Timber Springs Transitional Care

Based on observation, staff interviews, record review, and policy review, the facility failed to ensure oxygen therapy was provided as ordered by the physician for 1 of 2 residents (Resident #29) reviewed for oxygen therapy. This failure created the potential for adverse health outcomes, including poor oxygenation and impaired concentration, when Resident #29 was not receiving oxygen therapy as prescribed. Findings include:Resident #29 was admitted the facility on 7/15/25, with multiple diagnoses including chronic respiratory failure, respiratory disorder, and cognitive impairment.Resident #29's care plan, initiated 7/16/25, directed staff to provide oxygen as ordered.A physician order, dated 7/15/25, documented oxygen at 5 liters via nasal cannula continuously.A subsequent physician order dated 8/15/25 directed staff to wean oxygen therapy for oxygen saturation levels over 94%, and to administer 1-3 liters per minute via nasal cannula as needed to maintain oxygen saturation between 88-93%.On 9/10/25 at 9:03 AM, during a medication administration observation, Resident #29 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to ensure the Medical Director and Director of Nursing Services acted upon pharmacist recommendations for 1 of 5 residents (Resident #90) reviewed for unnecessary medications. This failure created the potential for adverse effects and for residents to continue receiving medications without clinical justification. Findings include:The facility's policy titled Medication Drug Regimen Review, revised December 2023, documented that a medication regimen review (MRR) includes a review of the resident's medical chart. Identified irregularities are to be documented on a separate written report that includes the resident's name, the relevant drug, and the irregularity identified. The report is to be sent to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) to be acted upon.Resident #90 was admitted to the facility on [DATE], with multiple diagnoses including dementia, need for assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, the facility failed to ensure that residents were free from significant medication errors for 1 of 5 residents (Resident #50) observed during medication administration. This failure created the potential for harm when RN #3 did not assess Resident #50's apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) prior to administering digoxin, a medication known to affect heart rate. Findings include:Resident #50 was readmitted to the facility on [DATE], with multiple diagnoses including cerebral infarction affecting the right dominant side, hypertension, and atrial fibrillation. A physician order, dated 3/14/25, documented digoxin 125 micrograms orally each morning for atrial fibrillation, with instructions to notify the provider for a heart rate less than 40 beats per minute. According to the Nursing Unbound Medicine website, accessed on 9/16/25, digoxin increases cardiac output and slows heart rate. The recommended assessment…

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 representative interview, record review, and staff interview it was determined the facility failed to ensure residents obtained routine and emergency dental care to 1 of 1 resident (Resident #68) reviewed for timely dental care. This deficient practice created the potential for harm if the resident's nutritional status was altered or if she developed an infection related to dental damage. Findings include: Resident #68 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including cellulitis of the left lower leg, diabetes, COPD, lack of coordination, delusional disorders, depression, and anxiety. A quarterly MDS Assessment, dated 7/24/25, documented Resident #68 was cognitively impaired. Resident #68's care plan, initiated 11/13/24, and updated on 3/12/25 alerted staff Resident #68 did not have teeth, would not wear dentures, and could be at nutritional risk related to additional diagnoses of diabetes and COPD. Resident #68's care plan, initiated on 7/1/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined the facility failed to ensure resident's received hydration beverages during dining. This was true for 1 of 18 residents (Resident #3) observed coughing without a hydration beverage. This deficient practice created the potential for harm if hydration was not provided during meals. Findings include: Resident #3 was readmitted on [DATE], with multiple diagnoses including atrial fibrillation, coronary artery disease, hypertension, renal insufficiency, and hyperlipidemia. On 9/8/25 at 12:00 PM, it was observed in the second-floor dining room Resident #3 was seated at a table with Resident #85. Resident #3 did not have beverages at her dining area; whereas Resident #85 had two beverages in front of him. On 9/8/25 at 12:30 PM, Resident #3 was observed coughing at her table while eating her lunch. The Dietary Manager (DM) asked Resident #3 if she was okay, she requested ice tea, which after drinking, her coughing stopped. On 9/8/25 at 12:45 PM, the DM stated…

