Garden View Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, law enforcement interview, staff interviews, and policy review the facility failed to investigate the misappropriation of resident medications that went missing for 1 of 1 residents (Resident #2) reviewed. The facility reported a census of 32 residents. Findings include:Review of Resident #2's Minimum Data Set (MDS) dated [DATE] indicated that Resident #2 was taking opioid medications during the seven day look back period. The MDS further indicated that Resident #2 had diagnoses of heart failure, renal failure, diabetes mellitus, acquired absence of the right leg below the knee, and chronic pain. Review of the Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Hydrocodone-Acetaminophen 10-325 MG (Milligrams) to give one tablet by mouth every 4 hours as needed for increased pain with a start date of 2/15/26 and a discontinued date of 4/24/26. Further review revealed another order for Hydrocodone-Acetaminophen 5-325 MG to give one tablet…

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

Based on observation, resident electronic health record review, staff interview, and policy review the facility failed to provide safe ambulation/transfer techniques by not using a gait belt to ambulate a resident that required assistance for 1 of 3 (Resident #14) residents reviewed. The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #14, dated 5/12/26, included diagnoses of cancer and anxiety disorder. The MDS identified the resident required substantial/maximal assistance of staff for sit to stand, transfers, and walking. The MDS identified the resident was occasionally incontinent of bladder and bowel and a Brief Interview for Mental Status score of 9, indicated moderate cognitive impairment for decision-making.Resident #14's Care Plan, with revision date 5/23/25, documented the following problems and interventions:a. Self-care deficit as evidenced by requiring assistance with activities of daily living, impaired balance during transitions requiring assistance and /or walking with an intervention for mobility of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to meet professional standards for ostomy care by not releasing the build up of gas in the ostomy bag, which caused the appliance to spill the contents for 1 of 1 (Resident #13) reviewed. The facility reported a census 32.Findings include:Review of Resident #13's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS further indicated Resident #12 had diagnoses of functional quadriplegia, ileostomy status, noninfective gastroenteritis (inflammation of the stomach and intestines) and colitis (inflammation of the inner lining of the large intestine), and Ogilvie syndrome (sudden paralysis and massive dilation of the colon). Review of Resident #13's Care Plan with a revision date of 4/28/26 indicated that Resident #13 requires an assist of 1 staff with colostomy care and emptying. Observation 5/26/26 at…

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

Based on observation, resident interview, electronic health record review, policy review, and staff interview the facility failed to provide a respiratory treatment timely for 1 (Resident #17) of 1 residents reviewed. The facility reported a census of 32 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #17, dated 2/24/26, included diagnoses of Panlobular Emphysema (a severe form of chronic obstructive pulmonary disease (COPD) with widespread lung damage) and COPD. The MDS identified a Brief Interview for Mental Status score of 9, indicated no cognitive impairment for decision-making.Resident #17's Care Plan documented a problem of resident has COPD and is at risk for shortness of breath, impaired breathing, and respiratory infections with the intervention to administer medications/inhalers as ordered.Observation on 5/14/26 starting at 10:00 AM, Resident #17 walked down the hall, leaning on the wall and holding the hand rail, was able to hear the resident wheezing and the resident appeared short of breath, and resident stated he needed a vial of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and policy review, the facility failed to provide appropriate treatment and services to meet a resident's highest practicable physical, mental, and psychosocial well-being for residents diagnosed with dementia for 2 of 2 residents reviewed (Resident #6, #11). The facility had a census of 32.Findings include:1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS score of 2/15 indicating severe cognitive impairment. The document revealed the resident displayed fluctuating inattention, physical behaviors directed towards other 4-6 days of the last 7 days of the reporting period, verbal behavioral symptoms towards other 1-3 days of the last 7 days of the reporting period and those behaviors significantly interfered with the resident's care, social interaction and significantly impacted the privacy, care, and living environment of others. The document disclosed the resident required significant assistance or was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, resident interviews, staff interview, and policy review the facility failed to order and dispense medications per physician orders for 3 of 7 residents reviewed (Residents #1, #16, #19). The facility reported a census of 32 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS Assessment documented diagnoses of atrial fibrillation, heart failure, hyperlipidemia (high cholesterol), and diabetes mellitus (DM). The document revealed the resident received 1 injection, antibiotics, diuretics, and hypoglycemic medications during the past 7 days of the reporting period. The clinical record's Medical Diagnoses included: Type 2 diabetes mellitus without complications, hyperlipidemia, and hypokalemia (lower than normal potassium in blood that helps regulate heart rhythms, muscle contractions, and nerve signals). Resident #1's Care Plan, revised…

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, resident interview and policy review the facility failed to regulate a resident's medication to treat the resident's medical condition for 1 of 3 residents (Resident #16) reviewed. The facility failed to provide a current diagnosis for a narcotic medication. The facility reported a census of 32 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. The MDS included the diagnoses of traumatic brain injury (TBI), and other psychoactive substance abuse, uncomplicated. The MDS provided the resident did not receive scheduled pain medication or non-pharmalogical pain medication, but did receive as needed (PRN) pain medication during the last 5 days of the reporting period. The MDS revealed the resident received opioid medication during the last 7 days of the reporting period. The clinical record's Medical Diagnoses included a diagnosis of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interviews, staff interviews, and facility policy review the facility failed to provide snacks to 3 of 4 residents (Residents #8, #19, #20) who wanted to eat at non-traditional times or outside of scheduled meal service times. The facility reported a census of 32 residents.Findings include: 1. Resident #8's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS documented diagnoses of anemia, hypertension -high blood pressure (HTN), and diabetes mellitus (DM). The document included the resident during 6 of the last 7 days of the reporting period the resident received an injection and hypoglycemic medication. The Care Plan revised 4/29/26 revealed a problem area related to DM and risk for frequent infections, visual impairment, hyper/hypoglycemia revised on 3/17/25 with staff interventions including all concerns with DM to be addressed with the primary care physician (PCP), diabetes…

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

Based on review of previous Centers of Medicare and Medicaid Services (CMS) form 2567, 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 31 residents. Findings include:A review of the Department of Inspections, Appeals, and Licensing website revealed the facility had repeated deficient practices identified during complaint investigations and recertification surveys from 2/2/2024 to 12/8/2025. The repeated deficiencies cited include:-4/5/2024 during a complaint and incident investigation: 609 failure to report and 842 resident records-identifiable information,-7/24/2024 recertification survey and complaint investigation: 880 infection prevention and control,-9/11/2024 complaint and incident investigation: 584 safe/clean/comfortable/homelike environment, 609 failure to report, 842 resident records-identifiable information, 865 QAPI program/plan, disclosure/good faith attempt, and 880 infection prevention 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, and staff interviews the facility failed to ensure maintain a clean, safe, and sanitary homelike environment. The facility reported a census of 31 residents.Findings include:On 4/2/2026 at 10:10 AM observed Resident #5's window cracked and her closet doors broken. Resident #5 stated these things have been broken since she was admitted to the facility not quite a year yet. She added the window rattles when doors open and close. Her room will at times become chilly in the winter when the wind blows. The resident was sitting in her recliner that is positioned next to the window. Both closet doors do not open or close and are not secured on the track. The outside door has a half dollar hole in it. On 4/2/2026 at 12:00 PM observed the following environmental concerns:-between rooms [ROOM NUMBERS]: 5 ceiling tiles with brown to light brown circular stains of various sizes,-between rooms 50-52 and 53-55 by the fire extinguisher cubbie: 6 ceiling tiles with brown to light brown circular stains 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 observations, clinical record review, staff interviews and facility policy review the facility failed to secure resident's medical records. The facility also failed to ensure 1 of 3 resident's (Resident #2) medical file was complete and accurate. The facility reported a census of 31 residents. Findings include:1.On 4/2/2026 at 9:00 AM observed through an unlocked door (conference room) to the right of the main entrance after entering the facility. Once through the door, observed a file cabinet, with no locking mechanisms that contained resident medical records. At 1:39 PM to the west of the facility outside, a garage with two garage doors was observed. The garage door on the left was opened approximately 6 inches. The Maintenance Director opened both garage doors without needing to unlock them. Once through the garage door on the right, noted a grey 60-gallon trash can that was filled with resident documents. Resident identifiers visible. On 4/2/2026 at 3:26 PM the Administrator was asked where their medical records are stored. He stated in a building off campus. It's a…

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

Based on observations, staff interviews, previous Centers of Medicare and Medicaid Services (CMS) form 2567, and policy review the facility failed to provide appropriate infection prevention and control for residents in the facility. The facility failed to resolve water intrusion and black substance in the basement and back substance in the laundry room. The facility reported a census of 31 residents.Observation on 4/2/2026 at 1:12 PM revealed the wall between the washers and driers in the laundry to have various areas of cracks in the paint. Behind an area close to the floor board revealed a black fuzzy substance. Behind the water heater stagnate water present as well as to the left of the first washer once inside the dirty side of the laundry room. The Maintenance Director stated at times the drainage hoses become clogged and the water runs over the water compartment. The water present was observed to be on a flat surface above the slope to the drain. On 1:17 PM observed a heavy mildew/musty smell while in the basement. Also observed stagnate water in the basement where the walls…

