Imboden Creek Senior Living

Based on observation, interview, and record review, the facility failed to maintain sanitary food storage areas, food service equipment, and food preparation areas. These failures have the potential to affect all 79 residents residing in the facility.Findings include:On 1/6/2026 at 9:48AM, the kitchen table mounted can opener and receiver were both soiled with heavy accumulations of dark and sticky food debris. The opener also had accumulations of metal shavings. On 1/6/2026 at 9:52AM, wire storage shelves present inside of the kitchen walk-in cooler were covered with white fuzzy biological growth resembling mold. Food was stored on all portions of the shelves. The cooler flooring surface was soiled with an unidentified puddle of brown liquid and another puddle of unidentified yellow liquid. Debris including plastic wrap, paper, and single serve condiment packets was scattered on the cooler floor which was also damp throughout.On 1/6/2026 at 9:54AM, the kitchen food preparation sink was heavily soiled and stained with brown deposits across all surfaces of the sink basins.On 1/7/2026…

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

Based on interview and record review, the facility failed to develop and implement an antibiotic stewardship program that included protocols to ensure appropriate antibiotic use, systems to monitor antibiotic outcomes, resistance, and adverse events, and use of standardized tools and criteria to assess resident infections. This failure has the potential to affect all 79 residents in the facility.Findings include:On 1/8/2025 at 10:11AM, V1 (Administrator) provided the facility antibiotic use logs for infections for the previous calendar year. June through December 2025 logs were present and no other months were present. On 1/8/2025 at 3:12PM, V1 (Administrator) reported the facility does not have any additional information related to their antibiotic stewardship or infection control program than the above records document. The provided infections logs do not document what symptoms residents experienced signifying an infection, if any standardized criteria were used to justify and guide antibiotic use, when antibiotic therapies were first initiated, if response to treatment was…

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

Based on interview and record review, the facility failed to prevent unnecessary use of psychotropic medications, failed to complete psychotropic medication assessments, failed to track targeted behaviors necessitating use of psychotropic medications, and failed to implement non-pharmacological interventions prior to the use of psychotropic medications. These failures affect one resident (R6) of five reviewed for unnecessary medications on the sample list of 29.Findings include:R6's Physician Order Summary Report, dated 1/8/2026, documents the following orders: Citalopram (Antidepressant) 10 milligrams (mg) one tablet by mouth in morning; Lorazepam (Benzodiazepine) 0.5mg one tablet by mouth daily; Risperidone (Antipsychotic) 0.5mg one tablet by mouth at bedtime and Zolpidem (Sedative-Hypnotic) one tablet by mouth at bedtime.R6's Medical Record does not document any psychotropic medication assessments or behavior tracking.R6's Care Plan (current) documents R6 has Psychotic Disorder with delusions, Major Depressive Disorder, Delusional Disorder, and Anxiety Disorder. The Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan. This failure affects three (R3, R6, and R71) of 18 residents reviewed for care plans on the sample list of 29. Findings include: 1. R3's Physician Order Summary Report, dated 1/8/26, documents the following orders: Warfarin Sodium (Anticoagulant) 2 milligrams (mg), take one tablet by mouth at bedtime every Wednesday, Thursday, and Friday, and Warfarin Sodium 3mg, take one tablet by mouth at bedtime every Monday, Tuesday, Saturday, and Sunday. R3's Care Plan (current) documents R3 is on Anticoagulant therapy Eliquis. This same record does not include R3's Warfarin use and/or monitoring. On 1/8/26 at 10:08 AM, V7, Regional MDS Coordinator, confirmed R3's Warfarin is not on R3's current care plan. 2. R6's Physician Order Summary Report, dated 1/8/2026, documents the following orders: Citalopram (Antidepressant) 10 milligrams (mg) one tablet by mouth in morning; Lorazepam (Benzodiazepine)…

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 resident diagnostics as ordered by a medical provider. This failure affects one resident (R7) of three reviewed for laboratory diagnostics on the sample list of 29.Findings include:R7's diagnosis list (1/7/2026) documents the diagnosis Convulsions. R7's Physician Orders (1/8/2026) document orders for Levetiracetam, Lamotrigine, and Divalproex sodium (all anti-convulsant medications).R7's neurology provider facsimile to the facility (12/9/2025) documents an order to obtain laboratory diagnostics for R7 including complete metabolic profile, complete blood count, ammonia level, Lamotrigine level, Levetiracetam level, and Divalproex sodium level. On 1/9/2026 at 12:09PM, V2 (Director of Nursing) reported R7's laboratory diagnostics ordered by R7's neurologist on 12/9/2025 were not obtained by the facility until 12/23/2025.R7's laboratory reports (12/23/2025, 12/24/2025) document the facility did not collect and submit R7's medical specimens to the laboratory until 12/23/2025.

Based on observation, interview, and record review, the facility failed to determine if a medication was appropriate and safe for self-administration. This failure affects one resident (R59) of 24 reviewed for supervised medication use on the sample list of 29. Findings include:R59's Resident Assessment (10/31/2025) documents R59 has intact cognition. R59's diagnosis list (1/13/2026) documents the diagnosis of Pain.R59's Physician Orders (1/8/2026) documents the medication order Tylenol Extra Strength Tablet, 500 MG, give two tablets by mouth every 8 hours as needed for pain.On 1/6/2026 at 2:05PM, R59 was seated in a chair in R59's room with a overbed table nearby. A medication cup was present on the table and contained two white oblong medication caplets resembling Tylenol. R59 reported the caplets were Tylenol and provided to him by the facility nurse the previous evening but were not taken. On 1/9/2026 at 12:19PM, V2 (Director of Nursing) reported staff should not leave medications in resident rooms for residents to take unsupervised. V2 reported the facility does not allow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide privacy during a procedure by not pulling the curtain for R36. R36 is one of 29 residents reviewed for privacy in a total sample of 29.Findings include:The Physician's Order Sheet dated January 2026 documents R36's diagnoses as Cancer, Malignant Neoplasm of the Colon, and CVA (Cerebrovascular Accident) with right side impairment. R36 is on hospice for his cancer diagnosis. The Minimum Data Set, dated [DATE], documents R36 has a BIMS (Brief Mental Status Assessment) of 7, which indicates severe cognitive impairment, that R36 is dependent on staff for activities of daily living, and that R36 has an indwelling urinary catheter and is frequently incontinent of bowel.On 1/7/26 at 10:48 AM, V6, CNA (Certified Nurse Assistant) performed urinary catheter care for R36. V6 did not pull the curtain before performing the catheter care for R36. R36's bed is the first bed when you enter the room. There were two times staff knocked on the door…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete a resident's comprehensive assessment. This failure affects one (R3) of 24 residents reviewed for accuracy of assessments on the sample list of 29.Findings include:R3's Comprehensive Assessment (MDS), dated [DATE], documents R3 is taking an antipsychotic medication.R3's Physician Order Summary Report, dated 1/8/2026, does not document R3 as being prescribed and/or receiving any antipsychotic medications.On 1/8/26 at 10:05 AM, V2, Director of Nursing, stated R3 has not been on any antipsychotic medication for months. On 1/8/26 at 10:08 AM, V7, Regional MDS Coordinator, stated R3 is not currently on any antipsychotic medications. V7 confirmed R3's MDS is incorrect.

