Nexus at Alton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide showers to 4 of 6 residents (R2, R5, R7, R15) reviewed for Activities of Daily Living (ADL) care in a sample of 15.Findings Include:Findings Include:1.) R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has medical diagnoses of Aphasia, Hemiplegia, Weakness, Abnormal Posture, Contracture of the Right and Left Knee, Contracture of the Right and Left Ankle, and Dementia.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is rarely/never understood, has a memory problem, has an upper and lower extremity impairment on both sides, uses a wheelchair, needs supervision or touching assistance with eating, is dependent on staff for toileting hygiene, showering/bathing, personal hygiene, rolling left and right, lying to sitting on side of bed, chair/bed to chair transfers, and is always incontinent of bladder and bowel.R2's Care Plan Date Initiated 11/19/23 documents R2 has Activities of Daily Living (ADL) Self Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to implement their Abuse Prevention Policy by not reporting an injury of unknown origin for 1 (R2) of 7 residents, reviewed for abuse, neglect, and injuries of unknown origin in the sample of 15.Findings Include:R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] with medical diagnoses of Aphasia, Hemiplegia, Weakness, Abnormal Posture, Contracture of the Right and Left Knee, Contracture of the Right and Left Ankle, and Dementia.R2's Care Plan Date Initiated 11/19/13 documents R2 has a communication problem related to Cerebrovascular Accident (CVA). [NAME] is nonverbal and only able to make unintelligible sounds and is unable to communicate effectively with verbal and non-verbal gestures.R2's Care Plan Date Initiated 3/2/17 documents R2 is considered at risk for abuse/neglect due to mood cognition, weakness, behavioral/physical deficits.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is rarely/never understood, has a memory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to report an injury of unknown origin immediately to Administration for 1 (R2) of 7 residents reviewed for abuse in a sample of 15.Findings Include:R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of Aphasia, Hemiplegia, Weakness, Abnormal Posture, Contracture of the Right and Left Knee, Contracture of the Right and Left Ankle, and Dementia.R2's Care Plan Date Initiated 11/19/13 documents R2 has a communication problem related to Cerebrovascular Accident (CVA). [NAME] is nonverbal and only able to make unintelligible sounds and is unable to communicate effectively with verbal and non-verbal gestures.R2's Care Plan Date Initiated 3/2/17 documents R2 is considered at risk for abuse/neglect due to, mood cognition, weakness, behavioral/physical deficits.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is rarely/never understood, has a memory problem, has an upper and lower extremity impairment on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to supply a mechanism to alert staff that assistance is needed while residents are in their room, including a call light for 2 (R7, R12) of 6 residents in a sample of 15.Findings Include:1.) R7's Undated Face Sheet documents R7 was admitted to the facility on [DATE] with medical diagnoses of Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease, and Muscle Weakness.R7's Minimum Date Set (MDS) dated [DATE] documents R7 is cognitively intact, needs partial/moderate assistance with toileting hygiene, showering/bathing, needs supervision or touching assistance with chair/bed to chair transfers, and is occasionally incontinent of bladder.R7's Care Plan Date Initiated 1/27/26 documents Activities of Daily Living (ADL): R7 requires assist with daily care needs related to muscle weakness.On 5/26/26 at 9:21 AM R7 stated she does not have a call light in her room. R7 denied having a bell or device to use to let staff know she needs assistance. R7 stated if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and record review, the facility failed to provide an adequate supply of towels and washcloths for 4 of 6 residents (R1, R3, R5, R8) reviewed for safe/clean/comfortable/homelike environment in the sample of 9.Findings Include:On 2/18/26 at 12:09 PM, there were no towels or washcloths on the 100, 300, or 400 hall linen cart. On the 200-hall linen cart there was 1 towel and no washcloths.On 2/18/26 at 2:32 PM, the clean linen room on the 100/200 hall was inspected. There were 3 towels and 8 washcloths.On 2/18/26 at 2:35 PM, the 100-hall linen cart was inspected and did not have any towels or washcloths.On 2/18/26 at 2:37 PM, the 200-hall linen cart was inspected and did not have any towels or washcloths. On 2/18/26 at 2:45 PM, the 300-hall linen cart was inspected and had 1 washcloth and no towels. On 2/18/26 at 2:47 PM, the 300/400 hall clean linen closet was inspected and had no washcloths.On 2/18/26 at 2:49 PM, the 400-hall linen cart was inspected and did not have any towels or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to administer medications within the specified time frame for 3 of 7 residents (R7, R8, R9) observed/reviewed for medication errors in the sample of 9.Findings Include:On 2/19/26 at 11:36 AM, V11, RN (Registered Nurse), was observed administering the following medications to R7: Loratadine, Nicotine Patch, Metformin, Atorvastatin, Buspirone, Famotidine, Hydrochlorothiazide (HCTZ), Lisinopril, Seroquel, and Mometasone Fureate Inhaler.On 2/19/26 at 12:10 PM, V7 stated sometimes she gets her medications late and sometimes at night she doesn't get her medications at all. R7's Medication Administration Record (MAR), dated 2/2026, documents the following physician orders: Loratadine 10mg (milligrams) PO (by mouth) Qd (daily) at 9:00 AM; Nicotine Patch 21mcg (micrograms) transdermal every 24 hours (V11 administered a 14mcg patch and not the ordered 21mcg) at 9:00 AM; Metformin 500mg PO BID (twice daily) at 9:00 AM and 8:00 PM; Atorvastatin 40mg PO…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, and record review, the Facility failed to serve appetizing food at palatable temperatures for 2 of 4 residents (R2, R3) reviewed for food and nutrition services in the sample of 9.Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including dementia and weakness. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, ambulated via wheelchair, and was on a therapeutic diet. R2's Diet Order dated 8/7/25 documents R2 has a regular diet. On 2/18/26 at 12:30 PM, R2 stated the food is horrible and is always cold. 2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, cerebral infarction, and chronic obstructive pulmonary disease (COPD). R3's MDS dated [DATE] documented R3 was cognitively intact, ambulated via wheelchair, and was on a therapeutic diet. R3's Diet Order dated 7/5/25 documents R3 has a carbohydrate-controlled diet. On 2/18/2026 at 11:57, AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to provide hot water for bathing for 4 out of 4 residents (R4, R6, R7 and R8); reviewed for Resident Rights in a sample of 8.Findings include:1.R4's Facesheet documented he was admitted to the facility on [DATE] with diagnoses of, in part, fracture of lumbosacral spine and pelvis, type two diabetes, and sleep disorder.R4's Minimum Data Set (MDS) dated [DATE] documented he was cognitively intact. On 12/29/25 at 9:23 AM, R4 stated early this month there was no hot water for 4-5 days, and he had to take a cold shower or wait until it was fixed.2.R6's Facesheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, cerebral infarction, type two diabetes mellitus and chronic obstructive pulmonary disease.R6's MDS dated [DATE] documented she was cognitively intact.On 12/29/25 at 1:03 PM, R6 stated she had to go two weeks without hot water and had to get wet wipe baths, no other alternative was given. R6 stated she will take showers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review the facility failed to provide hot water for bathing for 4 out of 4 residents (R4, R6, R7 and R8); reviewed for Physical Environment in a sample of 8.Findings include:1.R4's Facesheet documented he was admitted to the facility on [DATE] with diagnoses of, in part, fracture of lumbosacral spine and pelvis, type two diabetes, and sleep disorder.R4's Minimum Data Set (MDS) dated [DATE] documented he