Oakland Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, Electronic Health Record (EHR) review, policy review, resident interviews and staff interviews the facility failed to provide appropriate infection prevention practices when providing care to a resident with an indwelling catheter and a nephrostomy tube that was on Enhanced Barrier Precautions (EBP), failed to appropriately wear Personal Protective Equipment (PPE) during the sorting of laundry and failed to provide appropriated infection control standards for an outbreak of influenza A at the facility for 5 of 5 resident reviewed (Resident #8, #9, #28, #31 and #38). The facility reported a census of 32 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also documented diagnoses of quadriplegia, generalized muscle weakness, presence of urogenital implant and need for assistance with personal care. On 1/5/26 at 1:00 PM Resident #8 stated he had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Electronic Health Record (EHR) review, policy review, resident interviews and staff interviews the facility failed to provide dignity and respect to 2 of 14 residents reviewed (Resident #8 and #12). The facility reported a census of 32 residents.Finding include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS also documented diagnoses of quadriplegia, generalized muscle weakness and need for assistance with personal care. An observation on 1/5/26 at 1:19 PM Staff C, Certified Nurse Assistant leave room [ROOM NUMBER]. Staff C walked down the hall to join another CNA in room [ROOM NUMBER]. An observation of Resident #8 in bed with no sheets or clothes only a brief on. Staff D, Activities Director knocked on the door on 1/5/26 at 1:28 PM and entered the room. Staff D delivered mail to Resident #8. On 1/5/26 at 1:29 PM Staff C walked down the hall from room [ROOM NUMBER] to room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility policy review, the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 3 out of 5 sampled residents reviewed (Resident #5, #12, #20). The facility reported a census of 32 residents.Findings include:1. Review of Resident #5's Minimum Data Set (MDS) date 12/9/25 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS showed Resident #5 also took antidepressant medication during the review period. The MDS further revealed diagnoses of depression, diabetes, and respiratory failure.Review of Resident #5's Electronic Healthcare Record (EHR) page titled Medication Administration Record (MAR) revealed an order dated 9/19/26 for Citalopram 30 mg daily for major depressive disorder.Review of the Care Plan for Resident #5 with a revised date of 12/15/25 lacked non-pharmacological interventions and targeted behaviors 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews, documentation reviews and facility policy review, the facility failed to thoroughly investigate and report immediately alleged violations related to mistreatment of 1 resident (Resident #12) out of 8 reviewed. The facility reported a census of 32 residents.Findings include:Review of Resident #12's MDS dated [DATE] documented an admission to the facility on 6/30/25 and a Brief Interview for Mental Status (BIMS) of 08 indicating moderate cognitive impairment The MDS documented the following diagnoses: hemiplegia, diabetes, and depression. The MDS revealed Resident #12 depended on staff for total assistance with personal hygiene, upper and lower body dressing, and bathing. During an interview with Resident #12 on 1/7/2026 at 4:15 pm she stated Staff P, CNA recently slapped her upper leg while putting her feet up in bed. She stated she was attempting to get out of bed and Staff P noticed her while walking by her room, she then entered her room, was very mean verbally…

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 (EHR) review, staff interviews, and policy review the facility failed to obtain bed hold notifications for 1 of 3 residents (Resident #40) reviewed. The facility reported a census of 32 residents.Findings Include: Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of anxiety disorder, bipolar disorder, adult failure to thrive, and chronic kidney disease. Review of Resident #40's EHR page titled, Progress Notes revealed an entry dated 12/31/25 documenting that Resident #40 was transferred to the emergency room for evaluation. Further review of the progress notes revealed an entry dated 1/5/26 that Resident #40 was re-admitted back to the facility from a hospital stay. Review of the EHR page titled, Clinical Census revealed that Resident #40 had been in the hospital from [DATE] until 1/5/26. Interview on 1/8/26 at 9:22 AM with the Director of Nursing (DON) confirmed that Resident #40 was sent to the hospital on [DATE]. The DON then confirmed that no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review, staff interviews, and policy review, the facility failed to refer a resident with a negative Level I result for the Pre admission Screening and Resident Review (PASRR), who had an identified mental disorder, intellectual disability, or other related condition that was not addressed on PASRR completed prior to admission to the facility, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 resident (Resident #24) reviewed for PASRR requirements. The facility reported a census of 32 residents.Finding include:The Minimum Data Set (MDS) dated [DATE] documented Resident #24 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. The MDS revealed Resident #24 had a diagnosis of Post Traumatic Stress Disorder (PTSD) dated 2/7/25. The MDS documented Resident #24's admission date of 2/7/25.Review of document dated 1/30/25 titled, Preadmission Screening and Resident Review documented no diagnosis of PTSD under 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 interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 2 of 2 residents reviewed (Residents #27, #42) requiring the use of oxygen. The facility reported a census of 32 residents. Findings include: 1. Review of Resident #27's Minimum Data Set (MDS) dated [DATE] documented diagnoses of non-Alzheimer's dementia, Parkinson's disease, and depression. The Progress Notes in the Electronic Health Record (EHR) documented Resident #27 started receiving hospice services and was prescribed oxygen therapy via nasal cannula for comfort. An observation on 1/5/25 at 2:25 pm revealed oxygen was delivered via nasal cannula and the tubing attached to the oxygen concentrator located near the bed. The concentrator was turned on and set to deliver 2L/min of oxygen. The tubing did not have a label with the start date and staff initials. The tubing appeared flattened due to being jammed 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 clinical record review, resident and staff interviews and facility policy review the facility failed to separate Resident #1 and Resident #3 to prevent a resident-to-resident altercation. The facility reported a census of 39 residents.Findings Include:1) According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 9/13/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS listed the following diagnosis for Resident #1: hypertensive heart disease, anemia, renal failure, psychotic disorder (other than schizophrenia), mild cognitive impairment, insomnia, and metabolic encephalopathy.A Care Plan Focus Area with an initiation date of 1/15/2025 documented Resident #1 had a history or potential for delusions due to her cognitive status. The care plan documented she is redirectable, her short-term memory is impaired so diverting her attention can be effective. The care plan directed staff to reorient Resident #1 to her surroundings and situation.Record review…

