Tabor Manor Care Center

Based on clinical record review, interviews and policy review the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN), Form Center for Medicare Services (CMS)-10055 or Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123-NOMNC, for 2/3 residents reviewed (Resident #26, #11). The facility failed to provide the residents notification of the changes as soon as the change in coverage was made available. The facility reported a census of 40. Findings include:1. The Discharge Notification from therapy dated 8/31/25 for Resident #26 indicated the last treatment date for therapy would be on 9/4/25 and the discharge date would be 9/5/25. Resident #26 signed a NOMNC, Form CMA 10123-NOMNC approved 12/31/11, on 9/2/25 indicating coverage of therapy services would end on 9/5/25. Resident #26 signed the SNF-ABN form on 9/5/25 indicating the resident would begin occurring costs for therapy on 9/6/25 if electing to continue therapy services. The facility failed to provide the resident the document the charges that would occur prior to the last date 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, resident interview, policy review, and staff interview the facility failed to provide the residents with a homelike environment by serving meals on Styrofoam flatware to residents. The facility reported a census of 40 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #24 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment.On 2/23/26 at 11:03 AM Resident #24 stated the staff in the evening serve most of the meals on Styrofoam plates and bowls. Resident #24 explained she does not like being served on Styrofoam plates. Resident #24 stated she did not know why the facility does not use actual plates. On 2/24/26 at 11:32 AM Staff L, [NAME] stated she worked 3-4 days a week serving dinner meals of the day. Staff L stated if the dish machine was broken the cook would use Styrofoam for that meal. Staff L stated the dish machine had not been out of order when she had worked but she had heard the…

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

Based on clinical record review, facility document review, and staff interviews, the facility failed to report suspected abuse between two (2) residents (#2 & #37) to the State Agency after being made aware of the incident. The facility reported a census of 40 residents. Findings include:A grievance form dated 11/08/25 at 10:00 AM revealed Resident #37 informed Staff H, Restorative Aide (RA) that Resident #2 came in Resident #37's room and was bumping into everything. When he tried to stop Resident #2, Resident #2 grabbed Resident #37's shirt so Resident #37 grabbed Resident #2's shirt. Resident #2 let go of Resident #37's shirt and slapped at his hands. When Resident #37 let go of Resident #2's shirt, Resident #2 left the room.A document dated 11/08/25 titled Incident with <Resident #37 name> and <Resident #2 name> revealed the administrator interviewed Resident #37 and documented Resident #37 stated Resident #2 came in in his room and startled him and he spilt his coffee. He stated he tried to stop him by grabbing his merry walker (specialized walker with a seat to prevent falls…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, clinical record review, staff interviews, and policy review, the facility failed to complete an accurate comprehensive assessment for 1 of 1 resident (#29). The facility reported a census of 40 residents.Findings include:On 2/23/26 at 11:48 AM, Resident #29 stated she was hard of hearing and has been trying to get hearing aids but her insurance would not cover them.The Baseline Care Plan dated 3/27/25 revealed the resident was hearing impaired.The Care Plan dated 3/31/25 included a hearing deficit focus category and directed staff to validate the resident's message by repeating aloud.The Appointment Note dated 10/21/25 at 2:33 PM revealed the facility was waiting for the resident's Ear, Nose, and Throat (ENT) provider to supply a phone number for the facility to contact the resident's insurance company about hearing aids.Resident #29's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 07 out of 15 which indicated severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards for 1 of 14 residents (Residents #45). The facility failed to complete/document wound treatments per physician orders and failed to administer oxycodone per physician orders. The facility reported a census of 40 residents. Findings include:The Minimum Data Set (MDS) admission for Resident #45 dated 2/21/26 provided a BIMS score of 15/15 indicating normal cognition. The document revealed the resident had diagnoses of severe life threatening blood infection, diabetes and a rare flesh eating bacterial infection. The document revealed the resident had an open lesion and had the interventions of a pressure reducing device for the bed, repositioning program and application of nonsurgical dressings. Resident #45's Care Plan dated 2/24/26 contained a focus area of wound management dated 2/20/26 with interventions of measuring wound on regular intervals,…

