Loft Rehab Of Rock Springs, The

Based on observation, interview, and record review, facility staff failed to verify proper gastrostomy tube placement by checking for gastric residual before administering medications for one of two residents (R6) reviewed for gastrostomy tubes in a sample of 42. On 5/4/2026 at 3:18 PM V15, LPN (Licensed Practical Nurse) administered medications to R6 via gastrostomy tube (g-tube). Medications administered were Gabapentin capsule 100 mg (milligram) one capsule and Docusate Sodium 100 mg 1 tablet. R6 was to receive 30 cc (cubic centimeter) of water flush before and after administering medication. V15 inserted the syringe with 30cc of water into R6's gastrostomy tube, pushed the water into the g-tube removed the syringe placed the prepared medications into the syringe and re-inserted into the gastrostomy tube and administered the medications. V15 then drew up 30cc of water and flushed the gastrostomy tube per physician's order. V15 failed to check for placement of the gastrostomy tube before administering the first 30cc of water into the gastrostomy tube by checking to see if R6 had…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's call light was maintained in good working order. This failure affects one (R14) of 32 residents reviewed for call lights on a sample list of 42 residents. Findings include:On 5/3/26 at 9:45 a.m., R14 stated R14's call light is not functioning properly. R14 stated they have to hold down the button (on the call light) to get it to turn on. R14 stated although maintenance came to look at it and the light would turn on outside the door, it did not alert at the nurses' station.On 5/5/26 at 9:29 a.m., R14 was lying in bed and this surveyor asked R14 to press the call light. The light above R14's door failed to illuminate when the call light was activated. At this same time, V9 (Certified Nursing Assistant) was in the room and stated they would report the issue to the Maintenance Director. V9 stated not all call lights alert at the nurses' station. R14 stated, It hasn't worked for a while now. They [maintenance] came and looked at it before and nothing changed. I end up having to yell out, or it…

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

Based on interview and record review, the facility failed to ensure a resident received the correct medication in accordance with their physician orders, one (R3) of four residents reviewed for medication administration, in a sample of 14 residents.Findings include:On 4/14/2026 at 2:12 PM, V6 Licensed Practical Nurse (LPN), stated R3 got R3's scheduled medication and one of R3's roommate's pills. V6 LPN stated V6 left R3's and R3's roommates' medication at the bedside and walked out to get R3 a glass of water and when V6 came back, R3 took all R3's roommates' medication. V6 stated everyone was notified, and R3's doctor wanted R3 to stay one more day at the facility before going to the new facility.On 4/15/2026 at 10:45 AM, V6 LPN stated medications are not left at the resident's bedside.On 4/15/2026 at 10:35 AM, V16 LPN stated medications are not to be left at the resident's bedside.On 4/15/2026 at 10:40 AM, V13 LPN stated medications are not left at the resident's bedside.On 4/15/2026 at 2:45 PM, V2 Director of Nurses, stated V2 would expect nurses not to leave medications at a…

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

Based on observation, interview and record review the facility failed to maintain a clean environment for one (R4) of five residents reviewed for housekeeping on the sample list of seven.Findings include:R4's undated census report documents an admission date of 4/9/2016. The same report documents R4's diagnoses as Personal History of Covid-19, Age-Related Nuclear Cataract, Homonymous Bilateral Field Defects, Right Side, Cerebral Infarction, Hyperlipidemia, Essential (Primary) Hypertension, Major Depressive Disorder, Single Episode, Bipolar Disorder, Current Episode Manic Without Psychotic Features, Moderate, Anxiety Disorder, Vitamin Deficiency, Intermittent Explosive Disorder, Nicotine Dependence, Alcohol Abuse, and Obsessive-Compulsive Disorder.On 03/09/26 at 10:45AM R4's room contained a black bookcase shelving unit which contained model cars that were covered in dust. The shelves were also covered with dust. The windowsill had cobwebs/dust from the plant containers to the windowsill as well as cobwebs surrounding a decorative light in the windowsill.On 03/09/26 at 10:45AM 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of three residents (R6 and R7) reviewed for abuse in the sample of three.On 12/23/2025 at 1:15 PM V1, Administrator, provided an investigation file documenting a physical altercation between R6 and R7. The Abuse Investigation file dated 8/8/25 documents a physical altercation between R6 and R7. The file documents R6's statement of the incident involving R7 stating that R6 was grabbed and punched by R7 in the left arm. It documents R6 returned a punch hitting R7.On 12/23/2025 R6's care plan review documents R6's admission to the facility on [DATE] with the following diagnoses: End Stage Renal Disease, Chronic Diastolic (Congestive) Heart Failure, Type Two Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, and Stage Five Chronic Kidney Disease.On 12/23/2025 at 11:02 AM R6 stated she had a physical altercation a few…

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 an environment that was clean and free from environmental hazards for thirteen (R1, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19) of nineteen residents reviewed for Physical Plant Problems on a sample list of nineteen. Findings include:On 9/29/25 at 9:45 AM, R1's room where R1 resided during her stay at the facility was observed to have a ceiling in disrepair with evidence of a raised black substance with the appearance of mold present near a dirty sprinkler head. The toilet in the bathroom had a dark ring in the bowl and a dirty vent on the ceiling. On 9/30/2025 between 3:05 PM and 3:40 PM a tour of the resident rooms on the fourth floor was completed with V9 (Maintenance Director). V9 confirmed the ceiling tiles in rooms where R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, and R19 currently reside contained a raised black substance growing on them and it had the appearance of mold.On 9/29/25 at 9:10 AM, R1 stated there were ceiling tiles missing, paint chipping, and a black…

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 pressure relieving interventions and re-evaluate the effectiveness of a pressure ulcer treatment when the wound did not improve for one of three residents (R2) reviewed for pressure ulcers in the sample of five. Findings include: The facility's Pressure Injury Prevention and Management policy revised 2/10/2025 documents, the facility is committed to the prevention of avoidable pressure injuries, and to provide treatment and services to heal pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The same policy documents the facility will monitor interventions and revise as appropriate. R2's admission Record documents R2 was admitted to the facility on [DATE] after sustaining a fall at home and developing Rhabdomyolysis. R2's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] (Admission) documents R2 is at risk of developing a pressure ulcer due to limited mobility.…