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

Based on observation, record review, staff interview, and the Food and Drug Administration (FDA) Food Code, it was determined the facility failed to ensure: a) ice machines and pans were cleaned and sanitized, b) appropriate glove use was followed by employees, and c) stored food and spices were not expired. This was true for 98 resident's who consumed food stored and prepared by the facility. This deficient practice placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section 2-301.14 When to Wash documented food employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and before donning gloves to initiate a task that involves working with food.On 9/11/25 between 11:38 AM and 12:20 PM, multiple observations were made during tray line when Dietary Aide #1 did not wash his hands between changing tasks of using his bare hands to serve resident food with ladles and then donning gloves 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 review of the Division of Occupational Licenses database, facility personnel records, staffing schedules, and staff interviews it was determined the facility failed to ensure all registered nurses were working with a valid nursing license. This deficient practice had the potential to significantly harm residents if licensed nurses did not have the knowledge, competencies, and skill sets to provide care and respond to resident's needs. Findings include:On [DATE], a review of the Division of Occupational Licenses database documented RN #1's professional license had expired on [DATE].On [DATE], a review of the nurse staffing schedule documented RN #1 worked at the facility, performing licensed nursing duties on the following dates:[DATE]/[DATE]/[DATE]/[DATE]/25On [DATE] at 1:00 PM, the DON stated he found out RN #1's license was expired on [DATE] and reassigned her to do a 1:1 observation on a resident. The DON confirmed RN #1 worked 6 shifts before re-assigning her to the 1:1 observation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and review of the Left Ventricular Assist Device (LVAD) Management Manual, the facility failed to implement appropriate infection prevention and control practices during medication administration, medication storage, and a sterile dressing change for 2 of 2 residents (#2 and #50) reviewed for infection control. This failure created the potential for cross-contamination, infection, and life-threatening complications. Findings include: 1.On 9/10/25 at 8:25 AM, during a medication administration observation, RN #3 was preparing medications when a tablet fell from the medication cup onto the top surface of the medication cart. RN #3 donned a glove, picked up the tablet from the cart surface, and returned it to the medication cup. She continued preparing and administering medications to Resident #50.On 9/10/25 at 8:45 AM, RN #3 stated that cross-contamination may have occurred when the tablet contacted the cart surface. She reported sanitizing the cart at the beginning of 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 and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 63 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section 2-301.14 states food employees shall clean their hands and exposed portions of their arms as specified under paragraph 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; E) After handling soiled equipment or utensils; (F) During food preparation,…

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 policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an advanced directive. This was true for 6 of 16 residents (#12, #24, #42, #50, #54, and #55) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning. Findings include: The State Operations Manual, Appendix PP, defined an advance directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician Orders for Life-Sustaining Treatment (or POLST [POST]) paradigm form is a form designed to improve patient care by creating a portable medical order…

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, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a safe, clean, homelike environment. This was true for all 63 residents who resided in the facility whose environment was observed. This deficient practice created the potential for harm if: a) residents were embarrassed by dirty equipment and/or felt the lack of cleanliness in the facility was unacceptable, disrespectful, or undignified, and b) cross-contamination from spread of microorganisms. Findings include: The facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised September 2022, documented resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. The following was observed: - On 6/24/24 at 2:33 PM, the stand aide (a lifting device used to assist residents who 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure and liver disease. A progress note, dated 1/3/24 at 7:52 PM, documented Resident #42 had a change in condition: shortness of breath. A physician's order, dated 1/3/24, documented to send Resident #42 to the emergency room for evaluation and treatment. A Transfer form Document Checklist, dated 1/3/24 at 7:47 PM, was not completed. Resident #42's record did not include documentation pertinent medical information was provided to the receiving hospital. On 6/27/24 11:28 AM, the DON stated the resident's orders, resident profile, POST, DPOA (Durable Power of Attorney) forms, E-INTERACT form, progress note, any labs or x-rays are sent to the hospital with the resident. Two copies of these forms are made and sent with the resident. One copy is for the EMT (Emergency Medical Technician) and one for the hospital staff. A progress note is put in and it should include what was sent with the resident to the…

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

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and dated; this was true for 1 of 2 medication storage rooms and 1 of 2 medication carts inspected. This failure created the potential for residents to receive expired medications with decreased efficacy. Findings include: The facility's Medication Labeling and Storage policy, revised 2/2023, documented labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 1. On 6/26/24 at 9:17 AM, the facility's first floor medication storage room was inspected with LPN #1 present. The following medications were expired: * One bottle of Aspirin, expired 3/2024. * Three bottles of Saw Palmetto supplement, expired 3/2024. * One box of acetaminophen suppositories, expired 12/2022. On 6/26/24 at 7:58 AM, LPN #1 stated she was not sure whose job it was to check the medication room for expired medication. She also stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and resident and staff interview, it was determined the facility failed to maintain or enhance residents' dignity during dining when residents seated at the same table were served their meals at different times. This was true for 1 of 2 residents (Resident #5) observed during dining in the facility. This failure had the potential to cause a decrease in resident's sense of self worth and psychosocial wellbeing. Findings include: Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including anxiety, depression, and paraplegia (paralysis of the legs and lower body, typically caused by spinal cord injury). On 6/24/24 at 12:30 PM, Resident #5 and Resident #23 were seated across from each other at a table in the main dining room. Resident #23 was served her meal and started eating. Resident #5 did not receive his meal tray. He was quiet as he observed Resident #23 while she ate her meal. Resident #5 was also observed looking at the other residents seated at the table next…