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 treat 1 of 3 residents (Resident #1) with dignity when assisting with Activities of Daily Living (ADLs). The facility reported a census of 31 residents.Findings include:According to the quarterly Minimum Data Set (MDS) assessment with a reference date of 2/12/2026 documented Resident #1 had a Brief Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. The MDS documented he did not exhibit rejection of care during the review period. Resident #1 had an impairment to bilateral extremities; he utilized a wheelchair. The MDS documented he was dependent on staff for toileting hygiene and toilet transfers. The MDS indicated Resident #1 was always incontinent of stool. The following diagnoses were documented for Resident #1: atrial fibrillation, heart failure, renal failure, retention of urine, insomnia, and acute pain.The Care Plan Focus Area with a revision date of 3/12/2025 documented Resident #1 had self-care deficit as evidenced by…

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

Based on clinical record review and staff interviews the facility failed to ensure 1 of 3 residents reviewed (Resident #2) were provided transportation services for their out-of-town appointment. The facility reported a census of 31 residents.Findings include:According to the Significant Change Minimum Data Set (MDS) assessment tool with a reference date of 3/7/2026 documented Resident #2 had a Brief Interview of Mental Status (BIMS) score of 9. A BIMS score of 9 suggested mild cognitive impairment. The MDS listed the following diagnoses for Resident #2: heart failure, renal insufficiency, non-Alzheimer's dementia, anxiety, depression, and left leg below the knee amputation.Record review revealed a document titled Doctor's Orders and Progress Notes, dated 3/27/2026. The documented listed the following: please complete dry dressing changes daily to left lower extremity with gauze and ace bandage, non-weight bearing to left leg, and follow up on 4/3/2026 at 9:30 AM.Record review of progress note on 4/7/2026 at 3:05 PM revealed no progress notes documented related to the follow-up…

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, and facility policy review the facility failed to report an allegation of abuse within 2 hours of the alleged incident. The facility reported a census of 31 residents.Findings include:According to the quarterly Minimum Data Set (MDS) assessment with a reference date of 2/12/2026 documented Resident #1 had a Brief Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. The MDS documented he did not exhibit rejection of care during the review period. Resident #1 had an impairment to bilateral extremities; he utilized a wheelchair. The MDS documented he was dependent on staff for toileting hygiene and toilet transfers. The MDS indicated Resident #1 was always incontinent of stool. The following diagnoses were documented for Resident #1: atrial fibrillation, heart failure, renal failure, retention of urine, insomnia, and acute pain.The Care Plan Focus Area with a revision date of 3/12/2025 documented Resident #1 had self-care deficit as evidenced by…

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 and resident interviews the facility failed to provide Activities of Daily Living (ADLs) care for 1 of 3 residents reviewed (Resident #1) for ADL care. The facility reported a census of 31 residents.Findings include:According to the quarterly Minimum Data Set (MDS) assessment with a reference date of 2/12/2026 documented Resident #1 had a Brief Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. The MDS documented he did not exhibit rejection of care during the review period. Resident #1 had an impairment to bilateral extremities; he utilized a wheelchair. The MDS documented he was dependent on staff for toileting hygiene and toilet transfers. The MDS indicated Resident #1 was always incontinent of stool. The following diagnoses were documented for Resident #1: atrial fibrillation, heart failure, renal failure, retention of urine, insomnia, and acute pain.The Care Plan Focus Area with a revision date of 3/12/2025 documented Resident #1 had self-care deficit as evidenced by…

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, legal record review, resident and staff interviews, and facility policy review, the facility failed to provide a licensed nurse on a 24-hour basis. The facility failed to have a licensed nurse on premises on the overnight shift from 11/11/25-11/12/25. The facility reported a census of 37 residents. Findings include: Review of the facility's master schedule for staffing assignments for 11/25 revealed Staff A, Licensed Practical Nurse (LPN) was scheduled for 12 hour overnight shifts on 11/3, 11/4, 11/8, 11/9 and 11/11/25. Review of Staff A's timecard revealed he clocked in at the facility on 11/11/25 at 7:59 PM and clocked out of the facility on 11/12/25 at 1:15 AM working 5.27 hours. Review of a legal document from [NAME] County Sheriff's Office revealed on 11/12/25 at approximately 1:19 PM a traffic stop was initiated for a vehicle traveling with no lights on. The Deputy followed the vehicle with his emergency lights activated. The driver continued driving in the oncoming lane 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 staff interviews, personal record review, and facility policy review, the facility failed to ensure that nursing staff were adequately orientated and trained before they were scheduled to work independently with the residents for 2 of 2 nurse files reviewed. The facility reported a census of 37 residents. Findings include: On 12/3/25 at 6:20 AM, Staff D, Licensed Practical Nurse (LPN) stated that he didn't have any orientation or training before he worked with the residents on his own. Staff D said that he did not follow another nurse for a period of time, or have any orientation checklist to complete. A review of the file for Staff D revealed that the personal file lacked an orientation or training checklist. On 12/4/25 at 7:59 AM, Staff A, LPN said that he was not provided a check list for training when he started working at the facility. He said that he was trained on medication times and had some other paperwork, but he did not have any competency-based training on catheters, enteral tubes or tracheotomy cares. Staff A stated he was expected to suction a tracheostomy 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.

Based on staff interviews, staff file review and policy review, the facility administration failed to conduct annual staff evaluations for 3 of 3 personnel files reviewed. The facility reported a census of 37 residents.Findings include:A review of personnel files revealed the following:Staff N, Certified Nurse Aide (CNA) was hired on 11/22/21.Staff M, CNA, was hired on 8/20/21.Staff L, CNA, was hired on 8/23/21The personnel files for Staff L, Staff M and Staff N lacked any annual evaluations. On 12/03/25 at 1:20 PM, the Administrator said that they have not been doing evaluations for staff because no one has had a raise for 5 years. She said that they have a plan in place to begin implementation of annual evaluations. Facility policy titled: Performance Evaluations dated September 2020. The job performance of each employee would be reviewed and evaluated at least annually. Performance evaluations may be used in determining employee promotions, shift/position transfers, demolitions, terminations, way increase and to improve the quality of the employee's work performance.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on government record review, facility record review, resident interview, staff interview, policy review, and current survey results, the facility administration failed to provide effective administrative oversight. The facility failed to conduct further research on a national nurse license verification that documented a revoked nursing license in another state in 08/2025, failed to conduct reference checks prior to hire, and failed to investigate reported performance concerns for 1 of 1 employee records reviewed (Staff A, Licensed Practical Nurse [LPN]). The facility also failed to ensure quality improvement measures were taking place after being designated a Special Focus Facility in 07/2025. The facility reported a census of 37 residents.Findings include: 1.The State of Nebraska Department of Health and Human Services (NE DHHS) Findings of Fact and Conclusions of Law: Order dated and filed [DATE], recommended defendant's (Staff A, Licensed Practical Nurse [LPN]) privilege to practice as a Practical Nurse…

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

Based on document review, staff interviews, and facility plan review the facility failed to demonstrate good faith attempts to correct quality deficiencies based on issues that were identified with repeat deficiencies in 12 areas over the last year and monitoring / tracking of performance improvement plans that remained incomplete in a reasonable time frame. The facility reported a census of 37 residents.Findings include:Review of CMS Form 2567 with a date the survey was completed as 2/27/25 documented F-657 care plan revision, F-684 Quality Care, F-686 treatment of pressure ulcer, F-725 sufficient nursing staff, F-726 competent nursing staff, F-835 administration, F-842 resident records and F-865 good faith attempt Quality Assurance Performance Improvement (QAPI) program. 8 repeated deficiencies identified during the current survey.Review of CMS Form 2567 with a date the survey was completed as 4/10/25 documented F-656 care plan development, F-688 prevent decrease in ROM/Mobility, F-755 pharmacy services/records, F-804 palatable/prefer temperature of food and F-865 good faith…

