Silver Oak Nursing and Rehabilitation Center LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review, and staff and resident interviews, the facility failed to ensure sufficient staff in order to provide bathing and/or grooming assistance for 8 of 13 residents reviewed for activities of daily living assistance (Residents #2, #10, #13, #30, #46, #49, #71, & #231). The facility reported a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 2/18/25, listed diagnoses for Resident #2 which included heart failure, bipolar disorder, and depression. The MDS stated the resident required substantial/maximal assistance with bathing and listed her Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Nursing Services and Sufficient Staff, revised 2/5/25, stated the facility would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial…

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 policy and staff interview, the facility failed to carry out a system of surveillance to track and address infections and potential infections in the facility. The facility reported a census of 74 residents. Findings include: On 4/8/25 at 11:41 a.m., the Regional Director of Nursing (DON) stated infection control had not been completed well at the facility but they had a new person starting soon. She stated it was her expectation they carry out such activities such as mapping out infections and completing skills fairs. The facility lacked documentation of an infection control surveillance system designed to identify possible communicable diseases or infections before they could spread to other persons in the facility such as: a. systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff, and visitors. b. an ongoing system of surveillance designed to identify possible communicable diseases c. a system for surveillance based upon national standards of practice and the facility…

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

Based on observation, record review, resident interviews, staff interviews, and policy review the facility failed to treat 3 of 7 residents reviewed with dignity and respect while providing care and services (Residents #30, #49, and #51). The facility reported a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #30 dated 3/21/25 documented diagnoses of heart failure, weakness, seizure disorder, and anxiety. The MDS included a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated intact cognition. It reported the resident needed assistance with set up for oral care and was dependent for toileting hygiene, sit to stand, and chair/bed transfers. The resident was marked as touch assistance for toileting transfers with the MDS further documenting tub/shower transfers and bathing were not attempted in the look back period due to medical condition or safety concerns. The Care Plan for Resident #30 included interventions dated 7/10/24 to transfer the resident to her wheelchair at night for toileting, as well as to encourage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review, and staff and resident interviews, the facility failed to provide bathing and/or grooming assistance for 8 of 13 residents reviewed for activities of daily living assistance (Residents #2, #10, #13, #30, #46, #49, #71, #231). The facility reported a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 2/18/25, listed diagnoses for Resident #2 which included heart failure, bipolar disorder, and depression. The MDS stated the resident required substantial/maximal assistance with bathing and listed her Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Activities of Daily Living, dated 12/4/24, stated staff would assist residents with baths, dressing, and oral care. A 2/19/25 Care Plan entry stated the resident usually required assistance to provide supervision, verbal cues, and touching/steadying or contact assistance with bathing. The entry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interviews, the facility failed to carry out wound assessments and/or wound treatments for 3 of 6 residents reviewed for non-pressure wounds (Residents #63, #71, and #232). The facility reported a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 11/5/24, listed diagnoses for Resident #63 which included left foot drop, muscle weakness, and abnormal posture. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. A 7/30/24 Care Plan entry stated the resident had actual impairment to skin integrity related to a left foot surgical wound. An 8/1/24 surgical note stated the resident had a left fourth toe amputation and had a diagnosis of osteomyelitis(infection of the bone). A 12/20/24 Order Note requested the discontinuation of a betadine (an iodine solution used to treat wounds) treatment to the left foot due to the area long since healed.…

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, facility cleaning schedules, and staff interview, the facility failed to maintain adequate kitchen sanitation for 2 of 2 kitchen observations. The facility reported a census of 74 residents. Findings include: The initial kitchen tour, conducted on 3/31/25 at 9:33 a.m., revealed the following concerns: a. a thick layer of dust buildup on the back of the ice machine b. dust particles suspended from the 3 spigots of the fire suppression system located above the stove burners. A follow-up kitchen tour, conducted on 4/1/25 at 10:23 a.m., revealed the following concerns: a. dust particles remained suspended from the 3 spigots of the fire suppression system located above the stove burners. b. a shelf to the right of the three compartment sink covered with a film of dust and hairs, located directly over steam table lids. c. the ceiling above a prep area where staff wrapped silverware had strings of dust hanging down approximately 3 inches in length. d. a thick layer of dust hung from the sprinkler above the prep sink. e. dust particles suspended from the ceiling panels…

