Heartland Nursing & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement fall and accident prevention interventions according to a resident's care plan and physician orders. This failure affects one resident (R3) out of three reviewed for falls on the sample list of eight. Findings include: R3's Face Sheet dated 8/20/25 documents R3 had a legally established power of attorney. R3's Medical Diagnoses list of the same date includes Dementia, Major Depression, Hypertension, and Osteoarthritis of the Right Knee. R3's Census Detail of the same date documents R3 was admitted to the facility 1/13/22. R3's Physician order Sheet dated 8/22/25 documents R3 has physician orders to include non-skid strips on the floor in front of her recliner initiated 7/1/24, and to wear (cloth protective leggings) initiated 5/31/25. R3's Minimum Data Set, dated [DATE] documents R3 requires staff supervision and assistance for all aspects of daily living including hygiene, dressing, bathing, transfers, and transitioning between…

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 the services of a qualified director of food and nutrition services. This failure affects all 42 residents residing in the facility. Findings Include: On 12/10/24 at 9:55 AM, V5, Dietary Manager, was actively supervising and directing the food preparation and wares sanitation processes in the facility kitchen. At 11:50 AM and 12:08 PM, V5 was actively supervising and directing the meal service for lunch. On 12/10/24 at 9:55 AM, V5 stated she was the Dietary Manager. V5 further stated she had a (national company) cooking sanitation certificate. V5 continued to state she did not have a Certified Dietary Manager certificate (CDM, 6 to 9 month clinical nutrition curriculum), nor a Certified Food Protection Professional certificate (CFPP, CDM equivalent). V5 stated the facility utilized the services of a Registered Dietician one day per month on a consultant basis. V5 concluded by stating she did not meet the state requirements for a Director of Food Services nor meet the definition of a Dietetic Service…

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

Based on observation, interview, and record review, the facility failed to maintain kitchen utensils to prevent potential contamination of food, and failed to prevent food contamination by storing utensils in bulk food containers. These failures have the potential to affect all 42 residents residing in the facility. Findings Include: On 12/10/24 at 10:15 AM, there was a metal, long handle measuring scoop located inside the bulk sugar bin. The handle of the scoop was in direct contact with, and partially buried by, the sugar. On 12/10/24 at 10:15 AM, V5, Dietary Manager, and V6, Regional Dietary Representative, both stated the scoop should not be left in the sugar. On 12/10/24 at 10:20 AM, there was a silicone blade spatula in a kitchen utensil drawer with a broken corner approximately three-quarters of an inch diagonal, exposing the granulated and rough internal material of the spatula. This granulated surface potentially would crumble off and contaminate food during preparation, and was not easily cleanable. On 12/10/24 at 10:20 AM, V5 removed the spatula from the drawer to…

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

Based on interview and record review the facility failed to trend the facility's monthly infections. This failure has the potential to affect all 42 residents residing in the facility. Findings Include: The facility did not provide an Infection Control Surveillance and Monitoring Policy and no documents were provided for how the facility trends monthly infections to prevent further infection throughout the facility. The facility has no documentation for the identified infections pattern/trend and interventions. On 12/10/24 at 02:10 PM, V2 Director of Nursing (DON) Infection Preventionist (IP) stated V2 has not kept up with a log for infections for residents, and only has October and November 2024, for infection logs and only for residents and not for employees. V2 stated V2 and does not complete any Quality Assurance (QA) on infections that reoccur. V2 also stated there has been no completed trending for the facility's infections. The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24, documents there are 42 residents residing in the facility.

Based on interview and record review, the facility failed to develop an infection prevention and control program that includes an antibiotic stewardship program and failed to review this policy annually. This failure has the potential to affect all 42 residents residing in the facility. Findings Include: On 12/11/24 at 10:40 AM, V2 Director of Nursing (DON) stated V2 has not completed an Antibiotic Stewardship Program for the facility. V2 stated there are no antibiotic protocols or a system to monitor antibiotics in place. The facility's Antibiotic Stewardship Program stated the purpose of the policy is to monitor antibiotic use of the residents. This policy has a date of 2/7/23, which has not been updated annually. The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24, documents there are 42 residents residing in the facility.