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 utensils, dishes, and cookware were sanitized prior to serving foods to residents, failed to prevent cross contamination of foods from staff clothing during meal service, and failed to maintain a cooking environment free from debris. This failure has the potential to affect 107 residents residing in the facility. Findings include: The Daily Resident Roster dated 3/23/25 documents 107 reside in the facility. On 3/24/25 at 11:15 AM V29 [NAME] plated resident meals and then passed the plates of food across the food line to the dietary aides. V29's shirt grazed the food in the warmer trays several times when V29 would lean over to pass the plated meal to the dietary aides. On 3/24/25 at 11:30 AM the wall behind and above the food prep area, cooking and fry area had two areas approximately one foot wide and long of peeling paint that was hanging from the wall. These same areas had several pieces of debris that fell into the fryer oil and on top of the food prep area. On 3/24/25 at 11:45 AM V27 [NAME] tested…

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 hold one quarterly Quality Assurance Performance Improvement (QAPI) meeting for the 2024 year and failed to include the facility's Infection Preventionist in all QAPI meetings. This failure has the potential to affect all 107 residents in the facility. Findings include: The facility QAPI sign in sheets dated 2/4/25, 7/12/24 and 4/5/24 does not include an Infection Preventionist documented as attending the QAPI quarterly meeting. The facility is unable to provide documentation of a QAPI meeting being completed for the third quarter (July, August, September) of 2024. On 3/25/25 at 4:00 PM V1 Administrator stated the QAPI meeting is supposed to happen at least quarterly and include the Infection Preventionist. V1 stated she was unable to find any documentation of the facility having a third quarter QAPI meeting for 2024.

Based on observation, interview, and record review the facility failed to complete a risk assessment plan for Legionella and failed to prevent cross contamination during medication administration. These failures have the potential to affect all 107 residents who reside in the facility. Findings include: The Long Term Care Facility Application for Medicare and Medicaid dated 3/23/25 documents 107 residents reside in the facility. 1.) The facility provided water management program dated 2/1/25 documents it is the policy of this facility to establish water management plans of reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. The facility's Maintenance Director maintains documentation that describes the facility's water system, and a risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The risk assessment will consider the following elements: Premise plumbing, clinical equipment, at-risk…

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

Based on observation, interview and record review the facility failed to employ an Infection Preventionist (IP). This failure has the potential to affect all 107 residents residing in the facility. Findings include: The facility Daily Census dated 3/23/25 documents 107 residents reside in the facility. The Facility Assessment updated 3/17/25 documents the facility resources will include an Infection Preventionist. On 3/23/25-3/26/25 at various times there was no Infection Preventionist on site during the survey timeframe. On 3/25/25 at 4:00 PM V1 Administrator stated the facility does not have anyone in the Infection Preventionist role. On 3/25/25 at 4:05 PM V2 Director of Nurses (DON) stated V2 DON and V20 Regional Director of Clinical Services are both managing the Infection Control Program and neither V2 nor V20 have their IP certificate. V2 DON stated the facility has hired a new IP who will start April 1, 2025 but has not had anyone in the IP role since December 2024.

Based on observation, interview and record review the facility failed to provide clean and debris free heaters and a clean and hole free privacy curtain for five (R7, R17, R20, R36 and R41) of five residents reviewed for a clean, homelike environment from a total sample list of 35 residents. Findings include: The facility Resident Rights policy dated 2/12/25 documents that the resident has a right to a safe, clean, comfortable and homelike environment. 1.) On 3/23/25 at 10:39 AM, R41's resident room heater was dirty with chipping paint. On 3/23/25 at 10:40 AM, R41 stated that she would like her heater to be cleaned. 2.) On 3/23/25 at 10:51 AM, R17's resident room heater was dirty and had paint chipping off of it. On 3/23/25 at 10:52 AM, R17 stated, My heater needs to be cleaned and painted. 3.) On 3/23/25 at 8:23 AM, R20's resident room heater was dirty with dust and chipping paint. R20 stated, They need to fix my heater. 4.) On 3/23/25 at 8:32 AM, R36's resident room heater had chipping paint and was dirty. On 3/23/25 at 8:32 AM, R36 stated, I would like it to be clean. 5.) On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide notifications of discharge for two (R20 & R101) of two residents reviewed for discharge from a total sample list of 35 residents. Findings include: 1.) R20's undated census report documents discharges to the hospital on 8/14/25, 10/15/25, and 2/6/25. R20's medical record does not contain a bed hold or documentation of a transfer notification. 2.) R101's undated census report documents discharge to the hospital on [DATE]. R101's medical record does not include a bed hold, nor documentation of a transfer notification. On 3/25/24 at 9:00 AM, V1 Administrator stated that the facility did not notify the Ombudsman of discharge for R20, nor R101 on the above hospitalization dates. On 3/26/25 at 12:00PM, V30 Social Services Director stated that she is responsible for notifying the Ombudsman of resident discharges but was unaware that the notification included hospitalizations. I will start doing that.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide bed hold notices for two (R20 & R101) of two residents reviewed for transfers from a total sample list of 35 residents. Findings include: 1.) R20's undated census report documents discharges to the hospital on 8/14/25, 10/15/25, and 2/6/25. R20's medical record does not contain a bed hold notice or documentation of a refusal. 2.) R101's undated census report documents discharge to the hospital on [DATE]. R101's medical record does not include a bed hold, nor documentation of a refusal. On 3/25/24 at 9:00AM, V1 Administrator stated that the facility did not provide bed holds (notices) for R20, nor R101 on the above hospitalization dates. On 3/26/25 11:45AM V30 Social Services Director stated that the process for the facility is that the nurses on the floor are supposed to fill out the bed hold when a resident is discharged and then they get collected and scanned in. Our process isn't working. I know that we didn't get them for R20 nor R101 and we…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a Pre-admission Screening and Resident Review (PASARR) level I for one (R45) resident out of one resident reviewed for PASARR level I in a sample list of 35 residents. Findings include: R45's undated Face Sheet documents R45 admitted to the facility on [DATE]. This same face sheet documents medical diagnoses of Major Depressive Disorder, Anxiety and Schizoaffective Disorder which all have an initial date of 7/5/2021. R45's Minimum Data Set (MDS) dated [DATE] documents R45 as moderately cognitively intact. R45's Electronic Medical Record (EMR) does not document a PASARR level I completed. On 3/24/25 at 2:30 PM V1 Administrator stated the facility is unable to provide the Pre-admission Screening and Resident Review (PASARR) level I for R45. V1 stated, We (facility) looked for it and cannot find it. V1 Administrator stated the facility is obtaining a PASARR level I now. V1 Administrator stated the facility does not have a policy for PASARR's.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent two stage two pressure ulcers from developing, failed to prevent cross contamination during pressure ulcer care, and failed to implement dietary interventions for wound healing timely for three (R41, R6, & R352) of seven residents reviewed for pressure ulcers from a total sample list of 35 residents. Findings include: The facility policy dated 2/10/25 documents the facility will establish and utilize a systemic 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. 1.) R41's undated diagnosis sheet documents diagnoses including: Morbid Obesity. R41's Minimum Data Set, dated [DATE] documents R41 as cognitively intact. R41's admission skin assessment dated [DATE] documents no skin issues in the inguinal areas. R41's skin assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's personal electric fan was assessed for safety before use and failed to ensure a resident was safely positioned in bed to prevent a fall for two of two residents reviewed for accidents in the sample list of 35. Findings include: 1. The facility Electrical Safety Policy dated 2/11/25 documents that the intent of the policy is to provide staff with information about the facility's method for ensuring safety as it relates to electrical wiring and equipment. The Maintenance Director or designee is responsible for the inspection and testing of electrical components. This includes receptacles, power strips, extension cords, and equipment. A resident's personal electronic equipment shall be visually inspected prior to use. Nursing personnel are responsible for reporting new equipment to the Maintenance Director. R20's undated diagnosis sheet documents the following diagnoses: Quadriplegia, Urinary Tract Infections, Type II Diabetes Mellitus,…

