Royal Oaks Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility failed follow proper isolation precautions for 4 of 4 residents reviewed and failed to put on (don) an isolation gown while providing catheter care and incontinence cares for Resident #11. The facility also failed to provide personal protective equipment (PPE) for two residents that required contact precautions for Parainfluenza Virus for Resident #17, and for Clostridium difficile for Resident #29. The facility additionally failed to don PPE prior to transferring Resident #27. The facility reported a census of 83 residents.1.The Minimum Data Set (MDS) Assessment tool with 1/07/26 reference date revealed Resident #27 had diagnoses that included obstructive uropathy, urinary tract infection, hemiplegia (paralysis on 1 side of the body), sepsis from unspecified organism, gross hematuria (blood in the urine) and bacteremia (infection in the blood). The assessment revealed a urinary catheter used for urination. A physician order dated 3/16/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a home-like environment for residents due to persistent pungent odors throughout 2 of the 3 nursing units (Station 1 and Station 2). The facility reported a census of 88. Findings include: During an observation on 2/4/26 at 10:45 AM, an unpleasant strong odor was noted on the Station 2 nursing unit, especially near the shower room and the environmental service door. During an observation on 2/4/26 at 11:00 AM, a strong pungent odor was detected down the Station 1 nursing unit East hallway. It became stronger as one walked further down the hall. Approximately four hours later, at 2:00 PM, the same pungent odor was still present but not as strong.During an observation on 2/5/26 at 7:50 AM, a pungent odor was noted on the Station 1 nursing unit down the East hallway. There was evidence the facility attempted to combat the odor with the use of an air freshener. At 11:00 AM on this day, Staff O, Housekeeping Director, was seen using a deodorizing machine down the Station 1 East hallway. 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, observation, staff interview and policy review, the facility failed to follow infection control measures in order to prevent the spread of infection for 2 of 3 residents who received insulin(an injectable medication used to lower blood sugar) (Resident #6 and #14). The facility failed to ensure staff did not utilize multiple dose insulin pens for more than one resident. The facility staff failed to perform hand hygiene and change gloves before, during, and after resident cares for 2 of 5 residents observed for cares (Resident #7 and #11). The facility also failed to ensure staff followed infection control practices to protect against cross contamination and potential spread of infection for 2 of 3 residents on Enhanced Barrier Precautions (EBP's) (Resident #7 and #11). The facility staff also failed to use a barrier when a catheter was emptied and failed to properly disinfect a graduate container after use for 1 of 3 residents observed for catheter care (Resident #7). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health record review (EHR), observations, staff interview, and policy review, the facility failed to supervise resident administration of medications for 1 or 4 residents reviewed for medications (Resident #4). The facility reported a census of 88.Findings include:The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 with a Brief Interview for Mental Status score of 15, indicating intact cognition. Diagnoses atrial fibrillation (irregular heart rhythm), anxiety, arthritis, depression, diabetes, edema, and high blood pressure.The Care Plan, last revised on 10/20/25, documented that Resident #4 was resistive to cares and had a history of refusing medications if they did not feel the medications were necessary. Interventions for staff include education for the resident of possible outcomes of not complying. The Care Plan lacked documentation that the resident could self-administer medications.The Medication Administration Record (MAR) directed staff to offer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the physician's orders for 1 of 4 residents reviewed (Resident #3). The facility staff failed to return a [NAME] Monitor in a timely manner to the vendor after resident use which delayed downloading and analysis of the heart monitor data, follow up with the physician, and the potential treatment required. The facility reported a census of 88 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 admitted to the facility on [DATE] from an inpatient psychiatric facility and had diagnoses of atrial fibrillation, hypertension, catatonic disorder, and major depressive disorder. The MDS revealed the resident had a Brief Interview for Mental Status score of 15 out of 15, indicating cognition intact. The Inpatient Adult Psychiatry Discharge summary dated [DATE] revealed Resident #3 admitted to the medical-psych unit for management of the severe catatonic, depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bath records, resident interviews, staff interviews and policy review, the facility failed to offer and provide resident bathing on a consistent basis for 3 of 5 resident reviewed for bathing (Resident #1, #3, and #5). The facility reported a census of 88. Findings include: Resident Council meeting minutes from 11/24/25 noted 6 residents voiced not receiving showers consistently. 1.The Annual Minimum Data Set (MDS) Assessment completed on 1/21/26 revealed Resident #5 with a Brief Interview for Mental Status (BMIS) score of 15, indicating intact cognition. Diagnoses include arthritis, chronic pain syndrome, and heart failure. The Care Plan, last updated on 1/29/26, noted Resident #5 requires staff assistance with bathing and showers. During an interview on 2/4/26 at 11:10 AM, Resident #5 reported going over two weeks in-between showers. On many occasions, a bath or shower was not offered. At one point, the resident had to ask about receiving a shower. Resident #5…

