Integrity Hc Of Anna

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the food was served at a safe temperature. This has the potential to affect all 63 residents currently residing at the facility.Findings Include: The facility Daily Census dated 2/24/26 documents 63 residents currently reside at the facility.R13's admission Record with a print date of 2/26/26 documents R13 was admitted to the facility on with diagnoses that include diabetes, morbid obesity, heart failure, and chronic kidney disease.R13's MDS dated [DATE] documents a BIMS score of 14, indicating she is cognitively intact.R13's current Care Plan documents a Focus area of, Nutritional: She is on a NAS (no added salt), regular texture, thin liquids, two liter fluid restriction. She also is given protein supplement BID (twice daily). Date Initiated: 08/12/2025. This Focus area includes the intervention of, Prepare/serve the resident's nutritional diet as ordered. Date Initiated: 08/12/2025.On 2/26/26 at 12:43 PM, R13 stated the food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure they maintained linens to fit specialty mattresses for 1 of 3 (R1) residents reviewed for accommodation of needs in the sample of 20.Findings Include: R1's admission Record with a print date of 2/26/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease and morbid obesity.R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating she is cognitively intact.R1's current Care Plan does not address R1's linens/mattress in a Focus area or Intervention.On 2/25/26 at 9:40 AM, R1 was sitting in her wheelchair near her bed. Her bed had a flat sheet on the mattress that was partially tucked in under the mattress. There was no fitted sheet on the mattress, and the flat sheet was only partially covering it. R1 stated, They don't have sheets for my bed. R1 stated they have two sets that fit her mattress, and they can't always find…

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 supplements were served as ordered by the physician for 1 of 3 (R4) residents reviewed for nutritional supplements in the sample of 20. Findings Include:R4's admission Record with a print date of 2/26/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, spondylolysis, repeated falls, chronic obstructive pulmonary disease, heart disease, adult failure to thrive, anxiety, and cognitive communication deficit.R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating R4 has a moderate cognitive deficit.R4's Order Summary Report dated 2/26/26 includes the following physician order with a start date of 11/21/25, NCS (No Concentrated Sweets) diet Mechanical soft texture, Thins Liquids consistency, SC (super cereal) at breakfast, Health Shakes TID (three times daily) with meals. Fortified foods TID for diet.R4's current Care Plan Report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure diets were served in the consistency ordered by the physician for 1 of 3 (R4) residents reviewed for nutrition in the sample of 20.Findings Include: R4's admission Record with a print date of 2/26/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, spondylolysis, repeated falls, chronic obstructive pulmonary disease, heart disease, adult failure to thrive, anxiety, and cognitive communication deficit.R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating R4 has a moderate cognitive deficit.R4's Order Summary Report dated 2/26/26 includes the following physician order with a start date of 11/21/25, NCS (No Concentrated Sweets) diet Mechanical soft texture, Thins Liquids consistency, SC (super cereal) at breakfast, Health Shakes TID (three times daily) with meals. Fortified foods TID for diet.R4's current Care Plan Report documents a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement intervention to promote safety and healing of a diabetic ulcer for 1 of 3 residents (R1) reviewed for wounds in a sample of 7. The findings include:R1's admission Record documents an admission date of 1/26/2025 and documents that R1 was discharged to an acute care hospital on 1/22/26. This admission Record documents diagnoses including Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, Type 2 Diabetes Mellitus, Non-Pressure Chronic Ulcer of other parts of Right Foot with Fat Layer Exposed, Anxiety, Major Depressive Disorder, Lymphedema, Congestive Heart Failure, and Hypothyroidism. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12 indicating R1 has moderate cognitive impairment. Section GG documents R1 requires Partial/moderate assistance with shower/bathing, Substantial/maximal assistance with rolling left to right to back while in bed, sitting to lying, lying 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 interviews, observations and record reviews, the facility failed to implement interventions for preventing deterioration of a pressure ulcer for 1 of 3 (R2) residents reviewed for wounds in a sample of 7. The findings include:R2's admission Record documents an admission date of 8/10/2020 and includes diagnoses of Unspecified Sequelae of Cerebral Infarction, Pressure Ulcer of Right Buttocks (7/2/2025), Anemia, Hypertension, Schizoaffective Disorder, Psychosis, Vitamin D Deficiency, Hyperlipidemia, Vascular Dementia, Muscle Weakness, and Cognition Communication Deficit.R2's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, that R2 is rarely/never understood. There was no Brief Interview for Mental Status completed for R2. R2's cognitive skills for daily decision making is documented as severely impaired. Section GG, Functional Abilities, documents R2 is totally dependent on staff for all Activities of Daily Living (ADL's). Section H, Bladder and Bowel, documents R2 is always…