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 resident and staff interview, it was determined the facility failed to ensure the physician was notified of resident weight changes as ordered. This was true for 2 of 6 residents (#12 and #48) reviewed for timely physician notification. This placed Resident #12 and Resident #48 at risk of experiencing complications related to unexpected weight changes. Findings include: 1. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including end-stage renal disease (the stage of renal impairment that appears irreversible and permanent, requiring a regular course of dialysis or kidney transplantation to maintain life), and type 2 diabetes mellitus. A physician's order, dated 4/1/22, stated to obtain Resident #12's weight every dayshift for CHF, notify MD if weight gain greater than 2-3 pounds in 24 hours or 5 pounds in one week. Resident #12's treatment administration record (TAR) documented his weights were not taken or recorded for the following dates: 4/2/24, 4/4/24,…

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

Based on policy review, record review, review of facility grievances, and resident and staff interview, it was determined the facility failed to ensure grievances were investigated and prompt corrective action was taken to resolve them. This was true for 1 of 1 resident (Resident #16) reviewed for grievances. This failure created the potential for psychological harm if residents' grievances were not acted upon. Findings include: The facility's Grievances/Complaints, Filing policy, revised April 2017, documented upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within (5) working days of receiving the grievance and/or complaint. Resident #16 was admitted to the facility 1/3/24, with multiple diagnoses including opioid dependence, anxiety, depression, and morbid obesity. Resident #16's quarterly MDS assessment, dated 4/10/24, documented she was cognitively intact. On 6/25/24 at 2:37 PM, Resident #16 stated that about two weeks ago, while she was watching 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, record review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 1 of 16 residents (Resident #27) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plan. Findings include: The facility's Care Plan policy, revised 2022, documented the facility was to develop ongoing assessments and revise care plans as resident's condition changed. Resident #27 was admitted to the facility on [DATE], with multiple diagnosis including heart failure and kidney disease. 1. On 6/24/24 11:12 AM, Resident #27 was observed with upper and lower dentures in her mouth. Resident #27's care plan initiated 4/19/24, did not document she had dentures. On 6/28/24 at 9:45 AM, the DON stated Resident #27's dentures were not documented in her care plan, and it should have been. 2. On 6/24/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #27 was admitted to the facility on [DATE], with multiple diagnosis including heart failure and kidney disease. A physician order, dated 4/25/24, documented Resident #27 was to have half side rails x 2 to the right and left side of his bed to enable bed mobility. On 6/28/24 at 9:10 AM, with the DON present, Resident #27's bed was observed with no half side rails. On 6/28/24 at 9:13 AM, the DON stated Resident #27 should have had half side rails on her bed and the bed half side rails should have been documented in her care plan. On 6/28/24 at 1:14 PM, LPN #2 stated Resident #27 did not have half side rails on her bed and she should have. Based on record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 2 of 16 residents (#27 and #53) reviewed for quality of care. Resident #27's physician's order to install a siderail to her bed was not followed. Resident #53's bowel medications were not administered as ordered by 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 and staff interview, it was determined the facility failed to ensure respiratory equipment was stored in a sanitary manner. This was true for 1 of 1 resident (Resident #27), reviewed for respiratory services. This created the potential for respiratory infections due to growth of pathogens (organisms that cause illness) in respiratory treatment equipment. Findings include: Resident #27 was admitted [DATE], with multiple diagnosis including heart failure and kidney disease. On 6/28/24 at 9:10 AM, in Resident #27 's room with DON present, Resident #27 's oxygen tubing and nasal cannula were observed lying on the floor. On 6/28/24 at 9:15 AM, the DON stated Resident #27 's oxygen tubing and nasal cannula should have been placed in the bag attached to the oxygen concentrator when it was removed from Resident #27.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to ensure that prior to the placement of bed rails, alternatives to bed rails were attempted, individual residents were thoroughly assessed for the risk of entrapment, and consent was in place. This was true for 2 of 3 residents (#47 and #56) reviewed for bed rails. This failure created the potential for harm due to the risk of entrapment and due to lack of opportunity for the resident and/or their representative to make an informed decision regarding the use of bed rails. Findings include: 1. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy (disorders where medical problems such as infections, organ dysfunction, or electrolyte imbalance impair brain function), end stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), and diabetes. A…