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

Based on electronic health record review (EHR), staff interviews, and policy review, the facility failed to complete and document neurological exams (neuro-checks) and skin assessments for 1 of 4 residents reviewed for assessment and intervention (Resident #2). The facility reported a census of 88. Findings include: The Significant Change Minimum Data Set (MDS) Assessment completed 10/9/25 reviewed Resident #2 with a Brief Interview for Mental Status score of 13, indicating intact cognition. Diagnoses included anxiety, aphasia (communication disorder), diabetes, heart failure, hemiplegia, and stroke. Resident #2 noted to be dependent on staff for all cares and transfers. The MDS documented two or more falls since prior assessment. Resident #2 at risk of developing pressure injuries and was reported with a diabetic foot wound and an open foot lesion. The Care Plan, last revised 10/17/25, reported Resident #2 with falls. Interventions include neuro-checks per facility policy. Due to self-care performance deficits, skin inspections are care planned. Staff directed to observe 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 clinical record review and staff interviews, the facility failed to complete follow up assessments following a fall for one of four residents (Res #18) reviewed for falls. Findings include:The Progress Note of Resident #18 dated 8/22/25 at 11:44 am, authored by Staff O, Registered Nurse noted IDT (interdisciplinary team) met to discuss fall on 8/21/25. RCA (root cause analysis) performed. Hoyer (full body mechanical lift) sling to be tucked into sides of wheelchair. Review of subsequent progress notes failed to reveal any fall follow up was completed for Resident #18. On 10/21/25 at 3:44 pm, the Director of Nursing (DON) stated no incident report could be located for Resident #18 for a fall on 8/21/25. She agreed there was no documentation in the resident record of staff having followed up with pain assessments, vital signs or neurological checks as is protocol when there is a resident fall. On 10/21/25 at 4:16 pm, Staff O, RN stated she recalled the fall on 8/21/25 was in the morning. She stated the nurse that was on duty that morning for Station 2, where Resident #18…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of facility policy, the facilty failed to maintain complete medical records in accordance with professional standards for three of four residents reviewed (Res #1, #13, #18). Findings include: The Progress Note for Resident #1 dated 2/20/25 identified a witnessed fall and indicated neurological checks were initiated. Additional Progress Notes dated through 2/23/25 referenced continued neurological monitoring.Similarly, an Incident Report for Resident #13 dated 2/19/25 reported a fall. The corresponding Nursing Note dated 2/19/25 at 12:03AM documented neurological checks were initiated at the time of the fall. On 10/20/25 at 10:58 am, the Administrator stated the facility was unable to produce the neurological check sheets for Res #1 or Res #13. She stated the neuro checks were done on pen and paper and were lost.The Progress Note of Resident #18 dated 8/22/25, authored by Staff O, Registered Nurse noted IDT (interdisciplinary team) met to discuss fall on 8/21/25. RCA (root cause analysis) performed. Hoyer (full body…

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

Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. In addition, the facility failed to maintain the kitchen in a safe and hygienic manner that promotes food safety. The facility reported a census of 84. Findings include: During the initial kitchen observation on 05/12/2025 at 07:44 AM, it was noted approximately 1-2 inches of standing water covering half of the kitchen floor, with the deepest part of the water located near the walk-in cooler and freezer. One staff member was preparing breakfast while the Dietary Manager attempted to push water down the drain to help it clear faster. The ceiling above the food prep table was hanging several inches. The tiles of the floor were uneven, cracked, and in places missing. The ceiling above the oven was also hanging, with black spots covering the area. The sink was broken and spraying water, contributing to the water pooling inside of the kitchen. The walk-in freezer had a large buildup of ice on the floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide food at an appetizing temperature to 2 of 2 residents (Residents #64, and #79) reviewed. The facility reported a census of 84 residents. Findings include: 1. Review of Resident #64's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview 5/12/25 at 1:34 PM with Resident #64 revealed that the food is constantly cold, and tastes bland. 2. Review of Resident #79's admission MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Interview 5/12/25 at 2:08 PM with Resident #79 revealed that the food is often bland in taste, and that the food is often cold when served on a room tray. Observation 5/13/25 at 12:38 PM a sample tray was obtained from the South Hallway. Temperatures were obtained with the ham temping at 120.3 degrees Fahrenheit, and the green beans temping at 119…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly protect resident information from unauthorized access. The facility reported a census of 84 residents. Findings include: On 5/12/25 at 8:21 AM, an unsecured document was observed, face-up, on a medication cart containing resident specific health information. There were no residents or visitors in the hall however, several residents on that hall were independently mobile. On 5/12/25 at 8:23 AM, Staff Y, Licensed Practical Nurse (LPN) stated the information is normally supposed to be face down but a resident called her to take his blood pressure. She turned the paper over at that time. On 5/13/25 at 8:06 AM, an unattended, open laptop was observed with multiple residents' Electronic Health Information (EHR) visible. There were several mobile residents within eyesight of the laptop. Staff FF, Registered Nurse (RN) stated he made a mistake and left the laptop open. On 5/19/25 at 11:06 AM, the Director of Nursing (DON) stated protected health information should be secured at all times. A policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. On 5/15/25 at 7:11 AM, Staff B, Registered Nurse (RN) dropped a resident's medication on a report sheet on the medication cart. She picked up the medication with ungloved hands, put it back in the resident's medication cup, took it to the resident's room, and administered it to the resident. At 7:36 AM, Staff B stated she should've had gloves on or used a spoon to prepare medications. She also stated she should've never touched the medication with her hands. On 5/19/25 at 11:06 AM, the Director of Nursing (DON) stated the staff should have discarded the pill and gotten a new pill. An undated document titled Infection Control prevention directed staff to use strict aseptic technique when changing connections, accessing catheters, given IV push medications, changing bags, handling supplies, changing dressings, flushing and starting an IV. Based on clinical record review, observation, staff interview, and policy review the facility failed to utilize Enhanced Barrier Precautions (EBP) during wound care and while…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident and staff interview, and policy review, the facility failed to provide incontinence care at the resident's request for 1 of 23 residents (Res #81). The facility reported a census of 84 residents. Findings include: On 5/12/25 at 8:27 AM, Resident #81 propelled her wheelchair in the hall up to Staff Y, Licensed Practical Nurse (LPN) and notified her that she needed help because she wet her pants. Staff Y informed Resident #81 that Staff Z, Certified Nursing Assistant (CNA) would be in to change her. Staff Y continued to administer medications to other residents. She did not call for any staff to assist the resident. The resident remained in the hall in her wheelchair. At 8:28 AM, Resident #81 told Staff Y that she still needed help because she wet her pants. Staff Y told the resident someone would be in to help her. Staff Y did not call for assistance for the resident and continued to administer medications to other residents. At 8:29 AM, Staff Y pointed to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review, the facility failed to develop a baseline care plan within 48 hours after admission for 1 of 23 residents reviewed (#60). The facility reported a census of 84 residents. Findings include: On 5/12/25 at 4:07 PM, Resident #60 stated the she took medication for chronic pain and anxiety. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. The MDS documented the resident had diagnoses including Anxiety, depression, contracture of both feet, pain in joints of right hand, unspecified osteoarthritis. It also indicted she received antianxiety, antidepressant, antipsychotic, and opioid medication within the 7-day lookback period. It further indicated the resident was admitted to the facility on [DATE]. Social Service Note dated 8/28/24 at 9:45 AM documented the following; resident transferred 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.