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, facility document review, policy review and staff interviews, the facility failed to follow the menu and prepare food to meet the nutritional needs for 7 of 37 residents reviewed (#9, #12, #17, #21, #23, #26 and #30). The facility reported a census of 37 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #9 documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS also documented a diagnosis of dysphagia, oropharyngeal phase. Review of Resident #9's EHR titled, Orders documented an order for mechanical soft diet, regular texture and regular consistency.2. The MDS dated [DATE] for Resident #12 documented a BIMS of 1 indicating severe cognitive impairment. The MDS also documented a diagnosis of dysphagia, oropharyngeal phase.Review of Resident #12's EHR titled, Orders documented an order for regular diet, mechanical soft texture, regular consistency.3. The MDS dated [DATE] for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, document review, policy review and staff interviews the facility failed to prepare food in a form designed to meet individual needs by processing an incorrect consistency for modified diet ordered for 7 of 7 residents reviewed (Resident #9, #12, #17, #21, #23, #26 and #30). The facility reported a census of 37 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #9 documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS also documented a diagnosis of dysphagia, oropharyngeal phase. Review of Resident #9's EHR titled, Orders documented an order for mechanical soft diet, regular texture and regular consistency.2. The MDS dated [DATE] for Resident #12 documented a BIMS of 1 indicating severe cognitive impairment. The MDS also documented a diagnosis of dysphagia, oropharyngeal phase.Review of Resident #12's EHR titled, Orders documented an order for regular diet, mechanical soft texture,…

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 prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service to prevent cross contamination, not dating open food items and not disposing of expired food items. The facility reported a census of 37 residents.Findings include:During initial kitchen observation on 12/1/25 at 10:15 AM the walk-in refrigerator had a 5 lbs. container of sour cream, a 5 lbs. container of cottage cheese, a 1 gallon container of barbecue sauce, a 1 gallon container of salad dressing, a quart of coffee creamer and a 24 oz. container of chocolate syrup open and undated. The walk-in refrigerator also had 2 clear storage containers of salad dressing dated 11/17 and a clear storage container labeled ketchup dated 11/12. The walk-in freezer had a bag of dinner rolls and a bag of cookies open and undated.On 12/1/25 at 10:45 AM Staff T, Kitchen Manager stated the clear storage containers with salad dressing and ketchup should have had the contents disposed of and containers…

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 monitor and measure its success and track performance to ensure that improvements are realized and sustained for the Quality Assurance and Performance Improvement (QAPI) plan. The facility reported a census of 37 residents.Findings include:Review of document with implementation date of 10/16/25 titled, Quality Assessment and Assurance Action Plan Area of Concern: Skin Assessment documented 8 action/interventions developed all with target dates of 11/15/25. 2 of the 8 areas documented progress/evaluation. One area documented on 11/18/25 and the second on 11/28/25. A goal completion date of 12/31/25 documented. The last page of the document contained: the project, what's the best results, what's the worst result, what's the biggest difference this plan will make, what do we want to accomplish and how will we know when the project is completed. All of these areas on the document are blank.Review of document with implementation date of 10/16/25 titled, Quality Assessment and Assurance Action…

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 staff interviews, policy review and clinical record review the facility failed to ensure that the residents had rational for continued use of psychotropic medications and attempted Gradual Dose Reduction (GDR) of psychotropic medications for 3 of 5 resident reviewed (Residents #4, #6, #32). The facility reported a census of 37 residents. Findings include:1) The Minimum Data Set (MDS), dated [DATE] for Resident #4, showed that he had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficits.) Resident #4 was totally dependent of staff for dressing, toileting hygiene. Resident #4 had antipsychotic medications reviewed on a regular basis and a GDR had not been attempted because the physician documented as clinically contraindicated on 1/2/25. His diagnoses included: diabetes mellitus, non-Alzheimer's dementia, seizure disorder, depression and schizophrenia. The Care Plan for Resident #4, showed that the resident was at risk for adverse side effects due to use of anti-psych…

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, resident interview, staff interviews, and policy review the facility failed to accurately complete a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 assessment for 1 out of 14 residents reviewed (Resident #10). The facility census was 37. Findings include:Resident #10's MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document revealed the resident had diagnoses of traumatic spinal cord dysfunction, neurogenic bladder and quadriplegia. The resident had an impairment on bilateral upper extremities (BUE) and bilateral lower extremities (BLE) range of motion (ROM). The document provided that the resident received 2 days of restorative program (for at least 15 minutes/day) in the last 7 days for passive range of motion (PROM). The Care Plan dated 10/6/25…

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, clinical record review, and policy review, the facility failed to develop and implement a Comprehensive Care Plan for 1 of 14 residents (Resident #22) reviewed. The Care Plans failed to identify resident centered interventions for a resident who used continuous oxygen. The facility reported a census of 37 residents. Findings include:The Minimum Data Set (MDS) for Resident #22 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating normal cognition. The document revealed diagnoses of dependence on supplemental oxygen, diabetes mellitus, anxiety disorder, depression, chronic obstructive pulmonary disease (COPD) and respiratory failure. The document disclosed the resident received oxygen therapy, and was prescribed antidepressant, diuretic, antiplatelet and hypoglycemic medications. Resident #22's Care Plan dated 11/3/25 contained a problem area that it was the resident's preference to smoke while at the facility and did not want a smoking cessation program revised 7/22/25. The goal revealed the resident would smoke 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 clinical record review, resident interview, staff interviews, and facility policy review the facility failed to revise a Comprehensive Care Plan for 1 of 14 residents (Resident #10) reviewed. The facility failed to revise the interventions and goals for a resident who was not receiving a Restorative Nursing Program. The facility reported a census of 37 residents. Findings include: Resident #10's MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document revealed the resident had diagnoses of traumatic spinal cord dysfunction, neurogenic bladder and quadriplegia. The resident had an impairment on bilateral upper extremities (BUE) and bilateral lower extremities (BLE) range of motion (ROM). The document provided that the resident received 2 days of restorative program (for at least 15 minutes/day) in the last 7 days of the assessment period for passive range of motion (PROM). The Care Plan dated 10/6/25 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, staff interviews and policy review, the facility failed to follow physician orders for 1 of 3 residents reviewed (Resident #32). The facility reported a census of 37 residents. Findings include:The Minimum Data Set (MDS) for Resident #32 dated 11/18/25 documented a Brief Interview of Mental Status (BIMS) score of 6/15 indicating severe cognitive impairment. The MDS included diagnoses of stroke, heart failure, hypertension (HTN), peripheral vascular disease (PVD) and depression. The document identified no concerns with mood or behaviors during the reporting period. The MDS identified Resident #32 took antipsychotic, antidepressant, hypnotic, anticoagulant, diuretic, antiplatelet and anticonvulsant medications during the last 7 days of the assessment period. The document revealed the resident had 4 venous and arterial ulcers, had application of nonsurgical dressings other than to the feet, applications of ointments/medications other than to feet and application of dressings 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, staff interview and record review the facility failed to provide wound treatments as ordered for 2 of 2 residents reviewed with pressure ulcers. Resident's #2 and #34 were admitted with a history of severe skin breakdown and required consistent treatments. The clinical record showed that in September and October 2025, staff failed to document the treatments had been administered as ordered, and failed to document why the resident refused the treatments and that the doctor had been notified. The facility reported a census of 37 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, staff interview, and policy review the facility failed to provide range of motion (ROM) services to a resident with limited ROM to prevent further decrease in range of motion or development of contractures for 1 of 14 residents reviewed (Resident #10). The facility reported a census of 37.Findings include:Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document revealed the resident had diagnoses of traumatic spinal cord dysfunction, neurogenic bladder and quadriplegia. The resident had an impairment on bilateral upper extremities (BUE) and bilateral lower extremities (BLE) range of motion (ROM). The document provided that the resident received 2 days of restorative program (for at least 15 minutes/day) in the last 7 days of the assessment period for passive range of motion (PROM). The Care Plan dated 10/6/25 revealed a focus of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interview, and facility policy review the facility failed to provide a professional standard of quality of care by not completing catheter cares for 1 of 1 residents reviewed (Resident #10). The facility reported a census of 37 residents. Findings include:Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document revealed the resident had diagnoses of traumatic spinal cord dysfunction, neurogenic bladder and quadriplegia. The document disclosed the resident had an indwelling catheter. The Care Plan dated 10/6/25 revealed a focus area for a supra pubic catheter due to diagnosis of neuromuscular dysfunction of the bladder and C5 spinal cord injury revised 10/6/25. The goal disclosed the catheter will be managed appropriately and not exhibit signs of infection or urethral trauma through the next review date revised 8/6/25 and target…

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 interviews and clinical record review the facility failed to ensure they did not store unnecessary narcotics and failed to maintain accurate accounting for narcotics for 1 of 3 residents reviewed (Resident #38). The facility reported a census of 37 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #38 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability) The resident was independent in all care areas and received scheduled pain medications. He did not receive As Needed (PRN) pain medication or interventions for pain. The Care Plan for Resident #38, updated on 8/5/25, showed that he was at risk for pain/discomfort and was at increased risk for injury from decreased function related to pain and staff were directed to administer pain medications as ordered. In an observation of the medication carts on 12/1/25 at 12:20 PM, it was discovered that Resident #38 had three separate blister pack cards of PRN tramadol, 50…

