Helia Southbelt Healthcare

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 for 3 of 7 residents (R34, R44, R76) reviewed for care plans in a sample of 57. Findings include: 1.R34's face sheet, print date of 9/23/25, documented R34 has diagnoses including atherosclerotic heart disease, hypothyroidism, type 2 diabetes mellitus, hyperlipidemia, major depressive disorder, anxiety disorder, intermittent asthma, and muscle weakness. R34's MDS (Minimum Data Set), dated 7/4/25, documented R34 is moderately cognitively impaired and requires assistance with all ADLS (activities of daily living). R34's care plan, undated, documented resident has contractures of the right hand with interventions of ensure proper positioning as tolerated in bed and chair, meds as ordered and observe effectiveness of meds, observe for pain or increased stiffness, and notify MD of changes, provide gentle ROM (range of motion) during daily care as tolerated, and turn and reposition as needed while in bed/chair.…

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 properly and safely transfer 2 of 5 residents (R45 and R30) reviewed for safety in a sample of 57. This failure resulted in R30's leg being hit on the mechanical lift and experienced pain.Findings include: 1. R45's Care Plan, not dated, does not address R45's transfers. R45's Minimal Data Set (MDS), dated [DATE], documents that R45 has short- and long-term memory problems and is severely cognitively impaired. It also documents that R45 is dependent on staff for bed to chair transfers.R45's Clinical Observation - Transfer Assessment, dated 9/19/25, documents that R45 is to use the full body/Hoyer lift for all transfers.On 9/22/2025 at 10:08 AM observed V29, Certified Nurses Assistant (CNA), and V30, CNA, transfer R45 from the bed to the reclining wheelchair using a full body lift. V29 and V30 applied the sling straps to the lift bar. V30, operating the controls, with V29, standing at the foot of the bed, then raised R45 into the air above 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 observation, interview and record review the facility failed to perform complete incontinence care for 1 of 3 (R30) residents reviewed for toileting in a sample of 57.Findings include: R30's Care Plan, dated 3/21/23, documents that Problem: Resident is at risk for impaired skin integrity r/t (related to) incontinent of B&B and decreased mobility. Approach: Provide incontinence care for episodes of incontinence. Resident is incontinent of bowel and bladder and is not appropriate for B&B (bowel and bladder) program due to physical limitations. Approach: Provide incontinent care as neededR30's Minimum Data Set, dated [DATE], documents that R30 is frequently incontinent and dependent on staff for toileting.On 9/24/2025 at 9:20 AM observed V30, Certified Nursing assistant (CNA), provide incontinent care to R30. Observed R30 ambulating to the bathroom with heavily soiled incontinent brief hanging between R30's legs. V30 assisted R30 with removing the heavily soiled incontinent brief and R30 sat on toilet. V30…

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 prevent resident to resident abuse in 1 of 3 residents (R9) reviewed for abuse in a sample of 3.Findings Include:R9's Face Sheet, undated, documents R9 was admitted to the facility on [DATE] and has a medical diagnosis of Psychoactive Substance Abuse, Blindness Right Eye Category 3, Blindness Left Eye Category 3, and Hallucinations.R9's Minimum Data Set (MDS) dated [DATE] documents R9 is moderately cognitively impaired and has displayed verbal behaviors directed towards others. R9's Care Plan R9's Care Plan Last Reviewed/ Revised 8/18/2025 documents resident is considered at risk for abuse/neglect. R9's Progress Note dated 9/8/2025 at 6:05 PM documents This resident had an altercation with another resident related to resident hitting him in the groin. Then resident started slapping other resident in the face. No injury noted Admin and Director of Nursing (DON) made aware and police was call. Stated to keep everyone separated.The Facility's Initial…

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 requiring assistance for transfers were getting assistance and transferred with the mechanical lift for 1 of 3 residents reviewed for transfers in the sample of 11. Findings include: R3's Physician order Sheets (POS) for August 2025 documents a diagnosis of Unspecified osteoarthritis, unspecified site; Chronic venous hypertension (idiopathic) with other complications of unspecified lower extremity; Essential (primary) hypertension; Type 2 diabetes mellitus with hyperglycemia; Morbid (severe) obesity due to excess calories; Body mass index [BMI] 45.0-49.9, adult; Hyperlipidemia, unspecified; Hypothyroidism, unspecified; Other chronic pain; Insomnia; and Overactive bladder. R3's MDS dated [DATE] document R3 was cognately intact for decision making of activities of daily living. R3 uses a motorized wheelchair and is dependent on staff for transfers.R3's Care Plan with a revision date of 6/23/2025 documents. Problem: Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to adequately assess and provide supervision to prevent elopement for 1 of 5 residents (R7) reviewed for supervision in the sample of 8.Findings Include:On 8/13/25 at 11:00AM, R7 observed up in his electric wheelchair exiting the facility through the front door. R7 was able to enter the code and stayed in front of the facility.R7's Face Sheet, undated, documents R7 has the following diagnoses: Hemiplegia and Hemiparesis following a Cerebrovascular Disease Affecting the Left Non-Dominant Side, Cerebral Infarction, Vascular Dementia, and Acquired Absence Below the Knee of Right and Left Legs.R7's Minimum Data Set, MDS, dated [DATE], documents R7 has a BIMS (Brief Interview of Mental Status) score of 12, indicating R7 has moderate cognitive impairment.R7's Care Plan, dated 1/27/23, documents R7 is limited in physical mobility R/T hemiplegia and amputation. R7 utilizes an electric w/c (wheelchair). R7's electric w/c seat belt damaged.R7's 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 observation, record review, and interview, the facility failed to provide revise interventions/approaches for behaviors in a resident with Dementia related to wandering for 1 of 1 resident (R3), reviewed for Dementia Care in the sample of 8.Findings include:On 8/13/25 at 1:00PM, R3 was observed ambulating independently on the hallway he resides. R3 was wandering on the hallway, stopping at various doors but did not enter. R3 is alert to self only.R3's Face Sheet, undated, documents R3 has the following diagnoses: Dementia, Restless and Agitation, Unspecified Psychosis, Major Depressive Disorder, Generalized Anxiety Disorder, and Insomnia.R3's Minimum Data Set, MDS, dated [DATE], documents R3 has a BIMS (Brief Interview of Mental Status) score of 2, indicating R3 has severe cognitive impairment.R3's Care Plan, with a review date of 7/22/25, documents R3 is exhibiting wandering behaviors and is at risk for injury related to impaired safety awareness. He invades other's spaces without intention, gets…