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

Based on clinical record review, facility investigative file review, resident and staff interviews, the facility failed to complete a thorough investigation after an altercation between Resident #1 and Resident #2 on 10/17/2025 and between Resident #1 and Resident #3 on 10/18/2025. The facility reported a census of 39 residents.Findings Include:1) According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 9/13/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS listed the following diagnosis for Resident #1: hypertensive heart disease, anemia, renal failure, psychotic disorder (other than schizophrenia), mild cognitive impairment, insomnia, and metabolic encephalopathy.A Care Plan Focus Area with an initiation date of 1/15/2025 documented Resident #1 had a history or potential for delusions due to her cognitive status. The care plan documented she is redirectable, her short-term memory is impaired so diverting her attention can be effective. The care plan directed…

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, facility document review and staff interviews the facility failed to provide proper supervision for 1 of 3 residents reviewed (Resident #1). On 10/17/2025 Resident #1 had an altercation with Resident #2 and was placed on one-to-one supervision. On 10/18/2025 staff failed to provide one-to-one supervision which resulted in an altercation involving Resident #1 and Resident #3. The facility reported a census of 39 residents.According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 9/13/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS listed the following diagnosis for Resident #1: hypertensive heart disease, anemia, renal failure, psychotic disorder (other than schizophrenia), mild cognitive impairment, insomnia, and metabolic encephalopathy.A Care Plan Focus Area with an initiation date of 1/15/2025 documented Resident #1 had a history or potential for delusions due to her cognitive status. The care plan documented…

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 investigative file review, staff interviews and facility policy review the facility failed to timely report an allegation of abuse between 2 residents reviewed (Resident #1 and #2) to the appropriate management staff member. The facility reported a census of 40 residents.Findings include:According to the quarterly Minimum Data Set (MDS) with a reference date of 9/11/2025 documented a Brief Interview of Mental Status (BIMS) score of 10. A BIMS score of 10 suggested mild cognitive impairment. The MDS documented the following diagnoses: dementia, neurogenic bladder, schizophrenia, and post-traumatic stress disorder (PTSD).The Care Plan Focus Area with a revision date of 7/1/2022 documented Resident #1 had impaired cognitive function and impaired thought process due to his diagnoses of dementia and schizophrenia.A Progress Note documented on 9/27/2025 at 1:27 PM: between 11:00 AM and 11:30 AM Resident #1 began to become more agitated while sitting at the smoking doors, yelling out at staff stating let me out of this f*ing place, I want to go…

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

Based on record review, staff interviews and facility policy review the facility failed to update 2 of 3 resident's care plans (Resident #1 and Resident #2) after they were involved in a resident to resident altercation. The facility reported a census of 40 residents.Findings include:1) According to the quarterly Minimum Data Set (MDS) with a reference date of 9/11/2025 documented a Brief Interview of Mental Status (BIMS) score of 10. A BIMS score of 10 suggested mild cognitive impairment. The MDS documented the following diagnoses: dementia, neurogenic bladder, schizophrenia, and post-traumatic stress disorder (PTSD).A Progress Note documented on 9/27/2025 at 1:27 PM: between 11:00 AM and 11:30 AM Resident #1 began to become more agitated while sitting at the smoking doors, yelling out at staff stating let me out of this f*ing place, I want to go back to council bluffs. This nurse and a Certified Nursing Assistant CNA) came up to resident, said CNA attempted to push resident in his wheelchair but he grabbed the CNA's hand, ripping off her finger nail. Resident began to laugh,…