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 a pest free environment. This failure has the potential to affect all 66 residents residing at the facility. 1.On 08/18/25 at 12:16PM observed R68 in the dining room she was waving her hands in the air she was trying to wave the flies away from her hair and face. R68 stated she is so tired of these flies being all over her and on her food. R68's MDS (Minimum Data Set) dated 07/17/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 08 which indicates R68 has moderately impaired cognition. On 08/18/25 at 12:18PM observed R14 sitting at the table in the dining room she had pork, au gratin potatoes, zucchini with tomatoes and frosted cake. R14 was trying to take a bite of her frosted cake and she was waving over her cake trying to get the flies off of her cake. Observed 2 flies on top of the frosting on the cake. On 08/18/25 at 12:32PM. R14 stated that she is so tired of all the flies in the dining room. R14…

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 call lights were within reach for 4 of 4 (R11, R38, R41, and R49) residents reviewed for call lights on the sample list of 52.Findings include: 1. R11's admission Record documents an admission date of 11/6/24 with diagnoses including in part: end stage renal disease, dependence on renal dialysis, and diabetes. R11's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 08, indicating moderate cognitive impairment. R11's recent Care Plan document R11 is a fall risk with an intervention documented as be sure R11's call light is within reach and encourage R11 to use it for assistance as needed. R11 needs prompt response to all requests for assistance.R11's Fall Risk Assessment fated 8/16/25 documents R11 is a high risk for potential falls. On 8/18/25 at 10:12 AM, R11 was lying in her bed sideways with legs hanging off bed and her head against the wall with her pants pulled down to her knees. R11'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, observation, and record review the facility failed to dispose of medications properly and failed to check expiration dates for 5 of 5 (R3, R7, R31, R45, and R61) residents reviewed for medication expiration and storage in the sample of 52.Findings include: 1. R7's admission record documents an admission date of [DATE] and a discharge date of [DATE] with diagnoses including in part: diabetes, emphysema, chronic obstructive pulmonary disease, and acute respiratory failure with hypoxia. On [DATE] there was an expired inhaler for R7 in the medication cart, Ventolin HFA 108 mcg/act (micrograms per actuation aerosol inhaler) 2 puffs inhaled orally every 4 hours as needed for shortness of breath, with an expiration date of 07/2025 with 177 doses left. On [DATE] at 10:11 AM, V21 (License Practical Nurse) confirmed the medication was expired and stated R7 was using that medication prior to his discharge on [DATE]. 2. On [DATE] at 8:48am, a review of the facility medication storage was done. There 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, observation, and record review the facility failed to perform hand hygiene while performing eating and drinking assistance for 4 (R52, R57, R8 and R68) of 6 residents reviewed for dining in a sample of 52.Findings include:1. R52's admission Record documents an admission date of 6/10/2020 with the following diagnoses in part, Alzheimer's disease with early onset, Major Depressive Disorder and Gastro-Esophageal Reflux Disease without esophagitis.R52's Minimum Data Set (MDS) dated [DATE] documents that a Brief Interview for Mental Status (BIMS) was not completed because resident is rarely/never understood. Section GG- Functional Abilities documents that R52 is dependent on staff for eating.R52's current Care Plan document's that R52 requires extensive assistance with Activities of Daily Living.2. R57's admission Record documents an admission date of 2/23/23 with the following diagnoses in part, Gastro-Esophageal Reflux Disease without esophagitis, unspecified hearing loss, unspecified ear, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and record review the facility failed to provide Influenza and Pneumococcal Immunizations for 4 of 5 residents (R17, R51, R59 and R66) reviewed for Influenza and Pneumococcal Immunizations in the sample of 52. Findings include:Findings include:1. R17's Transfer/Discharge Report documents a date of birth that indicates R17 is [AGE] years old. This report also documents an admission date of 7/25/25, with the following diagnoses listed in part; acute respiratory failure with hypercapnia and chronic obstructive pulmonary disease, unspecified.R17's current complete medical record has no vaccinations listed in the immunization record or refusals of immunizations documented. 2. R51's Transfer/Discharge Report documents a date of birth that indicates R51 is [AGE] years old. This report also documents an admission date of 8/6/25, with the following diagnoses listed in part, bullous pemphigoid and essential primary hypertension.R51's complete medical record has no vaccinations listed in the immunization…