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 responsible party of a change in condition for 1 out of 3 residents, (R4); reviewed for Resident Rights in a sample of 11. Findings include: R4's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, dementia, chronic kidney disease, and Alzheimer's disease. R2's Minimum Data Set (MDS) dated [DATE], documented staff were unable to complete the interview to determine R4's Brief Interview of Mental Status (BIMS); it does document R2's cognitive skills for daily decision making are severely impaired and inattention is continuously present, does not fluctuate. R4's Care Plan last revised on 2/18/25, documented she has a communication deficit related to Alzheimer's dementia with interventions of, in part, to communicate with family to determine what works best for resident which was started on 12/03/2024. Wound Management details dated 4/17/25, documented R4 had a skin tear to her right ankle identified 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 interviews and record reviews the facility failed to ensure medications were completely administered and failed to accurately document the administration of medications for 1 out of 4 residents, (R2) reviewed for Pharmacy Services in a sample of 11. Findings include: R2's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, adrenocortical insufficiency, neuromuscular dysfunction of bladder, type two diabetes mellitus, and hypertension. R2's Minimum Data Set (MDS) dated [DATE], documented she was cognitively intact. R2's Care Plan last revised on 3/11/25 documented she presented with non-compliant behavior as evidenced by refusing medication due to wanting to take medications on her own time rather than while nurse is in her room. R2's Medication Administration Record (MAR) dated 4/27/25 documented that she was ordered to receive the following medications by mouth that could have been left in a pill cup, hydrocortisone 10 mg (milligram) tablet, hydrocortisone 5 mg…

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 prevent physical and verbal abuse for 1 of 3 (R2) residents investigated for abuse. Findings include: R2's EMR (electronic medical records) undated documents that resident was admitted to the facility on [DATE]. R2's EMR dated 05/16/24 documents diagnose of Acute respiratory failure, unspecified whether with hypoxia or hypercapnia, Dependence on respirator [ventilator] status, and Quadriplegia, unspecified. R2's MDS (Minimum Data Set) dated 8/16/24 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. R2's MDS dated [DATE] documents that resident is dependent for eating, oral hygiene, toilet hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Facility's Abuse Investigation dated 2/20/25 documents On 2/21/25 the resident (R2) Dx: quadriplegia, requested to speak with the administrator. Upon going to the resident's room, he stated that the previous night he had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent urinary tract infections for 3 of 4 residents (R3, R4, R5) reviewed for incontinent care in the sample of 8. Findings include: 1. R3's Face Sheet, print date of 2/14/25, documents that R3 was admitted on [DATE] with diagnoses of flaccid hemiplegia affecting the right dominant side and a personal history of urinary tract infections. R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact, requires partial to moderate assistance with toileting, always incontinent of urine, and frequently incontinent of bowel. On 2/14/25 at 4:15 AM, V9 Certified Nurse Assistant (CNA), transferred R3 from the bed, to the wheelchair, and then to the toilet. V9 removed the incontinent brief. The brief was slightly soiled with urine. When R3 finished, she stood up, V9 washed her rectal area with a soapy towel. V9 pulled up the incontinent brief and R3's pants. R3 was transferred back to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure 1 of 3 resident's (R6) prescription eye drops were documented as administered per professional standards regarding medication administration/documentation in a sample of 3. Findings include: R6's Undated Face Sheet, documents R6 was initially admitted to the facility on [DATE] with a diagnosis of glaucoma. R6's Physician's Order Sheet (POS), dated 4/2024 documents an order Latanoprost 0.005% 1 gtt (drop) both eyes at bedtime. The Reorder Fill History from the facility's pharmacy documents Latanoprost 0.005% eye drops were not refilled for the month of 4/2024. R6's Medication Administration Record (MAR) dated 4/2024 documents Latanoprost 0.005% was documented administered for all the days. R6's POS, dated 11/2024 documents Latanoprost 0.005% 1 gtt both eyes at bedtime. R6's MAR, dated 11/2024 documents Latanoprost 0.005% was administered on 11/1/2024. It was documented as a T for 11/2/2024 through 11/4/2024 - legend identified T as therapeutic…

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 use a gait belt during a one person transfer, and failed to implement fall precautions for 2 of 2 residents (R7, R11) in a sample of 21 reviewed for falls. Findings include: 1. R11's Undated Face Sheet, documents he was initially admitted to the facility on [DATE] with a recent readmission from the hospital on [DATE]. R11's Minimum Data Set (MDS) dated [DATE] documents severely cognitively impaired, substantial/maximal assistance with toilet transfer. R11's Care Plan documents problem: ADLs (Activities of Daily Living) functional status/rehabilitation potential. R11 required extensive assistance x1 with most ADLs. Transfers via assist x1 with use of gait belt. Wheelchair is primary mode of transportation. Goal: R11 will gain strength and ADL independence to d/c (discharge) to home. Problem: R11 is at risk for falls related impaired mobility. Goal: R11 will remain free from injury. Approaches: place bed in lowest position while resident is…

