Integrity Hc Of Carbondale

Based on observation, interview and record review the facility failed to prepare and distribute food in accordance with professional standards of food safety and failed to maintain appropriate sanitizer levels in the dish machine to prevent foodborne illness. This has the potential to affect all 51 residents living in the facility. Findings include:The facility, Resident List Report dated 07/17/25 documents there are 51 residents currently residing at the facility.On 07/17/25 at 11:45 AM, V1 (Administrator) stated the kitchen is currently closed down by the health department for pests and needing cleaning. V1 stated they are hoping the health department will open the kitchen today. V1 stated, the health department stated they could grill outside, they could just not use the kitchen.The Food Establishment Inspection Report dated 07/15/25 documents item #38 observation: live roach observed at time of inspection that crawled into the square mechanical/electrical compartment above the dish machine drain. General Comments: due to the number of foodborne illness risk factors and public…

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 provide a clean, safe, sanitary environment for 14 residents of 14 residents (R1, R2, R3, R4, R6, R8, R9, R10, R11, R12, R13, R14, R15 and R16) reviewed for environment in a sample of 18.Findings include:On 07/17/25 at 3:10 PM, the air vent in the ceiling in the hall right outside a room where the meal trays were being staged and approximately 20 feet from the dining room on the North Hall, had a black substance covering approximately 50 % of the vent. On 07/17/25 at 2:58 PM, there was a black substance on the ceiling tiles around the air vent and on the air vent after the doorway leading to the North Hall. The black substance went from the vent to the wall on the right side of the ceiling on the other side of the entryway to the North Hall.On 07/17/25 at 4:40 PM, V2 (Director of Nursing) stated, she has seen mold or a black moldlike substance on the North Hall. She believes she brought it to V1's (Administrator) attention Tuesday (07/15/25) morning. V2 stated, it should be cleaned.On 07/21/25 at 10:05 AM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to provide food that appeared palatable and attractive for 7 of 7 residents (R2, R3, R6, R8, R10, R15, and R16) reviewed for dining in a sample of 18.Findings include:1. On 07/17/25 at 1:10 PM the individual serving of pureed ham was microwaved in a paper product bowl, the pureed ham was dry looking, crusty around the edges and a grayish color after being microwaved to be heated to a servable temperature. The microwaved pureed ham was served to R3, R10, R15, R16. R3's order summary report documents a dietary order of regular diet with a pureed texture with an order date of 05/20/25 and no end date listed.R10's order summary report documents a dietary order of regular diet with a pureed texture, whole milk three times a day, health shake three times a day, nutritional ice cream with lunch and supper, super cereal at breakfast, ice cream two times a day, melted margarine to hot sides at lunch and supper, offer pudding three times a day, 1 scoop…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to serve food at palatable/preferred, appetizing temperatures for 5 (R27, R28, R35, R51, R105) of 22 residents reviewed for appetizing food temperatures in a sample of 42. Findings include: R51's admission Record documents an admission date of 01/09/25. R51's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 09, indicating moderately impaired cognition. On 01/27/25 at 10:17 AM, R51 stated the food is not good and is typically cold. On 01/28/25 at 7:30 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. On 01/28/25 at 7:45 AM, the dietary hall cart was starting to be filled. On 01/28/25 at 8:26 AM, V21 (Certified Nurse Aide/CNA) had two hall trays left to deliver. R35's tray was delivered and R35 refused her tray. V21 immediately returned the tray to the dietary cart,…

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 provide safe and sanitary food and dietary services. This failure has the potential to affect all 54 residents that reside at the facility. Findings include: 1. On 01/27/25 at 9:30 AM, a container of sugar was observed on the counter between the kitchen and dining room. The container of sugar was sitting by the coffee and tea on the dining service counter within residents' reach. There was a small plastic portion cup in the sugar container that was utilized by both staff and residents to get sugar for the drinks. On 01/27/25 at 11:30 AM, R12 was observed getting sugar from the container with the small plastic portion cup. On 01/27/25 at 11:53 AM, V21 (Certified Nurse Aide/CNA) used the portion cup in the sugar container to get sugar for a resident's drink. After touching the counter and the lid to the sugar container, V21 placed the portion cup back into the sugar container. On 01/29/25 at 10:15 AM, during Resident Council meeting, residents were asked if the container of sugar that sits on the counter by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control practices for Enhanced Barrier Precautions and for Covid-19 infections as recommended by the CDC (Centers for Disease Control and Prevention) to prevent the development and transmission of communicable diseases and infections for 6 of 9 residents (R5, R24, R36, R47, R49, and R51) observed for infection control in the sample of 42. Findings include: 1. R47's admission Record printed on 01/30/25 documents an admission date of 12/03/24 and included diagnoses of dysphagia, muscle weakness, gastrostomy status, hyponatremia, colostomy, pressure ulcer sacral region stage 4, infection, and inflammatory reaction due to internal left hip prothesis. R47's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, indicating R47 has severe cognitive impairment. Under Functional Abilities and Goals, the MDS documents R47 is dependent with turning and repositioning, eating, personal…

