Avantara Evergreen Park

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that (R1, R17, R49, R74, R105, R136) medications were labeled appropriately, failed to ensure multidose medication were dated when opened, failed to ensure medication carts were lock, failed to ensure medications were stored in locked storage areas, failed to ensure narcotic medications were double locked, and failed to ensure (R25, R133) refrigerated medications and six (6) emergency box insulins were stored within the required temperature range. These failures have the potential to affect 164 residents.Findings include:The 4/26/26 census includes 164 residents.On 4/28/26 at 9:02am, surveyor inspected the (100 - front) medication cart with V35 (LPN/Licensed Practical Nurse). R105's Humalog pen was not in a bag and did not have a pharmacy sticker attached. R105's name was handwritten (in smeared marker) on the Humalog pen and barely legible. Surveyor inquired if medications are supposed to be labeled V35 stated Absolutely and it should be bagged because the bag also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's refrigerators maintained temperature parameters for food safety; failed to properly log residents' refrigerator temperatures; failed to date outside open food items; and failed to ensure residents refrigerators were clean. These failures affect four residents (R17, R50, R78, and R89) reviewed for safety of personal food items, in a total sample of 67 residents.Findings include: On 4/27/26 at 10:25am, observation of R17's personal refrigerator revealed the absence of a temperature monitoring log. Additionally, a large amount of a brown, sticky substance was noted on the bottom shelf. On 4/27/26 at 10:25am, R17 said, Yes, that's my fridge. Just my food in there. The facility got it for me. Housekeeping usually comes and cleans it. No, I'm not sure when the last time they (housekeeping) came and cleaned it. There used to be a paper on top of the fridge that they (staff) were checking and putting down what the temp was. R17's face sheet documents diagnoses that include but are not limited to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record of review, the facility failed to develop a baseline care plan and failed to provide the resident with a copy/summary of the baseline care plan. This failure affected one resident (R202) in a sample of three residents reviewed for baseline care planning. Findings include: R202's face sheet documents R202 is a [AGE] year-old resident that admitted to the facility on [DATE]. R202's diagnoses include, but is not limited to: surgical aftercare following surgery on the skin, muscle wasting and atrophy, anemia, type 2 diabetes mellitus with hyperglycemia, hypertension, acute kidney failure, Fournier Gangrene. R202's progress notes document R202 admitted to the facility on [DATE] and is alert and oriented x 4 (person, place, time, situation). R202 was admitted to the facility following hospitalization for a fall and an infected groin wound. There is no indication in the progress notes that R202's baseline care plan was developed, or a copy of the baseline care plan was given…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that staff revise and update resident's (R197) care plan after a fall to address a newly acquired fracture and head injury and failed to update a resident's (R16) care plan to reflect the correct advance directives. These failures affect two (R16 and R197) of two residents reviewed for care plan revision in a sample of 67 residents.Findings include: R16 is [AGE] years old and have resided at the facility since 2025, face sheet listed the following past medical history in part: nontraumatic intracerebral hemorrhage, iron deficiency anemia, gastrostomy status, adult failure to thrive, hear failure, diabetes mellitus, etc. Per record review, R16 was listed as a do not resuscitate (DNR) and do not hospitalize (DNH) on his face sheet. IDPH uniform Practitioner order for life sustaining treatment (POLST) form dated [DATE] documented that R16 is a DNR and DNH. Care plan initiated [DATE] documented the following: ADVANCE DIRECTIVE STATUS (CODESTATUS:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy procedures, failed to ensure that multiple linen layers were not on the LALM (Low Air Loss Mattress) while in use, failed to implement preventive interventions, and/or failed to identify skin integrity impairment for one of 43 residents (R174) in the sample reviewed for pressure ulcers. Findings include: R174's progress note, dated 3/10/26, per V48 (Wound Care Nurse Practitioner), documents, in part, Patient (R174) was examined, found to have no active wounds. Continue current preventative measures. Nursing staff to contact wound care with any new open