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 timely and reliable transportation for medical care for 1 of 3 residents (R2) reviewed for provision of medically related social services in the sample of 21. Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including dementia, heart failure, weakness, and need for assistance with personal care. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, required partial assistance with bed mobility, required substantial assistance with transfer, and ambulated via wheelchair. R2's Appointment Calendar for the month of November 2024 documents R2 had an appointment with a MD (Medical Doctor) scheduled on 11/18/24 at 11:00 AM. The Facility's Grievance/Concern/Complaint Form from V15, R2's Family, on 11/18/24 documents, (R2) was late for her doctor's appt (appointment) today. This is the third time appt rescheduled. Transportation ran late w/another appt. Dr…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure 1 of 3 residents (R6) medication were refilled by the pharmacy or delivered to the facility for prescribed eye drops regarding medications per physician's orders in a sample of 3. Findings include: R6's Undated Face Sheet, documents R6 was initially admitted to the facility on [DATE] with a diagnosis of glaucoma. R6's Physician's Order Sheet (POS), dated 4/2024 and 11/2024 documents an order Latanoprost 0.005% 1 gtt (drop) both eyes at bedtime. On 12/11/2024 at 2:20 PM V25, Pharmacy Order Entry Technician, stated (R6's) prescription eye drops Latonoprost 0.005% was not refilled or delivered to the facility to be administered for the months of April 2024 and November 2024 and they would have ran out because the eye drop bottle is a 25 day supply if administered every day per physician's orders. The Reorder Fill History from the facility's pharmacy documents Latanoprost 0.005% eye drops were not refilled for the month of 4/2024 and 11/2024. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure 1 of 3 residents (R6) medication administration record was accurately documented for physician prescribed eye drops regarding documentation of medication administration in a sample of 3. Findings include: R6's Undated Face Sheet, documents R6 was initially admitted to the facility on [DATE] with a diagnosis of glaucoma. R6's Physician's Order Sheet (POS), dated 4/2024 documents an order Latanoprost 0.005% 1 gtt (drop) both eyes at bedtime. The Reorder Fill History from the facility's pharmacy documents Latanoprost 0.005% eye drops were not refilled for the month of 4/2024. R6's Medication Administration Record (MAR) dated 4/2024 documents Latanoprost 0.005% was documented administered for all the days. R6's POS, dated 11/2024 documents Latanoprost 0.005% 1 gtt both eyes at bedtime. R6's MAR, dated 11/2024 documents Latanoprost 0.005% was administered on 11/1/2024, T was documented for 11/2/2024 through 11/4/2024 which means therapeutic leave, 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 ensure residents were free from abuse for 1 of 3 residents (R2) reviewed for physical abuse in the sample of 3. Findings include: R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, depression, abnormalities of gait and mobility, and pain. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, ambulated via wheelchair, and was independent with bed mobility and transfer. R2's Care Plan updated 11/26/24 documents R2 is at risk for abuse and neglect. The Facility's Initial Report sent to the (State Agency) on 11/16/24 at 10:15 PM documents V1, Administrator, was notified on 11/16/24 at 10:00 PM that R2's CNA (Certified Nursing Assistant) became agitated with her during care and touched her face in a [NAME] way. The CNA was suspended pending investigation. R2's Progress Note by V5, Licensed Practical Nurse (LPN), on 11/16/24 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 records review and interviews, the facility failed to permit a resident to return to the facility from the hospital for 1 of 3 (R5) residents reviewed for discharge in a sample of 11. Finding included: R5's Electronic Heath Record (EHR), not dated, documents that R5 was admitted on [DATE] at 5:46 PM with diagnosis of Acute respiratory failure, unspecified whether with hypoxia or hypercapnia as Primary/admission and Dependence on respirator [ventilator] status, Quadriplegia, unspecified, Pain, unspecified, Major depressive disorder, single episode, unspecified, Neuromuscular dysfunction of bladder, unspecified, Encounter for attention to tracheostomy, Tracheostomy status, Presence of cardiac pacemaker, Personal history of pulmonary embolism, Chronic embolism and thrombosis of left femoral vein, Acute embolism and thrombosis of right peroneal vein, Extended spectrum beta lactamase (ESBL) resistance Note: Lung, Spinal stenosis, cervical region, Other nondisplaced fracture of third, fourth, and fifth…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to apply residents' continuous positive airway pressure (C-PAP)/bilevel positive airway pressure (Bi-PAP) machine at bedtime as ordered for 1 of 2 residents (R3) reviewed for respiratory care in a sample of 7. Findings include: On 10/7/2024 at 11:26 PM, R3 was in her room. She was wearing a hospital gown, eyes were closed, door was open. R3 was not wearing a C-PAC or Bi-PAP machine. On 10/8/2024 at 12:03 AM and again at 12:15 AM, R3 was still sleeping at a 45-degree angle, with no C-PAC machine on her face. R3's Face Sheet, with an admission date of 08/30/2019, documented R3 has diagnoses of but not limited to Congestive Heart Failure (CHF), Type II Diabetes Mellitus, and Obstructive sleep apnea (adult) (pediatric). R3's Minimum Data Set (MDS), dated [DATE], documented R3 is severely cognitively impaired and is dependent on staff for all her activities of daily living (ADLs). R3's Care Plan, admission date of 08/30/2019, has no…