Based on observation, staff interviews, and clinical record review, the facility failed to follow the physician's orders for 1 of 23 residents (#66). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) for Resident #66 dated 2/24/25 revealed a Brief Interview for Mental Status (BIMS) score of 02 out of 15 which indicated severely impaired cognition. The MDS documented the resident had the diagnoses including congestive heart failure, kidney disease, Non-Alzheimer's Dementia, and a right heel pressure ulcer. The MDS indicated the resident required maximal assistance with eating oral hygiene, bathing, and upper body dressing. It also indicated she was dependent with all other aspects of Activities of Daily Living (ADLs), mobility, and transfers. The Electronic Health Record (EHR) included a Physician's Order dated 3/14/25 for Prevalon boots on at all times as tolerated except when weight bearing every shift for promote wound healing. The Care Plan with initiated date of 4/14/25 included the resident's right heel ulcer and directed staff 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, resident interviews, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 2 of 4 residents reviewed (Residents #48, and #83) requiring the use of oxygen. The facility reported a census of 84 residents. Findings include: 1. Review of Resident #48 Minimum Data Set (MDS) dated [DATE] revealed an admission date to the facility of 3/25/25 from a short-term general hospital stay. The MDS further revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Observation 5/12/25 at 3:36 PM revealed no label or date on Resident #48's oxygen tubing as to when the tubing was changed. Interview 5/12/25 at 3:36 PM with Resident #48 revealed that the oxygen tubing had not been changed since being at the facility. Review of the Electronic Healthcare Record (EHR) page titled, Physician's Orders revealed orders for oxygen tubing to be changed weekly 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 record review, staff interviews, and policy review, the facility failed to include psychotropic medication target behaviors and non-pharmacologic interventions in the Care Plan for staff for 1 of 23 residents (#60). The facility reported a census of 84 residents. Findings include On 5/12/25 at 4:07 PM, Resident #60 was stated she took medication for anxiety. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety, depression, and unspecified osteoarthritis. It also indicted she received antianxiety, antidepressant, and antipsychotic medication within the 7-day lookback period. It further indicated the resident was admitted to the facility on [DATE]. The Progress Notes included multiple documentation the resident seemed less anxious or no anxiety noted but did not include associated target behaviors. It also did not include details or…

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

Based on observation, clinical record review and staff interview, the facility failed to have a process in place for a consistent accurate count of controlled medications. This failure resulted in narcotic medications prescribed to Resident #3 becoming unaccounted for. The facility reported a census of 84 residents. Findings include: The Quarterly Minimum Data Set (MDS) of Resident #3, dated 4/17/25, documented diagnoses that included cerebral palsy, stroke, and polyneuropathy (a condition affecting multiple nerves throughout the body which can cause numbness, weakness, burning, sharp pain and muscle cramping). The MDS coded the resident received scheduled and as needed pain medications during the 5-day look back period. The MDS documented the resident was receiving opioid medications. The Care Plan of Resident #3 identified a focus area of chronic pain, revised on 4/22/22. The Care Plan identified sources of pain as cerebral palsy, neuropathy, low back pain and muscle spasms, and directed staff to administer analgesic (pain relieving) medications as per physician orders. A self…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allow residents to make their own choices (Resident #2) and treat 3 of 3 residents with dignity and respect when they spoke with two (2) residents (Res #7 and #18) and failed to knock and wait for an invitation to enter a residents room/home for 2 residents reviewed (Resident #1 and #2). The facility identified a census of 83 residents. Finding include: 1. During an interview 11.14.24 at 1:35 p.m. Res #2, identified by the facility as interviewable, indicated she had a problem with Staff B, Certified Nursing Assistant (CNA) who made her go to bed when she had not been ready and had been rough with her during direct resident cares. 2. During an interview 12.3.24 at 1:28 p.m. Resident # 7, identified as interviewable by the facility, indicated Staff B presented as rude, disrespectful or unkind. The resident further described a recent incident when she asked the staff member where her call light had been positioned. The staff member then slapped her on the belly and threw her…