Based on observation, interview and record review, the facility failed to act on grievances from residents/family promptly, explain to residents how to file a grievance, inform residents where the survey book is located, and address lack of meal substitutes offered at mealtimes and not offering snacks at bedtime. This failure affects four of four residents (R3, R13, R21 and R25) reviewed for grievances in the sample list of 26. Findings include: On 12/11/24 at 10:00 AM, R3, R13, R21, and R25, all stated they can complain but that's as far as it goes. The residents stated staff say they will look into their concerns but the residents can not tell anything has been done. The residents stated they do not know about filling out a grievance form and they do not fill out grievances. The residents stated V9 Activity Director takes the complaints but then after that they do not hear anything more about it. The residents stated staff do not pass out snacks at bedtime and when asked about it they are only offered peanut butter and jelly (PBJ). The residents stated there is no anytime menu…

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 change, date and store oxygen tubing, humidifier bottles, nebulizer masks, and suctioning equipment in a sanitary manner for four of five residents (R4, R14, R34, R350) reviewed for oxygen in the sample list of 26. Findings Include: The facility policy Departmental Respiratory Therapy Prevention of Infection dated reviewed 4/27/24 documents the oxygen administration supplies consist of oxygen tubing and humidifier bottle. This policy documents to change the oxygen tubing cannula every seven days, and to discard the entire administration set up every seven days. 1. R34's Medical Diagnoses list dated December 2024 documents R34 is diagnosed with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. R34's Physician Order Sheet (POS) dated December 2024 documents an order for oxygen per nasal cannula at three liters continuously. R34 also has an order for nebulizer treatments every four hours as needed. The oxygen tubing and…

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

Based on Interview and record review, the facility failed to follow through with contacting Physicians for unaddressed Pharmacist recommendations, and failed to maintain documented evidence of Physician responses to Pharmacist recommendations. This failure affects four residents (R12, R16, R22, R26) out of six reviewed for unnecessary medications on the sample list of 26. Findings Include: 1. R16's Registered Pharmacist Consultant recommendation recorded in R16's Nursing Progress Notes dated 11/25/24 documents a Pharmacist recommendation to conduct an abnormal involuntary movement scale (AIMS) assessment to monitor for side effects of long-term Antipsychotic use. There was no documented evidence of a physician response, and no documented evidence of follow-up by the facility to obtain a physician response, in R16's electronic medical record (EMR). As of 12/11/24 at 11:20 AM, there was likewise no record of an AIMS assessment conducted for R16 historically. 2. R22's Registered Pharmacist Consultant Report dated 1/25/24 documents, This resident currently has an order for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct psychotropic medication assessments, failed to maintain accurate documentation in psychotropic medication assessments, failed to conduct abnormal involuntary movement assessments for Antipsychotic medications, failed to obtain a time period duration for PRN (as needed) psychotropic medications, and failed to attempt gradual dose reductions for residents receiving anti-psychotic medications. These failures affect five residents (R12, R16, R22, R26, and R29) out of six reviewed for unnecessary medications on the sample list of 26. Findings Include: 1. R16's Medical Diagnoses list dated 12/13/24 documents R16 experiences medical conditions including Alzheimer's Disease and Dementia. R16's current Physician Order Sheet dated 12/13/24 documents R16 has physician orders for psychotropic medications including Sertraline (antidepressant) 25 milligrams (mg) daily, and Olanzapine (Antipsychotic) 2.5 mg daily. This same Physician Order Sheet documents R16…

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 protect resident's dignity by failing to place a urinary catheter collection bag inside a covering or pouch. This failure affects two residents (R22 and R33) out of two reviewed for urinary catheters on the sample list of 26. Findings include: On 12/10/24 at 10:50 AM, R33's urinary catheter collection bag was positioned under his wheelchair without any covering, exposing approximately 400 cubic centimeters (cc's) of yellow colored urine inside the collection bag. On 12/10/24 at 10:55 AM, V2, Director of Nursing, shook her head no to indicate she did not like residents' catheter collection bags to be exposed and without a dignity pouch or bag. On 12/10/24 at 1:29 PM, V7, Private Caregiver for R22, stated it is about 50/50 whether the staff keep R22's urinary catheter collection bag covered. V7 stated there have been times when R22's family takes R22 out of the facility and she has had to run around the facility to look for a covering bag. On 12/10/24 at 1:50 PM, V1, Administrator, stated it is his expectation…

