Regency Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and policy review, the facility staff failed to ensure Enhanced Barrier Precautions (EBP) were in place for residents with multidrug-resistant organisms (MDROs) (Resident #24), failure of staff to wear appropriate personal protective equipment (PPE) when providing care to residents on EBP (Resident #8), and failure to follow proper infection control practices to prevent the transmission of infection with blood sugar monitoring. The facility reported a census of 58 residents.Findings include:1. Review of MDS dated [DATE] revealed Resident #24 BIMS of 11 indicating moderate cognitive impairment with diagnoses of Multidrug-Resistant Organism ((MDRO) bacteria that have become resistant to three or more classes of antibiotics) and Urinary Tract Infection, and incontinent of bowel and bladder with need for substantial/maximal assistance with ambulation and use of walker or wheelchair. Review of Resident #24's Care Plan initiated 1/23/26 documented incontinent 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 record review, observations, staff interviews and facility policy review the facility failed to complete an accurate Minimum Data Set (MDS) for 1 of 4 residents (Resident #2) reviewed. The facility reported a census of 68 residents. Findings include:According to the Discharge-Return Not Anticipated MDS assessment tool with reference date of 11/24/2025 documented Resident #2 was admitted to the facility on [DATE] and discharged home/community on 11/24/2025.The Care Plan Focus Area with a revision date of 11/24/2025 documented Resident #2 and responsible party choose long-term placement. Review of Resident #2's progress notes from 11/12/2025-12/1/2025 revealed no documentation of her being discharged from the facility. On 12/30/2025 at 11:45 AM Resident #2 was observed to be sitting in the dining room with her peers. On 12/30/2025 at 11:57 AM the Director of Nursing (DON) verified Resident #2 was in the building and not discharged . While reviewing the MDS that was completed on 11/24/2025 she acknowledged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy review the facility failed to ensure 1 of 4 residents' (Resident #1) care plan was updated to include interventions to offload her heals while in bed. The facility reported a census of 68 residents. Findings include:According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 11/29/2025 Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. Resident #1 had one pressure ulcer present upon admission/entry. She had a pressure reducing device for her bed and chair, utilized nutrition or hydration interventions to manage skin problems and received pressure ulcer care. Record review revealed wound care orders from a local hospital dated 11/21/2025. One order included to float Resident #1's heels with heel protectors at all times. The Care Plan Focus area with a revision date of 12/11/2025 documented she has the potential for impaired skin integrity…

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 accurately complete a Minimum Data Set (MDS) Assessment for 4 of 8 residents reviewed (Resident #6, #7, #9 and #12). The facility reported a census of 68 residents. Findings include: 1. The quarterly MDS assessment dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) Score of 4, indicating severe cognitive impairment. The MDS included diagnoses of medically complex conditions, non-Alzheimer's dementia, seizure disorder, anxiety disorder and depression. The MDS documented a wander/elopement alarm was not used. The Care Plan for Resident #6, with an initiation date of 6/5/23, included a focus area: the resident is having adjustment issues to admission. An intervention for this focus area included Wander guard in place to the left lower leg. Functioning will be checked QS (twice daily). This was initiated on 8/13/24. Review of the Electronic Health Record (EHR) Elopement Risk Evaluation for Resident #6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident interviews, staff interviews, and facility document review, the facility failed to ensure adequate staffing levels to meet the residents' needs safely and timely. The facility reported a census of 68. Findings include: During an observation 8/5/25 at 9:00 AM in the back hallways (Ambassador halls), observed one Certified Nursing Assistant (CNA) in the 5 hallway, one CNA in the 6 hallway and one CNA giving residents showers in the 5 and 6 hallway. A CNA was not observed in the 4 hallway. During an interview 8/5/25 at 9:50 AM, Staff F, CNA, stated to be fully staffed in Ambassador halls (halls 4, 5 and 6) they should have 2 CNA's on hall 5, two CNA's on hall 6 and then they split hall 4 with a floater CNA, they need 5 to 6 CNA's to be fully staffed on Ambassador halls. Staff F stated the back hallways are not normally staffed fully as they get more call ins back there, it is a more stressful area to work as residents have more care needs and there are more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 12 residents reviewed (Resident #12). The facility reported a census of 68 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS revealed the resident was on high risk drug classes to include insulin and had received insulin injections 5 days of the 7 day look back period. Review of the Electronic Health Record (EHR) admission papers for Resident #12 revealed the resident admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus. The admission medication list for the resident included the medications Empagliflozin (used to manage type 2 diabetes) 10 mg tablet one time each day and Metformin (used to treat type 2 diabetes) 500 mg tablet two tablets two times a day with meals. Review of the hospital…