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 and record review the facility failed to notify residents or resident representatives of room change decisions, or provide explanation for the changes for 4 of 4 residents reviewed (#19, #17, #8, #1). The facility reported a census of 47 residentsFindings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #19 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficit). She required partial assistance with dressing and hygiene and supervision only with walking and transferring. Resident #19 had daily wandering activity. The Care Plan for Resident #19, updated on 5/21/25, showed that she had the potential for eloping and staff were to remind her of the location of her room. The resident had a verbal altercation with another resident while rummaging through the wrong room, staff were to intervene as necessary to protect the rights and safety of others. During an ongoing observation on 7/1/25 at 3:40 PM, Resident #19 wandered throughout…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, Electronic Medical Record (EMR) reviews, and policy review the facility failed to notify the physician and resident representative when a change in medical condition and/or treatment occurred for 4 of 4 residents (Resident #1, Resident #14, Resident #19, Resident #18). The facility failed to notify a resident Power of Attorney (POA) of a positive Covid test, a resident's POA of a fall, a physician of oral and enteral feeding refusals with the resident having continued weight loss, and a resident's POA of a psychotropic medication change. The facility had a census of 47. Findings include:1) The Minimum Data Set (MDS) for Resident #1 dated 4/18/25 revealed the Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive deficit. The document revealed diagnoses of cancer, anxiety disorder, depression, psychotic disorder, spinal stenosis, oral phase dysphagia and pharyngeal phase dysphagia. The document revealed that while a resident of the facility 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 employee file review, staff interviews and facility policy review the facility failed to complete additional research for 1 of 3 employees (Staff D CNA) when her background check indicated it required additional research. The facility reported a census of 47 residents. Findings include:Review of Staff D Certified Nursing Assistant (CNA) employee file reviewed the following:-a hired date of 4/22/2022-a Single Contact License and Background Check was completed on 4/27/2022 at 12:01 PM. The background check documented further research was required.Staff D's employee file lacked the Department of Human Services (DHS) release that indicated she would be able or not able to work in the facility following further research in to her criminal history research. During an email correspondence on 7/3/2025 at 11:30 AM the Administrator indicated she was unable to track down Staff D's DHS work letter. On 7/8/2025 at 2:10 PM the Interim Director of Nursing (DON) stated Human Resource (HR) staff completes the background checks. Now that they do not have someone in HR it will be 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 the previous Centers for Medicare and Medicaid Services (CMS) form 2567 review, staff interviews, and facility policy review the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 47 residents. Findings include:A review of the Department of Inspections, Appeals, and Licensing website revealed the facility had repeat deficient practices identified during the annual, revisit surveys and complaint investigations from 12/20/2021 to 12/23/2024. The repeat deficiencies cited include:-12/20/2021 during a complaint investigation: 580 Notification of Changes, 684 Quality of Care, 693 Tube Feeding Management, and 880 Infection Control-3/25/2022 during a revisit survey: 880 Infection Control-6/3/2022 during a recertification and complaint survey: 580 Notification of Changes, 607 Develop/Implement Abuse/Neglect, etc Policies, 689 Accidents and Hazards, 692 Nutrition/Hydration Status Maintenance-8/31/2023 during a recertification survey: 657 Care Plan Timing and Revision, 684…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, facility investigative file review, and facility policy review. The facility failed to ensure 2 of 3 residents (Resident #31 and #34) were free from abuse. The facility reported a census of 47 residents. Findings include:1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 2/21/2025 documented Resident #31 had a Brief Interview of Mental Status (BIMS) score of 4. A BIMS score of 4 suggested she had severe cognitive impairment. The MDS documented she utilized a wheelchair for mobility. Resident #31 required substantial/maximal assistance for person hygiene (including combing her hair). The MDS listed the following diagnoses for Resident #31: hypertensive urgency, pneumonia, non-Alzheimer's dementia, adult failure to thrive, and dysphagia. The Care Plan Focus Area with an initiated date of 8/15/2024 documented Resident #31 has Activities of Daily Living (ADL) self-care deficit. The Care Plan documented she required the assistance 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, facility investigative file review, staff interviews and facility policy review the facility failed to report a reportable incident to the State Agency within 2 hours of the alleged incident. The facility reported a census of 47 residents. Findings include:According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 4/17/2025 documented Resident #31 had a Brief Interview of Mental Status (BIMS) score of 4. A BIMS score of 4 suggested she had severe cognitive impairment. The MDS documented she utilized a wheelchair for mobility. Resident #31 required substantial/maximal assistance for person hygiene (including combing her hair). The MDS listed the following diagnoses for Resident #31: hypertensive urgency, pneumonia, non-Alzheimer's dementia, adult failure to thrive, and dysphagia. The Care Plan Focus Area with an initiated date of 8/15/2024 documented Resident #31 has Activities of Daily Living (ADL) self-care deficit. The Care Plan documented she required…

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

Based on observations, staff interviews, clinical record review, and policy review the facility failed to review and revise the Care Plans for 2 of 36 residents reviewed (Resident #1 and Resident #34). The facility failed to revise the Interventions for a resident who received oral and enteral intake, and the Goals and Interventions for 2 residents for intimate relations. The facility reported a census of 47 residents.Findings include: 1. The Minimum Data Set (MDS) for Resident #1 dated 4/18/25 revealed the Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive deficit. The document revealed diagnoses of cancer, anxiety disorder, depression, psychotic disorder, spinal stenosis, oral phase dysphagia and pharyngeal phase dysphagia. The document revealed that while a resident of the facility and within the last 7 days the resident had a feeding tube and mechanically altered diet. Resident #1's Care Plan dated 6/4/25 revealed an Activities of Daily Living (ADL) Self Care Performance Focus Area dated 10/17/23 with an intervention for staff that the resident…