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 cross contamination during perineal care for one (R6) resident out of one resident reviewed for perineal care in a sample list of 35. Findings include: R6's undated Face Sheet documents medical diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction, Diabetic Mellitus, Chronic Multifocal Osteomyelitis, Sacral Pressure Ulcer Stage 4, Anemia, Neuromuscular Dysfunction of Bladder, Urinary Incontinence and Hypokalemia. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as severely cognitively impaired. This same MDS documents R6 as being dependent on staff for eating, toileting, bathing, dressing, personal hygiene and transfers. On 3/25/25 at 11: 00 AM V21 and V22 Certified Nurse Aides (CNA) completed perineal care for R6. V22 CNA did not provide a clean field for R6's perineal cleansing supplies. V22 CNA placed R6's wet washcloth and dry washcloth directly on R6's soiled bedside table. R6's bedside…

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 check the placement of a Gastrostomy tube prior to administering fluids and medication for one of one resident (R40) reviewed for Gastrostomy tubes in a sample list of 35 residents. Findings include: R40's undated Face Sheet documents diagnoses of Cerebral Infarction, Tracheostomy status, Metabolic Encephalopathy, Altered Mental Status, Abnormal Posture, Unsteady on Feet, Reduced Mobility, Muscle Weakness, Intellectual Disabilities and presence of Gastrostomy Tube (G-Tube). R40's Minimum Data Set (MDS) dated [DATE] documents R40 as moderately cognitively impaired. This same MDS documents R40 is dependent on staff for toileting, dressing, personal hygiene, bathing and bed mobility. R40's care plan intervention dated 11/20/24 instructs staff to check the placement of R40's G-Tube for gastric contents/residual volume per facility protocol. On 3/24/25 at 8:05 AM V8 Licensed Practical Nurse (LPN) did not check the placement of R40's Gastrostomy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop a behavioral plan to address self-harming behaviors for one (R20) of one resident reviewed for behavioral health services from a total sample list of 35 residents. Findings include: The facility provided Behavioral Health Services Policy dated 2/10/25 documents it is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental psychosocial functioning. Additionally, the resident plan of care will maximize the resident's dignity, autonomy, privacy, socialization, independence, and safety. The plan will be reviewed and revised as needed, such as when interventions are not effective or when there is a change of condition. R20's undated diagnosis sheet documents the following diagnoses: Quadriplegia, Urinary Tract Infections, Type II Diabetes Mellitus, Acquired Absence of the Left Upper Limb, Schizophrenia, Depression, Anxiety,…

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 administer medications according to the physician order for one of seven residents (R90) reviewed for medication administration in the sample list of 35 residents. The facility had three medication errors out of 28 opportunities resulting in a 10.71% error rate. Findings include: R90's Minimum Data Set (MDS) dated [DATE] documents R90 as moderately cognitively impaired. R90's Physician Order Sheet (POS) dated March 2025 documents physician orders for Paroxetine 30 milligrams (mg), Mirtazapine 15 mg and Atorvastatin 40 mg to be administered every bedtime. R90's Medication Administration Record (MAR) dated March 2025 documents R90's Paroxetine 30 milligrams (mg), Mirtazapine 15 mg and Atorvastatin 40 mg were scheduled to be administered at 5:00 PM. On 3/24/25 at 3:20 PM V9 Licensed Practical Nurse (LPN) administered R90's Paroxetine 30 milligrams (mg), Mirtazapine 15 mg and Atorvastatin 40 mg at 3:20 PM. On 3/24/25 at 3:29 PM V9 LPN stated…

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

Based on interview and record review the facility failed to offer a pneumonia vaccine for one (R352) of five residents reviewed for immunizations from a total sample list of 35 residents. Findings include: The facility Pneumococcal Vaccine Policy dated 12/19/22 documents that it is the policy of the facility to offer immunization against pneumococcal disease. Each resident will be assessed, educated and offered the pneumococcal immunization upon admission. R352's medical record does not document any pneumonia vaccine offered, refused, or given. On 3/26/25 at 10:00AM, V20 Regional Nurse stated that they did not have documentation of R352 being offered, refused or provided a pneumonia vaccine and that was supposed to occur at admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed repeatedly to maintain accurate and complete medical records for one of five residents (R1) reviewed for documentation on the sample list of six. Findings include: R1's Minimum Data Set, dated [DATE] documents the following: Brief Interview of Mental Status score of 15, out of a possible 15, indicating no cognitive impairment. R1's X-Ray results dated 2/18/25 at 9:48 pm documents the following: PROCEDURE: ELBOW 2V (views) Interpretation: Reason for Study: Acute Pain Due to Trauma. Elbow 2V, Right, FINDINGS: Acute transverse fracture involving right humeral condyles with modest displacement. There is associated joint effusion. CONCLUSION: Acute transverse fracture involving right humeral condyles with modest displacement. R1's Medical Practitioner Note (Physician/Nurse Practitioner) Note dated 2/19/2025 at 3:15 pm, with the date of service as 02/18/25 (the day of R1's fall), (unknown time) documents the following: R1 was assessed by V22, NP for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to honor a resident's right to choose when to have a shower and when the administration of a wound dressing would be changed. This failure affects one of three (R1) residents reviewed for resident rights/wound dressings on the sample list of six. Findings include: R1's Diagnoses Sheet updated 2/18/25, documents the following: Displaced Transcondylar Fracture of Right Humerus, Sequela (dated 2/18/25), Weakness, Cellulitis of Left Lower Limb, Cellulitis of Right Lower Limb, Essential (Primary) Hypertension, Paroxysmal Atrial Fibrillation, Anemia in Chronic Kidney Disease, Diabetes Mellitus Type II with Hyperosmolarity With Coma, and Body Mass Index 45.0-49.9, Adult (Morbid Obesity). R1's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status (BIMS) score of 15, out of a possible 15, indicating no cognitive impairment. The same MDS documents R1 is totally dependent on staff for bathing/showers. R1 Physician…