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 interviews, and policy review the facility failed to provide the needed services in accordance with professional standards for 2 of 14 residents (Residents #26, #1). The facility failed to complete neurological assessments post falls, and failed to complete wound assessments to ensure healing. The facility reported a census of 40 residents. Findings include:1. The Minimum Data Set (MDS) admission for Resident #26 dated 1/2/26 provided a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The document revealed the resident had diagnoses of stroke, anxiety, depression, bipolar disorder, psychotic disorder and schizophrenia. The document revealed the resident had a fall in the last month prior to admission, a fall in the last 2-6 months prior to admission, fracture related to a fall in the 6 months prior to admission, and no falls since the admission to the facility. The MDS Discharge Return Not Anticipated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and provider interview, the facility failed to assist the resident to obtain hearing devices through possible available resources for 1 of 1 resident (#29). The facility reported a census of 40 residents.Findings include:On 2/23/26 at 11:48 AM, Resident #29 stated she was hard of hearing and has been trying to get hearing aids but her insurance would not cover them.The Care Plan dated 3/31/25 included a hearing deficit focus category and directed staff to validate the resident's message by repeating aloud.The Appointment Note dated 10/21/25 at 2:33 PM revealed the facility was waiting for the resident's Ear, Nose, and Throat (ENT) provider to supply a phone number for the facility to contact the resident's insurance company about hearing aids.Resident #29's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 07 out of 15 which indicated severely impaired cognition. It included diagnoses 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, interviews, and policy review, the facility failed to monitor a pressure area in a manner to reduce the risk of wound development and failed to implement offloading procedures to decrease pressure for 1 of 1 residents reviewed (Resident #4). The facility reported a census of 40 residents.Findings include:Resident #4's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4/15 indicating severe cognitive impairment. The document included resident diagnoses of Alzheimer's, Non-Alzheimer's Dementia, and depression. The document disclosed the resident had an unstageable pressure ulcer due to coverage of the wound bed by dead hard tissue. The MDS included skin treatments including a pressure reducing device for chair, bed, pressure ulcer/injury care, application of dressings to feet and the resident utilized a wheelchair (w/c)The resident's Care Plan dated 2/13/26 contained a focus area of potential/actual impairment to skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and policy review the facility failed to develop programs maintaining residents strength, range of motion (ROM), mobility needs based on the comprehensive assessment and under the direct guidance of a Registered Nurse (RN) for 2 of 14 residents reviewed (Resident #26, #45). The facility reported a census of 40.Findings include:1. The Minimum Data Set (MDS) admission for Resident #26 dated 1/2/26 provided a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The document revealed the resident had diagnoses of stroke, anxiety, depression, bipolar disorder, psychotic disorder and schizophrenia. The document included the resident had functional limitations of ROM in both the upper and lower extremities. The document further disclosed the resident received 4 days of passive range of motion (PROM), 3 days of active range of motion (AROM), 2 days of splint or brace assistance, 5 days of bed mobility, 5 days 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 observations, clinical record review, policy review, resident interview and staff interviews the facility failed to provide respiratory services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #24) who required the use of a Continuous Positive Airway Pressure (CPAP) machine. The facility reported a census of 40 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #24 documented a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS documented Resident #24 had a diagnosis of obstructive sleep apnea.On 2/23/26 at 11:03 AM Resident #24 stated none of the facility's staff have ever cleaned her CPAP machine. Resident #24 stated she had not had her CPAP mask or machine cleaned at all since admission to the facility.On 2/23/26 at 11:10 AM an observation of Resident #24's CPAP machine revealed speckled white sediment covered the outside of the machine. [NAME] haze colored water present in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility document review, clinical record review, policy review, resident interviews and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 3 of 16 resident reviewed (Resident #3, #24, and #26). The facility reported a census of 40 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented diagnoses of acute and chronic respiratory failure with hypoxia, unspecified nondisplaced fracture of seventh cervical vertebra, unspecified fracture of first thoracic vertebra, functional quadriplegia and need for assistance with personal care. On 2/23/26 at 1:07 PM Resident #3 stated on the 2:00 PM - 10:00 PM shift and the overnight shift it can take much longer than 15 minutes to answer the call light. Resident #3 explained on the overnight shift it had taken over an hour to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, interviews and policy review the facility failed to ensure medication error rates were not 5 percent or greater by having a medication error rate of 8.33 percent. The facility reported a census of 40 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #22 had a Brief Interview of Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment. The resident's Care Plan 2/15/26 did not contain a focus area or intervention for independent medication administration. Observed on 2/24/26 at 7:00 AM Staff A, Registered Nurse (RN), obtained the following medications: 1 vial of Ipratropium-Albuterol Inhalation Aerosol Solution 20-100 MCG/ACT, Milvexian 25 mg, Levothyroxine 88 MCG, acetaminophen 500 mg (2), aspirin 81, Cymbalta 30 mg, Levetiracetam 500 mg, Meloxicam 15 mg, Pantoprazole 40 mg, Senna 8.6 mg and Cholecalciferol 25 mcg and took them with a cup of water to the Resident #22's room. The staff provided the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview the facility failed to provide appropriate infection prevention practices when providing care for a resident with a catheter for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 40 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #3 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented diagnoses of acute and chronic respiratory failure with hypoxia, unspecified nondisplaced fracture of seventh cervical vertebra, unspecified fracture of first thoracic vertebra, functional quadriplegia and need for assistance with personal care. The MDS documented the resident had an indwelling catheter. The Care Plan initiated 6/25/24 documented the resident has an indwelling catheter related to obstructive uropathy. The care plan interventions directed staff to position the catheter bag and tubing below the level of the bladder and away from…

