Loft Rehab Of Decatur

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent cross contamination during urinary catheter care for one (R9) of two residents reviewed for urinary catheters in the sample list of 57 residents. Findings include: The facility's Catheter Care policy dated 1/26/26 documents the following steps for female urinary catheter care: 9. Gently separate the labia to expose the urinary meatus. 10. Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). 11. Use a new part of the cloth or a different cloth for each side. 12. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. 13. Dry area with towel.On 5/3/26 at 8:52 AM, R9 received antibiotics for blood-tinged urine, symptoms have come and gone with additional antibiotic treatment. R9 stated staff don't clean R9's catheter daily, only intermittently. R9 stated R9 has occasional diarrhea 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.

Based on observation, interview, and record review the facility failed to accurately document the refusal of protective arm sleeves on the treatment administration record for one (R73) of one resident reviewed for accidents on the sample list of 57 residents. On 5/3/2026 at 9:00 AM, R73 was sitting in a wheelchair in R73's room. R73's right arm was bent with R73's hand lying on R73's chest. R73 was wearing a sweater; R73's left arm was in the arm of the sweater but R73's right arm was bare. R73's physician order dated 7/2/2025 documents an order to apply protective arm sleeves when up in wheelchair as resident allows. On 5/3/2026 at 1:44 PM, R73 was sitting in R73's wheelchair in R73's room. R73 was not wearing protective arm sleeves. When asked if staff offered to apply the protective skin sleeves, R73 stated, no. On 5/4/2026 at 9:30 AM and 2:35 PM and on 5/5/2026 at 09:31 AM, R73 was sitting up in the wheelchair and was not wearing protective skin sleeves. R73's Treatment Administration Record dated April of 2026 and May of 2026 documents that R73's protective skin sleeves were…

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

Based on interview and record review the facility failed to administer multiple medications per physician order. This failure affected three of three residents (R13, R14, R15) reviewed for medication administration on the sample list of fifteen. Findings Include: The facility's Medication Error Policy dated 2/2/26 documents the facility shall ensure medications are administered according to physician orders. If medication errors occur, staff are to notify the physician, document the incident in the medical record, and report the incident to the appropriate supervisor.The Resident/Family Complaint Form dated 1/26/26 documents R13 filed a complaint stating she did not receive her evening medications on 1/23/26.On 2/5/26 at 11:48 a.m., V2, Director of Nursing (DON), stated residents on the Northeast Hall did not receive their evening medications on 1/23/26. V2 stated R13 filed a grievance regarding the incident. V2 stated she reviewed which residents missed their medications, identified the medications that were omitted, and reviewed the incident and any potential outcomes with V13,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents right to dignified care for two of three residents (R1 and R3) reviewed for quality of care/abuse on the sample list of 15.Findings include:1. R1's current diagnoses list documents the following: Essential Hypertension; Chronic Obstructive Pulmonary Disease, unspecified; Bipolar Disorder with current episode depressed, mild or moderate severity, unspecified; Muscle wasting and atrophy, not elsewhere classified, multiple sites; Unsteadiness on feet; Lack of coordination; and History of falling.R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status score as nine out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R1 has limited range of motion of the bilateral upper extremities. The MDS further documents R1 is totally dependent for all activities of daily living except eating. R1 requires substantial to maximum assistance with toileting, has not ambulated…

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 recognize and report allegations of abuse to the administrator for two (R1, R3) of three residents reviewed for abuse on the sample list of 15.Findings include: 1.R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status score as nine out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R1 has limited range of motion of the bilateral upper extremities. The MDS further documents R1 is totally dependent for all activities of daily living except eating. R1 requires substantial to maximum assistance with toileting, has not ambulated during the look-back period, and uses a manual wheelchair requiring partial to moderate assistance once seated. R1 has had no behaviors toward self or others and no rejection of care.On 01/16/26 at 2:40 p.m., R1 was lying on her back in bed. R1 stated, The girl with the ponytail (later identified as V8, Certified Nursing Assistant) is the one who did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review multiple facility staff had knowledge of allegations of rough care and derogatory comments, failed to report to the Administrator/Abuse Prevention Coordinator which resulted in a delay in initiating an investigation and failure to remove the alleged staff perpetrators. This failure had the potential to affect two of three residents (R1 and R3) reviewed for abuse on the sample list of 15.Findings include:1. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status score as nine out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R1 has limited range of motion of the bilateral upper extremities and is totally dependent for all activities of daily living except eating. R1 requires substantial to maximum assistance with toileting, has not ambulated during the look-back period, and uses a manual wheelchair requiring partial to moderate assistance once seated. The MDS further documents R1 has had no behaviors toward…

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 for dignity and respect. This failure affected one of three residents (R3) reviewed for Abuse on the sample of five. Findings Include: The Resident's Rights for People in Long Term Care Facilities pamphlet dated November 2018 documents the facility must treat residents with dignity and respect and must care for residents in a manner that promotes their quality of life. The State Report dated 12/8/25 documents R3 alleged a staff member (later identified as V11 Certified Nurse Assistant CNA) was rude to her and threw the container of sanitary wipes at her and told her she needed to clean someone else's feces off of the toilet seat before she used the bathroom. R1's Minimum Data Set, dated [DATE] documents R3 is cognitively intact and requires partial/moderate assistance for toileting hygiene and toilet transfers. On 1/14/26 at 3:00 PM R3 stated she was being helped to the bathroom by V11 CNA when V11 noticed another resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect the resident's right to be free from misappropriation of property. This failure affected one of three residents (R4) reviewed for Abuse on the sample of five. Findings Include: The facility's Abuse, Neglect, and Exploitation policy dated 2/11/25 documents the facility develops and implements policies and procedures that prohibit and prevent abuse and misappropriation of resident property. The State Report Investigation dated 1/12/26 documents a staff member (later identified as V15 Certified Nurse Assistant) had taken a check from R4's check book without permission and had used the check to pay her rent. V15 had written the check and signed R4's name. The total amount was for $975.00. R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact. On 1/14/26 at 3:07 PM, R4 confirmed a staff member had stolen a check from her check book which she had kept in her room and had used it to pay their rent unbeknownst to her. R4 stated her son…

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

Based on interview and record review the facility failed to provide a copy of resident's medical records in a timely fashion following a request by resident's Power of Attorney for one of three residents (R1) reviewed for medical records requests on the sample list of five.Findings Include:R1's electronic medical record documents R1 resided at the facility from 4/16/25 until 4/23/25 when R1 was transported to the local hospital emergency department and R1 has not returned to the facility since that time.On 10/8/25 at 3:00PM V5, R1's family member stated (R1) is at (a different facility) now. I have asked and signed for (R1's) medical record from the facility, but I haven't gotten anything but the runaround.On 10/9/25 at 10:00AM V8, Medical Records stated (V5) did request (R1's) medical record in May. Since the request came from a lawyer I had to send it to corporate and I can verify that the record has not been sent to (V5's) lawyer.On 10/9/25 at 2:00PM V1, Administrator stated (R1's) medical record has now been sent out. It would be my expectation that it should have been sent some…