Based on observation, interview, and record review, the facility failed to ensure qualified staff applied medicated cream to a resident for one of two (R36) residents reviewed for urinary catheter care in the sample of 29. The EMR (Electronic Medical Record) form titled Medical Diagnosis, dated 1/14/26, documents the following diagnoses for R36: Malignant Neoplasm of the Colon and Secondary Malignant Neoplasm of the lung. R36 requires an indwelling urinary catheter for urination. On 1/7/26 at 10:48 AM, V6, Certified Nursing Assistant/CNA, performed catheter care for R36. After completing the procedure, V6 stated to R36, I am going to put this cream you have on your (buttocks) and on all your red spots. V6 took the cream off of the bed side table and put the cream on her gloves and applied the cream onto R36 buttocks, between his thighs, and also on the glans penis. V6 stated to R36, This cream should help your redness. The cream V6 used was labeled Silicone Cream with Zinc Oxide. R36's Physician's Orders dated January 2026 document under the Treatment Administration Record (TAR)…

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 develop a plan of care with pressure relieving interventions for one of three residents (R53) reviewed for pressure ulcers on the sample list of 29. Findings include:On 01/08/2026 at 9:30 AM, a quarter sized unstageable pressure ulcer containing 90 percent slough was present on R53's coccyx. At that time, V11, Wound Nurse, confirmed the area on R53's coccyx was an unstageable pressure ulcer. R53's Nurse's Note, dated 10/7/25, documents R53 was admitted to the facility on [DATE] at 3:33 PM due to left shoulder fracture. R53's Nurse's Note, dated 11/19/25 at 2:23 PM, reports pressure wound stage two on sacrum. R53's Medical Record nor Care Plan documents a plan of care with pressure relieving interventions until 12/23/25. On 1/9/25 at 11:00 AM, V2, Director of Nursing, stated R53's pressure ulcer plan of care with pressure relieving interventions was not developed until 12/23/25. V2 confirmed the pressure ulcer was identified on 11/19/25.…

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 observation, interview, and record review, the facility failed perform complete urinary catheter/perineal care and failed to prevent cross contamination during catheter/perineal care for one of two residents (R36) reviewed for urinary catheter care in a sample of 29. Findings include:The EMR (Electronic Medical Record) Medical Diagnosis sheet, dated 1/2026, documents R36 has diagnoses of Malignant Neoplasm of Colon, Secondary Malignant Neoplasm of the Lung, and Cerebral Vascular Accident. R36's January 2026 Physician Order Sheet documents an order to clean R36's urinary catheter twice daily.On 1/7/26 at 10:48 AM, V6, CNA (Certified Nurse's Assistant), performed catheter care for R36. V6, came in through the door with her hands full of wet clothes and towels. V6 stated V6 was going to complete R36's catheter care. V6 started by washing R36's penis shaft. V6 washed the shaft toward the glans penis with a soapy washcloth and cleansed the same area again without changing the area of the washcloth. V6 then went to the opposite side of the penis and washed the shaft once again…

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 nutritional supplements as ordered for a nutritionally at-risk resident. This failure affects one resident (R1) of three reviewed for nutrition on the sample list of 29.Findings include:R1's Physician Order Summary Report, dated 1/9/2026, documents R1 has the diagnosis of protein-calorie malnutrition. The Order Summary further documents the following dietary supplement orders: high calorie nutritional supplement twice a day; fortified pudding and whole milk with meals.R1's Care Plan (current) documents R1 is nutritionally at risk and supplements as ordered.R1's Lunch Meal Tray Slip, dated 1/9/26, documents R1 is to receive fortified pudding and whole milk with R1's meal.On 1/8/26 at 12:31 PM, R1 was eating lunch in the dining room. R1 did not have any nutritional supplements present with R1's lunch meal.On 1/9/26 at 12:02 PM, R1 was eating lunch in the dining room. R1 did not have any nutritional supplements present with R1's lunch meal.On 1/9/26 at 10:27 AM, V2, Director of Nursing, stated, (R1) 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 observation, interview, and record review, the facility failed to store respiratory care equipment in a sanitary manner. This failure affects one resident (R7) of six reviewed for oxygen therapy on the sample list of 29.Findings include:R7's diagnosis list (1/7/2026) documents diagnoses including Acute Respiratory Failure With Hypoxia, Chronic Obstructive Pulmonary Disease With Acute Exacerbation, Asthma, and Pneumonia.R7's Physician Orders (1/6/2026) document the order for two liters of oxygen as-needed. On 1/6/2026 at 11:11 AM, R7 was sleeping in bed with an oxygen concentrator located at the foot of R7's bed. Oxygen tubing and a nasal cannula were attached to the concentrator and were laying in direct contact with the floor. On 1/8/2026 at 11:15AM, R7's oxygen tubing and nasal cannula were coiled on top of R7's oxygen concentrator. On 1/8/2026 at 12:32PM, R7 reported R7 does use the oxygen concentrator, tubing, and nasal cannula in R7's room. On 1/9/2026 at 12:28PM, V2 (Director of Nursing) reported staff should store resident oxygen tubing and nasal cannulas in bags…

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 document administration of resident medication. This failure affects one resident (R59) of 24 reviewed for medications on the sample list of 29.Findings include:R59's Resident Assessment (10/31/2025) documents R59 has intact cognition. R59's diagnosis list (1/13/2026) documents the diagnosis of Pain.R59's Physician Orders (1/8/2026) document the medication order Tylenol Extra Strength Tablet, 500 MG, give two tablets by mouth every 8 hours as needed for pain.On 1/6/2026 at 2:05PM, R59 was seated in a chair in R59's room with an overbed table nearby. A medication cup was present on the table and contained two white oblong medication caplets resembling Tylenol. R59 reported the caplets were Tylenol and provided to him by the facility nurse the previous evening (1/5/2026) but were not taken. R59's Medication Administration Record (January 2026) does not document R59 received any Tylenol medication anytime January 1-January 8, 2026. On 1/9/2026 at 12:19PM, V2 (Director of Nursing) reported nurses should document…

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 respond timely to multiple pharmacy requests to reconcile duplicate medication orders resulting in duplicate administration of medication. This failure affects one resident (R7) of eighteen reviewed for medications on the sample list of 29.Findings include:R7's Physician Orders (1/8/2026) document an order for Lamotrigine (anti-convulsant medication), 100 milligrams, take one tablet by mouth twice daily with a start date of 11/8/2025 and a discontinuation date of 12/31/2025. The same record documents an additional order for Lamotrigine, 150 milligrams, take one tablet by mouth twice daily with a start date of 12/10/2025 and a discontinuation date of 12/31/2025. The Consulting Pharmacy Note (12/12/2025) documents: Please note that resident has a new order for Lamotrigine 150mg (milligrams) BID (twice daily), but previous order for Lamotrigine 100mg BID was not discontinued. Please clarify current dose with prescriber and discontinue previous order if necessary.R7's medication administration record (December 2025) documents…

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

Based on observation, interview, and record review, the facility failed to ensure droplet isolation infection control precautions were utilized for a resident with severe acute respiratory syndrome coronavirus 2 (COVID-19) infection. This failure affects one resident (R2) of 18 reviewed for infection control in the sample list of 29.1. On 1/6/26 at 11 AM, Enhanced Barrier Precaution signage was located on R2's room door and R2's room door was open.R2's Progress Note, dated 1/2/26, documents R2 tested positive for Covid-19 during routine testing and R2 was moved to a private room.On 1/6/26 at 10:08 AM, V1, Administrator, stated, Only one resident (R2) is Covid-19 positive in the facility at this time and the other Covid-19 positive resident (R75) is currently recovering at home.On 1/6/26 at 11:11 AM, V3, Certified Nursing Assistant, stated R2 has been residing in that room since 1/2/26 due to being Covid positive. V3 stated V3 was unsure who is responsible for putting the correct isolation signage on resident room doors.On 1/13/26 at 10:54 AM, V17, Regional Corporate Nurse/RN, 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.