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

Based on observation, staff interview, resident interview and facility policy review, the facility failed to maintain call lights in reach of 4 of 4 residents reviewed. The facility identified a census of 83 residents. Findings include: An observation 11.14.24 at 1:10 p.m. revealed the call light light/button positioned on the floor on the left side/window side of the Resident#13's bed while the resident had been positioned in bed and not in reach. An observation 11.14.24 at 1:24 p.m. revealed a pad type call light as it hung down the left side of the bed of Resident #12. The resident flagged down the surveyor and requested assistance to call his wife. As Staff A, Licensed Practical Nurse (LPN)/Nursing Supervisor/Manager ambulated down the hallway she had been informed the resident required assistance. When asked the resident where his call light had been located he reached for the positioning bar of the bed along wall side. When the call light had been pointed at on the left side of his bed/closest to the door the resident attempted to reach the device but had been unable to do so.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility record review, staff interview and facility policy review, the facility failed to provide a clean, sanitary and homelike atmosphere for the residents who resided in the facility and failed to maintain the cleanliness of resident transfer devices. The facility identified a census of 83 residents. Findings included: A photo taken 11.19.24 at 1:45 p.m. revealed a .25 cent size area of dried and hard oatmeal and other food debris on the bedside stand of Resident #3 along with dried food on the floor between the resident's bed and the wall, a brown stain consistent with a bowl movement on the wall beside the resident's bed and a long silver metal tray under the resident's bed with a large amount of a dried black substance with the appearance of dried coffee or a dried loose bowel movement with a dead bug adhered to the area. During an interview 12.4.24 at 1:25 p.m. Staff G, Licensed Practical Nurse (LPN) described resident's rooms as in disarray. During an interview 11.22.24 at 12 p.m. Staff E, Certified Nursing Assistant/Certified Medication Aide (CNA/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview and facility policy review the facility failed to properly transfer one (1) resident who required an assistive device (Resident #18), failed to provide appropriate oral cares for 2 residents reviewed (Resident #4 and #11) and failed to properly groom female resident's facial hair for 1 resident (Resident #6). The facility identified a census of 83 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) assessment form dated 11.14.24 indicated Resident #18 with diagnosis that included Non-Alzheimer's Dementia and Venous Insufficiency. The assessment indicated the resident with moderately impaired cognitive skills and as dependent on staff with transfers with an assistive lift device. A Care Plan identified Focus areas that included the resident sustained an actual fall revised 4.30.24 and required assistance with activities of daily living (ADL's) revised 11.2.23. The Interventions included the following: a. Staff education provided to have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to properly assess 2 of 3 following a fall, an injury and/or change of condition (Resident #5 and #8) and failed to follow Physician orders for 2 of 3 residents reviewed. (Resident #2 and #17 ) The facility identified a census of 83 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) form dated 8.8.24 indicated Resident #8 had diagnosis that included Non-Alzheimer's Dementia, Neurocognitive disorder with Lewy Bodies, muscle weakness, difficulty walking and unsteadiness on her feet. The assessment identified the Resident had severely impaired cognitive skills, short and long term memory deficits, dependent on staff with transfers and non-ambulatory. A Care Plan identified the resident required staff assistance with her activities of daily living (ADL's) (revised 7.5.22) and transfers due to impaired mobility and at risk for falls (revised 3.16.23). The Interventions included the following areas: a. Transferred with two (2) staff assistance and an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility pesticide invoices and staff interviews, the facility failed to provide a resident environment free of cock roaches. The facility identified a census of 83 residents. Findings include: During an interview 11.22.24 at 12 p.m. Staff E, CNA/CMA confirmed she observed cock roaches everywhere in the facility, in fact she killed a cock roach as it climbed/scattered across her medication cart that morning. The staff member observed cock roaches as they came out of resident sinks and resident rooms, up to and including a dead cock roach in the bed of Resident #20. During an interview 12.12.24 at 2:14 p.m. a family member confirmed he observed an alive cockroach on the sink in his mom's room just the other day. A photo taken 11.22.24 at 12:41 p.m. revealed multiple over 21 dead cock roaches in a trap in room of Resident #19 which is occupied by a resident with multiple cock roaches in a trap. During an observation and interview 12.3.24 at 1:50 p.m. revealed two (2) house cleaners in room of Resident #19 as they cleaned with the resident positioned in her bed.…

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

Based on clinical record review, staff interview and policy review the facility failed implement Care Plans for one (1) resident reviewed (Resident #6) The facility reported a census of 83 residents. Findings include: A Minimum Data Sent (MDS) assessment form dated 9.5.24 indicated Resident #6 as dependent on staff with personal hygiene, which included shaving. A Care Plan with a Focus area revised 11.4.24 indicated the resident required assistance with her activities of daily living (ADL's) due to Multiple Sclerosis (MS). The Interventions included the following: a. The resident preferred 1 staff assistance with personal hygiene (revised 11.4.24). An observation 12.3.24 at 2:50 p.m. revealed approximately ¼ to ½ inch long whiskers on her chin. An observation 12.3.24 at 4 p.m. revealed approximately ¼ to ½ inch long whiskers on her chin. During an interview at the same time the resident indicated she wanted them shaved and she had not liked them on her chin. Activities of Daily Living (ADL's) Supporting Policy with revised date March 2018 directed staff as follows; Residents who are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review, a facility staff member documented she performed a treatment for one (1) resident on the Treatment Administration Record (TAR) (Resident #10) when the treatment had not been performed. The facility identified a census of 83 residents. Findings include: A TAR dated 11.1.24 thru 11.30.24 for Resident #10 indicated the resident received a Physician Order dated 10.30.24 as follows: a. Ammonium Lactate Lotion 12% applied to his bilateral lower extremities (BLE) one time a day (QD) for his Xeroderma (skin condition), covered with a super absorb and non-adherent dressing over the open areas, wrap with Kerlix gauze and secured with Ace Wraps. On 11.19.24 Staff J, Licensed Practical Nurse (LPN) initialed the treatment as completed. During an observation and interview 11.20.24 at 2:14 p.m. Staff J, LPN confirmed the bandages on the resident's legs as dated 11.18.24. The staff member confirmed the Physician ordered dressing changes QD. During clinical record review and an interview on 11.20.24 at 2:43 p.m. the TAR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview the facility staff failed to maintain a locked and secured treatment cart and failed to provide appropriate nursing supervision to prevent a fall for one resident.(Resident #8). The facility identified a census of 83 residents. Findings include: On 11.21.24 at a time unknown the Interim Administrator identified 13 residents who wandered in the facility. Observations revealed the following as dated and timed: a. 11.14.24 at 1:11 p.m. a treatment cart in area of emergency crash cart across from nurse's station on the Terrace neighborhood left unlocked and unattended with no staff present. b. 11.19.24 at 12:09 p.m. observed the above treatment cart, in the same location, unlocked and unattended. c. 11.19.24 at 12:59 p.m. observed an unlocked and unattended medication cart positioned along the wall outside the nurse's station across from the emergency crash cart location on Terrace neighborhood. d. 11.20.24 at 10:04 a.m. Terrace cart B and C had been unlocked and unattended medication cart positioned along the outer wall of 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.

