Pioneer Valley Living And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #7's MDS assessment dated [DATE] revealed the resident had impairments in short term and long term memory, moderate impairment for daily decision making, inattention, and disorganized thinking as indicated by the staff. The document revealed diagnoses of Alzheimer's, Non-Alzheimer's Dementia, anxiety, and depression. The resident required substantial/maximal assistance for rolling in bed, and was dependent on staff for transfers. The document disclosed the resident was at risk for development of pressure ulcers and injuries, and treatments included pressure reducing devices for chair and bed. On 3/31/25 at 11:37 AM observed an unidentified staff member push Resident #7 to the dining room in a Broda Reclining Wheelchair (w/c) wearing Prafo boots. On 3/31/25 at 12:43 PM observed Resident #7 in the living area in the Broda Reclining w/c wearing Prafo boots. On 3/31/25 at 1:13 PM observed Resident #7 lying in bed on her back with Prafo boots. On 4/1/25 at 7:55 AM observed Resident #7 sleeping in 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, interviews and record review the facility failed to follow physician's orders for blood pressure parameters and daily weights for 2 of 6 residents reviewed (Resident #2 and #3.) The facility reported a census of 45 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 (moderate cognitive deficit). She required set up assistance for dressing and tub transfers, and was independent with transfers and toileting. The Care Plan for Resident #2, updated on 3/12/25, showed that she had bariatric surgery, she was diabetic and on anticoagulant therapy. Staff were directed to monitor for medication side effects such as significant or sudden changes in vital signs. The resident had diagnoses that included chronic kidney disease, weakness and adult failure to thrive. On 3/31/25 at 11:07 AM, Resident #2 was in her recliner with her feet elevated. She had supplemental oxygen running but the nasal cannula…

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 and policy review and interviews the facility failed to implement restorative services for 1 of 2 residents reviewed (Resident #1). The facility reported a census of 45 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit.) The resident was totally dependent on staff for toileting and transfers, and required substantial assistance with putting on and taking off footwear and lower body dressing. The resident had a stage 2 pressure injury and treatments included pressure ulcer care, application of ointments/medications and application of dressings to feet. The resident was on Hospice care. The Care Plan updated on 2/19/25, showed that Resident #1 had impairment to skin integrity related to fragile skin and a decline in his cognition and physical condition. The resident required a program to maintain strength and mobility. Staff were to monitor for ability to complete 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 the observation, staff interviews, and policy review the facility failed to reposition 1 of 3 reviewed (Resident #7). The facility reported a census of 45 residents. Findings include: Resident #7's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impairments in short term and long term memory, moderate impairment for daily decision making, inattention, and disorganized thinking as indicated by the staff. The document revealed diagnoses of Alzheimer's, Non-Alzheimer's Dementia, anxiety, and depression. The resident required substantial/maximal assistance for rolling in bed, and was dependent on staff for transfers. The document revealed the resident had a catheter, and was always incontinent of bowel. The document disclosed the resident was at risk for development of pressure ulcers and injuries, and treatments included pressure reducing devices for chair and bed. Resident #7's Care Plan, dated 3/5/25, identified a focus area indicating a risk for skin impairment related 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 2. Resident #10's MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognition. The document revealed diagnoses of cerebrovascular accident (stroke), hemiplegia (paralysis of 1 side of the body), and depression. The resident required substantial/maximal assistance for rolling in bed, and was dependent on staff for transfers. The document disclosed the resident was at risk for development of pressure ulcers and injuries, had a diabetic foot ulcer, and had pressure reducing devices for chair, bed, applications of ointments/medications other than to feet, and dressings to feet. Resident #10's Care Plan, dated 3/3/25, revealed the resident was at moderate risk for pressure ulcers. The document provided interventions for staff including pressure relieving cushion to the recliner, pressure relieving device to w/c, and an air mattress. The Electronic Medical Record (EMR) Clinical Physician Orders dated 12/18/25 had an order for completion 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, interviews and record review the facility failed to provide interventions for pressure ulcer prevention for 1 of 3 residents reviewed, (Resident #1). Resident #1 had a pressure ulcer to the right heel and was found to be without his protective boots and without the ordered treatment dressing. The facility reported a census of 45 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interviews, the facility failed to protect a resident from a possible accident and injury by pushing the resident in a wheelchair without foot rests for 1 of 5 residents (Resident #12). The facility reported a census of 45 residents. Findings include: Resident #12's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderate cognitive impairment. The MDS included diagnoses of non-Alzheimer's Dementia, and Depression. It revealed the resident required partial or moderate assistance for sit to/from stand positions, and transfers to/from bed, wheelchair and toilet. It further indicated the resident utilized a manual wheelchair and required partial/moderate assistance for 50 ' with 2 turns, and partial/moderate assistance for 150 ' in a hallway. Resident #12's Care Plan revealed a focus area of Activities of Daily Living (ADLS) self care performance deficit with interventions included…