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, document review, staff interview, family interview and policy review the facility failed to notify the resident's representative / family / Power of Attorney (POA) for change in condition / transfer to Emergency Department (ED) when a resident fell from a full body mechanical lift for 1 of 3 residents (Residents #1) reviewed. The facility reported a census of 39 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. MDS documented Resident #1 required maximum assistance by staff for transfers.Review of Resident #1's Electronic Health Record (EHR) dated 11/5/25 titled, Progress Notes entered by Staff C at 12:29 PM documented Resident #1 fell from a full body mechanical lift to the floor and landed in the prone position. Emergency Medical Services (EMS) were called and arrived at the facility. Resident #1 was transported to the ED of her choice. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy review, the facility failed to provide weekly skin assessments for 2 residents reviewed (Resident #2, #3) for pressure ulcers. The facility reported a census of 39 residents. 1. The Minimum Data Set (MDS) dated [DATE] for Resident #2 documented a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. MDS also documented Resident #2 had 1 unstageable pressure ulcer.Review of Resident #2's EHR titled, Progress Notes documented an unstageable pressure ulcer to the left heel was discovered on 6/2/25. Progress Notes documented wound assessments with size and description were completed on 6/8/25, 9/15/25, 10/13/25, 11/6/25, and 11/11/25.Review of Resident #2's document printed on 11/12/25 titled, Hospice Wound Record Report documented wound assessments to the unstageable pressure ulcer located on the left heel with size and description were completed on 8/4/25, 8/12/25, 8/18/25, 8/25/25, 9/22/25, 10/2/25, 10/16/25,…

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 record reviews, resident interviews, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards by not following physician orders for 4 of 4 residents (Resident #1, #2, #4, #5) reviewed. The facility reported a census of 40 residents. Findings include:1. The Minimum Data Set (MDS) for Resident #1 dated 7/17/25 provided a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document revealed the resident had diagnoses of anxiety disorder, depression, unspecified asthma with acute exacerbation, thyrotoxicosis, unspecified without thyrotoxic crisis or storm, insomnia, Myasthenia Gravis without acute exacerbation, Myasthenia Gravis with acute exacerbation, and paroxysmal atrial fibrillation. The document disclosed the resident's medications included antidepressant, hypnotic, anticoagulant, and anticonvulsant.The Care Plan updated 7/3/25 provided focus areas of alteration in hematological status related to long term use of anticoagulant therapy, alteration in…

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

Based on personnel file review, staff interview and policy and procedure reviews the facility failed to complete the Iowa Criminal History, Iowa Sex Offender Registry, and Iowa Central Abuse Registry prior to employment for 1 of 1 employees reviewed (Staff E). The facility census was 40. Findings include:The personnel file for Staff E, Licensed Practical Nurse (LPN), reflected a hire date of 6/9/25. The file contained a Single Contact License and Background Check (SING) dated 5/20/25. The document revealed the Criminal History required further research with record found results to be faxed. The personnel file did not contain the confirmation of approval to work statement indicating the background check process was completed and the employee was able to work at the facility. On 8/19/25 at 3:00 PM the Administrator stated the facility was looking for the response for the approval to work email. On 8/20/25 at 10:35 AM the Administrator stated at this time the facility had not found the email response in printed or electronic format for approval to work. The Administrator confirmed the…

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

Based on observation and staff interviews, the facility failed to post required notifications of State Survey Agencies and other support for advocacy in a form or manner accessible and understandable to residents or representatives. The facility reported a census of 43 residents. Findings include: Surveyor's observations throughout the survey dates 2/3/25 - 2/6/25 revealed information posted in the common area by the nurses station on how to contact state agencies was above eye level and in small print flyers. Information on Residents Rights was not posted. A framed flyer that read current state survey, fire marshall's report, medicaid and medicare information located in lobby bookcase did not have all listed information in the lobby's bookcase. Another flyer read nondiscrimination policy and at the bottom of the flyer the contact for the facility was outdated. During a facility tour on 2/4/25 at 3:00 pm with the Administrator Assistant, it was observed that the required postings with list of names, mailing and email addresses, and telephone numbers of all pertinent State regulatory…

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 interview, record review and facility policy review, the facility failed to make information on how to file a grievance available to the residents and make efforts to resolve complaints for 1 resident out of 8 residents reviewed. The facility reported a census of 43 residents. Findings include: During an observation on 2/3/25 at 10:24 am of the common areas, no information was posted on how to file a complaint or a grievance, including a name of the grievance official. In an interview with the Administrator on 2/3/25 at 3:00 pm he revealed the grievances forms and records were located in his office. During the review of the Grievances records, only 1 record was located in the binder filed on 1/2/25 and the section 3 for follow up comments was left blank. The Administrator confirmed the grievance was not followed up for a resolution. In a follow up interview with the Administrator on 2/6/25 at 2:34 pm he stated his expectations was that the residents had access to file grievances and he was responsible to complete and follow up on grievances. The Administrator provided…

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 safeguard medical record information against loss, destruction, or unauthorized use. The facility reported a census of 43 residents. Findings include: Observation on 100 hallway on 2/4/25 from 7:50 am until 8:00 am revealed an unattended medication cart located near the exit door of the hallway. The medication cart equipped with a built-in computer monitor on top of it displayed an Electronic Health Record of a current resident. It revealed personal identifiable information, including full name, room number, birthday, code status, and several medication/treatment orders. One resident walked past the unlocked computer monitor. Subsequent observations of the unlocked, unattended computer monitor with the EHR displaying residents' medical records: 1. 02/05/25 07:32 AM computer screen unlocked 2. 02/05/25 08:36 AM medication labels for refills stuck on the pill crusher 3. 02/05/25 08:37 AM facility visitor in the hallway walked by 4. 02/05/25 08:45 AM computer screen unlocked 5. 02/05/25 09:19 AM computer screen…