was cognitively intact. On 12/29/25 at 9:23 AM, R4 stated early this month there was no hot water for 4-5 days, and he had to take a cold shower or wait until it was fixed.2.R6's Facesheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, cerebral infarction, type two diabetes mellitus and chronic obstructive pulmonary disease.R6's MDS dated [DATE] documented she was cognitively intact.On 12/29/25 at 1:03 PM, R6 stated she had to go two weeks without hot water and had to get wet wipe baths, no other alternative was given. R6 stated she will take…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, and record review, the facility failed to provide Health Shakes for 5 of 5 residents (R14, R15, R16, R17, R20) reviewed for Dietary Supplements in the sample of 20.Findings include:On 9/24/25 at 12:17 PM the dining room was entered. R14, R15, R16, R17, and R20, all did not have their Physician prescribed health shake. On 9/24/25 at 12:20 PM, R16 stated, They forget the shakes a lot.On 9/24/25 at 12:28 PM, V15, Dietary Manager, stated the shakes are poured up and on this cart. The aides just took the tray and didn't look at the ticket to know that resident needed a health shake.1.R14's admission record, print date of 9/24/25, documents that R14 was admitted on [DATE] and has diagnoses of aphasia and Cerebrovascular disease.R14's Minimum Data Set, dated [DATE], documents R14 is severely cognitively impaired and requires supervision / touching assistance with eating.R14's Physician Order, dated 4/15/25, documents Diabetic shakes with meals Sugar Free. 2. R15's admission record,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, and record review, the facility failed to provide clean linens for 1 of 11 residents (R4) reviewed for linens in the sample of 20.Findings include:R4 admission record, print date of 9/17/25, documents R4 was admitted [DATE] with diagnoses of Chronic Respiratory Failure with Hypoxia and Tracheostomy Status.R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact, dependent on staff for activities of daily living, and mobility.On 9/16/25 at 12:00 PM, R4 is lying in bed. R4's pillowcase is soiled with a large brown stain.On 9/17/25 at 1:51 PM, R4's pillowcase remains with the large brown stain that was observed on 9/16/25 at 12:00 PM. On the right quarter side rail there is a white towel with dried green, brown stains on it.On 9/24/25 at 9:01 AM, V2, Director of Nurses, stated linens should be changed when dirty.On 9/29/25 at 11:19 AM, V1, Administrator, stated, I am not sure where the linen policy is, but I expect dirty linens to be changed no matter what.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent Urinary Tract Infections for 2 of 3 residents (R7, R13) reviewed for incontinent care in the sample of 20.Findings include:1. R7's admission record, print date of 9/25/25, documents R7 was admitted on [DATE] and has diagnoses of Chronic Obstructive Pulmonary Disease and Diabetes.R7's Minimum Data Set, dated [DATE], documents that R7 is severely cognitively impaired, dependent on staff for toileting, and is always incontinent of bowel and bladder. On 9/25/25 at 9:11 AM, V19, Certified Nurse Aide (CNA) removed R7's incontinent brief. The brief was soiled with urine and feces. R7 with pre-moistened periwash cloths cleansed, the groins, labia, perivaginal area, rolled R7 over onto her side, cleansed the rectal are with multiple cloths, placed a new incontinent brief, had R7 roll to her back, and then roll to the right to cleanse the right buttock, roll to her back and then fastened the incontinent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, and record review, the facility failed to provide complete tracheostomy care and educate the resident on the proper way to provide tracheostomy care for 1 of 2 residents (R4) reviewed for tracheostomies in the sample of 20.Findings include:R4 admission record, print date of 9/17/25, documents, R4 was admitted [DATE] with diagnoses of Chronic Respiratory Failure with Hypoxia and Tracheostomy (trach) Status.R4's Physician Orders, dated 11/7/24, documents, Change inner cannula daily on dayshift and PRN (as needed) every day shift AND as needed as needed.R4's Physician Orders, dated 10/18/24, documents, CHANGE TRACH COLLAR/TIES TWICE WEEKLY AND PRN every day shift every Tue, Fri AND as needed. R4's Physician Orders, dated 10/18/24, documents, TRACH CARE EVERY SHIFT AND PRN every shift.R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact and dependent on staff for activities of daily living.On 9/16/25 at 12:00 PM, R4 is lying in bed. R4 has a tracheostomy. R4's neck…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, and record review, the facility failed to wear a personal protective gown, wash hands when needed, change soiled gloves, encourage residents to wash hands, and clean multi-use equipment for 1of 5 residents (R4) reviewed for infection control in the sample of 20.Findings include:1. R4's Physician Orders dated 9/19/24, documents, Enhanced Barrier Precautions related to colonization for wounds, colostomy, tracheotomy.R4 admission record, print date of 9/17/25, documents R4 was admitted [DATE] with diagnoses of Chronic Respiratory Failure with Hypoxia and Tracheostomy Status.On 9/17/25 at 1:51 PM, V4, Licensed Practical Nurse, entered R4's room to provide tracheostomy care. V4 stated R4 does the tracheostomy care himself and needs very little assistance with the care. V4 washed her hands and donned gloves. V4 opened multiple drawers gathering supplies for the care and placed them on the bedside table. V4 changed her gloves without hand hygiene. R4 removed the left tracheostomy tie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review the facility failed to administer medications as ordered for 4 of 5 residents (R4, R6, R7, and R9) in a sample of 5.Finding Include:1. On 7/18/2025 at 12:06 PM R4 stated while admitted to the facility he did not always receive his medications daily.R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE] and has a diagnosis of Pain in the Left Knee, Chronic Diastolic (Congestive) Heart Failure, Morbid Obesity, Epilepsy, Cortical Age-Related Cataract, Low-Tension Glaucoma, Cardiomegaly, Barrett's Esophagus, Hypothyroidism, and Hypertension.R4's Quarterly Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact, needed supervision/touching assistance with showering/bathing, lower body dressing, personal hygiene, rolling left and right, sitting to standing, and chair/bed to chair transfers.R4's Physician Order dated 4/1/2025 at 4:25 PM documents Bumetanide Oral Tablet 1 MG (Bumetanide) Give 1 tablet by mouth one time a day every other day.R4'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 interview and record review the facility failed to perform wound treatment as ordered for 3 or 3 residents (R4, R6, R9), reviewed for Quality of Care in a sample of 3. Finding Include:1. On 7/18/2025 at 12:06 PM R4 stated while admitted to the facility he did not always receive his dressing change to his left knee as ordered.R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE] and has a diagnosis of Pain in the Left Knee, Morbid Obesity, Presence of Left Artificial Knee Joint, and Hypertension.R4's Quarterly Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact, needed supervision/touching assistance with showering/bathing, lower body dressing, personal hygiene, rolling left and right, sitting to standing, and chair/bed to chair transfers.R4's Care Plan date initiated 4/7/2025 documents skin complications related to right knee surgery, skin at risk for skin complications related to impaired mobility and obesity.R4's Physician Order dated 5/15/2025 at 10:09 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to answer call lights in a timely manner in 6 (R37, R14, R64, R18, R51, R61) of 6 residents reviewed for call lights in the sample of 33. Findings include: On 6/10/2025 at 1:45PM R37 stated They are understaffed here. They won't answer call lights, and I have sat on the bedpan for an hour before. R37's Minimum Data Set, MDS dated [DATE] documents R37 has no cognitive deficits. On 6/11/2025 at 1:30PM at resident council meeting R14 stated Staff ignore call lights even when I am in the shower. They know they put me in the shower, but they don't look for me to be done. R14's MDS, dated [DATE] documents R14 has no cognitive