Based on interview and record review, the facility failed to employee a Certified Dietary Manager for food services. This failure has the potential to affect all 75 residents currently residing in facility.Findings include:Facility Midnight Census, dated 11/28/2025 ,documents there are 75 residents currently residing in the facility.On 11/28/2025 at 1:19 PM, V11 (Dietary Manager (DM)) stated he is not certified for dietary management and he is not currently enrolled in any certification courses.On 11/28/2025 at 10:50 AM, V1 (Administrator) stated V11(DM) is not certified and V16 (Regional Registered Dietician) consults for facility on a monthly basis. On 11/28/2025 at 2:38 PM, V1 (Administrator) confirmed V11 (DM) is not a Certified Dietary Manager, and V11(DM) is not currently enrolled in any certification courses. The facility's job description for the Director of Food Services that is undated documents the general purpose of this job description is to assist in planning, organizing, developing, and directing the overall operation of the Dietary Department in accordance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician orders to use and clean a Continuous Positive Airway Pressure (C-PAP) machine and/or a Bilevel Positive Airway Pressure (BI-PAP) machine for four (R1, R7, R10, R11) residents and failed to obtain and monitor vital signs for three (R1, R10, R11) residents using C-PAP/BI-PAP machines. This failure affects four of four residents (R1, R7, R10, R11) reviewed for Oxygen use in a sample list of eleven residents. Findings include:1.R1's Minimum Data Set (MDS), dated [DATE], documents R1 as cognitively intact.R1's Hospital Record, dated 10/2/25, documents R1 utilizes Oxygen per nasal cannula at 2 Liters (L)/nasal cannula (NC). This same record documents R1 has his own C-PAP (Continuous-Positive Airway Pressure) machine.R1's Physician Order Sheet (POS), dated October 2025, does not document a physician order for R1 to wear C-PAP. R1's Nurse Progress Note, dated 10/2/15 at 1:05 PM, documents R1 was using Oxygen at 2 L/NC. This same…

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 an Infection Preventionist who remains onsite. This failure has the potential to affect all 70 residents residing in the facility. Findings include:The facility daily midnight roster, dated 8/24/25, documents 70 residents reside in the facility. The Facility Assessment, reviewed July 10, 2025, documents a member of the team of nursing directors is designated as the certified Infection Preventionist. Utilizing information exchange in daily report, referral reports, physician orders, pharmacy reports (antibiotic report) and quality measures, nursing directors are able to analyze data and know real time diagnosis and treatment to manage an effective infection control program. The facility is unable to provide an Infection Preventionist certificate for any employee working onsite. During standard survey observations on 10/24/25, 10/28/25-10/31/25, 11/4-11/6/25 there was not an Infection Preventionist in the facility. On 10/31/25 at 2:45 PM, V1, Administrator, stated the facility does not have an Infection…

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 complete a thorough fall investigation, complete post fall neurological assessments, properly transfer a resident after a fall, and implement fall interventions for four of four residents (R2, R4, R5, R9) reviewed for accidents in the sample list of eleven.Findings include: 1.R9's Electronic Medical Record (EMR) documents medical diagnoses as Right Femur Fracture, Cerebral Ischemia, Dementia, Lack of Coordination, Dysphagia, Anxiety, Sleep Disorder, Cognitive Communication Deficit, Cerebral Infarction, Systolic and Diastolic Heart Failure, History of Falling, Scoliosis, Atrial Fibrillation, and Lymphedema. R9's Minimum Data Set (MDS), dated [DATE], documents R9 as severely cognitively impaired. This same MDS documents R9 was dependent on staff for assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R9's Care Plan documents a fall intervention, dated 8/6/24, which instructs…

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 maintain accessible and complete medical records for five residents (R2, R4, R5, R7, R8) of five residents reviewed for medical records in the sample list of eleven. Findings include: 1. On [DATE] at 11:35 AM, 11:37 AM, and 11:40 AM, V15, Certified Nursing Assistant (CNA), V16 and V17, Licensed Practical Nurses (LPN), respectively were unable to verify which fall prevention interventions for R2, R4, and R5 had been implemented or completed because the fall interventions were not readily accessible in the resident's medical record. The facility's Electronic Medical Record system lacked a centralized location for staff to view or check off completed fall interventions which compromised staff's ability to deliver consistent care and monitor resident safety effectively. 2. The facility binder titled 'Face Sheet/Code Status' that resides in the front office for emergency use does not document advanced directives for R2, R7, and R8. R2'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.

Based on interview and record review, the facility failed to timely notify the physician of a resident fall for one of four residents (R9) reviewed for falls in the sample list of eleven residents. R9's Nurse Progress Note dated 10/18/25 at 5:10 AM documents R9 was found on the floor. This same note documents staff assessed R9 with no injuries and R9 denied pain. This same note documents staff assisted R9 back to bed and then informed V33 Licensed Practical Nurse (LPN), R9's nurse. This same note documents V33 LPN then assessed R9 in her room with no findings and no obvious injuries.R9's Progress Note dated 10/18/25 at 7:14 AM documents R9 had swelling to her Right Leg from Hip to Knee noted when staff assisted R9 to get dressed for the day. This same note documents R9 had swelling noted to Right Knee, Right Femur, pain noted when Right Leg/Right Hip moved, no redness or warmth noted to Right Leg, pain noted with touch as well.R9's Progress Note dated 10/18/25 at 5:53 PM documents R9 was sent to the emergency room to be evaluated for pain and swelling to her Right Leg.R9's Femur…

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 an undisturbed environment following the death of a resident prior to the arrival of the coroner for one of six residents (R1) reviewed for death in the sample list of eleven residents.Findings include: R1's Electronic Medical Record (EMR) documents R1 passed away at the facility on [DATE]. The facility video camera footage of R1's room door showed V8, V10, V21, and V26, Certified Nurse Aides (CNAs), in R1's room following her death at 9:45 AM and prior to V6, Coroner, arriving at the facility. This same camera footage shows V6, Coroner, entering R1's room at 10:36 AM and exiting at 10:44 AM. On [DATE] at 11:30 AM during observation of facility camera footage, V1, Administrator, stated the staff (V8, V10, V21, V26) CNAs were providing post-mortem care and transferring R1's body from the floor back to her bed using a total body mechanical lift. On [DATE] at 12:00 PM, V8, Certified Nurse Aide (CNA), stated V8, V10, V21, and V26,…

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

Based on observation, interview, and record review, the facility failed to assess wounds/skin and complete wound treatments for two of three residents (R1, R2) reviewed for pressure sores in the sample of five residents. Findings include: The Prevention of Pressure Ulcers/Injuries policy, revision date July 2017, documents, Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries; Tissue tolerance -the ability of the skin (and supporting structures) to endure the effects of pressure. Treatments/Wound Care policy, dated October 2010, documents treatment/wound care is to be done according to the physician order. On 09/16/25 at 2:30pm, R1's posterior right upper buttock unstageable deep tissue injury (pressure ulcer) wound care was completed by V3, Corporate Nurse, and V7, Licensed Practical Nurse (LPN). The wound had…

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

Based on interview and record review, the facility failed to notify a family member of an accident for one of three residents (R1) reviewed for resident injury in the sample list of 12. Findings include:R1's undated Diagnoses list includes fracture of other parts of the pelvis, subsequent encounter for fracture with routine healing, Chronic Pain due to trauma, other reduced mobility, unspecified abnormalities of Gait and Mobility, and unsteadiness on feet.R1's Care Plan dated 10/15/24, documents impaired cognitive function or impaired thought processes, impaired decision-making, long-term memory loss, short term memory loss related to age, history of falling, and decreased mobility with an intervention for an alarm when R1 is in the chair related to impulsivity. R1's Fall Risk Evaluation dated 6/13/25, documents R1 is at risk for falls due to intermittent confusion, being chair bound, and requiring use of assistive devices.On 9/3/25 at 9:30 AM V1 Administrator stated on 8/26/25 R1 was observed on the floor on R1's buttocks. V1 stated V3 Licensed Practical Nurse (LPN) found R1 as V3…