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

Based on policy review, staff interview, and record review, it was determined the facility failed to ensure the pharmacist recognized and reported medication irregularities related to PRN psychotropic medication. This was true for 1 of 5 residents (Resident #16) whose medications were reviewed. This failure created the potential for harm should residents receive medications that were unnecessary, ineffective, or used for excessive duration. Findings include: The State Operations Manual, Appendix PP, revised 02/03/23, documented PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Resident #16 was admitted to the facility 1/3/24, with multiple diagnoses including opioid dependence, anxiety, depression, and morbid obesity. Resident #16's physician's orders included the following: - Quetiapine (Seroquel - antipsychotic) Fumarate tablet 400 mg, give one tablet by mouth at bedtime for anxiety, ordered 1/3/24. - Quetiapine Fumarate 150…

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

Based on record review and staff interview, it was determined the facility failed to ensure PRN anti-psychotic medications were limited to 14 days. This was true for 1 of 5 residents (Resident #16) reviewed for unnecessary medications. This deficient practice created the potential for harm if residents receive PRN anti-psychotics medications that were unwarranted, ineffective, or used for excessive duration. Findings include: The State Operations Manual, Appendix PP, revised 02/03/23, documented PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Resident #16 was admitted to the facility 1/3/24, with multiple diagnoses including opioid dependence, anxiety, depression, and morbid obesity. Resident #16's physician's orders included the following: - Quetiapine (Seroquel - antipsychotic) Fumarate tablet 400 mg, give one tablet by mouth at bedtime for anxiety, ordered 1/3/24. - Quetiapine Fumarate 150 mg, one tablet by mouth PRN 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 record review and staff interview, it was determined the facility failed to ensure care was coordinated with a hospice provider and duties of the hospice provider and the facility were delineated. This was true for 1 of 3 residents (Resident #56) reviewed for hospice care. This failure created the potential for Resident #56 to receive inadequate care due to a lack of coordination between the facility and the hospice agency. Findings include: Resident #56 was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy (disorders where medical problems such as infections, organ dysfunction, or electrolyte imbalance impair brain function), left thigh fracture, alcohol dependence, and depression. A significant change in status MDS assessment, dated 5/17/24, documented Resident #56 received hospice services. Resident #56's care plan did not include documentation of the responsibilities or care delineated between the facility and the hospice agency. On 6/27/24 at 5:05 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, obsevation, record review, review of the Resident Council meeting minutes and staff interview, it was determined the facility failed to ensure there were sufficient numbers of staff available at all times to provide nursing and related services to meet the residents' needs and a charge nurse was identified for all shifts. This was true for 5 of 74 residents (#2, #40, #61, #62 and #69) reviewed for staffing concerns and had the potential to affect all resident in the facility. This created the the potential for physical and psychosocial harm if residents did not receive appropriate care or received a delay of care. Findings include: 1. The facility's Sufficient and Competent Nursing policy, revised 8/22, stated, A licensed nurse is designated as a charge nurse on each shift. This policy was not followed. During an interview on 5/5/23 at 10:43 AM, LPN #2 stated the staffing was sufficient on the weekends if there were no call-offs. LPN #2 stated there was no charge nurse on the…

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

Based on policy review, observations, record review, and staff interview, it was determined the facility failed to provide a well-balanced diet that met residents nutritional and special dietary needs for 21 residents (#2, #11, #22, #26, #32, #36, #37, #41, #42, #43, #45, #47, #56, #57, #58, #59, #62, #68, #70, #72, and #176) of 74 residents residing in the facility. This resulted in residents on mechanical soft diets being served more restricted foods than their diets required and the same items repeatedly, residents on cardiac diets receiving regular foods they should not have received; and residents on renal diets receiving regular diets without any modifications. Findings include: The facility's Therapeutic Diets policy, dated October 2017, stated Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific…

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, and staff and resident interview, it was determined the facility failed to ensure menus met the nutritional needs of the residents and menus were followed for 2 residents (Residents #10 and #40), approximately half of the residents who ate on the second floor (52 residents lived on the second floor), and to residents on regular diets (40 residents) of 74 residents residing in the facility. This put residents at risk of not having their nutritional needs met or being on a more restrictive diet than required. Findings include: Observations on 4/30/23 for the lunch meal, showed staff ran out of the entrée due to not following the menu and serving size for half of the residents on the second floor who received two portions of the entrée instead of a serving of the entrée and the soup. All 40 residents on regular diets were routinely served sugar free pudding, ice cream, and gelatin, contrary to the menu. Furthermore, the menus were evaluated and signed by a RD prior to numerous…