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 reviews, staff interviews, and policy review, the facility failed to identify target behaviors for psychotropic medication use for 2 of 2 residents reviewed (Residents #10, #18). The facility reported a census of 45 residents. Findings include: 1. Resident #10's MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognition. The document revealed diagnoses of cerebrovascular accident (stroke), hemiplegia (paralysis of 1 side of the body), and depression. It included the resident had no episodes of little interest/pleasure in doing things, feeling down/depressed, social isolation, hallucinations, delusions, physical/verbal behavior towards others, or behaviors not directed at others. The document revealed the resident rejected care 1-3 days during the reporting period. The MDS revealed Resident #10 took antidepressant medication during the last 7 days of the assessment period. Review of Resident #10's Electronic…

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

Based on observation, interview and record review the facility failed to ensure that staff followed Enhanced Barrier Precautions (EBP) while providing wound treatments for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 45 residents. Findings include: According to the Minimum Data Set (MDS) date 2/14/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit.) The resident was totally dependent on staff for toileting and transfers, and required substantial assistance with putting on and taking off footwear and lower body dressing. The resident had a stage 2 pressure injury and treatments included pressure ulcer care, application of ointments/medications and application of dressings to feet. The resident was on Hospice care. The Care Plan updated on 2/19/25, showed that Resident #1 had impairment to skin integrity related to fragile skin and a decline in his cognition and physical condition. He was admitted to Hospice services on 1/25/25. He had padded, protective boots that he was to wear as allowed. A wound…

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 previous CMS-2567 review, staff interview and facility policy review the facility failed to ensure a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 47 residents. Findings include: Review of the Department of Inspections, Appeals and Licensing (DIAL) website under the facility's visit history revealed repeated deficient practices identified during the facility's annual survey and complaint investigation on 2/15/24 and the facility's annual survey, complaint and facility reported incident investigation on 1/21/25. The repeat deficiencies cited included: 1. F636- Comprehensive Assessments and Timing 2. F637- Comprehensive Assessment After a Significant Change 3. F638- Quarterly Assessment at least Every 3 Months 4. F640- Encoding/Transmitting Resident Assessment 5. F656- Develop and Implement Comprehensive Care Plan 6. F658- Services Provided Meet Professional Standards 7. F684- Quality of Care 8. F865- QAPI Program and Plan 9. F880- Infection Prevention and Control The QAPI Facility Plan dated December…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and/or the resident's responsible person when residents transferred out of the facility and failed to provide written notice of bed hold for 4 of 4 residents reviewed, (Residents #23, #24, #28 and #33). The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of chronic obstructive pulmonary disease (COPD), respiratory failure and dependence on supplemental oxygen. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Review of Resident #24's Census Tab revealed the following information: a. 1/14/25- stop billing b. 1/20/25- active Review of Progress Notes revealed the following: a. On 1/14/25 at 11:35 a.m., resident left per facility van to go to local emergency room (ER). b. On 1/14/25 at 3:28 p.m., resident was admitted…

