Haven of Champaign

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete infection surveillance documentation and ensure one resident (R25) met the criteria for initiation of an antibiotic of four residents reviewed for antibiotic stewardship in a sample of 37 residents. Findings Include:R25's Care Plan initiated 2/22/26 includes the following diagnoses: Presence of Left Artificial Hip Joint, Presence of Cardiac Pacemaker, Malignant Neoplasm of Abdomen, Cataract, Atrial Fibrillation and Flutter, Hypertension, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Wound of Left Great Toe, Peripheral Vascular Disease, and Chronic Kidney Disease Stage III. R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact. R25's Wound assessment dated [DATE] documents R25 has an unstageable pressure ulcer in his left heel and left great toe. R25's Medication Administration Record (MAR) for February documents a physician's order dated 2/5/26 for Bactrim Oral Tablet 400-80…

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 Registered Nurse coverage for at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 50 residents residing in the facility.Findings include:The Facility assessment dated [DATE] with a review date of 10/9/2025 documents the following: Staffing: The facility will be staffed according to resident needs and required staffing guidelines and considerations of continuity of care.The facility's Daily Assignment Sheets dated December 16, 2025 through December 31, 2025 documents no Registered Nurse coverage on 12/25/25.On 12/31/25 at 10:24am, V2 (Director of Nursing) confirmed the facility did not have Registered Nurse coverage for 8 consecutive hours on 12/25/25. V2 stated the registered nurse who was scheduled had called off and V2 did not come in that day to cover the shift.The facility Room Roster dated 12/30/25 documents 50 residents reside in the facility.

Based on observation, interview and record review, the facility failed to conduct a procedure with a mechanical lifting device in a safe manner to prevent a resident fall. This failure affects one resident (R1) out of five reviewed for falls and mechanical lift use on the sample list of five. Findings include: R1's Face Sheet dated 11/30/22 documents R1 was admitted to the facility on this date and is her own responsible party and financial guarantor. This same Face Sheet, along with R1's Medical Diagnoses List (undated) documents R1 experiences medical conditions including Generalized Weakness, Polyarthralgia, Lymphedema, Class 3 Obesity, Gout, Physical Debility, Osteoarthritis of Bilateral Knees, Hypertension, and Diabetes Mellitus Type 2. On 4/24/25 at 8:40 AM, R1 was lying in bed in her own room. R1 could not make a complete fist with her left hand which was visibly swollen with taught skin. R1 had a compression wrap on her left knee. R1 stated a CNA (Certified Nursing Assistant, V6) had transferred her using a sit-to-stand mechanical lift, R1 tried to inform the CNA that she…

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

Based on observation, interview, and record review, the facility failed to acquire, dispense, and administer a resident's pain medication as ordered by the physician. This failure affects one resident (R1) out of three reviewed for pain on the sample list of five. Findings include: R1's Face Sheet dated 11/30/22 documents R1 was admitted to the facility on this date and is her own responsible party and financial guarantor. This same Face Sheet, along with R1's Medical Diagnoses List (undated) documents R1 experiences medical conditions including Generalized Weakness, Polyarthralgia, Lymphedema, Class 3 Obesity, Gout, Physical Debility, Osteoarthritis of Bilateral Knees, Hypertension, and Diabetes Mellitus Type 2. On 4/24/25 at 11:50 AM, R1 stated she had been experiencing increased pain in her left hand and knees ever since she fell off of the sit-to-stand mechanical lift on 3/9/25. R1 stated her doctor (V10) had prescribed Norco (Hydrocodone 5 milligrams with Acetaminophen 325 milligrams) that she is supposed to be able to have every 4 hours if she needs it. R1 further stated 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 follow up on grievances and document actions taken for six (R19, R29, R36, R37, R45, R57) of six residents reviewed for grievances in the sample list of 39. This failure has the potential to affect all 51 residents in the facility. Findings include: The facility's undated Resident Council Policy documents the purpose of the council meeting is to protect and preserve resident rights and for residents to discuss grievances/problems and to participate in the resolution of these concerns. This policy documents suggestions and complaints will be presented in writing to the facility's Administrator, Social Services Director, and other facility staff to review and implement follow up actions. The Concern/Suggestion form will be used to document concerns and the Administrator will respond to all council recommendations and complaints in writing, and per the facility's grievance policy. The facility's Grievance policy dated November 2016 documents the facility will post information on how to file a grievance and 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 employ a Director of Nursing and failed to provide the services of a registered nurse for eight consecutive hours seven days a week. This failure has the potential to affect all 51 residents residing in the facility. Findings Include: On 3/9/25, 3/10/25 and 3/11/25 there was not a full time Director of Nursing working in the facility. The resident roster dated 3/9/25 documents 51 residents reside at the facility. The facility's nursing working schedule from 2/24/25 to 3/10/25 documents the facility did not have the services of a Registered Nurse (RN) for eight consecutive hours on 2/24/25, 2/27/25, 2/28/25, 3/1/25 and 3/2/25. On 3/10/25 at 9:00am V3 Assistant Director of Nursing stated the facility has not had a Director of Nursing (DON) since 1/31/25 when the pervious Director of Nursing took another job. V3 stated the facility does not always have Register Nurse coverage for eight consecutive hours seven days a week. V3 confirmed the documentation on the working schedule provided was an accurate record of RN…

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 employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 51 residents in the facility. Findings include: On 3/10/25 at 11:15AM and 3/11/25 11:30am V3 Dietary Manager was actively supervising dietary operations in the facility kitchen. On 3/11/25 at 11:04am V3 Dietary Manager stated that V3 was hired a couple of weeks ago as Dietary Manager. V3 stated that V3's Food Safety/Dietary Manager Certificate expired over a year ago, and V3 is scheduled to take the test next month. V3 stated at this time V3 fails to meet the State of Illinois standards to be a food service manager or dietary manager. On 3/11/25 at 2:02pm V1 Administrator confirmed that V3 Dietary Manager does not currently have a valid Food Safety/Dietary Manager Certificate as required. The Facility Assessment (not dated) documents a full-time dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services is needed to provide competent…

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 employ dietary support staff with the appropriate competencies to carry out the functions of the food and nutrition service. This failure has the potential to affect all 51 residents residing in the facility. Findings include: On 3/10/25 at 11:00am V26 Dietary Aide was preparing residents food, assisting with plating and distributing resident's meals. On 3/11/25 at 3:30pm V19 Dietary Aide was preparing residents food, assisting with cooking residents food and preparing residents drinks. On 3/10/25 at 11:00am V26 stated that V26 does not have any training in food service or nutrition and does not have a food handlers certificate. On 3/11/25 at 11:04 am, V4, Dietary Manager, stated, We have six employees on the kitchen staff, four of those employees do not have a Food Handler's certificate. Those employees are (V19, V26, V27 and V28). On 3/11/25 at 11:26 am, V1, Administrator acknowledge that V9, V26, V7 and V28 do not have a current 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.