Based on observation, clinical record review, staff interview and facility policy review the facility failed to label liquid Morphine (narcotic) and Lorazepam (anti-anxiety medications) as expected for 3 of 3 residents reviewed. (Resident #8, #11 and #13 ) The facility identified a census of 83 residents. Findings include: During an observation and interview 11.20.24 at 10:10 a.m. revealed a plastic container in the Terrace A and B medication cart contained nine (9) unlabeled Morphine syringes as identified by Staff I, Licensed Practical Nurse (LPN) who confirmed the Nurse Managers/Supervisors drew up liquid Morphine and Lorazepam in unlabeled syringes for 2 months. During an interview 11.20.24 at 10:40 a.m., Staff A, LPN/Nurse Manager/Supervisor confirmed she pre-drew up the liquid Morphine as an estimate to how many a resident may have used in a 24 hour period of time based on the Physician orders. At 10:45 a.m. the staff member confirmed she pre-drew up Resident #13's Morphine syringes, not labeled. During an interview 11.20.24 at 10:40 p.m., the Interim Director of Nursing (DON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility record review, staff interview and facility policy review, the facility staff failed to DONN (put on) Personal Protective Equipment (PPE) while they provided direct resident cares with catheters, PICC lines and open skin treatments for 3 of 3 residents reviewed (Resident #2, #10), and failed to maintain a proper catheter tubing placement as a means to prevent infection for one (1) resident reviewed. (Resident #9) The facility identified a census of 83 residents. Findings include: 1. A photo dated 11.21.24 at 2:59 p.m. of an Enhanced Barrier Precautions sign posted on resident doors with such precautions included the following PPE directives to DONN when caring for residents: a. Gloves and gowns worn with the following high contact resident care activities: 1. Dressing, bathing/showering, transfers, linen changes, provision of hygiene, brief changes, toileting assistance, device care or use of a central line, urinary catheter, feeding tube or tracheotomy and wound care. 2. A photo…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff and resident interviews and policy review, the facility failed to provide assessment and intervention for the necessary care and services for 1 of 3 residents reviewed (Resident #1). The facility lacked assessments of the resident following a fall and an assessment prior to the resident being transferred to a higher level of care for evaluation and treatment. The facility reported a census of 77 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated the resident carried diagnoses that included: atrial fibrillation, end stage renal disease, diabetes mellitus, seizure disorder, fractured tibia and fibula, liver and kidney transplant status, and hemiplegia. Resident #1 required set-up assistance for eating, substantial assistance for bathing and personal hygiene and was dependent on staff for toileting 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 observation, clinical record review, staff and resident interview and policy review, the facility failed to provide treatment and services to promote the healing of a pressure ulcer for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 77 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented the resident admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated the resident carried diagnoses that included: atrial fibrillation, end stage renal disease, diabetes mellitus, seizure disorder, fractured tibia and fibula, liver and kidney transplant status, and hemiplegia. Resident #1 required set-up assistance for eating, substantial assistance for bathing and personal hygiene and was dependent on staff for toileting and transfers. Resident was at risk for developing a pressure ulcer, and received dialysis. The Medication and Treatment Administration Record 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, staff and resident interviews and policy review, the facility failed to provide a safe transfer for 1 of 3 residents reviewed (Resident #1). The facility failed to utilize 2 staff for a sliding board transfer as directed by the care plan resulting in a fall. The facility reported a census of 77 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated the resident carried diagnoses that included: atrial fibrillation, end stage renal disease, diabetes mellitus, seizure disorder, fractured tibia and fibula, liver and kidney transplant status, and hemiplegia. Resident #1 required set-up assistance for eating, substantial assistance for bathing and personal hygiene and was dependent on staff for toileting and transfers. The resident received antipsychotic, antidepressant, diuretic, opioid, and hypoglycemic medications and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, and facility policy review, the facility failed to follow physician orders for 2 of 3 residents reviewed for catheter order (Residents #2 and #5). The facility reported a census of 83 residents. Findings include: 1. The Quarterly Minimum Data Sheet (MDS) assessment dated [DATE] identified a BIMS score of 15 which indicated cognition intact. The MDS revealed the resident required maximum assistance of 2 for toileting hygiene and showering. The MDS revealed the resident totally dependent upon 2 person physical assistance for bed mobility and transfers. The MDS coded the presence of an indwelling catheter. The MDS reflected the resident always incontinent of bowel. The MDS documented diagnoses that included: Renal insufficiency, Neurogenic bladder, Diabetes Mellitus, Hypertension, Lymphedema, Polyosteoarthritis, Anxiety, and Depression. The MDS revealed Insulin, Antidepressant, Anticoagulant, Antibiotic, Diuretic, and Opioid. The 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 record review, resident interview, staff interview, collateral interview and policy review, the facility failed to assure each resident was treated with dignity and respect 1 of 2 residents reviewed for dignity (Resident #48). The facility reported a census of 80 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented Resident #48 had a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment. The MDS further documented the resident had diagnoses to include hip and knee replacement, cancer, multiple sclerosis and glaucoma. The Care Plan for Resident #48, with a