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 physical abuse for one (R3) resident of three residents reviewed for abuse in a sample list of 12.Findings include: The facility's Initial Report, dated 8/2/25, documents R2 and R3 made unwanted contact with one another. R2 yelled at R3 stating she stole my fan, I'm going to knock her head off as the reason for R2 making the unwanted contact with R3. This report also documents the resident (R3) was struck with an open hand in a smacking motion by R2.R2's undated Diagnoses include anxiety disorder, unspecified; Restlessness and Agitation; and Mild Cognitive Impairment of uncertain or unknown etiology.R2's Care Plan, dated 8/10/24, documents R2 has the potential to demonstrate verbally abusive behaviors Poor impulse control Verbal aggression towards staff and roommate, behavior problem with roommate and potential to demonstrate physical behaviors, Dementia, poor impulse control, and anger.R2's Minimum Data Set…

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 timely review and revise comprehensive care plans. This failure affects three residents (R1, R2, R3) of three residents reviewed for care plans in the sample list of 12 residents.Findings include:R1's most current Care Plan is dated 11/9/24. R2's most current Care Plan is dated 9/16/24, and R3's most current Care Plan is dated 12/15/24.On 9/4/24 at 10:49 AM, V1 Administrator stated, we don't have anyone at this facility doing care plans, it's all done at the corporate level.The facility's policy Care Plans, Comprehensive Person-Centered dated Revised December 2016, documents their policy is a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each of the residents. This same policy documents the care plan will identify problem areas and their causes and develop interventions that are targeted and meaningful to the residents. This same policy documents the Interdisciplinary Team must…

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 a fall intervention for one resident (R1) of three residents reviewed for resident injury in the sample list of 12.Findings include:R1's undated Diagnoses list includes fracture of other parts of the pelvis, subsequent encounter for fracture with routine healing, Chronic Pain due to trauma, other reduced mobility, unspecified abnormalities of Gait and Mobility, and unsteadiness on feet.R1's Care Plan, dated 10/15/24, documents impaired cognitive function or impaired thought processes, impaired decision-making, long-term memory loss, short term memory loss related to age, history of falling, and decreased mobility with an intervention for an alarm when in the chair related to impulsivity. R1's Fall Risk Evaluation, dated 6/13/25, documents R1 is at risk for falls due to intermittent confusion, being chair bound, and requiring use of assistive devices.Throughout the survey, on 9/3/24, 9/4/25, and 9/5/25, there was no alarm present in R1's wheelchair while R1 was present in the wheelchair. On 9/3/25 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a dependent resident, at risk for pressure ulcers, timely repositioning and incontinence care to prevent pressure ulcers. R9 is one of 13 residents reviewed for pressure ulcers on the sample list of 16. Findings include:R9's current Diagnoses list documents the following: Dementia in Other Disease Classified Elsewhere, Mild with Other Behavioral Disturbance, and Alzheimer's Disease, Unspecified. R9's Minimum Data Set (MDS), dated [DATE], documents R9 has severe cognitive impairment, is totally dependent on staff for activities of daily living, and is always incontinent of bowel and bladder.R9's same MDS documents R9 is at risk for pressure ulcers, and has the following interventions in place to prevention of skin impairment: Section M - Skin Conditions M1200. Skin and Ulcer/Injury Treatments Check all that apply (the following were marked): A. Pressure reducing device for chair.B. Pressure reducing device for bed.C.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinence care, free of cross contamination for a one (R9) of thirteen-resident reviewed for hygiene needs on the sample list of 16.Findings include: R9's Minimum Data Set, dated [DATE], documents R9 has severe cognitive impairment, is totally dependent on staff for all activities of daily living and is always incontinent of bowel and bladder.R9's Current Physician Order Sheet (POS) and Medication Administration Records (MAR) documents R9 was started on an antibiotic and probiotic for an infection. On 7/23/25 order was received for: Cephalexin Capsule (antibiotic) 500 MG , give 1 capsule by mouth, three times a day every 7 day (s), for infection and Probiotic Oral Tablet (live microorganisms that prevent antibiotic -associated diarrheas), Give 1 unit, by mouth, two times a day every 7 day (s) for infection. R9's Progress Note, dated 7/24/25 at 12:27 PM, documents: Note Text: Urine culture results from 7/21/25: Final…

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 supervise medication administration for one resident (R11) of two residents reviewed for supervision of medication administration in the sample list of 15. Findings:On 7/24/25 at 10:51 AM, surveyor went into R11's room to interview the roommate, R3, who was not present. A medication cup with medications in it was observed at R11's bedside full of 17 medications. R11 would not wake up when spoke R11's name. V1, Administrator, immediately came into R11's room to see the medication cup with medications at R11's bedside. At 10:58 AM, V1 stated the medications should have been taken by R11 with the nurse present and if the resident was asleep, V3, Licensed Practical Nurse (LPN), should not have left the medications at bedside.On 7/24/25 at 10:59 AM, V3, LPN, came to R11's room and woke R11 up to take the medications setting at bedside. V3 stated normally R3 takes the medications on his own but does not have an order stating that medications may be left at bedside. V3 stated, We're not supposed to leave medications…

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 interviews, the facility failed to maintain complete and accurate medical records for one (R9) of 14 residents reviewed for medical records on the sample list of 16. Findings include:R9's current Diagnoses list documents the following: Dementia in Other Disease Classified Elsewhere, Mild with Other Behavioral Disturbance, and Alzheimer's Disease, Unspecified. R9's Diagnosis list does not document a diagnosis of Psychosis.R9's historic Psychiatric Evaluation, dated 9/7/23, documents R9 had Psychosis, and Irritable/Frequent Anger when Risperdal Antipsychotic medication was originally ordered.R9's Minimum Data Set, dated [DATE] ,documents: Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? Yes - Antipsychotics were received on a routine basis only.R9's current Physician Order documents the following: Risperdal (anti-psychotic medication) oral tablet, give 0.25 mg (milligrams) by mouth in the morning…

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

Based on observation, interview, and record review, the facility failed to provide the services of a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 69 residents residing in the facility. Findings include: On 11/19/24 at 2:30 PM, V1 provided V15's employee file. The file contained a documented position offer to V15 as the Dietary Manager. The position offer letter documents that in this role, V15 will be required to manage all aspects of the Dietary department. This includes regulatory oversight in regard to local, state, and federal requirements as they pertain to safe food handling. The same document documents V15 must enroll and begin the Dietary Manager Course. On 11/19/24 at 2:30 PM, V1, Administrator, provided V15's employee file. V15's initial application documents V15 was hired on 7/12/2024 as the CDM (Certified Dietary Manager). On 11/18/24 at 11:10 AM, V15, Dietary Manager, was actively managing kitchen personnel and directing the food sanitation and preparation activities in the facility's kitchen. On 11/18/24 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 observation, interview, and record review, the facility failed to provide timely meals and without serving an evening snack. This failure has the potential to affect all 69 residents in the facility. Findings include: On 11/18/24 at 11:30AM, during resident council meeting, R18, R34, and R37 stated breakfast is served closer to 9AM, and an evening snack has not been offered for the past two to three months. On 11/19/24 at 10:15AM, V15, Dietary Manager, stated meal times are 8AM, 12PM, and 5PM. V15 stated the Dietary department provides snacks in the nutrition room (located off the common area) every evening. V15 stated the snacks are available to staff to pass out for resident consumption after the kitchen is closed. On 11/20/24 at 12:15PM, R57 stated R57 eats in R57's room. R57 had not been served lunch at this time. R57 stated R57 usually receives breakfast tray around 9AM and dinner at 6PM, R57 stated was not aware of snacks being available to residents in the evening. The facility Frequency of Meals Policy, revised July 2017, documents the following: Each resident shall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of resident to resident verbal abuse to the Abuse Coordinator for two of three residents (R23 and R29) reviewed for Abuse in a sample list of 34 residents. Findings include: The facility policy titled Abuse Prevention, dated 8/16/19, documents employees are required to repot any incident, allegation, or suspicion of crime or potential abuse, neglect or misappropriation or property they observe, hear about, or suspect to the Administrator. R23's Minimum Data Set (MDS), dated [DATE], documents R23 as severely cognitively impaired. R29's Minimum Data Set (MDS), dated [DATE], documents R29 as severely cognitively impaired. R23's Nurse Progress Note, dated 8/27/24 at 1:46 PM, documents, During lunch, (R23) started to cry and wanted to leave the dining room. Upon trying to leave (R23) ran into another resident's (R29)wheelchair. The two resident's (R23, R29) started yelling at each other. Staff intervened, (R23) asked to be brought to…