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, resident interview, staff interview and policy review the facility failed to provide food at an appetizing temperature to 3 of 14 residents reviewed (Resident #28, #31 and #35). The facility reported a census of 37 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #28 documented a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. On 12/1/25 at 1:57 PM Resident #28 said most of the time the food is okay. Resident #28 explained she ate meals in her room and she would be lucky if the food was still warm when she received her tray. Resident #28 said the facility does not have heated carts for room tray delivery. Resident #28 explained her biggest concern was that the food sits too long before being brought to the room. 2. The MDS dated [DATE] for Resident #31 documented a BIMS of 13 indicating no cognitive impairment. On 12/1/25 at 12:18 PM Resident #31 stated she had a room tray every meal and the meals were cold when the meal…

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 Records (EHR) review, staff interviews, and document review the facility failed to provide complete and accurately documented records when a resident inventory list was not completed upon admission for 1 of 5 resident reviewed (Resident #19). The facility reported a census of 37 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #19 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of Resident #19's EHR documented only an inventory list from 7/7/23.Review of Resident #19's EHR titled, Census documented facility admission 5/19/25.Review of Resident #19's EHR faxed 5/20/25 titled, discharge summary documented Resident #19 was discharged from the hospital to the facility on 5/19/25.On 12/4/25 at 12:05 PM Staff Y, Social Services stated a friend took Resident #19 to the emergency room and the facility admitted Resident #19 on 5/19/25. Staff Y stated Resident #19 should have had an inventory list completed 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 Electronic Health Records (EHR) review, resident interviews, staff interviews, and policy review the facility failed to provide an opportunity for bath or shower to 3 of 4 residents reviewed (Resident #1, #2 and #4). The facility reported a census of 37 residents.Finding include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. The MDS also documented Resident #1 required substantial/maximal assistance with shower/bathe self.Review of Resident #1's EHR titled, Care Plan documented an intervention for bathing/showering requiring 2 people assistance with encouragement of bathing 2 times a week.On 10/20/25 at 1:38 PM Resident #1 stated usually the facility staff give her 3 baths a week on Monday, Wednesday and Friday. Resident #1 stated there were times when she had not felt good that she had refused the bath or shower. Resident #1 stated she had missed baths back in June and July. Resident #1 stated…

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

Based on personnel file review, facility policy review, and staff interviews the facility failed to complete a background check related to abuse and criminal history in a timely manner for one staff member. The facility reported a census of 41 residents. Findings include: Review of a document titled [Company name redacted] Report Writer Generated Report, dated 4/98/25 revealed Staff E, Certified Nursing Assistant (CNA) hired on 1/3/23. Review of Staff E, CNA personnel file revealed a Single Contact License and Background Check document dated 2/5/25. During an interview on 4/10/25 at 11:32 AM, Staff J, Business Office Manger stated background checks were completed in February 2025 for any staff that did not have one on file due to a directive from the corporate office after a change in ownership. Staff J stated Staff E did not have a background check completed prior to February 2025. During an interview on 4/10/25 at 11:33 AM, Staff K Director of Business Office Services for the corporate office stated the Human Resources department spoke with Staff J about the missing background…

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, facility policy review, and resident and staff interviews, the facility failed to provide food at an appetizing temperature for 4 of 5 residents ( Residents #7, #17, #26, and #27) reviewed. The facility reported a census of 41 residents. Findings include: 1. Review of Resident #7's Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. During an interview on 4/07/25 at 10:23 AM, Resident #7 stated the food is disgusting, and that the food is often cold, especially with room trays. 2. Review of Resident #17's MDS, dated [DATE] revealed a BIMS score of 15 indicating intact cognition. During an interview on 4/07/25 10:06 AM, Resident #17 stated the food can be cold at times when it should be warm. During an observation 4/9/25 at 12:46 PM, a sample tray was served to the State Agency and temperatures of sweet and sour chicken and fried rice taken. The sweet and sour chicken had a temperature 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 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 41 residents. Findings include: A review of the Department of Inspections Appeals and Licensing website revealed that the facility had repeated deficient practices identified during the annual surveys and complaint investigations as follows: a. F880 Infection Control deficient practice cited during Recertification Survey ending on 7/25/24, Complaint Survey ending on 9/11/24, and Complaint Survey ending on 2/27/25. b. F865 QAPI Program deficient practice cited during the Complaint Survey ending on 9/11/24 and the Complaint Survey ending on 2/27/25 During an interview on 4/10/25 at 11:30 AM, the Administrator said that the QA (Quality Assurance) team has been meeting monthly since they started the transition of companies. He stated that they have made progress but there have been so many…

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, policy review, and staff interview the facility failed to use Enhanced Barrier Precautions (EBP) when providing ileostomy care for 1 of 3 residents (Resident #26), and complete an annual review of the facility Infection Prevention and Control Program (IPCP). The facility reported a census of 41 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE] for Resident #26 documented a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. MDS also indicated Resident #26 utilized an ileostomy (an opening in the abdominal will from the small intestine to the outside the body to allow waste to exit the body). During an interview on 4/7/25 at 1:35 PM, Resident #26 stated he had an ileostomy that was about a month old. Resident #26 stated the staff do not ever wear gowns when emptying his colostomy bag. Review the Care Plan, Date Initiated: 3/24/25 revealed a Focus area to address Requires enhanced barrier precautions related…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and staff interview the facility failed to offer residents a COVID-19 immunization in 2024 for 4 of 5 residents reviewed (Residents #30, #32, #22 and #38.) The facility reported a census of 41 residents. Findings include: 1. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #30 admitted to the facility on [DATE]. She had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) Her diagnoses included; diabetes mellitus, respiratory failure, Chronic Obstructive Pulmonary Disease (COPD) and morbid obesity. The clinical page in the electronic chart titled: Immunizations, indicated that on 10/2/24 the resident had an influenza immunization. The chart lacked documentation that the COVID-19 immunization had been offered. 2. Review of the MDS dated [DATE], revealed that Resident #32 admitted to the facility on [DATE]. His diagnoses include; spinal cord injury, muscle wasting atrophy, quadriplegia. The Immunizations tab…

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

Based on clinical record review, facility policy review and staff interviews the facility failed to provide a bed hold notification upon hospitalization for 1 of 3 residents (Residents #10) reviewed. The facility reported a census of 41 residents. Findings Include: Review of the clinical record revealed, Resident #10 transferred to the hospital on 1/24/25 and returned to the facility on 1/31/25. Review of the clinical record revealed a bed hold notification signed on 4/3/23. During an interview on 4/10/25 at 10:07 AM, the Director of Nursing stated the facility had the resident sign a bed hold form during admission for future bed hold purposes and that was the bed hold utilized for all future bed hold needs. During an interview on 4/10/25 at 10:15 AM, the Administrator stated a bed hold notification was required at the time the transfer occurred. The Administrator acknowledged the bed hold form was signed upon admission and that was not acceptable for bed hold notification. Review of policy titled, Bed-Holds and Returns, revised 10/2022 documented all residents/representatives were…

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

Based on clinical record review, facility policy review, family and staff interviews, the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of each resident and resident representative to allow developing the care plan and making decisions about his or her care to 1 of 3 residents reviewed (Resident #10). The facility reported a census of 41 residents. Finding include: During an interview on 4/7/25 at 2:29 PM, Resident #10's Daughter, as translated by Resident #10's granddaughter, reported the facilty had not called her about care plan conferences. Review of document titled, Resident Care Conference Signature Sheet, revealed a Care Conference had been completed for Resident #10 on 4/13/23, 7/13/23, 9/27/23, 12/5/23, 12/17/24 and 3/18/25 On 4/9/25 at 11:07 AM Staff L, Social Worker stated she had been employed at the facility since October 2024. Staff L stated she had never had to call Resident #10 ' s daughter. Staff L stated she called Resident #10 ' s family ahead of care conferences. Staff L…

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, policy review, and interview the facility failed to complete a discharge summary with a recapitulation of the residents stay, arrangements for support and follow up appointments, and medication reconciliation for 1 of 1 resident reviewed (Resident #42.) The facility reported a census of 41 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #42 was admitted to the facility on [DATE]. The resident had frequent pain, received scheduled pain medication and was taking an antidepressant. The Care Plan dated 11/22/24, revealed Resident #42, in part: Use of anti-depressant medications; Use of anti-anxiety medications; and Pain and discomfort related to a left hip fracture and use of as needed pain medications. Review of the January 2025 Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed the last day Resident #42 administered medications as 1/8/25. Review of the clinical record revealed a lack of documentation related to discharge…