revision date of 4/23/24, documented in the problem section the resident had a self-care deficit post-fall at home with fractured head of femur as evidenced by requiring assistance with transfers, impaired balance during transitions due to increased pain, and need for assistance with Activities of Daily Living (ADL's). In the intervention section, the resident is a one person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review and staff interview, the facility failed to ensure code status between the Iowa Physician's for Scope of Treatment (IPOST) and Care Plan were congruent for 1 of 1 residents reviewed for advanced directives (Resident #64). The facility reported a census of 80 residents. Findings include: Review of Resident #64's physician orders revealed a Do Not Resuscitate (DNR) order effective [DATE]. Review of Resident #64's IPOST form dated [DATE] revealed a DNR status. Review of Resident #64's Care Plan revised [DATE] revealed the resident and her responsible party requested a cardiopulmonary resuscitation (CPR)/full code status and the code status will be honored through the next review with a target date of [DATE]. The Care Plan directed staff to provide emergency measures as appropriate including CPR. Review of facility policy titled, Advanced Directives, revised [DATE], revealed changes or revocations of a directive may be made at any time and the care plan team will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to notify the physician of a change in a resident's nutritional status for 1 of 2 residents reviewed for nutrition and weight loss (Resident #6). The facility reported a census of 80 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) of 9, which indicatyed moderate cognitive impairment. The MDS further documented the resident had diagnoses to include medically complex conditions, renal insufficiency, osteoporosis and depression. The Care Plan for Resident #6, with an initiation date of 5/30/24, documented under the problem section resident is at risk for weight loss related to decreased appetite, with a goal the resident will weigh 160-170 pounds through the next review, with interventions to assess nutritional status quarterly and as needed, and to monitor weight and notify doctor of any significant change. Review of the electronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, collateral interview and policy review, the facility failed to report an allegation of alleged abuse to the State survey and certification agency for 1 of 1 residents reviewed for abuse (Resident #48). The alleged abuser also continued to work with residents. The facility reported a census of 80 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented Resident #48 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment. The MDS further documented the resident had diagnoses to include hip and knee replacement, cancer, multiple sclerosis and glaucoma. The Care Plan for Resident #48, with a revision date of 4/23/24, documented in the problem section the resident has a self-care deficit post-fall at home with fractured head of femur as evidenced by requiring assistance with transfers, impaired balance during transitions due to increased pain, and need for assistance with ADL's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, collateral interview and policy review, the facility failed to initiate and complete a thorough investigation of alleged abuse for 1 of 1 residents reviewed for abuse (Resident #48). The facility reported a census of 80 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented Resident #48 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment. The MDS further documented the resident had diagnoses to include hip and knee replacement, cancer, multiple sclerosis and glaucoma. The Care Plan for Resident #48, with a revision date of 4/23/24, documented in the problem section the resident has a self-care deficit post-fall at home with fractured head of femur as evidenced by requiring assistance with transfers, impaired balance during transitions due to increased pain, and need for assistance with ADL's (Activities of Daily Living). In the intervention section, the resident is a one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review the facility failed to notify the Long Term Care Ombudsman of discharge/transfer of residents as required for 1 of 3 residents reviewed who were discharged /transferred from the facility (Resident #26). The facility reported a census of 80 residents. Findings include: Review of the MDS (Minimum Data Set) assessment dated [DATE] and the facility's computer software program used for electronic medical record documentation revealed Resident #26 had discharged from the facility on 12/25/23, and hospitalized until reentered the facility on 12/29/23. The clinical record lacked documentation of notification to the LTC Ombudsman that Resident #26 had discharged to the hospital as required by federal regulation. During an interview 06/27/24 at 08:34 AM the Administrator stated the facility had not notified the Ombudsman when the resident discharged to the hospital. Review of the facility policy Transfer and Discharge, with a copyright date of 2023, 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 Based on clinical record review and staff interview, the facility failed to refer a resident (Resident #78) with a Level I Preadmission Screening and Resident Review (PASARR) with a diagnosed serious mental disorder for evaluation of a Level II PASARR at the time the diagnosis was known to the facility for 1 of 1 residents reviewed for PASARR. The facility reported a census of 80. Findings include: The Minimum Data Set (MDS) for Resident #78 dated 3/28/24 documented a Brief Interview for Mental Status (BIMS) of 6, indicating severe cognitive impairment. The MDS further documented diagnoses of acute diastolic heart failure, stage 3 chronic kidney disease, protein-calorie malnutrition, dementia, major depressive disorder and post-traumatic stress disorder (PTSD). The MDS reflected the resident was taking an antidepressant medication. The care plan dated 10/6/23 for Resident #78 documented a focus area related to resident being at risk for emotional and/or physical distress related to Post Traumatic Stress Disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident with a urostomy and urostomy bag (a surgical procedure that creates an opening in the abdomen to redirect urine