Ascension Resurrection Life

Based on observation, interview, and record review, the facility failed to follow their policy and store all drugs and biologicals in a safe and secure manner. This was true for 2 out of 4 medication carts and 1 out of 4 medication rooms reviewed for medication storage. Findings include: On 1/13/2026 at approximately 11:35 AM, a medication cart was outside of R52's room. R52's room door was closed. The nurse responsible for the medication cart was not present. The medication cart's lock was not engaged. Surveyor was able to open medication drawers. Surveyor also noted a set of keys with a blue spring keychain on top of the medication cart. On 1/13/26 at 11:39 AM, V7 (Nurse) exited out of R52's room. V7 stated [V7] was responsible for the mediation cart. V7 stated the medication cart contains medications for 22 residents. V7 stated [V7] was applying a cream to R52 and needs to administer Tylenol. V7 grabbed the keys that were on top of the medication cart and placed them inside scrub pocket. V7 donned personal protective equipment, went back inside R52's room, and closed the door. V7…

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 PPE (Personal Protective Equipment) was properly disposed of before the staff member exited one (R42) resident on EBP (Enhanced Barrier Precautions) room and failed to ensure PPE was donned when changing the linen for one (R69) resident on EBP. Findings Include: R42 has diagnosis not limited to Cellulitis of Right lower Limb, Lymphedema and Sepsis.R42's Physician's Orders document in part: Midline Insertion, Wound Care Right Knee and Wound Care Right Lower Leg. Enhanced Barrier Precautions, IV (Intravenous) therapy.R42's Care Plan document in part: Pressure Ulcers/Skin Prevention: R42 has right lower extremity cellulitis with open wounds to right lower extremity. Infection and IV's: R42 is on antibiotic therapy for cellulitis on bilateral lower extremities.On 01/13/26 at 11:35 AM V16 (Registered Nurse) exited R42's room with PPE (Personal Protective Equipment) on, doffed the PPE in the hallway, then put the PPE in a hamper located in the hallway. V16 stated R42 is on isolation for a wound. R42 is 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 interview and record review, the facility failed to clean and empty a resident's ileostomy bag in a timely manner. The facility also failed to ensure an accurate skin assessment upon admission. These failures affect one (R1) out of three residents reviewed for ostomy care. Findings include: R1's Face sheet documents that R1 was admitted to the facility on [DATE] and discharged on 08/26/2025. On 09/13/2025 at 12:51PM, V4 (Registered Nurse/RN) states R1 was admitted to the facility from the hospital on [DATE]. V4 states she was the nurse assigned to care for R1 on 08/26/2025. V4 states sometime after lunch around 12:30PM, V6 (R1's Family Member) asked the staff to change R1's colostomy bag because it was soiled and full. V4 states V5 (Certified Nursing Assistant/CNA) had begun cleaning R1's body before V4 arrived to R1's room. V4 states then V5 alerted her that while V5 was cleaning on the right side of R1's body, there was a [NAME] of fluids from what appeared to be a surgical wound that was located…

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 their policy of transferring a resident via a mechanical lift. This failure affected 1 (R1) resident reviewed for supervision in the total sample of 3 residents. Findings include: The 06/06/2025 List of Residents on Sit to stand and/or Mechanical Lift transfer include R1. On 06/06/2025, at 11:18 AM, inside R1's room, V12 (Certified Nursing Assistant/CNA) and V13 (Registered Nurse) transferred R1 from the wheelchair to the toilet seat with the use of the sit to stand lift. After sitting R1 on the toilet seat, V13 washed her hands and informed V12 to call her when R1 is done using the toilet. On 06/06/2025, at 11:30 AM, V12 transferred R1 from the toilet seat to R1's wheelchair with the use of the sit to stand lift all by herself. On 06/06/2025, at 11:32 AM, V13 went inside R1's room. V13 asked V12 Why did you not call me? On 06/06/2025, at 11:33 AM, V12 stated we need two-person assist for transfer via the sit to stand lift. I did not wait for her (V13) to assist me because she (R1) is already getting…