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

Based on interview and record review, the facility failed to provide weight management services for residents experiencing unplanned weight loss for two of three residents ((R13, R69) reviewed for weight loss on the sample list of 34 residents. Findings include: R13's medical record documents on 11/1/2024 at 10:04 PM a weight of 104.4 pounds, and on 10/9/2024 at 08:06 AM a weight of 114.5 pounds. That is a documented weight loss of 10.1 pounds or a weight loss of 9.1% in a month. There was no documentation the physician was notified. R69's medical record documents on 11/1/2024 at 10:04 PM a weight of 84.0 pounds and on 10/28/2024 at 07:41 AM a documented weight of 97.5 pounds. This is a documented weight loss of 13.5 pounds which equals a loss of 8.6%. There was no documentation the physician was notified. R69's medical record documents on 11/6/2024 at 7:17 PM, R69 was transported and admitted to the hospital. The medical record documents on 11/16/2024 at 8:54 PM, R69 was re-admitted to the facility with a PEG (Percutaneous Endoscopic Gastrostomy) tube in place for continuous…

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 attempt nonpharmacological intervention prior to implementing psychotropic medications, failed to identify target behaviors for the use of psychotropic medications, and failed to assess use of psychotropic medications for one resident (R6) of eight residents reviewed for Psychotropic medications in a sample list of 34. Findings include: The Facilities policy Psychotropic Medication Use, revised December 2016, documents psychotropic medications will generally only be considered if the following conditions are met: The behavioral symptoms present a danger to the resident or others; Behavioral interventions have been attempted and included in plan of care, except in an emergency. Pertinent non-pharmacological interventions must be attempted, unless contraindicated. R6's Medication Administration Record (MAR) for November 2024 includes the following orders for psychotropic medications: Quetiapine 25 milligrams, give 0.5 tablet twice a day for anxiety. On 11/19/24 01:37 PM, V2 (Director of Nursing) and V24 (Clinical 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 observation, interview, and record review, the facility failed to properly label medications for three residents (R5, R49, R67) out of four residents reviewed for medication administration in a sample list of 34 residents. Findings include: The facility policy titled Labeling of Medication Containers, revised April 2007, documents all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Labels for individual drug containers shall include all necessary information, such as: resident name, physician name, directions for use and expiration date. 1.) R5's Physician Order Sheet (POS), dated November 2024, documents a physician order for Polymyxin B-Trimethoprim Ophthalmic Solution 10000-0.1 unit/milliliter (ml) give one drop in Left eye six times per day, Hydrocortisone External Cream 1 % apply topically to skin around Left Eye three times per day, and Fluticasone Furoate Aerosol Powder Breath Activ 50 micrograms (MCG)/actuation (ACT) daily. On 11/18/24 at 8:12 AM, V10, Licensed Practical Nurse (LPN),…

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

Based on interview and record review, the facility failed to implement an antibiotic stewardship program by failing to assess criteria for determining an infection for one of one residents (R9)reviewed for antibiotic stewardship in the sample of 34 residents. Findings include: The Antibiotic Stewardship policy, dated December 2016, states, the purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. R9's Electronic Medical Record documents R9 receives Hospice services. A Communication Note with Physician, dated 11/14/24, by V28, Licensed Practical Nurse, documents the following: Hospice Certified Nursing Assistant concerned with resident (R9) confusion. Resident confused at times. Antibiotic to begin for urinary tract infection (UTI) and fluids encouraged. R9's Physician Orders (November 2024) documents an order, dated 11/14/24, for Bactrim DS(antibiotic) 800-160 milligram by mouth two times a day for an infection for 10 days. R9's Medical Record fails to document a McGeer Criteria for Infection Surveillance Checklist was completed,…

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 an accurate Advanced Directive for one (R5) of three residents reviewed for Advanced Directives from a total sample list of 16 residents. Findings Include: The facility provided Advanced Directives Policy, dated [DATE], documents that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if her or she chooses to do so. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and /or his or her legal representative, about the existence of any written advance directives. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident dignity was maintained by failing to provide timely bowel and bladder incontinence care, for one of three residents (R13) reviewed for incontinence care on the sample list of 24. Findings include: R13's Physician Order Sheet, dated 10/08/24, documents the following: Admit to (name of hospital) Hospice: dx (diagnosis) CHF (Congestive Heart Failure), and Aspiration Pneumonia. R13's Minimum Data Set (MDS), dated [DATE], documents R13 has a Brief Interview of Mental Status score of 12 out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R13 is always incontinent of bladder, and bowel function was not rated on this MDS. R13's Care Plan, dated 08/07/24, documents the following: The resident has an ADL (Activity of Daily Living), Self - Care Performance Deficit r/t ( related to) weakness and blindness. Self Care and TOILET USE: The resident is totally dependent on staff for toilet use. 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 observation, interview, and record review, the facility failed to accurately measure food portions during of meals service for residents in the dining room and residents that dine in their rooms. This failure affects three residents (R1, R4, R18) and has the potential to affect all 75 residents residing in the facility. Findings include: 1.) On 10/11/24 at 10:50 am, V24, Licensed Practical Nurse, stated, Portion sizes really depends on who is cooking. Some residents ask for seconds and have to wait until everybody has been served first. I think they should be able to get seconds when they ask. On 10/11/24 at 11:05 am, V11, Certified Nursing Assistants (CNA), stated, There are a lot of dietary problems in the facility. V11 also stated, The portion sizes-- residents do complain about. One time they may get a lot, other times a spoonful. On 10/11/24 at 11:51 am, V14, CNA, stated, There are a lot of dietary concerns. It seems like everybody complains about the presentation. Some hungry people get a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide wound treatments as ordered by the physician and failed to have a pressure sore plan of care for two (R1, R2) of three residents reviewed for pressure sores in the sample list of three. Findings include: The Facility's Treatment and Wound Care policy, dated October 2010, documents the nurse is to apply treatments as ordered by the Physician. 1. R2's Minimum Data Set, dated [DATE], documents R2 is cognitively intact. On 9/12/24 at 9:55 AM, R2 was sitting in a recliner chair in the room. R2 stated R2 has wounds on his buttocks. R2's Care Plan, dated 9/12/24, does not document a wound on R2's left buttocks. V8 Wound Doctor Notes, dated 9/9/24, document R2 has a stage three pressure sore to the left buttock measuring 1.3 x 0.5 x 0.1 centimeters (cm) with a total surface area of 0.65 cm. This wound note documents a new treatment order to apply Calcium Alginate then cover with a hydrocolloid sheet three times per week and as needed for…

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

Based on interview and record review, the facility failed to prevent the potential for foodborne illness by serving undercooked hamburgers. This failure affected one resident (R2) of three reviewed for food safety in the sample of three. Findings include: R2's assessment (4/5/2024) documents R2 is cognitively intact. On 4/30/2024 at 11:50AM, R2 reported receiving undercooked hamburgers in the facility several times that were pink in coloration. On 4/30/2024 at 11:56AM, V5 (Cook) reported a former Dietary employee had grilled hamburgers outside recently for a resident lunch meal, and many were undercooked when they were returned to the kitchen to serve to residents. V5 reported Dietary staff thought they had caught all the undercooked hamburgers before they were served to residents. On 5/2/2024 at 2:47PM, V10 (Regional Dietary Manager) stated V10 would consider any hamburger served to residents while still pink in color to be a foodborne illness risk.