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

Based on observations, interviews, Electronic Medical Record (EMR) reviews, and policy review the facility failed to provide services meeting professional standards for 1 of 36 residents reviewed (Resident #1). The facility failed to enter orders on the Medication Administration Record (MAR) - Treatment Administration Record (TAR) for correct route, complete and document physician orders on the MAR - TAR, and follow physician orders for interventions required during oral intake. The facility had a census of 47. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 4/18/25 revealed the Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive deficit. The document revealed diagnoses of cancer, anxiety disorder, depression, psychotic disorder, spinal stenosis, oral phase dysphagia and pharyngeal phase dysphagia. The document revealed that while a resident of the facility and within the last 7 days the resident had a feeding tube and mechanically altered diet. The assessment revealed the resident did not have a 5% weight loss in the past month…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews and record review, the facility failed to ensure that residents received baths per preference for 1 of 3 residents reviewed. Resident #32 a paraplegia was unable to sit in the shower chair due to lack of trunk support. Staff were providing bed baths only. The facility reported a census of 47 residents. Findings include:According to Minimum Data Set (MDS) dated [DATE], Resident #32 was admitted to the facility on [DATE] from another nursing home. He had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficits.) He was impaired on both sides upper and lower extremities, and had an indwelling urinary catheter. He was totally dependent on staff for hygiene showers, dressing and transfers and used a motorized wheel chair for mobility. The residents' diagnoses included: neurogenic bladder, paraplegia, recurrent dislocation of left hip, pressure ulcer of sacral region, insomnia and adult failure to thrive. The Care Plan dated 5/29/25, showed…

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, provider interview and policy review, the facility failed to ensure that residents received adequate and timely assessments and interventions for 2 of 12 residents reviewed (Residents #23 and #31). Staff failed to consistently monitor Resident #23 for side effects from psychotropic medications, and failed to complete neurological assessments after Resident #31 had an unwitnessed fall. The facility reported a census of 47 residents. Findings include:1. According to the Minimum Data Set (MDS) dated [DATE], Resident #23 had a Brief Interview of Mental Status (BIMS) score of 11 (moderate cognitive deficits). The resident required supervision with hygiene, dressing, toileting and transfers. Her diagnoses included: anxiety, depression, bipolar disorder, chronic pain disorder, opioid dependence. The high-risk medication included: antipsychotic, antianxiety, antidepressant, and opioids.The Care Plan for Resident #23 updated on 3/20/25, showed that she had a history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that they monitored urine output for residents with urinary catheter and were at risk for urinary tract infections for 1 of 3 residents reviewed. (Resident #32.) The facility reported a census of 47 residents. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #32 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficits.) The resident was totally dependent and on staff for toileting hygiene, showers, dressing and transfers. He was always incontinent of bowel, and had a urinary catheter. His diagnoses included: neurogenic bladder, paraplegia and adult failure to thrive. The Care Plan dated 5/2/25, showed that Resident #32 had self-care performance deficit and required staff assistance to turn and reposition in bed. The resident had a suprapubic catheter due to diagnosis of neurogenic bladder. Staff were to monitor for signs 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 electronic medical record (EMR) review, staff interviews, provider interview and policy review the facility failed to develop and implement interventions to stabilize or improve a resident's nutritional status before complications arose for 1 of 1 resident reviewed (Resident #1). The facility failed to monitor enteral and oral intake, respond to continuous weight loss over a 7 month period, and develop an integrated approach to the progression of enteral intake to oral intake. The facility reported a census of 47 residents. Findings include:The Minimum Data Set (MDS) for Resident #1 dated 4/18/25 revealed the Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive deficit. The document revealed diagnoses of cancer, anxiety disorder, depression, psychotic disorder, spinal stenosis, oral phase dysphagia, and pharyngeal phase dysphagia. The document revealed that while a resident of the facility and within the last 7 days the resident had a feeding tube and mechanically altered diet. The assessment revealed the resident did not have a 5% weight…

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 Health Record (EHR) reviews, staff interviews, and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during resident cares for 3 of 3 residents (Resident #33, Resident #1, and Resident #32). The facility failed to maintain appropriate placement of catheter bag placement, utilize hand hygiene, appropriate glove use, and Enhanced Barrier Precautions (EBP). The facility reported a census of 47. Findings include:1. The Minimum Data Set (MDS) for Resident #33 dated 7/3/25 in progress revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognitive function. The document revealed diagnoses of Cerebrovascular Accident (CVA)/Transient Ischemic Attacks (TIA), anxiety order, depression, psychotic disorder, Schizophrenia, and Cauda Equina Syndrome. The MDS identified the resident had an indwelling catheter.Resident #33's Care Plan dated 7/2/26 under development revealed…

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

Based on observations, staff interviews and policy review the facility failed to implement appropriate infection control practices to mitigate the spread of pathogens and diminish the risk of spreading SARS-CoV-2 (COVID-19) during an active outbreak. The facility reported a census of 48. Findings include: Observed on 12/23/24 at 9:25 AM upon entry into the facility a sign posted that stated all visitors must wear masks due to Covid. Observed on 12/23/24 at 9:30 AM Staff A, Dietary Cook, stood in the dining room, looked at the front door and back towards the nurses station and said Are we ready? Staff A proceeded to walk through the dining room, to the front door, opened the door, and led the Surveyor through a living room/dining room area, and down a hall to meet Staff G, Minimum Data Set (MDS) Coordinator/backup Infection Preventionist (IP). The total distance walked by Staff A was 100 feet. Staff A walked past 5 residents who were not wearing masks. Observed on 12/23/24 at 9:35 AM 14 rooms designated as being COVID-19 positive rooms with Personal Protective Equipment (PPE) hanging…