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 residents' right to be free from verbal abuse when a staff member (V12) refused to assist a resident (R4) with a requested transfer, ambulation, and toileting hygiene. This failure affects one of three residents (R4) reviewed for abuse on the sample list of six. Findings include: R4's Census Detail dated 3/14/25 documents R4 was admitted to the facility 1/18/25 and discharged [DATE]. R4's Diagnoses List documents R4 experiences medical conditions including Post-procedural Partial Obstruction of the Colon, Ataxia (lack of coordination, clumsy movements), and Dizziness. R4's Care Plan dated 1/18/25 documents R4 has impaired vision, requires assistance for transfers and ambulation, and assistance with other activities of daily living as needed. This care plan documents R4 is at risk of abuse, a new intervention initiated 1/29/25. R4's Minimum Data Set, dated [DATE] documents R4 has highly impaired vision, is cognitively intact, experiences no mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a dependent residents shower and wound dressing change, prior to a doctor's appointment. This failure affected one of three residents (R1) reviewed for shower/wounds on the sample list of six. Findings include: R1's Diagnoses Sheet updated 2/18/25, documents the following: Displaced Transcondylar Fracture of Right Humerus, Sequela (dated 2/18/25), Weakness, Cellulitis of Left Lower Limb, and Cellulitis of Right Lower Limb. R1's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status (BIMS) score of 15, out of a possible 15, indicating no cognitive impairment. The same MDS documents R1 is totally dependent on staff for bathing/showers. On 3/13/25 (Thursday) at 3:20 pm R1 stated she requested staff provide a shower and a dressing change to her lower legs, before going to a doctor's appointment on Friday 3/14/25. It appears they have enough staff. My needs are met, except showers. I don't know that…

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

Based on observation, interview, and record review the facility failed to ensure services were provided by a Registered Nurse for eight consecutive hours per day. This failure has the potential to affect all 108 residents residing in the facility. Findings include: The facility's Facility Assessment with a revision date of 9/30/24 documents the facility's average census is 92. This assessment documents the facility requires direct care by a Registered Nurse daily. This assessment documents that the facility will have three Registered Nurse's available to provide direct care. During this investigation on 11/25/24 and 11/26/24 from 9:00 AM to 3:00 PM, there was not a Registered Nurse providing resident cares. The facility's November 2024 staffing sheets did not document that a Registered Nurse was scheduled for the dates of 11/11/24, 11/12/24, 11/15/24, 11/16/24, 11/17/24, 11/20/24, 11/21/24, or 11/25/24. V13's (Assistant Director of Nursing) name is written on the top corner of the staffing sheets dated 11/21/24, 11/20/24, 11/17/24, 11/16/24, 11/12/24, and 11/11/24. V14's (Assistant…

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

Based on observation, interview, and record review, the facility failed to provide the services of a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 108 residents residing in the facility. Findings include: On 11/25/24 at 10:45 AM V3 stated V3 is the dietary manager and is required to manage all aspects of the dietary department. This includes regulatory oversight in regard to local, state and federal requirements as they pertain to safe food handling. V3 stated V3 is not certified and must enroll to begin the Certified Dietary Manager Course. V3 stated V3 will be enrolling in the class today (11/25/24). On 11/25/24 at 11:00 AM V3, Dietary Manager, was actively managing kitchen personnel and directing the food sanitation and preparation activities in the facility's kitchen. On 11/25/24 at 2:30 PM V1 Administrator stated V3 is the Dietary Manager and is not certified. On 11/26/24 at 11:15 AM V1 provided the dietary personnel schedule for 11/13/24 thru 12/10/24 that states V3 is the Dietary Manager across the bottom of the…

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

Based on observation, interview, and record review, the facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition service. This failure has the potential to affect all 108 residents residing in the facility. Findings include: On 11/25/24 at 10:45 AM V3 stated V3 is the dietary manager and is required to manage all aspects of the dietary department. This includes regulatory oversight in regard to local, state and federal requirements as they pertain to safe food handling as well as daily staffing/scheduling of the dietary department. On 11/25/24 at 11:00 AM V3, Dietary Manager, was actively managing kitchen personnel and directing the food sanitation and preparation activities in the facility's kitchen including the dietary staff that is on duty. V3 was acting as cook due to lack of support personal. On 11/26/24 at 11:15 AM V1 Administrator provided the dietary personnel schedule for 11/13/24 thru 12/10/24 that showed a schedule of two staff members to perform essential dietary services 11/13/24, 11/16/24, 11/17/24,…

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 observation, interview, and record review, the facility failed to follow posted/printed menus. This failure has the potential to affect all 108 residents residing in the facility. Findings include: On 11/25/24 at 10:15 AM the posted menu outside of the kitchen on the bulletin board for residents/visitors to read documented the lunch menu as Herb Roasted Pork Loin, Candied Sweet Potatoes, Buttered Cabbage, Apple Cobbler, Dinner Roll/margarine and beverage for lunch. On 11/25/24 at 12:15 PM V3, dietary manager, was serving a pork chop onto the plates from the steam table not a piece of pork loin as documented on the posted menu. V12, dietary aide/cook, placed a sliced bread onto the trays in a plastic bag, not a dinner roll as documented on the posted menu. On 11/25/24 at 12:40 PM V12, Dietary aide/cook, stated to V3 they are out of apple cobbler. V3, dietary manager, stated they shouldn't be out of apple cobbler, V3 then instructed V12, dietary aide/cook, to get two cans of apple slices and add cinnamon to the apples and serve that for dessert. V12 gathered two five pound…