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, facility policy review and staff interviews,the facility failed to apply a hand splint in an attempt to prevent further decrease in range of motion for 1 of 3 residents (Resident #19) reviewed. The facility reported a census of 41 residents. Findings include: Review of Resident #19 ' s Minimum Data Set (MDS) dated [DATE] revealed Resident 19 admitted to the facility 5/31/18 from the community. The MDS further revealed diagnosis of stroke, hemiplegia affecting left nondominant side, and contracture of muscle to the left hand. Review of Resident #19 ' s Care Plan with a revision date of 4/3/25 revealed Resident #19 has contractures in the left hand and Resident #19 is to wear a splint to the left hand when out of bed except for when bathing and grooming to prevent contractures. Review of the electronic health record (EHR) page titled Tasks revealed a 30 day look back from 4/8/25 for assistance with left hand splint on when out of the bed during the daytime revealed 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 clinical record review, Shift Change Controlled Substance Inventory Log review, facility policy review and staff interviews, the facility failed to ensure medications for a bowel program to treat constipation were available when needed for 1 of 1 resident (Resident #32). And the facility failed to consistently complete shift to shift inventory counts for controlled medications. The facility reported a census of 41 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE], Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The MDS revealed Resident #32 dependent on staff for toileting, transfers, dressing and eating. The MDS indicated the resident used an indwelling urinary catheter and was always incontinent of bowel. The diagnoses listed included, in part: spinal cord injury at C5 (injury of the 5th vertebrae in cervical spinal cord region), quadriplegia (paralysis of all four limbs), muscle wasting, and neurogenic bladder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review and staff interviews, the facility failed to ensure a resident received insulin as prescribed by a physician resulting in a significant medication error for 1 of 6 residents reviewed (Resident #20). The facility reported a census of 41 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #20 documented a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. The diagnoses list in the MDS included type 2 diabetes mellitus with hyperglycemia. Review the Care Plan, revised on 11/19/24, revealed a Focus are to address [Name redacted] has Insulin Dependent Diabetes Mellitus; taking long and shore acting insulin w/SS (with sliding scale - insulin units administered depend on blood sugar readings). Interventions included, in part: Administer insulins as prescribed by physician. Update insulin changes in MAR (Medication Administration Record). Date Initiated: 5/11/23. Review of the April 2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, and policy review the facility failed to follow physician order's for 2 of 4 residents (Resident #2 and #3) reviewed. The facility also failed to obtain an order to discontinue a medication prior to destroying it for 1 of 4 residents (Resident #6) reviewed. The facility reported a census of 37 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of [DATE] documented Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The resident did not refuse cares during the review period and received insulin. The following diagnoses were listed for Resident #2: type 2 diabetes mellitus, renal failure. The Care Plan focus area with a revision date of [DATE] documented Resident #2 had diabetes mellitus type 2. Staff were directed to administer diabetes medications as ordered by her doctor and to monitor/document for side…

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, staff interviews and facility policy review the facility failed to complete a full assessment, initiate neuros, and have a licensed nurse assess Resident #5 after she sustained an unwitnessed fall. The facility also failed to complete assessments for 6 residents (Resident #1, #8, #11, #12, #13, and #14) that tested positive for COVID-19 and 1 resident (Resident #9) that tested positive for influenza A. The facility reported a census of 37 residents. Findings include: 1. According to the significant change Minimum Data Set (MDS) assessment tool with a reference date of 1/24/2025 documented Resident #5 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. Resident #5 had one sided impairment to her upper and lower extremities and utilized a wheelchair. The MDS documented Resident #5 did not have any falls since her admission/entry or reentry or prior assessment. The following diagnoses were listed for the resident: stroke, diabetes mellitus, dementia, anxiety disorder, depression, bipolar…

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

Based on, facility nursing schedule review, facility staffing sheets, management call in logs, facility's Payroll Based Journal (PBJ), staff interviews and facility assessment review the facility failed to have Registered Nurse (RN) coverage daily for 8 consecutive hours, 7 days a week. The facility reported a census of 37 residents. Findings include: Review of the January 2025 nursing schedule and Facility Staffing sheets revealed the facility failed to have a Registered Nurse (RN) for 8 consecutive hours and 7 days a week on: 1/1 and 1/23. Review of the February 2025 nursing schedule and Facility Staffing sheets revealed the facility failed to have RN coverage daily for 8 consecutive hours, 7 days a week on: 2/1, 2/2, 2/4, 2/5, 2/7, 2/8, 2/9, 2/10, 2/11, 2/15, and 2/16. Review of the facility's PBJ report for October 1, 2024 - December 31, 2024 revealed the facility did not have RN coverage on 11/26/2024, 12/6/2024, 12/10/2024, 12/23/2024, 12/24/2024, and 12/25/2024. On 2/13/2025 at 11:43 AM Staff C Licensed Practical Nurse (LPN) laughed when asked how the RN coverage was, she…

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

Based on observations and staff interviews the facility failed to ensure the nurse staffing information was posted to include accurate required information and updated daily for residents and visitors to see. The facility reported a census of 37 residents. Findings include: On 2/13/2025 at 11:45 AM the daily staff posting was located at the front of the building to the left of the nurse's station, at the start of center hall dated 2/11/2025. At 2:25 PM the daily staff posting located where center, west and east halls met was dated 2/11/2025. On 2/14/2025 at 8:38 AM the daily staff postings was located at the front of the building to the left of the nurse's station; at the start of center hall and at where center, west and east halls met and was dated 2/14/2025. On 2/19/2025 at 9:56 AM the daily staff posting was located at the front of the building to the left of the nurse's station; at the start of center hall and at where center, west and east halls met and was dated 2/18/2025. On 2/26/2025 at 11:45 AM the Director of Nursing (DON) stated the night nurses fill out the staff…

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

Based on observations, staff interviews, clinical record review, and facility assessment review the decisions in administering the facility contributed to deficient practice. The facility reported a census of 37 residents. Findings include: On 2/13/2025 at 11:43 AM Staff C Licensed Practical Nurse (LPN) stated last month residents reported they did not get their medications when the Assistant Director of Nursing (ADON) worked the floor. Staff C filled out medication error incident reports and the ADON grilled her about doing that. On 2/13/2025 at 12:04 PM Staff K Certified Medication Aide (CMA) stated on 2/12/2025 the Administrator approached her as she was at the nurse's station, basically ripping on her. She was not sure if the Administrator knew if she called with concerns about not having a nurse in the building. Staff K stated he agreed with her that it was not right but he felt like it should have been kept in the facility and not talked about. On 2/13/2025 at 1:36 PM Staff D Certified Nursing Assistant (CNA) was asked to discuss staff on 2/12/2025. She stated they had 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.

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 37 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 complaint survey ending on on 2/2/2024: a) F725 Sufficient Nursing Staff b) F727 Sufficient Nursing Staff c) F732 Posted Nurse Staffing Information, The facility's complaint survey ending on 4/5/2024: a) F684 Quality of Care b) F842 Resident Records-Identifiable Information The facility's annual recertification survey ending on 7/25/2024: a) F684 Quality of Care b) F725 Sufficient Nursing Staff c) F727 Sufficient Nursing Staff d) F689 Free of Accidents/Hazards/Supervision/Devices e) F880 Infection Control The facility's complaint and facility report incident survey ending on 9/11/2024: a) F689 Free of Accidents/Hazards/Supervision/Devices b)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff and resident interviews, and facility policy reviews the facility failed to ensure all staff wore masks, and provided masks upon entry in to the facility while in outbreak status. Staff also failed to follow proper practices when obtaining a resident's blood sugar and prior to administering resident's insulin. The facility reported a census of 37 residents. Findings include: 1. On 2/13/2025 at 11:45 AM on the front entrance door was a sign that notified visitors the facility was in outbreak status, masks are required. Once inside the main entrance double doors, no masks were available to put on. There were no masks and no one at the nurse's station at the start of center hall. One had to walk down center hall to the nurse's station where the three halls meet to ask for a mask. On 2/13/2025 at 12:20 PM the Administrator walked in the surveyor's room with no mask on, there was no mask present around his neck or in his hands. At 2:25 PM the Administrator was at the back…

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, record review, staff and resident interviews, and policy review the facility failed to update 2 of 7 (Resident #4 and #5) resident's care plans. The facility reported a census of 37 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 1/14/2025, documented Resident #4 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented Resident #4 had an indwelling catheter, ostomy and received tracheostomy care. The following diagnoses were listed for Resident #4: sepsis, renal failure, neurogenic bladder, multidrug-resistant organism, pneumonia, quadriplegia, multiple sclerosis, anxiety, respiratory failure, stage 4 pressure ulcer. The Care Plan focus area with a revision date of 11/4/2024 documented Resident #4 had bowel and bladder incontinence related to disease process, history of urinary tract infection (UTI), and impaired mobility. The Care Plan documented he used an adult brief and staff are to change the brief on rounds…

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, resident and staff interviews, and facility policy review the facility failed to complete treatments as ordered for 1 of 2 residents (Resident #1) with pressure ulcers. The facility reported a census of 37 residents. Findings include: According to the annual Minimum Data Set (MDS) assessment tool with a reference date of 11/19/2024, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she was at risk for developing pressure ulcers/injuries and had one stage two pressure ulcer. The MDS indicated she had 2 venous and arterial ulcers present. Resident #1 utilized a pressure reducing device for her chair, had nutrition or hydration interventions to manage skin problems, had pressure ulcer/injury care, and had orders for the application of nonsurgical dressing as well as ointments and/or medications. The following diagnoses were documented for Resident #1: end stage renal disease, anemia, diabetes mellitus, and stroke. The Care Plan focus area with a…