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 request a Preadmission Screening and Resident Review PASARR II Screening for (R26) who has a diagnosis of Schizoaffective Disorder and is receiving Antipsychotic medication. R26 is one of one resident reviewed for PASARR screening on a sample list of 26. Findings Include: R26's Medical Diagnosis sheet dated 12/13/24 lists (R26's) Primary Medical Diagnosis for admission on [DATE] as Interstitial Pulmonary Disease. Included with the list of diagnoses is Schizoaffective Disorder with date of 9/2/2022. The Medical Diagnosis Sheet states under the column Classification for the Schizoaffective Disorder as During Stay. R26's PASARR (Preadmission Screening and Resident Review) Screen ,which is required for admission to the nursing facility, was completed on 8/8/2021 and documents (R26) did not need to be screened for a Level II screening. This PASARR screening was done when (R26) was a resident of a different nursing facility. On 12/12/24 at 12:50…

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 document a discharge summary that includes a recapitulation of stay, a final summary of the resident's status, and a post discharge plan of care. This failure has the potential to affect one of one resident (R49) reviewed for discharge on the sample list of 26. Findings Include: The facility's Discharge Summary and Plan Policy Statement dated 2/17/24 documents when a resident's discharge is anticipated, a discharge summary and medication plan will be developed to assist the resident to adjust to his/her new living environment. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's course of illness, treatment, or therapy since entering the facility, current…

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 complete antibiotic doses for a urinary tract infection for one resident (R42) of one resident reviewed for infections on the sample list of 26. Findings Include: R42's Nursing Notes dated 11/9/24 at 2:13 PM, document per urology orders replaced indwelling catheter, also dip-tested urine to reveal abnormal urine sample, sending to lab for urine analysis (UA) and culture and sensitivity. R42's Nursing Notes dated 11/12/24 at 2:10 PM, document V22 Medical Director aware of UA results, new order received for Bactrim DS everyday for five days. R42's Medication Administration Record (MAR) dated November 2024, documents Bactrim DS tablet 800-160 milligrams (Sulfamethoxazole-Trimethoprim) one tablet by mouth twice a day for urinary tract infection for five days, with a start date of 11/12/24 at 8:00 AM. This same MAR has no indication that this antibiotic was given on 11/16/24 as the 8:00 AM dose and the 5:00 PM dose are not documented as given. R42's Nursing Notes dated 12/8/24 at 3:12 PM, document R42's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to accurately assess for smoking safety and failed to provide supervision for a potential smoking accident for one of one resident (R6) assessed for smoking safety on the sample list of 26. Findings Include: R6's Care Plan dated 1/31/2023 documents the following diagnoses: Presence of Right Artificial Shoulder Joint, Dependence on Renal Dialysis and Tobacco use. The same care plan for R6 documents a goal of (R6) will maintain safety while following smoking protocol. This was dated 7/9/24. An intervention for the goal was R6 is supervised while smoking. Date initiated 07/09/24. Another intervention for the goal was smoking materials are kept secured by staff. Date initiated 07/09/24. R6's Minimum Data Set (MDS) assessment dated [DATE] which was a re-admission assessment documents 15 for (R6's) BIMS ( Brief Mental Status) score. R6 is cognitively intact. The facility's assessment titled Smoking Assessment for (R6) on the following dates 8/2/24,…

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

Based on interview and record review the facility failed to notify the resident's physician of significant weight loss and failed to develop a plan of care to adequately address a resident's significant risk for weight loss. These failures affected one of one resident (R350) reviewed for nutrition on the sample list of 26. Findings Include: The facility's Weight Assessment and Intervention policy dated September 2008 documents the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. Any change of 5% or more nursing will notify the Dietician and Primary Care Physician. Greater than 5% loss within one month will be considered severe weight loss. R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Dysphagia and Gastrostomy Status. R350's Physician Order Sheet (POS) dated December 2024 documents orders for R350 to be NPO (Nothing by Mouth) and for Enteral Feed, four times a day related to Severe Protein-Calorie Malnutrition. R350 is to be weighed weekly for four weeks. R350's Weight record…

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

Based on interview and record review the facility failed to monitor and obtain a physician order regarding Gastrostomy site monitoring, dressing changes and self administration of medication via Gastrostomy tube. These failures have the potential to affect one of one resident (R350) reviewed for Gastrostomy Tube on the sample list of 26. Findings Include: R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Dysphagia and Gastrostomy Status. R350's Physician Order Sheet (POS) dated December 2024 documents orders for R350 to be NPO (Nothing by Mouth) and for Enteral Feed, four times a day related to Severe Protein-Calorie Malnutrition. On 12/10/24 at 11:32 AM R350 stated she administers her own feedings and medications through her gastrostomy tube. On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R350 administers her own feedings and medications via her gastrostomy tube. V2 confirmed there were no orders for self administration of medication, gastrostomy site maintenance/dressings or monitoring by staff, and no documentation that nursing staff 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.