Based on interview and record review, the facility failed to update R2's care plan subsequent to a fall. This failure affects one resident (R2) of three reviewed for care plans in the sample of three. Findings include: R2's nurse progress notes (1/24/2024-1/26/2024) document R2 had a fall on 1/24/2024 when attempting to ambulate independently in the facility living room. The same notes document R2 was noted to have a decline in transfer ability when screened by therapy, and has been mobile via wheelchair versus a walker previously used by R2. The facility Resident Incident Report (1/24/2024) documents the facility Interdisciplinary Team met and discussed R2's fall and updated R2's care plan to keep R2's wheelchair close to R2. R2's care plan (3/26/2024) does not document R2's 1/24/2024 fall or any new interventions designed to prevent R2 from falling in the facility, including keeping R2's wheelchair close to R2. On 3/26/2024 at 1:35PM, V8 (Infection Preventionist) reported R2's care plan should have been updated after R2's fall on 1/24/2024. The facility care plan policy (December…

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 mechanical lifts are routinely inspected and maintained in good working order. This failure has the potential to affect 18 (R2, R3, R5-R20) out of 18 residents reviewed for mechanical lifts in the sample list of 20. Findings include: On [DATE] at 10:24 AM, the full mechanical lift located on the [NAME] hallway was viewed with V7, Certified Nursing Assistant (CNA). The lift did not contain the secondary emergency release, and this was confirmed with V7. V7 stated, There are problems with the lift batteries not always getting charged, and we have to make sure the batteries get placed on the charging docks routinely. The utility room near the hallway was viewed with V7. There were multiple batteries located in this room on a shelf ,and there were two charging docks that contained batteries. The lights were not lit up to indicate if the batteries were charging. V7 stated, The charging light does not always light up when the batteries…

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 a resident's right to be free from physical and mental abuse by an employee. This failure affects one of five residents (R1) reviewed for abuse in the sample list of 20. Findings include: R1's cumulative Diagnosis/History, dated 12/5/23, documents R1's diagnoses include Unspecified Dementia with Behavioral Disturbances, Parkinson's Disease, and Depression. R1's Minimum Data Set, dated [DATE], documents R1 is rarely/never understood, and has short and long term memory impairment. R1's Care Plan dated 5/2/23 documents R1 has behaviors of biting, scratching, and refusing cares. This care plan includes an intervention, dated 11/23/23, staff involved in recent incident of 11/21/23 received inservice training on the abuse policies and procedure. The facility's undated Final Report of R1's abuse allegation documents the following: On 11/21/23 at 7:30 PM, V5, Certified Nursing Assistant (CNA), told V1, Administrator, that V5 overheard unidentified…

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 timely report an allegation of staff to resident abuse to the administrator. This failure affects one (R1) of five residents reviewed for abuse in the sample list of 20. Findings include: R1's cumulative Diagnosis/History, dated 12/5/23, documents R1's diagnoses include Unspecified Dementia with Behavioral Disturbances, Parkinson's Disease, and Depression. R1's Minimum Data Set, dated [DATE], documents R1 is rarely/never understood and has short and long term memory impairment. R1's Care Plan, dated 5/2/23, documents R1 has behaviors of biting, scratching, and refusing cares. This care plan includes an intervention, dated 11/23/23, staff involved in recent incident of 11/21/23 received inservice training on the abuse policies and procedure. The facility's undated Final Report of R1's abuse allegation documents the following: On 11/21/23 at 7:30 PM, V5, Certified Nursing Assistant (CNA), told V1, Administrator, that V5 overheard unidentified staff…

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 thoroughly investigate abuse allegations and maintain accurate documentation of the investigations for two residents (R1, R4), and failed to document a thorough investigation into a resident incident/injury for one (R2) of five residents reviewed for abuse in the sample list of 20. Findings include: The facility's Abuse Prevention Policy and Procedures, dated 8/16/19, documents the appointed abuse investigator will follow the Resident Protection Abuse Investigation Procedures for investigating and conducting interviews. This policy documents the final investigation report that is submitted to the Illinois Department of Public Health should include the date, time, and location of the allegation. The policy documents to interview any witnesses to the incident, the resident involved, staff who had contact with the resident and accused perpetrator during the incident identified time frame, and other residents and staff who have regular…

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 Dementia Management training for staff. This failure affects one (R1) of five residents reviewed for abuse in the sample list of 20. Findings include: R1's cumulative Diagnosis/History, dated 12/5/23, documents R1's diagnoses include Unspecified Dementia with Behavioral Disturbances, Parkinson's Disease, and Depression. R1's Minimum Data Set, dated [DATE], documents R1 is rarely/never understood and has short and long term memory impairment. R1's Care Plan, dated 5/2/23, documents R1 has behaviors of biting, scratching, and refusing cares and includes an intervention, dated 11/23/23, that there was an incident on 11/21/23 and staff received training on the facility's abuse policies. The facility's undated Final Report of R1's abuse allegation documents the following: On 11/21/23 at 7:30 PM, V5, Certified Nursing Assistant (CNA), told V1, Administrator, that V5 overheard unidentified staff talking at the nurses station that V3, Registered 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 observation, interview, and record review, the facility failed to follow weekly menu's and the corresponding spreadsheets for appropriate serving sizes. This failure has the potential to affect all 68 residents who reside at the facility. Findings Include: 1.) On 10/30/23 at 9:20 am, V4 (R1's family) stated on 10/22/23, R1 was not served what was on the menu, and hardly any food, explaining R1 was only served a small spoonful of mashed potatoes, small spoonful of soup, and a slice of bread. V4 stated the Dietary staff was confronted and the cook, later identified as V11, reported V11 didn't know what to do, because V11 was a dishwasher, not a cook, but V11 was just cooking that night. The Week At A Glance, Week 4 Menu, documents on 10/22/23 for supper, the facility was to have; chicken and rice soup, crackers, stuffed baked potato, seasoned spinach, fruit cup, and ice cream. On 10/30/23 at 12:22 pm, V5, Dietary Manager, stated V5 was aware of the situation of serving sizes not being followed last weekend when V11 was the cook. V5 explained V5 had received a picture of R1'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 provide timely toileting assistance to one of three residents (R2) reviewed for toileting assistance on the sample list of three. Findings Include: The Facility Resident Council Minutes dated 8/19/23, documents, There is still a delay getting assistance to the restroom. On 10/30/23 at 10:53 am, V8, CNA (Certified Nursing Assistant) responded to R2's activated call light. R2 stated R2 had to use the restroom, and V8 instructed R2 to come to the shower room for toileting. Once R2 went to the shower room, V8 along with V9, CNA, assisted R2 to stand, and removed R2's incontinence brief, which was wet with urine, and placed R2 onto the toilet. R2 voided and had a bowel movement while on the toilet, then requested V8 to apply two incontinence briefs onto R2. At this time, V8 stated, I don't like to do that, but (R2) is alert and oriented and can make (R2's) own decision and that is (R2's) request. (V8) placed two incontinence briefs on R2 then assisted R2 back into R2's wheelchair. After cares were complete, R2…

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

Based on interview and record review, the facility failed to complete a restraint assessment and obtain an order for restraints prior to restraining one of three residents (R1) reviewed for abuse on the sample list of nine. Findings Include: R1's ongoing Diagnosis listing documents Diagnoses of Alzheimer's Disease, Dementia with Behaviors, and Unspecified Convulsions. R1's Abuse Investigation by V1, Administrator, dated 8/24/23, documents it was reported V4, CNA (Certified Nursing Assistant), used a device to help keep R1 in R1's chair while feeding R1. R1 has a BIMS (Brief Interview for Mental Status) of 0, {indicating R1 has severe cognitive impairments}, and due to increased Dementia behaviors, R1 has been assigned to one on one care. Facility staff attempted to interview R1, however, due to R1's cognitive status/diagnosis, R1 was unable to participate in an interview. V4 was interviewed and stated V4 was providing one on one care for R1. V4 explained V4 had some difficulty getting R1 to sit at the table, but once R1 was seated, V4 put a gait belt loosely around R1's waist and…