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

Based on clinical record review, staff interviews and facility policy review the facility failed to ensure a gait belt was used for 1 of 14 residents (Resident #5) reviewed for falls. The facility reported a census of 37 residents. Findings include: According to the significant change Minimum Data Set (MDS) assessment tool with a reference date of 1/24/2025 documented Resident #5 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. Resident #5 had one sided impairment to her upper and lower extremities and utilized a wheelchair. The MDS documented Resident #5 did not have any falls since her admission/entry or reentry or prior assessment. The following diagnoses were listed for the resident: stroke, diabetes mellitus, dementia, anxiety disorder, depression, bipolar disorder, lack of coordination, abnormalities of gait and mobility, and muscle weakness. The Care Plan focus area with a revision date of 10/22/2024 documented Resident #5 required assistance with Activities of Daily Living (ADL's) related to a history of 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, agency staff schedule, facility schedule, staff interviews and facility assessment the facility failed to provide nursing coverage on [DATE] from approximately 1:30 PM until approximately 4:30 PM. Staff indicated Staff A Agency LPN started her shift on [DATE] at 6:00 PM and worked until [DATE] at approximately 1:30 PM due to another staff member calling sick to work. The Administrator advised Staff A to go back to the hotel to nap and get her medications before her next shift started at 6:00 PM. The facility reported a census of 37 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of [DATE], documented Resident #4 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented Resident #4 had an indwelling catheter, ostomy and received tracheostomy care. The following diagnoses were listed for Resident #4: sepsis, renal failure, neurogenic…

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 assessment review the facility failed to ensure the appropriate licensed staff were competent to complete an assessment after Resident #5 had an unwitnessed fall. The facility also failed to ensure the appropriate certified staff assisted Resident #5 with a transfer after she sustained an unwitnessed fall. The facility reported a census of 37 residents. Findings include: According to the significant change Minimum Data Set (MDS) assessment tool with a reference date of [DATE] documented Resident #5 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. Resident #5 had one sided impairment to her upper and lower extremities and utilized a wheelchair. The MDS documented Resident #5 did not have any falls since her admission/entry or reentry or prior assessment. The following diagnoses were listed for the resident: stroke, diabetes mellitus, dementia, anxiety disorder, depression, bipolar…

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, staff interviews, and facility policy review the facility failed to ensure 1 of 4 residents reviewed (Resident #7) was free from unnecessary medications. The facility reported a census of 37 residents. Findings include: According to the Annual Minimum Data Set (MDS) assessment tool with a reference date of 1/9/2025 documented Resident #7 had a Brief Interview of Mental Status (BIMS) score of 5. A BIMS score of 5 suggested severe cognitive impairment. The MDS documented he did not display physical, verbal, or other behavioral symptoms during the review period. Resident #7 did not exhibit rejection of care behaviors. The MDS documented he received scheduled pain medication regimen, did not receive an as needed (PRN) pain medications or was offered or declined, and he did not receive a non-medication intervention for pain. He did not receive an opioid during the 7-day review period. The following diagnoses were documented for Resident #7: stroke, cancer, heart failure, benign prostatic hyperplasia, renal failure, diabetes mellitus (DM), dementia,…

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

Based on observations, staff interviews, and facility policy review the facility failed to appropriately store six medications after they were delivered to the facility from the pharmacy. The facility reported a census of 37 residents. Findings include: On 2/13/2025 at 5:03 PM an opened and unattended blue plastic bag sat on top of the counter at the nurse's station. Inside the bag were the following medication cards: sertraline (anti-depressant), oseltamivir (treatment of influenza), Lisinopril (treatment of hypertension), pyridostigmine (treatment of myasthenia gravis), Eliquis (anti-coagulant), and metoprolol (treatment of hypertension). At 5:30 PM the blue bag was behind the counter of the nurse's station, out of reach from passersby. On 2/25/2025 at 10:30 AM Staff E Certified Medication Aide (CMA) stated she tries to have the nurse put the delivered medications away when she is working. On 2/26/2025 at 11:00 AM Staff C Licensed Practical Nurse (LPN) and Staff J CMA stated when medications are delivered from the pharmacy they are usually in white or blue bags. The nurse or CMA…

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, staff interviews and facility policy review the facility failed to ensure Resident #5, #9, and #10's records were complete and accurate. Resident #5's clinical record did not contain an incident report after she sustained an unwitnessed fall nor did staff complete an assessment. Resident #9's clinical record did not contain information about his positive Influenza A status and Resident #10's clinical record did not contain information about his positive COVID-19 status. The facility reported a census of 37 residents. Findings include: 1. According to the significant change Minimum Data Set (MDS) assessment tool with a reference date of 1/24/2025 documented Resident #5 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. Resident #5 had one sided impairment to her upper and lower extremities and utilized a wheelchair. The MDS documented Resident #5 did not have any falls since her admission/entry or reentry or prior assessment. The following diagnoses were listed for the resident: stroke,…

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

Based on observation, record review and staff interviews the facility failed to maintain medical records that were systematically organized and failed to safeguard the medical records from loss or destruction. The facility reported a census of 37 residents. Findings include: On 9/9/24 at 9:40 AM a continuous observation of the building revealed the following: -Outside the facility to the left of the cellar door revealed a window well unable to determine depth with washed away soil next to the window well approximately 1 foot x 1.5 foot. -Observation of the basement revealed a room where the window well with washed away soil had a red painted wall with black fuzzy substance growing on the wall. The paint was chipping, loose, and bubbled up. Approximately the whole wall consistently had these concerns. Observation of 2 rooms filled with stacks of resident records. The boxes had fallen over and signs of water damage to the boxes and resident records in the boxes. On 9/9/24 at 9:55 AM Staff T Maintenance Director stated there had been concerns with the soil that washed away near that…

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, staff interviews, and facility policy review the facility failed to demonstrate evidence of systematic identification of reporting, investigation, analysis, and prevention of adverse events. The facility failed to demonstrate the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility reported a census of 37 residents. Findings include: Review of the facility's past survey violations document revealed the following repeated deficiencies since the Administrator's hire date of 12/30/2019: -F609, reporting alleged violations, during surveys ending on 4/27/23, 8/8/23, 4/5/24 and current survey. Survey ending on 8/8/23 and current survey resulting in a harm level deficiency. -F689, free of accidents/hazards and supervision, during surveys ending on 3/19/2020, 4/20/2021, 10/5/22, 7/25/24 and current survey. Surveys ending on 4/20/21, 7/25/24, and current survey resulting in a harm level deficiency. -F725, sufficient nursing…

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, resident interviews, staff interviews and policy review the facility failed to maintain a safe and comfortable environment free of possible hazards by having insufficient linens, and residents' beds not being made on a consistent basis. The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #6 dated 6/26/24 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated normal cognition. Resident #6 on 9/7/24 at 1:20 PM stated the facility runs out of bed soakers frequently. The resident stated that with the size of the facility they should have a large enough supply to not run out of linens, but they do. 2. The MDS for Resident #10 dated 6/5/24 identified a BIMS score of 15 which indicated normal cognition. Resident #10 on 9/9/24 at 8:06 AM stated that she had returned from dialysis on multiple days where her bed had not been made. The resident stated she goes to dialysis later in the day on Mondays, Wednesdays, and Fridays. 3. The MDS for Resident #11 dated 8/19/24 identified…

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, staff interviews, and policy review the facility failed to develop, implement and follow Comprehensive Care Plans for 3 of 14 residents (#1, #2, #11) reviewed. The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 7/24/24 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented diagnoses that included: hypertension, renal insufficiency, non-Alzheimer's dementia, depression, chronic obstructive pulmonary disease (COPD), difficulty in walking, and unsteadiness on feet. The document revealed that since the previous quarterly assessment was completed on 5/1/24 the resident had 1 fall without injury and two or more falls with injury, except major. Resident #1 was independent with toileting, dressing, transfers, and ambulation. The resident utilized a walker and a wander/elopement alarm that was used daily. The Elopement Risk form dated 5/1/24 documented Resident #1 was a high risk for wandering. The Care Plan printed 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.