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

Based on clinical record review, facility policy review, and staff interview, the facility failed to offer influenza vaccines to 4 of 5 residents reviewed for immunizations (Residents #2, #8, #10, and #63). The facility reported a census of 74 residents. Findings include: The facility policy Influenza Vaccination, dated 6/14/23, stated the facility would offer residents annual immunizations against influenza. 1. The Minimum Data Set (MDS) assessment tool, dated 2/18/25, listed diagnoses for Resident #2 which included heart failure, bipolar disorder, and depression. The MDS stated the resident required substantial/maximal assistance with bathing and listed her Brief Interview for Mental Status (BIMS) status as 15 out of 15, indicating intact cognition. 2. The MDS assessment tool, dated 4/1/25, listed diagnoses for Resident #8 which included diabetes, seizure disorder, and low back pain and listed her BIMS score as 9 out of 15, indicating moderately impaired cognition. 3. The MDS assessment tool, dated 1/5/25, listed diagnoses for Resident #10 which included non-Alzheimer's dementia,…

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

Based on clinical record review, facility policy review, and staff interview, the facility failed to offer a Covid-19 vaccine for 1 of 5 residents reviewed for vaccinations (Resident #2). The facility reported a census of 74 residents. Findings include: The facility policy Covid-19 Vaccination reviewed 11/4/24, stated the facility would offer residents the Covid-19 vaccine. 1. The Minimum Data Set (MDS) assessment tool, dated 2/18/25, listed diagnoses for Resident #2 which included heart failure, bipolar disorder, and depression. The MDS listed her Brief Interview for Mental Status (BIMS) status as 15 out of 15, indicating intact cognition. The resident's clinical record lacked documentation the facility offered the resident a Covid-19 vaccination. On 4/8/25 at 2:38 p.m., the Director of Nursing (DON) stated residents should be up to date with their vaccinations. On 4/9/25 at 8:10 a.m., the Regional DON stated she could locate no additional Covid-19 vaccine documentation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interviews, the facility failed to ensure resident records included advance directive wishes for 2 of 24 residents reviewed for code status (Residents #2 and #10). The facility reported a census of 74 residents. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated [DATE], listed diagnoses for Resident #2 which included heart failure, bipolar disorder, and depression. The MDS listed her Brief Interview for Mental Status (BIMS) status score as 15 out of 15, indicating intact cognition. A Care Plan entry, dated [DATE], stated the resident wished to be a Full Code. On [DATE] at 8:45 a.m., the resident's face sheet on her electronic health record (EHR) did not include any information under the heading Code Status. The binder at the nurse's station also did not include her Iowa Physician Orders for Scope of Treatment (IPOST). On [DATE] at 8:46 a.m., the Director of Nursing (DON) confirmed that Resident #2's IPOST was not in the binder nor the EHR. She…

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

Based on observation, clinical record review, pharmacy record review, resident interview, police narrative, staff interviews, and policy review the facility failed to protect 1 of 3 residents reviewed for abuse from misappropriation of property and exploitation (Resident #51). The facility reported a census of 74 residents. Findings include: The MDS (Minimum Data Set) for Resident #51, dated 2/9/25, included diagnoses of multiple sclerosis, neurogenic bladder, anxiety, and depression. The resident scored 15/15 on the BIMS (Brief Interview for Mental Status assessment) which indicated intact cognition. The Care Plan for Resident #51 with an admission date of 12/9/24 included focus areas, goals, and interventions related to multiple sclerosis care, depression, anxiety, mood, and medication monitoring. Three documents titled Shipment Details indicated the following medication deliveries for the resident from the resident's pharmacy: Sildenafil Citrate 50 mg tablet, quantity 15, filled 8/30/24 (treat erectile dysfunction) Sildenafil Citrate 50 mg tablet, quantity 15, filled 9/8/24…

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

Based on observation, clinical record review, pharmacy record review, resident interview, staff interviews, and policy review the facility failed to report potential misappropriation and exploitation for 1 of 3 residents reviewed (Resident #51). Facility staff indicated they were aware of potential incidents as early as July 2024. The facility reported a census of 74 residents. Findings include: The MDS (Minimum Data Set) for Resident #51, dated 2/9/25, included diagnoses of multiple sclerosis, neurogenic bladder, anxiety, and depression. The resident scored 15/15 on the BIMS (Brief Interview for Mental Status assessment) which indicated intact cognition. The Care Plan for Resident #51 with an admission date of 12/9/24 included focus areas, goals, and interventions related to multiple sclerosis care, depression, anxiety, mood, and medication monitoring. According to pharmacy records, the facility received the following medication cards for Resident #51: Sildenafil Citrate 50 mg tablet, quantity 15, filled 8/30/24 (treat erectile dysfunction) Sildenafil Citrate 50 mg tablet, quantity…

