Zearing Health Care, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility investigation file, observation, staff interviews, and facility policy review, the facility failed to have two staff members present when narcotic medications were destroyed for 4 of 4 residents reviewed for controlled substance use (Resident #1, #2, #3, #4). Additionally, the facility failed to remove expired medications from the medication cart in a timely manner (Resident #3 and Resident #4) and have a system in place to adequately dispense and reconcile controlled drugs (Resident #1 and #6). The facility reported a census of 34 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #1 functioned independently with bed mobility, transfers, and ambulation. The MDS included diagnoses of Huntington's disease (neurodegenerative disorder). The MDS documented Resident #1 received opioid medication during the last 7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, resident interview and policy review, the facility failed to complete and document appropriate assessments and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being for 1 of 3 residents reviewed (Resident #7) for skin. The facility reported a census of 34 residents.Findings include:Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #7 required partial/moderate assistance with putting on/taking off footwear and was independent with transfers/ambulation. The MDS included diagnoses of diabetes mellitus with diabetic nephropathy (kidney damage caused by poorly controlled diabetes). The Care Plan with a target date 9/7/26 revealed Resident #7 had diabetes mellitus. The care plan directed staff to monitor, document, and report to Physician as needed for signs/symptoms 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 interview, physician interview and policy review, the facility failed to obtain a follow up urinalysis (UA) after completion of an antibiotic for a urinary tract infection (UTI) as ordered by the Physician for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 34 residents.Findings include: Resident #5's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS identified Resident #5 was dependent on staff with transfers to the toilet and toileting hygiene. The MDS documented Resident #5 was always incontinent of bowel and bladder. Resident #5's MDS included diagnoses of Huntington's disease (neurodegenerative disorder) and non-Alzheimer's dementia. The Care Plan with a target date 6/18/26 lacked documentation regarding Resident #5's urinary incontinence or risk for UTIs. The Progress Note dated 3/20/26 documented a new order was received 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 obtain informed consent for psychotropic medications that have black box warnings (the most serious safety warning the Food and Drug Administration (FDA) uses and requires the healthcare provider to have a comprehensive discussion with the resident/representative about the risks, benefits and alternatives for use) for 5 of 5 resident reviewed for psychotropic medications (Resident #1, #2, #3, #4 and #10). The facility reported a census of 31 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS included diagnoses of depression and cerebral palsy (disorder affecting movement, posture, and coordination due to non-progressive damage to the developing brain). Resident #1 received an antidepressant and benzodiazepine (2 types of psychotropic drugs that are used to manage various mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and policy review the facility failed to develop a comprehensive, person-centered Care Plan for 3 of 4 residents reviewed for falls (Residents #2, #10 and #29). Staff members reported each resident had a history of putting themselves on the floor, but their Care Plans didn't reflect the behavior. The facility reported a census of 31.Findings include: In an interview on 1/21/26 at 3:15 PM with Staff A, Registered Nurse (RN), and the Assistant Director of Nursing (ADON), Staff A stated Resident #2 tries to get out of bed, so they have a mattress and pads on the floor. Staff A added its Care Planned as she is compulsive and gets agitated. She said Resident #10 rolls herself out of bed when she wants up as she does not use the call light. The ADON stated if she rolled out 2-3 times, they would get her up as she probably wanted up. Resident #29 is noncompliant with lots of things and is known to put himself on the floor.In an interview on 1/22/26 at 9:40…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 kitchen service observations, interviews and record review, the facility failed to use gloves correctly to prevent cross contamination. The facility's kitchen staff applied gloves and left them on while touching food and nonfood items. The facility reported a census of 31 residents. Findings include:On 1/20/26 at 11:00 PM, observed the staff puree food. The Dietary Manager (DM) donned (applied) gloves to both hands. After donning gloves she touched the ladle, the pan containing the rolls, placed 6, 6-ounce servings of soup in a container. With the same gloves on, she added 6 rolls, then dumped the contents of the container into a food processor and pureed the food. The DM grabbed the package of bread with the same gloved hands, opened it, and grabbed the 3 pieces of bread out. With the same gloved hands, she tore up the bread, placed them in the food processer and pureed the contents more. The DM poured the soup back into the pan and put the pan in the oven to heat up more. Without changing her gloves or completing hand hygiene, the DM grabbed plates and bowls before…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review, resident, and staff interviews, the facility failed to treat residents with dignity and respect while assisting with their activities of daily living (ADL) for 2 of 5 residents reviewed (Residents #1 and #2). The facility reported a census of 32 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 3/14/22. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required supervision or touching assistance with eating and substantial/maximal assistance with mobility. The MDS included diagnoses of Huntington's disease and non-Alzheimer's dementia.The Care Plan Focus revised 8/6/25 reflected Resident #1 had a potential nutritional problem related to swallowing issues. The Interventions instructed the following:a. Resident #1 needed a calm, quiet setting at meals with adequate time to eat.b. She used curved utensils, a Kennedy cup (spill proof…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 separate residents from alleged perpetrator of verbal abuse in a timely manner for 1 of 1 resident reviewed for abuse (Resident #1). The facility reported a census of 32 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 3/14/22. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required supervision or touching assistance with eating and substantial/maximal assistance with mobility. The MDS included diagnoses of Huntington's disease and non-Alzheimer's dementia.The Care Plan Focus revised 8/6/25 reflected Resident #1 had a potential nutritional problem related to swallowing issues. The Interventions instructed the following:a. Resident #1 needed a calm, quiet setting at meals with adequate time to eat.b. She used curved utensils, a Kennedy cup (spill proof cup with handle 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 interviews, and facility policy/procedure review, the facility failed to follow the 5 rights of medication administration and physician orders to prevent a medication error from occurring. On 5/3/25, during the morning medication pass, a Registered Nurse (RN) took Resident #2's oral medications and gave them to Resident #1. The facility reported a census of 34 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] reflected they could usually make themselves understood and understood others. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The MDS listed Resident #1 as dependent in all activities of daily living (ADL). The MDS included diagnoses of non-Alzheimer's dementia and Huntington's disease. The Care Plan included Focuses of: a. Revised 2/26/20: Resident #1 has impaired cognitive function/dementia or impaired thought processes related to Huntington'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, staff interview and policy review, the facility failed to report an allegation of abuse timely for 1 of 1 residents reviewed for alleged abuse (Resident #1). The facility reported a census of 35 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. The MDS included a diagnosis of Huntington's disease (causes nerve cells in the brain to decay over time, affecting the person's movements, thinking ability, and mental health). The Care Plan Focus revised 10/27/22 described Resident #1 as a smoker, who required supervision to smoke. During an interview on 2/17/25 at 12:25 PM, Staff A, Certified Nurse Aide (CNA), reported she worked with Staff B, CNA, and Staff C, CNA, on 1/3/25. After she came in the building after she took residents out to smoke, Resident #1 came up to smoke late. Staff A reported as she assisted another resident take off her coat,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, policy review and staff timecard punch detail, the facility staff who witnessed an alleged abuse to a resident on 1/3/25 failed to report the incident to the facility administration or the Department of Inspections, Appeals, and Licensing. Due to the facility's staff failing to report the alleged abuse to the Administration, the facility Administration failed to separate the alleged abuser from the resident for 1 residents reviewed for alleged abuse (Resident #1). The Administrator reported he didn't learn of the situation until 1/10/25, allowing the alleged abuser to continue to work with Resident #1 and other residents in the facility for approximately 7 days after the incident. Please refer to deficiency F609 for additional information. The facility reported a census of 35 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. 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.