Based on clinical record review, facility document review, resident interviews, staff interviews, and policy review the facility failed to provide adequate nursing staff to assure residents safety and well-being. The facility reported a census of 37 residents. Findings include: 1. Review of the August 2024 schedule revealed on the day shift less than 4 CNA's worked on 8/25 and 8/31/24. Review of the August 2024 schedule revealed on the evening shift less than 3 CNA's worked on 8/25, 8/26, 8/27, 8/28, 8/29, 8/30, and 8/31/24. Review of the August 2024 schedule revealed on the overnight shift less than 2 CNA's worked on 8/26, 8/27, 8/30, and 8/31/24. Review of the September 2024 schedule revealed the day shift less than 4 CNA's worked on 9/1, 9/7, and 9/8/24. Review of the September 2024 schedule revealed the evening shift less than 3 CNA's worked on 9/1, and 9/4/24. Review of the September 2024 schedule revealed the overnight shift less than 2 CNA's worked on 9/1, 9/2, 9/3, 9/7, and 9/8/24. Review of the facility document, Facility Assessment, updated 8/14/24 revealed the ratio 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, clinical record review, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices for residents at the facility. The facility failed to prevent, investigate and identify possible infection control issues from the water intrusion and black substance in the basement. The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS also indicated Resident #7 had a dependence on supplemental oxygen, shortness of breath, chronic respiratory failure, and obstructive sleep apnea. Review of the document titled, Discharge summary dated [DATE] for Resident #7 revealed after admission to the hospital on 8/9/24 Resident #7 developed acute hypoxic respiratory failure requiring BIPAP, that had been weaned off 8/14/24 to room air yesterday but on 8/15/24 required 3L 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, resident interviews, staff interviews, facility document review and clinical record review the facility failed to provide adequate staffing to ensure that the needs of the residents were met, and that the call lights were answered in a timely manner. The facility reported a census of 40 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #35 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He was totally dependent on staff for eating, hygiene, dressing and transfers. Diagnoses to include injury of C5 level of cervical spinal cord, degeneration of the autonomic nervous system, and neurogenic bowel. The Care Plan last revised on 1/31/24, showed that Resident #35 had a diagnosis of C5 level spinal injury and quadriplegia. He had no control of muscles, and required the use of a mechanical lift for transfers, with 2 assistance. On 7/22/24 at 3:01 PM, Resident #35 said that sometimes the call lights could…

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 staff interviews, facility record review and policy review, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours each day. The facility reported a census of 40 residents. Findings include: A review of the nursing schedule for June and July 2024 revealed that on following days, the facility failed to provide 8 hours of RN coverage: June 10, 19, 22, 28, 11, 20, 27. July 1, 6 and 7th. On 7/23/24 at 11:37 AM, the Administrator acknowledged the gap in RN coverage. She said that it was in the timeframe when they were in transition with the Director of Nursing (DON) so they had to cover the shifts with Licensed Practical Nurses (LPN's.) On 7/24/24 at 11:56 AM, Staff E, LPN said that before the new DON started in July, there were strings of days with no RN coverage. The LPN's have stepped up to fill in the gap the best they could. On 7/24/24 at 3:35 PM, Staff D, LPN, said that the expectations on the nurses was overwhelming and many times they only have 2 staff people on the floor. When residents are a 2 assist, they need her there and she can't get…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to revise and update the Comprehensive Care Plan for 4 of 17 residents (Resident #13, #2, #6, and #27) reviewed. The facility reported a census of 40 residents. Findings include: 1. Record review of the Minimum Data Set (MDS) 5 Day Medicare assessment for Resident #13, dated 5/7/24 documented a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident cognitively intact. The document revealed the resident required dependence for toileting, bathing, lower body dressing, shoes, and partial moderate assistance for upper body dressing. The resident was dependent for rolling, lying to and from seated positions and transfers. Resident #13 had occasional bowel and bladder incontinence. Diagnoses included: orthostatic hypotension, renal insufficiency, hip fracture (fracture unspecified part of neck of left femur, subsequent for closed fracture with routine healing, seizure disorder/Epilepsy (conversion 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.

Based on observation, staff interview, and policy review the facility failed to prepare, serve and distribute food by failing to provide hand hygiene and glove use according to professional standards. The facility reported a census of 40 residents. Findings include: During a continuous observation on 7/23/24 at 11:00 AM Staff L, Cook, and Staff M, Dietary Aide, completed noon meal preparations. Staff L took temperatures as food items were removed from the steam oven (fried rice, plain rice, fried rice without vegetables, plain chicken) and broccoli from the stovetop. The staff did not clean the thermometer between food items and placed the uncovered thermometer(s) on the countertop throughout the meal process amongst papers, pen, and trash. Staff M moved in and out of the kitchen completing dining room tasks and kitchen tasks without hand hygiene. Staff L carried dirty dishes to the washroom, rinsed, placed dishes in the sink, and returned to the kitchen without hand hygiene. During the meal service there were 2 discarded plates with Staff M taking plates to the dish room 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 observations,staff interviews, provider interview, clinical record review and policy review the facility failed to ensure that residents had accurate and timely assessment and interventions for 2 of 13 residents reviewed. Resident #40 and Resident #6 had chronic skin ulcers, staff failed to complete weekly skin assessments and failed to provide skin treatments as ordered. The facility reported a census of 40 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #40 was unable to complete a Brief Interview for Mental Status (BIMS). He had moderately impaired cognitive skills for daily decision making and disorganized thinking. The resident required set up assistance with eating and upper body dressing, partial assistance with lower body dressing and toileting hygiene. His diagnosis included heart failure, hypertension, peripheral vascular disease, aphasia and cerebrovascular accident (CVA). The Care Plan updated on 2/22/24, showed that Resident #40 had…

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 policy review the facility failed to provide ongoing assessment and oversight for residents before and after dialysis for 2 of 2 residents (Resident #2, and #27) reviewed. The facility reported a census of 40 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 5/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. The MDS further revealed diagnosis of chronic kidney disease, stage 5, and morbid obesity. Review of Resident #2's Care Plan dated 7/23/24 revealed Resident #2 had a focus area related to hemodialysis and renal failure. Interventions identified for staff included dates of dialysis, assessments per protocol, labs per protocol, and notification to the physician. Review of the Electronic Health Record (EHR) for the month of July 2024 noted 6/9 dialysis documents in the record. Documents 7/19 and 7/17 contained both pre and post dialysis assessments. Documents dated 7/12, 7/10, 7/8 and 7/5/24 contained…

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, staff interviews and policy review the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens for 2 of 4 resident reviewed. Wound care treatments without hand hygiene for Resident #40 and #6. The facility reported a census of 40 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #40 was unable to complete a Brief Interview for Mental Status (BIMS). He had moderately impaired cognitive skills for daily decision making and disorganized thinking. The resident required set up assistance with eating and upper body dressing, partial assistance with lower body dressing and toileting hygiene. The diagnoses included heart failure, hypertension, peripheral vascular disease, aphasia and Cerebrovascular Accident (CVA). The Care Plan updated on 2/22/24, showed that Resident #40 had Hemiplegia/Hemiparesis related to CVA. He had difficulty communicating 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 staff interview, clinical record review and policy review the facility failed to offer influenza immunization to 1 of 5 residents reviewed. Resident #16 signed the consent for the immunization, but the chart lacked evidence that she received the shot. The facility reported a census of 40 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). She was totally dependent for toileting, lower body dressing and transfers. Her diagnoses included anemia, heart failure, renal insufficiency, pneumonia and septicemia, and chronic respiratory failure. The Care Plan revised on 1/12/24 showed that Resident #16 had a tracheostomy and required suction as necessary. She had a cardiac pacemaker and an automatic cardiac defibrillator. According to the Immunizations tab in the electronic charting, Resident #16 did not receive the influenza vaccine in 2023. An Informed Consent for…

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

Based on facility investigative file review, staff interviews and policy review the facility failed to report a reportable event in a timely manner for 1 of 3 residents (Resident #6) reviewed for reportable events. The facility reported a census of 41 residents. Findings include: The facility's 5-day investigation summary involving Resident #6 documented the alleged incident occurred on 3/23/24 and was reported on the company compliance hotline on 3/27/24. The summary documented the following description of the incident: the caller reported on the compliance hotline that Staff A Licensed Practical Nurse (LPN) had said to a paralyzed resident that you f*ing stink. There's no reason your lazy a can't shower. Get in the shower now. The staff reported it happened on 3/23/24. On 4/4/24 at 10:49 AM Staff B LPN stated she called the corporate hotline to report on 3/23/24 that Staff B told Resident #6 that he stinks, is lazy and needs to get up to shower because he stinks. Staff B indicated she was at the nurse's station when she heard this. When Staff B came to the nurse's station…

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, hospital staff interview and policy review the facility failed to allow a resident to return to the facility after a facility initiated transfer to an acute setting for 1 of 3 residents (Resident #2) reviewed for appropriate discharge. The facility reported a census of 41 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 3/7/24 Resident #2 had a Brief Interview Mental Status (MDS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented he had no physical, verbal, or other behavioral symptoms directed to others during the review period. Resident #2 also did not reject care during the review period. The MDS documented the following diagnoses: malignant neoplasm of rectum, unspecified mood disorder, constipation, and moderate intellectual disabilities. The MDS documented active discharge planning occurring for the resident to return to the community and no referrals…