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 resident rooms are clean and free of debris and the walls are in good repair. This failure affects five (R6, R7, R2, R8, R4) of eight residents reviewed for environment on the sample list of eight. Findings include: The facility's Resident Council Meeting minutes dated 9/9/24 document residents would like for housekeeping to clean their rooms better and take out their trash. The Resident Council Meeting minutes for 10/14/24 document residents would like housekeeping to clean their rooms and not complain when they are doing their jobs. The Resident Council Meeting minutes for 11/11/24 document residents would like housekeeping to clean their rooms better and not complain when they are doing their job. On 11/25/24 at 9:10 AM, R6's room contained piles of unfolded blankets and full black trash bags piled on top of each other in corner of the room. The room was cluttered with boxes of cereal, shoes, and other items along the wall. The bedside table was covered with books, soda cans, and other items. On…

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

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This failure affects two residents (R1, R2) of four reviewed for abuse in the sample of four. Findings include: The facility Abuse, Neglect and Exploitation policy (12/5/2023) documents: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. The same record documents Physical Abuse includes, but not limited to hitting, slapping, punching and kicking. R2's diagnosis list (8/13/2024) documents diagnoses including: Mild Intellectual Disability,…

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

Based on observation, interview, and record review the facility failed to provide nutritional supplements as ordered for wound healing and failed to apply wound treatments for two (R1, R3) of three residents reviewed for pressure ulcers on the sample list of three. Findings include: The facility's Pressure Injury Prevention and Management policy with a review date of 12/6/22 documents that evidence based interventions will be implemented for residents who have a pressure injury present. This policy documents interventions to maintain or improve nutrition and hydration status maybe utilized. This policy also documents that treatments will be provided for all residents who have a pressure injury (ulcers). 1. On 6/3/24 at R1 was lying in bed. A 3 inch by 1.5 inch pressure ulcer was present on R1's sacral area. R1's Care Plan with a review date of 4/2/24 documents R1 has a stage four pressure ulcer on the sacrum. This care plan includes an intervention to administer treatments as ordered. This care plan also documents an intervention to provide supplements as ordered. R1's Nurse's note…

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 physician orders for oxygen use for three (R1,R2, and R5) of five residents reviewed for oxygen in the sample list of five. Findings include: The facility's Oxygen Administration policy dated 5/10/21 documents: Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen. 1.) R1's Hospital Progress Note…

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 two of sixteen days reviewed for RN staffing. This failure has the potential to affect all 95 residents in the facility. Findings include: The facility Nursing Schedule (April 22, 2024 through May 7, 2024) document on 5/3/24 and 5/5/24, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 5/7/24 at 12:05pm, V1 Administrator confirmed the hours listed on the facility nursing schedule were correct and the facility failed to have RN coverage on 5/3/24 and 5/5/24. The facility Resident Midnight Census dated 5/6/24 documents 95 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to allow participation in a dietary assessment, failed to allow participation with an advance directive choice, and failed to obtain consent for psychotropic medications for four (R28, R198, R78, and R11) of 24 residents reviewed for choices on the sample list of 46. Findings include: 1. On 2/26/24 at 1:38 PM, R28 was sitting in his room. R28 had a gastrostomy tube. R28 stated he wants to eat and that he used to get pudding or applesauce. R28 stated no one has asked him about his diet. R28's Dietitian assessment dated [DATE] at 3:10 PM documents R28 receives tube feeding and receives nothing by mouth. This assessment documents R28 is tolerating the feeding well and R28's weight is stable. This assessment does not document R28 was involved in the assessment or that R28 had a desire to eat. On 2/26/24 at 2:30 PM, V20 Registered Dietitian stated she last assessed R28 about two weeks ago. V20 stated she assesses R28 every month. V20 stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance with personal hygiene, a transfer out of bed, and set up help at a meal for five (R28, R37, R198, R13, and R65) of 24 residents reviewed for activities of daily living on the sample list of 46. Findings include: 1. On 2/25/24 at 9:39 AM, R28's fingernails were long and jagged with accumulated dirt underneath them. R28 had a moustache with over growth of cheek and chin hair. R28 stated he likes to keep the sides and chin on his face shaved. On 2/27/24 at 11:54 AM, R28's fingernails were long with accumulated dirt underneath them. R28 was not shaven. R28 stated he would like to have his fingernails trimmed and would like to be shaved. R28 stated he needs help with his fingernails and face. R28's care plan with a review date of 1/10/24 documents R28 has a diagnosis of hemiplegia/hemiparesis following cerebrovascular disease. This care plan includes interventions to assist resident as needed with activities of daily living.…

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 This failure resulted in two deficient practice statements. A. Based on observation, interview, and record review the facility failed to provide supervision while smoking for eight of eight (R91, R53, R48, R2, R9, R43, R63, and R6) residents reviewed for smoking on the sample list of 46. B. Based on observation, interview, and record review the facility failed to thoroughly investigate falls to determine root cause and implement post fall interventions for two (R64, R78) of four residents reviewed for falls in the sample list of 46. Findings include: A. 1. On 2/27/24 at 9:10 AM, R91, R53, R48, R2, R9, R43, R63, and R6 were outside smoking. No staff was present on the patio where the residents smoke. V31 Housekeeper was standing inside of the building with her back up against the door not facing the residents. At that time, V31 stated she was waiting for the residents who smoke to be finished so that she could let them back in the door. V31 then walked out to the patio where the residents were smoking; when…

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.

3.) R11's Order Summary Report dated 2/25/24 documents diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Pneumonitis Due to Inhalation of Food and Vomit and Unspecified Cerebrovascular Disease. These orders do not document any orders for oxygen administration or orders to change the oxygen tubing. On 2/25/24 at 9:08 AM, R11 was in bed with a mattress on the floor next to the bed R11 had oxygen on via nasal cannula with the oxygen concentrator set on 3 liters. On 2/26/24 at 10:29 AM, R11 was in bed with the oxygen concentrator running and the oxygen tubing and nasal cannula were laying on the floor. R11 was lying in bed sleeping. R11's Care Plan with an initiated date of 11/23/23 documents R11 has oxygen therapy related to diagnoses of Acute/Chronic Respiratory Failure with Hypoxia with an intervention of oxygen via nasal cannula per Physician order. On 2/28/24 at 9:36 AM, V2 Director of Nursing confirmed there was no Physician's Order for oxygen in the computer on 2/25/24. Based on observation, interview, and record review the facility failed to store…

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 the safety of self-administration of medications for two of two residents (R58, R44) reviewed for self-administration of medication on the sample list of 46. Findings Include: The facility's Resident Self Administration of Medication policy with a revision date of 1/24/23 states, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be administered safely. This policy also states, The results of the interdisciplinary team assessment are recorded on Medication Self-Administration form, which is placed in the resident's medical record. 1. R44's Physician's Order Summary printed 2/29/24 includes an order for Sevelamer Carbonate 800 milligrams one tablet three times a day with meals on Tuesday, Thursday, and Saturday. This order documents that it may be left at bedside and given according to dialysis schedule. R44's medical record does…