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 interview and the MDS 3.0 Resident Assessment Instrument User's Manual the facility failed to complete and/or submit MDS assessments in a timely manner for 4 of 37 residents reviewed, (Resident #23, #36, #39 and #96). The facility reported a census of 47 residents. Findings include: 1. On [DATE] at 10:56 AM a review of Resident #23's Minimum Data Set (MDS) tab in his Electronic Health Record (EHR) revealed the most recent MDS was completed on [DATE] with a listed description as Significant Change. A Progress Note dated [DATE] at 7:39 AM documented Resident #23 was sent to the emergency room (ER). At 10:32 AM a Progress Note documented he was being admitted to the hospital and his Power of Attorney (POA) was aware. The facility failed to complete a discharge assessment once he was transferred and admitted to the hospital on [DATE]. 2. On [DATE] at 11:12 AM a review of Resident #36's MDS tab in his EHR revealed his End of Prospective Payment System (PPS) Part A Stay dated [DATE]…

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 observation, record review and staff interview the facility failed to develop comprehensive care plans for continuous positive airway pressure (CPAP), pain management, urinary tract infection, catheter, and hospice services for 4 out of 22 residents reviewed, (Residents #21, #24, #28 and #33). The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 documented the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The MDS showed diagnoses of anemia, coronary artery disease and heart failure. The MDS also showed Resident #21 experienced shortness of breath or trouble breathing when laying flat. The Physician Orders showed on 10/17/24 a CPAP ordered for at night and every evening. Review of the Care Plan for Resident #21 showed the facility failed to develop a comprehensive care plan for the need and usage of the CPAP. Observation on 1/18/25 at 9:49 AM showed Resident #21…

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 develop resident-specific care plans for 4 of 22 residents reviewed, (Resident #31, #11, #39 and #32). The facility reported a census of 47 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #31 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). The resident required moderate assistance with toileting hygiene, lower body dressing, and toileting transfers. His diagnosis included; renal insufficiency, peripheral vascular disease, and hip fracture. Resident #31 did not have a pressure injury upon admission on [DATE] and staff were to provide a pressure reducing device for his chair and bed. The Care Plan last reviewed on 8/30/24, showed Resident #31 had insomnia and chronic fatigue. He did not participate in activities and preferred to stay in his room. The resident required 1-2 staff assistance with a walker for transfers and he was encouraged to use the call…

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

Based on observation, interview and record review facility failed to monitor for expired medications, and failed to document open dates on insulin medications for 6 of 6 resident reviewed, (Resident #31, #32, #47, #54, #30 and #27). The facility reported a census of 47 residents. Findings include: On 1/29/25 at 6:02 AM the oncoming nurse Staff R Registered Nurse (RN) just started her shift for the day and looked through the bubble pack cards of narcotics in the medication cart. Staff R said that the pharmacy would document the dates on the back when the medications should be destroyed. She said that if there were no dates documented, the rule of thumb was 6 months from delivery. Hydrocodone for Resident #31 delivered on 6/7/24 expired 12/7/2024. Hydrocodone for Resident #32 delivered on 7/15/24 expired 1/15/2025. On 1/28/25 at 7:45 AM the following insulin pens were found in the medication cart without documentation of the dates that they were opened: a. Resident #47 Lantus delivery on 1/8/25. b. Resident #54 Xultophy insulin delivery date of 12/31/24 c. Resident #30 Gargine insulin…