deficits. On 6/11/2025 at 1:30PM at resident council meeting R18 stated Staff ignore call lights. R18's MDS, dated [DATE] documents R18 has no cognitive deficits. On 6/11/2025 at 1:30PM at resident council meeting R51 stated Staff ignore call lights. R51's MDS, dated [DATE] documents R51 has no cognitive deficits. On 6/11/2025 at 1:30PM 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 Based on interview, observation, and record review the facility failed to follow its Fall Prevention and Management policy and complete a root cause analysis after each fall, failed to implement interventions after each fall, and failed to implement fall interventions according to resident care plans for 3 of 4 residents (R2, R3, R6) reviewed for falls in the sample of 15. Findings Include: 1. R2's medical diagnosis form, print date of 5/21/25, documented R2 has diagnoses including aphasia following cerebral infarction, apraxia, cerebrovascular disease, hemiplegia, type 2 diabetes mellitus, depression, anxiety, hypertension, heart disease, contractures of lower extremities, and dementia. R2's MDS (Minimum Data Set), dated 2/24/25, documented R2 is severely cognitively impaired and dependent on staff for all ADLS (Activities of Daily Living). R2's fall risk evaluation, dated 2/18/25, documented R2 is at high risk for falls. R2's care plan, undated, documented R2 is at high risk for falls related to poor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, and record review, the facility failed to provide residents with the correct diet as ordered by the physician for 4 of 4 residents (R3, R8, R11, R12) reviewed for residents receiving the correct diets in the sample of 12. The Findings include: 1. R3's admission Record, dated 5/19/25, documents R3 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Type 2 Diabetes Mellitus (DM), Alzheimer's disease, Asthma, Hypertension, Idiopathic Neuropathy, Left Below Knee Amputation (BKA). R3's Care Plan, dated 4/29/25, documents R3 is at risk for altered nutrition and hydration. Interventions: Honor fluid/food preferences based on MD orders and Dietary Restrictions, ST as needed, Therapeutic diet as ordered. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has a severe cognitive impairment and is dependent on staff for Activities of Daily Living (ADLs). R3 requires supervision/touching assistance from staff for eating. R3's Physician Order, dated 4/17/25, documents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review the facility failed to ensure all alleged violations were thoroughly investigated for 2 of 6 residents (R1, R6) reviewed for abuse investigation in the sample of 12. Findings include: 1-R1's Face sheet dated 5/13/25, documents R1 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Cerebral Palsy, Epilepsy, Schizophrenia, and Major Depressive Disorder. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires the use of a wheelchair. R1's Care Plan, dated 2/14/25, documents R1 is at risk for abuse and neglect. R1's Care Plan, dated 3/18/25: Alleged sexual assault. R1's Care Plan, dated 5/12/25: Recipient of alleged sexual assault. Interventions: 3/18/25 Social Service Director had conversation with resident about inappropriate behavior. Residents not able to sit together in dining room, if seen together to separate. R1's Care Plan, dated 3/18/25: placed on enhanced supervision. R1's Care Plan, dated 5/12/25 Notified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews and interviews the facility failed to transcribe medications to Physician Order Sheet, the Medication Administration Record, obtain medications from the pharmacy and administer medications as ordered by the physician for 1 of 3(R3) residents reviewed for providing care according to professional standards. Findings include: R3's Census Report, not dated, documents that R3 was admitted to the facility on [DATE] and discharged from the facility on 4/7/2025 with the following diagnoses: AKI/Acute Kidney Injury on CKD/Chronic Kidney Disease Stage IV non anion gap Metabolic Acidosis Prostatomegaly, Complicated UTI/Urinary Tract Infection bladder stents, Fracture of left Humerus, Pacemaker, Accelerated Hypertension, Ataxia, Coronary Artery Disease status post CABG/Coronary Artery Bypass Graft, Chronic Diastolic Congestive Heart Failure, Anemia of Chronic Disease, Paroxysmal Atrial Fibrillation Mobitz second degree block, Prolonged QTc/corrected QT interval, Non-insulin dependent Diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer a nighttime snack for 4 of 6 residents (R2, R3, R4, R5) reviewed for snacks in the sample of 21. Findings include: 1. R2's Face Sheet, print date of 3/19/25, documents R2 was admitted on [DATE] and has a diagnosis of End Stage Renal Disease. R2's Minimum Data Set (MDS), dated [DATE] documents R2 is cognitively intact. On 3/17/25 at 11:34 AM, R2 stated, I am not offered a snack at bedtime. 2. R3's Face Sheet, print date of 3/19/25, documents R3 was admitted [DATE] and has a diagnosis of dependence on Renal Dialysis. R3's MDS, dated [DATE], documents R3 is moderately cognitively impaired. On 3/17/25 at 9:05 AM, R3 stated, R3 stated sometimes he gets a snack at night but not every night. 3. R4's Face Sheet, print date of 3/19/25, documents R3 was admitted on [DATE] and has a diagnosis of Diabetes Mellitus. R3's MDS, dated [DATE], documents R4 is cognitively intact. On 3/17/25 at 1:35 PM, R4 stated I am a diabetic and they never offer me a snack. 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 interview and record review, the facility failed to notify the Power of Attorney for the use of a narcotic and refusing therapy for 1 of 3 residents (R6) reviewed for notification in the sample of 21. Findings include: R6's Face Sheet, print date of 3/20/25, documents R6 was admitted on [DATE] and has diagnoses of Schizophrenia, Dementia, Alzheimer's Disease, and Dependence on Renal Dialysis. This Face Sheet also documents V3 as R6's legal guardian. R6's Minimum Data Set, dated [DATE], documents R6 is severely cognitively impaired. R6's Physician Progress Note, dated 2/26/25, documents, Interval history: Patient seen and examined today for acute care visit. Nursing staff reports patient is having difficulty sleeping at night. Staff also reports patient having concerns with pain unrelieved by PRN (as needed) Tylenol. Patient reports severe chronic pain in both feet and all over at times. Patient is unable to use NASIDs (Non-Steriodal Anti- Inflammatory) due to HD/ESRD (Hemodialysis/ End Stage Renal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to provide a final abuse investigation report for 2 of 5 residents (R19, R20) reviewed for abuse reporting in the sample of 21. Findings include: R19's and R21's Initial Serious Injury Incident and Communicable Disease Report, incident report of 2/7/25, dated 2/7/25, documents, it was reported that a possible altercation happened between (R19) 58 yr (year) year old male and (R21) [AGE] year-old male. Assessments completed, no injuries to note. Residents were separated immediately. R19's Nurses Note, dated 2/7/25 at 1:13 PM, documents, Resident was involved in an altercation with another resident. Coffee was thrown on patient. No obvious scars or blisters to be noted at this time. Both residents denied the altercation. Eyewitness from the dietary department claims to have seen this resident hitting the other. Administrator aware. Patient is his own responsible party. Resident denies pain and discomfort. Resident remains in the dining room eating lunch.