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

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (July 1-September 30, 2024) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 43 residents. Findings include: The PBJ Staffing Data Report run date 1/29/25 for quarter four 2024 triggered for excessively low weekend staffing and failed to have licensed nursing coverage 24 hours a day. Review of weekend staffing schedules for quarter 4 months of July, August, and September 2024 revealed equal staffing during the week and the weekend. On 2/6/25 at 12:06 PM Staff E, Assistant Administrator acknowledged time sheets were not turned in for a traveling nurse in particular and was not appropriately being sent to the billing email. Staff E acknowledged this was the reason for the inaccuracy in reporting staffing data. On 2/6/25 at 12:02 PM the Administrator stated he had inaccuracies probably related to agency staff hours being reported. Stated the…

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

Based on facility record review, staff interview, and policy review the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program in place to provide quality care for residents. The facility failed to make good faith attempts to correct quality deficiencies, and maintain and implement a comprehensive QAPI program and plan. The facility identified a census of 43 residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) document CASPER Report 0003D dated 1/29/25 revealed the facility had repeated deficient practices in the years 2019, 2021, 2022, 2024, and 2025 as exhibited by the following: F582 Medicaid/Medicare Coverage/Liability Notice (2021, 2025) F623 Notice Requirements Before Transfer/Discharge (2021, 2022) F625 Notice of Bed Hold Policy Before/Upon Transfer (2019, 2021, 2022) F641 Accuracy of Assessments (2021, 2024, 2025) F644 Coordination of Pre-admission Screening and Resident Review (PASRR) and Assessments (2019, 2022, 2024, 2025) F655 Baseline Care Plan (2019, 2025) F656 Development/Implement Comprehensive…

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

Based on staff interview, and policy review the facility failed to properly establish and implement written policies and procedures for the Quality Assurance and Performance Improvement (QAPI) plan. The facility reported a census of 43 residents. Findings include: The facility policy, QAPI Policy and Protocol, revealed no effective procedures to identify, collect, use and monitor data for all departments, and utilize the Facility's Assessment. The document did not identify how the facility would report, track, investigate and analyze adverse events and/or problem prone concerns. The facility policy did not describe how the facility developed corrective actions to effect change at the systems level to prevent quality of care, quality of life and safety problems. The document did not contain how the facility monitored the effectiveness of its Performance Improvement Plans (PIPs) to ensure improvements were sustained. The facility did not contain the required committee members. On 2/10/25 at 11:40 AM the Administrator stated the facility was unable to provide any on-going QAPI…

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 record review, staff interview, and policy review the facility failed to maintain records of Quality Assurance and Performance Improvement (QAPI) committee meetings 1 of the 3 quarters reviewed and the required attendees. The facility reported a census of 43 residents. Findings include: The facility provided documents titled, Q.A. Meeting, dated 7/10/24 and 12/5/24 revealed all the required members were in attendance. No further quarterly documentation was provided for the previous 3 quarters. The facility policy, QAPI Policy and Protocol undated, revealed the members did not include the Infection Preventionist and Medical Director as required. The document further revealed the team would meet monthly and as needed. The facility document, QAA Committee, revealed the members included the Administrator, Director of Nursing (DON), Minimum Data Set (MDS) Coordinator, Dietary Manager, Activities Director, Social Services, Medical Director, and Pharmacy. The document did not include Infection Preventionist. On 2/10/25 at 11:40 PM the Administrator stated the core members…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review, record review, and staff interviews the facility failed to have correct documentation of residents' choice related to advance directives for 3 of 7 residents reviewed (Resident #24, Resident #194 and Resident #9). The facility reported a census of 43 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #24 entered the facility on 1/6/25. The MDS documented resident entered with Hospice services. Review of the current Medication Administration Record (MAR) revealed Advance Directive as Do Not Resuscitate (DNR). The EHR lacked Resident Advance Directives form signed on admission to reflect the DNR wishes and signed by the resident or representative and the physician. On 2/4/24 at 3:00 pm, the Director of Nursing (DON) stated that advance directives are verified at the time of admission and confirmed the EHR and the physical chart did not have the Resident Advanced Directives form. During the follow up review of the physical record for Resident #24,…