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

Based on record review, facility investigative file review, resident and staff interviews, and policy review the facility failed to treat 1 of 3 residents (Resident #5) with dignity while assisting with cares and during transfers. 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 7/26/24 Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested the resident had no cognitive impairment. Resident #5 did not display behaviors during the review period and was not resistive to cares. The MDS documented the following diagnoses for Resident #5: UTI, heart failure, Parkinson's disease, depression, osteoarthritis, overweight, insomnia, chronic pain. The Care Plan focus area with a revision date of 8/8/2022 documented Resident #5 had self-care deficit related to tremors with weakness. The Care Plan documented she required the assistance of one staff with personal cares. A Progress Note dated 10/15/2024 at 11:30 AM documented resident's eyes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy review and record review the facility failed to complete a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS), Resident Assessment Instrument (RAI) Version 3.0 Manual assessment for 3 of 4 residents reviewed, (Residents #50, #51 and #149). The facility reported a census of 47 residents. Findings include: The Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated October 2023 defined an annual assessment as a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless the facility completed a significant change status assessment or a significant correction to the prior quarterly assessment since the previous comprehensive assessment. The Assessment Reference Dates (ARD) must be set within 366 days after the ARD of the previous comprehensive assessment and within 92 days of the quarterly or SCQA (ARD of previous Quarterly…

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 facility record review and staff interviews the facility failed to complete a significant change MDS within 14 days of the facility recognizing the resident had a significant change for 1 out of 22 residents reviewed, (Resident #33). The facility reported a census of 47. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #33 documented diagnoses of stroke, cancer and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #33's Census status revealed 12/13/24 primary payer of hospice private. Review of residents Progress Notes revealed the following: a. On 12/13/24 at 1:46 p.m., resident admitted back to facility from hospitalization. Power of Attorney elected to move forward with hospice admission. Resident will be admitted to hospice today. b. On 12/16/24 at 9:39 a.m., hospice will manage anxiety medications. Review of the care plan with a revision date of 1/27/25 lacked documentation…

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

Based on interview, policy review and record review the facility failed to complete a Quarterly Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS), Resident Assessment Instrument (RAI) Version 3.0 Manual assessment for 3 of 3 residents reviewed, (Resident #19, #39 and #49). The facility reported a census of 47 residents. 1. Review of Resident #19's Minimum Data Set (MDS) tab in her Electronic Health Record (EHR) revealed a Quarterly MDS assessment was completed on 6/28/2024. A second Quarterly MDS assessment was completed on 11/29/2024. The Quarterly MDS assessment completed on 11/29/2024 was completed five months after the 6/28/2024 Quarterly assessment was completed. 2. Review of Resident #39's MDS tab in his EHR revealed an admission MDS assessment was completed on 7/10/2024. A Quarterly MDS assessment was completed on 12/6/2024. The Quarterly MDS assessment completed on 12/6/2024 was completed five months after the 7/10/2024 admission MDS was completed. The facility failed to complete the Quarterly assessments every three months. 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, facility policy and staff interview the facility failed to provide accurate assessments on residents to reflect the residents current needs for 1 of 22 residents reviewed, (Resident #33). The facility reported a census of 47 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #33 documented diagnoses of stroke, cancer and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the MDS dated [DATE] revealed the following information: a. Resident had a pressure ulcer or injury, a scar over bony prominence, or a non-removable dressing device. b. Question of does this resident have one or more unhealed pressure ulcers or injury was answered yes. c. Number of stage 2 pressure ulcers was answered 1. Interview on 2/3/25 at 3:00 p.m., with Staff J, Director of Nursing (DON) revealed Resident #33 does not have a pressure ulcer and Staff U, DON revealed Resident #33 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 clinical record review, facility policy and staff interview the facility failed to provide a written summary of the baseline care plan for 3 of 22 residents reviewed, (Resident #24, #28 and #41). The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of chronic obstructive pulmonary disease (COPD), respiratory failure and dependence on supplemental oxygen. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Review of Resident #24's Census tab revealed an admission date of 1/2/25. Review of Resident #24's record lacked documentation that facility staff reviewed the initial care plan with the resident or her representative or provided a copy of the baseline care plan to the resident or her representative. 2. The MDS assessment dated [DATE] for Resident #28 documented diagnoses of hypertension, non-Alzheimer's Dementia and coronary artery disease.…