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 clean comfortable rooms consisting of clean floors and rooms that are free of dirty dishes and debris for two (R1, R2) of three residents reviewed for comfortable homelike environment.Findings Include:On 7/21/25 at 10:00 AM initial tour of the facility hallways labeled 100, 200 and 300 observed to have several unmade beds, some beds observed without linen, some beds had soiled linen on the unmade bed. 1. R1's Minimum Data Set, dated on July 11, 2025, documents R1 as cognitively intact.On 7/21/25 at 1:15 PM R1 stated the staff does not make the bed daily, and often times there are dishes left over in his room from meals that he doesn't eat in the dining room. R1 stated that R1 prefers bed/sponge baths and staff do not change the sheets on the bed after wiping him down. On 7/21/25 at 11:10 AM V3, R1 family, stated V3 visited R1 recently during lunch time, there was trash on the floor, used gloves on the floor, and used napkins on the floor. V3 stated that there were dirty dishes with old food on them…

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 secure R2's indwelling catheter tubing, document urinary output every shift, and provide a dignity cover to cover the urinary collection bag. R2 is one of one residents reviewed for urinary catheters.Findings Include:On 7/21/25 at 10:22 AM R2 is observed lying in bed with indwelling urinary catheter tubing dangling from the bedside unsecured to the lower extremity and urinary collection bag hanging on the right side of the bed uncovered and facing/exposed to the hallway. On 7/21/25 at 12:00 PM V4 confirmed R2 is lying in bed with indwelling urinary catheter tubing dangling from the right bedside unsecured to the lower extremity and urinary collection bag hanging on the right side of the bed uncovered and facing/exposed to the hallway.On 7/21/25 at 2:20 PM V1, V2 and V5 confirmed R2 is lying in bed with indwelling urinary catheter tubing dangling from the right bedside unsecured to the lower extremity and urinary collection bag hanging on the right side of the bed uncovered and facing/exposed to 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 report allegations of abuse to the state survey agency for one (R4) of three residents reviewed for abuse on a sample list of eight. Findings include: The facility's Abuse, Neglect and Exploitation policy dated 2/11/25 documents the facility will have written procedures that include: reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. On 5/14/25 at 10:26 AM, V1 Director of Nursing (DON) stated that she received an allegation of verbal abuse towards R4 on 5/5/25 from V10 (R4's daughter) and an allegation of physical abuse towards R4 on 5/12/25 from V11 Certified Nurse Assistant (CNA).…

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

Based on interview and record review, the facility failed to ensure there were sufficient nursing staff in the facility to provide adequate care and assistance for residents, resulting in long call light response times and wound treatments and assessments not being completed timely for eight (R41, R7, R58, R66, R84, R79,R40, R52) of 32 residents reviewed for staffing out of a sample list of 48. Findings Include: The undated Facility Assessment documents the facility will follow Federal minimum staffing standards. Facilities with higher acuities and needs may need to adjust their staffing numbers higher than the minimum standard. The undated Facility Assessment documents the facilities daily Certified Nursing Assistant (CNA's) needs are 24 CNAs for a resident census of 97. The facilities Daily Staffing sheets documents on 2/28/25, 3/1/25, and 3/2/25 there was 19 CNA's who worked, on 3/3/25 and 3/4/25 there were 20 CNA's who worked. The Resident Council Minutes dated 1/27/25 documents under new business that call lights are taking over thirty minutes to be answered. Resident Council…

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 post daily, up-to-date, nurse staffing information. This failure has the potential to affect all 97 residents residing in the facility. Findings Include: On 3/3/25 at 10:28 AM posted staffing in case near front entrance dated 2/28/25. On 3/5/25 at 9:15 AM and 4:00 PM posted staffing in case near front entrance remains dated 2/28/25. On 3/4/25 at 3:51 PM V2 Interim Regional Director of Nurses (DON) confirmed Posted Daily Staffing should be updated daily. Throughout the survey concerns were identified related to staffing, showers, cold food, turning and repositioning, toileting, incontinence care, infection control, and call light wait times. The Resident Council Meeting Minutes dated 1/27/25 and 2/14/25 both document resident concerns with call light wait times. The Long Term Care Facility Application for Medicare and Medicaid dated 3/2/25 documents 97 residents reside in the facility.

Based upon interview and record review the facility failed to employ a qualified Social Worker on a full-time basis in a facility of 150 beds. This failure has the potential to affect all 97 residents who reside in the facility. Findings Include: The facility's undated Facility Assessment documents there are 150 licensed beds in the facility. This assessment also documents the facility requires one full time social worker on staff. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 3/2/25, documents there are 97 residents residing in the facility. On 3/6/25 at 1:30 PM, V1 Administrator stated V32 Social Service Director, is covering Activities and Social Services. V1 confirms V32 does not meet the qualifications to be a Social Worker in the facility. V1 stated V32 does not have a degree in Social Work or Human Services.

Based on interview and record review, the facility failed to implement their water management plan that included the required risk assessment, control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 97 residents in the facility. Findings Include: The facility's Water Management Plan dated 2023, fails to fully document the required facility water system risk assessment where Legionella and other pathogens could grow and spread in the facility water system. The facility failed to implement any specific testing protocols, acceptable ranges for control measures, or any corrective actions when control limits are not maintained to reduce the risk of waterborne pathogens in the facility water system. On 3/7/25 at 9:30 AM, V1 Administrator stated V1 does not have access/documentation to what has been completed, if it has been completed. The facility's Water Management Program dated Revised 5/1/24, documents a risk assessment will be conducted by the water management…

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 record all financial transactions for five (R60, R11, R74, R347 and R18) of seven residents reviewed for resident funds on the sample list of 48 residents. Findings Include: On 3/4/25 at 9:55 AM, stapled plastic pill pouches containing money were taped to the underside of the lid of the narcotic section of the medication cart. R60, R347, R74, and R18's names were written in marker on the outside of the pill pouches. R60's pouch contained $2.00, a pill pouch with a dark black marker was labeled lost and found 2.00, R347's pouch contained $5.00, R18's pouch contained $1.00, R74's pouch contained $5.00, and an nonlabeled unknown pouch contained $21.00. At that time, V13 (Licensed Practical Nurse) stated the money in the pouches is the residents money and that they have it because the business office is closed on the weekends. V13 stated they will give them their money if they need it. V13 stated there is no sign out sheet for nurses to document how much money each resident has or how much has been given to each…