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 assess for the use of a restraint, obtain physician orders, and develop a care plan for restraint use for one of one resident (R70) reviewed for restraints in the sample list of 46. Findings include: The facility's Restraint Free Environment policy dated 1/5/23 documents: Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to: Applying leg or arm restraints, hand mitts, soft ties, or vests that the resident cannot remove. Using bed rails to keep the resident from voluntarily getting out of bed. Tucking in a sheet tightly so that the resident cannot get out of bed, or fastening fabric or clothing so that a resident's freedom of movement is restricted. Falls do not constitute…

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 monitor and record daily weights as ordered for one (R64) of 24 residents reviewed for physician's orders in the sample list of 46. Findings include: On 2/25/24 at 8:24 AM, R64 was sitting in a wheelchair and R64's left arm and hand were swollen. R64's February 2024 Physician's Orders documents an order dated 2/3/24 for daily weights due to retention and to notify the physician of three pound (lb.) weight gain in 24 hours or five lb. gain in a week. This order is transcribed onto R64's February 2024 Treatment Administration Record, but the daily weight amounts are not recorded. R64's X-Ray dated 2/7/24 documents F64 has a non united transverse supracondylar fracture of the left distal humerus with displacement of osseous fragments. R64's Weight Summary documents R64 weight as 100.6 lbs. on 2/26/2024, 100.6 lbs. on 2/25/24, 102 lbs. on 2/5/24, and 98.2 lbs. on 2/2/24. On 2/25/24 at 11:31 AM, V14 Licensed Practical Nurse stated daily weights are documented on the Medication Administration Record (MAR) or under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately complete a vision assessment and provide vision services for one (R76) of 24 residents reviewed for vision on the sample list of 46. Findings include: On 2/25/24 at 9:30 AM, R76 was lying in bed. R76 stated she enjoys reading but can't because she can't see with her glasses. R76 stated her glasses are not the right prescription. R76's glasses were sitting on her bedside table. R76 stated the prescription has been bad for six months to a year. R76's admission Minimum Data Set (MDS) assessment dated [DATE] documents R76's vision is adequate with glasses. R76's Quarterly MDS dated [DATE] documents R76's vision is adequate with glasses. On 2/26/24 at 9:53 AM, V16 Social Service Director stated he does not use the Resident Assessment Instrument (RAI) manual instructions to complete the vision assessment or to code the Minimum Data Set assessments. V16 stated he usually just asks the residents how they are seeing and asks the staff if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement interventions to prevent pressure ulcers for one (R26) of four residents reviewed for pressure ulcers in a sample list of 46. Findings include: R26's Minimum Data Set, dated [DATE] documents R26 is cognitively intact. R26's Care Plan updated 1/1/24 documents, (R26) is at risk for skin breakdown related to diagnosis of quadriplegia, immobility, Left arm amputation, Incontinence, Bedfast, and Chair fast. (R26) needs staff assistance for turning and repositioning every two hours. R26's progress note dated 9/11/23 at 11:52 AM documents, CNA (Certified Nurse's Aide) called nurse to (R26's) room to find a bedpan shaped bruise across (R26's) bottom on both his left and right cheek. The area is not open but red in color. R26's progress note dated 9/13/23 at 6:36 AM documents, CNA called Nurse to (R26's) room. (R26) reports being on the bedpan since second shift 9/12/2023. (R26) does have a bedpan shaped bruise at (this) time. On 2/27/24 at 10:00 AM,…

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

Based on observation, interview, and record review the facility failed to obtain catheter orders, provide routine catheter care, maintain a urinary catheter drainage bag in a sanitary manner, follow up on a urinary tract infection, and develop a care plan to address isolation related to a urinary tract infection for two (R65, R76) of five residents reviewed for urinary care in the sample list of 46. Findings include: 1.) The facility's Catheter Care policy dated 1/24/23 documents catheter care will be performed every shift and as needed, document catheter care, and urinary catheter drainage bags will be covered at all times with a privacy bag. On 2/25/24 at 12:49 PM, R65 was lying in a bed that was positioned low to the floor and R65's urinary catheter drainage bag was hanging on the bed frame, not in a privacy bag, and touching the floor. On 2/26/24 at 11:48 AM, V19 and V28 Certified Nursing Assistants (CNAs) entered R65's room to provide catheter care. R65's urinary drainage bag was touching the floor and not in a privacy bag. There was a dried brown substance on the urinary…

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

Based on observation, interview, and record review the facility failed to evaluate and attempt to restore eating skills, administer G-tube (Gastrostomy tube) feedings per physician's orders, check G-tube placement prior to use, document feeding intakes, and ensure the head of the bed was elevated when administering feeding for three of three residents (R49, R65, R28) in the sample list of 46. Findings include: The facility's Care and Treatment of Feeding Tubes with a Reviewed/Revised date of 12/19/22 documents, It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. 1. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and it caloric value, volume, duration, mechanism of administration, and frequency of flush. 4. The facility will utilize the Registered Dietitian in estimating and calculating a resident's daily nutritional and hydration needs. 6. In accordance with facility protocol, licensed nurses…

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 document targeted behaviors and nonpharmacological intervention responses to support the use of psychotropic medications, periodically assess for the use of psychotropic medications, complete AIMS (Abnormal Involuntary Movement Scale) assessments, and attempt gradual dose reductions (GDRs) or document clinical rational to justify maintaining the dose for five of five residents (R78, R92, R8, R10, R11) reviewed for unnecessary medications in the sample list of 46. Findings include: The facility's Use of Psychotropic Medication policy dated 9/27/23 documents: Residents 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 medication(s). The indications for initiating, withdrawing, or withholding medications, as well as…

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

Based on interview and record review the facility failed to complete Certified Nursing Assistant performance reviews/evaluations to identify training needs and implement training. This failure has the potential to affect all 95 residents who reside in the facility. Findings Include: The facility's midnight census report dated 2/7/24 documents 95 residents reside at the facility. The Facility's Assessment tool (not dated) documents, Skills competencies are completed upon hire and annually to ensure all employees have and maintain necessary skills to provide high quality care to residents in all departments. The nursing department complete competencies on their personnel monthly on various topics to ensure all skills are maintained throughout the year. On 2/7/24 V1, Administrator stated, We do not do annual evaluations of our staff. We do in-services with all staff, but do not do individual skills assessments. No individual skills assessments were provided by the facility.