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

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (April 1 - June 30) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 51 residents. Findings include: The PBJ Staffing Data Report run date 11/13/24 for quarter 3 2024 triggered for excessively low weekend staffing and one star staffing rating. Review of weekend staffing schedules for quarter 3, months of April, May, and June revealed equal staffing during the week and the weekend. On 11/20/24 at 2:01 PM the Administrator stated the facility followed the per patient day (PPD) formula defined in the facility assessment for staff numbers and there is no change in the numbers for staffing on the weekend. The Administrator acknowledged the PBJ was reported inaccurately. The Administrator stated the facility was going to review the PBJ to ensure the reported information was accurate.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the record review, resident interviews, staff interviews and policy review the facility failed to provide access to personal funds managed by the facility or manage personal funds deposited at the facility. The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. On 11/18/24 at 12:13 PM Resident #4 stated he obtained money on Saturday this week from Staff K. Resident #4 stated Staff K worked in the business office across from the Administrator. Resident #4 stated residents could not get the money when the business office was closed. Resident #4 stated he could not get money at night or after the business office closes. Resident #4 stated the bank hours were 9am - 2pm Monday through Friday. 2. The MDS assessment dated [DATE] documented Resident #21 had a BIMS score of 15 indicating no cognitive impairment. On 11/18/24 at 1:41…

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

Based on observations, and staff interview, the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The facility reported a census of 51 residents. Findings include: On 11/18/24 at 10:00 am, an observation revealed multiple areas of missing or damaged floor tile in the north hall. On 11/19/24, a follow-up observation revealed the flooring tile had not been repaired or replaced. On 11/20/24 at 2:09 pm, the Maintenance Director stated he was responsible for minor repairs but major repairs required a contract company respective to the repair need. He stated cosmetic repairs were entered into a facility application available to all staff but indicated there were no unresolved building repairs. He also stated maintenance rounds were performed on a monthly basis. At 2:17 pm, he stated floor tile repair was a task he could repair and added he had no reason for why it had not been repaired. On 11/21/24 at 1:03 pm, the Corporate Director of Operations stated the facility did not have a policy specifically for homelike…

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

Based on observations, and staff interviews, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 51. Findings include: On 11/20/24 at 7:32 am, Staff A, Cook, checked the temperature of the breakfast menu items. The sausage gravy temperature was recorded at 180° Fahrenheit (F). On 11/20/24 at 8:33 am, Staff A checked the temperature of the remaining breakfast items. The sausage gravy temperature was recorded at 130° F. On 11/20/24 at 3:11 pm, the Dietary Manager stated staff should check the food temperatures before, during, and after meal service to ensure the food maintains regulatory temperature. On 11/21/24 at 1:03 pm, the Corporate Director of Operations stated the facility did not have a policy specific to holding temperatures for meal service.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to properly label stored food, failed to maintain sanitary practices by using the dedicated hand hygiene sink to fill a pitcher of water for resident use, and failed to ensure the appropriate amount of sanitizer solution was used to effectively sanitize food preparation surfaces. The facility reported a census of 51 residents. Findings include: On 11/18/24 at 11:15 am, Staff B, Registered Nurse (RN) was observed using the kitchen hand hygiene sink and filled a pitcher of water for resident use. Staff C, Cook, asked Staff B if she was supposed to use the hand hygiene sink for resident water to which Staff B replied she was instructed to use the (hand hygiene) sink. On 11/20/24 at 6:30 am, a kitchen observation revealed the [NAME] refrigerator contained the following items: a) An unlabeled package of round, pink meat. b) An unlabeled, undated, tan pitcher of liquid in the refrigerator. On 11/20/24 at 6:35 am, the pantry contained the…