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 person-centered discharge plan of care for 5 out 5 residents (R1, R2, R3, R4 and R5) reviewed for care plan. Finding includes: R1 is [AGE] years old, initially admitted in the facility on 02/27/2025. R1 medical diagnosis includes atrial fibrillation, deep vein thrombosis on the right leg, spinal stenosis, radiculopathy lumbosacral region and malaise. R1's cognition based on her BIMS score of 15 dated 03/05/2025. On 04/01/2025 at 10:32 PM, V3 (Ombudsman) stated that R1 and her daughter (V6) had concern about being discharge prematurely. Care plan of R1 was reviewed in relation to discharge planning. Per R1's care plan R1 does not plan to make the community/facility a long-term home that was dated on 02/27/2025. Goal is for R1 to be assisted with plan of stay in the community/facility until discharge is practicable, through the next review period. Interventions includes associates/facility staff will support R1 plan to stay short term. And assist…

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 observations, interviews, and record reviews, the facility failed to a.) ensure all food items were labeled with an opened and use by date, b.) discard expired food based on use by date documented on label, c.) follow manufacturer guidelines for storage. These failures have the potential to affect all 132 residents receiving food prepared in the facility's kitchen. Findings include: On 10/01/24 at 9:12 AM, V11 (Dining Services Director/Certified Dietary Manager) stated all items are marked with a received by label which contain the date the item was delivered. V11 stated the kitchen uses a label machine to generate label stickers to put on all prepared or opened refrigerated items and opened non-refrigerated food items. The label stickers generated by the label machine has an area to write in the name of the product, the opened date (today's date) and the use by date or expiration date (Good Thru). V11 stated the use by or best by dates vary depending on what the product is. V11 stated the kitchen staff should be making sure all food items are labeled and that they are…

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 observations, interviews, and record reviews, the facility failed to dispose eye drops after the discard date, refrigerate an unopened insulin pen, and lock a medication cart when not in use or in view for two out of four carts reviewed for medication storage and labeling. The facility also failed to properly dispose of R76's controlled medication after opening and failed to ensure controlled medications for R64 were under a double lock for 1 of 4 medication carts and 1 of 2 medication rooms reviewed for medication storage and labeling. Findings include: 1.) On 10/01/2024 at 2:14 PM, surveyor reviewed the medication cart designated for the intermediate and memory-impaired units with V6 (Registered Nurse). There was a bottle of Systane Gel Eye Drops for R44. The written open date was 8/28 and the written discard date was 9/28. V6 stated V6 did not notice the discard date that morning. V6 stated staff should have tossed the medication and V6 will reorder it. R44's Physician Orders document in part Systane Gel Eye Drops place one (1) drop into both eyes twice a day. 2.) In the…

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

Based on observations, interviews, and record reviews, the facility failed to a.) follow their policies by not wearing the appropriate Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) during high-contact resident care activities for 4 (R8, R28, R54, R223) residents and b.) handle and contain soiled linen during linen changing and transport. These failures have the potential to affect all residents residing on the first floor and second floor units. Findings Include: 1.) R28 has diagnosis not limited to Acute Embolism and Thrombosis of Femoral Vein, Bilateral, Localized Edema, Polyneuropathy, Unsteadiness on feet, Mature T/NK-Cell Lymphoma, Muscle Spasm, Thrombocytopenia and Heart failure. R28's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Physician Order dated 09/06/24 document in part: Enhanced Barrier Precaution due to wound. Care Plan Document in part: Place (EBP) Enhance Barrier Precaution signage and PPE (Personal Protective Equipment) supplies at entrance to resident…