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 staff followed physicians' orders for 2 of 22 residents reviewed, (Resident #31 and #39). Staff failed to contact the physician with high blood pressures for Resident #31. Resident #39 had an order for anti-anxiety medication, staff failed to utilize and document as ordered. The facility reported a census of 47 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #31 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). The resident required moderate assistance with toileting hygiene, lower body dressing, and toileting transfers. His diagnosis included; renal insufficiency, peripheral vascular disease, and hypertension. The Care Plan last reviewed on 8/30/24, showed Resident #31 had insomnia and chronic fatigue. He did not participate in activities and preferred to stay in his room. The resident had hypertension, staff were to provide daily blood pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with staff and Hospice Nursing, record and medication review, the facility failed to assess residents and ensure they had appropriate interventions for 3 of 22 residents reviewed, (Resident #152, #33 and #24). Resident #11 had an unwitnessed fall that resulted in a fracture, staff failed to send her to the hospital for observation until 6 hours later and failed to document neurological assessments. Residents #33 and #24 missed medication doses because they were not available at the facility. The facility reported a census of 47 residents. Findings include: 1) According to the MDS dated [DATE], Resident #152 had a BIMS score of 12 (moderate cognitive deficits.) She used a walker and wheelchair for mobility. Resident #152 required set up assistance for hygiene and eating and was independent with sit to stand, toileting, transfer and walking 10 feet. The resident had diagnoses that included; hip fracture, cerebrovascular accident. The resident did not have any pain in the 5 day look back period.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews and policy reviews, the facility failed to change and label oxygen tubing for 1 of 2 residents reviewed, (Resident #24). The facility reported a census of 47. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of chronic obstructive pulmonary disease (COPD), respiratory failure and dependence on supplemental oxygen. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Observation on 1/27/25 at 11:04 a.m., revealed Resident #24 wearing oxygen tubing with supplemental oxygen running. Observation further revealed the oxygen tubing lacked a date of application. Interview on 1/27/25 at 11:04 a.m., with Resident #24 revealed she has a CPAP machine that she is to be wearing when she is sleeping and napping and she has had to argue with the staff to put it on. Resident #24 further revealed that on 1/26/25 she had to argue with the staff to apply 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to identify specific targeted behaviors related to high risk medications in 1 out of 7 sampled residents reviewed, (Resident #24). The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of chronic obstructive pulmonary disease (COPD), respiratory failure and dependence on supplemental oxygen. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Interview on 1/27/25 at 11:04 a.m., with Resident #24 revealed she takes hydroxyzine as needed for her claustrophobia. Resident #24 continued that she has asked for it and she has not gotten it and it makes it hard for her to be able to wear her machine at night and then she cannot sleep well. Review of Resident #24's January Medication Administration Record revealed the following orders: a. Hydroxyzine 1 tablet every 24 hours as needed for anxiety…