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

Based on interview and record review, the facility failed to provide morning cares, breakfast, and toileting timely for one of five residents (R7) reviewed for Activity of Daily Living assistance on the sample list of nine. Findings Include: On 9/12/23 at 9:50 am, R7 stated sometimes it takes staff awhile to answer the call light, sometimes up to 45 minutes, causing R7 to be incontinent of urine. R7 stated, It's embarrassing, nobody wants to wet themselves. R7 also stated in August, R7 was supposed to have an insurance interview and was still in bed when it was supposed to happen. R7 explained V17 (R7's family) was at the facility and had to help R1 with the call/interview because R7 had not been gotten up yet out of bed, gotten ready, or eaten breakfast at that time, which was a little before 9:00 am. R7's MDS (Minimum Data Set), dated 7/14/23, documents R7 is alert and oriented, requires limited assistance with bed mobility, transfers, personal hygiene, and toileting and extensive assistance with dressing. A witness statement, dated 8/30/23 at 9:00 am by V3, Former DON (Director…

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

Based on interview and record review, the facility failed to complete yearly performance reviews of Certified Nursing Assistants. This has the potential to affect all 72 residents residing at the facility. Findings Include: The Facility's Employee Summary Report, dated 8/22/23, document the following CNA's and their dates of hire: V30 - 6/7/22; V31 - 3/1/22; V32 - 3/1/22; V33 - 3/1/22; V22 - 3/1/23; V34 - 3/1/22; V35 - 3/1/22; V37 - 3/1/22; V38 - 8/18/22; V39 - 3/1/22; V40 - 3/1/22; V26 - 6/7/22; V41 - 3/1/22; V42 - 3/1/22; V13 - 3/1/22; and V43 - 3/1/22. There was no documentation provided by the facility, of CNA's listed above, yearly performance reviews being completed. On 8/22/23 at 12:43 PM, V2, DON (Director of Nursing), stated V2 has only been DON since June 2023, but V2 has not completed any CNA performance reviews since taking over the position. On 8/22/23 at 1:12 PM, V17, Regional Nurse/IP (Infection Preventionist), stated V17 has not evaluated staff performance since starting in Mid-July 2023. On 8/22/23 at 1:12 PM, V21, Regional Clinical Nurse, stated V21 has only been…

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, interview, and record review, the facility failed to have a certified Dietary Manager on staff. This failure has the potential to affect all 72 residents in the facility. Findings include: The facility resident census and condition report, dated 8/20/23, documents 72 residents in the facility. The 2023 facility assessment documents a staffing plan, based on a census of 48 residents, including a Certified Dietary Manager. On 8/20/23 at 8:05AM, various food service items were on the kitchen floor. Additionally, trash and debris were noted on the floor in the dry storage room, under the carts. On 8/21/23 at 9:16AM, various food service items were on the kitchen floor. On top of the dishwasher, lime and dirt build up on top of it, with no cleaning schedule. On 8/20/23 at 8:30AM, V16, Dietary Manager, stated, I don't have my certification as a Dietary Manager yet.

Based on observation and interview, the facility failed to maintain a safe, clean and hygienic kitchen. This failure has the potential to affect all 72 residents in the facility. Findings include: The facility resident census and condition report, dated 8/20/23, documents 72 residents in the facility. On 8/20/23 at 8:00AM, the kitchen floor had opened boxes laying on it, trash under the storage carts, and dishes, pitchers, and plastic containers laying in a corner of the kitchen. On 8/20/23 at 8:15AM, V16, Dietary Manager, stated, We are expected to clean the kitchen. We have had problems with pests in the kitchen in the past. On 8/20/23 at 8:15AM, the ice machine had 2 ice scoops laying on top of the ice maker, without any container or drainage. On 8/20/23 at 8:16AM, V16, Dietary Manager, stated, We use that ice for everyone. On 8/21/23 at 9:16AM, the kitchen had open boxes on the floor with items such as dishes, plastic containers, and pitchers, being stored in the corner of the kitchen. The top of the dishwasher contained lime and dirt build up on top of it. On 8/21/23 at 9:17AM,…

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 record review and interview, the facility failed to establish an Infection Prevention and Control Program. This failure has the potential to affect all 72 residents residing at the facility. Findings Include: The Facility's Surveillance for Infections Policy, dated September 2017, documents, The Infection Preventionist will conduct ongoing surveillance for Health-Associated Infections and other epidemiologically significant infections that have substantial impact on potential resident outcome an that may require transmission-based precautions and other preventative interventions. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The Infection Control Committee and/or QAPI (Quality Assurance Performance Improvement) Committee may be involved in interpretation of the data. The surveillance should include a review of any or all of the following information to help identify possible indicators of infections: laboratory records, infection control rounds or interviews, infection documentation…

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 the facility's dryers in a safe operating condition. The failure has the potential to affect all 72 residents who reside at the facility. Findings Include: On 8/22/23 at 10:35 AM, one of the two dryers has the upper door covering the heating element of the dryer open, so the gas flames were visible. With the door being open, there was a horizontal platform that had a thick layer of lint and debris on it. This lint was approximately 5 inches away from the open flames. At this time, V15, Regional Director of Operations, and V49, Housekeeping/Laundry Supervisor, were present, and both stated the lint with the open flames was a fire hazard. V49 stated the laundry personnel are responsible for cleaning the dryers and they should be done a couple times a week, but stated the facility does not have a cleaning check list, so V49 is not sure when the dryer was last cleaned and the lint removed. The facility's Cleaning and Disinfection of Environmental Surfaces Policy, dated June 2009, documents environmental…

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 obtain consents, abnormal involuntary movement scales, and assessments for psychotropic medications for four (R6, R67, R54, R64) of five residents reviewed for psychotropics from a total sample list of 40. Findings include: The facility Behavioral Assessments, Intervention and Monitoring Policy, dated March 2019, documents, When medications are prescribed for behavioral symptoms, documentation will include: rationale for use, potential underlying caused of the behavior, other approaches and the interventions tried prior to the use of antipsychotic medications, potential risks and benefits of medication as discussed with the resident and or family, specific targeted behaviors and expected outcome, dosage, duration, monitoring for efficacy and adverse consequences and plan for gradual dose reduction if appropriate. Additionally, the facility provided Antipsychotic Medication Use policy, dated 12/2016, documents assessments and documentation regarding 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 offer and/or administer Pneumococcal Immunizations for four of five residents (R13, R30, R38, R61) reviewed for immunizations on the sample list of 40. Findings Include: R13, R38, and R60's ongoing Immunization Logs do not document they have received the Pneumococcal Immunization. Their Medical Records do not contain an Influenza and Pneumococcal Consent/Decline Authorization Form. R30's undated Influenza and Pneumococcal Consent/Decline Authorization signed by V28 (R30's family) documents V28 wants R30 to receive the Pneumococcal Immunization. R30's ongoing Immunization Log does not document R30 has ever received the Pneumococcal Immunization. On 8/22/23 at 1:50 PM, V17, IP (Infection Preventionist), and V21, Regional Nurse Consultant, both stated they were not able to find any Pneumococcal Consents/Declination Forms for R13, R38 and R60. Both V17 and V21 stated the Pneumococcal Immunization should be offered and given if requested. V21 stated V21 is unsure if there is any of the immunization in the facility to be given.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident's Advanced Directives were consistent throughout the medical chart for 3 of 4 residents (R11, R69, R12) reviewed for Advanced Directives in the sample list of 40. The findings include: The facility's Advance Directives policy, with a revised date of [DATE], documents, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not 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 identify the use of body pillows as a restraint, assess for the restraint, care plan the restraint and accurately code the Minimum Data Set for one of one residents (R56) reviewed for restraints on the sample list of 40. Findings Include: R56's MDS (Minimum Data Set), dated 5/26/23, documents R56 does not use any restraints while in bed, but does use restraints daily when up in the chair and out of bed. R56's Care Plan dated 8/1/23, does not document any restraint use. R56's Physical Restraint Assessment, dated 5/26/23, documents R56 does not use any restraints at this time. On 8/20/23 at 8:00 AM, R56 was lying in a low bed, with body pillows placed under the fitted sheet on both sides of the bed. The pillows were approximately 9 inches tall. On 8/21/23 at 10:10 AM, V13, CNA (Certified Nursing Assistant), and V14, CNA, both stated R56 does not utilize a restraint, however, does use body pillows on both sides of R56 when in bed and a bed alarm, and has for a very long time. V13 stated R56 is able to move…