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

Based on observation, interview, and record review the facility failed to ensure call light was within reach for one (R32) out of eight residents reviewed in a total sample of 26 for call lights. Findings include: On 10/01/24 at 12:34 PM, R32 was lying in bed in room. R32's call light was lying on the floor, out of R32's reach. R32's call light had a clip on attached to the cord of the call light. R32 stated when R32 needs help from the staff R32 uses the call light to call for help. R32 stated R32 does not know where the call light is right now. R32 stated R32 cannot reach it. On 10/01/24 at 1:23 PM, observed R32 lying in bed in room. R32's call light lying on the floor, out of R32's reach. On 10/01/24 at 1:29 PM, V6 (Registered Nurse) stated the call light should be within reach of the resident. V6 observed R32's call light on the floor and quickly picked it up off the floor and stated the call light should not be on the floor. V6 stated the call light should be clipped on the bedding to prevent it from dropping on the floor, and from it being out of reach of the resident. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their discharge against medical advice policy for 1 (R120) resident reviewed for discharge in a sample of 26. Findings Include: R120 was admitted to the facility on [DATE] with diagnosis not limited to Epilepsy, Mild Intermittent Asthma, Unspecified Fall, Obesity, Syncope and Collapse and Unilateral Primary Osteoarthritis. Based on review of R120's progress note, R120 was admitted to the facility at 04:00 PM on 08/05/24 and left the facility AMA (Against Medical Advice) on 08/05/24 at 07:30 PM. Progress note dated 08/05/24 10:26 PM document in part: Resident admitted at 4 pm with dx (diagnosis) multiple falls at home with head injury. 7 staples intact to the back of the head. Syncope, epilepsy, seizure disorder, elevated troponin, obesity, asthma, right knee pain, osteoarthritis. Resident's medications reviewed with resident and resident's nephew. All prescriptions faxed to pharmacy; writer called pharmacy for medications to be delivered.…

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

Based on interview and record review, the facility failed to ensure a resident's initial preadmission screening was completed prior to admission to the nursing facility for 1 (R40) out of 2 sampled residents reviewed for Preadmission Screening and Resident Review (PASARR). Findings Include: R40's clinical records show an initial admission date of 3/27/24 with included diagnoses not limited to Major Depressive Disorder, Bipolar Disorder and Generalized Anxiety Disorder. R40's Notice of PASRR Level I Screen Outcome shows a review date of 8/14/24. On 10/02/24 at 9:52 AM, interviewed V15 (Business Development Coordinator) and stated that R40's PASARR was done after admission because R40 came from home. At 11:29 AM, interviewed V1 (Administrator) and stated PASSAR screening is done prior to admission to make sure that residents being admitted are eligible and meet the requirements to come to the nursing facility. V1 stated if it was somebody coming from a community the facility is doing post screen and should be done right away. The facility's policy titled, PASARR (Pre admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow a resident's (R64's) and their representative's wishes for no hospitalization for 1 out of 3 residents reviewed for hospice. Findings include: R64's Face Sheet documents in part a Code Status of NO CPR (cardiopulmonary resuscitation). R64's Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form documents in part wishes for Do Not Attempt Resuscitation/DNR, Comfort-Focused Treatment: Primary goal of maximizing comfort. Request transfer to hospital only if comfort needs cannot be met in current location. POLST signed/active since [DATE]. R64's [DATE] Physician Orders document in part: Patient has a DNR (Do Not Resuscitate) Order signed [DATE] and Do Not Hospitalize with an order/start date of [DATE]. On [DATE] at 11:41 AM, V25 (R64's Family Member) stated facility transferred R64 to the hospital against their wishes. V25 stated facility transferred R64 around Sunday ([DATE]) at 6:15 AM. Facility didn't call the family until 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to correctly set an air loss mattress based on weight for one (R32) of 8 residents reviewed in a total sample of 26 for pressure wound treatment services. Findings include: On 10/01/24 at 12:34 PM, R32 was lying in bed on air loss mattress. The air loss mattress was set at setting 4 indicating 250-pound weight per the display panel. On 10/01/24 at 1:24 PM, R32 was lying in bed on air loss mattress. Air loss mattress still set at 4 indicating 250-pound weight. V6 (Registered Nurse) observed the mattress setting at 4 on the display panel and stated R32 does not weight 250 pounds. V6 stated the Maintenance Department sets the rate of the air loss mattress when they deliver the mattress to the room. On 10/01/24 at 1:26 PM, V16 (Director of Facilities Management) came into R32's room and stated V16's department delivers the air loss mattress to the resident's room, but the nurse is the one who sets the rate of the air loss mattress. V16 stated…