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 ensure staff completed an accurate and timely resident assessment as necessary for 1 of 3 residents reviewed for elopement (Resident #7). The facility reported a census of 68 residents. Findings include: The annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #7 had a BIMS score of 3, indicating severe cognitive impairment. The resident had diagnoses to include medically complex conditions, hyperlipidemia, thyroid disorder, non-Alzherimer's dementia, anxiety disorder, depression and psychotic disorder. The Care Plan for Resident #7, with an initiation date of 3/21/25, included a focus area: potential for elopement risk/wanderer risk. Interventions included: assess for elopement/wander risk and wander alert, left ankle device. Review of the Electronic Health Record (EHR) Elopement Risk Evaluation for Resident #7 completed on 3/20/25 revealed the resident at risk for elopement. Review of the EHR for Resident #7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility reported a census of 68 residents. Findings include: During an observation on 8/5/25 at 9:40 AM, Staff F, Certified Nursing Assistant (CNA), and Staff G, CNA, performed a mechanical lift transfer for Resident #4. After the transfer was completed, Staff F moved the mechanical lift equipment into the hallway without cleaning or sanitizing the equipment and placed it in the hallway. The mechanical lift did not have a sanitizing agent in the basket attached to the lift. During an interview 8/5/25 at 9:50 AM, Staff F, CNA, stated during training, no one trained her on cleaning the equipment after each transfer. Staff F stated there are no cleaning/sanitizing wipes on the mechanical lift in this hallway. Staff F stated even if a resident is on Enhanced Barrier Precautions (EBP) or Transmission Based…

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 interview, and policy review, the facility failed to ensure proper food equipment handling practices during meal service one of one meal service observed. The facility reported a census of 76. Finding include: During a lunch service observation on 4/13/24 at 11:45 AM,Staff H, Dietary, was seen transferring resident glasses to and from their table to the drink cart with fingers inside the glasses (empty glasses) or by the rim (full glasses) for a total of six occurrences. Staff H also observed carrying drinks back to resident tables with glasses held up against their apron for a total of 3 occurrences. During an interview on 4/16/25 at 9:50 AM, the Certified Dietary Manager (CDM) voiced dietary staff should be carrying drinks to and from resident tables one at a time. The CDM also states staff should be carrying cups/glasses by the bottom and not by the rim. The policy Handling Dinnerware, Utensils, Tableware, and Smallware, with a revised date of 3/20/24, states glassware and cups should be held by their handles, and glassware should be held by 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 electronic health record review, staff interview, and policy review, the facility failed to update and revise resident Care Plans for 2 of 17 residents reviewed for personalized Care Plans (Residents #2 and #25). The facility reported a census of 76. Findings include: 1. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 with a Brief Interview for Mental Status (BIMS) Score of 12, which indicated a moderate cognitive impairment. Diagnoses on the MDS include benign prostatic hyperplasia, diabetes, neurogenic bladder, non-Alzheimer's dementia, schizophrenia, seizure disorder/epilepsy, and stroke. Resident #2 had an indwelling urinary catheter. The MDS further documented Resident #2 was independent with transfers and required staff supervision/touching assistance for ambulation (without assistive devices). The Care Plan, with a targeted completion date of [DATE], noted Resident #2 with a suprapubic urinary catheter and use of a leg urinary drainage bag. Interventions on the Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, electronic heath record review, and staff interview, the facility failed to provide oxygen therapy as prescribed by the physician for 1 of 2 residents reviewed for respiratory care (Resident #43). The facility reported a census of 76. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 with a Brief Interview for Mental Status score of 7, which indicated severe cognitive impairment. Diagnoses on the MDS include diabetes, heart failure, and respiratory failure. The MDS further indicated Resident #43 receiving continuous oxygen therapy and experiences shortness of breath with exertion and when laying flat. The following observations on Resident #43 revealed the following: a. On 4/15/25 at 7:45 AM, while sitting in the dining room, the oxygen setting was at 2 liters (L) b. On 4/15/25 at 9:05 AM, while laying in bed, the oxygen setting was at 2 L c. On 4/15/25 at 3:45 PM, while sitting up in a wheelchair after staff assisted with personal cares, the…