Based on interview and record review the facility failed to annually implement and evaluate the effectiveness of a performance improvement plan. This failure has the potential to affect all 51 residents in the facility. Findings include: The facility's undated Quality Assurance Performance Improvement (QAPI) Plan documents the QAPI committee will conduct a self assessment of the facility on an annual basis and prioritize activities, policies and procedures and continually monitors for improvement through the use of self assessment. The facility will consider input from staff, residents, and family members, adverse events, performance indicators, survey findings, and complaints/grievances. Root Cause Analysis will be used for identifying contributing causal factors designed to get to the underlying cause of a problem, which leads to identification and effective interventions to make improvements. Measurements are used by gathering data and analyzing trends and implementation of interventions will be evaluated to ensure continuation and progress is continued or sustained. On 3/11/25…

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.

Based on interview and record review the facility failed to have quarterly Quality Assurance meetings. This failure has the potential to affect all 51 residents in the facility. Findings include: The facility's undated Quality Assurance Performance Improvement (QAPI) Plan documents the facility will take a proactive approach to improve the care provided and will create systems to achieve compliance through tracking, investigating, and trying to prevent recurrence of adverse effects, investigating complaints, seeking feedback from residents and staff, setting targets for quality, and striving for deficiency free surveys. This plan documents the interdisciplinary team will ensure resident's needs are met through QA meetings. QA meeting documented 1/9/25. All required members present. On 3/11/25 at 12:08 PM V1 Administrator provided the facility's QAPI meeting dated 1/9/25. V1 stated V1 has been the Administrator since December 2024 and has only had one QA meeting in January 2025. At 12:15 PM V1 provided additional QAPI meeting sign in sheets dated 4/26/24 and 9/5/24. V1 stated 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 implement their water management plan, prevent potential cross contamination of a pressure sore and the treatment cart, and implement Enhanced Barrier Precautions. These failures have the potential to affect all 51 residents residing in the facility. Findings include: The facility's Water Management Plan-Legionella Bacteria Risk Management Policy dated 11/17/24, documents the facility will develop the following documents and process as components of the Water Management Plan which includes: identify the end user of water to determine at risk consumers, identify all areas where water is processed after entering facility, develop process flow diagrams to describe how water is processed at the facility, verify that the process flow diagrams are accurate by on-site verification, perform a Hazard Analysis based on process flow diagrams, and identify critical points. This policy states hot water tanks will have temperature checked everyday, deliverable hot/cold water temperatures checked weekly, hot water…

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 have access to their personal funds for four (R57, R14, R19, R37) of seven residents reviewed for personal funds in the sample list of 39. Findings include: The facility's Resident Personal Trust Funds policy dated 4/15/24 documents the resident personal funds will be maintained in the business office and social services staff can assist residents in obtaining funds from the business office. This policy documents residents may make deposits or receive funds at the business office during regular business hours Monday through Friday or at the specified times posted in the facility. Withdrawals for less than $60 will be made immediately and over $60 will require a 24 hour notice. 1.) On 03/09/25 at 9:19 AM R14 stated R14 has a $60 monthly income that the facility keeps in trust fund account. R14 stated R14 does not have access to R14's personal funds on the weekends when V17 Business Office Manager isn't in the facility, which isn't right.…

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 quarterly statements for personal fund accounts for four (R1, R7, R14, R18) of seven residents reviewed for personal funds in the sample list of 39. Findings include: The facility's Resident Personal Trust Funds policy dated 4/15/24 documents the resident personal funds will be maintained in the business office and quarterly statements for all transactions will be provided to the resident or legal representative. 1.) On 03/09/25 at 9:19 AM R14 stated R14 has a $60 monthly income that the facility keeps in trust fund account. R14's Minimum Data Set, dated [DATE] documents R14 as cognitively intact. The facility's Resident Council Minutes dated 2/20/25 document concerns that residents need account statements for what they are paying for. R14's Resident Statement dated 3/10/25 documents transactions between 1/1/25 and 3/5/25, with a remaining balance of $2,496.20. 2.) R7's Resident Statement dated 3/10/25 documents transactions between 1/2/25 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide numerous showers as scheduled for dependent residents. These failures affect two residents (R9, R43) of three reviewed for activities of daily living in the sample list of 39. 1. On 3/9/25 at 9:00am R10 stated that R9 is R10's Husband and R9 does not get two showers a week. R10 stated that R9 needs help from staff to get a shower, due to R9's not knowing how to take one without someone helping R9. On 3/11/25 at 9:15am V3 Assistant Director of Nursing (ADON) stated all residents are scheduled for two showers a week, and if a resident refuses a shower after three attempts a bed bath is offered. V3 stated if the resident still refuses, a nurse is notified and documents it in the resident's chart. V3 stated after giving the resident a shower, the Certified Nursing Assistant (CNA) documents it on a shower sheet. V3 stated all showers must be documented on a shower sheet whether the resident receives a shower, bed baths or refusals. On 3/11/25 at…

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

Based on interview and record review, the facility failed to offer immunization education, immunization consent forms, and vaccinations for five residents (R9, R28, R41, R52, R160) of five residents reviewed for immunizations in the sample list of 39. Findings include: R9, R28, R41, R52, and R160 have no documentation of education for vaccinations, no consents for vaccinations, and no documentation of vaccines being offered or administered in their medical records. On 3/11/25 at 2:30 PM, V2 Corporate Nurse stated there is no documentation for immunizations for the five residents (R9, R28, R41, R52, R160) requested. The facility's Immunization of Residents Policy dated Revised 1/23/20, documents this facility will offer immunizations and vaccinations that aid in the prevention of infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director.