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 complete an updated facility assessment to accurately reflect their current resident acuity levels and population. This failure has the potential to affect all 104 residents residing in the facility. Findings include: On 8/8/24 at 2:14 PM, the facility assessment, dated 1/2023 through 12/2023, was reviewed and failed to document updated resident acuity and population to develop an appropriate plan for caring for their current population. The facility has recently added a new specialty area of ventilator/tracheostomy care and treatment and is not included in the in their current resident population. On 8/6/24 at 2:17 PM, V1, Administrator, stated they do not have an updated facility assessment. The Centers for Medicare and Medicaid Services, form 671, documents the facility has 104 residents residing in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent abuse in 5 of 5 residents (R34, R53, R63, R67, R77,) reviewed for abuse in the sample of 43. Findings include: 1. R34's Abuse Report, dated 8/4/24, documents an allegation was made that R34 made contact with R77's left arm due to R77 bumping into him with her wheelchair. R34's Abuse Report, dated 5/18/24, documents R34 struck R77 with a wet floor sign, R77 sustained a laceration to her forehead. R34's Abuse Report, dated 4/8/24, documents R34 struck R77. When R34 was asked why he struck R77, he stated she was too close to me. R34's Abuse Report, dated 2/11/24, documents R34 hit R77 in the chest. When R34 was asked why he hit R77, he stated she rolled over his toes. Allegation of resident to resident abuse is substantiated. R34's Abuse Report, dated 12/14/23, documents R77 rolled over R34's feet and he took his water mug and hit her in the elbow. R34's Abuse Report, dated 12/6/23, documents R34 took a broom that was left on the hall 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, observation and record review, the facility failed to provide activities for 4 of 4 residents (R34, R57, R72, R77), reviewed for activities in the sample of 43. Findings include: 1. On 8/6/24 at 9:40 AM, R34 was observed in the dining room with his head down with no activities going on. On 8/9/24 at 9:21 AM, R34 was observed up in his wheelchair sitting in the hallway. No activities going on. R34's Face Sheet, undated, documents R34 has a diagnosis of Dementia, Encephalopathy, Unspecified Mood Disorder and Depression. R34's MDS (Minimum Data Set), dated 4/19/24, documents R34 has a BIMS (Brief Interview for Mental Status) of 8, indicating R34 has moderate cognitive impairment. R34's Care Plan, dated 5/20/24, documents R34 enjoys both group activities and independent leisure activities favorite act's include spirituality. R34 finds it important to listen to a variety of music, have books/magazines/newspapers available upon request, be around dogs or cats, keep up with the news, do things with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation the facility failed to hold and serve food at safe temperatures for therapeutic diets for 7 out of 7 residents (R25, R47, R54, R66, R88, R90, and R92) reviewed for food procurement store/prepare/serve food in the sample of 43. Findings Include: R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact. R25 stated during the group meeting on 8/8/24 at 2:00 PM that the food is always cold for breakfast. R47's MDS dated [DATE] documents R47 is cognitively intact. During the group meeting on 8/8/24 at 2:00PM R47 stated that the food is always cold at breakfast. R92's MDS dated [DATE] documents R92 is cognitively intact. On 8/8/24 at 2:00PM in the group R92 stated the food is always cold at breakfast. R54's Physician Order Sheet (POS) dated 1/28/24 documents that R54 is on a regular diet mechanical soft. R54 MDS dated [DATE] documents R54 is moderately cognitively intact. On 8/6/24 at lunch time she was served mechanical soft beef tips that were 110 degrees…

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 wound care treatments as ordered by the Physician to promote wound healing in 1 of 4 residents (R2) reviewed for quality of care in the sample of 7. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Chronic Kidney Disease, Heart Disease, Venous Insufficiency, Rheumatoid Arthritis, Chronic Non-Pressure Related Ulcer to the Buttock and Open Wound of the Left Buttock. R2's Minimum Data Set, dated [DATE], documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's Care Plan, dated 3/3/22, documents R2 is at risk for impaired skin integrity. The Wound Log, dated 7/16/24, documents R2 has a wound to his left medial buttock. R2's Physician Order Sheet documents an order dated 6/24/24, to cleanse the left medial buttock with normal saline, apply Silver Silvadene, collagen powder and calcium alginate and cover with a dry dressing daily and 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, observation and record review, the facility failed to infuse tube feeding at a rate ordered by the physician to aid in nutrition in 1 of 4 residents (R4) reviewed for tube feeding management in the sample of 7. Findings include: R4's Face Sheet, undated, documents R4 has the following diagnoses: Amyotrophic Lateral Sclerosis, Protein-Calorie Malnutrition, Gastrostomy Status and Dysphagia. R4's Minimum Data Set, dated [DATE], documents R4 receives 51% or more of his nutrition through tube feeding. R4's Care Plan, dated 2/6/24, documents R4 is dependent on tube feeding for all nutrition and hydration needs with an intervention to administer tube feeding as ordered. R4's Progress Note by the Dietician, dated 7/8/24 at 1:31 PM, documents R4's current body weight on 7/5/24 was 108.8 lbs, which indicates an undesirable weight loss from the previous usual body weight of 116 - 118 lbs. Decline noted since readmission last month. Continues Nutren 2.0 at 40ml (milliliters)/hr (hour) for 23 hours with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to provide and implement fall interventions as care planned for 4 of 5 (R1, R2, R4, R5) residents reviewed for accidents. R1's face sheet, print date 7/3/24, documented R1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, epileptic seizures, heart disease, type 2 diabetes mellitus, and depression. R1's MDS (Minimum Data Set), dated 5/10/24, documented that R1 is cognitively intact. R1's care plan, undated, documented that R1 is at risk for falls related to an unsteady gait and that R1 is to have the following interventions in place: reminder signs placed to remind to use call light for assistance, canoe mattress on bed, and dycem in her wheelchair to prevent sliding. R1's EMR (Electronic Medical Record) progress note dated 12/22/23 at 10:03 am documented resident observed on floor. Resident stated she was sleeping and rolled out of bed. Injury (hematoma) noted to left side of forehead. Resident stated her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide insulin for the first five days of admission for one of three residents( R2) reviewed for significant medications errors in the sample of 9. Findings Include: R2's Minimum Data Set, dated [DATE] documents R2 is moderately cognitively impaired. R2's Electronic Health Record under CCD (Continuity of Care) Diagnosis documents Type 2 Diabetes without complications was added on 5/13/24. R2's Face Sheet documents R2 was admitted on [DATE]. R2's admission Note dated 5/13/24 resident admitted to facility via family transportation from (Another State). resident present A&Ox2-3 (Alert and Oriented). Resident in good spirit with minor confusion on where he is. Resident currently has on a back brace related to recent fall and sustained T12 fracture as well as 11th and 12th rib fracture per family and referral paperwork. resident noted to be in minimal pain at this time. Resident transferred to bed two assist with a cane. VS (Vital Signs)…