Based on interview and record review, the facility failed to have a physician document in R4's medical record at the time of transfer from the facility to the hospital R4's specific needs the facility could not meet, the facility attempts to meet R4's needs, and how the receiving facility could meet R4's needs. This failure affects one resident (R4) of three reviewed for discharge in the sample of three. Findings include: R4's Progress Notes (2/15/2024) document R4 was transferred from the facility to the hospital on 1/27/2024. R4's care plan printed 2/20/24 documents R4 was admitted to the facility 9/26/23. Behavioral and emotional disorders, anxiety disorder, borderline personality disorder, and depression are documented diagnosis on R4's care plan. Behavioral focus areas with interventions and goals are documented on R4's care plan initiated 9/26/23. R4's medical record documents the following: 12/29/2023 diagnosis of PTSD (post-traumatic stress disorder), ADHD (attention deficit hyperactivity disorder), Depression, Borderline Personality Disorder, GAD (generalized anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their bed hold policy allowing a resident to return to the facility following hospitalization. This failure affects one resident (R4) of three reviewed for discharge. Findings include: R4's Census sheet ([DATE]) documents R4 admitted to the facility on [DATE] with Medicaid as R4's payor source for the duration of R4's stay in the facility. R4's Progress Notes ([DATE]) document R4 was transferred from the facility to the hospital on [DATE]. R4's Bed Hold Notice (signed by R4 on [DATE]) documents R4 requested the facility hold R4's bed during R4's hospitalization. R4's admission Contract (signed by R4 on [DATE]) section titled Bed Hold Policy Notification documents the following: The Nursing Home Care Act requires a nursing facility to hold a bed for a maximum of ten days when you are hospitalized . The facility must hold a bed (not necessarily your specific bed) for up to 10 days during a hospitalization. On the 11th day there is no requirement…

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

Based on observation, interview, and record review, the facility failed to maintain the kitchen dishwashing room in a sanitary manner. This failure has the potential to affect all 100 residents residing in the facility. Findings include: On 1/26/24 at 9:15 AM, along the twelve foot long junction between the stainless steel table and leading towards the dishwasher and the wall behind the table, there was an inch high and quarter-inch thick accumulation of a blackened unidentified substance. On the wall behind the water sprayer section, there was an accumulation of unidentified blackened substance in an arch shape approximately two and one-half feet diameter and two and one-half feet high. On 1/26/24 at 9:24 AM, V4, Dietary Aide, reached out and manually pulled a chunk of the blackened material from the wall behind the water sprayer area approximately three-eighths of an inch diameter and stated, I think that's dirt. On 1/26/24 at 9:30 AM, V3, (Acting) Dietary Manager, observed the wall in the facility dishwashing room and stated, That could use a good cleaning. V3 stated a likely…

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 their industrial dryers in a safe operating condition. This failure has the potential to affect all 100 residents residing in the facility. Findings include: On 1/26/24 at 9:50 AM, there were layers and piles of accumulated lint on the font tops of the four industrial clothes dryers, up to two inches thick in places. The backsides of the dryers had accumulations of lint all around the gas burner compartments and around the motor enclosures up to one inch thick. There were also scattered piles approximately one-quarter inch of lint accumulations along the lengths of the burner supply tubes. On 1/26/24 at 10:27 AM, V6, Maintenance Assistant, was actively cleaning the lint accumulations from the facility dryers. V6 stated, I have been trained to clean the lint once per week, but mainly to make sure the motors and walls are kept clean of lint. We usually hire someone to come in and clean the burner areas. I have been working about one month so I don't feel like I have been trained yet on everything I am…

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

Based on observation, interview, and record review, the facility failed to serve meals at an appropriate temperature to residents eating meals in their own rooms. This failure affects nine residents (R3, R5, R7, R8, R9, R10, R11, R12, and R13) out of eleven interviewed for meal temperatures in a total sample of 13. Findings include: On 1/26/24 at 11:52 AM, R2 declined to be interviewed about the meal temperatures. On 1/26/24 at 11:54 AM, R3 stated, The food is not hot, it might be hot when they serve it out of the kitchen or it might be hot when it gets up to the floors, but by the time it gets here it isn't hot. The food is supposed to be covered with plastic lids but a lot of times it is covered with foil, maybe the oatmeal stays hot but nothing else. On 1/26/24 at 12:02 PM, R5 stated, The food is not bad, it is never hot, always warm to cold. I don't think they have the storage to keep it hot, it all comes on open carts and trays. On 1/26/24 at 12:15 PM, R7 stated, The food is not hot. I go to resident council meetings, and they (facility staff) know about it. They were supposed…

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 prevent the potential for fire and burn hazards by utilizing portable space heaters throughout the facility. This failure has the potential to affect all 94 residents in the facility. Findings include: On 1/16/24 at 8:55am, a push cart containing portable space heaters was observed in the main lobby of the facility. On 1/16/24 at 9:17am, V1 Administrator stated the facility lost heat yesterday afternoon (1/15/24) around 3-3:30pm. V1 stated a pipe to one of the boilers burst causing the heat loss. V1 stated the facility placed four portable space heaters on each of the resident floors in dining areas/hallways in case the facility had to start evacuating and to maintain the temperature. On 1/16/24 at 9:58am, V7 Licensed Practical Nurse (LPN) stated the space heaters were placed in the common areas on the floor when the heat went out on 1/15/24. V7 stated V7 was not provided any training on safety precautions regarding the use or placement of the space heaters. On 1/16/24 at 10:00am, V6 Housekeeping stated the…

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

Based on interview and record review, the facility failed to thoroughly investigate and document an allegation of resident-to-resident physical abuse. This failure affects one resident (R1) of three reviewed for abuse in the sample of five. Findings include: The facility Abuse, Neglect and Exploitation Policy dated 12/5/22 documents the following: When suspicion of abuse or reports of abuse occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members and visitors in the area. Obtain witness statements. Document the entire investigation chronologically. Notify the attending physician and the resident's family/legal representative. Monitor and document the resident's condition, including the response to medical treatment or…