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

Based on facility document review, staff interviews and clinical record review, the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment and failing to provide annual abuse training. The facility reported a census of 43 residents. Findings include: 1. Review of the document dated 2/4/25 titled, Employee Contact List documented Staff I, Certified Nurse Assistant (CNA) was hired 7/29/24. Review of the document for Staff I titled, Single Contact License and Background Check documented background check was completed 7/25/22. On 2/6/25 at 9:44 AM Staff E, Assistant Administrator acknowledged Staff I's background check was last completed 7/25/22. Staff E stated he would expect that a background check would have been completed prior to being hired 7/29/24. On 2/6/25 at 12:21 PM the Administrator stated the facility's expectation was that a background check would have been completed prior to Staff I's employment at the facility. 2. A review of the Resident #15 Electronic Health Record (EHR) titled Progress Notes documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. The MDS for Resident #16 dated 1/16/25 identified a BIMS score of 11 indicating moderate cognitive impairment. The MDS indicated the following high-risk drug classes: antidepressant, diuretic, opioid, antiplatelet, hypoglycemic, and anticonvulsant. The MDS identified verbal behavioral symptoms directed toward others occurring at a frequency of every 1 to 3 days. Resident #16's Care Plan revised 12/8/23 documented the resident had the potential to be verbally aggressive towards staff related to poor impulse control. A desired outcome identified the resident will demonstrate effective coping skills through the review date. However, the interventions/tasks did not include the resident's target behaviors or which coping skills to implement. It also lacked non-pharmacological interventions, ordered medications or other treatments available. Review of Resident #16's Physician Orders dated 10/11/2024 identified the resident was prescribed Fluoxetine HCI Capsule 30 mg 1 capsule by mouth daily for depressive 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 employee file review, staff interviews, State Agency website, and facility policy review the facility failed to ensure that a hired nurse aide that had worked longer than 4 months had completed a training and competency evaluation program approved by the state. The facility reported a census of 43 residents. Findings include: Review of the document dated 2/4/25 titled, Employee Contact List documented Staff I, Certified Nurse Assistant (CNA) was hired 7/29/24. Review of Staff I's employee files revealed no CNA certificate. No proof that Staff I had completed a training and competency evaluation program, a competency evaluation program approved by the State or that Staff I had been deemed or determined competent as a CNA by an approved source. A review of the State Agency (SA) website titled, Direct Care Worker Registry and Health Facility Database documented Staff I's status with CNA certification as no test, currently employed as no, and certification date/expiration date as blank. On 2/6/25 at 9:38 AM Staff J Administrative Assistance stated the facility should report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy review, the facility failed to identify target behaviors for psychotropic medication use for 5 of 5 residents reviewed (Resident #33, #16, #2, #22 and #194). The facility reported a census of 43 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #33 dated 12/26/24 identified a BIMS score of 8/15 which indicated moderate cognitive impairment. The MDS included diagnoses of Non-Alzheimer's Dementia and depression. It identified a lack of pleasure/interest in doing things for 2-6 days of the reporting period. It did not identify indicators of psychosis. It revealed the resident exhibited behavioral symptoms towards others occurring 1-3 days, verbal behaviors towards others 4-6 days, and other behavioral symptoms not directed towards others for 1-3 days. The document revealed the resident refused cares for 4-6 days. The MDS identified Resident #33 took antipsychotic and antidepressant medications during the last 7 days 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 observations, staff interviews, and policy review the facility failed to store food in accordance with professional standards by not dating food items removed from boxes or disposing of expired food items. The facility reported a census of 43 residents. Findings include: On 2/3/25 at 11:15 am an observation in the dry storage room revealed a sealed bag of pretzels with expiration date of September 2024, a bag of dry gravy mix with expiration date of January 2025, 12 sealed cans of chicken noodle soup with expiration date of December 2024, and a cardboard flat of 24 cans of tomato soup with expiration date of January 2024. The dry storage room also revealed 12 sleeves of sealed saltine crackers removed from boxes stored in a large plastic tote without receiving date or expiration date and 8 large bags of cereal sealed removed from boxes without receiving date or expiration date. On 2/3/25 at 11:20 am an observation of the walk-in freezer revealed 10 frozen bags of fried rice removed from the box without a receiving date or expiration date. On 2/3/25 at 11:30 Staff F,…

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, and staff interview the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or centralized work area by the system having a known issue that prevents the entire call light system from working. The facility reported a census of 43 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #194 documented a Brief Interview for Mental Status (BIMS) of 11 indicating no cognitive impairment. The MDS documented diagnoses of acute respiratory failure with hypoxia and unspecified asthma with acute exacerbation. On 2/3/25 at 12:55 PM Resident #194 stated every staff member knows that her call light does not work appropriately. Resident #194 stated she used to live in a room on the west side and it did not work appropriately. Resident #194 stated she had just had her call light on for the last 30 minutes a couple minutes ago and…

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

Based on facility document review, staff interviews and policy review the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. The facility reported a census of 43 residents. Findings include: A request for documentation from the Administrator and Staff E, Assistant Administrator of training for Staff I, Certified Nurse Assistant (CNA) in Dependent Adult Abuse / Mandatory Reporter revealed no documentation of completion or certificate of completion. A request for documentation from the Administrator and Staff E of training for Staff M, CNA in Dependent Adult Abuse/Mandatory Reporter revealed no documentation of completion or certificate of completion. On 2/6/25 at 9:44 AM Staff E, Assistant Administrator stated he just sent an email to Staff M that requested a copy of her Dependent Adult Abuse/Mandatory Reporter certificate. Staff E…