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 develop and implement Covid-19 immunization policies and offer and/or provide Covid-19 immunizations for 4 residents of 5 residents (R17, R51, R59, and R66) reviewed for immunizations in a sample of 52. Findings include: 1. R17's Transfer/Discharge Report documents a date of birth that indicates R17 is [AGE] years old. This report also documents an admission date of 7/25/25, with the following diagnoses listed in part; acute respiratory failure with hypercapnia and chronic obstructive pulmonary disease, unspecified.R17's current complete medical record has no vaccinations listed in the immunization record or refusals of immunizations documented.2. R51's Transfer/Discharge Report documents a date of birth that indicates R51 is [AGE] years old. This report also documents an admission date of 8/6/25, with the following diagnoses listed in part, bullous pemphigoid and essential primary hypertension.R51's complete medical record has no vaccinations listed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were treated with dignity for 3 of 4 residents (R21, R35, R48) reviewed for dignity in the sample of 52. Findings include: 1.R21's admission Record documents an admission date of 7/16/25 with the following diagnoses in part, Parkinsonism, major depressive disorder, anxiety, and repeated falls. R21's only completed Minimum Data Set, dated [DATE] does not document a Brief Interview for Mental Status. R21's current care plan only documents one focus area, Nutritional. On 8/20/25 at 12:31pm, R21 was observed in the dining room with a puddle under her and her jeans appeared wet. On 8/20/25 at 12:40pm, R21 was observed still sitting in the dining room with a puddle under her and wet pants. On 8/20/25 at 12:44pm, R21 was observed wheeling back to her room with her pants still wet. On 8/20/25 at 2:23pm, R21 was observed laying in her bed, still in wet pants. On 8/20/25 at 2:26pm, V4 (CNA/ Certified Nursing Assistant) stated she…

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 complete an initial comprehensive assessment for 1 of 3 residents (R21) reviewed for assessments in a sample of 52. Findings Include: R21's Transfer/Discharge Report documents an admission date of 7/16/25 with the following diagnoses in part, Parkinsonism, major depressive disorder, anxiety, and repeated falls. R21's medical record only contains the entry Minimum Data Set (MDS) dated [DATE], it does not document a Brief Interview for Mental Status. There was no admission assessment for R21 in R21's medical record. On 8/21/25 at 12:00pm, V1 (Administrator) stated under the assessment tab, there is a baseline assessment that should be completed by nursing on admission, and they believe that staff are mistaking this for other things. V1 stated staff have been educated. V1 stated they do not have a policy for MDS assessments. On 08/21/2025 at 2:45 PM, V8 stated that R21's entry MDS had been completed, but not her admission. V8 stated the reason R21'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 develop and implement a comprehensive care plan and failed to develop a plan of care for indwelling urinary catheter use for 2 of 4 residents (R11, R21) reviewed in a sample of 52. Findings include: 1. R21's Transfer/Discharge Report documents an admission date of 7/16/25 with the following diagnoses in part; Parkinsonism, major depressive disorder, anxiety and repeated falls.R21's only completed Minimum Data (MDS) Set dated 7/16/25 does not document a Brief Interview for Mental Status.R21's current care plan only documents one focus area, Nutritional.On 8/21/25 at 12:00pm, V1 (Administrator) stated the care plan for R21 that only contains one focus area is the current care plan. V1 stated under the assessment tab, there is a baseline assessment that should be completed by nursing on admission, and they believe that they are mistaking this for other things. V1 stated staff have been educated.2. R11's Transfer/Discharge Report documents an admission…