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 a police narrative, clinical record review, resident interview, staff interviews, and facility policy review the facility failed to prevent further potential misappropriation of property and exploitation and failed to conduct thorough investigations into two incidents for 1 of 3 residents reviewed (Resident #51). The facility reported a census of 74 residents. Findings include: The MDS (Minimum Data Set) for Resident #51, dated 2/9/25, included diagnoses of multiple sclerosis, neurogenic bladder, anxiety, and depression. The resident scored 15/15 on the BIMS (Brief Interview for Mental Status assessment) which indicated intact cognition. The Care Plan for Resident #51 with an admission date of 12/9/24 included focus areas, goals, and interventions related to multiple sclerosis care, depression, anxiety, mood, and medication monitoring. On 4/1/25 at 8:01 PM the Administrator notified the surveyor they received a call from the local police department requesting information about Staff M (RN) and Resident #51. The Administrator stated Staff M, Registered Nurse (RN) 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.

Based on clinical record review, interview, and facility policy review the facility failed to provide services according to physician orders for 1 of 4 residents reviewed (Residents #49). The facility reported a census of 74 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #49 dated 3/16/25 included diagnoses of chronic pain syndrome, arthritis, osteoporosis, and fibromyalgia. It documented a Brief Interview for Mental Status (BIMS) of 15/15 indicating intact cognition. The resident's Care Plan with an admission date of 8/21/23 indicated staff should anticipate pain and respond immediately to complaints of pain, evaluate the effectiveness of pain interventions including review for compliance, dosing schedules, and resident satisfaction with results, and monitor/record/report signs and symptoms of non-verbal pain. On 03/31/25 at 01:40 PM Resident #49 reported her medications were often late and her pain cream was missed some days. She stated she had discussed this with nurses, the Director of Nursing, and the Administrator. The resident's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interview, the facility failed to complete regular assessments and treatments to treat a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #71). The facility reported a census of 74 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of…

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 interview, the facility failed to ensure safe wheelchair movement for 1 of 1 residents reviewed for wheelchair safety (Resident #41). The facility reported a census of 74 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 1/21/25, listed diagnoses for Resident #41 which included heart failure, non-Alzheimer's dementia, and anxiety. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 3 out of 15, indicating severely impaired cognition. A 10/28/23 Care Plan entry stated the resident was dependent on staff to move the wheelchair. On 3/31/25 at 12:53 p.m., Staff A, Certified Nursing Assistant (CNA) pushed Resident #41 down the hall in her wheelchair and her left foot drug on the ground during the transfer. Staff A pushed the resident approximately 50 feet down the hall. On 4/7/25 at 9:22 a.m., the Director of Nursing (DON) stated staff should utilize foot pedals when pushing residents in a wheelchair. On 4/9/25 at approximately 2:00 p.m., the Administrator stated the facility…

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

Based on personnel file review, the Health Facility Database (HFD), and interviews the facility failed to ensure 1 of 4 Certified Nursing Aides (CNAs) was certified prior to employment. The facility reported a census of 74 residents. Findings include: A review of staff personnel files on 4/8/25 determined that Staff J did not have an active CNA certification. A note in the file dated 11/6/23 written by Staff K documented that the facility was waiting on his CNA application. A criminal background check documented that on 11/13/23 there was not a record found for a CNA with Staff J's name and date of birth . An additional undated document in the file from the HFD confirmed there was not a certification date for Staff J. On 4/10/25 at 3:27 PM the HFD page titled DCW Details (Direct Care Worker) did not include a certification date for Staff J and documented that he was not currently employed. An interview with the Administrator on 4/8/25 at 3:37 PM confirmed Staff J was not certified. She stated he had told the facility he was certified in another state. She reported there was 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 personnel file review, staff training records, and interviews the facility failed to ensure 1 of 4 Certified Nursing Aides (CNAs) received a performance evaluation, competency evaluation, or training based on performance reviews. The facility reported a census of 74 residents. Findings include: A review of staff personnel files on 4/8/25 determined that Staff J was not evaluated for performance between his hire date of 12/5/23 and 4/8/25. The personnel file did not include orientation training or competency evaluations. Training records documented a single training on 3/19/24 for 15 minutes of education regarding communicating effectively. During an interview with the Administrator on 4/8/25 at 3:37 PM she confirmed she was not able to locate evaluations or training based on CNA evaluations.