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

Based on employee file review and staff interview the facility failed to complete required in-service training for nurse aides to ensure continued competence no less than 12 hours per year. The facility reported a census of 43 residents. Findings include: On 2/5/25 at 3:34 PM Staff D, Certified Nurse Assistant (CNA) stated she had worked at the facility for about a year and a half. Staff D stated the facility provided online in-services for mandatory reporters. Staff D stated she had not gotten regular in-service training related to resident rights, dementia care, infection control or behavioral health. Review of Staff D's employee file revealed no documents of yearly in-service training related to resident rights, dementia care, infection control or behavioral health. On 2/5/25 at 3:47 PM the Director of Nursing (DON) stated there was not currently any training being conducted as the annual training. The DON acknowledged there was no yearly in-services related to resident rights, dementia care, infection control or behavioral health that had been completed. The DON stated not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review, the facility failed to treat residents with dignity and respect throughout cares provided for 1 of 7 residents reviewed (Resident #15).The facility reported a census of 43 residents. Findings include: Record Review of Resident #15 Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 06 indicating severe cognitive decline. The MDS reflected Resident #15 diagnoses of non-Alzheimer's dementia, hemiplegia (paralysis on one side of the body), seizure disorder, and ataxia following cerebral infarction (poor muscle coordination and balance after a stroke). The MDS further documented Resident #15 required total dependence on staff for performing activities of daily living. Clinical record review of Resident #15 documented a nurse's Progress Note dated 1/10/25 at 8:49 am a concern about a staff member holding resident's hands down and forcing medications. During an interview on 2/4/25 at 3:13 pm…

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 document review, staff interview, and policy review the facility failed to provide residents and families with 48 hour notification of financial responsibility when Medicare Part A services were scheduled to be discontinued for 2 of 3 residents reviewed (Resident #11, and #15). The facility reported a census of 43 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #11 had a Brief Interview for Mental Status (BIMS) score that should not be completed by the resident and needed to be completed by the staff. Cognitive patterns identified by the staff included memory problems for short and long term memory, inability to normally recall the season, location of bedroom, staff names and faces, and residing in a nursing home. The document further revealed severely impaired cognitive skills for daily decision making, inattention and disorganized thinking that was continuously present and did not fluctuate. The MDS revealed the resident had diagnoses 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 Electronic Health Records (EHR) review, observations, resident interview and staff interview the facility failed to provide the residents with a comfortable homelike environment by leaving feces and urine in a commode without being emptied for at least 8 hours for 1 of 19 residents (Resident #20) reviewed. The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #20 documented a Brief Interview of Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. Review of Resident #20's EHR documented Resident #20 resided in room [ROOM NUMBER]-A by herself. On 2/3/25 at 4:02 PM entered room [ROOM NUMBER] and observed a commode full of urine and toilet paper with the toilet taped shut. Strong odor of urine noted when entered room [ROOM NUMBER]. On 2/5/25 at 11:05 AM entered room [ROOM NUMBER] and noted a strong smell of urine and feces. A commode in the bathroom was about 1/4 full of urine, feces and toilet paper. On 2/5/25 at 11:07 AM…

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 interview, facility document review and the facility policy review, the facility failed to thoroughly investigate, prevent further potential abuse or mistreatment and report all results of allegations of abuse to the State Survey Agency within 5 working days of the incident for 1 of 6 residents reviewed (Resident #15). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) for Resident #15 dated 1/16/25 documented a Brief Interview of Mental Status (BIMS) score of 06 indicating severe cognitive decline. The MDS reflected Resident #15 diagnoses of non-Alzheimer's dementia, hemiplegia (paralysis on one side of the body), seizure disorder, and ataxia following cerebral infarction (poor muscle coordination and balance after a stroke). The MDS further documented Resident #15 required total dependence on staff for performing activities of daily living. The Progress Note for Resident #15 documented on 1/10/24 at 8:49 am a concern about a staff member holding resident's hands down and forcing medications. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the MDS by not accurately assessing the use of insulin and antianxiety medication for 1 of 10 residents reviewed (Resident #2). The facility reported a census of 43 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 documented a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. Review of Resident #2's MDS dated [DATE] documented use of insulin therapy by Resident #2. Review of Resident #2's Medication Administration Record (MAR) documented a physician's order for Ozempic 0.25 mg once a day every 7 days. Review of Resident #2's MAR documented no physician order for insulin. On 2/4/25 at 9:11 AM Staff P, Licensed Practical Nurse (LPN)/MDS Coordinator stated she had worked at the facility. Staff P acknowledged the Ozempic was identified as an insulin on 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, staff interview, and policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 1 residents (Resident #3), who was diagnosed with new mental disorder diagnoses since admission to the facility. The facility reported a census of 43 residents. Findings include: Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive deficit. The MDS further revealed diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder, and Post Traumatic Stress Disorder (PTSD). The document indicated the resident took antipsychotic and antidepressant medications. Review of a facility provided document titled, The Preadmission Screening and Resident Review (PASRR) Level I Screen Outcome, dated 6/14/22 revealed a summary of findings indicating that Resident #3 that did not show evidence of a serious mental illness or an intellectual or developmental disability (IDD)…