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 showers as scheduled and failed to provide shaving, nail care, and grooming for four of four residents (R18, R41, R70, and R195) reviewed for showers and hygiene/grooming on the sample list of 48. Findings Include: The facility's Activities of Daily Living Policy dated 2/10/25, documents a resident who is unable to carry out activities of daily living will receive the necessary care to maintain grooming and personal care. 1. R18's Minimum Data Set (MDS) dated [DATE], documents R18 is dependent for personal hygiene. R18's Care Plan dated 1/7/25, documents R18 is at risk for deterioration in Activities of Daily Living (ADL) related to generalized weakness and decline in functional status, a history of Cerebral Vascular Accident (CVA) with left sided weakness, Range of Motion (ROM) limitations to the left arm and the left ankle/foot. On 3/2/25 at 10:00 AM, R18's hair appeared unclean, nails long, food was in R18's beard and on R18's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have an adequate indication for the use of a psychotropic medication, failed to try non-pharmacological interventions prior to administering a psychotropic medication, failed to do behavior tracking for multiple months after starting a psychotropic medication, and failed to attempt a gradual dose reduction of a psychotropic medication for two of four residents (R71, R46) reviewed for Psychotropic Medications on the sample list of 48. Findings Include: The facility's Use of Psychotropic Medications policy dated 2/10/25, documents a chemical restraint refers to any drug used for discipline or makes it more convenient for staff to care for a resident, and not required to treat medical symptoms. This includes instances when a psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, because they are less dangerous to a resident's health and safety. The residents…

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 food was palatable and food temperatures were satisfactory, and failed to ensure meals were served timely, for five (R79, R58, R47, R30, R84) of five residents reviewed for food satisfaction on the sample list of 48. Findings Include: The facility's Food Temperatures policy revised 2/12/25 documents to ensure food safety, hot food will be held and served at a temperature no lower than 135 degrees Fahrenheit (F). A resident council meeting was conducted on 3/03/25 at 10:03 AM. R79 stated the food doesn't taste good and it's served cold both in the dining room and when eating in her room. R79 stated there is no way for them to keep the food hot since it is on open racks. They don't have the staff to pass the trays timely. On 03/02/25 at 10:31 AM, R58 was sitting in his wheelchair asleep with an untouched breakfast tray in front of R58 with scrambled eggs, toast, oatmeal, and milk. R58 stated he hasn't eaten breakfast because food is cold. On 3/2/25 at 9:18 AM, R47 stated the food is always cold when his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's rights to dignified activities of daily living. This failure affects one of nine residents (R195) reviewed for dignity on the sample list of 48. Findings Include: The facility's Promoting/Maintaining Resident Dignity Policy dated 2/12/25 documents it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality and all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. R195's undated Diagnoses List, documents R195 is diagnosed with Cerebral Infarction due to unspecified occlusion or stenosis of Left Posterior Cerebral Artery, Metabolic Encephalopathy, Rhabdomyolysis, and Hemiplegia, unspecified affecting left nondominant…

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 a call light was in reach for two (R58, R345) of 32 residents reviewed for call lights out of a sample list of 48. Findings Include: The facility's Call Light: Accessibility and Timely Response policy revised 2/6/25 documents all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 1. R58's Minimum Data Set (MDS) dated [DATE] documents R58 is cognitively intact. The same MDS documents R58 needs partial/moderate assist of one staff member to transfer or ambulate. On 03/02/25 at 10:31 AM, R58 was sitting in his wheelchair in his own room. R58's untouched breakfast tray was in front of R58 on the bedside table with eggs, toast, oatmeal, and milk. R58's call light was attached to R58's bedrail on opposite side of the bed from where R58 was sitting. On 3/2/25 at 10:40 AM, R58 stated he hasn't eaten breakfast because his food is cold. R58…

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 review and accurately record physician's orders for life sustaining treatment for one (R30) of 32 residents reviewed for advance directives in the sample list of 48. Findings Include: The facility's Residents' Rights Regarding Treatment and Advance Directives policy dated 2/10/25 documents on admission the facility will determine if the resident has an advance directive, copies of the advance directive will be placed in the resident's chart and communicated to staff, and the facility will review advance directives with the resident or representative as part of the care planning process. On 3/02/25 at 12:22 PM R30 stated R30 has a Do Not Resuscitate order. R30's Minimum Data Set, dated [DATE] documents R30 as cognitively intact. R30's Hospital Discharge Orders dated 2/15/25 document R30's code status as full code. R30's active profile and physician's orders document R30's code status as full code. R30's Physician's Order for Life Sustaining…

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 bed that was comfortable and in working condition for one (R346) of 32 residents reviewed for environment on a sample list of 48 residents. Findings Include: R346's skilled nursing assessment documents that he is alert and oriented. R346's care plan dated 3/2/25 documents R346 requires assistance with bed mobility due to fracture, infection of the right femur, and a diagnosis of low back pain. On 3/5/25 at 8:35 AM, R346's was lying in bed on his back. The right side of the head of the bed was elevated approximately 30 degrees. The left side of the head of the bed was elevated approximately 20 degrees. R346 stated that his bed was broke and has been since 1:00 AM that morning. R346 stated he has been laying in the same position since 1:00 AM and he is uncomfortable. R346 stated that the staff called maintenance but nobody ever came in. R346 then picked up the remote to the bed and pushed multiple buttons on the remote but the bed did not move. At that time, V30 (Certified Nursing Assistant) entered…

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 it's abuse policy by failing to investigate and report an allegation of verbal abuse for one (R345) of 32 residents reviewed for abuse on the sample list of 48 residents. Findings Include: The facility's abuse policy with a revision of 2/11/25 documents the facility will prevent and prohibit abuse. This policy documents verbal abuse as a type of abuse. This policy documents the facility will notify the state agency within 24 hours of receiving an allegation of abuse. This policy documents that allegations of abuse will be immediately investigated. On 3/2/25 at 10:23 AM, R345 stated he was verbally abused by V26 Licensed Practical Nurse on 2/23/25. On 3/6/25 at 9:23 AM, V1 (Administrator) stated she received a phone call from V25 (R345's family member) stating that V26 was rude to R345 which upset R345. V1 stated she did not notify the state agency or begin an investigation until 3/3/25.

Based on interview and record review, the facility failed to notify the state agency of an allegation of verbal abuse for one (R345) of 32 residents reviewed for abuse on the sample list of of 48 residents. Findings Include: On 3/6/25 at 9:23 AM, V1 (Administrator) stated she received a phone call from V25 (R345's family member) stating that V26 Licensed Practical Nurse was rude to R345 and made R345 upset. V1 stated she did not notify the state agency until 3/3/25. The facility's report to the state agency dated 3/3/25 documents that the state agency was not notified regarding R345's allegation of verbal abuse by V26 until 3/3/25.