Based on clinical record review, facility policy review, and staff and resident interviews, the facility failed to ensure the availability of routine medications for 2 of 7 residents reviewed for medications (Resident #17 and #13) The facility reported a census of 74 residents. Findings include: 1. The Minimum Data Set(MDS) assessment tool, dated 1/17/25, listed diagnoses for Resident #17 which included heart failure, diabetes, and anxiety. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A 9/25/23 Care Plan entry directed staff to administer medications as ordered. On 3/31/25 at approximately 1:00 p.m., the resident stated she missed some pills today. The March 2025 Medication Administration Record (MAR) listed an order for Methocarbamol (a muscle relaxant) 750 milligrams(mgs) three times per day. The following entries lacked a check to indicate staff administered the medication: 3/30/25 supper dose, 3/31/25 lunch and supper doses. eMAR Administration Notes on 3/30/25 at 4:35 p.m., 3/31/25 at 1:08 p.m., and…

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

Based on observation, facility menus, facility policy review, and staff interview, the facility failed to follow the menu for 2 out of 2 residents on a pureed diet to ensure nutritional needs were met. The facility reported a census of 74 residents. Findings include: On 4/1/25 at 11:01 a.m., Staff D, Cook, pureed meatballs. Staff D did not puree any bread with the meatballs. On 4/1/25 at 12:03 p.m., a resident on a pureed diet received the following lunch: pureed meatballs, mashed potatoes, and pureed cake. The tray contained no bread. The Week 2 Therapeutic Spread Report stated resident on a regular diet should receive 1 slice of bread and residents on a pureed diet should receive 1/2 cup of pureed orzo (a type of pasta). On 4/2/25 at 3:56 p.m., the Administrator stated they would order pureed bread mix and add it to the meat during preparation. The facility policy Food Preparation Guidelines, dated 4/9/24, directed staff to follow written menus during food preparation in the form that met individual resident needs.

Based on observation, facility policy review, and resident and staff interviews, the facility failed to ensure staff served food at palatable hot holding temperatures for 1 of 1 meal observed. The facility reported a census of 74 residents. Findings include: 1. The facility policy Food Preparation Guidelines, dated 4/9/24, directed staff to serve food at a safe and appetizing temperature. On 3/31/25 at 1:11 p.m., Resident #13 stated that the food in the East dining room was cold so she preferred to eat in the main dining room. On 4/1/25, the Dietary Manager obtained the following temperatures: Carrots 163 degrees Fahrenheit at 11:32 a.m. Mashed Potatoes 163 degrees Fahrenheit at 11:33 a.m. Meatballs 189 degrees Fahrenheit at 11:33 a.m. On 4/1/25 at 11:35 a.m., Staff D, Cook, began to plate meals for the East hall cart. The State Agency (SA) requested a test tray with a thermometer to be placed on the cart. Staff D placed a test tray on the cart and began plating the rest of the resident meals for the East cart. The plates that Staff D utilized did not come from a plate warmer. At…

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

Based on personnel file review, staff training records, and interviews the facility failed to ensure 1 of 4 Certified Nursing Aides (CNAs) completed 12 hours of in-services per year that included abuse and dementia training. The facility reported a census of 74 residents. Findings include: A review of staff personnel files on 4/8/25 determined that Staff J did not complete orientation training, competency evaluations, or annual CNA training between his hire date of 12/5/23 and 4/8/25. The orientation checklist in the file was blank. Training records for this CNA documented one training on 3/19/24 for 15 minutes of education regarding communicating effectively. Staff J's files did not include a record of Dependent Adult Abuse training, abuse prevention, or dementia training for residents with cognitive impairments. During an interview with the Administrator 4/7/25 at 5:06 PM she stated she had to own that the facility was not caught up on training. They had staff meetings but their online training platform was switched and they were not caught up. On 4/8/25 at 3:37 PM the…

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

Based on clinical record review, facility policy, provider interview, and staff interviews the facility failed to notify resident's representatives and providers in a timely manner of test results related to changes in clinical conditions for 2 of 3 residents reviewed for notification (Residents #2 and #3). The responsible parties were not notified of x-ray results (Resident #2) or a new urinary tract infection (Resident #3). The facility further failed to provide x-ray and urine culture results to providers in a timely manner (Residents #2 and #3). The facility reported a census of 77 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #2 dated 1/19/25 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated severely impaired cognition. Active diagnoses included Alzheimer's disease, malnutrition, and essential hypertension. Resident #2's Care Plan (CP) documented altered cardiovascular status related to hypertension and congestive heart failure. Effective 4/30/24 it directed staff to assess for chest pain, shortness of breath, 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 review of the electronic health record, hospital reports, facility policy, and interviews the facility failed to provide sufficient resident assessments and interventions to maintain resident's highest practical physical and psychosocial well-being for 2 of 3 residents reviewed (Residents #2 and #3). The review revealed staff assessed a resident with new orders for as needed (PRN) oxygen and new complaints of breathing and chest discomfort 1 time during a 56 hour period, and did not assess a resident with pending urine culture results for 8 days. The facility reported a census of 77 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #2 dated 1/19/25 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated severely impaired cognition. Active diagnoses included Alzheimer's disease, anxiety disorder, and essential hypertension. Resident #2's Care Plan (CP) documented altered cardiovascular status related to hypertension and congestive heart failure. Effective 4/30/24 it directed staff to assess for chest pain, shortness of breath,…