Based on observation, interview, and record review the facility failed to administer medication in a timely manner for one resident (R10) of four residents reviewed for timely medication in a sample list of ten residents. Findings Include: R10's Medication Administration Record (MAR) documents R10 is scheduled to receive the following medications at 8:00AM: Ascorbic Acid 500Mg (Milligrams), Cholecalciferol 50Mcg (Micrograms), Famotidine 40Mg, Fluoxetine 20 Mg, Furosemide 40Mg, Gabapentin 100Mg, Phentermine 15Mg, Potassium Chloride 20Meq (Milliequivalents), Spiriva one puff, Symbicort 160/4.5Mcg one puff, Bupropion 100Mg, Cranberry Tab 900Mg, and MiraLAX 17Gm (Grams). On 8/6/24 at 10:17AM V5, Licensed Practical Nurse (LPN) was observed preparing the above medications for R10 in the hall at the medication cart outside R10's room. V5 verified the medications were R10's 8:00AM doses. V5 stated the medications are late because I had another resident going in for cataract surgery and I got behind. It does happen sometimes especially when there is only one nurse working. R10's MAR…

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 obtain a physician's order for oxygen and maintenance of supplemental oxygen for three residents (R1, R5, R6) of six residents reviewed for oxygen in a sample list of ten residents. Findings Include: 1. R5's Care Plan updated 7/24/24 includes the diagnosis: Chronic Respiratory Failure. On 8/5/24 at 10:00AM R5 was observed sitting in his room with oxygen in place at three liters per minute flow per nasal cannula. On 8/5/24 at 10:30AM R5's physician's orders did not document a physician's order for supplemental oxygen. R5's Treatment Administration Record (TAR) for August 1, 2024, to August 31, 2024, does not document a physician's order specifying when oxygen tubing/humidification bottle should be changed. 2. R6's Care Plan updated 7/30/24 documents (R6) has an Activities of Daily Living Self Care Performance Deficit: Activity Intolerance, Confusion, Dementia, Shortness of Breath. This Care Plan also documents a diagnosis of Chronic Obstructive Pulmonary Disease. On 8/5/24 at 10:06AM R6 was observed sitting in…

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

Based on observation, interview, and record review, the facility to prevent the potential for physical cross-contamination of food. This failure has the potential to affect all 49 residents in the facility. Findings include: 1. On 11/6/2023 at 10:02 AM, two ice scoops were stored in a container located adjacent to the facility ice maker. One scoop was made of white plastic and the other scoop was clear plastic. Both scoops were heavily chipped on the leading edges and missing pieces of plastic up to a quarter of an inch in size. On 11/6/2023 at 12:16 PM, V3 (Dietary Manager) was using the white colored ice scoop from above to obtain ice from the ice maker for residents. On 11/07/2023 at 12:12 PM, the white ice scoop from above remained in the storage container. V3 was present and stated no (she doesn't know where the missing chips of plastic from the scoops are located). 2. On 11/6/2023 at 12:16 PM, a can opener was mounted on a food prep table in the kitchen. The opener was soiled with accumulations of metal shavings where the cutting blade makes contact with canned food items…

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 arbitration agreements provide for the selection of an arbitration venue convenient to both parties. This failure has the potential to affect five residents (R48, R102, R202, R204, R208) of five reviewed for arbitration agreements on the sample list of 31. Findings include: The facility arbitration agreements signed by R48, R102, R202, R204, and R208 do not include any language providing for the selection of an arbitration venue convenient to both parties. The contract documents the arbitration will occur in the county where the facility is located. On 11/8/2023 at 10:39 AM, V4 (Business Office Manager) reported the facility arbitration agreement does not have the required language related to arbitration venue selection.