Based on interview and record review, the facility failed to immediately investigate an allegation of verbal abuse for one (R345) of 32 residents reviewed for abuse on the sample list of 48 residents Findings Include: On 3/6/25 at 9:23 AM, V1 (Administrator) stated she received a phone call from V25 (R345's family member) stating that V26 Licensed Practical Nurse was rude to R345 and made R345 very upset. V1 stated she did not investigate this as an allegation of abuse until 3/3/25. The facility's report to the state agency dated 3/3/25 documents that an investigation regarding R345's allegation of verbal abuse by V26 was initiated on 3/3/25.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to coordinate a Pre-admission Screening and Resident Review (PASARR) level II evaluation for one of two residents (R85) reviewed for PASARR II completion on the sample list of 48. Findings Include: R85's Clinical Census dated March 2025 documents R85 was admitted to the facility on [DATE]. R85's Medical Diagnoses List dated March 2025 documents R85 is diagnosed with Generalized Anxiety Disorder and Post Traumatic Stress Disorder. Both diagnoses have been in place since 10/5/16. R85's PASARR Level 1 dated 12/3/24 documents no Level II evaluation is required due to R85 not having any Significant Mental Illness (SMI) diagnosis. On 3/5/25 at 3:00 PM V2 Regional Interim Director of Nurses (DON) confirmed if R85 had a SMI diagnosis on admission or was later diagnosed with a SMI diagnoses the facility should coordinate a PASARR level II evaluation to be completed. R85's PASARR level I evaluation upon admission should have been reviewed for accuracy.

Based on interview and record review the facility failed to follow physician orders to obtain daily weights for one of two residents (R59) reviewed for weights on the sample list of 48. Findings Include: R59's Medical Diagnoses List dated March 2025 documents R59 is diagnosed with Chronic Diastolic Congestive Heart Failure and Chronic Kidney Disease Stage 4. R59's Physician Order Sheet (POS) dated March 2025 documents a physician order on 10/3/24 for daily weights, every day shift, notify the physician if there is a weight gain greater that three pounds in 24 hours or a weight gain greater than five pounds in seven days. R59's Care Plan dated 11/22/24 documents R59 is at risk for fluid volume overload related to Chronic Kidney Disease Stage 4. Interventions include to monitor/document and report any signs or symptoms of fluid overload including sudden weight gain. R59's Treatment Administration Record (TAR) for December 2024 documents 12 missed days for daily weights. R59's January 2025 TAR documents 11 missed days for daily weights with a 12.9 pound weight gain from 1/7/25 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 monitor risk of bleeding related to medication use for one (R15) of seven residents reviewed for unnecessary medications in the sample list of 48 residents. Findings Include: The facility's Anticoagulants High Risk Medications policy dated 2/10/25 documents risks associated with antiplatelet and anticoagulant use includes bleeding and hemorrhage, drop in hematocrit and blood pressure, and thromboembolism. This policy documents that resident's care plan should include interventions to minimize risk of adverse consequences. R15's Physician Order dated 2/19/25 documents administer Eliquis (anticoagulant) 2.5 milligrams (mg) by mouth twice daily. R15's Physician Order dated 2/20/25 documents administer Clopidogrel Bisulfate (antiplatelet) 75 mg by mouth daily. R15's medical record does not include physician orders to monitor for risk and signs of bleeding related to anticoagulant and antiplatelet use. R15's Care Plan dated 11/1/23 documents is at risk for bleeding and bruising related to Aspirin and Clopidogrel use, 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 sufficient Registered Nursing (RN) hours for six of fifty-five days reviewed for RN staffing. This failure has the potential to affect all 95 residents in the facility. Findings include: The facility Nursing Schedule (January 1, 2025 through February 24, 2025) documents on 1/3/25, 1/13/25, 1/17/25, 1/27/25, 1/31/25 and 2/11/25 the facility floor schedule assignment sheets did not document eight (8) hours of RN coverage for a 24 hour period. On 2/24/25 at 12:05pm, V1 Administrator confirmed the hours listed on the facility nursing schedule were correct and the facility failed to have eight (8) hours of RN coverage in a 24 hour period on 1/3/25, 1/13/25, 1/17/25, 1/27/25, 1/31/25 and 2/11/25. The facility Resident Midnight Census dated 2/24/25 documents 95 residents reside in the facility.

Based on interview and record review the facility failed to maintain an accurate facility assessment which is reviewed no less than annually and is updated as needed. This failure has the potential to affect all residents who reside in the facility. Findings Include: The facility census dated 2/6/25 documents 95 residents reside at the facility. The Facility Assessment does not document date or time the interdisciplinary team met to review the facility assessment or document it had been reviewed at least annually. The assessment does not address the direct care staff needed to meet the needs of the resident population by shift. On page ten of the assessment under the resident need Behavioral symptoms and cognitive performance the number recorded was zero. The facility's Matrix (CMS802) printed 2/6/25 at 9:40AM documents the facility has 29 residents diagnosed with Alzheimer's or Dementia. On 2/24/25 at 2:10PM V1, Administrator, verified the facility assessment was not accurate and provided a signature page with the date 12/20/24 separate from assessment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to answer call lights in a timely manner for two of three residents (R1, R2) reviewed for call light wait times in the sample of five. Findings Include: The facility's Call Lights: Accessibility and Timely Response policy dated 1/5/25 documents all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The facility Resident Council Meeting Minutes dated 1/27/25 document complaints of call lights taking 30 minutes or longer to be answered. Residents voiced that the staff often answer the call lights, turn the light off, say they will be back, but then never return to meet the resident's need. 1. R1's Medical Diagnoses List dated February 2025 documents R1 is diagnosed with Ischemic Heart Disease, Congestive Heart Failure, Type II Diabetes, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Asthma,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide safe transfers for two of three residents (R1, R2) reviewed for transfers in the sample of five. Findings Include: The facility's Safe Resident Handling/Transfers policy dated 12/15/24 documents all residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. Two staff members must be utilized when transferring residents with a mechanical lift. 1. R1's Medical Diagnoses List dated February 2025 documents R1 is diagnosed with Ischemic Heart Disease, Congestive Heart Failure, Type II Diabetes, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Asthma, Chronic Kidney Disease, Major Depression, Hypertension, Anxiety, Pain, Insomnia, and Obesity. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact and requires a wheelchair and is dependent on staff for transfers and Activities of Daily Living. On 2/6/25 at 2:30 PM R1 stated staff do…

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 rooms were clean. This failure affects six (R1, R2, R4, R5, R9, R10) of ten residents reviewed for housekeeping in the sample of ten. Findings include: 1.) On 9/10/24 at 9:36 AM, R10's garbage can was full. R10 stated R10's garbage can has not been emptied since yesterday. At 11:22 AM and 1:12 PM R10's garbage can remained full. At 1:12 PM, V6 Housekeeper stated V6 has not cleaned R10's room yet today. V6 stated V6 will empty the garbage can when V6 cleans the room. R10's Minimum Data Set (MDS) dated [DATE] documents R10 has a Brief Interview for Mental Status score of 12, the higher end of moderate cognitive impairment. 2.) On 9/10/24 at 9:40 AM, there was a medical glove on the floor behind the door and a pile of wet/used paper towels on the floor near the sink in R4's/R5's room. There were food particles, dirt, and two hairbrushes on the floor under R5's bed. R4 stated the paper towels have been there since last night…