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to conduct an investigation for 2 of 5 residents (R19, R21) reviewed for abuse reporting in the sample of 21. Findings include: R19's and R21's Initial Serious Injury Incident and Communicable Disease Report, incident report of 2/7/25, dated 2/7/25, documents, it was reported that a possible altercation happened between (R19) 58 yr (year) year old male and (R21) [AGE] year-old male. Assessments completed, no injuries to note. Residents were separated immediately. R19's Nurses Note, dated 2/7/25 at 1:13 PM, documents, Resident was involved in an altercation with another resident. Coffee was thrown on patient. No obvious scars or blisters to be noted at this time. Both residents denied the altercation. Eyewitness from the dietary department claims to have seen this resident hitting the other. Administrator aware. Patient is his own responsible party. Resident denies pain and discomfort. Resident remains in the dining room eating lunch. R21's Nurses Notes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to obtain a consent from a Power of Attorney for a psychotropic medication for 1 of 4 residents (R6) reviewed for psychotropic medications in the sample of 21. Findings include: R6's Face Sheet, print date of 3/20/25, documents R6 was admitted on [DATE] and has diagnoses of Schizophrenia, Dementia, Alzheimer's Disease, and Dependence on Renal Dialysis. This Face Sheet also documents V3 as R6's legal guardian. R6's Minimum Data Set, dated [DATE], documents R6 is severely cognitively impaired. R6's Physician Progress Note, dated 2/26/25, documents, Interval history: Patient seen and examined today for acute care visit. Nursing staff reports patient is having difficulty sleeping at night. It continues, Trazodone 50 mg QHS (every hour of sleep) nightly. R6's Physician Order, dated 2/27/25, documents, Trazodone HCl Tablet 50 MG (milligram) Give 1 tablet by mouth at bedtime for Insomnia Give 1 at night for insomnia. R6's Medication Administration Record, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, and record review, the facility failed to prevent verbal abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 7. Findings include: R3's Face Sheet, print date of 1/16/25, documents that R3 has diagnoses of Polyarthritis and Chronic Obstructive Pulmonary Disease. R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact. The facility Long Term Care - Serious Injury Incident and Communicable Disease Report, dated 1/13/25, documents, Final. Upon investigation, it was founded that the dietary staff (V3) did curse at (R3) on 1/7/25 during breakfast time in the dining room. The employee was immediately suspended and sent home after writing her statement. In her statement she said she did curse at (R3) and she knew it was wrong. The employee is effectively terminated as of 1/7/25. V3's written statement, dated 1/7/25, documents, I cussed at (R3), and I knew it was wrong. V4's written statement, dated 1/7/25, documents that V3 yelled at R3 and stated, yall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review the facility failed to thoroughly investigate and report allegations of sexual abuse for 1 of 3 residents (R2) reviewed for sexual abuse in the sample of 11. Findings include: R2's Care Plan, dated 10/23/24, documents ABUSE: At risk for abuse and neglect r/t (related to). It continues Assess resident for abuse and neglect upon admission and quarterly. Assure the resident that staff members are available to help, and department heads maintain an open door policy. Continue to in-service the staff about abuse and neglect. Continue to monitor medication, ADLs, status and behaviors. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him/her feel safe. R2's Minimum Data Set, dated [DATE], documents that R2 is cognitively intact. R2's Progress Note, dated 10/13/2024 at 4:02 PM, documents Nurses Notes Late Entry: Note Text: Resident came to nursing station with another female resident. second female resident looked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review the facility failed to initiate its Abuse Prevention policy for 1 (R2) of 3 three residents reviewed for sexual abuse in the sample of 11. Findings include: On 10/31/2024 at approximately 1:00 PM V9, Regional Director of Operations, stated that they were made aware of the incident that occurred on 10/22/24. V9 stated that (V2), Director of Nursing, and (V5), Wound Nurse, came up to facility. V9 stated that they were notified that (V6), Staffing Coordinator, was outside on smoke break and that no event occurred out there. V9 stated that no further investigation was done and it was not reported to outside agency because they did not believe it was necessary because (V6) did not witness anything outside. V9 stated that in the days following they were made aware of the incident that occurred on 10/13/2024. V9 stated that this was not reported or investigated. V9 verified that the facility has cameras and that they had not viewed the [NAME] footage. On 10/31/2024 at approximately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, and record review, the facility failed to measure, assess, monitor, and treat wounds when identified and obtain orders to treat wounds for 1 of 1 (R4) reviewed for wounds in the sample of 11. Findings include: R4's admission Record, print date of 11/4/24, documents that R4 was admitted on [DATE] with diagnoses of Osteomyelitis, Diabetes Mellitus. R4's Minimum Data Set, dated [DATE], documents that R4 is cognitively intact. R4's admission Note, dated 10/8/2024 22:30, documents, 18) Left elbow left elbow infection osteomyelitis. R4's Nurses Note, dated 10/8/2024 22:24, documents, The patient arrived to facility via EMS (Emergency Medical Services). Patient alert and oriented times 3. Patient oriented to room, call light within reach, Left elbow infection/wound noted. R4's Nurses Note, dated 10/9/2024 12:55, created date of 10/16/2024 15:58:26, documents, Late Entry: Resident admitted to (facility) on IV (intravenous) antibiotics due to osteomyelitis, resident admitted with a venous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, and record review, the facility failed to assess and monitor pressure ulcers, provide Physician prescribed treatment, and maintain clean dressings for 2 of 3 residents (R1, R11) reviewed for pressure ulcers in the sample of 11. Findings include: 1. On 10/31/24 at 3:00 PM, R1 is lying in bed. R1 has no dressing on his left heel. R1's right heel protector boot is positioned on the middle of his calf. R1's right heel dressing is at his ankle and his mid foot. R1's dressing is red, tan and brown in color with drainage. R1's sheet has fresh and old blood stain in multiple areas at the bottom half of the right side of the sheet. On 10/31/24 at 3:00 PM, R1 stated that his heel has been bleeding all night. R1 stated that it has been a problem for the last 3 or 4 days. R1 stated that his right heel dressing was last changed yesterday or the day before. R1 stated that his left heel never has a dressing on it. On 10/31/24 at 3:10 PM, V3, Assistant Director of Nurses, entered R1's room to do…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, and record review, the facility failed to replace a loose dressing for 1 of 2 residents (R4) reviewed for Peripherally Inserted Central Catheter (PICC) lines in the sample of 11. Findings include: On 10/31/24 at 12:13 PM, V3, Assistant Director of Nurses / Registered Nurse (RN) entered R4's room. V3 disconnected the Intravenous (IV) antibiotic from R4's left upper arm Peripherally Inserted Central Catheter (PICC) line, flushed the line with 5 milliliters of normal saline, and capped the lumen. The PICC line dressing was not attached at the bottom of the dressing. V3 washed her hands and left the room. On 10/31/24 at 4:16 PM, V3 stated that she was aware that (R4's) PICC line dressing was not attached at the bottom. I told the night RN that just came in about it so she would change it. R4's admission Record, print date of 11/4/24, documents that R4 was admitted on [DATE] with diagnoses of Osteomyelitis and Diabetes Mellitus. R4's Physician Orders, dated 10/28/2024, documents,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review the Facility failed to support the resident's right for the Power of Attorney (POA) to access their family's personal medical records and honor their written request for records for 1 of 3 residents (R2) reviewed for medical records in the sample of 6. Finding include: R2's Face sheet printed 9/19/2024 documents a diagnoses of sepsis, transient cerebral ischemic attack, type 2 diabetes, morbid obesity, difficulty in walking, unsteadiness on feet, cognitive communication deficit, weakness, anemia, Alzheimer disease, anxiety disorder, severe sepsis with septic shock. R2's Face sheet also documents she was admitted to the facility on [DATE]. R2's Minimum Data Set (MDS) dated [DATE] documents (R2) is moderately impaired for cognition for decision making of activities of daily living. R2's Care Plan for ADL (activities of daily living) document she (R2) requires assist with daily care needs related to recent