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

Based on clinical record review and staff interviews the facility failed to maintain accurate and complete clinical records for 2 of 3 residents reviewed for records (Residents #2 and #3). The medical records for Resident #2 and Resident #3 failed to reflect the resident's current health conditions and the services provided to ensure communication throughout the interdisciplinary team. The facility reported a census of 77 residents. Findings include: 1. Resident #2 received an order for chest x-rays on the morning of 1/17/25. The resident's clinical record did not contain documentation that the resident received the chest x-rays, the same day results of the x-rays, timely follow up with the provider, or documentation of resident assessments, monitoring, and interventions related to an acute change in condition. On 2/4/25 at 2:35 PM the Director of Nursing (DON) reported she had not been able to determine through investigation and interviews why the chest x-ray results were not addressed by the nursing staff between 1/17/25 and 1/20/25. She confirmed the resident was transferred 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 observation, policy review, and staff interview the facility failed to serve hot food at least 135 degrees Fahrenheit and provide a palatable meal for 2 of 2 noon meal trays tested. The facility reported a census of 78 residents. Findings include: During the noon meal service on 11/19/24 a test tray was provided with the last cart of room trays to be delivered. The temperatures of the food included cauliflower at 117.8 degrees Fahrenheit. The cauliflower tasted cold. The chicken had marinara sauce and parmesan cheese on it. Despite this, the chicken was dry and difficult to chew. During the noon meal service on 11/20/24 a test tray was provided with the last cart of room trays to be delivered, The temperatures of the food included vegetables at 127 degrees Fahrenheit. The vegetables were not tasted for palatability as it took many attempts to get the temperature up to 127 and Staff A, dietary, used her gloved hands in the food to get the temperature. The Salisbury steak appeared dry and crusty around the edge. During an interview on 11/19/24 at 12:34 PM, Staff A explained…

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

Based on observation, clinical record review, policy review, and resident and staff interview the facility failed to complete pre-dialysis and post-dialysis assessments for 1 of 1 resident on dialysis (Resident #2), and the facility failed to routinely assess a resident's skin condition for 1 of 1 resident reviewed for skin impairments (Resident #4). The facility reported a census of 78 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #2 dated 10/23/25, documented the resident received dialysis while a resident of the facility. The MDS documented diagnoses including renal disease, hyperparathyroidism of renal origin, and dependence on renal dialysis. The clinical record lacked pre-dialysis assessments, post-dialysis assessments, and assessment of the shunt site. Facility policy titled Hemodialysis dated 11/22 directed staff to provide dialysis services consistent with professional standard of practice including assessment of the resident's condition and monitoring for complications before and after dialysis treatments. The policy further directed staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, policy review, and observations the facility failed to provide adequate assessment and timely interventions for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 73 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had diagnoses which included Diabetes Mellitus Type 1, peripheral vascular disease, kidney failure, and heart failure. The MDS indicated the resident had intact cognitive ability and gave accurate information. The resident required total staff assistance for hygiene, toileting, and bathing. Review of the resident Care Plan dated 4/9/24 revealed the resident had a diagnosis of Diabetes Mellitus and directed staff to give diabetic medications as ordered by the physician, to monitor and document for side effects and effectiveness. The Care Plan directed the staff to report any sign and symptoms of hypoglycemia (low blood sugar) sweating, tremors, increased heart…

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

Based on clinical record review, facility policy and staff interview, the facility failed to follow physician orders for 1 of 3 residents reviewed. (Resident #2). The facility reported a census of 70 residents. Findings include: The MDS (Minimum Data Set) dated 4/15/2024 revealed Resident #2 had severe cognitive impairment, dependent on staff for transfers from one surface to another, incontinence of bowel and bladder, and history of falls. The resident diagnoses included falls, encephalopathy, opioid use disorder, depression and COPD (chronic obstructive pulmonary disease). The Care Plan for Resident #2 directed staff to administer psychotropic medications as ordered and observe for side effects. The resident admitted to the facility from the hospital on 4/8/2024 with physician orders that included: a. Buprenorphine HCL - Naloxone HCL (Suboxone) sublingual (under the tongue) 8-2 mg (milligrams). Give one tablet sublingually four times a day for Opioid use disorder. b. Fluoxetine HCL (Prozac) oral capsule, 20 mg tablets, give three tablets (60 mg) by mouth one time a day. Used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to provide appropriate assessment and interventions for 1 of 3 residents reviewed. (Resident #1). The facility reported a census of 70 residents. Findings include: The MDS (Minimum Data Set) an assessment tool dated 4/15/2024 revealed Resident #1 had intact cognitive abilities, transferred with the assistance of one staff, a history of falls and pain. The MDS reported the resident received dialysis treatment and had IV (intravenous) access. The MDS documented the resident had diagnoses including diabetes, fracture, anemia, heart failure, renal (kidney) insufficiency, epilepsy and depression. The resident admitted to the facility on [DATE]. On 4/17/2024 the Care Plan added the focus: Resident has a PICC ( Peripherally inserted central catheter) line. The care plan directed staff to provide an IV (intravenous) dressing, change dressing and record observation of site per doctor order. Flush PICC line per physician order and monitor for signs…