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 resident records reflected accurate care provided for 2 of 22 residents reviewed, (Resident #149 and #31). The facility reported a census of 47 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE] Resident #149 had a Brief Interview for Mental Status (BIMS) score of 15. She used a feeding tube for medications and nutrition. The Care Plan updated on 8/30/24, showed that she was at risk for aspiration and altered nutritional status related to enteral feeding. Staff were to evaluate and report significant changes to the physician as needed. On 1/27/25 at 4:55 AM, Staff O, Licensed Practical Nurse (LPN.) prepared and administered medications and nutritional supplement for Resident #149 and said that she did not take anything in by mouth. A review of the clinical record revealed a fax sent to the doctor on 12/24/24 at 12:05 PM, where staff reported that the resident had a significant weight loss. 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 2. Observation on 2/3/25 at 10:50 a.m, included observation of Resident #24's catheter bag laying directly on the floor. The catheter bag lacked a privacy cover. Facility did not provide a policy on catheter bags not touching the floor. Interview on 2/6/25 at 9:11 a.m., with the Director of Nursing revealed the catheter bag should not ever be on the floor. Based on observation, interview and record review the facility failed to implement infection control practices for 2 of 22 residents reviewed, (Resident #149 and #24). While staff provided nutrition and medications through a feeding tube, she failed to wear all of the required Personal Protective Equipment (PPE). The nurse stood on the resident's oxygen tubing while providing care to Resident #149. The urinary catheter bag for Resident #24 was laying on the floor. The facility reported a census of 47 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE] Resident #149 had a Brief Interview for Mental Status (BIMS) score of 15. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review, resident interview, and staff interview the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. The facility reported a census of 47 residents. Findings include: 1. The MDS dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. On 2/13/24 at 7:28 AM Resident #4 stated during the weekend of 2/10/24 and 2/11/23 the staff in the kitchen did not show up. The facility had the Certified Nurse Aide (CNA's) cook and serve the evening meal. Resident #4 added they had one other weekend where no one from the kitchen showed up to work, as well. On 2/13/24 at 4:25 PM Staff L, CNA, said she had to work in the kitchen on 2/10/24. Staff L stated she cooked grilled cheese and eggs. Staff L reported the macaroni salad was already prepared. Staff L explained they didn't have anyone in the dietary department. Staff L reported the morning shift cook…

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

Based on document review, staff interview, and policy review the facility failed to properly review the facility assessment annually with the minimum staff required. The facility reported a census of 47 residents. Findings include: The undated and unsigned Facility Assessment, revealed a paragraph in which the facility had an average census of 46 residents for 2023. During an interview 2/13/24 at 1:06 PM, the Administrator reported they should review the Facility Assessment annually. He usually just typed the revision date on the form as to when it is reviewed. The Administrator added they update the facility assessment after the end of each year, and he changed the date in the documentation. During a follow up interview on 2/13/24 at 1:14 PM the Administrator revealed he expected the facility assessment to be reviewed annually by the required members, signed, and dated when done. The Administrator added the facility didn't have a policy to review as the facility followed the standards of practice and the set of regulations.

Based on document review, staff interview, and policy review the facility failed to properly monitor and identify current issues in a timely manner. The facility reported a census of 47 residents. Findings include: Review of Performance Improvement Plans (PIPs) revealed there were no PIPs to review. During an interview 2/14/24 at 9:01 AM Staff J, Chief Operating Officer/Minimum Data Set (MDS) Coordinator/Care Plan Coordinator, reported she hasn't been good at completing the Care Plans and the MDS'. Staff J added she didn't know which resident Care Plans, and MDS assessments got completed in the last 6 months. Staff J reported she talked to corporate and the Administrator of the facility that she struggled to get the Care Plans completed. Staff J added that the facility's corporate Chief Executive Officer (CEO) spoke with her about not completing the MDS assessments and Care Plans. Staff J reported they completed a PIP to remove her from the MDS and Care Plan Coordinator role. Staff J could not recall the start date of the PIP. During an interview 2/15/24 at 8:57 AM the Administrator…

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

Based on document review, staff interview, and policy review the facility failed to establish and implement written policies and procedures for the Quality Assurance and Performance Improvement (QAPI) plan. The facility reported a census of 47 residents. Findings include: The undated Quality Assessment and Assurance Committee Policy lacked guidance on policies or procedures for feedback, data collections systems, and monitoring. During an interview on 2/15/24 at 8:57 AM the Administrator reported he didn't know the expectations for the QAPI policy and procedure requirements. The Administrator added the staff could bring concerns to the Administrator, or Director of Nursing. The Administrator then revealed the facility does have a suggestion box for anonymous comments, but the facility is not currently working on any Performance Improvement Plans (PIP). The Administrator explained the facility didn't have policy to review as the facility followed the Federal regulations.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The Infection Prevention and Control Program revealed the last revision date completed as March 2020. During an interview 2/13/24 at 1:04 PM, the DON/Infection Preventionist (IP) reported that she didn't know if the infection control policy got reviewed annually. During an interview 2/13/24 at 1:06 PM the Administrator and the DON said they should review the policy annually. They type the revision date on the form as to when it is reviewed. The Administrator acknowledged the Infection Control Policy listed the last revised March 2020. The Administrator added he expected the facility to review the infection control policy annually, sign, and date it when they reviewed the document. The Administrator explained they didn't have a policy to review as the facility followed the set of Federal regulations and standards of practice. Based on observation, record review, policy review, and staff interview the facility failed to provide adequate infection prevention practices during medication administration for 1 of 8…