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

Based on observation, staff interview, clinical record review, and policy review, the facility failed to assure a medication error rate of less than 5%. Medication errors were observed for Resident #15 & Resident #61. A total of 28 ordered medications were reviewed with two errors, an error rate of 7%. The facility reported a census of 76 residents. Findings include: 1. On 4/14/25 at 8:54 am, the observation of medication pass began. Staff A, Licensed Practical Nurse (LPN) prepared a total of 17 medications for Resident #15. Among the medications observed, Staff B prepared one tablet of Folic Acid, 400 micrograms (mcg). Staff A administered the medications to the resident at 9:05 am. 2. Staff A next prepared medications for Resident #61. He was witnessed preparing and administering nine medications for Resident #61. Staff A administered the medications to the resident at 9:21 am. When reconciling the observed medication pass against the orders for Resident #15, it was noted the Resident's order for Folic Acid was for 1 milligram (mg) rather than the 400 mcg the resident received. It…

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, bathing documentation, interviews, and facility policy the facility failed to provide residents at least two showers or bed baths per week for 4 of 4 residents reviewed (Residents #1, #2, #5, and #6). Documentation determined residents went as long as 10 days without a shower. The facility reported a census of 79 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #1 dated 8/26/24 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated moderate cognitive impairment. The MDS documented diagnoses including neurogenic bladder (bladder control issues due to damage to the brain, spinal cord, or nerves), septicemia (bacteria in the blood causing systemic infection), and quadriplegia. Resident #1 was dependent on staff for cares. The Care Plan for Resident #1 initiated 8/22/24 indicated Activities of Daily Living (ADL) self-care performance deficits due to quadriplegia and tracheostomy. Interventions included offering bathing/showering twice weekly and as necessary, and to provide a sponge bath when a full bath…

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 report an allegation of abuse to the Department of Inspections, Appeals and Licensing (DIAL) (state survey agency) within 24 hours of the allegation for 1 of 1 incident reviewed (Resident#1). The facility reported a census of 79 residents. Findings Include: The admission Minimum Data Set (MDS) dated [DATE] for Resident#1 documented a score of 12 out of 15 for the Brief Interview for Mental Status (BIMS), which indicated moderately impaired cognitive skills. The MDS documented that the resident had no behaviors, and diagnoses including high blood pressure, quadriplegia (paralysis of all four limbs), and anxiety. Progress Note written on 11/20/24 at 3:30 PM documented Resident #1 had concerns about Staff C, Certified Nursing Assistant (CNA), being rough with him while positioning the resident and he requested she not work with him in the future. Progress Note written on 11/20/24 at 3:40 PM documented Resident #1 explained 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, clinical record review, and resident and staff interviews the facility failed to provide routine perineal cares of incontinent residents for 1 of 4 residents observed for cares (Res #2). The facility reported a census of 79 residents. Findings Include: The Minimum Data Set (MDS) report dated 11/12/24 documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated no cognitive impairment. The MDS reported the resident required substantial/maximal assistance for toileting and toilet transfers. The Medical Diagnosis list initiated 10/22/24 documented diagnoses including: malignant neoplasm of colon (cancer), need for assistance with personal cares, and difficulty walking. The Care Plan dated 10/22/24 for Resident #2 instructed staff to use an EZ stand with assist of 2 staff for toileting, and documented a check and change audit was initiated 10/28/2024 due to the resident and family denying cares were being provided. It further noted the resident had bowel incontinence and instructed staff to observe the pattern of incontinence…

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

Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 73. Findings include: A direct observation on 06/24/24 at 8:09 AM of the facility refrigerators revealed 1 bag of broccoli stored in a clear unlabeled bag. 1 Bag of croissants stored in a clear, unlabeled bag. 1 Bag of oriental vegetable blend stored in a blue unlabeled bag. 3 bags of cake stored in a clear unlabeled bag. A direct observation on 06/24/24 at 8:17 AM of the facility freezers revealed one freezer contained chunks of what was later identified to be potato frozen to the bottom of the freezer unit. They were not contained and appeared significantly oxidized. An interview on 06/26/24 at 1:18 PM with Staff A, Dietary cook, she stated she had been made aware of the improperly stored food. She noted it should have been labeled before it was placed in storage. She stated that policy dictates improperly stored food should be disposed of immediately after…