Based on observation, interview, and record review the facility failed to have a physician order for medication found at the bedside for one (R39) of one resident reviewed for self administration of medications in the sample list of 39. Findings include: The facility's Medication Administration policy dated 11/18/17 documents medications will not be kept at the bedside unless there is a physician order to do so. On 3/09/25 at 8:50 AM there was a Combivent inhaler on R39's overbed table. R39 stated R39 self administers the inhaler, two puffs, two to four times per day and the inhaler is always kept in R39's room. R39's March 2025 Physician Order Summary does not document an active order for the Combivent inhaler or for R39 to keep this medication at the bedside prior to 3/9/25. On 3/9/25 between 12:48 PM and 12:52 PM V7 Registered Nurse stated R39 has an inhaler that R39 keeps in her room and self administers. V7 reviewed R39's active physicians orders and Medication Administration Record and confirmed there is no order for the Combivent inhaler. V3 Assistant Director of Nursing…

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 physician's ordered treatments, monitor daily weights, report weight gain, and develop a care plan for lymphedema and congestive heart failure (CHF) for one (R10) of two residents reviewed for edema in the sample list of 39. Findings include: On 03/09/25 at 9:51 AM R10 stated R10's legs are suppose to be wrapped every morning and removed every night, but that doesn't always get done. R10 stated R10's leg wraps have been on for several days. R10 stated R10 was hospitalized in November 2024 for cough and lymphedema. R10's legs had lymphedema and the leg wraps were sliding down onto R10's feet. R10's Minimum Data Set (MDS) dated [DATE] documents R10 is cognitively intact. R10's active care plan lists diagnoses of Lymphedema and CHF, but does not document a problem, goal, and interventions to address R10's CHF and Lymphedema. R10's January 2025 Physician's Order Summary documents an order to monitor weight daily, notify physician of…

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

Based on observation, interview, and record review, the facility failed to obtain a treatment order for a newly discovered pressure area, monitor the area and follow manufactures recommendations for a treatment application for one resident (R43) of two residents reviewed for pressure ulcers in the sample list of 39. Findings include: R43's undated diagnoses list documents R43's diagnoses as: Acute and Chronic Respiratory Failure without Hypoxia, Type II Diabetes Mellitus without complications, Chronic Obstructive Pulmonary Disease, and Cognitive Communication Deficit. Pressure Wound is not listed as a diagnosis in R43's medical record. R43's Hospice notes dated 12/19/24, document redness to buttocks. R43's medical Record has no other documentation regarding this area until another Hospice note dated 1/2/25. This Hospice note documents a stage II wound measuring 2 centimeters (cm) by 2 cm and recommended a treatment. A telephone order written on 1/8/25, was given with treatment orders for R43's pressure wound. R43's Treatment Administration Records (TAR) for December 2024 has no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide complete and hygienic catheter care, failed to maintain the urinary catheter tubing and drainage bag off the floor, failed to have a physician order for a urinary catheter and failed to record catheter care and urinary output for two (R31, R36) of two residents reviewed for urinary catheters in the sample list of 39. Findings include: The facility's Catheter Care policy dated February 2018 documents for female catheter care, separate the labia and wash the perineal area prior to cleansing the urinary catheter. 1.) On 3/09/25 at 9:51 AM R31 stated staff doesn't always empty R31's urinary catheter drainage bag when requested. R31 stated R31 has had the urinary catheter for about a month and that no staff provide routine cleaning of the catheter. R31 stated the hospital staff cleaned R31's urinary catheter when R31 was at the hospital. R31 stated R31 has a history of bladder infections and urinary retention, which is why the catheter…

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 implement gradual dose reductions (GDR), identify and track targeted behaviors, implement nonpharmacological interventions, and assess for the use of psychotropic medications for one of five residents (R14) reviewed for unnecessary medications in the sample list of 39. Findings include: The facility's Psychotropic Medication Policy dated 11/28/17 documents the following: An unnecessary drug is any drug used in an excessive dose, for excessive duration, without adequate monitoring, without indications for use, and drugs should be reduced or discontinued if adverse consequences are present. Rule out causative agents of behaviors, implement nonpharmacological interventions to decrease behaviors and prior to prescribing psychotropic medications, complete a Pre-Psychotropic Medication Assessment prior to a new psychotropic medication order and complete quarterly Psychotropic Medication Assessments. Residents with psychotropic medications will have documented behaviors and behavior tracking sheets implemented for monitoring.…

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 medications according to physician orders and manufacturer recommendations for two of five residents (R30 and R31) reviewed for medication administration on the sample of 39. The facility had two errors out of 28 opportunities resulting in a medication error rate of 7.14 percent. Findings include: The facility's policy titled Medication Administration revision date 11/18/17 states Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. 1.) R30's March 2025 Physician Order Sheet (POS) documents an order for Lisinopril 2.5 mg (milligram) once a…

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

Based on observation, interview, and record review the facility failed to follow a diet order for thickened liquids for one (R210) of 24 residents reviewed for meals in the sample list of 39. Findings include: The facility's Diet Orders policy dated June 2006 documents the physician should be contacted to receive diet orders, nursing notifies the dietary department in writing of the correct diet order using the Diet Order Form, and the food service manager is responsive for reviewing the resident's medical record to ensure a written order exists and matches the diet order. This policy documents Diet Order Forms are kept on file in the dietary department for staff to reference. On 3/09/25 at 9:26 AM R210's breakfast tray contained regular consistency water and juice. V5 Certified Nursing Assistant (CNA) stated R210 refused breakfast, but R210 drinks a lot of water that is supposed to be thickened. V5 confirmed R210's breakfast tray contained regular consistency liquids. On 3/09/25 at 1:27 PM R210 was in bed and R210's noon meal tray was at the bedside. R210's meal consisted of…

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

Based on interview and record review the facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day. This failure has the potential to affect all 46 residents residing in the facility. Findings include: The facility's August 2024 Nurse Schedule and Nursing Daily Sheets dated 8/4/24 and 8/7/24 do not document an RN was scheduled to work. On 8/14/24 at 1:51 PM-2:47 PM the facility's staffing and daily sheets were reviewed with V2 Director of Nursing. V2 reviewed employee time cards and schedules, and confirmed the facility did not have an RN on duty on 8/4/24 and 8/7/24. V2 stated V6 RN is the full time RN, V15 RN works as needed, V3 Minimum Data Set Coordinator is also an RN, and V2 fills in on the weekends when RN coverage is needed. V2 stated V2 and V3 were out sick with COVID-19, which is why there was no RN coverage on 8/4/24 and 8/7/24. The facility's Room Roster dated 8/13/24 document 46 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have adequate dietary staff to ensure meals are served timely. This failure affects four (R1, R4, R5, R6) of five residents reviewed for meals in the sample list of 13. This failure has the potential to affect all 46 residents residing in the facility. Findings include: On 8/13/24 at 11:10 AM, R1 stated kitchen staff was out sick with COVID-19 (Human Coronavirus Infection), so the meals weren't served on time for two days before the facility had additional staff come in to help. R1 stated breakfast was served at 11:00 AM instead of 8:00 AM, lunch was around 3:00 PM, and supper was at 7:00 PM. On 8/13/24 at 1:56 PM, R4 stated: Meals aren't served timely. This weekend it was 10:00 AM for breakfast and 1:00-1:30 PM for lunch. Meals aren't served timely. On 8/13/24 at 2:28 PM, R5 stated recently the facility has lost many kitchen staff and meals are served two to three hours later than scheduled. On 8/13/24 at 3:45 PM, R6 stated breakfast is served around…