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

Based on interview, record review and policy review the facility failed to ensure the Administration conducted annual ethics trainings and reviewed the ethics policy on an annual basis. The facility reported a census of 47 residents. Findings include: Upon entry to the facility for the annual survey, it was discovered that the facility had 47 residents residing. According to Minimum Data Set (MDS) information submitted, there were just 22 residents. Further investigation revealed that many of the assessments had not been submitted in a timely manner. On 2/14/24 at 9:00 AM the Minimum Data Set (MDS) Coordinator reported the corporation hired her and she also owned a part of the company. She said that she understood that payment percentage was determined by the level of care that a resident required. She said that a resident that required a higher level of care would result in a higher pay rate and this was determined by the MDS assessment. When asked if it could be a conflict of interest to be part owner in the company, and the MDS coordinator, she responded that it could possibly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to complete a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual assessment for 4 out of 4 residents reviewed (Residents #11, #12, #124, and #151). Findings include: During the Entrance Conference on 2/12/24 at 11:00 AM, the facility reported a census of 47 residents. The Long-Term Care Survey Process form labeled MDS Indicator Facility Rate Report for the survey ending 2/15/24 generated by the MDS assessments completed by the facility listed a total number of assessments as 22. The Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated October 2023 defined an annual assessment as a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless the facility completed a significant change status assessment or a significant correction to the…

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

Based on record review and interview the facility failed to submit change of condition assessment information for 2 of 2 residents reviewed (Residents #14 and #136). After Residents #136 and #14 began hospice services, the facility failed to complete the Minimum Data Set (MDS) assessment within the required timeframe as directed by the The Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual regarding a change in status. Findings include: The CMS RAI Version 3.0 Manual dated October 2023 indicated a significant change in status assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on 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 electronic health record review (EHR), policy review, and staff interviews the facility failed to complete quarterly comprehensive assessments for 4 of 4 residents reviewed (Residents #3, #4, #6, and #126) as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3 Manual. Finding include: The CMS RAI Version 3 Manual dated October 2023 regarding the assessment schedule directed an Omnibus Budget Reconciliation Act of 1987 (OBRA) assessment (comprehensive or Quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. An OBRA comprehensive assessment is due every year unless the resident is no longer in the facility. There must be no more than 366 days between comprehensive assessments. PPS assessments follow their own schedule. See Chapter 2 for details. 1. Resident #3's Clinical-MDS listed the Next Qtrly (Quarterly): Assessment Reference Date (ARD) Quarter (Q)1: 12/25/23, directed to complete by 1/8/23. The list lacked a completed…

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 chart review and interviews the facility failed to transmit Minimum Data Set (MDS) resident assessment information as directed by the The Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual within 14 days from the date the Registered Nurse (RN) certifies completion of the Care Area Assessment for 4 of 4 residents (Residents #7, #8, #22, and #154) reviewed. Findings include: During the Entrance Conference on 2/12/24 at 11:00 AM, the facility reported a census of 47 residents. The Long-Term Care Survey Process form labeled MDS Indicator Facility Rate Report for the survey ending 2/15/24 generated by the MDS assessments completed by the facility listed a total number of assessments as 22. The CMS RAI Version 3 Manual dated October 2023 directed the following: a. Encoding Data: Within 7 days after completing a resident ' s MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility's MDS software). The encoding requirements are as follows: For a comprehensive…