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 records reviews, the facility failed to follow the fall care plan intervention for one resident (R98) of 8 residents reviewed for falls out of a total sample of 26. Findings Include: R98's diagnosis includes but not limited to Unspecified Dementia with Agitation, Repeated Falls, Anxiety Disorder. R98's clinical records show R98 has a history of multiple falls. R98's Minimum Data Set (MDS) dated [DATE] shows R98 had severe cognitive impairment and requires partial/moderate assistance with chair to bed to chair transfer. R98's fall care plan documents in part, resident is at risk for falls due to impaired mobility and weakness, moderate vascular dementia with mood disturbance and resident takes psychoactive medications. One of R98's fall care plan interventions initiated on 07/10/24 reads, floor mats in when resident is in bed and thick mats to extend sleeping area dated 09/07/24. R98's Fall Risk Assessment completed 09/22/24 documents in part that R98 has a grand score of 40 indicating…

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 follow their policy and procedure to ensure a.) oxygen equipment was dated and changed weekly, b.) physician orders for oxygen administration rate were followed, c.) nebulizer equipment was stored in a plastic bag with the resident's name and date on it when not in use. These failures have the potential to affect two (R9, R273) of eight residents reviewed for respiratory care in a total sample of 26. Findings include: 1.) On 10/01/24 at 12:20 PM, observed R9 lying in bed with oxygen infusing via nasal canula and oxygen concentrator set between 3-4 liters per minute. The humidifier bottle was not dated. The oxygen tubing had a bright orange label which documented, Change Sunday 09/22/24 at 6AM On 10/01/24 at 12:26 PM, V6 (Registered Nurse/RN) looked up R9's oxygen order in R9's paper medical record and stated R9's physician order is for R9 to receive 2 liters per minute continuously via nasal canula. V6 stated the oxygen infusion rate 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.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident (R221) was free of any significant medication errors for one out of five residents reviewed for medication administration. Findings include: R221's Face Sheet and Physician Orders document in part a medical diagnosis of Essential (primary) hypertension (high blood pressure). R221's Care Plan documents in part a Potential for alteration in blood pressure related to diagnosis of hypertension (Problem onset: 09/26/2024). Approaches include Medications as ordered and monitor for side effects. On 10/01/2024 at 8:54 AM, V28 (Agency Registered Nurse) prepared R221's morning medications. Surveyor observed V28 prepare Apixaban (Eliquis), Furosemide, and Carvedilol for R221. At 9:12 AM, R221 took the oral pills. At 9:14 AM, V28 stated [V28] completed R221's medication pass and continued to R87's room. Surveyor reviewed R221's October 2024 eMAR (Electronic Medication Administration Record). It documents in part a 9:00 AM dose for Losartan Potassium 25 MG (milligram) one tablet by mouth. V28 did…

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 serve mechanical soft food to a resident on mechanical soft diet order. This failure affected 1 (R19) of 4 residents reviewed for mechanical soft diet prepared in the facility's kitchen, in a total sample of 26 residents. Findings Include: On 10/01/24 at 11:26 AM, observed R19 eating in the unit dining room. R19 had a large plate of salad with raw Romaine lettuce, tomato wedges, chopped hardboiled egg, bacon pieces and chunks of chicken. Observed R19 putting a piece of lettuce and bacon in R19's mouth and then using R19's fingers to take the lettuce and bacon back out of R19's mouth and placing the semi chewed lettuce and bacon on the side of R19's plate. Observed R19's meal ticket which read Mechanical Soft, CCD (Controlled Carbohydrate Diet) and pink piece of paper titled, Food Substitution Request for lunch checked Alternative Menu and the words mech handwritten on the bottom of the form. On 10/01/24 at 11:32 AM, V10 (Activity Aide) observed the large salad plate in front of R19 and stated R19 usually gets…