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 take and record food temperatures before and during meal service, to maintain food at the proper temperatures when delivering meals to the residents, and to perform glove changes and hand hygiene during serving of the food. This has the potential to affect all 114 residents residing at the facility. The findings include: 1. R3's Face Sheet, undated, documents R3 was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (DM), Anemia, Hypertension (HTN), Hyperlipidemia, Morbid obesity, Sleep apnea, Right Below Knee Amputation (RBKA), Major depressive disorder, COVID-19, and Chondrocalcinosis. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact. On 6/3/24 at 3:15 PM, R3 stated, I eat in my room and in the dining room, and the food is ok, but it is always cold, especially the potatoes. I told a supervisor this once, who told me she would test a french fry from the kitchen, and I insisted 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 ensure resident showers for activities of daily living were being given for 5 of 8 residents (R2, R3, R5, R7 and R8) reviewed for activities of daily living to maintain good grooming and personal hygiene in the sample of 10. Finding include: 1-R3's Minimum Data Set, (MDS) dated [DATE] document R3 was cognitively intact for decision making of activities of daily living. The MDS also documents R3 has impairment on both sides of the lower extremity, and documents for Shower/bath R7 requires substantial/maximal assistance with helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. On 3/12/2024 at 10:03 AM, R3 stated, I am not getting my showers, it has been a few weeks now since I last had a shower. I like to get showers and always feel better after I get a shower. R3's Shower Sheets documents, a Bed bath was given on 3/12/2024, (3/12/2024 to 3/21/2024 (9 days without a shower), 3/8/2024, 3/5/2024…

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 showers were being given for 7 of 8 residents (R3, R6, R7, R8, R9, R10, R11) reviewed for showers in the sample of 24. Finding include: On 2/23/2024 at 11:38 AM, V4, Ombudsman stated, I am not sure what is happening in the facility. I have been getting several complaints from multiple residents about not getting showers. I have approached the Administrator on several occasions because every time I go out to the facility there is another person complaining about it. When I ask the Administrator what is going on she tells me she does not understand and has no reason why the showers were not being done. I am not sure why this is happening, and residents are not getting their showers. 1-R7's Minimum Data Set, (MDS), dated [DATE] documents, R7 was moderately impaired for decision making of activities of daily living. R7 was documented as using a wheelchair. R7's Care Plan 2/22/2022 documents, R7 is limited in ability to transfer self-related 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 observation, interview, and record review, the facility failed to perform timely incontinent care for 2 of 3 residents (R1, R2,) reviewed for Activities of Daily living in the sample of 9. Findings Include: 1. R1's Face Sheet documents an admission date of 3/30/2022. Diagnosis includes: History of Malignant Neoplasm to Bladder, Right Below the Knee Amputation, Chronic Kidney Disease, Atherosclerotic Heart Disease, Peripheral Vascular Disease On 11/16/2023 at 11:40AM, R1 stated to V3 CNA and V4 LPN that she was dirty with a bowel movement (BM). V3 nor V4, did not do incontinent care while in room. At 12:00PM V7, CNA, completed incontinent care to R1. No issues noted. R1's Minimum Data Set, MDS, dated [DATE] documents R1 has no cognitive impairments and is frequently incontinent of bowels. MDS dated [DATE] documents R1 requires extensive assist with bed mobility, transfers, and toileting. R1's care plan updated 7/11/2023 documents Requires assistance with Toileting for BM and requires assist with urostomy…

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 ostomy care consistent with professional standards of practice for 2 of 2 residents (R1, R4) reviewed for ostomy care in the sample of 9. Findings include: 1. R1's Face Sheet documents an admission date of 3/30/2022. Diagnosis includes History of Malignant Neoplasm to Bladder, Right Below the Knee Amputation, Chronic Kidney Disease, Atherosclerotic Heart Disease, Peripheral Vascular Disease. On 11/16/2023 at 11:15AM, V4(Certified Nursing Assistant/CNA) came into R1's room. V4, CNA, stated to R1 Lets drain your ostomy bag. When V4 pulled down R1's sheet, V4, CNA, stated I have never seen a dressing on there before. Surveyor observed an abdominal pad over stoma site. V4, CNA, stated, I will have to get the nurse. V4, CNA, and V3, Licensed Practical Nurse, LPN, came into room within minutes. V4, LPN, removed abdominal pad. Dark yellow drainage noted on abdominal pad. Skin around stoma site appeared dark red and irritated. V3, LPN,…