hospitalization for severe sepsis, weakness, and TIA (transient ischemic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review the Facility failed to provide and document sufficient preparation and orientation for a safe and orderly discharge from the facility for 1 of 3 residents (R1) reviewed for discharge in the sample of 6. Findings include: R1's Physician Order Sheet (POS) for diagnoses of cerebral infarction due to embolism of left middle cerebral artery, type 2 diabetes mellites without complications, acute respiratory failure, unsteadiness on feet, lack of coordination, abnormal posture, chronic allergic conjunctivitis, bipolar, unspecified convulsion, acute kidney failure, acquired absence of right leg above knee, and depression. R1's POS documents he was taking levetiracetam oral tablets 750 milligrams two tablets twice a day related to epilepsy, oxcarbazepine tablet 600 mg., give 1 tablet by mouth two times a day (seizures), and spironolactone tablet 25 mg one time by mouth, one time a day (high blood pressure and heart failure). R1's Minimum Data Set (MDS) dated [DATE] documents R1 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 interview and record review the facility failed to obtain consent for an antipsychotic medication prior to administering antipsychotic and antidepressant medication for 2 of 3 residents (R3, R4) reviewed for informed treatment/treatment decisions in a sample of 8. Findings include: 1. R3's Care Plan, dated 9/3/2024, documents PSYCHOTROPIC MEDS: (R3) requires the use of psychotropic medication (Zoloft) to assist with managing mood and behavior r/t (related to) Depression. R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact. R3's Physician Order Sheet (POS) documents Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for major depressive order for 90 Days. R3's Medication Administration Record (MAR) and Treatment Administration Record (TAR) documents that R3 received Zoloft 25 mg from 8/31/2024 to 9/13/2024. On 9/17/2024 at 11:00 AM a review of R3's electronic health record (EHR) was reviewed. No psychotropic consent documented in chart 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 interview and record review the facility failed to provide tracheostomy (trach) care for 1 of 1 resident (R3) reviewed for trach care in a sample of 8. Findings include: 1. R3's Care Plan, dated 9/3/2024, documents R3 is at risk for complications r/t (related to) tracheostomy placement (trach tube) #6. It continues to document that staff should assess for signs and symptoms (s/s) of infection such as erythema, swelling, unusual drainage or odor or presence of a fistula, at noc (night) place on a Venturi mask with 28 % per trace collar at 10-15 Umin. Perform trach care as ordered and as needed. Trach collar with 28% humidified air continuous. R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact. R3's Medication Administration Record (MAR) and Treatment Record (TAR) documents 8/28/2024 Change Trach collar twice weekly and as needed The MAR documentation of R3's trach collar changes for August and September 2024. In addition, the order, dated 8/28/2024, documents Cleanse Trach every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure food was served in the appropriate portions for 8 of 13 (R2, R7, R8, R9, R10, R11, R12, and R13) residents reviewed for food services. Finding includes: 1. The facility menu Week 2 Wednesday documents Supper: Chicken Nuggets (7 ea (each)= 3 oz (ounces)pro (protein)), Barbecue Sauce (I Tbsp (tablespoon)), Crispy French Fries (4 oz spdl = 1/2 cup), Seasoned Mixed Vegetables (#8 scoop= 1/2 cup), Powdered Sugar Brownie (I piece), 2% Milk (8 oz), Coffee/Hot Tea (6 oz), Condiments (1 ea). R2's Fall Assessment, dated 8/23/2024, documents that R2 is alert and oriented. The facility provided a roster and identified R2 as interviewable. On 9/3/2024 at 11:00 Am R2 stated that he has been at the facility for 7 days. R2 stated that the food is horrible and that the portion sizes are small. R2 stated that the facility served chicken nuggets one evening for supper. R2 stated that he was given 4 nuggets and a few fries. R2 stated that when asked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to obtain and properly document code status for 5 of 6 residents (R58, R261, R264, R265, R266) reviewed for advanced directives, in the sample of 43. Findings include: 1. R261's Face Sheet, undated, documented that R261 was admitted to the facility on [DATE] with diagnoses including type 1 diabetes mellitus, end stage renal disease, and dependence on renal dialysis. On [DATE] at 2:00 PM, R261's Electronic Health Record did not list a Code Status. On [DATE] at 2:10 PM, requested R261's Physician Orders and the State Agency Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form from V2, Director of Nursing (DON). R261's Order Summary Report, printed [DATE] at 2:55 PM, documented that R261 was a Full Code as of [DATE]. There was no Code Status listed prior to [DATE]. R261's State Agency Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form, dated [DATE], documented, Yes CPR: Attempt cardiopulmonary resuscitation (CPR). 2. R58'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 interview and record review, the Facility failed to ensure palatable and appetizing meals for 5 of 5 residents (R18, R13, R24, R33, R267) reviewed for food palatability and temperature in the sample of 43. Findings include: 1-R18's Face Sheet documents R18 was admitted to the facility on [DATE]. R18's Minimum Data Set (MDS) dated [DATE] documented R18 was cognitively intact. R18's Physician Order dated 2/12/24 documents R18 is on a regular diet. On 5/5/24 at 9:52 AM, R18 stated the food is not good, and even when it is decent, it is always still cold. 2-R13's Face Sheet documents R13 was admitted to the facility on [DATE]. R13's MDS dated [DATE] documented R13 was cognitively intact. R13's Physician Order dated 2/12/24 documents R13 is on a regular diet. On 5/5/24 at 11:40 AM, R13 stated the food is horrible. R13 stated she has to order meals from outside the Facility. 3-R24's Face Sheet documents R24 was admitted to the facility on [DATE]. R24's MDS dated [DATE] documented R24 was cognitively intact.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the Facility failed to follow their alternative menu for 6 of 6 residents reviewed for alternative food choices in the sample of 43. Findings include: 1-R40's Face Sheet documents R40 was admitted to the facility on [DATE] with diagnoses including chronic systolic heart failure, chronic obstructive pulmonary disease, and atherosclerotic heart disease. R40's Minimum Data Set (MDS) dated [DATE] documented R40 was cognitively intact. R40's Physician Order dated 2/12/24 documents R40 is on a NAS (No Added Salt) diet. On 5/5/24 at 10:05 AM, R40 stated there is too much pork served at meals and no good substitutes offered. 2-R263's Face Sheet documents R263 was admitted to the facility on [DATE] with diagnoses including functional dyspepsia, cerebral infarction, and dysphagia. R263's MDS dated [DATE] documented R263 was independent with cognitive skills for daily decision making. R263's Physician Order dated 2/12/24 documents R263 is on a NCS/NAS (No Concentrated Sweets/No Added…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, Interview, and Record Review, the facility failed to maintain infection control during dialysis treatment on 7 residents (R266, R41, R10, R30, R261, R53, R32) in the sample of 43. Findings Include: R266's Face sheet documents an admission date of 5/1/2024 and diagnosis includes Encephalopathy, Cirrhosis of the Liver, End Stage Renal Disease, Ascites. R266's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. R41's Face sheet documents an admission date of 9/20/2022 and diagnosis includes End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Vascular Prosthetic, Type 2 Diabetes, Bacteremia. R41's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. R10's Face sheet documents an admission date of 7/29/2019 and diagnosis include End Stage Renal Disease, Toxic Encephalopathy, Respiratory Failure, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease. R10's order sheets dated 4/1/2024 document Hemodialysis in house with dialysis company. R30's Face sheet documents an admission date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transcribe and carry out a physician order for a specialist appointment for 1 of 1 resident (R57) reviewed for quality care, in the sample of 43. Findings Include: R57's admission Record, dated 3/28/24, documented that R57 had a diagnosis of unspecified cirrhosis of liver, malignant neoplasm of the colon, ascites, thrombocytopenia unspecified and decreased white blood cell count unspecified that were added to the diagnosis list on 4/19/24. R57 Minimum Data Set (MDS), dated [DATE], documented that R57 was moderately cognitively impaired. R57's Physician Order Sheets, (POS), dated 4/19/24, documented, Refer to the hematologist diagnoses Leukopenia and Thrombocytopenia one time only related to decreased white blood cell count and unspecified Thrombocytopenia. R57's POS, dated 4/27/24, documented, Refer to hematologist for Leukopenia and Thrombocytopenia. On 5/6/24 at 10:00, V20 Transportation/Appointment [NAME], stated, I was not aware of that…