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 dignity was maintained during dining when staff remained standing to provide feeding assistance for 1 (R205) of 4 residents reviewed for resident rights in a sample of 42. Findings include: R205's admission Record dated 01/30/25 documents an admission date of 01/15/25 with diagnoses in part of unspecified dementia, altered mental status, Parkinson disease, and muscle weakness. R205's Baseline Care Plan with a date of 01/15/25 documented under functional ability and goals self-care of eating set-up. R205's Minimum Data Set (MDS) dated [DATE] documents in a Brief Interview for Mental Status (BIMS) score of 04, indicating R205 has severely impaired cognition. Under Functional Abilities, the MDS documented R55 required set-up and supervision with eating. On 01/27/25 at 12:35PM, V21 (Certified Nurse Assistant/CNA) walked over to assist R205 with eating. V21 stood up next to R205 and attempted to feed R205 her meal. V21 never sat down…

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 resident's and/or resident representative's preferences for room accommodations and showers to ensure dignity were maintained for 2 (R55 and R51) of 4 residents reviewed for reasonable accommodations/preferences in a sample of 42. ' Findings include: 1. R55's admission Record documents an admission date of 01/17/25 and included the following diagnoses: vascular dementia, mild with psychotic disturbances, history of falling, depression, muscle weakness and difficulty walking, not elsewhere classified. R55's MDS (Minimum Data Set) dated 01/24/25, documents a BIMS (Brief Interview for Mental Status) of 11, indicating that R55 is moderately cognitively impaired. Under Functional Abilities, the MDS documents that R55 requires partial/moderate assistance with toileting hygiene and lower body dressing. In the section for indoor mobility R55 needs some help-Resident needed assistance from another person to complete any activities. Under…

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 notify the physician of missing medications and a change in resident's condition for 1 of 5 residents (R55) reviewed for physician notification in the sample of 42. Findings include: R55's admission record documents an admission date of 01/17/25 and list the following diagnoses in part; vascular dementia, mild with psychotic disturbances and type 2 diabetes mellitus. R55's MDS (Minimum Data Set) dated 01/24/25, documents a BIMS (Brief Interview for Mental Status) score of 11, indicating that R55 is moderately cognitively impaired. Section I-active diagnoses documents an active diagnosis of diabetes mellitus. R55's care plan documents an initiation date of 01/28/25 for a focus area that states R55 is at risk for complications r/t (related to) dm (diabetes mellitus). R55's Physician's Order Sheet (POS) documents an order with an order date and a start date of 01/17/25 for Toujeo Solostar Subcutaneous Solution pen-injector 300 Units/ML, (Insulin Glargine) (long-acting insulin), Inject 70 units at bedtime for diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide privacy during wound care treatment or urinary catheter treatment for one (51) of 4 residents reviewed for personal privacy in the sample of 42. Findings include: 1. R51's admission Record documents an admission date of 01/09/25 and included the following diagnoses: muscle weakness, retention of urine and secondary malignant neoplasm of the brain. R51's Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 09, indicating R51 has moderate cognitive impairment. Under Functional Abilities, the MDS documents R51 is dependent for toileting hygiene, lower body dressing and bed mobility. R51's Care Plan documented a focus are of at risk for skin breakdown r/t frequently incontinent of bowel, has Foley catheter, requires assist with bed mobility. Has open area to left buttock and skin tear to right buttock. On 01/29/2025 at 02:26 PM, wound care was provided to R51 by V4 (Licensed Practical…