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, staff interviews and policy review the facility failed to complete a recapitulation of stay for 2 of 3 residents (Resident #4 & #5) reviewed. The facility reported a census of 41 residents. Findings include: 1. According to the discharge return not anticipated Minimum Data Set (MDS) assessment tool with a reference date of 3/1/24 Resident #4 discharged from the facility. The MDS documented active discharge planning occurred for the resident to return to the community. The Care Plan focus area with an initiation date of 2/13/2024 documented Resident #4 wished to be discharged to the community. On 3/1/24 at 4:39 PM a progress note documented discharged . Review of the documents tab in Resident #4's clinical record contained a document titled discharge paperwork with an uploaded date of 3/6/24. The discharge paperwork lacked a recapitulation of the resident's stay that included course of illness/treatment or therapy, pertinent lab, radiology, and consultation results, reconciliation of all pre-discharged medications with the resident's post-discharge…

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, staff interviews and facility policy review the facility failed to complete discharge assessments when 3 of 3 residents (Resident #2, #4, and #4) discharged from the facility. The facility reported a census of 41 residents. Finding include: 1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 3/7/24 documented Resident #2 had a Brief Interview Mental Status (MDS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented he had no physical, verbal, or other behavioral symptoms directed to others during the review period. Resident #2 also did not reject care during the review period. The MDS documented the following diagnoses: malignant neoplasm of rectum, unspecified mood disorder, constipation, and moderate intellectual disabilities. The Care Plan focus area with an initiated date of 11/10/23 documented Resident #2 wished to discharge to the community. The care plan indicated the facility was to evaluate and discuss with Resident #2 the prognosis for independent or assisted living.…

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, hospital staff interview, and policy review the facility failed to have complete and accurate medical records for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 41 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 3/7/24 Resident #2 had a Brief Interview Mental Status (MDS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented he had no physical, verbal, or other behavioral symptoms directed to others during the review period. Resident #2 also did not reject care during the review period. The MDS documented the following diagnoses: malignant neoplasm of rectum, unspecified mood disorder, constipation, and moderate intellectual disabilities. The Care Plan focus area with an initiated date of 11/10/23 documented Resident #2 wished to discharge to the community. The care plan indicated the facility was to evaluate and discuss 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 observations, resident and staff interviews, resident council minutes, and facility assessment, the facility failed to provide adequate staff to meet residents' needs. The facility reported a census of 43 residents. Findings include: On 1/31/24 at 7:45 AM Resident #7 sat in the back-dining room with his peers. His hair was greasy. Resident #5 also sat in the back-dining room with his peers. He wore a black t-shirt that had white flakes throughout. At 2:00 PM Resident #8 and #9 sat in their rooms both had greasy hair. On 2/1/24 at 11:25 AM Resident #8 sat in the back-dining room with his peers. He wore a blue long-sleeved shirt that had white flakes throughout his shirt. He also wore blue and grey plaid pajama pants that also had white flakes in the lap of his pants. His fingernails were long. He indicated he received a bath today; hair appeared clean and brushed. Review of Resident Council Minutes revealed during their 12/29/23 meeting residents indicated the facility was understaffed-certain residents…

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 staff roster, daily schedules, monthly schedule, payroll-based journal (PBJ), facility assessment, and staff interviews, the facility failed to have a Registered Nurse (RN) for eight consecutive hours a day, 7 days a week as required. The facility reported a census of 43 residents. Findings include: Review of the facility's staff roster revealed the facility employed two Registered Nurses (RN). Review of the facility's Payroll-Based Journal (PBJ) for October 1, 2023-December 1, 2023 revealed the facility reported no Registered Nurse (RN) hours on 10/25/23, 10/26/23, 10/31/23, 11/13/23, 11/26/23 and 12/31/23 Review of the Facility Assessment with a last reviewed date of 4/27/23 documented an average daily census of 45.34 in the last year. The ratio of RN's and Licensed Practical Nurses (LPN's) to Certified Nursing Assistants (CNA's) shall be sufficient to assure professional guidance and supervision in the nursing care of the residents. Facility retains sufficient staffing to maintain a 24-hour licensed nurse (8-hours are a registered nurse, 7-days a week). Review of 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, resident and staff interviews, and policy review the facility failed to develop a comprehensive Care Plan for 1 of 6 residents reviewed (Resident #6). The facility reported a census of 43 residents. Findings include: Observation on 1/31/24 at 7:45 AM revealed Resident #6 sat in his motorized wheelchair in the back-dining room. He had a urine drainage bag hooked to his wheelchair, gripper socks on, and wore glasses. According to the admission Minimum Data Set (MDS) with a reference date of 11/7/23 documented Resident #6 had a Brief Interview for Mental Status (BIMS) score for 13. A score of 13 suggested intact cognition. The MDS documented he utilized a wheelchair for mobility; wore corrective lenses; was dependent of staff for showering/bathing, toilet use, putting on and taking off footwear, set up assistance for oral and personal hygiene, partial/moderate assistance for upper body dressing, and substantial/maximal assistance for lower body dressing. The MDS documented he had an indwelling catheter and was always incontinent of bowel. Resident #6 was at risk…

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, record review, staff and resident interviews, and grievance forms review the facility failed to provide bathing opportunities for 3 of 3 residents reviewed (Residents #4, #5, and #6). The facility reported a census of 43 residents. Findings include: On 1/31/24 at 7:45 AM Resident #7 sat in the back-dining room with his peers. His hair was greasy. Resident #5 also sat in the back dining room with his peers. He wore a black t-shirt that had white flakes throughout. At 2:00 PM Resident #8 and #9 sat in their rooms both of their hair was greasy. On 2/1/24 at 11:25 AM Resident #8 sat in the back dining room with his peers. He wore a blue long-sleeved shirt that had white flakes throughout his shirt. He also wore blue and grey plaid pajama pants that also had white flakes in the lap of his pants. His fingernails were long. He indicated he received a bath today; hair appeared clean and brushed. 1. According to the quarterly Minimum Data Set (MDS) with a reference date of 11/13/23 documented Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15. A…

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

Based on record review, staff and resident interviews, and facility policy review the facility failed to carry out restorative programs for 2 of 2 residents reviewed (Resident #4 and #5). The facility reported a census of 43 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) with a reference date of 11/13/23 documented Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she was independent when eating, required moderate assistance for oral hygiene, dependent on staff for toilet use, hygiene, shower/bathing, and substantial assistance for personal hygiene. The MDS documented she did not perform her restorative programs in the last 7 calendar days The MDS listed the following diagnoses: seizure, depression, respiratory failure, and morbid obesity. Review of Resident #4's Electronic Health Record (EHR) revealed she was to complete the following tasks: nursing rehab- Active Range of Motion AROM bilateral lower extremities seated exercise/balloon kicks 3 times per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to maintain a safe and sanitary environment. The facility reported a census of 46 resident. Findings include: Observations starting on 7/21/23 at 9:50 AM revealed the following: - room [ROOM NUMBER]'s air conditioning unit contained brown stains on top of the vent area where the air is pushed out in to the resident room - room [ROOM NUMBER]'s air conditioning unit contained multiple black speckles on the internal and external vents where the air is pushed out to the resident's room, floor of the air vent, and on the vent cover over the filter. The room had missing chunks of tile out of the floor, paint missing on the wall next to the resident's bed, and the floor felt sticky with black debris that outlined a rectangle shape - room [ROOM NUMBER]'s air conditioning unit contained black debris built up where the air is pushed out to the resident's room - room [ROOM NUMBER]'s air conditioning unit contained black, white, grey debris built up where 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, staff interviews, and hospital staff interviews the facility failed to ensure 1 of 3 residents (Resident #4) went to their follow up appointments, had the appropriate labs, and diagnostic work as ordered. Findings include: Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The MDS indicated that he required extensive assistance from one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS included diagnoses of malignant neoplasm of bladder (bladder cancer that spread), cancer, heart failure, diabetes mellitus, dementia, and depression. The Care Plan Focus area dated 2/21/23 indicated that Resident #4 had bladder cancer. The After Visit Summary dated 6/28/22 included the following scheduled appointments: - 11/23/22 lab scheduled at 9:30 AM - 11/23/22 a Magnetic Resonance Imaging (MRI) scheduled at 11:20 AM - 11/23/22 return…

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 and facility policy review the facility failed to report a reportable event for 1 of 3 residents reviewed (Resident #2). Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS listed that she required extensive assistance of one person for bed mobility, dressing, and personal hygiene. In addition, the MDS indicated that she required extensive assistance of two persons for transfers and toilet use. The MDS included diagnoses of diabetes mellitus, heart failure (impaired heart function), hypertension (high blood pressure), renal failure (severely impaired kidney function), seizure disorder, and depression. The Care Plan Focus revised 12/29/22 reflected that Resident #2 had a risk of falling due to weakness, need for assistance with cares, and required encouragement to use her call light. The Interventions directed the following: a. Revised…

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.