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 meal supplements, toenail care and incontinence care for 3 of 3 (R38, R48 and R50) residents reviewed for help with Activities of Daily Living (ADL's) in a sample of 52. Findings include: 1.R38's admission record documents an admission date of 12/19/23 with diagnoses including: chronic obstructive pulmonary disease with (acute) exacerbation, essential hypertension, hyperlipidemia, overactive bladder, dementia, gastro-esophageal reflux disease, and iron deficiency anemia. R38's Minimum Data Set, dated [DATE] documents a brief interview of mental status of 02 indicating severe cognition impairment. Section GG documents R38's eating ability as supervision or touching assistance needed. R38's order summary report documents a diet order of regular diet, mechanical soft texture, thin liquids consistency, and health shakes two times a day with an order date of 07/22/24 with no end date listed. R38's care plan documents a…

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

Based on interview and observation the facility failed to handle cups/glasses in a manner to prevent contamination for 2 (R38 and R48) of 6 residents reviewed for dining in a sample of 52. Findings include: On 08/19/25 at 7:50 AM, V17 (Certified Nurse Aide/CNA) delivered R48's drinks by transferring them by the rims where the resident would drink from, after touching a wheelchair handle and her scrub pants. On 08/19/25 at 8:13 AM, V18 (CNA) transferred R38's drinks from the tray to his table by the rim, where the resident would drink from, after touching a wheelchair handle and a resident's shirt. On 08/21/25 at 2:32 PM, V12 (Dietary Manager) stated drinks should not be transferred by the rims of the glasses where the residents drink from, especially after touching any unclean surface. V12 stated, he does not know who trains the CNAs or other staff for dietary procedures.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient staff to meet resident's needs. These failures have the potential to affect all 63 residents living in the facility. Findings include: 1.R1's admission Record, dated 06/06/25 documents an admission date of 04/28/25 to the facility with diagnoses in part of Type 2 diabetes mellitus, emphysema, chronic obstructive pulmonary disease, diarrhea, anxiety disorder, major depressive disorder, and heart failure. R1's MDS (Minimum Data Set) dated 05/05/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 15 which indicates R1 is cognitively intact. Section GG documents that R1 is dependent for toileting, showers, and personal hygiene. R1's Care Plan dated 05/28/25 documents a focus area titled Activities: R1 is dependent on staff for activities, cognitive stimulation and social interaction r/t (related to) limited mobility. On 06/03/25 at 10:49AM, R1 stated that sometimes it takes staff 30 minutes or more to answer his…

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 facility failed to maintain a clean comfortable home like environment for 5 of 5 residents (R7, R8, R9, R10, R11) reviewed for environment in a sample of 16. Findings include: 1. R7's admission Record documents an admission date of 5/20/25 with diagnoses including in part hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side and aphasia following cerebral infarction. R7's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13 indicating R7's cognition is intact. R11's admission Record documents an admission date of 3/27/25 with diagnosis including in part mild cognitive impairment of uncertain or unknown etiology, anxiety, and depression. R11's MDS dated [DATE] documents a BIMS of 15 indicating R11's cognition is intact. A facility Midnight Census Report dated 6/3/25 documents that R7 and R11 are roommates. On 6/5/25 at 10:08AM, R7 stated he has had problems with not having bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents who require assistance receive a shower for 4 of 6 residents (R1, R3, R5, and R6) reviewed for Activities of Daily Living assistance in the sample of 16. Findings include: 1.R1's admission record, dated 06/06/25 documents an admission date of 04/28/25 to the facility with diagnoses in part of Type 2 diabetes mellitus, emphysema, chronic obstructive pulmonary disease, diarrhea, anxiety disorder, major depressive disorder, and heart failure. R1's MDS (Minimum Data Set) dated 05/05/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 15 which indicates R1 is cognitively intact. Section GG documents showers/bathing as dependent. R1's Care Plan dated 05/28/25 documents a focus area titled Activities: R1 is dependent on staff for activities, cognitive stimulation and social interaction r/t (related to) limited mobility. On 06/05/25 at 8:30AM, R1 stated that he believes the facility is short on staff. R1 said he…