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 residents were free from verbal abuse from staff for 1 of 3 residents (R55) reviewed for abuse and neglect in the sample of 42. Findings include: R55's admission record documents an admission date of 01/17/25 and list the following diagnoses in part; vascular dementia, mild with psychotic disturbances and type 2 diabetes mellitus. R55's MDS (Minimum Data Set) dated 01/24/25, documents a BIMS (Brief Interview for Mental Status) of 11, indicating that R55 is moderately cognitively impaired. On 01/27/25 at 10:03am, V36 (Family member) stated on 01/17/25, the first day R55 was in the facility, there was a nurse who was being terribly mean to her for no reason, he stated they reported it to staff a couple times, but nothing was done until they had her care plan meeting. V36 stated that V1 (Administrator) told them that they were not going to do anything with the nurse that did it because she was moving back to the Philippines soon, but she wouldn't be caring for R55 anymore. On 01/27/25 at 10:04am, V35 (Family member)…

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 an allegation of staff to resident verbal/mental abuse resulted in an accurate conclusion and failed to ensure corrective action to prevent further potential abuse for 1 of 3 residents (R55) reviewed for abuse in the sample of 42. Findings include: R55's admission record documents an admission date of 01/17/25 and list the following diagnoses in part; vascular dementia, mild with psychotic disturbances and type 2 diabetes mellitus. R55's MDS (Minimum Data Set) dated 01/24/25, documents a BIMS (Brief Interview for Mental Status) of 11, indicating that R55 is moderately cognitively impaired. On 01/27/25 at 10:03am, V36 (Family member) stated the first day R55 was here, there was a nurse who was being terribly mean to her for no reason, he stated they reported it to staff a couple times, but nothing was done until they had her care plan meeting. V36 stated that V1 (Administrator) told them that they were not going to do anything with the nurse that did it because she was moving back to the Philippines soon, but 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 develop and implement a baseline care plan within 48 hours for 1 of 3 (R105) residents reviewed for care plans in the sample of 42. Findings include: R105's admission Record with a print date of 1/28/2025 documents R105 was admitted to the facility on [DATE] with diagnoses that include fracture of femur, falls, epilepsy, and muscle weakness. R105's facility medical record does not document a baseline care plan. On 01/28/25 at 3:50 PM, V2 (Director of Nurses) stated the nurse who responsible for completing it upon R105's admission to the facility had forgotten to do it and it was being completed now.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide indwelling urinary catheter care in accordance with facility policy and standard of practice for 1 (R47) of 2 residents reviewed for catheter care in the sample of 42. Findings include: R47's admission Record printed on 01/30/25 documented an admission date of 12/03/24 with diagnoses in part of dysphagia, muscle weakness, gastrostomy status, hyponatremia, colostomy, pressure ulcer sacral region stage 4, infection, and inflammatory reaction due to internal left hip prothesis. R47's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, which indicates severely impaired cognition. Section GG of the MDS documented R47 is dependent with toileting and turning and repositioning. Section H documented indwelling catheter. R47's Care Plan documents a focus area of R47 is at risk for UTI (Urinary Tract Infection) r/t (related to) use of (Urinary) Catheter (Indwelling Catheter) with date initiated of 01/29/25.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to follow facility policy and procedure by failing to check the placement of a gastrostomy tube prior to administering medication and flusing with water and feeding for 1 of 1 resident (R47) reviewed for gastrostomy tube use in the sample of 42. Findings include: R47's admission Record printed on 01/30/25 documents an admission date of 12/03/24 with diagnoses that included dysphagia, muscle weakness, gastrostomy status and hyponatremia. R47's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 5, which indicates severely impaired cognition. Under Functional Abilities and Goals, the MDS documents R47 is dependent with eating. Under Swallowing/Nutritional Status, the MDS documents R47 has a feeding tube. R47's Care Plan dated 12/23/24 documents a focus area of R47 is at risk for nutritional deficit r/t (related to) dx (diagnosis) dysphagia, COPD (Chronic Obstructive Pulmonary Disease). Has 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 observation, interview, and record review the facility failed to ensure medications were administered per current standards of practice for 5 of 7 (R9, R15, R16, R17, R18) residents reviewed for pharmacy services in the sample of 19. Findings Include: 1. R9's admission Record with a print date of 12/02/24 documents R9 was admitted to the facility on [DATE] with diagnoses that include esophageal obstruction, dysphagia, fracture of sternum, gastrostomy, bipolar disorder, depression, and generalized anxiety disorder. R9's MDS dated [DATE] documents a BIMS score of 13, which indicates R9 is cognitively intact. R9's Order Summary Report with Active Orders as of 12/02/2024 includes the following physician orders, valproic acid oral solution 250 milligrams (mg)/5 milliliters (ml) give 10 ml via G-tube (gastrostomy tube) three times a day for anti-seizure, sucralfate oral suspension give 10 ml via G tube four times a day for GERD (gastroesophageal reflux disease), hydroxyzine 25 milligrams (mg) one tablet three…