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 a clean and sanitary kitchen. This failure has the potential to affect all 46 residents residing in the facility. Findings include: On 8/13/24 at 9:50-9:57 AM, the kitchen was toured with V10 Dietary Manager. There was dust and debris on the floor and dirt built up on the floor around the range and prep table. There were dark, dried splatters on the side of the range and on the wall near the three sink washing station. On 8/13/24 at 11:55 AM-12:35 PM, V10 served the noon meal trays for all of the residents. V14 Dietary Aide swept the floor and there was a large pile of dirt and debris. There was dark dirt build up on the floor around the range and prep table, and there were dark, dried splatters on the side of the range and wall near the three sink station. This was confirmed with V10 and V11 Dietary Aide. V11 stated the floors are suppose to be swept and mopped at the end of each shift and should have been done last evening. V10 stated the kitchen is cleaned daily and a deep clean is done weekly, but…

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 implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus Infection) by failing to maintain a supply of N95 respirators, ensure staff wear appropriate Personal Protective Equipment (PPE), ensure staff wear PPE correctly, and routinely disinfect high touch surfaces during a COVID-19 Outbreak. This failure affects seven (R3, R5, R2, R10, R11, R12, R13) of seven residents reviewed for Infection Control in the sample list of 13. These failures have the potential to affect all 46 residents residing in the facility. Findings include: 1.) The facility's August 2024 Staff Infection Control Log documents 16 employees tested positive for COVID-19 between 8/2/24 and 8/6/24. The Facility's August 2024 Resident Infection Control Log documents 24 residents tested positive for COVID-19 between 8/1/24 (when the outbreak began) and 8/8/24. Positive residents included R2, R3, R11, R12. On 8/13/24 at 9:58 AM, V19 Resident Care Coordinator stated 24 residents have contracted COVID-19 during this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain functioning call lights for four (R3, R5, R8, R9) of four residents reviewed for call lights in the sample of 13. Findings include: 1.) On 8/13/24 at 2:28 PM, R5 was lying in bed and there was a handheld bell on R5's bed beside R5. R5's room did not contain a call light cord attached to the call light box in R5's room. There was contact and droplet isolation signage posted on R5's room door. On 8/15/24 at 11:03 AM, R5 was in R5's room with a handheld call bell beside her. There was no call light cord plugged into the call light box in R5's room. R5 stated the other night R5 kept ringing the handheld bell and it took a long time for staff to answer, and usually R5 has to wait 30 minutes or more for staff to respond. R5 stated the staff told R5 that they didn't know where the bell sound was coming from. On 8/13/24 at 3:22 PM, V17 Certified Nursing Assistant (CNA) stated R5's call light hasn't been working for a few weeks. R5'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 sufficiently staff housekeepers in order to provide a clean and homelike environment. This failure affects three (R2, R5, R6) of seven residents reviewed for housekeeping in the sample list of 13. Findings include: 1.) On 8/13/24 at 3:45 PM, R6 stated the facility doesn't have enough housekeeping staff and R6's room isn't always cleaned daily. R6 stated no one has been in to clean R6's room yet today. R6's floor was sticky. There were paper towels on the bathroom floor, the garbage can was overflowing with garbage, and the toilet bowl contained dried feces. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. 2.) On 8/13/24 at 4:06 PM, R2 stated housekeeping hasn't been in to clean R2's room yet today. There was dust and food wrappers observed on R2's floor. R2 stated housekeeping staff was out sick with COVID-19 (Human Coronavirus Infection) and the rooms weren't getting cleaned every day. R2's MDS dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide scheduled showers for one (R4) of seven residents reviewed for Activities of Daily Living in the sample list of 13. Findings include: On 8/13/24 at 1:56 PM, R4 stated R4 prefers to have showers weekly, but R4 has not received a shower for two weeks since the facility has a COVID-19 (Human Coronavirus Infection) outbreak. R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact and is dependent on staff for bathing. The facility's Shower List dated 4/15/24 documents R4's showers are scheduled on Thursdays. R4's August 2024 shower sheets were requested from the facility on 8/15/24. On 8/14/24 at 9:21 AM, V6 Registered Nurse stated there was a staffing shortage due to the COVID-19 outbreak on the second week of August, around the 9th, which affected showers being given. On 8/15/24 at 11:11 AM, V8 Certified Nursing Assistant provided R4's shower sheet dated 8/1/24. V8 confirmed V8 is the facility's assigned shower aide. V8 stated that…

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

Based on observation, interview, and record review the facility failed to follow a physician ordered diet for one (R1) of five residents reviewed for diet in the sample list of 13. Findings include: On 8/13/24 at 11:10 AM, R1 stated R1 is a diabetic, but is not on a special diet. R1 states R1 just monitors what R1 eats. On 8/13/24 at 11:55 AM and 12:35 PM, V10 Dietary Manager served all of the residents' meal trays. R1's meal tray consisted of Salisbury steak, gravy, mashed potatoes, one slice of bread, sunshine carrots, and ice cream. R1's meal tray card documented regular diet. V10 stated low concentrated sweets and controlled carbohydrate diets are similar, and the bread is not served for those diets for this meal. R1's Brief Interview for Mental Status dated 7/30/24 documents R1 is cognitively intact. R1's August 2024 Physician's Order Summary (POS) documents R1's diagnoses include Type 2 Diabetes Mellitus and R1's diet is Controlled Carbohydrate. On 8/14/24 at 3:50 PM, V10 confirmed R1's meal tray card documents regular diet and the prescribed diet on the POS should be what is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 49 residents residing in the facility. Findings include: The facility assessment dated [DATE] documents that a dietician or other clinically qualified nutrition professional will serve as the director of food and nutrition services. The facility provided dietary schedule documents no dietary manager until July 25, 2024 and no certified dietary manager on staff during the month of July 2024. On 7/25/24 at 1:45PM, V1 Administrator said that he had been cooking for the last 12-14 days due to lack of staff, including a dietary manager. V1 Administrator then said that he hired V8 dietary manager who started orientation on 7/25/24. On 7/29/24 at 11:25PM, V1 Administrator said that the only documented training that V8 Dietary Manager has provided is a food handler's certificate and that he could not provide documentation that V8 was a certified dietary…

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 employ sufficient staffing with the appropriate competencies to provide food service. This failure has the potential to affect all 49 residents who reside in the facility. Findings include: The facility food service staffing and scheduling policy dated 12/2006 documents that it is the policy (facility name)Health Care that sufficient, competent support personnel are employed to carry out the functions of the department. The facility assessment dated [DATE] documents that the dietary department needs include 8 hours of a director of food and nutrition services and 12 hours of food and nutrition services staff per day. On 7/25/24 at 1:45PM, V1 Administrator said that he had been cooking for the last 12-14 days due to lack of staff, including a dietary manager (DM). The facility provided dietary schedule dated July 2024 documents that a dietary manager was scheduled on July 25, 26, 27, 28, 29 and 30. The facility provided dietary schedule…