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

Based on observations, clinical record review, staff interviews and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during resident cares (Resident #48), medication administration and laundry delivery. The facility reported a census of 51. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #48 dated 10/17/24 identified a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS documented diagnoses that included: septicemia, multiple sclerosis, pressure ulcer of right hip, unstageable, bacteremia, neurogenic bladder, urinary tract infection and rhabdomyolysis. Resident #48's Care Plan revealed the resident had an indwelling catheter and a wound to the right hip and coccyx/bilateral buttocks. The Catholic Health Initiatives (CHI) laboratory report dated 10/14/24 revealed the right hip had moderate mixed microbial flora with Moderate Gram Negative Rods (2 colony types) including Probable Proteus species. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing the use of an anticoagulant, insulin or an indwelling catheter for 3 of 10 residents reviewed (Resident #25, #32 and #48). The facility reported a census of 51 residents. Finding include: 1. The MDS assessment dated [DATE] for Resident #25 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #25's MDS dated [DATE] documented use of anticoagulant therapy by Resident #25. Review of Resident #25's Medication Administration Record (MAR) documented a physician's order for clopidogrel bisulfate (Plavix) oral tablet 75 mg, an anti-platelet. Review of Resident #25's MAR documented no physician order for use of an anti-coagulant. 2. The MDS assessment dated [DATE] for Resident #32 documented a BIMS score of 15 indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review and staff interviews the facility failed to provide a comprehensive care plan that included goals or interventions for enhanced barrier precautions (EBP) for a resident with a catheter and use of an anti-platelet for 2 of 10 residents reviewed (Resident #25 and #48). The facility reported a census of 51 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #25's Medication Administration Record (MAR) documented a physician's order for clopidogrel bisulfate (Plavix) oral tablet 75 mg an anti-platelet. Review of Resident #25's Care Plan documented no focus, goals or interventions for anti-platelet therapy. On 11/19/24 at 1:44 PM the DON stated that Plavix was an antiplatelet. The DON stated Resident #25 should have a Care Plan in place related to the risk for bleeding on the Care Plan. The DON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and staff interviews, the facility failed to protect residents from possible accidents and injuries for 2 of 17 residents (Resident #8, and #15) reviewed. The facility reported a census of 51 residents. Findings include: 1. Review of Resident #8's Minimum Data Set ( MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating normal cognitive function. Section GG, Functional Abilities, disclosed the resident utilized a manual wheelchair (w/c) and required substantial/maximal assistance. Resident #8's Care Plan dated 7/13/24 revealed the resident required the use of a Hoyer for transfers. Observation on 11/19/24 at 11:42 AM revealed Staff E, Certified Nursing Assistant (CNA), pushing Resident #8 in his w/c without foot pedals from his bedroom to the dining room. On 11/19/24 at 11:53 AM Staff E stated she was a contract staff, but had worked here many times. The staff stated she had been provided on training from 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide accurate and timely assessment and interventions. Staff failed to obtain a physician's order for home medications for 1 of 3 residents reviewed (Resident #3). Staff failed to adequately assess 1 of 3 residents reviewed for falls (Resident #4), and failed to contact the physician with high blood glucose levels for 2 of 2 residents reviewed (Resident #2, #9). The facility reported a census of 48 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a BIMS score of 15 (intact cognitive ability). He needed some help with self-care and used a manual wheelchair. Resident #3 required partial assistance with dressing, and toileting. He had an external urinary catheter and was always incontinent of bowel. Diagnosis included anemia, obstructive uropathy, diabetes mellitus, malnutrition and schizophrenia. The care plan showed that Resident #3 had been approved for short-term nursing home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, family interview, pharmacy staff interview, home health staff interview, facility staff interviews and facility policy review, the facility failed to ensure adequate discharge planning for 4 of 5 residents reviewed. Facility staff discharged Resident's #1, #3 and #6 without ensuring that they had the needed home medications. Staff discharged Resident #4 without advanced planning or arranging for the needed home health and therapy services. The facility reported a census of 48 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The MDS documented the resident independent with all cares and mobility. His diagnoses included seizure disorder, chronic obstructive pulmonary disease, early onset ataxia, alcohol dependence and adult failure to thrive. The MDS documented active discharge planning already occurring for the resident to return to the community…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, family interviews, resident interview, staff interviews and facility policy review the facility failed to notify resident representatives after falls for 2 of 3 residents (Resident #6, and #4) reviewed. The facility reported a census of 48 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive deficits). The resident required set-up assistance with hygiene, dressing needs, and supervision for walking and toileting. The resident's diagnoses included coronary artery disease, non- Alzheimer's dementia, encephalopathy, and alcohol dependence with persisting amnestic disorder. The Care Plan updated on 3/18/24, showed that Resident #6 had limited physical mobility related to alcohol abuse and dementia, and the discharge plan was to go home. Staff directed to evaluate and record the resident's abilities. The resident admitted for a short term stay and required therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility policy review the facility failed to follow standard infection control practices related to proper hand hygiene for 1 of 3 residents reviewed. While providing incontinence cares for Resident #7, two Certified Nurse Aides (CNA) failed to change their gloves and perform hand hygiene after they had wiped the resident's legs and buttocks. The facility reported a census of 48 residents. Findings include: According to the Minimum data Set (MDS) dated [DATE], Resident #7 had a Brief interview for Mental Status (BIMS) score of 14 (intact cognitive ability). He required substantial assistance with dressing and hygiene and was totally dependent on staff for toileting and bathing. His diagnosis included anemia, coronary artery disease, heart failure renal insufficiency, diabetes mellitus, and cerebrovascular accident (CVA). The Care Plan updated on 2/29/24, showed that Resident #7 required assistance for meeting emotional intellectual, physical and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing need for restraints and catheter for 4 of 4 residents reviewed (Resident #12, #29, #35, and 41). The facility reported a census of 45 residents. Finding include: 1. The MDS for Resident #12 dated 5/25/23 documented a Brief Interview of Mental Status (BIMS) of 15 out of 15 indicating no cognitive impairment. The MDS documented the resident used bed rails daily as a physical restraint. The Care Plan for Resident #12 documented the resident has a self-care performance deficit and directed staff that an assistive device placed on her bed to help increase bed mobility and increase independence. It also directed staff that the resident had U bars to bilateral head of the bed. On 8/27/23 at 3:47 PM the Assistant Director of Nursing (ADON)/MDS coordinator stated she did not understand that portion 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 personnel document review, and staff interviews the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a qualified professional serve as the dietary manager. The facility reported a census of 45 residents. Findings include: Review of personnel records for Staff C, the Dietary Manager, revealed no current certification. During an interview 8/27/23 at 9:53 AM with Staff C revealed that the current Dietary Manager did not have her certification, but was enrolled in the classes. During an interview 8/27/23 at 11:37 AM with the facilities Dietary Manager revealed she does not have education and training completed to be a qualified professional to serve as the Dietary Manager at the facility. During an interview 8/27/23 at 11:37 AM with Staff A revealed she did not have her certification for dietary manager. She further revealed she is enrolled in the classes, but has not started. During an interview 8/27/23 at 3:46 PM with the Administrator revealed her…