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

Based on observations, interviews, and records review, the facility failed to follow their Discarding and Destroying Medications policy, and failed to assure that medications to be disposed were secure and inaccessible to unauthorized staff and residents. These failures have the potential to affect 80 residents living on the first floor that may be able to access the unsecured room. Findings include: On 12/16/2023 at 10:37am, tour of the soiled utility room on the East side of the facility next to the loading dock with V10(Registered Nurse-RN/Quality Director/Infection Preventionist), the door to the soiled utility room was not locked and observed in the room were six 13 gallon clear plastic bags, with five of the plastic bags knotted at the top, and one of the bags was open and medications were observed spilling to the floor, with pills, opened/no wrapper on the floor. Two pills were round, pink in color, one red round pill, one yellow oval pill. V10 said there were around 80 residents on the first floor. V10 said the medications in the room were not properly secured, and if 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 records review, the facility failed to follow infection control policy by failing to properly dispose of used needles, contaminated blood draw equipment, failed to secure the contaminated equipment by over filling the sharps containers and leaving needles and contaminated tubing exposed, failed to properly close sharps containers by leaving them without top covers while filled with sharps. This deficiency has the potential to affect all 80 residents living on the first floor. Findings include: On 12/16/2023 at 10:37am, tour of the soiled utility room on the East side of the facility next to the loading dock surveyor with V10(Registered Nurse-RN/Quality Director/Infection Preventionist), the door to the soiled utility room was not locked surveyor with V10 observed were four large cartons filled with red sharps containers. Some of the sharps' containers were observed with a black cover/cap, while others were observed to have no covers and were overflowing, with some having needles outside of the sharps' containers. V10 said sharps containers should…

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 remain free from abuse, for one of three (R1) residents reviewed for abuse. This failure resulted in R1 being physically abused by a Certified Nursing Assistant. This past noncompliance occurred from 11/9/2023 to 11/11/2023. Findings include: R1's current face sheet documents R1 is an [AGE] year-old individual with diagnosis that include but not limited to: Unspecified injury of the head, chronic obstructive sleep apnea, asthma, depression, encephalopathy. R1's BIMS (Minimum Data Set) section C, dated 11/25/2023 documents R1's BIMS as 3/15, indicating R1 has severe cognitive function. MDS section GG dated 10/01/2023 documents R1 needs substantial/maximal assistance with ADL (Activities of Daily Living) care. Facility Reported Incident (FRI) report dated 11/09/2023 documents: On November 8 at around 11:30 pm, V7(Certified Nursing Assistant/CNA) notified that when he was taking care of resident across the hallway, he heard 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 interviews and records review, the facility failed to ensure a Certified Nursing Assistant/CNA possessed the competencies and skill sets necessary to provide nursing and related services in a safe manner for one (R1) resident of three reviewed. This failure resulted in a CNA physically abusing (hitting) R1. This past noncompliance occurred from 11/9/2023 to 11/11/2023. Findings include: On 12/16/2023 at 3:17pm, V1(Administrator) said R1 was a resident of the facility, and V7 (Certified Nursing Assistant/CNA) witnessed V8 (CNA) slapping R1's hands. V1 said hitting a resident is physical abuse, and V8 was removed from the building after she was witnessed hitting R1. V1 said she was aware this was a noncompliance because the policy is for residents to remain free of abuse. V1 said staff were educated regarding resident abuse. V1 said the policy is before a staff starts working at the facility, the staff should have had abuse prevention training, and V1 said V8 fell through the cracks and there is no training on abuse for V8 before V8 started taking care of residents at 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 provide group activities to meet the needs and interests of 1 resident (R1) out of 3 reviewed for resident rights. This failure resulted in R1 having limited interaction with peers and resident feeling isolated. Findings include: R1 has a diagnosis of but not limited to Hemiplegia Following Cerebral Infarction, Depression, Spinal Stenosis, Hypertension, Peripheral Vascular Disease. R1's Minimum Data Set (MDS) section B dated 12/26/22 documents R1's vision is severely impaired. R1's Brief Mental Status Interview (BIMS) dated 01/30/23 documents score of 15/15 indicating intact cognition. R1's has a care plan for being legally blind and activities care plan dated 12/21/23 which documents in part R1 will participate in activity of her choice and interact with peers. On 10/04/23 at 11:22 AM, R1 stated after she attends mass in the morning at 9:30 AM and that from 10:30 AM onward she is in the room for the rest of the day, especially on the weekends, Mondays, and Tuesdays. R1 stated she attends mass which is a group…