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 protect two (R1 and R2) of three residents from verbal and mental abuse from a total sample of three residents reviewed for abuse. Findings include: The facility provided Abuse Prevention Program Policy dated 11/28/2016 documents that the facility affirms the right of its' residents to be free from abuse or mistreatment including protecting residents from verbal abuse from staff. Verbal abuse is identified in the policy as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to threats of harm, or saying things to frighten a resident. Mental abuse includes threats of punishment or deprivation. On 7/29/24 at 9:00AM, R1 was sitting at the table in the dining room. R1 did not respond to verbal communication. R1's 7/14/23 cognitive assessment documents R1 as severely cognitively impaired. R2's 6/13/24…

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 implement its abuse policy by failing to immediately report suspected abuse to the abuse coordinator and failing to ensure that the alleged abuser was immediately removed from the facility for two (R1 and R2) of three residents reviewed for abuse from a total sample list of three. Findings include: The facility Abuse Prevention Program Policy dated 11/28/16 documents that employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. Employees of this facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the administrator or designee. Employees accused of alleged mistreatement, exploitation, neglect, abuse or misappropriation of resident property shall not…

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 employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 47 residents residing in the facility. Findings include: On 7/18/24 at 10:40 AM, V1 Administrator stated they do not have a Dietary Manager at this time, V1 stated the facility had a Dietary Manager for five days but that person abandoned the job so we let him go. V1 stated V1 has been working in the kitchen a lot and comes in every weekend and at other times to cook. V1 stated V2 Director of Nursing (DON) has also been helping to cook. On 7/18/24 at 12:30 PM, V2 DON stated V2 has been cooking for the past one and a half to two weeks. Throughout this survey, from 7/18/24 through 7/19/24, a Dietary Manager was not present in the facility. The facility's Food Service Manager job summary dated 10/16, documents qualifications for this position include: must have taken or be willing to take the Dietary Managers Course and have passed 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 have qualified dietary aides and a cook. This failure has the potential to affect all 47 residents who reside in the facility. Findings include: The Facility assessment dated [DATE], documents food and nutrition services staff be in the facility 14 hours per day. The facility's Diet Aide job summary dated 10/16, documents a dietary aide must have passed the sanitation test or be willing to take the course approved by the state the facility is in and must receive food handler's training within 30 days of employment. On 7/18/24 at 12:30 PM, V2 Director of Nursing (DON) stated V2 has been cooking at the facility for one and a half to two weeks. On 7/18/24 at 3:30 PM, V1 Administrator stated V4, the cook, does not have a cooking/sanitation certificate, also V5 and V6 diet aides do not have a food handlers certificate at this time. At this same time, V1 stated V1 was not aware that V4 needed a cooking/sanitation certificate. On 7/18/24 at 3:45…

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 administer a dietary supplement according to physician's orders for one resident (R3) of one resident reviewed for following physician's orders in the sample list of three. Findings include: R3's undated Cumulative Diagnosis Log, documents R3's diagnosis as: Transischemic Attack (TIA) and Cerebral Infarction. R3's Physician Order Sheet (POS) dated 7/1/24 to 7/31/24, documents Med Pass 2.0 Supplement 60 milliliters (ML) by mouth twice a day. R3's Medication Administration Record (MAR) dated 7/1/24 through 7/31/24, documents Med Pass 2.0 Supplement as not given to R3 on the following dates: 7/7/24, AM and PM; 7/11/24 AM and PM; 7/16/24 PM; and 7/19/24 AM. On 7/18/24 at 3:06 PM, V2 Director of Nursing (DON), verified on previous dates, R3 did not receive Med Pass Supplement. R3's Care Plan dated 3/22/24, documents to provide and serve supplements as ordered. The facility's Conformance with Physician Medication Orders dated Reviewed 9/27/17, documents all medication, headache remedies, vitamins, etcetera shall be given upon…

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 protect the resident's right to be free from verbal and mental abuse by a staff member. This failure affected one of four residents (R1) reviewed for abuse in the sample of four. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. The facility is committed to protecting the residents from abuse. Abuse includes the willful intimidation resulting in mental anguish which can include verbal or mental abuse. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental abuse includes humiliation. The Abuse Investigation Report dated 5/22/24 documents V3 Certified Nurses Assistant (CNA) was verbally inappropriate towards R1. V3 made R1 feel embarrassed 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.

Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on four of eighteen days reviewed for RN staffing. This failure has the potential to affect all 49 residents in the facility. Findings include: The facility Nursing Schedules from April 23, 2024 through May 10, 2024 were reviewed for RN staffing. The Facility Nursing Schedule (April 23, 2024 through April 30, 2024) documents on 4/23/24, 4/25/24, and 4/27/24, the facility scheduled four (4) hours of RN coverage for a 24 hour period. This same record documents on 4/29/24, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 5/9/24 at 1:32pm, V5 Resident Care Coordinator confirmed the hours listed on the facility nursing schedule were correct and the facility failed to have sufficient RN coverage on 4/23/24, 4/25/24, 4/27/24, and 4/29/24. The Long-Term Care Facility Application for Medicare and Medicaid report dated 5/8/24 documents 49 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to maintain the range hood in a sanitary condition to protect food being prepared on the range, and failed to maintain the commercial dishwasher sanitizer levels to sanitize meal service wares and utensils. These failures have the potential to affect all 49 residents residing in the facility. Findings include: 1. On 5/7/24 at 9:28 AM, the range hood in the facility kitchen had a dull appearance and there was a general coating of a dull light brown colored greasy substance with darker brown grease trails running down the interior surface of the range hood. There was a pot of Brussels sprouts cooking on the range, as well as a cooked blueberry cobbler cooling on the side of the range, both items being directly underneath the hood. On 5/7/24 at 9:28 AM, there was an applied sticker on the outside of the range hood which documented a last cleaning date of 6/27/23. V6, Dietary Manager, stated, That sounds about right. I have been trying to keep it clean myself, but we need to get the cleaning service to come back 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 interview and record review the facility failed to conduct quarterly Quality Assurance (QA) meetings. This failure has the potential to affect all 49 residents residing in the facility. Findings include: The facility's Quality Assurance meeting sign in sheets for the last year were requested and were provided by V1 (Administrator). The facility had a documented meeting on 4/26/2024. The QA Meeting sign in sheet dated 4/26/2024 documents the facility reviewed information from the months of January, February and March 2024. There are no documented QA meeting sign in sheets for any other quarterly committee meeting. On 5/9/24 at 9:15 am, V1 Administrator and V12 Regional Support confirmed there were no more sign in sheets for the Quarterly Committee Meetings. V1 on 5/10/24 at 9:45 am, confirmed the meeting sheet dated 4/26/24 covered the months of January, February and March 2024. The facility's undated policy titled Quality Assurance Plan documents the facility will have quarterly meetings. The facility's Resident Roster dated 5/7/24 and Form 671, Long Term Care 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.