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 a Preadmission Screening and Resident Review (PASARR) level II screening was completed for one (R6) of one residents with a serious mental illness and reviewed for PASARR level II screenings from a total sample list of 40 residents reviewed. Findings Include: The facility's Behavioral Assessment, Intervention and Monitoring policy, dated March 2019, documents new onset or changes in behavior that indicated newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR Level II evaluation. R6's level I PASARR, dated 11/17/21, documents a level II PASARR is not required, due to R6 not having an SMI (Severe Mental Illness) Diagnosis and admission to the facility on [DATE]. R6's psychiatric appointment, dated 2/14/23, documents a telehealth visit including diagnoses of Bipolar Disorder and Borderline Personality Disorder, with a medication review including: Trazodone 200 milligrams…

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 a baseline care plan for staff to reference for one of six residents (R174) reviewed for pressure ulcers on the sample list of 40. Findings Include: R174's Progress Notes document R174 was admitted to the facility on [DATE]. On 8/21/23, R174 did not have a baseline care plan in R174's medical record. On 8/21/23 at 11:00 AM, V3, QA (Quality Assurance)/IP (Infection Preventionist)/LPN (Licensed Practical Nurse), stated V10, MDS (Minimum Data Set)/Care Plan Coordinator, just started last week and has no MDS/Care Plan experience, so V10 probably did not know she needed to complete a baseline care plan. On 8/21/23 at 2:22 PM, V21, Regional Clinical Nurse, produced a Baseline Care Plan, dated 8/18/23. At this time, V21 stated R174's Baseline Care Plan was completed offsite by V20, Corporate Care Plan Nurse, but was not sent to the facility until today, three days after admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to assess a laceration upon admission and obtain wound treatment orders for one of one residents (R174) reviewed for non-pressure wounds on the sample list of 40. B. Based on observation, interview and record review, the facility failed to coordinate care with hospice for one of one resident (R174) reviewed for hospice services on the sample list of 40. Findings Include: A. R174's Progress Notes document R174 was admitted to the facility on [DATE]. On 8/20/23 at 9:48 AM, R174 was lying in bed, slightly on R174's left side. V47, R174's family, stated R174 has a head laceration on the upper back of the head with sutures from a fall at home. On 8/21/23, R174's Medical record does not contain any assessments for the head laceration, and R174's August 2023 Physician Orders does not contain a treatment order for the head laceration. On 8/21/23 at 11:10 AM, V6, LPN…

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

Based on observation, interview, and record review, the facility failed to obtain a treatment order upon admission, complete treatments as ordered, maintain a dressing over a pressure ulcer, perform hand hygiene to prevent potential cross contamination during pressure ulcers treatments, utilize an appropriate mattress for the stage of pressure ulcer, and implement pressure relieving/preventing interventions for two of six residents (R47, R174) reviewed for pressure ulcers in the sample list of 40. Findings include: The facility's Prevention of Pressure Ulcers/Injuries policy with a revised date of July 2017 documents, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries; c. Areas of impaired circulation due to pressure from positioning or medical devices. Support Surfaces and Pressure Redistribution Select appropriate…

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 check the placement of a gastrostomy tube prior to giving medications, and failed to allow medications and water to infuse by gravity for one of one residents (R16) reviewed for gastrostomy tubes on the sample list of 40. Findings include: R16's plan of care, dated 1/2/23, documents R16 requires a gastrostomy tube for supplemental nutrition. This care plan includes an intervention to check placement of tube before meds and feedings. The facility's Administering Medications Through An Enteral Tube policy, with a revision date of November 2018, documents under step 12 to, Administer medication by gravity flow. On 8/22/23 at 2:48 PM, V29, Registered Nurse, administered two tablets of Tylenol 325 milligrams (mg) and one tablet of Hydralazine 100 mg through R16 gastrostomy tube. V29 did not check placement prior to flushing R16's gastrostomy tube when giving the medication. After V29 poured the medication into the gastrostomy tube syringe, V29 pushed the medication into the tube. V29 then pushed the water flush…

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 a medication before breakfast per manufacturers directions for one (R38) of five residents reviewed for medication administration on the sample list of 40. Findings include: The Levothyroxine manurfactcturer's package insert, with a revision date of 4/2019, documents, Administer once daily, preferably on an empty stomach, one-half to one hour before breakfast. R38's physician order, dated 5/5/23, documents an order for Levothyroxine 125 micrograms once a day at 8:00 AM every day. On 8/22/23 at 10:11 AM, V6, Licensed Practical Nurse, administered morning medications to R38, which included one Levothyroxine 125 milligram to R38. R38 was sitting up in a chair with a half empty breakfast tray on the bedside table. V6 stated the hallway is a heavy workload and medications were running late today. On 8/22/23 at 11:01 AM, V17, Corporate Regional Nurse/Registered Nurse, stated R38's Levothyroxine should not have been scheduled at 8:00 AM, and that usually thyroid medications are given at 6:00 AM. On…

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

Based on observation, interview, and record review, the facility failed to label insulin vials and pens when opened for three (R16, R43, and R223) of four residents reviewed for insulin on the sample list of 40. Findings include: On 8/21/23 at 12:38 PM, V29, Registered Nurse, took a bottle of R16's Novolog insulin out of the medications cart. V29 administered 2 units of insulin to R16. R16's bottle did not have an open date written on the bottle. At that time, V29 stated whenever insulin is opened, the date should be written on the bottle. On 8/21/23 at 1:17 PM, the North hall cart contained a bottle of Levemir insulin. This bottle did not contain a label with a name or directions. The bottle also did not have a date in which the bottle was opened. V29 stated the bottle belonged to R43. The cart contained a Levemir Flexpen insulin for R223 . This pen did not have a date in which the bottle was opened. The cart also contained a Tresiba Flexpen for R16. This pen did not have a date in which the pen was opened. V29 stated all insulin should be dated when opened. The facility's Insulin…

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 a closet with working closet doors that allowed access to residents clothing. This failure affects two of 24 residents (R7, R13) reviewed for environment on the sample list of 40. Findings include: R13's Quarterly Minimum Data Set Assessment, dated 5/26/23, documents R13 finds it very important to choose the clothes she wears and to take care of her personal belongings. On 8/20/23 at 8:09 AM, R7 and R13's closet door was off of the track. R13 stated, They need to take the door off or something. They will come in and fix it and then it comes off again. When it is off, we can't get to our clothes. The right closet door was off of the track, lying on the clothes in the closet. On 8/21/23 at 10:16 AM, V5, Maintenance Director, stated he put R13's door back on the track yesterday. V5 stated the door comes off the track when it is bumped by R7 and R13 when they are sitting in their wheelchairs. V5 stated he also had to bend the track back in place. V5 stated the closet doors come off all the time. 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.