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 of unnecessary medications when they failed to discontinue psychotropic medications as ordered by the physician for 1 of 3 (R12) residents reviewed for unnecessary medications in the sample of 19. Findings Include: R12's admission Record with a print date of 12/5/24 documents R12 was admitted to the facility on [DATE] with diagnoses that include fracture of left femur, hypotension, diabetes, schizophrenia (diagnosis added on 11/07/24), bipolar disorder (added on 11/07/24) difficulty walking, and muscle weakness. R12's MDS (Minimum Data Set) dated 10/17/2024 documents R12 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R12 is cognitively intact. R12's current Care Plan documents a Focus area of (R12) uses psychotropic medications (Escitalopram) r/t (related to) dx (diagnosis) depression, anxiety, schizophrenia. 10/9/24 Clonazepam for agitation. 10/27/24 Clonazepam increased. 10/29/24 Escitalopram…

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 tube feeding as ordered for 1 (R1) of 3 residents reviewed for gastrostomy tube care in a sample of 3. Findings include: On [DATE] at 9:29 AM, V12 (R1's State Guardian) said the facility was not completing R1's tube feedings as ordered. V12 said she had spoken with the facility wanting R1's tube feeding orders to be changed from bolus feeding to continuous due to R1's decline and weight loss during a hospitalization prior to R1 being admitted to the facility. V12 said the facility had told her they would speak with the dietitian to see if R1's tube feeding orders could be changed. V12 said she had been notified the dietitian had recommended R1's tube feeding orders be changed to continuous. V12 said 8 to 10 days, V12 was unsure of the exact dates, she received a call from someone visiting R1 and was told R1 was still receiving bolus tube feedings. V12 said on [DATE] she arrived at the facility and saw R1 was still receiving bolus tube…

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 accurately document narcotic medication administration according to facility policy, and failed to consistently and accurately reconcile narcotic medication counts in accordance with professional standards of practice for 4 (R1, R4, R5, and R6) of 6 residents reviewed for pharmacy services in the sample of 9. This failure has the potential to affect all 55 residents residing in the facility. Findings include: 1. R5's Face Sheet documented an admission date of 7/1/20 with diagnoses including: diabetes mellitus with diabetic polyneuropathy, acquired absence of left leg below the knee, Barrett's Esophagus, acquired absence of right leg below the knee. R5's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating R5 was moderately cognitively impaired. R5's Order Summary Sheet documented a 2/15/23 order for hydrocodone/acetaminophen 5/325mg (milligram) tablet give 1 tablet by mouth…

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 prevention of misappropriation of resident property for 6 (R1, R3, R4, R5, R6, and R7) of 6 residents reviewed for abuse in the sample of 9. Findings include: 1. R5's admission Record documented an admission date of 7/1/20 with diagnoses including: diabetes mellitus with diabetic polyneuropathy, acquired absence of left leg below the knee, Barrett's Esophagus, and acquired absence of right leg below the knee. R5's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating R5 was moderately cognitively impaired. R5's Order Summary Sheet documented a 2/15/23 order for hydrocodone/acetaminophen 5/325mg (milligram) tablet give 1 tablet by mouth every 6 hours as needed for severe pain. On 9/24/24 at 3:20 PM, V1 (Administrator) said the pharmacy had sent her the hydrocodone/acetaminophen 5/325mg refill request for R5 from 9/1/24 by V3 (Licensed Practical Nurse/LPN). V1 verified V3'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 observation, interview, and record review the facility failed to report allegations of abuse and misappropriation of property within the required time frames for 4 (R1, R2, R3, and R7) of 6 residents reviewed for abuse in the sample of 9. Findings include: 1. R3's Face Sheet documented an admission date of 6/23/21 with diagnoses including: anxiety disorder, Charcot's Joint, chronic pain syndrome. R3's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 was cognitively intact. On 9/19/24 at 12:17 PM, R3 said he had a laptop computer stolen about a month prior to this investigation. R3 said he had purchased a rose gold laptop and had kept it on top of the microwave in his room. R3 said when he had returned to his room from the dining room, he had noticed it was missing. R3 said he had reported it to V1 and had given V1 the receipt and serial number in hopes it could be found. On 9/19/24 at 12:27 PM, V1 (Administrator) said she was aware of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to initiate and complete investigations of abuse allegations in accordance with required time frames for 4 (R1, R2, R3, and R7) of 6 residents reviewed for abuse in the sample of 9. Findings include: 1. R3's Face Sheet documented an admission date of 6/23/21 with diagnoses including: anxiety disorder, Charcot's Joint, chronic pain syndrome. R3's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 was cognitively intact. On 9/19/24 at 12:17 PM, R3 said he had a laptop computer stolen about a month prior to this investigation. R3 said he had purchased a rose gold laptop and had kept it on top of the microwave in his room. R3 said when he had returned to his room from the dining room, he had noticed it was missing. R3 said he had reported it to V1 and had given V1 the receipt and serial number in hopes it could be found. On 9/19/24 at 12:27 PM, V1 said she was aware of R3's missing…