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

Based on record review and interview the facility failed to ensure that assessments were transmitted timely for 2 of 2 (R12 and R31) residents reviewed for assessments timely transmitted in a sample of 30. The Findings Include: 1. R12's face sheet documents an admission date of 12/7/21 and includes the following diagnosis: cognitive communication deficit, dementia, anxiety and weakness. R12's most recent MDS (Minimum Data Set) which was a quarterly documents it was completed 8/22/24. 2. R31's face sheet documents an admission date of 5/8/24 and includes the following diagnosis: cognitive communication deficit, depression, Parkinson's, and diabetes. R31's most recent MDS which was a quarterly documents it was completed 8/21/24. On 09/25/24 at 11:00 AM, V3 (MDS Coordinator) stated that the R12'S Quarterly MDS was complete by 8/22/24 when it was due but she didn't know how to transmit them until she called today to speak with her supervisor. At this same time V3 confirmed that R31's Quarterly MDS was due and completed on 8/21/24 but was submitted late also due to this error. On 9/26/24…

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

Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosed mental disorder for 3 (R37, R46, R47) of 3 residents reviewed for PASRR Screening in the sample of 30. Findings Include: 1. R37's Face Sheet documented an initial admission date to the facility as 7/11/2024. Diagnoses listed on this form included unspecified psychosis not due to a substance or known physiological condition. R37's Notice of PASRR Level I Screen Outcome dated July 8, 2024, documented No Level II Required- No SMR (Serious Mental Illness). On 9/26/2024 at 9:23 AM, V4 (Business Office Manager) stated, she does complete the PASRR screening for residents in the facility. V4 stated, R37 did not get referred for a PASRR level II evaluation because he did not have a diagnosis that would qualify for a PASRR Level II. V4 stated, it is her understanding that the dementia diagnosis overrules the unspecified psychos diagnosis. 2. R46's Face Sheet documented an initial admission date to the facility as…

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 sufficient staff were available to meet resident needs. This failure has the potential to affect all 56 residents living in the facility. Findings include: 1. On 04/15/24 at 3:15PM, R1 On 04/15/24 at 3:15PM, R1 stated he has had to wait on several occasions to be laid down after getting back from dialysis. R1 stated that he is always so sick and very tired after he gets back from dialysis and just wants to lay down right away. R1 stated that one day last week it took staff a very long time to lay him down because they didn't have enough staff to help lay him down. R1 wasn't sure how long he had to wait, but he knows it took a very long time before they came and laid him down. R1 stated that they could use more staff at nighttime. R1's Face Sheet, dated 04/17/24, documents an admission date of 03/14/23 to the facility with diagnoses of Type 2 diabetes mellitus, Hypertension, Chronic Kidney Disease Stage 4, and Arthritis. R1's Minimum Data Set…

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 immediately report allegations of abuse to the Administrator for 4 of 13 residents (R14, R15, R16, and R17) reviewed for abuse in a sample of 17. Findings include: On 4/16/24 at 11:40AM, V9 (Certified Nurse Assistant/ CNA) stated that the V11 (Licensed Practical Nurse/LPN) has been rude and yells at R16 and R15. V9 said that R15 will touch other resident food and V11 will tell R15 to get his nasty fingers out of other residents' food. V9 said that V11 will yell at R16 to get away or move out of the way. V9 stated that she did not know who the abuse coordinator was and that she didn't know who to report abuse to. V9 said she wanted the number for public health to report the abuse to, but she said the administrator wouldn't give her the number for public health. V9 said that she wasn't aware of any other staff being verbally or physically abusive to any other resident. On 04/16/24 at 1:00PM, V7 (Certified Nurse Assistant/CNA) stated that V11 (LPN) has…