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 provided adequate fluids for 4 of 4 residents reviewed (Residents #14, #125, #145, and #159). When Resident #14 went to the hospital for high blood glucose levels, they diagnosed her with dehydration. Resident #125 required a feeding tube with free water 4 times a day. The Medication Administration Record (MAR) lacked documentation indicating they received the order as written. Residents #145 and #159 reported that their water pitchers did not get filled on a daily basis. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #14 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive deficit. Resident #14 required totally dependence from two persons for locomotion, dressing, and toilet use. Resident #14 required extensive assistance from one person with eating. The MDS included diagnoses of type 2 diabetes mellitus, chronic kidney disease, vascular dementia, and anxiety disorder.…

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, and staff interviews, the facility failed to failed to implement offloading procedures to decrease pressure for 1 of 3 residents as directed by their Care Plan (Resident #137). Resident #137's Care Plan directed to use a pressure relieving pad while in his chair. Multiple observations revealed Resident #137 sat in his reclining chair (recliner) without a pressure relieving pad. Resident #137 reported his buttocks hurt. Findings include: Resident #137's Minimum Data Set (MDS) assessment dated [DATE] indicated he required total assistance of 2 people for bed mobility, transfers, and used a manual wheelchair for all mobility. The assessment reflected Resident #137 had a risk for developing pressure ulcers/injuries, but did not have any unhealed pressure ulcers/injuries. Resident #137's skin and ulcer/injury treatments included: pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, nutrition or hydration program,…

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 staff administered medications according to physician's orders for 2 of 2 reviewed (Resident #132 and #159). According to the Medication Administration Record (MAR) on the weekend of February 10th and 11th, Residents #132 and #159 did not get their scheduled insulin. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #132 had a Brief Interview for Mental Status (BIMS) score of 4 (severe cognitive deficit). She required supervision with eating and hygiene, and required substantial assistance with sit to stand and toileting. The resident received insulin injections 7 days a week. The care plan updated on 7/21/22, showed that Resident #132 had self-care deficits related to scoliosis with dementia. She was at nutritional risk related to diagnosis of type 2 diabetes and was taking oral agent metformin, Trulicity, and long insulin glargine. Staff were directed to administer medications as ordered and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to provide accurate and timely assessment and interventions for 2 of 17 residents reviewed (Resident #14 and #3). Resident #14 had a diagnosis of type 2 diabetes. On the early morning of 11/16/23 she had a change in condition and staff failed to obtain a blood glucose level or set of vitals until 4 hours later. She was then sent to the hospital with Diabetic Ketoacidosis and a blood glucose level of 434 milligrams per deciliter (mg/dL) (normal range being 80-130 mg/dL). Resident #3 reported that she had pain at her stoma site and cream relieved the pain. Staff failed to provide the treatments to her stoma that provided her relief. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #14 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive deficit. The resident was totally dependent on two staff for locomotion, dressing and toilet use. The resident required extensive assistance…

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 prepare, serve, and distribute food in accordance with professional standards. The facility reported a census of 47 residents. Findings include: On 2/12/24 from 12:10 PM to 12:35 PM observed Staff F continue to wear the same gloves without hand hygiene as she touched pot holders, carry plates, and deliver plates to 3 residents in the dining room after grabbing door handles to exit and enter the kitchen, handles on pans, and opening the freezer doors. With the same gloves, watched Staff F prepare a plate for a resident and then cook an egg for another resident. Witnessed Staff F crack an egg, remove her gloves, then perform hand hygiene. During an interview 2/12/24 at 1:22 PM, Staff G, Certified Dietary Manager, said she expected good hand hygiene while serving, prepping food, and serving meals. During an interview 2/12/24 at 3:25 PM the Administrator reported he expected proper hand hygiene, applying gloves, and removing gloves at the appropriate times when preparing or distributing food. The undated…

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.