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 interviews, and facility policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 45 residents. Findings include: During continuous observation on 8/27/23 from 11:25 AM through 12:00 PM Staff D observed washing his hands and then applying gloves. After gloves applied Staff D observed touching cups on the brim of the glass, trays, fridge handles, reaching inside of the fridge for drink cartons, drawer handles, and pouring drinks while wearing the same pair of gloves. Staff D then doffed his gloves and washed his hands. Interview 08/27/23 at 12:00 PM with the facility Dietary Manager revealed her expectation is for good hand hygiene to be completed. The Dietary Manager further revealed her expectation is for staff not to touch everything with the same pair of gloves. Interview 8/27/23 at 3:49 PM with the Director of Nursing (DON) revealed her expectation is for staff to change gloves between each task and to complete hand hygiene. Review of provided facility policy…

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 documents, and staff interviews the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 1 of 3 residents (Resident #37) reviewed. The facility reported a census of 45 residents. Findings include: Review of the Electronic Health Record (EHR) revealed Resident #37 was hospitalized from [DATE] through 7/31/23. Review of a facility provided document titled, Notice of Discharge to Ombudsman, dated July 2023 revealed that Resident #37's hospitalization for 7/10/23 was documented. This document further revealed that Resident #37's hospitalization was not documented for 7/25/23. This document further instructed that this report was to be due by the beginning of the following month. During an interview on 8/30/23 at 3:07 PM with the Administrator revealed her expectation is for notification to the Ombudsman to identify if someone is admitted to the hospital more than once in a month. During an interview 8/30/23 at 4:45 PM with Staff J revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interviews the facility failed to refer 2 residents for the Pre-admission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 5 residents (Resident #18 and #37) reviewed for PASRR requirements. The facility reported a census of 45 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #18 documented a Brief Interview of Mental Status (BIMS) of 1 out of 15 indicating severe cognitive impairment. The MDS revealed diagnoses of schizoaffective disorder. Review of document titled Notice of PASRR Level 2 Outcome revealed completed on 4/25/23. Document also revealed no documentation of schizoaffective disorder review in the mental health diagnosis questions portion of the document. Review of Resident #18's Electronic Health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review the facility failed to update the resident's care plan to accurately reflect the resident for 1 of 23 residents reviewed (Resident #29). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #29 documented a Brief Interview of Mental Status (BIMS) of 15 out of 15 indicating intact cognition. The MDS further documented diagnosis of renal insufficiency, morbid obesity, and diabetes mellitus. Review of Resident #29's Care Plan with revision date of 8/7/2023 lacked information that the resident had an indwelling catheter, lacked staff directives and potential complications. Interview 8/29/23 at 12:50 PM with the Director of Nursing (DON) revealed her expectation is for care plans to be updated and revised to match physician orders. Review of the facility provided policy titled Comprehensive Person-Centered Care Plan, with a reviewed date of 10/23/2019 instructed: Upon a Change…

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

Based on observation, clinical record review, staff interviews, and facility policy review the facility failed to provide enteral tube feeding as appropriate per orders for 1 of 1 residents reviewed (Resident #45). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) for Resident #45 dated 6/6/23 revealed diagnosis of stroke, aphasia (loss of ability to understand or express speech), hemiplegia (paralysis to one side of the body), and respiratory failure. Observation 8/29/23 at 3:02 PM of Resident #45's feeding pump revealed tube feeding rate noted to be 50 millimeters an hour with 50 milliliters water flush every hour. Review of Medication Administration Record (MAR) dated 8/1/2023-8/31/2023 revealed physician order for Glucerna 1.5 50 ml/hr with water flushes at 20 ml/hr to run continuously. Interview 8/29/23 at 3:03 PM with Staff B Licensed Practical Nurse (LPN) revealed she paused the feeding earlier to give meds around 9 AM, but did not check the feeding rate of the pump. Observed Staff B adjust the rate of the water at this time.…