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 discard outdated medications for 2 (R9 and R16) residents. The facility failed to properly store medications requiring refrigeration for 2 (R3 and R7) residents. The facility also failed to ensure that medication cart was locked when not in use. These failures can potentially affect 23 residents assigned to V6 (Agency Licensed Practical Nurse) reviewed for medication storage and labeling in 2 of 4 medication storage rooms and 3 of 6 medication carts. The findings include: On 9/5/23 at 9:01 am V2 (Director of Nursing) stated that facility has 4 medication storage rooms (2 on each floor - 1st and 2nd floor) and 6 medication carts (3 on each floor - 1st and 2nd floor). On 9/5/23 at 2:03 pm 1st floor medication cart observed parked by the nurse's station, medication cart observed open, not locked, and unattended. Medication cart inspected with V6 (Agency Licensed Practical Nurse), stated the room assignment has a total of 23 residents for this cart. Observed the following medications inside the medication cart:…

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

Based on observation, interview, and record review the facility failed to ensure PPE (Personal Protective Equipment) was properly worn by staff when entering a resident's room on Transmission-Based Precautions with COVID-19 (Coronavirus). This failure has the potential to affect 18 residents residing on the 1B unit. The facility also failed to clean or disinfect reusable equipment, vital sign monitor with stand and was used in between resident during medication administration. This failure can potentially affect 13 residents assigned to V10 (Agency Registered Nurse). Findings Include: 1.) R2 has a diagnosis not limited to Pneumonia, Acute Respiratory Failure with Hypoxia, Venous Insufficiency, Cough, Heart Failure, Essential (Primary) Hypertension and COVID-19. R2's Physician Orders document in part: Maintain Special Droplet Precautions Per Protocol. R2's Care Plan document in part: R2 has tested positive for COVID-19 infection. Provide PPE (Personal Protective Equipment) per protocol. Special Droplet Precautions per protocol. R2 requires isolation due to an infection. Signage…

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 observations, interviews, and record reviews, the facility failed to ensure that the call light was within reach for R14 and failed to respond to R34's needs for two out of a total sample of 25 residents reviewed for call lights. Findings include: 1.) On 9/05/2023 at 12:05 PM, R34 stated staff are busy and have no time to answer the call lights at times. R34 stated They should at least come and check on me. At 12:13 PM, R34 pressed the call light button. R34 stated feeling short of breath and wanted the nebulizer mask. R34 stated R34 will wait two to three hours during some nights before someone responds to it. At 12:28 PM, V23 (Certified Nurse Assistant) entered R34's room to drop off the lunch tray. V23 turned off the call light and left the room without asking what R34 needed. At 12:29 PM, R34 stated Staff just come in, do what they need to do and just leave. Now I have to eat lunch and just wait to see how I feel I guess. At 12:40 PM, R34 turned on the call light. V23 passed by R34's room and did not answer it. At 12:44 PM, R34 stated wanting a nebulizer treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that residents' code statuses were consistent with their Physician Orders for Life-Sustaining Treatment (POLST) forms for three (R34, R46, R91) out of a total sample of 25 residents reviewed for Advanced Directives. Findings include: 1.) R34's POLST documents in part NO CPR [Cardiopulmonary Resuscitation]: Do Not Attempt Resuscitation (DNAR). R34's comprehensive care plan contains a problem onset with a date of [DATE]. It documents in part: Resident will have advance directives reviewed upon admission. [R34] is full code status [attempt resuscitation]. 2.) R46's POLST documents in part NO CPR [Cardiopulmonary Resuscitation]: Do Not Attempt Resuscitation (DNAR). R46's comprehensive care plan contains a problem onset with a date of [DATE]. It documents in part: Resident will have advance directives reviewed upon admission. [R46] is full code status. 3.) R91's POLST documents in part NO CPR [Cardiopulmonary Resuscitation]: Do Not Attempt…

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 revise the care plan for 1 (R72) resident reviewed for wound preventive measures in a sample of 25. Findings Include: R72 has diagnosis not limited to Progressive Supranuclear Ophthalmoplegia, Vitamin D Deficiency, Weakness, Abnormalities of Gait and Mobility, Contracture, Right Hand, Contracture, Left Hand, Muscle Weakness (Generalized) and Lack of coordination. Physician Orders: document in part: pressure relieving mattress to bed and cushion to wheelchair. Care Plan document in part: R72 is at risk for impaired skin integrity due to reduced mobility and incontinence. Impaired mobility due to weakness secondary to progressive supranuclear ophthalmoplegia. Braden Risk Assessment Report dated 07/18/23 document in part: Risk score 15, Risk Level Mild. Mobility: Very limited. Moisture: Occasionally Moist. Activity: Chair Fast - Ability to walk severely limited or non-existent. On 09/05/23 at 10:21 AM R72 was observed sitting in the wheelchair at the bedside with no footrest in place. A folded towel was observed…