Based on observation, interview and record review, the facility failed to answer call lights in a timely manner for seven residents (R21, R29, R31, R37, R39, R40, R46) and failed to provide privacy while giving an insulin injection in the dining room for one resident (R40) of eight residents reviewed for dignity in the sample list of 32. Findings include: Resident Council Meeting Minutes document the following: 6/23/2023, call lights need to be answered more timely; 7/21/2023, call lights are not being answered timely due to staff availability; 10/20/2023, call lights not being answered timely; 11/17/2023, second shift late answering call lights; 2/15/2024, answering call lights late; 3/21/2024, need to be more prompt answering call lights; 4/18/2024, call lights need to be answered sooner. On 5/7/24 at 3:01 PM, during the resident council interview, R21, R29, R31, R37, R39, R40, R46, all stated call lights are not answered timely (on each shift). R40's Physician Order Sheet (POS) dated 5-1-24 - 5-31-24, documents Insulin Lispro 100unit/milliliter - inject 5 units subcutaneous…

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 label insulin pens after opening for five residents (R5, R15, R16, R27, R40) of five residents reviewed for insulin storage in the sample list of 32. R5's Physician Order Sheet (POS) dated 5-1-2024 - 5-31-24, documents Insulin Glargine-YFGN Units 100 inject 15 units subcutaneous (SQ) two times a day; Fiasp 100 units/milliliter (ml) 3 ml pen inject 5 units SQ three times daily before meals and Insulin Fiasp 100ml 3 ml per sliding scale four times a day. R15's POS dated 5-1-2024 - 5-31-24, documents Insulin Glargine -YFGN U100 inject 15 units SQ at bedtime, Insulin Lispro 100units/ml inject four times a day per sliding scale. R16's POS dated 5-1-2024 - 5-31-24, documents Insulin Lispro 100u/ml SQ before meals four times a day. R27's POS dated 5-1-2024 - 5-31-24, documents Novolog 100 units/ml per sliding scale four times a day, Insulin Aspart 100units/ml 3 ml four times a day. R40's POS dated 5-1-2024 - 5-31-24, documents Insulin Lispro 100units/ml inject 5 units SQ before meals per sliding scale, Levemir…

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

Based on observation, interview, and record review, the facility failed to ensure that food served was palatable and attractive. This failure affects seven (R21, R29, R31, R37, R39, R40, R46) residents reviewed for dining services. Findings include: On 5/7/24 at 3:01 PM, resident council interview was held. At this time, R21, R29, R31, R37, R39, R40, and R46 all stated the food is terrible, doesn't look appetizing, is either hot or cold when not supposed to be, and they have the same things. Resident Council Minutes document: 6/23/24, food needs to be cooked more thoroughly; 9/15/23, cold food, want more fried chicken and magic cups; 12/21/23 cold food in dining room; 1/18/24, cold food all three shifts; 3/21/24, change meals, more coffee, too much butter; 4/18/24, hall trays for three meals are cold when they reach the residents, no coffee available to drink, more salt, pepper, sugar to be available, want alterations with how the food is being cooked. On 5/8/24 at 12:30 PM, surveyor asked V1 Administrator to come to dining room. At this time, surveyor and V1 observed at least 7…

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 resident with an Advance Beneficiary Notice (ABN) at the termination of a Medicare Part A covered stay, thereby nullifying the resident's right to continue therapy services at their own expense, or decline therapy services. This failure affects one resident (R5) out of a sample of three reviewed for Beneficiary Notices on the sample of 32. Findings include: R5's Beneficiary Protection Notification Review (undated) documents R5 began a Medicare Part A covered stay at the facility 3/26/24, with a last covered date of 4/4/24. There was no evidence that R5 received an Advance Beneficiary Notice of her options to decline to receive further therapy, or to continue therapy services at her own expense. On 5/8/24 at 11:06 AM, V4, Business Office Manager, stated, I use the ABN notice for Medicare Part B. V4 then located ABN notices for two other residents discharged from Medicare Part A and stated, I don't know why I didn't make out an ABN for (R5).

Based on interview and record review, the facility failed to report and notify the Administrator and a supervisor of injuries of unknown origin and failed to notify the administrator of a resident to resident incident for three of three (R11, R31 and R17) residents reviewed for Abuse Allegations in the sample list of three. Findings include: R11's undated Face Sheet documents R11's diagnoses as Acute Metabolic Encephalopathy, History of falling, repeated falls, need for assistance with personal care. R11's Physician Order Sheet (POS) dated 5/1/24-5/31/24, documents R11's diagnoses as Anxiety, Bipolar, Depression, Vertigo, Vitamin D Deficiency, Fibromyalgia, Chronic Back Pain. R11's Nursing Notes dated 5/2/24 at 10:00 AM, document some bruises noted to A (anterior) R (right) and L (left) hands and upper stomach - resident (R11) denies hitting somewhere. There is no further documentation in R11's medical regarding this finding. On 5/8/24 at 11:30 AM, facility Abuse allegations were reviewed. There is no documentation of R11's bruising being investigated. R17's undated Face Sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete comprehensive Minimum Data Set assessments (Resident Assessment Instrument) in the required time frames. This failure affects two residents (R14 and R39) out of two reviewed for assessment timing on the sample list of 32. Findings include: 1. R14's comprehensive admission Minimum Data Set (MDS) dated [DATE], section A1600 documents R14 was admitted to the facility 12/21/23. This same MDS section A2300 documents an Assessment Reference Date of 12/28/23. This MDS documents the Care Area Assessments section V0200B2, and Care Plan Completion date section V0200C2, were signed as completed 3/27/24. This MDS section Z0500B documents the signed completion date as 3/27/24. 2. R39's comprehensive admission MDS dated [DATE], section A1600 documents R39 was admitted to the facility 12/20/23. This same MDS section A2300 documents an Assessment Reference Date of 12/27/23. This MDS documents the Care Area Assessments section V0200B2, and Care Plan Completion…