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

Based on Interview and Record Review, the facility failed to provide timely access to medical records, for 2 of 2 (R3, R4) residents, reviewed for rights to access medical records, in a sample of 12. Findings Include: R3's Face sheet, undated, documented an admission date of 12/16/2023. On 4/18/2024 at 3:00PM, V10, R3's daughter, stated I have asked for (R3's) medical records and still have not received anything. I emailed (V5, Medical Records) worker, all the required documents on 2/9/2024. I then followed up with (V5) on 2/15/2024 and needed to send another proof of identification. I sent that proof in the same day and have not heard anything. I sent (V5) an email in March to see if (V5) had heard anything about (R3's) medical records, and she emailed back that she sent everything to the corporate office and knew nothing else. I still have none of (R3's) medical records. On 4/18/2024 at 11:00AM V5, Medical Records, stated, R3's Power of Attorney, POA, put in a request for (R3's) medical records. The facilities do not give out medical records. The records are sent from 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 interview and record review, the Facility failed to ensure residents were free from mental abuse for 2 of 7 (R1, R2) residents reviewed for abuse in the sample of 8. Findings include: 1- R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, morbid obesity, asthma, acute respiratory failure with hypoxia, anxiety, hypothyroidism, and major depressive disorder. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact and ambulated via wheelchair and walker. R1's Care Plan documents R1 was at risk for abuse and neglect related to needing assistance and behaviors at times. 2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, schizophrenia, acute respiratory failure, heart failure, generalized anxiety disorder, and major depressive disorder. R3's MDS dated [DATE] documented R3 was independent with cognitive skills for daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review the facility failed to provide feeding assistance with meals for 2 of 3 residents (R3, and R7) reviewed for ADL (activities of daily living) assistance in the sample of 8. Findings include: 1. On 10/26/2023 during the noon meal there was one Certified Nursing Assistant. (CNA), in the dining room providing hands on assistance to residents. R3 was not observed being assisted with his meal. During that meal R2's fortified pudding in bowl untouched at the end of meal V2, Director of Nursing, (DON), walked over and placed spoon in R3's pudding and at that time R3 ate 75% of his fortified pudding. R3's Care plan dated 5/8/2023 documents that R3 is at nutritional risk as disease progresses Diabetes Mellitus, colon cancer. R3's care plan documents R3 has experience unplanned weight loss due to cancer and is currently on hospice care and weight loss is expected to continue. R3's care plan documents, the following interventions 3/13/2023 supervision of meals at assisted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review, the facility failed to ensure there were sufficient Nursing Staff in the facility to provide adequate care and assistance for residents, resulting in residents not gotten out of bed for meals and residents not receiving showers. This failure has the potential to affect all 64 residents in the living in the facility. Findings include: 1. On 10/2/2023 at 8:04 AM a walk through of 100-hall and 200-hall revealed no staff on the halls. On 10/2/23 at 8:08 AM V25, Licensed Practical Nurse, (LPN), stated, that she got to the facility at 7AM and no CNAs were at the facility. V25 stated, that there has not been a CNA since 6 AM. V25 stated, that this has not been the first time that this has happened. V25 stated, that this effects the care that is given. V25 stated, that V7, Restorative Aide, is helping, but she is not assigned to the hall. V25 stated, that at this time none of her CNAs have shown up and that she does not have any staff at this time for hall-100 and 200…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and record review, the facility failed to maintain walls and floors in good repair for 11 of 27 residents (R11, R15, R14, R16, R17, R18's, R19's, R20, R21, R22's and R23's) reviewed for Physical Environment on the sample list of 27. Findings include: 1. R11's Minimum Data Set, dated [DATE], documents, that R11 is cognitively impaired. On 9/25/2023 at 11:50 AM, observed large hole in wall in R11's room. On 9/26/2023 at approximately 2:00 PM V13, Maintenance Director, stated, that he was working on the hole, but at this point was not able to complete. V13 stated, that the pipes were exposed, but did not verify mold. V13 measured the hole at 5ft, (foot), x 1.2ft. V13 stated, that he was not sure how the hole occurred. 2. On 9/27/2023 at 9:00 AM a walkthrough, of 100-hall and 200-hall were completed and revealed: A large hole, approximately 1ft x 2ft, behind the toilet in R15's bathroom and a large hole, approximately 1 ft x1 ft in R14's bathroom. A large hole approximately 2ft x 1ft…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, the facility failed to submit an initial resident abuse allegation to the state agency within the 2-hour time frame for allegation of abuse for 1 of 3 resident (R13) reviewed for abuse on the sample of 27. Findings include: R13's Care Plan, dated 3/30/23, documents ABUSE: At risk for abuse and neglect r/t, (related to), behaviors at times. It continues: Staff will monitor well-being of others. Resident will have zero episodes of abuse and neglect throughout next review. Immediately report any episodes of unknown injury, abuse or change in resident's behaviors to Administrator for immediate intervention and review. Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him/her feel safe. R13's Minimum Data Set, dated [DATE], documents, that R13 is cognitively intact. R13's Incident report, dated 8/27/2023, documents, Nursing Description: Reported to this Nurse per RN, (Registered Nurse),…

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

Based on observation, interview and record review, the facility failed to store medication, label insulin and Tubersol in accordance with standards of practice. This has the potential to affect all 76 residents living in the facility. Findings include: 1. On 4/3/2023 at 9:22 AM 200-Hall medication cart was observed. The medication cart contained the following: 4 liquid medication cups with multiple pills in them; 1 cup had 20 yellow pills, 1 cup 15 black pills, 1 cup with 12 yellow pills, 1 cup with 17 red capsules. R61's opened and used multi dose Humalog pen was not labeled with an opened date. R274's multi dose Novolin R Insulin vial was not labeled with an open date. R274's Electronic Medical Record documents that R274 was admitted to the facility 7/26/22 and discharged on 8/4/22. 