Based on interview and record review the facility failed to honor the choice to refuse the influenza vaccine for one (R22) of five residents reviewed for immunizations on the sample list of 31. Findings include: The facility's Influenza Vaccine policy with a revised date of August 2016 documents, Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. This policy also documents, A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record. R22's Influenza and Pneumococcal Vaccine Consent/Declination form signed on 9/25/23 by V20 (R22's Power of Attorney) documents V20 declined to have R22 receive the Influenza Vaccine and the Pneumococcal (PCV20) Vaccine. This form is also signed by V9 Licensed Practical Nurse/Infection Preventionist. R22's electronic immunization record documents R22 was given the Influenza Vaccine on 9/22/23 in 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 evaluate and obtain orders for self administration of medications for two (R6, R26) of two residents reviewed for self administration of medications from a total sample list of 31 residents. Findings include: The facility provided Administering Medications Policy dated December 2012 documents that residents may only self-administer medication if the attending physician in conjunction with the interdisciplinary care planning team has determined that they have the decision making capacity to do so safely. The facility provided Self-Administration of Medications Policy dated December 2016 documents that the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate for the resident including a full and complete assessment of the resident's ability to self-administer medications. The staff and practitioner will document their findings of the assessment. R6's November 2023 Medication Administration Record documents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately code Minimum Data Set assessments for two (R50, R27) of 17 residents reviewed for assessments on the sample list of 31. Findings include: 1. R50's Nursing Notes dated 9/06/2023 at 10:49 AM, documents R50 was discharged and medications including narcotics were sent with R50. R50's Discharge Minimum Data Set assessment dated [DATE] documents R50 was discharged to the hospital. On 11/8/23 at 3:00 PM, V18 Regional Nurse Consultant stated R50 was discharged to home not the hospital and that the Discharge Minimum Data Set assessment dated [DATE] was coded incorrectly. 2. R27's Minimum Data Set, dated [DATE] documents that R27 is on an antipsychotic medication. R27's August Medication Administration Record documents no anti-psychotic medications were ordered for R27. On 11/7/23 at 11:26 AM, V8 Minimum Data Set Coordinator stated, I must have mis-coded R27's Minimum Data Set. She has never been on an antipsychotic.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a pressure relieving intervention (cushion) for one of three residents (R22) reviewed for pressure ulcers in the sample list of 31. Findings Include: The facility's Prevention of Pressure Ulcers/Injuries policy with a revised date of July 2017 documents, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. This policy also documents, Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. R22's Face Sheet documents diagnoses including Pseudobulbar Affect, Vascular Dementia and Hypothyroidism. R22's Minimum Data Set (MDS) dated [DATE] documents R22 is at risk for developing pressure ulcers, has a pressure reducing device for the chair and documents R22's mobility devices as a walker and a wheelchair.…

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 safe transport for one of three residents (R42) reviewed for accidents on the sample list of 31. Findings include: The facility's Operation Instructions for the shower chair with the model # SC9200 MS documents, Precautions: Exaggerated user movement in any direction or sitting on the edge of the seat may cause the chair to tip. This policy also documents, Safety/Maintenance Information: Make certain chair is assembled according to the enclosed instructions. R42's Face Sheet documents a diagnosis of Altered Mental Status, Morbid (Severe) Obesity and Weakness. R42's electronic medical record documents R42's weight on 11/5/23 was 246.6 pounds. R42's Minimum Data Set, dated [DATE] documents R42 has moderately impaired cognition, R42 does not walk and R42 is totally dependent on two staff for bathing. On 11/6/23 at 10:44 AM, R42 was being pushed down the hallway from R42's room to the shower room, approximately 35 feet, in a shower…

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 oxygen per physician's orders for one of one resident (R42) reviewed for oxygen administration in the sample list of 31. Findings include: The facility's Oxygen Administration policy with a revised date of October 2010 documents Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. This policy also documents, Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. R42's Physician Order dated November 2023 documents a diagnosis of Chronic Diastolic Congestive Heart Failure and documents an order for Oxygen at 2 liters per nasal cannula continually. R42's Minimum Data Set, dated [DATE] documents R42 uses oxygen. R42's Electronic Medication Administration Record dated November 2023 documents an order for Oxygen at 2 liters per nasal cannula with a start date of 8/31/23. On…