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 policy review, review of Food Committee meeting minutes, and staff interview, it was determined the facility failed to ensure concerns from the Food Committee meetings were documented and the Activity Director addressed. This deficient practice placed residents at risk of ongoing frustration and decreased sense of self-worth when their concerns were not promptly addressed by the facility. Findings include: The Resident Council policy, dated 4/2017, documented the facility would support residents' rights to organize and participate in the Resident Council. The purpose of the Resident Council was to provide a forum for: - Residents, families, and resident representatives to have input in the operation of the facility; - Discussion of concerns and suggestions for improvement; - Consensus building and communication between residents and facility staff; and - Disseminating information and gathering feedback from interested residents. This policy was not followed. On 5/4/23 at 2:17 PM, the Activity Director stated the Food Committee meetings started in 12/2022 due to residents'…

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

Based on policy review, record review, and staff interview, it was determined the facility failed to give the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage to 3 of 3 residents (Residents #58, #66, and #178) reviewed who were admitted to the facility with Medicare coverage. Findings include: The facility's policy, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, stated the facility was to issue form CMS-10055 to the resident when the facility believed the resident would no longer be eligible for Medicare covered services. This policy was not followed. Residents #58, #66, and #178 were not provided with form CMS-10055 when discharge from the facility was anticipated, as follows: a. Resident #58 was admitted to the facility for Medicare Part A services on 11/23/22 and discharged on 2/3/23. Resident #58 received Physical Therapy services while at the facility. The facility failed to provide evidence CMS Form-10055 was given to Resident #58. b. Resident #66 was admitted to the facility for Medicare Part A services on 1/10/23 and discharged on 4/7/23.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, record review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as needed. This was true for 4 of 26 residents (#10, #18, #19, #61, and #329) whose care plans were reviewed. This created the potential for harm if care and/or services were not provided appropriately due to inaccurate information in the care plan. Findings include: The facility's Care Plan policy, revised 2022, documented the facility was to develop ongoing assessments and revise care plans as residents' condition changed. This policy was not followed. 1. Resident #329 was admitted to the facility on [DATE], with multiple diagnoses including right femur fracture and dementia. Resident #329 required assistance with personal care. a. A weekly head-to-toe skin check assessment, dated 9/6/21, documented Resident #329 developed nine new skin issues, as follows: - Right elbow: red. - Left elbow: red. - Coccyx (Tailbone): eschar (dead skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including lymphedema (a condition that results in swelling of the leg or arm due to blockage in the lymphatic system which is part of the immune system), Parkinson's disease ( disorder of the central nervous system that affects movement), hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), and dysarthria (difficulty speaking) following a stroke. A physician order, dated 11/29/19, directed staff to provide her nail care every Monday night. On 5/1/23 at 9:18 AM, Resident #19's representative stated Resident #19's fingernails on her left hand were too long and asked the staff to trim them. Resident #19's fingernails on her left hand were observed on 4/30/23 at 3:36 PM, 5/1/23 at 9:22 AM, and 5/2/23 at 9:01 AM. Resident #19's left hand was closed in a fist, her left thumb was bent over her four fingers. Resident #19's thumb, ring finger and little fingernails were long,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The Neurological Assessment policy, dated 2018, documented neurological assessments were indicated as follows: - Upon physician order; - Following an unwitnessed fall; - Following a fall or other accident/injury involving head trauma and - When indicated by resident's condition. The policy stated also stated, When assessing the neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures). This may be indicative of increasing intracranial pressure (ICP). Any change in vital signs or /neurological status in a previously stable resident should be reported to the physician immediately. This policy was not followed. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's Disease (a disorder of the central nervous system that affects movement), muscle weakness, dementia, bipolar disorder (a disorder that exhibits mood swings), anxiety, and history of falling.…