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 and interview the facility failed to ensure a sink was properly secured to the wall for one (R4) of three residents reviewed for a safe, clean, and homelike environment on the sample list of nine. Findings Include: On 8/28/2024 at 10:30 AM, R4 was sitting in a recliner with a cabinet type sink directly to R4's left side. The sink top was not secured to the cabinet base, with the left side of the sink hanging off of the cabinet approximately 1 inch and the entire sink top not secured to the wall with an approximate one inch gap from the back of sink to wall. The sink was unstable and wobbled when touched. At this time, R4 stated R4 never grabs onto the sink from R4's recliner because it is too unsteady. R4 stated a maintenance man was here 2-3 weeks ago and said it needs resealed and then never resealed it. On 8/28/2024 at 10:39 AM, V13 CNA (Certified Nurses Assistant) confirmed that the sink in R4's room was unsteady and stated it had been reported. On 8/29/2024 at 9:30 AM, V11 Corporate Maintenance, confirmed that R3's sink was unsteady due to not being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement a call light intervention for a resident with a recent fall. This failure affected one of three residents (R6) reviewed for falls on the sample list of nine. Findings include: R6's current diagnoses sheet documents the following diagnosis: Muscle Weakness (generalized) and Alzheimers' Disease Unspecified. R6's Fall Risk Assessments dated 7/25/24 documents R6 is at moderate risk (25 to 44 points) of falls score 30. R6's Fall Risk Evaluation dated 8/21/2024 at 11:22 pm documents: Fall Risk: History of falls (past 3 months): 3 or more falls in past 3 months. R6's Minimum Data Set, dated [DATE] documents the following:BIMS 4/15. No impairment upper or lower extremities. Uses a wheelchair for assistive mobility device. R6's Care Plan updated 8/21/24 documents the following: (R6) is at risk for falls r/t (related to) Incontinence and Weakness [Falls] Fall interventions include: (On) 7/25/24 floor mat placed next to bed in low position…

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

Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on five of fourteen days reviewed for RN staffing. This failure has the potential to affect all 92 residents in the facility. Findings include: The facility Nursing Schedule (July 24, 2024 through August 6, 2024) document on 7/27/24, 7/29/24, 8/1/24, 8/3/24 and 8/4/24, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 8/7/24 at 1:45pm, V1 Administrator confirmed the hours listed on the facility nursing schedule were correct and the facility failed to have RN coverage on 7/27/24, 7/29/24, 8/1/24, 8/3/24 and 8/4/24. The facility Resident Midnight Census dated 8/7/24 documents 92 residents reside in the facility.

Based on interview and record review the facility failed to ensure call lights were answered in a timely manner and was within reach for residents. This failure affects three of four residents (R2, R3, R6) reviewed for call lights on the sample list of six. Findings Include: Call lights: Accessibility and Timely Response Policy dated 8/1/2019 on line 9 states process for responding to call lights: A. Response times should be a Priority. 1. R2's admission Record dated 1/18/24 documents R2 is diagnosed with Abnormalities Of Gait And Mobility, Gout, and Morbid (Severe) Obesity. R2's Care Plan dated 03/11/2024 documents R2 is dependent on staff for physical needs and is at risk for falls. The Care Plan documents staff should encourage the resident to use bell to call for assistance. On 8/6/24 at 2:09 PM, R2 states that he uses the call light but staff don't always come very quickly, and he will have to wait a long time to be changed. 2. R3's admission Record dated 7/16/24 documents R3 is diagnosed with Fracture Of Head And Neck Of Left Femur, Abnormalities Of Gait And Mobility, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review the facility failed to follow their narcotic destruction policy for one (R4) of four residents reviewed for medication errors out of a sample of six residents. Findings include: The facility policy Destruction of Unused Drugs dated 6/1/24 documents The actual destruction of drugs conducted by our facility must be witnessed by two nurses. R4's Health Status note written by V11 Licensed Practical Nurse documents on 8/2/2024 at 4:13 PM that, Writer made aware of resident he's been transferred to hospital for hypotension and upon arrival it was observed that resident had on two fentanyl patches and received Narcan and is currently in the Intensive Care Unit (ICU). On 8/6/24 at 2:05 PM, V11 (Licensed Practical Nurse) stated on 8/2/24 at approximately 3:00 PM, I received a call from the Hospital stating that R4 was sent to the ER from Dialysis and the ER found 2 Fentanyl patches on R4, which were removed and Narcan was given. V11 stated she cared for R4 on 8/2/24 prior to R4…

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 patient representative of an X-ray result for one of three residents (R1) reviewed for notification of changes in the sample list of six. Findings include: The facility's Notification of Changes policy with a Revised date of 12/13/23 documents, the purpose of this policy is to ensure the facility promptly informs the resident, consults the residents physician; and notifies, consistent with his or her authority, the residents representative when there is a change requiring notification. R1's progress note dated and timed 7/1/2024 at 11:15 AM states R1 complained of pain in the left foot and V4 LPN (Licensed Practical Nurse), notified the physician and an X-ray of R1's left foot was ordered. On 7/10/24 at 12:32 PM, V3, R1's Family, stated that the facility has not called V3 with the results of the left foot X-ray that was completed on 7/2/24. On 7/11/24 at 09:06 AM, V2 Director of Nursing confirmed that the X-ray result was received by the facility and the physician was notified on 7/3/24. V2, Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement a fall prevention intervention for one of three residents (R2) reviewed for falls in the sample list of six. Findings include: The facility's Fall Prevention policy with a Revised date of 1/24/23 documents, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The nurse will indicate on the (Fall Risk Assessment) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. R2's Care Plan printed on 7/10/24 documents diagnoses including History of Falling, Urinary Tract Infection, Dementia, Wedge Compression Fracture of T11-T12 Vertebra, Wedge Compression Fracture of First Lumbar Vertebra, Abnormalities of Gait and Mobility and Muscle Weakness. R2's Care Plan with an initiated date of 5/19/24 documents R2 was at Moderate risk for falls related 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the dignity of two residents (R1, R2) by not providing timely incontinence care out of three residents reviewed for incontinence cares in a sample list of five residents. Findings include: The facility Resident Council Minutes dated April 11, 2024 documents Residents voiced that they are being left on bed pans for a long periods of time on second shift. Residents voiced that Certified Nurse Aides (CNA) still turning off call lights without seeing what their needs are. The facility Resident Council Minutes dated 5/21/24 documents Residents voiced complaints the call lights are not getting answered throughout the day. The facility Resident Council Minutes dated 6/20/24 documents Residents voiced that call lights are not being answered in a timely manner. Residents voiced that it takes 45 minutes to an hour for call lights to be answered. 1.) R1's undated Face Sheet documents R1's medical diagnoses as Cerebral Infarction, Hemiplegia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their Abuse Prevention Policy by not immediately suspending a staff member accused of abuse of one (R1) resident out of one resident reviewed for abuse in a sample list of five residents. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1's Physician Order Sheet (POS) dated June 2024 documents a physician order for Duloxetine 25 milligrams (mg). Give two tablets every morning. On 6/27/24 at 4:38 PM, V5 Licensed Practical Nurse (LPN) was assisting residents in the hallway. V5 LPN actively working in facility as a nurse assisting residents and directing staff in coordination of cares. On 6/28/24 at 8:10 AM, V5 Licensed Practical Nurse (LPN) was passing medications to residents on R1's hallway. On 6/28/24 at 8:30 AM, V5 Licensed Practical Nurse (LPN) administered medication to R1 in R1's room. On 6/27/24 at 3:40 PM, R1 stated V5 Licensed Practical Nurse (LPN) would not administer 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain resident equipment in safe functioning order for one (R1) resident out of three residents reviewed for Physical Environment in a sample list of five residents. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. On 6/27/24 at 3:30 PM, R1 was laying in R1's bed in her room. R1's bed cord had several areas that were wrapped in black electrical tape. On 6/27/24 at 3:40 PM, R1 stated V16 Physical Therapy Assistant (PTA) was working with R1 for therapy in R1's room on 6/21/24. R1 stated We (R1, V16) both heard this loud pop sound and saw a spark. It scared us both. (V16) jumped and said 'that shouldn't happen'. (V16) PTA left me to go get someone to look at my cords. I saw a spark and heard a loud pop sound. Then I smelled something like it was on fire. I was pretty scared until they (facility) got it fixed. On 6/27/24 at 4:30 PM, V16 Physical Therapy Assistant (PTA) stated I was working 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 record review and interview the facility failed to maintain accurate and complete medical records by failing to transcribe a physician order for blood glucose monitoring, and failed repeatedly to document the blood glucose measurement in R12's medical record. R12 is one of three residents review for blood glucose monitoring on the sample list of 13. Findings include: R12's Diagnosis List dated 5/6/24 documents the following diagnosis: Diabetes Mellitus, Due to Underlying Condition With Ketoacidosis, Without Coma. R12's Minimum Data Set (MDS) dated [DATE] documents R12's Brief Interview of Mental Status score as 15 out of a possible 15, which indicates no cognitive impairment. R12's same MDS documents R12 had received insulin injections, every day for the past seven days, of the look back period for this assessment. R12's Physician Visit Summary dated 5/14/24 signed by V25, Physician documents the following order: Testing Strips: Use to check blood sugar three times daily. May use any testing supplies…