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 by the physician for 1 of 6 residents (R3) reviewed for pharmacy services in the sample of 13. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Hyperlipidemia, Seizures, Heart Disease, Major Depressive Disorder and Pneumonia. R2's Minimum Data Set, dated [DATE], documents R2 is cognitively intact. R2's Care Plan, dated 5/4/22, documents R2 receives scheduled medications for seizure disorder and to administer medications as ordered. R2's Medication Administration Record (MAR) documents the following physician orders: 8/13/23 through 8/21/23 - Augmentin (Amoxicillin Clavulanate) 875 milligrams (mg)/125 mg twice daily (BID) for Pneumonia; 8/22/23 through 8/31/23 - Augmentin 875 mg/125 mg BID for Pneumonia; 10/6/22 - Atorvastatin 20 mg daily (Qd); 12/13/22 - Venlafaxine 37.5 mg Qd; 10/6/22 Valproic Acid 250 mg give 3 tabs every 8 hours. R2's MAR goes on to document the following…

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 showers to residents on a twice weekly basis for 4 of 4 (R1, R2, R3, R41) residents in the sample of 6. Findings include: R1's admission Record undated documents, R1 was admitted to the facility on [DATE]. R1's EMR, (Electronic Medical Record), documents, R1's medical diagnosis includes chronic kidney disease stage 4, atherosclerotic heart disease, chronic peripheral venous insufficiency, morbid obesity, rheumatoid arthritis. R1's Care Plan dated 03/03/22 documents, Problem: Resident is limited in mobility/functional status and requires the use of (mechanical) lift and 2 attends. Res totally dependent on staff for mobility. R1's Care Plan dated 03/03/22 documents Problem: Bathing: Independent--Set up--Assist of 1--Assist of 2 Total Assistance dependence -X-N/A. R1's MDS, (Minimum Data Set), dated 06/02/23 documents, a BIMS, (Brief Interview for Mental Status), score of 15 out of 15. The MDS documents, that R1 requires extensive assistance of one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician in 4 of 7 residents (R1, R2, R4 and R6) reviewed for medication administration in the sample of 9. Findings include: 1. R1's Medication Administration Record (MAR), documents R1 is on the following medications: 6/22/23 thru 7/15/23 - Erythromycin 5 milligrams (mg)/gram (gm), administer to the left eye three times daily (TID) for Cellulitis of the Left Orbit; 7/7/23 - Amlodipine 10mg daily for Hypertension (HTN); 6/12/23 thru 6/22/23 - Gentamicin 0.1% apply to left eye TID for acute Angle Closure Glaucoma. R1's MAR goes on to document Erythromycin was not given 5 times as ordered from 6/22/23 thru 7/15/23 due to the medication not being available, Amlodipine was not given 10 times in 6/2023 due to the medication not being available and Gentamicin was not given 8 times in June 2023 due to the medication not being available. 2. On 8/3/23 at 8:50 AM, R2 stated, they frequently run out of her…

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

Based on observation, interview, and record review, the facility failed to have sufficient staff in the facility in order to maintain the resident's cleanliness, including incontinent care, and the assistance with ADLs (Activities of Daily Living). This deficiency has the potential to affect all 103 residents living in the facility. Findings include: On 7/24/23 at 9:30 AM, The staff working on Monday 7/24/23: 100-hall had one Licensed Practical Nurse, (LPN), and one Certified Nursing Assistant, (CNA), (the other CNA scheduled quit and left). The 200-hall has one LPN and two CNAs. The 300 and 500-halls share staff and had one RN and two CNAs. The 400-hall has one LPN and two CNAs. On 7/26/23 at 10:50 AM, R14 was lying in bed. Her gown was dirty, hair appeared to be greasy and stringy, fingernails were long, dirty and unkept. On 7/26/23 at 10:52 AM, R14 stated, I haven't had a shower since coming to the facility, but they had been giving me an occasional bed bath. The last time I got a bed bath was two weeks ago. The facility doesn't have enough staff. There was one day when they only…

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, observation, and record review, the facility failed to maintain residents' dignity by staff being on their cell phones and/or ear buds during their shift and while caring for the resident's needs for 5 of 5 residents (R2, R3, R6, R7, R13) in the sample of 16, but this has the potential to affect all 103 residents in the facility. Findings Include: On 7/24/23 at 11:55 AM, R3 stated, The staff are always on their cell phones and will hold a conversation while they are in my room, they just don't care. On 7/24/23 at 12:10 PM, V5 (Certified Nursing Assistant/CNA) had an ear bud in her right ear while she was caring for R3, and while talking to surveyor. On 7/24/23 at 12:16 PM, R7 stated the staff are always on their cell phones here. They will stay on it while taking care of me. Not all of them, but most of them. On 7/24/23 at 12:28 PM, R6 stated the staff are always on their cell phones. The CNA was cleaning me up in bed the other day, and she was talking to someone that sounded like maybe her girlfriend, on her cell phone, while she was cleaning me up. On 7/24/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with bathing, grooming, and hygiene to dependent residents for 4 of 8 residents (R2, R7, R9, R14) reviewed for ADL (Activities of Daily Living) care in the sample of 16. Findings include: 1. R2's admission Record, undated, documents, R2 was admitted to the facility on [DATE]. R2's Electronic Medical Record, documents, R2's medical diagnosis include, Left Artificial Knee Joint, Diabetes Mellitus (DM), Phlebitis and Thrombophlebitis of Left Iliac Vein. R2's Care Plan, dated 7/18/23, documents, I (do) have pain, Left TKR, (total knee replacement). I will have pain screening on admission, daily, and PRN, (as needed). I will receive comfort measures. I will receive pain medication per Physician/NP (Nurse Practitioner), orders and be observed or report pain medication effectiveness as appropriate or within one hour of receiving pain medication. Interventions: Percocet PRN, Ice PRN Left Knee. It continues Safety: I will need…