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 policy review, review of facility staffing and staff interview, it was determined the facility facility failed to ensure an RN was on duty for eight consecutive hours per day, seven days a week. This failure created the potential for harm if routine and/or emergency nursing needs went unmet and had the potential to affect all 74 residents living in the facility. Findings include: The facility's Staffing, Sufficient and Competent Nursing policy, revised 8/2022, stated, A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. The facility daily staffing sheets dated 1/1/22 through 6/30/22, documented there was no RN coverage on 2/5/22, 2/13/22, 2/19/22, 3/6/22, 3/27/22, 4/3/22, 4/10/22, 4/17/22, 4/24/22, 5/1/22, 5/7/22, 5/8/22, 5/15/22, 5/22/22, 6/5/22, and 6/12/22. The facility daily staffing sheets dated 10/1/22 through 12/31/22, documented there was no RN coverage on 10/1/22, 10/2/22, 10/09/22, 10/16/22, 10/10/22, 10/15/22, 10/22/22, 10/23/22, 10/29/22, 10/30/22, 11/6/22, 11/13/22, 11/20/22, 12/10/22, 12/11/22, 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 policy review, record review, and staff interview, it was determined the facility failed to ensure residents receiving psychotropic medication had resident-specific target behaviors identified and monitored. This was true for 4 of 7 residents (#10, #12, #19, and #61) reviewed for unnecessary medications. This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without clear indication of need. Findings include: The facility's Psychotropic Medication Use policy, dated 7/2022, documented residents would not receive medications that were not clinically indicated to treat a specific condition. Psychotropic medications management includes: indications for use, adequate monitoring for efficacy and adverse consequences, dose, duration and preventing, identifying and responding to adverse consequences. This policy was not followed. 1. Resident #19 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses…

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 policy review, observation, record review, and resident and staff interview, it was determined the facility failed to serve palatable food to 8 of 8 residents (Residents #7, #13, #19, #25, #30, #34, #61, and #66) who were interviewed about food temperature and taste. This had the potential to create dissatisfaction with meals and decrease residents' quality of life. Findings include: The facility's Food and Nutrition Services policy, dated 2018, stated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident .Food and nutrition services staff will inspect food trays .the food appears palatable and attractive, and it is served at a safe and appetizing temperature. The policy was not followed. 1. During the survey, resdients reported the food was not at the right temperature when it was served and the food was not consistently palatable, as follows: a. During 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 policy review, observation, record review, and resident and staff interview, it was determined the facility failed to obtain food preferences and dislikes from residents upon admission and on an ongoing basis and failed to serve preferred foods, offer choices, and provide selected foods which directly impacted 11 of 11 residents (Residents #7, #10, #19, #25, #30, #34, #38, #57, #61, #63, and #66) who were interviewed about food preferences. This had the potential to impact all residents who consumed food by mouth who resided in the facility. In addition, alternates were not always available and/or residents had to wait an extended time to receive them. These failures created the potential for dissatisfaction with meals and decreased quality of life. Findings include: The Resident Food Preferences policy, dated 2018, stated, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team .Upon the resident's admission (or within twenty-four-hour (24) hours after his/her admission) the Dietitian or nursing staff will identify a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure physician-ordered therapeutic diets were followed for 2 of 2 residents (Residents #22 and #70) whose renal diets were reviewed. This resulted in residents on renal diets receiving regular diets. Findings include: The Therapeutic Diets policy, dated October 2017, stated Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrient in the diet, or to alter the texture of a diet. This policy was not followed. 1. During an observation on 4/30/23 at 9:33 AM, dietary staff were preparing the lunch meal. The ALF DM stated the lunch menu was tomato basil soup, broccoli cheese frittata (an egg custard without a crust),…

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 policy review, observation, record review, and resident and staff interviews, it was determined the facility failed to assess whether residents had the ability to self-administer their medications for 2 of 4 residents (Residents #20 and #61) reviewed for self-administration of medications. This failure created the potential for adverse effects if medications were self administered inappropriately by the residents. Findings include: The facility's Self-Administration of Medication policy, revised 2018, stated, Residents have the right to self-administer medications/treatments if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As a part of the overall evaluation, the staff and practitioner will assess each resident's mental and physical ability to determine whether self-administering medications/treatments is clinically appropriate for the resident. This policy was not followed. 1. Resident #20 was admitted to the facility on [DATE], with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, record review, and resident and staff interview, it was determined the facility failed to ensure a resident's light switch in the room was within reach for 1 of 1 resident (Resident #61) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident experienced falls or accidents because the room was dark and not being able to sleep when the room was too bright. Findings include: Resident #61 was admitted to the facility on [DATE] with multiple diagnoses including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain) and unsteadiness on feet. A quarterly MDS assessment, dated 1/27/23, documented Resident #61 was cognitively intact. He required supervision with set-up assistance for ADLs and one-person extensive assistance for toileting. He used a walker and wheelchair and was not steady when walking and turning around. On 5/1/23 at 9:39 AM, Resident #61's room was observed to be dark and no lights…

