9/10/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance twice weekly for 3 of 3 residents reviewed for bathing (Resident #4, #23 and #35). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of hypertension, depression, bipolar disorder and diabetes mellitus. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Interview on 9/9/24 at 2:05 p.m., with Resident #4 revealed showers are kind of sporadic here. Sometimes we get them when we are supposed to and other times we do not as they tell us they are short staffed. We are not getting them like we are supposed to. Review of Resident #4's Task List revealed bathing as needed and scheduled for Monday and Thursdays. Review of Resident #4's Care Plan lacked frequency of bathing. Review of facility provided documentation…

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 the facility failed to complete assessment and interventions for the necessary care and services. Clinical record review revealed the nursing staff failed to complete all required skilled assessments for 1 out 12 residents reviewed (Resident #37). The facility reported a census of 33 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #37 documented diagnosis of renal insufficiency, Diabetes Mellitus (DM) and coronary artery disease. The MDS showed a BIMs score of 14, indicating no cognitive impairment. The Progress Note with the effective date of 8/1/24 showed Resident #37's primary care provider documented the resident returned from the hospital on skilled level of care after a prolonged hospital stay for sepsis, hypoxia, rhabdomyolysis, DM, Chronic obstructive pulmonary disease (COPD) and myocardial infarction. The Skilled Evaluations for Resident #37 showed the facility failed to complete skilled…

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 and record review, the facility failed to provide a restorative program to a resident with mobility concerns for 1 of 1 resident reviewed (Resident #4). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of hypertension, depression, bipolar disorder and diabetes mellitus. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Interview on 9/9/24 at 2:06 p.m., with Resident #4 revealed she was not receiving restorative therapy anymore. Resident #4 explained there is not a staff member to do it anymore. Resident #4 further revealed that was the only exercise my legs got. She explained that since the facility has stopped doing restorative therapy she feels like there is a difference in her legs. Review of Physical Therapy Discharge summary dated and signed 9/1/23 revealed discharge recommendations included: a. Restorative range of motion…

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 the facility failed to complete assessment and interventions for the necessary care and services related to dialysis. Clinical record review revealed the nursing staff failed to complete all required dialysis evaluations for 1 out 2 residents reviewed (Resident #37). The facility reported a census of 33 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #37 documented diagnosis of renal insufficiency, Diabetes Mellitus (DM) and coronary artery disease. The MDS showed a BIMs score of 14, indicating no cognitive impairment. The Physician Order dated 8/14/24 instructed staff to complete dialysis evaluations prior to dialysis and post dialysis on Monday, Wednesday and Friday. One dialysis evaluation on Tuesday, Thursday, Saturday and Sunday. The Dialysis Evaluations for Resident #37 showed the facility failed to complete evaluations on: a. 8/2/24 b. 8/4/24 c. 8/5/24 d. 8/16/24 e. 8/23/24 f. 8/27/24 g. 8/28/24 h.…

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

Based on document review, staff interviews, and policy review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a qualified professional serve as the dietary manager. The facility reported a census of 40 residents. Findings include: Interview on 6/26/23 at 10:15 AM with the facility Dietary Manager revealed she does not have education and training completed to be a qualified professional to serve as the Dietary Manager at the facility. Interview on 6/26/23 at 10:15 AM with Staff B revealed she did not have her certification for dietary manager. She further revealed that she is currently taking the classes to become certified. Interview 6/28/23 at 2:15 PM Administrator revealed her expectation is for the dietary manager to have a Dietary Manager Certification. Review of the facility ' s policy titled, Dietician, last revised October 2017 instructed the following: 7. If a dietitian is not employed full time (35 or more hours per week) a director of food service…