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 incontinence care in a timely manner to maintain residents dignity, for one of three residents (R13) reviewed dignity/call lights on the sample list of 13. Findings include: R13's Diagnoses List updated 5/16/24 documents the following diagnoses: Cerebral Infarction Due to Unspecified Occlusion Stenosis of Right Anterior Cerebral Artery, Hemiplegia and Hemipareses Following Cerebral Infarction, Affecting Left Non-dominant Side, and Major Depressive Disorder, Single Episode, Unspecified. R13's Minimum Data Set (MDS) dated [DATE] document the following: Brief Interview of Mental Status (BIMS) score as 13 out of a possible 15, indicating no cognitive impairment. The same MDS documents R13 is always incontinent of bladder and frequently incontinent of bowel and has a history of pressure ulcer. R13's BIMS updated 6/14/24 documents score as 15 out of a possible 15, indicating, no cognitive impairment. R13's Care Plan dated 5/23/24…

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

Based on interview and record review the facility failed to follow Physician's Order for blood glucose monitoring and document blood glucose results for one of three residents (R1) reviewed for following physician's orders in the sample list of 13. Findings include: The facility's Medication Administration policy with a Reviewed/Revised date of 1/4/24 documents, Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Administer medication as ordered in accordance with manufacturer specifications. R1's Order Summary Sheet dated 6/18/24 documents a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. This Order Summary documents an order to complete accuchecks every morning and every evening at bedtime with a start date of 6/3/24. R1's Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated 6/20/24 documents R1's blood glucose levels were not recorded on the MAR/TAR from 6/3/24 through 6/17/24. R1's Nurses Progress Notes document blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed repeatedly to implement fall interventions for two of four residents (R2 and R3), reviewed for falls/interventions on the sample list of 13. Findings include: 1.) R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status (BIMS) score of nine, out of a possible 15, indicating moderate cognitive impairment. R2's Interdisciplinary Team (IDT) note dated 5/28/2024 at 1:31 pm documents the following: Time of fall: 09:28 am. Date of fall: 5/25/2024. Activity at time of fall: Resident was sitting up in wheelchair, self-propelling around facility. Location of fall and position found: Resident was observed lying on the floor on her left side up against the wall of the front hallway near receptionist's desk. Witnessed or Unwitnessed: unwitnessed. Description of fall: Resident stated 'I was trying to stand up and grab onto the rail, I fell.' Description of injuries/pain (if applicable including measurements): 1.5 cm (…

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 assistance with morning care in a timely manner, to maintain resident's dignity, for one of thirteen residents (R9) reviewed dignity/call lights on the sample list of 13. Findings include: R9's Minimum Data Set, dated [DATE] documents R9's Brief Interview of Mental status score as 15 out of a possible 15, indicating no cognitive impairment. R9's Care Plan dated 4/02/24 documents the following: (R9) is Moderate risk for falls related to gait/balance problems, and incontinence. The same care plan documents: Anticipate and meet the resident's needs and be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The facility Daily Assignments sheet dated 5/31/24 documents V18, Certified Nursing Assistant (CNA) called off for 6:00 am - 2:00 pm shift. V19's CNA Time Card Report dated 5/31/24 documents V19, clocked into…

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 document grievance resolution plan/ report resolution to resident/resident council. This failure has the potential to affect all residents who reside at the facility. Findings Include: The facility's Long Term Care Application for Medicare and Medicaid documents the Census as 84. The facility's policy Resident/Family Grievance Policy and Procedure revised 12/6/23 states In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written conclusion will include at minimum: The date the grievance was received. The steps taken to investigate the grievance. A summary of pertinent findings. A statement as to whether or not a grievance was confirmed or not confirmed. Any corrective action taken or to be taken by the facility as a result of the grievance. The date the written decision was issued. The facility's Resident Council grievance form…

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

Based on interview and record review the facility failed to ensure the required members attended quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure has the potential to affect all 84 residents residing in the facility. Findings include: The Long Term Care Application for Medicare and Medicaid dated 4/24/24 documents 84 residents in the building. The facility Quality Assurance Performance Improvement Plan dated 2/26/24 documents that the Quality Team meets quarterly. The team members required at this meeting are the Administrator, Director of Nursing, Medical Director, Regional Nurse, Regional Operations, Dietary Manager, Assistant Director of Nursing/Infection Preventionist, Assistant Director of Nursing/Wound Nurse and the Teligen Consultant. The facility provided sign in sheets for quality meetings held on 8/25/23, 10/27/23, 2/14/24 and 4/10/24. The Medical Director was not signed in or present at the 8/25/23 or 2/14/24 meetings. On 4/23/24 at 3:00 PM, V1 Administrator said that the Medical Director is supposed to attend all quarterly quality…