away from the bladder and into a bag outside the body for collection) for 1 of 3 residents reviewed for urinary catheter (Resident #17). The facility reported a census of 80 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The MDS further documented the resident had diagnoses to include other neurological conditions, neurogenic bladder and paraplegia. The MDS documented that the resident had ostomy under the bladder and bowel section. The Care Plan for Resident #17, with a revision date of 6/5/24, documented under the problem section the resident is at risk 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, record review, resident, family, and staff interview and policy review, the facility failed to provide services that met professional standards regarding following physician orders related to flushing catheters, proper medication administration with insulin pens and allowing a resident to self-administer a cream without a physician order for 4 of 18 residents observed. (Resident #21, #40, and #61). The facility reported a census of 80 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #21 dated 5/28/24 included diagnoses of multiple sclerosis, anxiety disorder, chronic cystitis, peripheral vascular disease, major depressive disorder and chronic pain. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented the resident was dependent on staff for all activities of daily living and had a catheter. The Care Plan dated 10/12/16 with a revision date of 1/18/24 revealed a focus area 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, record review, resident interview, staff interview, and collateral interview, the facility failed to ensure a resident's environment was free from accident hazards for 1 of 1 residents reviewed for smoking (Resident #48). The facility reported a census of 80 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented Resident #48 had a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment. The MDS further documented the resident had diagnoses to include hip and knee replacement, cancer, multiple sclerosis and glaucoma. The Care Plan for Resident #48, with a revision date of 5/25/24, documented in the problem area the resident had acute delirium related to declining mental health status and instructed staff in the intervention section to engage resident in simple, structured activities that avoid overly demanding tasks, redirect and provide gentle reality orientation as required, reorient to person, place, time, 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 record review and staff interview, the facility failed to have the minimum required members present at their quarterly Quality Assurance (QA) meetings as directed by Centers for Medicare and Medicaid Services (CMS). The facility reported a census of 80 residents. Findings include: Record review reviewed revealed QA meetings were conducted on the following dates: 1. 4/20/23 2. 7/20/23 3. 9/25/23 4. 10/12/23 5. 2/16/24 6. 5/25/24 7. 6/13/24 Further record review revealed mandatory QA members were not present during the following meetings: 1. 4/20/23-No Administrator 2. 7/20/23-No Infection Preventionist 3. 9/25/23-No Infection Preventionist 4. 10/12/23- No Infection Preventionist 5. 2/16/24-No Medical Director During an interview 6/27/24 at 8:20 AM, the Administrator acknowledged all the required members were not present at the quarterly Quality Assurance meetings as expected.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, staff interview, collateral interview and policy review, the facility failed to establish policies regarding smoking, smoking areas, and smoking safety for 1 of 1 residents reviewed for smoking (Resident #48). The facility reported a census of 80 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #48 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment. The MDS further documented the resident had diagnoses to include hip and knee replacement, cancer, multiple sclerosis and glaucoma. The Care Plan for Resident #48, with a revision date of 5/25/24, documented in the problem area the resident has acute delirium related to declining mental health status and instructed staff in the intervention section to engage resident in simple, structured activities that avoid overly demanding tasks, redirect and provide gentle reality orientation as required, reorient to person, place, time, 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, clinical record review, staff interviews and facility policy review the facility failed to perform proper hand hygiene during 2 of 3 residents (Resident #4 and #5) reviewed for wound dressing and treatments. The facility also failed to ensure resident assistive devices were maintained in a manner to keep them sanitary. The facility also failed to ensure resident's toilets were cleaned, failed to ensure the resident's drainage canisters were changed in an adequate timeframe and dated when they were changed out. The facility failed to properly wash the clothes of residents with COVID-19 and residents without COVID-19 appropriately to stop the spread of COVID-19. The facility reported a census of 80 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment tool with a reference date of 12/17/23 documented Resident #4 had a Brief Interview of Mental Status (BIMS) score of 10. A BIMS score of 10 suggested mild cognitive impairment. The MDS documented she had moisture…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and cleaning schedule review the facility failed to maintain a safe and sanitary environment. The facility reported a census of 80 residents. Findings include: Observations starting on 1/24/24 at 8:01 AM revealed the following: -room [ROOM NUMBER]'s wall air unit vent, where the air is pushed out of the unit in to the resident's room, observed multiple black specks throughout the area. - room [ROOM NUMBER]'s wall air unit vent was on and set at 80 degrees Fahrenheit (F). Where the air is pushed out of the unit in to the resident's room, observed black specks throughout the area. -room [ROOM NUMBER]'s wall air unit was on and set at 70 degrees F. Where the air is pushed out of the unit in to the resident's room observed black specks through out the area. - room [ROOM NUMBER]'s wall air unit vent was on and set at 80 degrees F. Where the air is pushed out of the unit in to the resident's room, observed multiple black specks throughout the area. - room [ROOM NUMBER]'s wall…