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 3. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease (a movement disorder that affects the nervous system), muscle weakness, and history of falling. Resident #2's care plan, dated 12/8/20, documented Resident #2 was at risk for falls r/t [related to] impaired mobility, fall prior to admission resulting in left femur [thigh bone] fracture, self-transferring, impaired cognition with poor safety awareness, elimination needs, pain, and medication regimen. A nurse's note, dated 11/18/22 at 9:00 PM, stated Resident #2 had an unwitnessed fall in her room on 11/18/22 at 8:30 PM. Resident #2 was on the floor between her wheelchair and bed and sustained a cut to her head with a moderate amount of bleeding and the nurse provided wound care by placing steri-strips (adhesive skin closure strips) to the skin opening. A quarterly MDS assessment, dated 4/7/23, documented Resident #2 was severely cognitively impaired and required a one person extensive assistance 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, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a sanitary environment. This was true for 1 of 1 resident (Resident #380) reviewed for a sanitary environment. This deficiency created the potential for cross contamination from spread of microorganisms. Findings include: Resident #380 was readmitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord). The facility's Pet, Animal, and Plant policy, revised May 2017, stated animals in the facility were monitored and managed to prevent the spread of microorganisms/infections due to contact with the animals. It also stated animals were not allowed in food preparation areas, dining areas, bathrooms, or treatment areas. This policy was not followed. On 8/8/23 at 9:15 AM, Resident #380 was observed resting in bed with her cat on her lap. Resident #380's bathroom was observed with a cat litter box…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #61 was admitted to the facility on [DATE], with multiple diagnoses including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain) and unsteadiness. A quarterly MDS assessment, dated 1/27/23, documented Resident #61 was cognitively intact. On 5/1/23 at 9:32 AM, Resident #61 stated he fell about a month ago and smashed the middle of his forehead. The fall was witnessed by three staff members, and there were no vital signs were taken or any assessments performed for him. Resident #61 stated he walked back to his bed by himself after the fall. The first staff member who checked him was CNA #6 the following day. Resident #61 stated the CNA #6 asked him why he had blood all over his face. Resident #61 was observed with a small raised area in the middle of his forehead when Resident #61 mentioned and pointed to it. An I&A report, dated 3/31/23 at 7:30 PM, documented the charge nurse was preparing Resident #61's medication. The charge nurse saw Resident #61 walking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #61 was admitted to the facility on [DATE], with multiple diagnoses including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain) and unsteadiness on feet. A quarterly MDS assessment, dated 1/27/23, documented Resident #61 was cognitively intact. On 5/1/23 at 9:32 AM, Resident #61 stated he fell about a month ago and smashed the middle of his forehead. The fall was witnessed by three staff members, and there were no vital signs were taken or any assessments performed for him. Resident #61 stated he walked back to his bed by himself after the fall. The first staff member who checked him was CNA #6. The following day, Resident #61 stated the CNA #6 asked him why he had blood all over his face. Resident #61 was observed with a small raised area in the middle of his forehead when it was mentioned and pointed to. An I&A report, dated 3/31/23 at 7:30 PM, documented the charge nurse was preparing Resident #61's medication. The charge nurse saw Resident #61 walking…

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 policy review, staff interview, and record review, it was determined the facility failed to ensure information was provided to the receiving hospital for 1 of 3 residents (Resident #8) reviewed for transfer. This deficient practice had the potential to cause harm if the residents were not treated in a timely manner due to lack of information. Findings include: The facility's policy, Transfer of Discharge, Facility-Initiated, dated 10/2022, documented if a resident was transferred or discharged for any reason, the following information was to be communicated to the receiving facility or provider: - The basis for transfer or discharge, - Contact information of the practitioner(s) responsible for the care of the resident, - Resident representative information and contact information, - Advance Directive information, - All special instructions/precautions for ongoing care, and as appropriate treatments - Comprehensive care plans and goals and - All other information such as resident status, medications,…