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 encode and transmit residents' Minimum Data Set Assessments (Resident Assessment Instrument) within the required time frame. This failure affects two residents (R14 and R39) out of two reviewed for assessment transmissions on the sample list of 32. Findings include: 1. R14's admission Minimum Data Set (MDS) dated [DATE] section A2300 documents an Assessment Reference Date of 12/28/23. This same MDS section Z0500B documents the signed completion date as 3/27/24 (reference F636). 2. R39's admission MDS dated [DATE], section A2300 documents an Assessment Reference Date of 12/27/23. This same MDS section Z0500B documents the signed completion date as 3/27/24 (reference F636). The Centers for Medicare and Medicaid Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual dated effective 10/1/23 documents the timetable for transmitting a completed MDS is no later than twenty-one days after the completion date. On 5/10/24 at 9:23 AM, V21,…

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 encode residents' Minimum Data Sets (Resident Assessment Instrument) to accurately reflect residents' health status. This failure affects two residents (R13, R34) out of ten reviewed for Minimum Data Set accuracy on the sample list of 32. Findings include: 1. R13's Minimum Data Set (MDS) dated [DATE] section M0100 documents R13 had a pressure ulcer. This same MDS section M0300 documents R13's pressure ulcer as a stage 3, full thickness of skin loss with underlying fatty tissue exposed, that was not present on admission to the facility. This same MDS section M1040 documents R13 had 2 venous or arterial ulcers present. This MDS section A1600 documents R13 was admitted to the facility 9/16/23. On 5/8/24 at 09:38 AM, V14, Licensed Practical Nurse, stated, (R13) never had a pressure ulcer since he was admitted , he is mobile, gets himself up and down, and changes position on his own. (R13) did have some venous ulcers on both lower legs but that has all…

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 obtain a Level 2 Pre-admission Screening and Resident Review (PASARR) for a resident diagnosed with severe mental illness while residing in the facility. This failure affects one resident (R40) out of three reviewed for Pre-admission Screening on the sample list of 32. Findings include: R40's Level 1 PASARR dated 10/6/22 documents a Level 2 screen was not required because R40 was not diagnosed with any SMI (Severe Mental Illness), ID (Intellectual Disability), nor RC (Related Condition). R40's Cumulative Diagnosis Log (undated) documents R40 has a medical diagnosis of Schizophrenia, a severe mental illness (SMI). R40's current Physician Order Sheet (POS) dated for May 2024 documents R40 has a medical diagnosis of Psychosis, a severe mental illness (SMI). This same POS documents R40 was admitted to the facility 10/7/22. On 5/8/24 at 4:07 PM, V4, Business Office Manager, stated, Usually the way it works is the information for the residents' screens are put in while the resident is in the hospital before they come here, so it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow its shower and bathing policy and procedures to ensure all residents received a bath/shower at least once a week. This failure affects two residents (R21 and R23) out of 3 residents reviewed for activities of daily living assistance from a total sample list of 32. Findings include: 1. On 5/8/24 at 9:30am, R23 stated R23 needs total assistance from staff, which includes showers. R23 stated R23 is suppose to get 2 showers a week, but only gets them every once in a while. R23 stated R23 does not get 2 showers a week, and maybe gets 2 showers in a whole month. On 5/9/24 at 1:30pm, V17 Certified Nursing Assistant stated when a resident receives a shower whether they are total dependent on staff or set up/supervision, a Shower/Abnormal Skin Report should be completed. V17 stated when the resident is completed with the shower, the Shower/Abnormal Skin Report is completed by the CNA assisting the resident and is placed in a box at the nurses station.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow physician orders in obtaining oxygen saturation levels and documenting them on the residents Treatment Administration Record (TAR). This failure affects one resident (R23) reviewed for following physician orders from a total sample list of 32. Findings include: R23's Facility Census documents R23 was admitted to the facility on [DATE] and has the following medical diagnoses; Atrial Fibrillation, Malignant Neoplasm of Prostate, Anemia, Type 2 Diabetes, Depression, Essential Primary Hypertension, Cardiac Arrhythmia, Insomnia, History of Extended Spectrum Beta Lactamase, Difficulty in Walking, Chronic Respiratory Failure with Hypoxia, Gastro-Esophageal Reflux Disease, Chest Pain, Atrial Flutter, Obstructive Sleep Apnea, History Pulmonary Embolism and Pulmonale. R23's Minimum Data Set (MDS) dated [DATE] documents R23's Brief Interview for Mental Status (BIMS) score 14, cognitively intact. R23's Physician Order Sheet (POS) dated 4/1/24 to present…

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 correctly perform supra pubic catheter care for one of one residents (R101) reviewed for catheter care in the sample list of 32. Findings include: The Physician's Order Sheet (POS) dated 5/1/24 for R101 documents the following diagnosis: Chronic Obstructive Pulmonary Disease, Urinary Tract Infection, Chronic Heart Failure, and Neuropathy. The same POS documents catheter care to be provided by staff every shift for R101. R101 requires total assistance for all activities of daily living and requires a mechanical lift transfer with two assist. On 5/8/24 at 10:10 AM, Certified Nurses Assistants (CNA) V7 and V10 provided catheter care to R101. V7 explained to R101 they were going to clean his supra pubic catheter and V10 was doing the actual care for the procedure. V10 while cleaning the supra pubic catheter continued to go over the same area three times without changing the position of the wash cloth. V10 stated on 5/8/24 at 10:30 AM, I did not realize I did that, you are to change the cloth each time you wash 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 serve a physician ordered diet texture to a resident who required mechanically altered food. This failure affects one resident (R18) out of ten reviewed for diet textures on the sample list of 32. Findings include: On 5/7/24 at 12:35 PM, R18 was seated at a dining room table being assisted to eat by V7, Certified Nursing Assistant (CNA). R18 had a sandwich on his plate consisting of 2 slices of bread with thick slices and chunks of roast turkey. R18 had not eaten any of the sandwich since it was served at 12:22 PM. On 5/7/24 at 12:35 PM, R18's tray card had a blue sticker with the word mechanical on the sticker. When asked, V7, CNA, used a fork to lift the top piece of bread from the sandwich, then stated and confirmed, No that sure is not mechanical. V7 then went to the kitchen service window and obtained a new plate of lunch for R18 including mechanical texture of the roast turkey. R18 consumed approximately 90% of the mechanical…