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 update and revise resident care plans following a resident-to-resident altercation. This failure affects two residents (R1 and R2) of three reviewed for abuse in the sample of five. Findings include: The facility abuse investigation file dated 12/20/23 documents V14 Licensed Practical Nurse reported to V1 Administrator and V2 Director of Nursing that R1 reported R2 hit R1. This same record documents V14 reported R2 was on R1's side of R1 and R2's room when V14 heard R1 state R2 hit R1. On 1/2/24 at 11:41am, R1 stated R2 was mad at me [R1] and yelling. R1 stated R2 hit R1 on the back of the head for being on R2's side of the room. On 1/2/24 at 11:52am, R2 stated R2 and R1 had been roommates for a long time. R2 stated R1 would not stay on own side of room and kept kicking R2's bed. R2 stated R2 told R1 go on own side of room and leave me alone. R2 stated, I pushed [R1's] wheelchair back to [R1's] side of the room because [R1] kept messing with my bed by kicking it. R2 stated R1 started swinging R1's arms and R2 put up R2's…

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

Based on interview and record review, the facility failed to fully document the details of a resident-to-resident physical abuse allegation and investigation in residents' medical records. This failure affects two residents (R1 and R2) of three reviewed for abuse in the sample of five. Findings include: The facility abuse investigation file dated 12/20/23 documents V14 Licensed Practical Nurse reported to V1 Administrator and V2 Director of Nursing that R1 reported R2 hit R1. This same record documents V14 reported R2 was on R1's side of R1 and R2's room when V14 heard R1 state R2 hit R1. On 1/2/24 at 11:41am, R1 stated (R2) was mad at me [R1] and yelling. R1 stated R2 hit R1 on the back of the head for being on R2's side of the room. On 1/2/24 at 11:52am, R2 stated R2 and R1 had been roommates for a long time. R2 stated R1 would not stay on own side of room and kept kicking R2's bed. R2 stated R2 told R1 go on own side of room and leave me alone. R2 stated, I pushed [R1's] wheelchair back to [R1's] side of the room because [R1] kept messing with my bed by kicking it. R2 stated R1…

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 properly screen employees for illnesses affecting four (R1, R2, R4 and R8) of four residents reviewed for infection control. Findings include: The facility Coronavirus Surveillance Policy dated 12/18/22 documents that an outbreak refers to any one positive case traced to the facility, either staff or resident. Additionally, staff who report or signs and symptoms of a respiratory infection or (Sars-Co-V2) shall not report to work. Any staff that develop signs and symptoms while on-the-job shall immediately stop work, put on a facemask and isolate at home. They will also inform the infection preventionist and communicate those individuals, equipment and locations they had had contact with and contact and follow the local health department recommendations for next steps such as testing and locations for treatment. R1's undated diagnosis sheets documents the following diagnoses: Asthma, History of Stroke, Type II Diabetes, Hypertension, Atherosclerosis, Cerebellar Stroke Syndrome and Depression. R2's undated diagnosis sheets…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the dignity of two (R1, R4) of four residents reviewed for abuse. Findings include: The State of Illinois Ombudsman Program, Resident Rights in Long Term Care Facilities dated November 2018 documents that all residents have a right to dignity and respect. The facility Abuse, Neglect and Exploitation Policy dated 12/5/22 documents that all residents have the right to be free from abuse and mistreatment. Additionally, when a suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted including interviewing the resident, interviewing all witnesses separately including residents and staff and documenting the investigation chronologically. The facility must supervise staff to identify inappropriate behaviors such as using derogatory language, rough handling or ignoring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a thorough investigation of an abuse allegation for one (R1) of four residents reviewed for abuse. Findings include: The facility Abuse, Neglect and Exploitation Policy dated 12/5/22 documents that all residents have the right to be free from abuse and mistreatment. Additionally, when a suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and the initial reporting has occurred, an investigation should be conducted including interviewing the resident, interviewing all witnesses separately including residents and staff and documenting the investigation chronologically. The undated, facility provided abuse log does not document any abuse allegation involving R1. R1's undated diagnosis sheet documents the following diagnoses: History of Stroke, Type II Diabetes, Hypertension, Atherosclerosis, Cerebellar Stroke Syndrome, 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 provide feeding assistance for lunch for four residents (R8, R9, R10, R11) of four residents reviewed for feeding assistance in the sample list of 16. Findings include: 1. R8's undated Face Sheet documents R8's diagnoses as unspecified Dementia, mild, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance; Type 2 Diabetes Mellitus without complications; and Anxiety and Major Depressive Disorder, recurrent, unspecified. R8's Care Plan dated 7/10/23, documents Dietary Altered Nutritional status and to provide diet as ordered, and resident (R8) needs assistance with activities of living (ADL's) due to diagnosis of malnutrition. R8's Minimum Data Set (MDS) dated [DATE], documents R8 is severely cognitively impaired and disorganized thinking continuously. This same Care Plan documents R8 requires one person physical assist with eating. 2. R9's undated Face Sheet documents R9's diagnoses as Anorexia; Alzheimer's Disease,…

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 send a dietary recommendation for wound healing to the physician for one (R2) of three residents reviewed for wounds on the sample list of seven. Findings include: R2's Dietary Assessment, written by V12 Former Dietitian dated 6/1/23, documents R2 requires increased protein needs due to stage two pressure ulcer to the sacrum. This assessment includes a recommendation for liquid protein twice a day and fortified foods twice a day. R2's medical record does not document R2's recommendation was sent to the physician or that R2 received liquid protein until 6/22/23. R2's Dietary note written by V4 Dietitian dated 6/21/2023, documents R2 has a sacrum and left heel pressure area. This note documents a recommendation to add liquid protein 30 milliliters twice a day. On 8/9/23 at 1:00 PM, V3 Assistant Director of Nursing stated, V12 did make a recommendation of liquid protein and fortified foods. V3 stated the facility did not send the recommendation to the physician. V3 stated the recommendation for liquid protein was made again on…

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

Based on observation, interview, and record review the facility failed to provide enteral feedings per physician orders for one (R1) of three residents reviewed for tube feedings on the sample list of seven. Findings include: On 8/9/23 at 9:20 AM, R1 was lying in bed. Osmolite 1.5 was infusing in R1's gastrostomy tube at 30 milliliters per hour. The bottle of Osmolite contained 550 milliliters of enteral feeding. The bottle of Osmolite was a 1,000-milliliter bottle. The date of 8/7/23 and time of 9 was written on the bottle. At that time, V3 Licensed Practical Nurse was standing outside of the door. V3 stated she worked yesterday and did not need to hang a new bottle. V3 stated the bottle of Osmolite was the same bottle as yesterday. V3 stated it runs for 20 hours at a time. V3 stated the bottle should have been almost empty. At that time, V3 confirmed that there were 550 milliliters of feeding in the bottle. R1's Enteral Feed Order dated 8/1/23 through 8/7/23 documents Osmolite 1.5 at a rate of 30 milliliters per hour for twenty hours. This order documents the feeding start time as…

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.