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

Based on observation, interview, and record review the facility failed to relieve pain by failing to provide pain medication as ordered for three (R9, R32, R47) of three residents reviewed for pain on the sample list of 31 residents. Findings include: The facility Administering Medications Policy dated December 2012 documents that medication must be given as ordered including any required time frame. 1.) R9's undated diagnosis sheet documents Chronic Kidney Disease, Leg pain and Lymphedema. On 11/6/23 at 10:43 AM, R9 was sitting up in wheelchair and rubbing shoulder and hands stating that she was in pain. On 11/6/23 at 10:44 AM, R9 was sitting in a wheelchair in the dining room and stated, My pain patch ran out on Thursday, and they still haven't gotten it for me. I have been having a lot of pain. I have to get out of bed at night and sit up in my wheelchair to help with the pain, but I need my patch. R9's October and November Medication Administration Record documents an order for a Butrans 10 micrograms per hour pain patch to be administered weekly (Thursdays). On 11/7/23 at 1:14…

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 pain medication as ordered by the physician for two (R9 and R32) of two residents reviewed for pain on the sample list of 31 residents. Findings include: The facility Administering Medications Policy dated 12/2012 documents that medication must be given as ordered, including any required time frame. 1.) R9's October and November Medication Administration Record documents an order for a Butrans 10 micrograms per hour transdermal pain patch to be administered weekly (Thursdays). On 11/6/23 at 10:44 AM, R9 was sitting in a wheelchair in the dining room and stated, My pain patch ran out on Thursday, and they still haven't gotten it for me. I have been having a lot of pain. I have to get out of bed at night and sit up in my wheelchair to help with the pain, but I need my patch. On 11/7/23 at 1:14 PM, V7 Registered Nurse stated, (R9) should have had her patch weekly. (R9) missed 12 days, from October 26 until November 6, 2023. On 11/6/23 at 3:20 PM, V22 Medical Director stated, I can tell you exactly when I got the fax…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess the need for psychotropic medications and reassess the need for as needed antianxiety medication for three of five residents (R6, R22, R29) reviewed for unnecessary medications on the sample list of 31. Findings include: The facility's Antipsychotic Medication Use policy with a revised date of December 2016 documents, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. Diagnosis of a specific…

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

Based on observation, interview, and record review the facility failed to assess a bed rail for areas of entrapment for one of one (R29) resident reviewed for bed rails on the sample list of 31. Findings include: On 11/06/23 at 10:33 AM, R29 was lying in bed. There was a half side rail at the end of the bed. The gaps between the rails on the bed rail were greater than 4.5 inches. The gaps between the rail measured approximately 10 inches. V21 Caregiver stated the rail was added to the bed two weeks ago. R29's medical record did not contain a bed rail assessment to identify areas of entrapment. On 11/08/23 at 1:27 PM, V18 Regional Nurse Consultant stated that they did not have a bed rail assessment to identify areas of entrapment when the bed rail was placed on the bed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive person centered care plan for one resident (R1) of three residents reviewed for care plans in the sample list of three. Findings include: R1's undated Face Sheet documents R1's diagnoses as unspecified Psychosis not due to a substance or known physical condition, Non-traumatic Chronic Subdural Hemorrhage, unspecified Intracranial injury with loss of consciousness of unspecified duration, sequela, unspecified Mental Disorder due to known Physiological Condition, unspecified Mood. R1's Minimum Data Set (MDS) dated [DATE], documents R1 as moderate cognitive impairment and inattention and disorganized thinking. R1's Departmental Notes dated 7/27/23 at 9:48 PM, documents R1 was reported by north wing nurse that she was able to punch front door code and go outside. R1's Departmental Notes dated 8/15/23 at 10:00 AM, documents resident exited the front door of the facility to go to (a fast food restaurant), staff followed her (R1) out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision for a resident (R1) at risk for eloping from the facility. This failure affects one of three (R1) residents reviewed for elopement in the sample list of three. Findings include: R1's undated Face Sheet documents R1's diagnoses as unspecified Psychosis not due to a substance or known physical condition, Non-traumatic Chronic Subdural Hemorrhage, unspecified Intracranial injury with loss of consciousness of unspecified duration, sequela, unspecified Mental Disorder due to known Physiological Condition, unspecified Mood. R1's Minimum Data Set (MDS) dated [DATE], documents R1 as moderate cognitive impairment, inattention and disorganized thinking. R1's Departmental Notes dated 7/27/23 at 9:48 PM, documents R1 was reported by north wing nurse that she was able to punch front door code and go outside. R1's Departmental Notes dated 8/15/23 at 10:00 AM, documents resident exited the front door of the facility to go to (a fast food…

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