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 interview, it was determined the facility failed to complete comprehensive assessments when residents experienced a significant change in their health and functional status. This was true for 2 of 26 residents (Residents #61 and #329) reviewed for the comprehensive assessment process. This failure had the potential for harm if facility staff did not timely recognize significant changes in residents' health status and needs. Findings include: The facility's policy, Change in Condition, revised 2018, documented if a significant change in the resident's physical or mental condition occurred, significant change in status assessment would be conducted as required by the MDS RAI Manual. A significant change of condition is a major decline or improvement in the resident's status, based on the MDS RAI manual as well as the following: - Will not resolve itself without intervention by staff or by implementing standard clinical interventions. - Impacts more than one area of the resident's 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 observation, record review, and resident and staff interview, it was determined the facility failed to ensure residents urinary care needs were met to decrease the risk of UTI. This was true for 2 of 5 residents (#3 and #10) reviewed for UTI and/or indwelling catheter. This failed practice placed residents at risk for UTI. Findings include The facility's Catheter Care policy, revised 2018, directed staff to provide catheter care to residents with a urinary catheter to prevent urinary tract infections and document the following: - The date and time the catheter care was given. - The name and title of the staff giving the catheter care. - All assessment data obtained when giving the catheter care. - Any problems noted at the catheter-urethral junction during perineal care, such as drainage, redness, bleeding, irritation, crusting, or pain. - Any problems or complaints made by the resident during catheter care. - If the resident refused the care, document the reason why and what intervention taken. This…

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, and staff interview, it was determined the facility failed to ensure nutrition and fluids were administered as ordered b y the physician for 1 of 1 resident (Resident #64) identified by the facility as receiving nutrition and fluids by tube feeding (a tube inserted through the abdomen into the stomach). This resulted in the potential for a resident to experience weight loss, poor nutritional status, and dehydration. Finding include: 1. Resident #64 was admitted to the facility on [DATE], was discharged to the hospital on 4/25/23, and readmitted to the facility on [DATE]. Resident #64's diagnoses included a stroke, dysphasia (difficulty swallowing) and aphasia (difficulty speaking). Resident #64's Care Plan documented tube feeding was to be continuous. Resident #64's physician order, dated 3/1/23, stated Resident #64 was to receive Jevity 1.5 (a dietary formula) 50 milliliters [ml]) of formula every hour by tube feeding to meet Resident #64's nutritional needs. Resident #64…

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 policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident received oxygen therapy per physician's orders. This was true for 1 of 1 (Resident #66) reviewed for respiratory care. This failure put Resident #66 at risk for oxygen toxicity (breathing oxygen at increased pressures, resulting in cell damage and death). Findings include: The facility's Oxygen Administration policy, dated 2020, stated Verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. This policy was not followed. 1. Resident #66 was admitted to the facility on [DATE], with multiple diagnoses including saddle embolus of pulmonary artery (a large blood clot in the pulmonary artery) and shortness of breath. Resident #66's quarterly MDS assessment, dated 3/2/23, documented Resident #66 was cognitively intact and required oxygen. Resident #66's physician order, dated 11/29/22, 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 document review and staff interview, the facility failed to assure a licensed pharmacist reviewed each residents' medications at least monthly, and the physician/prescriber addressed the medications irregularities identified by the pharmacist. This was true for 2 of 7 residents (#14 and #31) whose medications were reviewed. These deficient practices created the potential for harm if residents' medications were administered without a clinical rationale. Findings include: The facility's Medication Regime Reviews (MRR) policy, revised 4/2007, stated, The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions. Copies of drug/medication regimen review reports, including physician responses will be maintained as part of the permanent medical record. Routine reviews will be done monthly. This policy was not followed. 1. Resident #14 was admitted 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, policy review, and staff interview, it was determined the facility failed to ensure nutritional assessments were completed. This was true for 1 of 4 residents (Resident #380) whose records were reviewed for nutritional assessments. This failure created the potential for residents to experience malnutrition. Finding include: The facility's Nutritional Assessment policy, dated October 2017, stated nutritional assessments were completed on admission within current baseline assessment timeframes, as indicated by a change in condition, and with a comprehensive assessment. This policy was not followed. Resident #380 was readmitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord). Resident #380's care plan, revised on 4/27/23, documented the Registered Dietitian was to evaluate nutritional needs quarterly and as needed. A nutritional assessment, dated 3/24/23, did not include Resident #380's food…

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, policy review, record review, and resident and staff interview, it was determined the facility failed to ensure documentation of self-administration of medication was maintained. This was true for 1 of 3 residents (Resident #20) reviewed for self-administration of medication. This created the potential for harm if Resident #9 did not receive medications as ordered. Findings include: Resident #20 admitted to the facility on [DATE], with multiple diagnoses including Asthma (a chronic lung condition that causes breathing difficulties and inflammation of the airway). The facility's Self-Administration of Medication policy, revised 2/2021, stated the nursing staff determined who was responsible for documentation of medications. It also stated if the resident was able and willing to take responsibility for documenting self-administration of medications, the resident was instructed on how to complete a record indicating the administration of the medication. This policy was not followed. A…

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