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, policy review, and staff interviews the facility failed to store food in accordance with professional standards. The facility reported a census of 40 residents. Findings include: Observation on 6/23/23 at 10:15 AM revealed a single door white freezer had an outside thermometer reading 7 degrees. Upon opening the freezer the inside thermometer read 20 degrees. Food inside of the freezer was cool to the touch, defrosted, and mushy. Foods observed included premade egg omelets, sausage links, hamburger patties, sliced ham, ice cream, pies, and hashbrowns. Review of the facility ' s policy titled, Refrigerators and Freezers, last revised December 2014 documented: Acceptable temperature ranges are 35 degrees fahrenheit to 40 degrees fahrenheit for refrigerators and less than 0 degrees fahrenheit for freezers. In an interview on 6/23/23 at 10:30 AM Staff B revealed everything would be getting thrown away from the freezer and her expectation was for frozen foods to be frozen. During a follow up observation on 6/23/23 at 3:30 PM the single door white freezer was empty.

Based on record review and staff interview the facility failed to properly complete the Centers of Medicare & Medicaid form #10055 for 2 of 3 sampled residents, (Residents #34 and #38). The facility reported a census of 40 residents. Findings Include: 1. The ABN form #10055 dated 2/27/23 for Resident #34 revealed the form lacked the reason Medicare may not pay and the estimated cost of services. 2. The ABN form #10055 dated 3/4/23 for Resident #38 revealed the form lacked the estimated cost of skilled nursing care. The Medicare Advanced Beneficiary Notice policy Dated April 2021 identified if the admissions coordinator or business office manager believes (upon admission or during the resident ' s stay) that Medicare (Part A of the Fee-for-Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident ' s potential liability for payment of the non-covered service(s). The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (CMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review, staff interviews, and policy review the facility failed to correctly code the Minimum Data Set (MDS) by not accurately recording resident assessments for 2 of 15 residents reviewed, (Resident #2 and #42). The facility reported a census of 40. Findings include: 1. The MDS dated [DATE] for Resident #2 documented the Resident had an enteral tube (feeding tube). Record review of a document titled Clinical Physician Orders, Resident #2 physician orders revealed he has never had a feeding tube. 2. The MDS dated [DATE] for Resident #42 documented the Resident had an indwelling catheter. Record review of a document titled Clinical Physician Orders, Resident #42 physician orders revealed he has never had an indwelling catheter. During interview on 6/28/23 at 9:16 AM the Director of Nursing (DON) revealed her expectation is for Minimum Data Sets (MDS) assessments to be completed accurately. Interview on 6/28/23 at 2:09 PM with the MDS Coordinator revealed Resident #2 has never had an enteral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to assure the activity preferences of each resident were provided for 3 of 4 residents reviewed, (Resident #23, #22, and #42). The facility reported a census of 42 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #23 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required limited assistance of 1 person for locomotion on and off the unit. The resident had diagnoses including legal blindness. The Care Plan identified the resident independent/dependent on staff in helping with meeting emotional, intellectual, physical, and social needs, revised 5/24/23. Interventions included she enjoyed television, introducing her to residents with similar background and interests, and encouraging/facilitating interaction, inviting to scheduled activities, providing with the activities calendar, and notifying her of any changes to the…

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

Based on record review and staff interviews the facility failed to maintain accurate medical records for 1 out of 15 residents reviewed (Resident #98). The facility reported a census of 40 residents. Findings included: 1. Review of Progress Notes dated 5/16/2023 at 6:24 PM documented Resident #98 was eating dinner and was choking in the dining hall, Heimlich was performed, food was removed. On 6/27/23 at 2:36 PM further review of Resident #98 ' s medical record showed the facility failed to document additional information and details of the choking event. In an interview on 6/27/23 at 11:24 AM, Staff E, Certified Nurse Assistant, (CNA), reported on 5/16/23 that she witnessed staff performing the Heimlich Maneuver on Resident #98. In an interview on 6/27/23 at 11:44 AM, Staff D, Licensed Practical Nurse, (LPN), reported that she responded to Resident #98 during the choking event that occurred on 5/16/23. The Emergency Procedure - Choking policy dated August 2018 identified the person performing this procedure should record the following information in the resident ' s medical record:…

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.