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 document review, staff interview, and facility policy review the facility failed to update care plans in a timely manner to reflect the resident's condition for 3 of 5 residents (Resident #19, #23, and #33) reviewed. The facility reported a census of 43 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #19 documented a significant change in status and hospice care program. Review of Resident #19's Care Plan lacked significant change to include hospice care or end of life care and interventions. In an interview on 2/6/25 at 3:05 pm the Director of Nursing (DON) stated her expectation was that Resident #19's Care Plan would have been updated at the time to reflect hospice services. 2. The MDS for Resident #23 dated 11/25/24 identified a BIMS score of 12/15 indicating a moderate cognitive impairment. The MDS included diagnoses of hypertension, cerebrovascular accident, paraplegia, diabetes mellitus, and personal history of other venous thrombosis and embolism. It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, family interview and staff interviews, the facility failed to enter physician's orders into the electronic health record (EHR) and follow physician orders for a resident with an order to wear a mitt/glove for 1 of 8 residents (Resident #22) reviewed. The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #22 documented a Brief Interview for Mental Status score as rarely/never understood indicating severe cognitive impairment. The MDS also documented use of a gastrostomy tube. On 2/3/25 at 1:20 PM Resident #22's mother stated she brought Resident #22 mitts but the facility told her that the mitt was seen as a restraint. Resident #22's mother stated Resident #22 never had the mitt on when she came to the facility. Resident #22's mother stated she bought Resident #22 three pairs of mitts. Review of the document dated 10/30/24 titled Physician's Order documented to place a mitt/glove on the right hand daily. Remove 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, family interview, staff interviews and facility protocol review the facility failed to provide quality of nursing care by not completing an assessment related to the use of a restraint that was ordered by the physician for 1 of 3 residents reviewed (resident #22). The facility reported a census of 43 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #22 documented a Brief Interview for Mental Status score as rarely/never understood indicating severe cognitive impairment. The MDS also documented use of a gastrostomy tube. On 2/3/25 at 1:20 PM Resident #22's mother stated she brought Resident #22 mitts but the facility told her that the mitt was seen as a restraint. Resident #22's mother stated Resident #22 never had the mitt on when she came to the facility. Resident #22's mother stated she bought Resident #22 three pairs of mitts. Review of the document dated 10/30/24 titled Physician's Order documented to place a mitt/glove on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, pharmacy documentation review and facility policy review, the facility failed to ensure all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions. The facility reported a census of 43 residents. Findings include: 1. During a medication administration observation on 2/5/25 at 7:21 am, Staff B, Registered Nurse (RN) verified a medication against the Medication Administration Record (MAR) for a resident on hall 100. The MAR order directed the medication of insulin injection of 20 units. The insulin pen labeled with the resident's name and read 12 units of insulin to be injected. When asked to verify if the MAR and the insulin pen labels matched, Staff B, RN, stated they don't look at the labels, only in the MAR and she was surprised the label was still attached to the insulin pen because they often just fall off. She didn't read the label prior to…

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

Based on clinical record review, staff and primary care provider (PCP) interviews, and policy review the facility failed to notify 1 of 3 resident's (Resident #1) PCP of the resident refusing his newly scheduled breathing treatments. The facility reported a census of 39 resident. Findings include: According to the quarterly Minimum Data (MDS) assessment tool with a reference date of 5/12/24 Resident #1 had severely impaired cognitive skills for daily decision making. The MDS listed the following diagnoses for Resident #1: cerebral infarction, atrial fibrillation, pneumonia, stroke, dementia, seizure disorder, anxiety, depression and gastrostomy status. The Care Plan focus area with a revision date of 11/21/23 documented Resident #1 had altered respiratory status/difficulty breathing related to wheezing. The Care Plan directed staff to administer medications/puffers as ordered, monitor for effectiveness and side effects. The following Progress Notes were documented: a) 5/16/24 at 3:00 PM resident returned from PCP office with new order for nebulizer treatments scheduled three times a…

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

Based on clinical record review, physician and staff interviews and policy review the facility failed to have 1 of 1 resident (Resident #1) PEG tube replaced when it was found to be leaking. The facility also failed to receive a physician's order to administer Resident #1's medications and feedings via Foley catheter. The facility reported a census of 39 residents. Findings include: According to the quarterly Minimum Data (MDS) assessment tool with a reference date of 5/12/24 Resident #1 had severely impaired cognitive skills for daily decision making. The MDS documented he had a feeding tube while a resident. The MDS listed the following diagnoses for Resident #1: cerebral infarction, atrial fibrillation, pneumonia, stroke, dementia, seizure disorder, anxiety, depression and gastrostomy status. The Care Plan focus area with a revision date of 6/16/21 documented Resident #1 has a swallowing problem related to swallowing assessment results. The Care Plan focus area with a revision date of 11/21/23 documented Resident #1 required tube feeding due to dysphagia and swallowing problems.…