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 for 4 of 4 residents (R1, R3, R4, R5) reviewed for incontinence care in the sample of 16. Findings include: 1. R3's admission Record, undated, documents, R3 was admitted to the facility on [DATE]. R3's Electronic Medical Record, documents R3's Diagnosis include: Hemiplegia/Hemiparesis, HTN, Hyperlipidemia, Chronic Obstructive Pulmonary Disease, (COPD), Type 2 DM, (Diabetes Mellitus), Cerebral Infarction, Major depressive disorder, Arteriosclerotic Heart Disease, (ASHD), Benign prostatic hyperplasia, (BPH), Peripheral Vascular Disease, (PVD), Anemia, Chronic Kidney Disease, (CKD), stage 2, Gastroesophageal Reflux Disease, (GERD), Deep Vein Thrombosis, (DVT), Dysuria, Pneumonia, Vascular Dementia, COVID-19, Pressure Ulcer buttock, Right Below Knee Amputation, (RBKA), Left Below Knee Amputation, (LBKA), Contracture left hand, Polyneuropathy. R3's Care Plan, dated 6/21/23, documents, (R3) unable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to administer medications in a timely manner to residents in order to meet their needs for 4 of 5 residents (R2, R3, R6, R16) reviewed for medication administration in the sample of 16. Findings include: 1. R2's Face sheet, undated, documents, R2 was admitted to the facility on [DATE]. R2's Electronic Medical Record, documents, R2's Diagnosis include Left artificial knee joint, Diabetes Mellitus (DM), Phlebitis and Thrombophlebitis of left iliac vein. R2's Care Plan, dated 7/18/23, documents, I do have pain, L (left) TKR, (Total Knee Replacement). I will have pain screening on admission, daily, and PRN, (as needed). I will receive comfort measures. I will receive pain medication per physician/NP, (Nurse Practitioner), orders and be observed or report pain medication effectiveness as appropriate or within one hour of receiving pain. Interventions: Percocet PRN, Ice PRN L Knee. It continues Safety: I will need to be monitored to prevent falling in my new…

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 ensure the initial skin assessment was done in a timely manner, weekly skin assessments were completed, timely turning and repositioning was done, incontinent care was done in a timely manner, and interventions were put into place to prevent an avoidable pressure ulcer for 1 of 3 (R1) residents who were reviewed for pressure ulcers in a sample of 16. This failure resulted in R1 developing a sore to her left buttock and her right inner thigh. Findings include: On 07/26/23 at 9:45 AM, R1 was observed in 15-minute increments until 11:45 AM, sitting in her bed on her back with the head elevated and R1 leaning to the right side. During this time R1 was not turned, repositioned, or checked for incontinence. At 11:45 AM, V13 (Certified Nursing Assistant/CNA) went into R1's room and lowered the head of her bed. V13 then went out of the room to gather stuff to do incontinent care. R1 remained on her back with her head flat until V13 Came back into the…

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

Based on observation, interview, and record review, the facility failed to properly store, prepare, and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 97 residents living in the facility. Findings include: On 7/11/23 at 8:03 AM, in the dry storage room there was a 48-ounce jar of grape jelly, that was previously opened and half empty with smears of a light brown creamy substance inside. The jar was not refrigerated or dated upon opening. There was a bag of powdered sugar that had been opened and resealed but was not dated. There was a bag of chicken gravy mix that was previously opened and resealed, but not dated. There was a bottle of liquid thickener directly on the floor underneath the shelf. On 7/11/23 at 8:05 AM, underneath the preparation table in the main kitchen area, there were six clear containers of dry cereal that were not labeled or dated and were sticky to the touch. On 7/11/23 at 8:09 AM, there were ice crystals in the deep freeze next to the tray line, approximately one inch thick. There was no thermometer inside the…

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

Based on interview and record review, the facility failed to develop an ongoing infection control surveillance program. This has the potential to affect all 97 residents living in the facility. Findings include: The Facility's Infection Tracker does not document an organism causing R21's 7/11/23 urinary infection. The log documents R21 was treated with the antibiotic Doxycycline Monohydrate. The Facility's Infection Tracker does not document an organism causing R28's 6/26/23 urinary infection. The log documents, R28 was treated with the antibiotic Sulfamethoxazole-Trimethoprim. The Facility's Infection Tracker does not document an organism causing R61's urinary infection. The log does not document any antibiotic treatment for R61's urinary infection. The Facility's Infection Tracker does not document an organism causing R68's urinary infection. The log does not document any antibiotic treatment for R68's urinary infection. On 7/14/23 at 8:26 AM, V2 (Director of Nursing/DON) stated that she expects the facility to get an organism for every urinary infection. She stated, sometimes it…