2. On 4/3/2023 at 10:20 AM 100 and 200-Hall medication room was observed. The medication room contained the following: An open bottle of Geri Lanta with expiration date of 11/2022. An open bottle of Geri-Kot (Senna 8.6 handwritten on bottle) expiration date 8/2022. An open bottle of Vitamin D3 50,000…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review, the facility failed to provide assistance with bathing, grooming, and hygiene to dependent residents for 4 of 8 residents (R8, R24, R25, R43) observed for activities of daily living (ADL) in the sample of 37. Findings include: 1. R8's Face Sheet, dated 4/5/23, documents that R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record documents that R8's diagnoses include Asthma, Morbid Obesity, End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, Schizoaffective Disorder, Spinal Muscular Atrophy. R8's Care Plan, dated 3/21/23, documents (R8) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness, ESRD, and spinal muscular atrophy. (R8) primarily uses a wheelchair, is incontinent of B&B (bowel and bladder). Interventions: Bathing: (R8) requires total care with bathing. Personal Hygiene: (R8) requires extensive assistance with personal hygiene. R8's Minimum Data Set (MDS), dated [DATE], documents that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe transfer for 4 of 4 residents (R8, R33, R40, R43) reviewed for safe transfers in the sample of 37. Findings include: 1. R8's Face Sheet, dated 4/5/23, documents that R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record, documents that R8's diagnoses include Morbid Obesity, Dysphasia, End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, Polyosteoarthritis, Spinal Muscular Atrophy. R8's Care Plan, dated 3/21/23, documents (R8) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness, ESRD, and spinal muscular atrophy. She primarily uses a wheelchair, is incontinent of B&B (bowel and bladder). Interventions: Bathing: (R8) requires total care with bathing. Personal Hygiene: (R8) requires extensive assistance with personal hygiene. Transfer: (R8) requires extensive assistance to dependence with transfers. R8's Minimum Data Set (MDS), dated [DATE], documents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review, the facility failed to provide timely and complete incontinence care and catheter care for 4 of 4 residents (R28, R40, R43, R53) residents reviewed for incontinent care/catheter care in a sample of 37. Findings include: 1. R28's Electronic Medical Record documents R28's diagnoses include Type 2 Diabetes Mellitus (DM), Cerebral Infarction, Aphasia, Hemiplegia/Hemiparesis, Epilepsy, Hypertension, and Dysphagia. R28's Care Plan, dated 3/29/23, documents (R28) has bladder incontinence r/t (related to) history of CVA (Cerebral Vascular Accident) with residual deficits. Interventions: Brief Use: The resident uses disposable briefs. Change every two hours and PRN (as needed). Incontinent: Check the resident every two hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. It continues (R28) has bowel incontinence r/t history of CVA with residual deficits. Interventions: Check resident every two hours 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 4. R8's Face Sheet, dated 4/5/23, documents that R8 was admitted to the facility on [DATE]. R8's Electronic Medical Record, documents that R8's diagnoses include Malnutrition, Asthma, Morbid Obesity, Dysphagia, End Stage Renal Disease (ESRD), COVID-19, Dependence on Renal Dialysis, Obstructive and reflux uropathy, Anemia, Seizures, Transient Ischemic Attack (TIA), Schizoaffective Disorder, Major Depressive Disorder, Psychosis, Polyosteoarthritis, Atherosclerotic Heart Disease, Spinal Muscular Atrophy. R8's Care Plan, dated 3/21/23, documents (R8) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness, ESRD, and spinal muscular atrophy. She primarily uses a wheelchair, is incontinent of B&B (bowel and bladder). Interventions: BATHING: R8 requires total care with bathing. PERSONAL HYGIENE: R8 requires extensive assistance with personal hygiene. TRANSFER: R8 requires extensive assistance to dependence with transfers. R8's Minimum Data Set (MDS), dated [DATE], documents that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to provide tube feedings as ordered by the physician for 1 of 1 resident (R29) reviewed for tube feedings in the sample of 37. Findings include: R29's Electronic Medical Record documents R29's medical diagnoses include Type 2 Diabetes Mellitus, COVID-19, Dysphagia, Major Depressive Disorder, Atherosclerotic Heart Disease, Adult failure to thrive, Gastrostomy. On 4/3/23 at 10:40 AM, R29 stated, I have a feeding tube, and I take care of it myself. I give myself a feeding bolus twice a day, flush the tube, and then clean and put a new dressing on it. The nurses really don't do anything for my tube feedings. On 4/4/23 at 8:55 AM, R29 stated, I am not going to give myself any tube feeding this morning, because my blood sugar was too high. I usually give myself a feeding twice a day and will flush it afterwards. Guess I will not be flushing my tube this morning either since I'm not giving myself a feeding. On 4/5/23 at 2:50 PM, R29 stated, The nurses never…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, and record review, the facility failed to employ a Registered Nurse (RN), 8 hours per day, 7 days per week. This has the potential to affect all 71 residents living in the facility. Findings Include: On 1/4/2022 at 4:34 PM, V1, Administrator, stated, I have been here since October 2021 and we have had corporate in the building working. I am not aware of any issues with not having a RN. We have not had an RN every day consecutively working the floor but we have had an RN working in the building. (V8) was working as the RN. We do not have a full time Director of Nursing (DON) but (V2) is working as the interim DON. On 1/04/2022 at 4:13 AM, V8, Corporate Regional Nurse, stated, I am aware we have been struggling to find an RN full time and meeting 8 hours a day seven days a week. We have been using agency, but it has been difficult. I have not been working the floor. Facility staffing schedules were reviewed dated from 12/22/2021 to 01/04/2022 and fail to document an RN as working on the day, afternoon, and/or night shifts for 12/22/2021, 12/23/2021, 12/26/2021 and…

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

Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 71 residents living in the facility. Findings include: 1.On 01/04/22 at 8:58 AM, during the initial tour of the facility's kitchen freezer, the temperature gauge read 5 degrees Fahrenheit (F). Upon opening the freezer door icy condensation was noted on the flaps leading into the freezer. A block of ice approximately 4 inches long had formed in the upper right corner of the flaps. The meat on the middle and bottom shelfs remained frozen solid. The frozen vegetables on the top shelves also remain frozen solid. None of the freezer foods in the freezer were noted in a thawed or thawing state. On 01/04/22 at 9:15 AM, V7, Dietary Manager stated, The freezer needs a seal around the door. I notified maintenance and the administrator. The maintenance man is out sick, and I do not have access to his records. The door seal has been missing for about a month. I do not have a record of the request to…

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

Based on interview and record review the facility failed to develop an ongoing infection control program that collects data to calculate and analyze infection rates and failed to implement infection control procedures that prevents the spread of COVID-19 and other infections. This has the potential to affect all 71 residents living in the facility. Findings Include: 1.On 1/5/2022 at 9:01 AM, documentation regarding how the facility identifies, analyzes data, and provides surveillance of infections within the facility was requested for the past year including pathogens and organisms. The October 2021 infection and antimicrobial log/surveillance Log provided by the facility only documented 6 residents with one urinary tract infection documented. 2. R25's Physician Order Sheet (POS) for the month of October 2021 document he was on nitrofurantoin macrocrystal capsule 100 milligrams (mg) by mouth two times a day related to urinary tract infection (UTI). R25's information regarding R25's UTI was not on the October 2021 Infection and Antimicrobial Log/Surveillance Log. 3. R54's POS for 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 interview, observation, and record review the facility failed to clean the CPAP (continuous positive airway pressure) as ordered for 5 of 5 residents (R2, R3, R10, R14, R39) reviewed for respiratory care in the sample 48. Findings include: 1. R2's Minimum Data Sheet (MDS) dated [DATE], documents R2 uses a CPAP. R2's Face Sheet documents his diagnoses include the following: Chronic Obstructive Pulmonary Disease, Other Asthma, Chronic Obstructive Pulmonary Disease with (Acute Exacerbation). R2's Order Summary Report, dated 01/11/22 documents, Place CPAP mask and tubing into a sink with warm soapy water. Use a small amount of mild dish detergent. Agitate these supplies in the water for approximately 5 minutes. Rinse well with warm water and allow to dry until all the moisture is gone, every day- shift for CPAP. Start Date: 12/24/21. R2's Care Plan dated 12/30/2019 documents R2 diagnoses Emphysema/COPD and asthma related to history of smoking. The goal for this care plan is, (R2) will be free of signs and…