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 resident care in a timely and dignified manner for 2 (R1, R3) of 3 residents reviewed for timely assistance in the sample of 3. The Findings Include: R1's admission Profile documents an admission date of 8/21/23 with diagnoses to include: encounter for surgical aftercare following surgery on the nervous system, spinal stenosis, obesity, difficulty in walking, bipolar, and anxiety. R1's care plan documents a focus area of being at risk for falls due to bilateral lower extremity weakness with diagnoses of neuropathy, cervical spondlyosis, spinal stenosis, use of anti anxiety and antidepressant medication and opoid use. The goal date of initiation documents 9/8/23 and states R1 is to have falls/injuries minimized through management of risk factors while maintaining maximum independence/quality of life through the next review. Interventions are as follows: be sure her call light is within reach and encourage her to use it for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to maintain resident rights and dignity by not providing adequate grooming and providing food on non-disposable ware for 15 of 16 residents (R24, R6, R39, R33, R36, R41, R49, R5, R8, R11, R29, R17, R50, R28 and R12) reviewed for resident rights and dignity in a sample of 53. The findings include: 1. R24's Face Sheet, undated, documents R24 was admitted to the facility on [DATE] with diagnoses of unspecified sequelae of cerebrovascular disease, unspecified atrial fibrillation, asthma, Type 2 diabetes mellitus without complications, Peripheral Autonomic Neuropathy, Morbid Obesity due to excessive calories, Bipolar Disorder, Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Dominant side, Major Depressive Disorder Recurrent, and Essential Hypertension. R24's Care Plan dated 12/21/22 documents that R24 has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Disease Process (Asthma),…

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 provide a safe sanitary bathroom/shower room for 24 (R4, R32, R52, R8, R11, R26, R6, R2, R23, R1, R34, R53, R44, R48, R51, R16, R50, R31, R28, R47, R30, R12, R18 and R38) of 24 residents reviewed for environment in a sample of 53. Findings include: On 02/05/24 at 8:45 AM, the community shower/bathroom on the North hall across from room N16 was observed. The shower/ bathroom did not contain any soap in the soap dispenser by the handwashing sink. The shower stall had mold and dirt where the wall met the floor on all three sides approximately 1 inch up from the floor. There was a soiled washcloth hanging on the safety grab bar that was dry and the shower stall was dry. On 02/05/24 at 8:45 AM, the community shower/bathroom on the North hall across from room N5 was observed. The shower/ bathroom was missing 53 one inch by one inch tiles on the floor of the shower stall. On 02/06/24 at 7:35 AM the community shower/bathroom on the North hall across from room N5 did not contain any paper towels by the handwashing…

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 incontinent care, showers, and assistance with eating for 6 (R24, R25, R35, R38, R40, and R43) of 11 residents reviewed for activities of daily living in a sample of 53. The findings include: 1. R24's face sheet documents that R24 was admitted to the facility on [DATE] with a diagnosis of unspecified sequelae of unspecified cerebrovascular disease. R24's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score is 14, indicating that R24 is cognitively intact. Section GG, Functional Abilities and Goals, documents that R24 requires setup/clean up assistance with eating, oral hygiene, dependent with toileting hygiene, substantial/maximal assistance with showering, bed mobility, dependent with upper body dressing, lower body dressing, and personal hygiene. R24's Care Plan dated 12/21/22 documents that R24 has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t…