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 that residents who require assistance with transfers into bed were assisted in a timely manner for 1 of 1 resident (R1) reviewed for Activities of Daily Living (ADL) in the sample of 17. Findings include: R1's Face Sheet, dated 04/17/24, documents an admission date of 03/14/23 to the facility with diagnoses of Type 2 diabetes mellitus, Hypertension, Chronic Kidney Disease Stage 4, and Arthritis. R1's Minimum Data Set (MDS) dated [DATE], documents in Section C a Brief Interview for Mental Status (BIMS) score of 8, indicating that R1 has moderately impaired cognition. Section GG documents R1 is dependent for transfers, toileting, showers, and personal hygiene. R1's Current Care Plan, documents a focus of Skin at risk for skin complications r/t related to incontinence, potential for friction/shearing and weakness. At increased risk for further skin breakdown due to refusal of pressure relieving boots with intervention of turn and position 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 complete baseline care plans for 4 of 4 residents (R1, R2, R4, R6) reviewed for assessments in a sample of 6. Findings include: 1. R1'S Face Sheet documented R1 is a [AGE] year-old female, who admitted to the facility on [DATE]. Diagnoses listed on this document are Sepsis, unspecified organism, Urinary Tract Infection, site unspecified, bipolar disorder, unspecified, unspecified intellectual disability, unspecified glaucoma. V13 (Physician) is listed as being R1's Primary Care Physician. The only emergency contact listed for R1 on this document is V30 (Guardian/Emergency Contact # 1). R1 was discharged on 03/25/2024, after being sent to (Local hospital) emergency room on [DATE]. R1's Physician order sheet dated 04/02/2024 documents: Clonazepam Oral Tablet 0.5 MG Give 1 tablet by mouth at bedtime for bipolar with an order date of 02/20/2024. Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for blood thinner with an order date…

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 develop and implement comprehensive care plans for 4 of 4 residents (R1, R2, R4, R6) reviewed for care plans in a sample of 6. Findings include: 1. R1's Face Sheet documented R1 is a [AGE] year-old female, who admitted to the facility on [DATE]. R1 was discharged on 03/25/2024, after being sent to (Local hospital) emergency room on [DATE]. Diagnoses listed on this document are Sepsis, unspecified organism, Urinary Tract Infection, site unspecified, bipolar disorder, unspecified, unspecified intellectual disability, unspecified glaucoma. V13 (Physician) is listed as being R1's Primary Care Physician. The only emergency contact listed for R1 on this document is V30 (Guardian/Emergency Contact # 1). On 03/25/2024 during a review of R1's Electronic Medical Record the following were noted: An undated baseline admission care plan, a Minimum Data Set (MDS) with a completion date of 02/27/2024 were present. A Comprehensive Care Plan had not yet been initiated…

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 for proper physical restraint use for 3 of 3 residents (R1, R4, R5) reviewed for restraints in a sample of 6. The findings include: 1. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Unspecified and Unspecified Intellectual Disabilities. R1's Face Sheet documents discharged from the facility on 3/25/2024. R1's Minimum Data Set (MDS) dated [DATE] documents Section C, Brief Interview for Mental Status (BIMS) score is 13, indicating R1 is cognitively intact. Section GG, Functional Abilities and Goals, documents that R1 is dependent with all activities of daily living. On 3/26/2024, at 10:40 AM, V11 (Certified Nursing Assistant/CNA) stated that she remembers seeing multiple scratch areas to R1's chest like she had dug into her chest. V11 stated that the staff would put socks over her hands to help keep her from scratching. On 3/27/2024, at 8:45 AM, V29 (Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) coding was completed for 3 of 4 (R1, R2 and R4) residents reviewed for accuracy of assessments in the sample of 6. Findings include: 1. R1's Face Sheet documented R1 is a [AGE] year-old female, who admitted to the facility on [DATE]. R1 was discharged on 3/25/2024, after being sent to (Local hospital) emergency room on 3/21/2024. Diagnoses listed on this document are Sepsis, unspecified organism, Urinary Tract Infection, site unspecified, bipolar disorder, unspecified, unspecified intellectual disability, unspecified glaucoma. V13 (Physician) is listed as being R1's Primary Care Physician. The only emergency contact listed for R1 on this document is V30 (Guardian/Emergency Contact # 1). R1's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 13, that R1 is cognitively intact. Section A, question A1500 of R1's MDS documents: R1 is currently considered by…