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

Based on record review and staff interview, the facility failed to attempt to enter into a transfer agreement with a hospital in an effort to ensure that the transfer of residents was safe and orderly. The deficient practice had the potential to affect all residents who resided in the facility. The facility identified a census of 67 residents. Findings include: Review of the facility provided records for the Extended Survey on 2/21/24 at 3:30 PM revealed the facility lacked a Transfer Agreement with the local hospital(s). On 2/22/24 at 8:30 PM the Director of Nursing (DON) reported she didn't know anything about hospital transfer agreements and would have to check with the Administrator. During an interview on 2/22/24 at 8:35 AM the Administrator reported she wasn't sure what a transfer agreement was. She reported she had spoke to their Medical Director about the transfer agreement and he stated that since COVID 19 residents go through the emergency room before getting admitted to the hospital. She reported she could talk with the Medical Director to get an agreement in place with…

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

Based on observations, clinical record review, staff and resident interviews and facility policy review the facility failed to treat 4 out of 4 resident reviewed with dignity for cares and meals (Resident #32, 34, 52, and 56). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident # 52 dated 12/278/23, included diagnoses of adult failure to thrive, neurogenic bladder, and cancer. The Brief Interview for Mental Status (BIMS) listed a score of 15, intact cognition. The MDS failed to identify any behaviors for Resident #52. The MDS identified Resident #52 as dependent on staff for toileting and personal hygiene. The Care Plan for Resident #52 dated 8/31/23, directed check for incontinence, wash, rinse and dry the perineum. Change clothing as needed after incontinence. The Behavior Monitoring dated 2/24, failed to show behaviors for Resident #52. On 2/20/24 at 12:26 PM, Resident # 52 reported a staff just came in her room to see why she turned on her call light. Resident #52 stated she told them her underpants needed…

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

Based on observation, interview, and facility policy review the facility failed to cover resident drinks during transportation through the hallways in 2 of 3 hallways observed for resident room tray delivery. The facility reported a census of 67 residents. Findings include: On 2/20/24 at 12:37 PM, observed Certified Nursing Assistant (CNA) staff transport resident room trays via shelved cart in East hallway with various staff and residents present in the area. Noted 4 trays on the cart contained uncovered glasses filled with various drinks. Observed 3 of the 4 trays removed from cart and taken into resident rooms. On 2/20/24 at 12:40 PM, observed CNA staff transport resident room trays via cart in the North hallway with various staff and residents present in the area. Noted 4 room trays on cart contained uncovered glasses filled with various drinks delivered to resident rooms. On 2/22/24 at 8:25 AM, Staff M, CNA, informed that trays are collected from main kitchen and taken to South hall dining room where staff prepare drinks and place on trays for delivery to resident rooms. Staff…

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

Based on record review, interviews, and policy review the facility failed to document education and/or administration of flu and pneumococcal immunizations for 4 of 5 residents reviewed for immunizations (Residents #1, #4, #31, and #267). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #1 dated 1/25/24 documented a birth date of 11/24/57 and an admission date of 9/27/18. It included a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Immunization tab of the electronic health record for Resident #1 documented a flu shot on 10/17/23 and a first dose pneumovax 4/24/18. It lacked documentation of a second immunization. A document titled Patient Information with Immunization Records lacked documentation of a pneumococcal vaccine. Progress Notes lacked documentation that pneumococcal immunization was offered, declined, or that education was provided in 2023. 2. The MDS for Resident #4 dated 2/4/24 documented a birth date of 1/26/50 and an admission date of 2/15/23. It included a BIMS…