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 the physician order for wound preventive measures were followed for 1 (R72) resident review for wound prevention in a sample of 25. Findings Include: R72 has diagnosis not limited to Progressive Supranuclear Ophthalmoplegia, Vitamin D Deficiency, Weakness, Abnormalities of Gait and Mobility, Contracture, Right Hand, Contracture, Left Hand, Muscle Weakness (Generalized) and Lack of coordination. Physician Orders: document in part: pressure relieving mattress to bed and cushion to wheelchair. Care Plan document in part: R72 is at risk for impaired skin integrity due to reduced mobility and incontinence. Impaired mobility due to weakness secondary to progressive supranuclear ophthalmoplegia. Braden Risk Assessment Report dated 07/18/23 document in part: Risk score 15, Risk Level Mild. Mobility: Very limited. Moisture Occasionally Moist. Activity: Chair Fast - Ability to walk severely limited or non-existent. On 09/05/23 at 10:21 AM R72 was observed sitting in the wheelchair at the bedside with no footrest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure a resident received the correct oxygen flow rate as ordered by the physician and to properly label oxygen tubing and humidifier bottle for 2 (R12, R94) out of 3 residents reviewed for oxygen use in a sample of 25. Findings Include: 1.) On 9/5/23 at 10:44 AM, R12 was lying in bed alert and awake. R12 was receiving supplemental oxygen via nasal cannula at 3 liters per minutes (LPM). R12's oxygen tubing and humidifier bottle had no labels with the dates when they were last changed. On 9/5/23 at 10:57 AM, V8 (Registered Nurse) stated that oxygen tubing is changed on 11-7 shift every Sunday and the humidifier is changed when it's consumed. V8 stated that when the tubing is changed, there should be a tape around the tubing with the date written the day it was changed, and it should be changed weekly to prevent infection for the residents. R12's clinical records show R12 has diagnoses not limited to Heart Failure and Dementia. R12'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.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5% for 2 (R67 and R229) of 6 residents reviewed for medication administration. There were 30 opportunities and 5 errors resulting in a 16.67% medication error rate. The findings include: 1.) R67's health record documented admit date of 2/21/23 with diagnoses not limited to Peripheral vascular disease, Atherosclerotic native arteries of right leg with ulceration of thigh and left leg with ulceration of calf, Encounter for surgical aftercare following surgery on the circulatory system, Peripheral vascular angioplasty status with implants, Anemia, Acute respiratory failure with hypoxia, Chronic Obstructive pulmonary disease, Chronic systolic and diastolic heart failure. On 9/5/23 at 10:26 am Medication administration conducted with V10 (Agency Registered Nurse). R67 observed lying in bed, head of bed elevated, alert and verbally responsive. Observed V10 prepared the following medications: 1. Apixaban 5mg 1 tablet 2. Ascorbic acid 1000mg 1 tablet 3. Aspirin chewable…

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 interviews and record reviews the facility failed to ensure that resident is free of any significant medication errors. This failure applies to 1 (R67) of 6 residents reviewed for medication administration in a sample of 25. The findings include: R67's health record documented admit date of 2/21/23 with diagnoses not limited to Peripheral vascular disease, Atherosclerotic native arteries of right leg with ulceration of thigh and left leg with ulceration of calf, Encounter for surgical aftercare following surgery on the circulatory system, Peripheral vascular angioplasty status with implants, Anemia, Acute respiratory failure with hypoxia, Chronic Obstructive pulmonary disease, Chronic systolic and diastolic heart failure. On 9/5/23 at 10:26 am Medication administration conducted with V10 (Agency Registered Nurse) Observed R67 lying in bed, head of bed elevated, alert and verbally responsive, with oxygen via nasal cannula at 2L/min. Observed V10 checked temperature = 97.2F; Blood pressure = 120/48; Pulse rate = 70/min. Observed V10 prepared the following medications: 1.…

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.