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, hospital record review, guidance from The Cleveland Clinic, and staff interviews, the facility failed to draw and monitor laboratory values for one of three residents reviewed during medication administration, (Resident #81 in Stage III kidney failure who was receiving medications which had the potential to affect kidney function). Findings include: The Medication Administration Record (MAR) dated December 1, 2023 to December 31, 2023 documented Resident #81 had diagnoses including Chronic Kidney disease, Stage 3, and essential hypertension. The MAR documented the resident to be receiving Cozaar, 100 milligram (mg), an Angiotensin Receptor Blocker (ARB) medication used to treat high blood pressure, heart failure and chronic kidney disease. The MAR reflected the resident was also receiving 20 milliequivalents (MEQ) of Potassium daily and 80 mg of furosemide (also known as Lasix, a diuretic) twice daily. An article from The Cleveland Clinic, Titled Angiotensin II Receptor Blockers, review date 6/17/22 cited ARB medications are used for high blood…

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, interview and drug manufacturer's administration instructions, the facility failed to administer medications at an error rate of under 5%. The survey team observed 2 errors out of the 35 medications administered. The medication error rate was 5.7%. Findings include: During observation on 6/27/24, beginning at 7:13 am, Staff B, Licenses Practical Nurse (LPN) checked the blood glucose level of Resident #75. After obtaining her blood glucose, she prepared to administer 4 units of Lispro insulin. Staff B, LPN obtained the insulin pen from her cart, turned the dose indicator to 2 units of insulin, and stated she was priming the pen. She then connected a needle to the pen, turned the dose indicator to 4 units, and used appropriate hand hygiene and gloves administered the insulin to Resident #75. The document from the manufacturer's website titled Instructions for Use, Insulin Lispro KwikPen documented pen use as follows; Priming your pen: -Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use…

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, and resident and staff interviews, the facility failed to ensure staff responded and answered residents' call lights within 15 minutes, and met residents needs in a timely manner for two of two nursing units observed. The facility staff also failed to provide adequate supervision of residents during dining for 3 of 3 meal observations. The facility reported a census of 77 residents. Findings include: Observations revealed the following: 1. On 11/1/23 at 12:40 PM, Hall 5 had three call lights on. A certified nursing assistant (CNA) turned the last call light off at 12:59 PM. 2. On 11/1/23 at 12:50 PM, eight residents sat in the middle dining room with no staff present in the dining room. A female resident asked for someone to hand her some water. Resident # 6 sat in a wheelchair by the dining room table crying out I can't get this thing (wheelchair) to go, can you move it for me? At 12:56 PM, a male employee walked through the dining room and asked Resident #6 what she needed, then told the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interview, and policy review, the facility failed to ensure staff changed gloves when contaminated or before touched other objects and utilized infection control practices to protect against cross contamination and potential spread of infection. The facility staff also failed to complete proper hand hygiene in-between dirty to clean tasks for 3 of 6 residents reviewed for incontinence cares and dressing changes (Resident #1, #6, and #7). The facility reported a census of 77 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnoses of multiple sclerosis, failure to thrive, second or third degree burns, and a history of COVID-19. The resident required extensive assistance of one for bed mobility and toileting, and had incontinence. The Care Plan revised 7/28/23 revealed the resident had impaired skin integrity and a risk for developing pressure ulcers due to immobility and incontinence. The care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, resident and staff interviews, and facility policy review the facility failed to assess and provide interventions for a resident who developed a skin sore for one of three residents reviewed (Resident #3), and failed to complete treatments as ordered for one of three residents reviewed (Resident # 1). The facility reported a census of 77 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had diagnoses of heart failure, renal insufficiency, and long-term use of anticoagulants. The resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognition intact. The MDS revealed the resident had no skin issues. The Care Plan initiated on 10/18/23 revealed the resident had a potential for impaired skin integrity. The care plan revised on 11/1/23 revealed the resident had an abrasion to the back of her left leg and lambs wool wrapped over the bottom part of the recliner. The Order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and facility policy review the facility failed to provide complete and proper incontinence care to minimize the risk of cross-contamination and infection for 3 of 3 residents observed for incontinence care (Resident #1, #6, and #7). The facility reported a census of 77 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had diagnoses of diabetes, right above the knee amputation, cancer, and hemiplegia. The MDS indicated the resident required extensive assistance of one for bed mobility, and total dependence on two for transfers and toileting. The MDS indicated the resident had incontinence. The Care Plan revised 8/7/23 revealed the resident had bladder incontinence and a risk for impaired skin integrity as evidenced by pressure injury and incontinence. The care plan directed staff to provide assistance of one, check and change the resident, and cleanse the peri-area after each incontinence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure a system was in place to verify and track resident medications, to ensure medications administered as ordered, and ensure measures in place to prevent inadvertent duplication of medication. The facility reported a census of 77 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had diagnoses of chronic obstructive pulmonary disease (COPD), heart failure (CHF), hypertension (HTN) (high blood pressure), hyperlipidemia (high cholesterol/lipids in the blood), and diabetes. The MDS revealed the resident had a Brief Interview for Mental Status score of 15, indicating cognition intact. The Care Plan initiated 5/1/23 revealed the resident had HTN, hyperlipidemia, coronary artery disease, CHF, and diabetes. The care plan directed staff to give medications as ordered. The Medication Administration Record revealed hydralazine 25 mg by mouth three times a…