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 treat residents with dignity while providing cares by being on their cell phones during cares, not pulling outside curtains prior to starting personal care, standing while providing dining assistance and failing to serve all residents at the dining table at the same time for seven of 18 residents (R7, R39, R44, R61, R63, R68, and R234) reviewed for dignity on the sample list of 50. Findings Include: The facility Promoting/Maintaining Resident Dignity Policy dated 12/5/23 documents it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. During actions with residents, staff must report, document and act upon information regarding resident…

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

Based on observation, interview and record review, the facility failed to complete residents' psychotropic medication assessments, ensure justification for use of psychotropic medications, identify targeted behaviors, monitor behaviors, and develop and implement non-pharmacological interventions to assist residents with behavior management. These failures affect four of five residents (R5, R37, R68, and R287) reviewed for unnecessary medications on the sample list of 50. Findings Include: The facility's Use of Psychotropic Medication Policy dated 9/27/23 documents resident are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants,…

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 and interview, the facility failed to ensure palatability of food and follow their menu for pureed food for 6 of 18 residents (R6, R18, R23, R36, R50, and R68) reviewed for food palatability on the sample list of 50. Findings Include: 1) On 4/21/24 at 10:22 AM, R68 was eating breakfast in R68's room and stated, R68 had just received her breakfast tray about 10 minutes ago. R68 stated the scrambled eggs were cold, and the sausage patty was as hard as asphalt. The sausage patty was dark brown and appeared very dry. R68 attempted to cut the sausage patty and was not able to. R68 also stated, the food is always late so it's cold. On 4/23/24 at 12:50 PM, a test tray was delivered to the surveyor after all trays on R68's hall cart, which included lunch trays for R6, R18, R23, R36, R50 and R68) were delivered. The lunch consisted of Pork, corn casserole, beans and a fruit/marshmallow salad. All food temperatures were checked in Fahrenheit and was: pork -127.2 degrees, corn casserole - 127 degrees, beans - 130 degrees and fruit/marshmallow salad - 70.8 degrees. 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 utilize isolation for clostridium dificile, failed to utilize enhanced barrier precautions for residents who and failed to monitor high risk water sources for the presence of Legionella. These failures affect six residents (R65, R38, R187, R45, R62, R39) and have the the potential to affect all 84 residents who reside in the facility. FIndings Include: The Long Term Care Application for Medicare and Medicaid dated 4/24/24 documents 84 residents in the building. 1) The facility's Water Management Program dated 12/26/23 documents it is the policy of this facility to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens (Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, Nontuberculous Mycobacteria, and Fungi) in the facility's water systems. A water management team has been established to develop and implement the facility's water management program, including facility leadership, 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 assess for safe self administration of medication for one of one resident (R287) reviewed for self administration of medication in the sample list of 50. Findings include: The facility's Resident Self-Administration of Medication policy with a revised date of 1/4/24 documents, A resident may only self-administer medication after the facility's interdisciplinary team has determined which medication may be self-administered safely. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff. The resident's ability to ensure that medication is stored safely and securely. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. On 4/21/24 at 9:24 AM, R287 was in her room sitting on the bed. There was an inhaler sitting on her bedside table. It was an Albuterol sulfate HFA inhaler. she says…

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 record a resident's preference for life-sustaining treatment in the medical record for 1 of 24 residents (R41) reviewed for advance directives in the sample list of 50. Findings include: The facility's Residents' Rights Regarding Treatment and Advance Directives policy with a revised date of [DATE] documents, It is the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. R41's face sheet documents admission to the facility on [DATE]. R41's signed Physician's Order for Life Sustaining Treatment (POLST)…

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 notify the Ombudsman, resident and resident representative, in writing, about a hospital transfer for two of two residents (R61, R83) reviewed for hospitalizations on the sample list of 50. Findings Include: 1) R61's ongoing Census documents R61 was hospitalized from [DATE] - 10/13/23. R61's medical record does not document that R61, V20 (R61's resident representative), or the Ombudsman was notified in writing of R61 being sent and admitted to the hospital. On 4/21/24 at 12:27 PM, V20 stated that when R61 was sent to the hospital in October or November 2023, the facility called V20 to report the transfer but did not send V20 anything in writing. 2.) R83's progress notes document admission to the facility on 1/15/24. R83's progress notes document discharge to the hospital on 2/29/24. R83's medical record does not document a written notification of transfer to the ombudsman or that family was provided written notification. On 4/22/24 at 12:07 PM, V1…

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 a bed hold policy to the resident and/or resident representative for two of two residents (R61, R83) reviewed for bed holds on the sample list of 50. Findings Include: The facility Bed Hold Notice Upon Transfer Policy dated 12/23/22 documents at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. 1) R61's ongoing Census documents R61 was hospitalized from [DATE] - 10/13/23. R61's medical record does not document that R61 and/or V20 (R61's resident representative) were provided a bed hold policy nor is there a copy of the bed hold policy in R61's medical record. On 4/21/24 at 12:27 PM, V20 stated that when R61 was sent to the hospital in October or November 2023, the facility did not provide V20 with a…

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

Based on interview and record review, the facility failed to insure that a Preadmission Screening and Resident Review (PASARR) level II screening was completed for one (R57) of one residents reviewed for PASARR level II screenings, from a total sample list of 50 residents reviewed. Findings Include: R57's level I PASARR dated 10/22/21 documents that a level II PASARR is not required. R57's diagnosis sheet dated 8/28/23 documents a diagnoses of Schizoaffective Disorder. R57's progress notes dated 1/10/24 document that R57 is seeing psychiatry for mental health issues. On 4/22/24 at 11:45AM V1 Administrator said that a level two was initiated but not completed. We should have followed up on it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop a baseline care plan for 1 of 24 residents (R39) reviewed for baseline care plans in the sample list of 50. Findings include: The facility's Baseline Care Plan policy with a revised date of 12/6/23 documents, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. R39's Order Summary Report dated 4/23/24 documents R39 was admitted on [DATE] with diagnoses including Vitamin D…

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 assistance with shaving for one resident (R187) of two residents reviewed for ADL (Activities of Daily Living) assistance in a sample list of 50. Findings Include: The facility's policy Activities of Daily Living (ADLs) revised 12/5/23 states A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and person oral hygiene. R187's Minimum Data Set (MDS) dated [DATE] documents R187 was cognitively in tact and required partial to moderate assistance with ADLs. On 04/21/24 at 02:53 PM, R187 was observed in her bed. R187's arms were very edematous from the shoulders to the finger tips. R187 had long unkept chin whiskers. When asked R187 if R187 would like to be shaved R187 stated YES, YES, YES! R187 stated My arms are so swollen I can't do that myself and it embarrasses me. On 4/23/24 at 8:00 AM, V9 Licensed Practical Nurse (LPN) stated of coarse any…