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, resident interview, and staff interviews the facility failed to change oxygen tubing for respiratory care and services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #3) requiring the use of oxygen. The facility reported a census of 45 residents. Findings included: The Minimum Data Set (MDS) for Resident #3 dated 6/4/23 documented a Brief Interview of Mental Status (BIMS) of 15 out of 15 indicating intact cognition. The MDS further documented diagnosis of chronic obstructive pulmonary disease (COPD), respiratory failure, anxiety, morbid obesity, and a need for assistance with personal care. The MDS documented the need for oxygen in the last 14 days. Review of a document titled Clinical Physician Orders dated 9/4/22, revealed a physician's order to change oxygen tubing every night shift on Sundays. During an observation on 8/27/23 at 11:15 AM revealed oxygen tubing connected from the concentrator to the continuous positive airway pressure (cpap) machine was dated 4/2. Interview 8/27/2023 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clincial record review, facility policy review and staff interviews the facility failed to provide dialysis services consistent with professional standards by not completing a post dialysis assessment to 1 of 1 residents reviewed (Resident #31). The facility reported a census of 45 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #31 documented a Brief Interview of Mental Status (BIMS) of 14 out of 15 indicating no cognitive impairment. The MDS documented diagnosis of end stage renal disease. On 8/30/23 at 11:52 AM Staff B stated the facility's procedure is to take the vitals and give medication prior to Resident #31 leaving. Staff B stated when Resident #31 returns from the dialysis center, the nurse was supposed to complete a post dialysis assessment. Staff B stated the facility's dialysis document no longer has a post assessment portion. Staff B stated post assessment is not documented in electronic health records (EHR). On 8/30/23 at 12:15 PM the ADON stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner. The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview of Mental Status (BIMS) of 4 out of 15 indicating severe cognitive impairment. On 8/30/23 at 1:50 PM a continuous observation revealed Resident #7's call light on. Continued observation revealed the call light answered by staff at 2:08 PM. On 8/30/23 at 2:08 PM Staff H stated call lights should be answered within one to three minutes. Staff H stated that she thought the CNA's did their best for having three CNA's on the floor. On 8/30/23 at 2:11 PM Resident #7 who resided in room [ROOM NUMBER] stated she turned the call light on to raise her head up in the recliner. On 8/30/23 at 2:29 PM the Director of Nursing (DON) stated the facility's expectation was call lights to be answered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, pharmacist interview and clinical record review the facility failed to ensure that residents did not have unnecessary medication prescribed for 1 of 5 reviews for narcotic medication use (Resident #30). The facility reported a census of 45 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #30 was totally dependent on 2 staff for dressing, toileting and personal hygiene. She had diagnosis that included anxiety disorder, depression and psychotic disorder. On 8/29/23 at 8:30 AM observed Certified Medication Aide (CMA), Staff I look through the locked drawer that contained narcotic medications and found that Resident #30 had 31 tabs of lorazepam. According to the Controlled Substance Accountability Sheet Resident #30 had an order for lorazepam 0.5 milligrams (mg) and from 8/9/23 through 8/22/23 the number of tablets had increased from 7 to 31 tabs. Staff I said that the number was increasing because the medication dispenser continued to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility document review, staff interviews and clinical record review the facility failed to properly label and store resident medications according to regulations. In an observation on [DATE], it was discovered that three insulin pens did not have documentation of the date opened and 1 insulin pen was being used passed the recommended 28 days after opening. The facility reported a census of 45 residents. Findings include: In an observation of the medication pass on [DATE] at 7:38 AM it was discovered that 3 pens containing insulin in the medication cart did not have the dates open documented. Two of the pens belonged to Resident #29. One contained Insulin Aspart, used three times a day, and the other was Detemir used once a day. A further investigation of the medication cart containing insulins found a Novolog pen for Resident #12 did not have a opened date and a pen for Resident #10 with Novolog was dated [DATE]. According to a screenshot dated [DATE] provided by the facility, from a web…

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 provide a well balanced diet that meets nutritional and special dietary needs for 1 of 10 residents reviewed (Resident #32) The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #32 documented a Brief Interview of Mental Status (BIMS) of 13 out of 15 indicating no cognitive impairment. The MDS revealed diagnosis of adult failure to thrive and prediabetes. Review of Resident #32's physician orders revealed an order for low concentrated sweets (LCS) diet, regular texture, thin consistency with low sodium and consistent carbohydrate for prediabetes dated 3/30/23. On 8/29/23 at 9:08 AM Staff N stated the kitchen offered smaller portions for dessert otherwise the residents all received the same meals. On 8/29/23 at 9:12 AM Staff A stated diabetics are served low concentrated sweets (LCS) and follow the menu for LCS which is half sized snacks and follow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews, and policy review the facility failed to provide food at an appetizing and palatable temperature to 3 of 18 residents reviewed (Resident #1, #6, and #40) The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview of Mental Status (BIMS) of 15 out of 15 indicating no cognitive impairment. On 8/27/23 at 2:41 PM Resident #1 stated the food could be better. Resident #1 stated the food is occasionally cold. 2. The MDS dated [DATE] for Resident #6 documented a BIMS of 2 out of 15 indicating severe cognitive impairment. On 8/27/23 at 10:44 AM Resident #6 stated she eats her food in her room. Resident #6 stated the food is always cold when it arrives in the room. Resident #6 stated that she just eats it. 3. The MDS dated [DATE] for Resident #40 documented a BIMS of 15 out of 15 indicating no cognitive impairment. On 8/28/23 at 9:03 AM Resident #40 stated the food sucks. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to provide infection control measures to mitigate the spread of pathogens. An observation of the laundry room found that the wash machine chemical pumps were not working and none of the chemicals or soaps were getting into the wash. Observations during food service and during patient care revealed inadequate hand hygiene and lack of appropriate glove use. The facility reported a census of 45 residents Findings include: 1) In an observation of the laundry area on 8/30/23 at 9:14 AM, the Laundry Manager (LM) pointed out two wash machines in the corner of the room. Both of the machines contained full loads of clothing and linens. Behind the machines were 8 pumps on the wall (4 per machine), with tubes that led into buckets of detergent, odor preventative agent, softener and chlorine. The pumps were not moving and there were no lights on them. As the machines ran through the cycle it was observed that none of the liquids were moving through 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.