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 resident-to-resident abuse for 6 of 6 residents (R6, R18, R20, R52, R74, R79) reviewed for resident-to-resident abuse in the sample of 45. Findings include: 1. R74's Minimum Data Set, dated [DATE] documents, R74 has moderately impaired cognitive skills for decision making. R74's Behavior Care Plan dated 7/12/23 documents, resident has episodes of yelling and screaming, refusing and resisting care, agitation and angry outbursts, combative with staff, requires PRN, (as needed), administration of Haldol, 2/23/22 residents behaviors have decreased, PRN medications DC, (discontinued), remains a potential problem 6/14/22 resident has increased anxiety, arguing with other resident and running into other residents with her w/c, (wheelchair), purposefully 6/24/22 Res, (resident), erratic behaviors with aggression toward staff and threatening to other residents. continue UA, (urine analysis), ordered with labs per MD, (Medical Doctor),…

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 showers to residents on a twice weekly basis for 7 of 7 (R86, R33, R303, R31, R70, R41, R21) residents in the sample of 45. Findings include: R86's Face Sheet documents diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; hypo-osmolality and hyponatremia; nonspecific low blood-pressure reading; dysarthria following cerebral infarction; long term (current) use of anticoagulants; anxiety disorder, unspecified; and pain, unspecified. R86's Minimum Data Set, MDS, dated [DATE] documented R86 was moderately cognitively impaired and required total dependence with bathing. R86's Care Plan dated 2/26/23 documents, Resident will bathe with required assistance. On 7/12/23 at 8:15 AM, V18 (R86's Family Member) stated, (R86) has not gotten showers for 3 weeks at a time. They told me R86 was refusing, but R86 told me she never refuses. The Facility provided R86's Bath/Shower Sheets for the past month.…

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 that residents with limited range of motion (ROM) receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 4 out of 4 (R10, R45, R66, R81) residents in a sample of 45 investigated for contractures. Findings include: 1. R10's Physician Order dated 02/11/19 documents, contracture, left hand. R10's Physician Order dated 02/24/22 documents, Restorative Therapy Program for AROM (Active Range of Motion), q (every) shift 6-7x/wk.(week), and Restorative Therapy Program for bed mobility q shift 6-7 x/wk. R10's Care plan dated 08/06/13 documents, Problem: Requires total care with all ADLs (Activities of Daily Living) d/t (due to) dx, (diagnoses) of CVA, (cerebrovascular accident), w/(L) left, hemiparesis, Aphagia, Dysphagia, CAD, (coronary artery disease), MI (myocardial infarction), HTN (hypertension), Dyslipidemia, NIDDM (non-insulin-dependent diabetes mellitus). DJD…

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 a resident-to-resident altercation for 1 of 5 residents (R52) reviewed for resident-to-resident altercations in the sample of 45. Findings include: R52's MDS dated [DATE] documents, R52 has moderately impaired cognitive skills for daily decision making. R52's Care Plan dated 6/13/23 documents, resident is considered at risk for abuse/neglect due to history of sexual abuse as a child. R74 Nurses Note dated 7/2/23 documents, the resident (R74) was going into another resident's (R52) room. She entered R52's room and began hitting him. The resident (R52) was yelling stop hitting me and get out before I slap you back. The CNA (Certified Nursing Assistant) went to get her out and direct her to her room. I encouraged her to stay in her own room. On 7/14/23 at 10:00 AM, V1 (Administrator) stated, An investigation was not done for this. On 7/14/23 at 12:00 PM, V2 (Director of Nursing/DON) stated it was never reported to me. The facility policy entitled…

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 tube feedings for one of one resident (R45) reviewed for tube feedings in the sample of 45. Findings Include: R45 Care Plan dated 4/19/23 (R45) requires nutrition through g-tube. NPO, (Nothing by Mouth). Receives Tube feeding as ordered. Tube placement checks per auscultation before meals. All medications given through g-tube per order. H2O (water) flush as recommended 1/5/22 enteral feeding per MD (Medical Doctor) order for 15hrs daily. R45's Minimum Data Set, dated [DATE] documents, R45 is cognitively intact. R45's Physician Order Sheet dated 5/16/23 documents, tube feeding Nutren 1.5 80 ml (milliliters), per hour from 3 PM to 6 AM. On 7/13/23 at 3:00 PM, there was a bag of clear liquid hanging on a tube feeding pole labeled 7/13 at 8 AM. No enteral feeding product was hanging. R45 stated, They don't always do it. You know that. At 4:00 PM, the enteral feeding was still not hung. 07/14/23 08:08 AM, V2 (Director 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.

Based on interview and record review, the facility failed to establish an infection prevention and control program that include antibiotic use protocols in 2 of 2 residents (R17, R94) reviewed for antibiotic stewardship in the sample of 45. Findings include: 1. R17's Physician Order Sheets dated 5/19/2023 documents, Macrobid capsule 100mg twice daily. End date 5/26/2023. R17's May's Medication Administration Record (MAR), documents, R17 received doses of Macrobid on 5/19/23 through 5/26/2023. No culture documented. R17's Physician Order Sheet dated 6/26/2023 documents, Augmentin 875mg by mouth twice daily for Urinary Tract Infection (UTI). End date 7/6/2023. R17's June's MARs document R17 received doses of Augmentin on 6/26/2023 through 7/6/2023. No culture documented. 2. R94's Physician Order Sheet dated 7/4/2023 documents, Cephalexin capsule 250mg once daily open ended. Long term use of antibiotic with no culture documented. R94's MAR documents, R94 received doses of Cephalexin on 7/4/2023-7/13/2023. Facility Policy dated 8/2018 states, It is the appropriate authorized…

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.