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, resident and staff interviews and clinical record review, the facility failed to complete a resident assessment for 1 of 1 residents reviewed for self-administration of medications, (Resident #19). A resident's medication was left in their possession without a completed assessment to determine if self-administration was clinically appropriate. The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 12/18/2023 listed diagnosis for Resident #19 as End Stage Renal disease, heart failure, hypertension, diabetes mellitus with other diabetic kidney complication and thyroid disorder. The MDS listed the Brief Interview for Mental Status (BIMS) as 15 out of 15, indicating intact cognition. The Care Plan dated 12/13/2023 did not address self-administration of medications. Observations during an the initial interview of Resident #19 on 2/19/24 at 12:20 PM revealed a tablet in a medicine cup on the residents bedside table next to her recliner. On 2/19/24 at 12:20 PM, Resident #19 stated she did not know the name…

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, manufacturer's recommendations and staff interviews, the facility failed to follow manufacturer ' s recommendations while administering insulin utilizing a KwikPen, for 1 of 1 residents reviewed for insulin administration (Resident #167). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #167 had a Brief Interview for Mental Status of 15 indicating intact cognition. The MDS further revealed the resident had diagnoses including diabetes mellitus (DM) and malnutrition. The Medication Administration Record for Resident #167 dated February 2024 documented the following order: HumaLOG KwikPen Subcutaneous Solution, Pen-injector 100 UNIT/milliliter (ML) (Insulin Lispro), Inject 11 units subcutaneously with meals for DM. Hold if blood sugar is less than 100 During an observation on 2/20/24 at 9:01 AM, Staff B, Licensed Practical Nurse (LPN), injected Resident #167 utilizing a KwikPen with 11 units of Humalog insulin Lispro…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and facility policy review, the facility failed to assess and document an open ulcerated wound and further failed to perform hand hygiene at appropriate times during wound care to prevent infection for 1 of 2 residents reviewed for skin conditions, (Resident #267). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #267 had open lesions on the foot, required a pressure reducing device for bed, and had occasional pain symptoms that limited participation in activities and made it hard to sleep at night. Diagnoses included Diabetes Mellitus, malnutrition, necrosis (dead tissue) of right toes, and pain of both feet. The Care Plan, initiated 1/2/24, revealed a focus area for skin impairment of both legs and the right foot with a goal that skin injury to right foot will be healed by the review date. Interventions included: Follow facility protocol for treatment of injury; Weekly treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, document review and staff interview the facility failed to ensure licensed and certified nursing staff had documented competency skills to show skill proficiency for 2 of 2 employees sampled (Staff B and C). The facility identified a census of 67 residents. Findings include: 1. Resident #167 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS listed a diagnosis of diabetes mellitus, pneumonia and documented Resident #167 received insulin injections 7 days per week. The Care Plan revised 2/21/24 documented Resident #167 with a diagnosis of diabetes mellitus and directed the nursing staff to provide diabetes medication as ordered by the doctor. The Care Plan goal documented Resident #167 to be free from complications of diabetes mellitus. A 2/13/24 Physician Order documented Humalog Kwik Pen subcutaneous solution pen-injector 100 units/milliliter (Insulin Lispro), inject 11…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interviews, the facility failed to follow physician ' s orders for 1 of 1 residents reviewed for insulin administration (Resident #167). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #167 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS further revealed the resident had diagnoses including diabetes mellitus (DM) and malnutrition. During an observation on 2/20/24 at 9:01 AM, Staff B, Licensed Practical Nurse (LPN), injected Resident #167 with 11 units of Humalog insulin. Review of the February 2024 Medication Administration Record (MAR) for Resident #167, revealed he had a blood sugar obtained by Staff B, Licensed Practical Nurse (LPN) of 98 the morning of 2/20/24 prior to administration of 11 units of Humalog insulin. The February 2024 MAR for Resident #167 documented the following order: HumaLOG KwikPen Subcutaneous Solution, Pen-injector…

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, interviews, and policy review the facility failed to document education and/or administration of COVID-19 immunizations for 3 of 5 residents reviewed for immunizations (Residents #4, #31, and #267). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #4 dated 2/4/24 documented a birth date of 1/26/50 and an admission date of 2/15/23. It included a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The Immunization tab of the electronic health record for Resident #4 indicated no immunizations were found. A document titled COVID-19 Vaccine Consent Form dated 12/21/23 indicated the resident declined the vaccine. The document lacked information regarding who gave the verbal consent and sections titled screening for vaccine eligibility, education, and consent were not completed. The section titled declination was marked with an X and lacked documentation of the reason for declining. Progress Notes lacked documentation that the COVID-19 immunization was offered,…

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

Based on personnel record review and staff interview, the facility failed to ensure mandatory Dependent Adult Abuse training had been completed within 6 months of employment for 1 of 5 staff reviewed (Staff F). The facility reported a census of 67 residents. Findings include: Personnel record review for Staff F, Cook, revealed a hire date of 1/16/23. The personnel record lacked verification of completion of mandatory Dependent Adult Abuse training. During an interview on 2/20/24 at 12:45 PM, the Human Resources Director acknowledged Staff F had yet to complete mandatory Dependent Adult Abuse training and she had been employed by the facility for more than 6 months. On 2/21/24 at 1:30 PM via electronic mail, the Administrator revealed the facility did not have a policy that is directly for Dependent Adult Abuse training to be completed in 6 months.