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 assess and seek timely treatment for a self- inflicted injury for 1 (R1) of 3 residents reviewed for skin impairment in a sample of 6. The findings include: R1's Face Sheet documents that R1 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Unspecified and Unspecified Intellectual Disabilities. R1's Face Sheet documents a discharge date from the facility of 3/25/24. R1's Minimum Data Set (MDS) dated [DATE] documents Section C, a Brief Interview for Mental Status (BIMS) score of 13, indicating that R1 is cognitively intact. Section GG, Functional Abilities and Goals, of the same MDS documents that R1 is dependent with all activities of daily living. R1's hospital notes Discharge summary dated [DATE], and prior to R1's admission to the facility, under Physical Exam documents in part .There was a circumferential sore on the left forearm, believed to be related to ischemia from a bracelet; No other sores or rashes noted.…

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 staff were following the proper PPE (Personal Protective Equipment) protocols for residents in isolation. This has the potential to affect all 59 residents living in the facility. The findings include: On 10/4/23 at 8:45am, V1 (Administrator) said that they had 27 positive COVID residents, 16 exposures and 14 staff that tested positive also. V1 said that the first positive case was a staff member on 9/22/23 and the last positive case was on 10/3/23. V1 said that each resident was placed on droplet precautions and signs posted on the door. 1. On 10/4/23 at 10:00am, Observations were made of signage outside of R4's door indicating the sequence for putting on personal protective equipment (PPE) noting: 1. gown. 2. mask or respirator 3. goggles or face shield 4. gloves. On 10/4/23 at 10:00am, V5 (CNA/Certified Nurse Assistant) was observed in R4's room pulling R4 backwards through the door. V5 was wearing a N95 mask and gloves. V5 was not wearing a face shield or a gown. R4 was not wearing a mask. 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.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure the facility is free of flies. This has the potential to affect all 60 residents residing in the facility. Findings include: On 7/25/23 at 10:45 AM during the lunch preparation, several flies were observed to be flying over the stove, the steam table and landing on the countertops. V4 (Dietary Supervisor) stated that he wishes that they could get rid of the flies. V4 went on to state that he believes that the residents going in and out the front door is part of the reason they are so bad inside the facility. On 7/25/23 at 12:00 PM, during lunch observation in the dining room several flies were observed flying throughout the dining room and landing on resident dining room tables while waiting for their lunch to be delivered. On 7/25/23 during initial tour of the facility from 9:00 AM - 2:00 PM, several flies were observed throughout the entire facility flying in all areas of the facility. On 7/25/23 at 1:00 PM, R26 stated that the flies are terrible and she…

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 refer a resident for Preadmission Screening and Resident Review (PASRR) as recommended for 2 (R46 and R7) of 4 residents reviewed for PASRR's in the sample of 30. Findings Include: 1. R46's Face Sheet documents an initial admission date to the facility as 1/27/23, with diagnoses including but not limited to Diffuse Traumatic Brain Injury without loss of consciousness, subsequent encounter, Depression, Unspecified, and Anxiety, Unspecified and Other Seizures. R46's Notice of PASRR Level I Screen Outcome documents under the section labeled Ascend Outcome with a review date of 01/25/2023, Level I Outcome: Exempted Hospital Discharge. Rationale: Exempted Hospital Discharge 30 Day Approval- A 30 day or less stay in the NF (nursing facility) is authorized. Re-screening must occur by or before the 30th day if the individual is expected to remain in the NF beyond the authorization timeframe. The individual meets criteria for a 30-day hospital exemption admission, due to known or suspected Serious Mental Illness diagnosis indicated…

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.