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

Based on clinical record review, resident interview and staff interviews, the facility failed to ensure each resident is treated with dignity and respect. (Resident #7) The facility reported census was 77. Findings include: According to a Minimum Data Set (MDS) with a reference date of 7/12/23, Resident #7 had a Brief Mental Status (BIMS) score of 15 out of 15 indicating an intact cognitive status. The MDS documented the resident required total dependence with transfers, mobility, dressing, toilet use and personal hygiene needs and is always incontinent of bowel and bladder. The MDS documented diagnoses to include non-Alzheimer's dementia. According to Resident #7's plan of care dated 10/13/22 she has an ADL (activities of daily living) self care performance deficit with interventions which include required 2 assistance with toilet use and one assistance with personal hygiene needs. On 10/11/23 at 11:40 am Staff J stated this morning while she received report from the overnight aide (Staff M), she was told Resident #7 was incontinent and her gown and pad was wet. Staff M stated 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 clinical record review, resident and staff interviews, the facility failed to ensure residents are provided incontinence care for 1 of 4 residents dependent on staff (Residents #7). The facility reported a census of 77. Findings include: According to a Minimum Data Set (MDS) with a reference date of 7/12/23, Resident #7 had a Brief Mental Status (BIMS) score of 15 out of 15 indicating an intact cognitive status. The MDS documented the resident required total dependence with transfers, mobility, dressing, toilet use and personal hygiene needs and is always incontinent of bowel and bladder. The MDS documented diagnoses to include non-Alzheimer's dementia. According to Resident #7's plan of care dated 10/13/22 she has an ADL (activities of daily living) self care performance deficit with interventions which include required 2 assistance with toilet use and one assistance with personal hygiene needs. On 10/11/23 at 11:00 am Staff J stated this morning while she received report from the overnight aide (Staff M) she was told Resident #7 was incontinent and her gown and pad 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 observation, clinical record review and staff interviews the facility failed to provide a prompt response to the resident's use of the nurse call system for 2 of 7 residents reviewed (Resident #4, #7). The facility reported census was 77. Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of 9/16/23, Resident #4 had a Brief Mental Status (BIMS) score of 13 out of 15 indicating an intact cognitive status. The MDS documented the resident required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and is always incontinent of bowel and has a catheter. The MDS documented diagnoses to include cerebrovascular accident (stroke), renal and respiratory failure, diabetes mellitus and cancer. Resident #4's plan of care dated 8/15/23 included use of an EZ stand lift with transfers, resident to get up one time daily into recliner or wheelchair and staff assistance with repositioning. During an observation on 10/10/23 at 7:40 a.m. observed Resident #4 in bed, lying supine with her TV on. Resident #4 remained in bed…

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's controlled substance accountability document review, staff interview, and policy review, the facility staff failed to have measures in place to ensure accurate documentation and tracking of controlled substance medications to prevent possible drug diversion for 3 of 3 residents reviewed (Resident #1, #2 and #9) and had controlled substance medications ordered. Schedule II-V controlled medications have a potential for abuse and may also lead to physical or psychological dependence. The facility reported a census of 75 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnosis of hemiplegia (paralysis on one side of the body), anxiety disorder, and a history of COVID-19. The MDS revealed the resident took opioid medication seven of seven days and had no pain during the look-back period. The Care Plan revised on 4/18/23 revealed the resident had pain related to osteoarthritis, polyneuropathy, muscle spasms, and 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.