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

Based on observations, clinical record review, resident and staff interviews the facility failed to provide catheter drainage bag covers for 3 of 4 residents (Resident #1, #11, and #15) reviewed for dignity. The facility reported a census of 80 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment tool with a reference date of 1/18/24 documented 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 had an indwelling catheter. The MDS documented the following diagnoses: neurogenic bladder, multiple sclerosis (MS), malnutrition, anxiety, and depression. The Care Plan focus area with a revision date of 1/18/24 documented Resident #1 had an indwelling suprapubic catheter with diagnoses of neurogenic bladder and urinary retention related to MS. On 1/23/24 at 1:39 PM observed Resident #1 in her motorized wheelchair throughout the facility with her catheter drainage bag attached to the front of her wheelchair, with no dignity bag to cover the drainage bag. Observed 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 interview, and facility policy review, the facility failed to ensure staff accurately recorded controlled substance medications counts, and failed to ensure proper destruction of controlled substances for 1 of 3 residents (Resident #1) reviewed for use of controlled substances. The facility also failed to ensure the facility staff documented two staff signatures to indicate they performed and witnessed the narcotic counts whenever the facility had a transition in staff for 2 of 2 medication carts reviewed. The facility reported a census of 81 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had diagnoses of non-Alzheimer's dementia, Parkinson's Disease, and renal insufficiency. The MDS documented the resident had a Brief Interview for Mental Status score of 6, indicating severely impaired cognition. The MDS indicated the resident took scheduled and PRN (as needed) opioid pain medication 4 of 7 days during the look-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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, resident and staff interviews, and facility policy review, the facility failed to develop comprehensive care plans for three of four residents reviewed (Resident #6, #7, and #9). The facility reported a census of 81 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had diagnoses of COVID-19, asthma, and sleep apnea. The MDS documented the resident used oxygen. The Care Plan revised 1/10/22 revealed the resident at risk for alteration in skin integrity and required ear cushions on his oxygen tubing at all times. The Care Plan lacked information regarding oxygen use, care, and settings. The Bedside [NAME] Report dated 11/30/23 lacked information about oxygen use or staff directives for oxygen application and care. The Order Summary Report revealed an order for supplemental oxygen 2-3 liters (L) per nasal cannula (NC) continuously started on 11/3/22. Observation revealed: a. On 11/28/23 at 9:15 AM, Resident #6 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, resident and staff interviews, and facility policy review, the facility staff failed to follow physician's orders for a treatment and dressing change performed for 1 of 3 residents reviewed for treatment and dressing changes (Resident #5). The facility also failed to follow physician's orders and ensure a resident had oxygen on when a resident was sent out of the facility to a doctor's appointment for 1 of 3 residents reviewed for oxygen use (Resident #4). The facility reported a census of 81 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had diagnoses of cerebral palsy, Parkinson's Disease, and renal disease. The MDS also revealed the resident had a surgical wound. Resident #5's Care Plan revised on 12/16/22 revealed the resident had a chronic buttock wound and impaired skin integrity related to a surgical dehiscence. Staff directives included to apply treatments per doctor's order. The Order Summary 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 record review, resident and staff interview along with the facility policy/procedure, the facility failed to follow physician orders for 1 of 3 residents reviewed for which the resident failed to receive their Parkinson's Disease medication for two days, this caused the resident to be admitted to the hospital with severe tremors.(Resident #2). The facility reported a census of 83 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #2 with diagnoses that included: Parkinson Disease, tremors, Peripheral Vascular Disease and hypertension. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 14 for which indicated no cognitive impairment. The resident was independent in activities of daily living and had the ability to be understood and understands others The Admit to Nursing Facility Order dated 4/25/2023, instructed staff to give Amantadine HCL ER (Gocovri)(Parkinson medication) 137 milligrams (mg) capsules, Take 274 mg by mouth every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 properly destroy Resident #6's narcotic (pain) medication per facility policy/procedure. The facility identified a census of 83 residents. Findings include: 1. Resident #6' s Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 00, indicating no decision making abilities and an opiod (pain medication) was used in the last 7 days of the look back period. The MDS documented the resident with frequent pain in the last 5 days of the look back period and on a numeric scale of 1-10 as a 5, (Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine) and less than 6 month life expectancy. Diagnosis include heart failure, hypertension, other fracture, cerebral palsy, anxiety and depression. An Investigation Summary for Self-Report with date of incident 6/22/23 documented, On 6/23/23, Staff A, (licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Medication Administration Records and Facility Policy reviews and staff interviews, the facility failed to develop a Comprehensive Care Plan that included measurable objectives and time frames related to resident specific concerns in regards to medications prescribed for 4 of 19 residents reviewed (Resident #6, #14, #73, and #71). The facility reported a census of 81 residents. Findings Include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #14 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including arthritis, Parkinson's disease, bipolar disorder, anxiety disorder, atrial fibrillation, and a stroke. The resident received antidepressant, hypnotic, and opioid medications. The March Medication Administration Record (MAR) documented Resident #14 received the following medications: a. Xanax (antianxiety) 0.5 milligrams (mg) 3 times a day for anxiety with a start date of 1/30/23.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Menu review, and staff interview, the facility failed to serve the appropriate portion of meat for 5 of 5 residents who received pureed meat (Resident #12, #18, #40, #51 and #52) and failed to serve the posted Menu for 4 of 4 residents who received full pureed meals (Resident #12, #18, #40 and #52). The facility reported a census of 81 residents. Findings Include: The facility's Week 3 Menu for Wednesday lunch identified the following items to be served for the meal on Wednesday, 3/29/23: a. Apple butter pork loin, 3 oz b. Stuffing, #12 scoop (2 & 2/3 oz) c. Roasted butternut squash, 4 oz Resident Diet Orders revealed 5 residents with orders for pureed texture meats and 4 residents with complete meal puree texture. During observation on 3/29/23 starting at 10:09 a.m., Staff A, [NAME] reported she was preparing six servings of pureed meat. She said four residents had a puree diet and one resident had puree meats only, and one extra serving would be prepared. After performing appropriate hand hygiene and gathering equipment and foods, Staff A placed 6 pre…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee interviews, the facility failed to properly sanitize resident dishes and utensils to prevent potential foodborne illness when the facility's dishwasher failed to heat the water to a proper temperature during the wash and rinse cycles. The facility reported a census of 81 residents. Findings Include: In the observation of meal service preparation beginning on 3/29/23 at 10:04 a.m., it was observed the dishwasher was being used to prepare for lunch service. Staff A, Cook, completed the puree process. During the puree process, she used the dishwasher multiple times to wash the measuring pitchers and the food processor bowl. When preparing for full meal service, on 3/29/23 at 10:55 a.m., the Dietary Manger reported the booster for the heat box on the dishwasher was currently broken. She further explained she was aware this was broken on 3/28/23 and that the dishwasher was continued to be used but the water was not getting as hot as it normally does. During observation of meal service for the residents on 3/29/23 at 12:43 p.m., the dining room 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide residents or their representative the appropriate written notices when they no longer qualified for Skilled Care Services covered by Medicare for 3 of 3 residents reviewed (Resident #9, #20 and #62). The facility reported a census of 81 residents. Findings Include: 1. Resident #9's Clinical Census page showed she was on Medicare A (Skilled Care) from 11/11/22 to 12/6/22. A review of Resident #9's record showed the resident's representative signed a Notice of Medicare Non-Coverage (NOMNC) indicating her Skilled Nursing Services would end 12/5/22. Resident #9's record lacked a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was presented to the resident's representative as required. 2. Resident #20's Clinical Census page showed she was on Medicare A from 2/17/23 to 3/30/23. A review of Resident #20's record showed the resident's representative signed a NOMNC indicating her Skilled Nursing Services would end 3/29/23. 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 observation, clinical record review, staff interviews and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 2 residents reviewed for nutrition (Resident #54). The facility reported a census of 81 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated cognition intact. The MDS revealed the resident required setup help from staff to eat and ate independently following set up. The MDS documented diagnoses that included: end stage renal disease (kidney failure), anemia, diabetes mellitus, hyperkalemia (high potassium) and malnutrition. The MDS identified a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS dated [DATE] for Resident #54 continued to identify a diagnosis of malnutrition and a weight loss of 5% or more in the last month or loss of 10% or…

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