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 provide a call light system near the toilet in the hall bathroom for 24 (R4, R32, R52, R8, R11, R26, R6, R2, R23, R1, R34, R53, R44, R48, R51, R16, R50, R31, R28, R47, R30, R12, R18 and R38) of 24 residents reviewed for call light systems in a sample of 53. The findings include: On 02/05/24 at 8:45 AM, the tub room next to the shower/bathroom on the North hall contained a toilet, with urine in it, and no accessible call light. The call light activator was approximately six feet up from the floor with no attachment hanging down not allowing the light to be activated when seated or from the floor. On 02/07/24 at 11:15 AM, R32, R23, R26, R52 and R11 stated, they use whichever bathroom is open on the north hall. R32, R23, R26, R52 and R11 are alert and oriented. On 2/5/24, V1 (Administrator) provided the Midnight Census report with a print date of 2/5/24, that documents the residents that reside on the north hall and can utilized the shower/bathroom are R4, R32, R52, R8, R11, R26, R6, R2, R23, R1, R34, R53, R44,…

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 ensure reasonable accommodation of a wheelchair to assist in maintaining and/or achieving independent functioning for 1 of 6 residents (R24) reviewed for accommodation of needs in a sample of 53. The findings include: R24's Face Sheet, undated, documents R24 was admitted to the facility on [DATE] with diagnoses of unspecified sequelae of cerebrovascular disease, unspecified atrial fibrillation, asthma, Type 2 diabetes mellitus without complications, Peripheral Autonomic Neuropathy, Morbid Obesity due to excessive calories, Bipolar Disorder, Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Dominant side, Major Depressive Disorder Recurrent, and Essential Hypertension. R24's Care Plan dated 12/21/22 documents that R24 has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Disease Process: Asthma, Impaired balance and muscle weakness. R24 is occasionally incontinent of bladder…

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 administer gastronomy tube water flushes per physician's orders for 1 of 2 residents (R45) reviewed for tube feeding in a sample of 53. Findings include: R45's face sheet documents an admission of 05/20/2023 with diagnoses including Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Dysphagia following Cerebral Infarction, Anoxic Brain Damage, not elsewhere Classified, other seizures, other recurrent Depressive Disorders, Anxiety Disorder, unspecified, Encephalopathy, unspecified, Gastronomy Status, Pneumonia, unspecified organism, Insomnia, unspecified, Chronic Obstructive Pulmonary Disease, Unspecified, and Aphasia. R45's Care Plan documents a Focus area with an initiation date of 5/25/23 that R45 is at risk for nutritional deficit related to a diagnosis of Dysphagia, is NPO (nothing by mouth), has G-tube bolus feedings TID (three times a day). The care plan documents interventions to provide feedings and flushes as ordered. R45's Order Summary Report, with a date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to notify the physician of a significant change in a residents condition for 2 of 3 (R1 and R2) residents reviewed for physician notification in the sample of 15. Findings Include: 1.R2's admission Record with a print date of 11/01/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, heart failure, heart disease, hypertension, anemia, hyperlipidemia, anxiety disorder, obstructive sleep apnea, and muscle weakness. R2's MDS (Minimum Data Set) dated 10/16/23 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area initiated 10/25/23 of (R2) is at risk for complications r/t (related to) dx (diagnosis) of HTN (hypertension). The interventions for this care area include give antihypertensive medications as ordered, avoid taking the blood pressure reading after physical activity or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were monitored, assessments were documented, and physicians were notified of a significant change in condition for 1 of 3 (R2) residents reviewed for change of condition in the sample of 15. Findings Include: R2's admission Record with a print date of 11/01/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, heart failure, heart disease, hypertension, anemia, hyperlipidemia, anxiety disorder, obstructive sleep apnea, and muscle weakness. R2's MDS (Minimum Data Set) dated 10/16/23 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area initiated 10/25/23 of (R2) is at risk for complications r/t (related to) dx (diagnosis) of HTN (hypertension). The interventions for this care area include give antihypertensive medications as ordered, avoid taking the blood…

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

Based on interview and record review, the facility failed to provide a written Notice of Transfer for one hospitalized resident (R17) of one resident reviewed for transfer/discharge in the sample of 24. Findings include: On 03/07/23 at 10:34 am, R17 was interviewed in his room. R17 was alert and oriented to person, place, and time. R17 stated he has been hospitalized three times within the past three months. R17 stated the facility did not provide him with a written notice of transfer at the time of any of these transfers to the hospital. R17's Nursing Progress Notes documented the following: 01/2/23: Labs were reported to the nephrologist and orders received to send resident out to hospital for further evaluation. 02/04/23: Resident (sent) out of facility on transfer to (local hospital). 03/01/23 (Physician) .gave order to send to ED(Emergency Department). On 03/09/23 at 8:52 am, V18, Regional Nurse Consultant, acknowledged that the facility has not been providing residents with a written notice of transfer at the time of their transfer to the hospital. V18 confirmed the facility…

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.