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

Based on facility policy review and staff interviews the facility failed to maintain an infection prevention and control program that was reviewed annually. The facility reported a census of 42 residents. Findings incude: Review of the facility provided document titled, Infection Prevention and Control Standard Precautions, revealed the last revision date was completed 1/24/23. On 4/3/24 at 11:45 AM the Director of Nursing/Infection Preventionist (DON/IP), Registered Nurse (RN), stated there was an infection control policy, but was unsure if it had been reviewed and signed by the Medical Director. The DON/IP stated the facility had not had their first Quality Assurance & Performance Improvement (QAPI) meeting of the year with the Medical Director present. The DON/IP stated would look for a signature page for the policy. On 4/3/24 at 3:35 PM the Administrator confirmed the Infection Control Policy should be reviewed annually, and the facility did not have a signature page acknowledging the review of the Infection Control Policy within the past year.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review, and guidance from the Resident Assessment Instrument (RAI), the facility failed to document the Minimum Data Set (MDS) Assessment to accurately reflect the status of 2 of 16 residents reviewed (Residents #25, #1). The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment of Resident #25, dated 2/23/24 identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The resident had diagnoses of frontotemporal neurocognitive disorder, chronic nephritic syndrome with unspecified morphologic changes, diabetes mellitus with diabetic chronic kidney disease, and unilateral primary osteoarthritis, right knee. The assessment section entitled Functional Abilities and Goals (GG) revealed Resident #25 required supervision/touching assistance for toileting hygiene, putting on/taking off footwear, partial moderate assistance for shower/bathing, lower body dressing. Sit to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Pre-admission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #10) reviewed for PASRR requirements. The facility reported a census of 42 residents. Findings include: Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS further revealed diagnosis of anxiety disorder, depression, and bipolar disorder. Review of a facility provided document titled, PASRR Notice of Nursing Facility Approval, dated 12/10/12 revealed a summary of findings indicating that Resident #10 did not meet the criteria for intellectual disability, but did…

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, clinical record review, and policy reviews the facility failed to review and revise the care plan to include a goal for 1 of 16 residents reviewed (Resident #25). The facility reported a census of 42 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #25 scored 7 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident had diagnoses of frontotemporal neurocognitive disorder, chronic nephritic syndrome with unspecified morphologic changes, diabetes mellitus with diabetic chronic kidney disease, and unilateral primary osteoarthritis, right knee. The assessment section entitled Functional Abilities and Goals (GG) revealed Resident #25 required supervision/touching assistance for toileting hygiene, putting on/taking off footwear, partial moderate assistance for shower/bathing, and lower body dressing. Sit to stand, chair<>bed transfers documented as set up or clean-up assistance.…

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

Based on observation, clinical record review, staff interview and facility policy review, the facility failed to ensure residents who were reliant on enteral feed nutrition received tube feeding per physician orders for 1 of 2 residents reviewed for tube feeding (Resident #20). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) of Resident #20, dated 3/7/24, documented diagnoses to include gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) . The MDS recorded the resident received 51% or greater of total calories through tube feeding and 501 cc/day (cubic centimeters per day) or more fluid intake per tube feeding. The Care Plan of Resident #20 reflected a focus area of tube feeding due to a swallowing problem. On 4/2/24 at 3:20 pm, observation of tube feed by Staff G, Registered Nurse (RN) began. After performing hand hygiene and donning gloves, Staff G, RN, performed oral cares for Resident #20. She then opened a dresser drawer and removed a 237 milliliter(ml) box of Jevity…

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

Based on observation, clinical record review, staff interview and facility policy review, the facility failed to prevent a significant medication error for 1 of 3 (Resident #5) residents observed for medication pass. The facility reported a census of 42 residents. Findings include: On 4/3/24 at 7:55 am continuous observation of medication pass began with Staff F, Licensed Practical Nurse (LPN). Staff F opened a drawer of the medication cart and removed several cards of medication for Resident #5 and began dispensing the medication into a medication cup. Staff F then replaced the medication cards into the medication cart and locked the cart and administered the medication to Resident #5. Staff F, LPN not observed to check the medication cards against the Medication Administration Record (MAR) prior to administering the medications. The State Surveyor recorded each medication given during the observation which included 200 mg of Amiodarone, an anti arrhythmic medication (a medication to treat heart rhythm problems). Following the observation of the medication pass, the list 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 clinical record review, staff interview, and facility policy/protocol review the facility failed to document for 1 of 5 residents (#7) that the resident either received the influenza immunization or did not receive the immunization due to medical contraindications. The facility reported a census of 42 residents. Findings include: Record review of Resident #7's Immunizations in the Electronic Health Record (EHR) on 4/3/24 lacked documentation if the influenza vaccine received or not given due to medical contraindications. Progress note in the EHR dated 10/31/23 by Staff D, Minimal Data Set (MDS) Coordinator, revealed Resident #7's Power of Attorney (POA) provided verbal consent for the influenza vaccine during the facility's clinic on 11/2/23. On 4/3/24 at 11:45 AM the Director of Nursing/Infection Preventionist (DON/IP) stated Resident #7 did not receive the influenza vaccine on 11/2/24 as the resident had Covid and the vaccine was contraindicated at the time. The DON/IP stated the resident did receive the vaccine at a later date at the physician's office. The DON/IP…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and policy review the facility failed to meet a resident's need related to adequately planned transfer for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 42 residents. Findings include: Resident #4's admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 7 out of 15 indicating mild cognitive impairment. The MDS documented he had physical behaviors for 1 to 3 days during the review period. Resident #4 would significantly intrude on the privacy or activities of others and disrupt care or the living environment. Resident #4 rejected care 1 to 3 days during the review period. He required limited assistance of staff for bed mobility, transfers and toilet use. He utilized a walker and wheelchair for mobility. The MDS documented the following diagnoses for the resident: Parkinson's disease, urinary tract infection, (UTI), thyroid disease, arthritis, depression, and alcohol abuse.…

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.