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 therapy services were provided for three (R1, R2, R3) of three residents reviewed for therapy services on the sample list of six. Findings include: On 3/14/24 from 9:00 AM to 2:00 PM there were no therapists working in the facility, and the therapy room was locked. 1. On 3/14/24 at 12:50 PM, R1 was sitting in R1's wheelchair in the dining room. R1 stated, I have not received any Physical or Speech therapy since I've been in the facility. I had orders to receive therapy, but there is no therapist in the building, and I was hoping to go home after therapy. R1's Face Sheet documents R1 was admitted to the facility on [DATE]. R1's Physician Order Sheet (POS) dated 1/18/24 documents Occupational Therapy (OT) five times a week for four weeks. For therapy activities, Neuromuscular re-education, group therapy and self-care management. R1's Physician Order Sheet (POS) dated 1/23/24 documents Speech Therapy (ST) two times a week for four…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive care plan in the required twenty-one days after admission to the facility. This failure affects one resident (R1) on the sample of three reviewed for falls. Findings include: R1's admission Nursing assessment dated [DATE] documents R1 was admitted to the facility 1/19/24. On 2/15/24 at 1:15 PM, there was not a comprehensive care plan located in R1's medical record. On 2/15/24 at 1:25 PM, V3, Licensed Practical Nurse/ Resident Care Coordinator, stated, We have the baseline care plan in the chart. On 2/15/24 at 1:25 PM, V16, Regional Clinical Nurse, stated, We have the baseline care plan in the chart, the comprehensive is on it's way. I think the comprehensive care plan is due 21 days after admission, 14 days to complete the initial minimum data set, then another seven days to complete the care plan, but I will need to check that to make sure. On 2/15/24 at 1:48 PM, V16 stated, We do not have a comprehensive care plan for R1. V16…

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 revise a care plan for one (R2) of three residents reviewed for fall care plans. Findings include: The facility fall prevention policy dated 11/10/2018 documents that all falls will be discussed in the morning quality assurance meeting and any new interventions will be written on the care plan. R2's fall review documents that on 1/19/24 at approximately 11:00 PM, R2 fell in his room while using his walker and stumbled, sustaining a skin tear on his left elbow. R2's fall care plan dated 3/1/16, documents R2's most recent fall was on 11/13/23. Neither the fall, nor any interventions from the 1/19/24 fall, were documented on the care plan. On 2/15/24 at 9:10AM, V7 Social Services Director stated that R2's care plan did not have any interventions documented for the 1/19/24 fall. On 2/15/24 9:15AM, V3 Resident Care Coordinator stated that R2's care plan should be updated and that neither the fall of 1/19/24, nor the interventions for that fall were documented on the care plan.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct a fall assessment, failed to implement interventions to prevent falls, and failed to properly assess the resident after a fall for one (R3) of three residents reviewed for falls. Findings include: The facility fall prevention policy dated 11/10/2018 documents that fall assessments will be conducted with a change of condition. After a fall, a fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will document the circumstances of the fall in the nurse's notes, or an Assessment, Implement, Management (AIM) for Wellness form along with any new intervention deemed to be appropriate at the time. All falls will be discussed in the morning quality assurance meeting and any new interventions will be written on the care plan. R3's fall assessment dated [DATE] documents R3 as a high risk for falls. On 2/15/24 at 10:45AM, V15 Licensed Practical Nurse stated, I was working…

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 have an infection control program based on current standards including; maintaining infection control records, following guidelines for employees returning to work, testing for Covid-19 as recommended and reporting outbreaks as directed. This failure has the potential to affect all 52 residents residing in the facility. Findings include: The facility provided Covid-19 Control Measures Policy dated 5/19/23 documents that health care providers with confirmed Covid-19 infection should remain off work for 10 days or 7 days with 2 negative tests on day 5 and day 7 and should be asymptomatic or mildly symptomatic with improving symptoms and fever free for 24 hours without the use of fever reducing medications. Additionally, the facility will maintain infection control logs, reviewing tracking daily for any patterns or trends and maintain employee infection control logs. The facility will review daily to identify any patterns or trends of employees exhibiting sign/symptoms of Covid-19. Employees who are ill will be asked if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have an infection preventionist on staff, responsible for the infection control program. This failure has the potential to affect all 52 residents residing in the facility. Findings include: The facility Room Roster dated 9/20/23 documents 52 residents residing at the facility. The facility provided Infection Control Surveillance and Monitoring Policy dated 4/11/22 documents that the facility shall employee, at a minimum, a part time Infection Control Preventionist. The facility assessment dated [DATE] documents that the Infection Control Nurse is V12 Licensed Practical Nurse. On 9/20/23 at 10:00 AM, V1 Administrator stated, I put V12 Licensed Practical Nurse on the facility assessment as the Infection Preventionist because I was going to have her take the class, but we didn't get to it. I don't have anyone functioning in the Infection Preventionist role other than me and I'm not a clinical person. On 9/20/23 at 8:20 AM, V4 Licensed Practical Nurse…

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

Based on interview and record review the facility failed to offer and or provide influenza, pneumonia and Covid-19 vaccinations to three (R1, R3 and R4) of five residents reviewed for immunizations from a total sample list of five residents. Findings include: The facility provided Immunization of Residents Policy dated 1/23/20 documents that the facility will offer immunizations and vaccination that aid in the prevention of infectious disease unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. Document the immunization on the resident's medication administration record and on the resident's immunization record. V1 Administrator provided a list of residents who received the influenza and Covid-19 vaccinations or refused them. R1, R3 nor R4 were included on the list. R1's undated face sheet documents admission to the facility on 2/26/23. R1's resident pneumonia vaccine consent dated 9/14/23 documents that R1 wanted the pneumonia vaccine but did not receive it. On 9/20/23 at 1:30 PM, V1 Administrator said that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to obtain a written Physician recommendation/order for admission to the facility for one of three residents (R2) reviewed for Physician services in the sample list of three. Findings include: The facility's Physician Services policy with a revised date of 1/8/18 documents, Physician Services are those services provided by a physician responsible for the care of individual residents. Such services include, but are not limited to: A. A written report of a physical examination conducted five (5) days prior to, or within seventy-two (72) hours after admission; B. A medical evaluation of the resident and written order for care and treatment. R2's Face Sheet documents R2 was admitted to the facility on [DATE]. R2's Physician's Order Sheet dated 7/3/23 through 7/31/23 documents diagnoses including Acute Systolic Heart Failure, Congestive Heart Failure, Coronary Artery Disease, Diabetes, Unstable Angina and Chronic Obstructive Pulmonary Disease. R2's Nurse's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a resident was seen and assessed by a Physician within 30 days after admission to the facility and failed to have documentation of Physician and/or Nurse Practitioner visits for two of three residents (R2, R3) reviewed for Physician Services in the sample list of three. Findings include: The facility's undated Admissions policy documents, Each resident shall be under the care of an attending physician of their choice. The attending physician must visit the resident at least once every thirty (30) days for the first 90 days after admission, and at least every 60 days thereafter. Each resident shall have a complete physical examination within five (5) days prior to, or within seventy-two (72) hours after admission. 1.) R2's Face Sheet documents R2 was admitted to the facility on [DATE]. R2's Physician's Order Sheet dated 7/3/23 through 7/31/23 documents diagnoses including Acute Systolic Heart Failure, Congestive Heart Failure, Coronary Artery…

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.