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

Based on observation, interview and record review, the facility failed to date opened insulin pens and to ensure physician's orders have the appropriate route for 4 of 4 residents (R54, R12, R22, R27) reviewed for medications in the sample of 48. Findings include: 1. On 1/6/22 at 8:10 AM, upon investigation of the 300-hall medication cart with V13, Registered Nurse (RN), R54's Restasis (medication for dry eyes) EMU 0.05% is labeled as give one drop by mouth two times a day for dry eyes. During an interview on 1/6/22 at 10:00 AM, V13 stated she noted Restasis route was by mouth on R54's medication bottle and on the electronic medical record but the route should be eye not by mouth. V13 contacted R54's physician. 2. On 1/6/22 at 1:48 PM, upon investigation of the 400-hall medication cart with V14, RN, R12's Humalog insulin was not dated. V14 stated insulin should be dated once opened per manufacturer's guidelines. On 1/6/22 at 1:00 PM, upon investigation of the 300-hall medication cart with V10, Licensed Practical Nurse (LPN). 3. R22's Lantus insulin pen was not dated. 4. R27'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 interview and record review the Facility failed to provide residents with food according to their food plan/preferences for 4 of 25 residents (R29, R30, R39, R106) reviewed for food choices in the sample of 48. Findings include: 1. R30's Physician Order Sheet (POS) for January 2022 document an order for vegetarian diet, regular texture, thin liquids. R30's Minimum Data Set (MDS) dated [DATE] document he was cognitively alert for decision making of activities of daily living. R30's Care Plan document he has a potential nutritional problem related to diagnosis of schizophrenia and drug induced dyskinesia. Appetite good. R30's January 2022 Diet Card documents no meat, eggs, and cheese, milk or milk products, Vegetarian. On 1/5/2021 at 1:00 PM, during the group meeting R30 stated he was a vegetarian and did not eat meat and the facility was not honoring his wishes and was serving him the same food as everyone else including meat. R30 stated My family brought in some cans of beans for me and I asked them 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 interview and record review, the Facility failed to provide residents with flavorful and properly cooked food for 5 of 25 residents (R29, R34, R39, R108 and R157) reviewed for palatable food in the sample of 48. Findings include: 1.R39's MDS dated [DATE] document R39 was cognitively intact decision making of activities of daily living. During the group meeting on 1/15/2022 at 1:00 PM, R39 stated, Food is cold and it was even worse now because of COVID we are eating in our rooms and we are served on Styrofoam containers. There is no insulation or anything to keep the food hot. Staff are so busy they do not have time to heat up your cold food and if you ask them, they tell you we do not have time. 2. During the group meeting on 1/15/2022, R108 stated the food is cold and served cold for all of our meals. R108 stated We are eating in our rooms now and they serve us on Styrofoam, and it does not keep the food cold. A lot of times the food is sitting there on the trays waiting for staff to pass the food out.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to secure medications to ensure residents do not have access for one of one resident (R9) reviewed for 1 of 1 accident investigations in a sample of 48. Findings include: R9's Nurse's Note, dated 11/28/21 at 7:16 PM documents R9 was sent out to the hospital. R9's Nurse's Note, dated 11/29/21 at 12:50 PM documents During investigation of incident that occurred on 11/28/2021 (R9) admitted to taking medication that was not her medication. She also stated she is slowly dying and wanted to make things easier on her mom by killing herself. Suicidal precautions were initiated immediately. Q5-10 min (every 5 to 10-minute) visual checks initiated, and MD notified. Received orders to send to (local hospital) for psych (psychiatric) eval (evaluation) and monitoring r/t (related to) suicidal ideations with a plan. POA (power of attorney) is to be updated related to (R9) being sent out to hospital per floor nurse. R9's Nurse's Note, dated 11/29/21 at 12:58 PM documents R9 was sent to local hospital vial ambulance service transport 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 interview and record review the facility failed to monitor and assess the hemodialysis shunt sites for 2 of 4 residents (R12, R21) reviewed for dialysis in the sample of 48. Findings Include: 1. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is moderately cognitively impaired. R12's Hemodialysis Care Plan documents dated 1/7/22 documents observe access site for infection redness, drainage, swelling, and pain every shift. R12's December 2021 Treatment Administration Record (TAR) documents that R12's hemodialysis access site was only assessed 30 times for 3 shifts for the month of December (should have been 90 times). On 1/6/22 at 3:00 PM, R12 stated, I don't know if they check it or not. 2. R21's MDS dated [DATE] documents R21 is moderately cognitively impaired. R21's Hemodialysis Care Plan dated 1/7/22 documents observe access site for infections redness, drainage, pain and swelling every shift. R21's December 2021 TAR documents that R12's hemodialysis access site was only assessed 34 times for…

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

Based on observation, interview and record review, the facility failed to ensure medications were given as ordered. There were 25 opportunities with 2 errors resulting in an 8% medication error rate. The errors involved 2 residents (R54, R108) in the sample of 48 out of 3 residents observed during the medication administration. Findings include: 1. On 1/6/22 at 8:10 AM, V13, Registered Nurse (RN), administered medication to R54. V13 did not administer Carvedilol 3.125 milligrams (mg) to R54. V13 stated she thought all medications were administered to the resident that were ordered by the physician. She does not know what occurred that the medication was not administered. R54's Physician's Order Sheet (POS), dated 1/1/2022 documents an order to administer Carvedilol Tablet 3.125 MG 1 tablet by mouth two times a day for Hypertension. There was no nurse's note regarding the missed dose of Carvedilol Tablet 3.125 mg. 2. On 1/6/2022 at 8:42 AM, V14, RN, handed R108 an Advair inhaler and told R108 to take 2 puffs. V14 did not educate/instruct R108 to wait 1 minute between puffs per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately document in the medical record a resident's change in condition which required emergency care for one of one resident (R255) reviewed for documentation in a sample of 48. Findings include: R255's admission Nurse's Note dated [DATE] at 5:01 PM documents report received from local hospital. The Note documented R255 originally came to hospital for Atrial fibrillation (irregular heartbeat). The Note documented R255 was a [AGE] year-old man who, resides at a local nursing home, he was COVID positive as of today and will be coming to facility for 10-day quarantine and then will return to prior facility. The Note documented R255 displays no COVID symptoms, on room air, no respiratory distress. The Note documented R255 is alert to self, has schizophrenia and wanders. On [DATE] at 11:00 AM, R255 was on oxygen per nasal cannula, he was asleep in bed. R255's Physician Order Sheet (POS), dated 1/2022 documents full code/attempt cardiopulmonary…

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