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 prevent potential cross contamination during wound treatment, failed to complete a skin risk assessment on admission, and failed to complete wound treatments as ordered, for one of four residents (R39) reviewed for pressure ulcers in the sample list of 50. Findings include: The facility's Pressure Injury Prevention and Management policy with a revised date of 12/6/23 documents, The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as 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 provide securement for urinary catheter tubing, failed to provide catheter care/perineal care per the facility policy, and failed complete catheter care daily for two (R62 and R37) of three residents reviewed for urinary catheters from a total sample of 50. Findings include; 1.) The facility provided Catheter Care Policy dated 1/24/24 documents that catheter care will be performed every shift and as needed by nursing personnel and that the catheter care will include both washing and drying of perineal area. R62's undated diagnosis sheet documents the following diagnoses including: Hemiplegia, Hemiparesis following a Cerebral Infarction, Polyneuropathy, Type II Diabetes Mellitus, Obstructive and Reflex Uropathy, Placement of Urogenital Stents, Major Depression and Atherosclerosis. R62's physician order dated 3/9/24 documents an order for an indwelling urinary catheter. R62's physician order dated 3/9/24 documents an order for a catheter securement device that is to be changed weekly. On 4/23/24 at 1:00 PM, R62's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to intervene following a significant weight loss for one resident (R66) of four residents reviewed for nutrition in a sample list of 50. Findings Include: R66's Care Plan updated 3/26/24 includes the following diagnoses: Sepsis, Falls, Recent Myocardial Infarction, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. R66's Minimum Data Set (MDS) dated [DATE] documents R66 is cognitively intact. R66's Progress Note dated 4/17/24 at 9:13 PM documents noted to have an open area to midspine. On 4/21/24 at 12:30 PM, R66 stated You can't get a substitute if you don't like the food. I lost 13 pounds. I don't always care for the food here. One night for Supper I asked for a cheese burger since it is on the alternate menu. It was after 9:00PM when I finally got a cold greasy grilled cheese wrapped in foil. I ate it because I was hungry but it wasn't a cheese burger and it wasn't good. R66's weight flow sheet printed 4/24/24 at 3:55PM…

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 physician orders for weekly weights and enteral nutrition, document the amount of enteral feeding administered to the resident, ensure open enteral feedings were disposed of after 24 hours, and change enteral feeding supplies daily for one of three residents (R65) reviewed for enteral nutrition on the sample list of 50. Findings Include: The facility Care and Treatment of Feeding Tubes Policy dated 12/19/23 documents feeding tubes will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Feeding Tubes will also be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. Ensure the product has not exceeded the expiration date. R65's April 2024 Physician Orders document the following orders: 12/27/23 - Enteral Feed of Jevity 1.2 75 ml (milliliters) per hour for 20 hours; start at 6 pm, and stop 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 record review and interview, the facility failed to ensure ongoing communication and assessments with the dialysis center for one of two residents (R36) reviewed for dialysis on the sample list of 50. Findings Include: The facility Special Needs - Dialysis Policy dated 12/14/23 documents the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive care plan and the resident's goals and preferences, to meet the special medical, nursing mental and psychosocial needs of residents receiving dialysis. Nursing staff will provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day, and as needed. If no written report is received upon return from dialysis, nursing staff will call the dialysis provider to receive a report. R36's MDS (Minimum Data Set) dated 1/9/24 documents R36 is alert and oriented and receives dialysis. R36's April 2024 Physician Orders document an order to monitor dialysis access site every shift and monitor…

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 view, the facility failed to offer and/or administer the influenza and pneumococcal vaccine to one of five residents (R61) reviewed for vaccinations on the sample list of 50. Findings Include: R61's ongoing Census documents R61 was admitted to the facility on [DATE] and is 88years old. R61's Medical Record does not contain any consents or declination for the influenza or pneumococcal vaccination, or a listing of vaccinations received prior to admission. On 4/23/24 at 2:32 pm, V18 Infection Preventionist provided immunization consents dated 4/23/24 that documents R18 would like both the influenza and pneumococcal vaccination. V18 explained V18 was not able to find the consents from the time of admission so V18 had R61 sign them today. V18 stated V18 would administer the pneumococcal vaccination as requested but isn't able to administer the influenza vaccination because it is past the time to give it now. The facility's Influenza Vaccination Policy dated 10/20/22 documents it is the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer and administer the COVID-19 immunization for one of five residents (R61) reviewed for vaccinations on the sample list of 50. Findings Include: R61's ongoing Census documents R61 was admitted to the facility on [DATE] and is 88years old. R61's Medical Record does not contain any consents or declination for the COVID-19 immunization. or a listing of historical immunizations that R61 had prior to admission. On 4/23/24 at 2:32 pm, V18 Infection Preventionist provided an immunization consent for the COVID-19 immunization dated 4/23/24 that documents R18 would like to receive the COVID-19 immunization. V18 explained V18 was not able to find the original consent from the time of admission so V18 had R61 sign it today. V18 stated the contract company that does the COVID-19 immunizations for the facility was last at the facility in January 2024 and had V18 known R61's request to receive the immunization, R61 could have been administered at that time but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to investigate a fracture of unknown origin for a resident. This failure affects one resident (R3) of three residents reviewed for accidents in a sample list of four. Findings include: R3's Incident report dated 11/17/23 at 3:57 PM, documents (R3) was seen by the Wound Medical Doctor on 11/16/23 due to wound to rule out osteomylitis. X-ray was done on 11/17/23. Type of injury: Acute fracture to lateral malleolus. Medical Doctor and Power of Attorney Notified New order for (R3) to be nonweight bearing on left leg, Orthopedic referral and Tramadol 50 milligrams every six hours as needed. R3's Care Plan reviewed 12/6/23 documents the following diagnoses: History of Falls, Anxiety, Type II Diabetes, Morbid Obesity, Neuropathy, Chronic Kidney Disease Stage III, Chronic Ulcers of the Buttocks. R3's Minimum Data Set, dated [DATE] documents R3 is cognitively in tact Requires staff assistance for transfer and uses a wheelchair for mobility. On 1/29/24 at 155 PM, R3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess resident, monitor fluid restriction, and monitor weight during a residents stay at the facility from 6/8/23 through 7/3/23 for a resident with congestive heart failure. The facility also failed to arrange for the residents cardiology follow-up and testing. These failures affect one resident (R18) of three residents reviewed for death in a sample list of 18 residents. Findings include: R18's Care Plan created 6/8/23 includes the following diagnoses: Congestive Heart Failure, Type II Diabetes, Peripheral Artery Disease, Status Post Left Above the Knee Amputation, Chronic Diabetic wounds. This Care Plan also documents R18 chooses to be fully resuscitated in the event her heart stops or she quits breathing. R18's Minimum Data Set (MDS) dated [DATE] documents R18 is cognitively intact. R18's Hospital Patient Discharge Plan dated 6/8/23 documents Discharge Follow-up Appointments: (V18, Cardiologist) Call office for appointment in 5-7 days. Cardiology…

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.