Based on record review, staffing assignment sheets, and staff interviews the facility failed to have eight hours of continuous Registered Nurse (RN) coverage in 24-hours in the month of September. The facility reported a census of 56. Findings include: The September 2023 staffing sheets reflected that the facility failed to have the required continuous eight hours of RN coverage for two days. The September staffing sheets provided by the Administrator revealed the facility had six hours and 15 minutes of RN coverage on 9/9/23 and no RN coverage on 9/10/23. On 10/5/23 at 10:30 AM, Staff D, Administrator, said they have been working on sign-on bonus, different staffing options, and having on-call management staff present in the building when they are on-call. She explained that they have recognized that they don't have RN coverage as they should and continue to work on this issue.

Based on observation and staff interview, the facility failed to provide housekeeping services in a manner to maintain a safe, clean, comfortable, and homelike environment. The facility reported a census of 55 residents. Findings include: On 9/27/23 at 10:30 AM and 10/5/23 at 9:00 AM observed the east shower room with a black/brown substance around the perimeter of the tiled shower room, multiple areas of missing paint on the walls, brown substance around the base of the toilet, and cracked tiles in front of the toilet. The exhaust fan had dust buildup on the exterior surface, and four floor strips near the shower entrance appeared tattered and partially removed. The east hall floor had heavy grime throughout. Rooms E-18, E-13, E-11, E-10, E-7, E-20 had heavy grime on the floor. Room S-12 had missing paint, plaster, and a base board near the room entrance door. On 9/27/23 at 10:30 AM, Staff L, Housekeeping Supervisor, reported that the facility had plans to remodel the shower rooms. They planned to start with the south hall shower room. The south hall shower room is currently closed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff, and resident interviews the facility failed to provide 4 of 4 residents reviewed with two baths a week (Residents #1, #3, #7, and #9). Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She required total assistance from two persons with transfers and bathing. Resident #1 used a wheelchair to move around the facility. The MDS listed Resident #1 as incontinent of bowel and bladder. The MDS included diagnoses of diabetes, morbid obesity, carotid stenosis (narrowing of the arteries in the neck restricting blood flow to the brain and head) and schizophrenia. The Care Plan Focus dated 2/28/23 indicated that Resident #1 has an activities of daily living (ADLs) self-care deficit. The Intervention dated 2/28/23 directed the staff that she required extensive assistance from 2 persons to shower twice a week. The June 2023 bath records…

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, observations, staff, and resident interviews the facility failed to complete a shift to shift narcotic count. The facility reported a census of 56. Findings include: On 9/26/23 at 1:22 PM observed a building wide narcotic count that reflected 2 of 2 medication carts with incomplete, shift to shift, narcotic counts. The south medication cart reflected that from 7/23/23 - 9/26/23, the staff failed to do shift to shift narcotic count 97 times. The east medication cart reflected that from 8/1/23 - 8/15/23, the staff failed to do shift to shift narcotic count 18 times. According to the Staff P, Director of Nursing (DON), on 9/26/23 medical records could not locate the count sheets for the east hall medication cart for September 2023. All they could find is two hand written sheets that indicated two nurses completed the narcotic count on 9/12/23 and 9/15/23. On 9/26/23 at 6:10 PM, Staff N, Licensed Practical Nurse (LPN) stated she just counts the narcotics but doesn't sign off that she completed the count. On 9/27/23 at 9:00 AM, Staff P denied knowing of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews and observations the facility failed to follow physician's orders for 1 of 10 residents reviewed (Resident #9). Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] indicated that they required extensive assistance from one person with transfers, ambulation, dressing, and bathing. Resident #9 required total assistance from one person for eating. The MDS included diagnoses of metachromatic leukodystrophy (rare disorder that affects the brain and nerves), stem cell transplant status, convulsions, and a communication deficit. The use gastric tube (g-tube feeding tube) for nutrition. The Care Plan Focus dated 8/31/21 indicated that Resident #9 is self-determined. She will grab at the staff's hands when they attempt to do treatments such as changing the dressing around the g-tube site. Resident #9 has pulled out her g-tube. The Interventions directed the staff to alert the nurse if Resident #9's g-tube is leaking, to monitor…

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.