wounds. R174's progress note, dated 4/09/26, per V57 (Wound Care Nurse Practitioner), documents, in part, Patient (R174) being seen today for new skin alteration. New site noted to right bunion, treatment recommendation provided. Wound Assessment: Location: Right bunion; Primary Etiology: Pressure Ulcer/Injury; Stage/Severity: DTI (Deep Tissue Injury); Wound Status: New; Size: 1 cm x 1.1 cm x 0 cm. Calculated area is 1.1 sq cm.; Treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow policy procedures, failed to follow physician orders, failed to ensure that designated times were specified for applying/removing restorative devices, failed to include all required device(s) in Nursing Rehab tasks, and failed to ensure that staff provide and/or document restorative care/devices for two of 43 residents (R1, R59) in the sample reviewed for range of motion/mobility. Findings include: The general care policy (revised 6/30/25) states that upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs. The facility will assist the residents to meet these needs. R1's diagnoses include hemiplegia and hemiparesis following cerebral infarction- affecting the right side. R1's Physician Orders include (12/22/25) Right knee brace for contracture management 4 hours daily to progress to as tolerated. (1/20/26) Nursing Rehab: right hand resting splint. R1's (4/14/26) care plan affirms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provider order for continuous oxygen, failed to ensure the nebulizer mask was labeled with the date it was changed, and failed to ensure the respiratory equipment was contained when not in use. These failures affected two (R101 and R129) residents reviewed for respiratory care in the total sample of 67 residents.Findings include: On 04/27/2026 at 10:53am, there was a red and white sign posted on R129's door frame No smoking, No open Flame, Oxygen in use. Inside R129's room, there was a nebulizer mask and tubing by R129's nightstand. On 04/27/2026 11:03am, V22 (Registered Nurse) checked R129's nebulizer mask on R129 nightstand and stated the nebulizer mask and tubing were not labeled with date and were not contained. V22 stated these should be dated and contained in clear plastic bag. V22 took R129 mask and tubing and stated she would provide her (R129) with a new nebulizer mask and tubing. On 04/28/2026 at 2:02pm, V2 (Director of Nursing) stated the nebulizer mask should be contained in clear plastic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document post-fall charting and neurological checks (neurocheck) charting in a timely manner, in accordance with professional standards. This failure caused R197's medical records not to be readily accessible or accurate for up to 9 days after R197's fall. This failure affected one (R197) of 67 residents reviewed for resident records. R197's face sheet documents R197 was a [AGE] year-old resident with a prior medical history of chronic obstructive pulmonary disease, dementia without behavioral disturbance, restlessness and agitation, iron deficiency anemia, contusion of the head, and displaced supracondylar fracture of the right humerus. R197's minimum data set ([DATE]) documents R197 had a brief interview of mental status summary score of 3, indicating R197 had severe cognitive impairment. R197 required substantial/maximal assistance with personal hygiene (including washing/drying face) and required partial/moderate assistance with transferring.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 requirements by failing to submit an initial and final report, for an injury of unknown origin (of serious bodily injury), to the State Agency in a timely manner. This failure affected one (R1) of three residents reviewed for abuse. R1 sustained a displaced right hip fracture that required an emergency surgical fixation of right basicervical femoral neck with cephalomedullary nail.Findings include:R1 is [AGE] year-old admitted on 1/`9/2026, with diagnosis including, but not limited to End stage renal disease, difficulty walking, not elsewhere classified, cognitive communication deficit, other symbolic dysfunction, other complications of vascular dialysis catheter, adult failure to thrive, pressure ulcer of sacral region stage 2, essential primary hypertension, atypical atrial flutter etc.On 3/17/2026 at 10:28AM, V3 (DON) said that she spoke to R1's daughter (V4) (on 3/6/2026) who said that R1's hip was not looking right. R1 went to therapy but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow up in a timely manner for Grievance/concerns and provide Dental services. This failure affects one (R7) of three residents reviewed for resident rights.Findings include:R7 is an [AGE] year-old admitted to the facility on [DATE] with the following diagnosis in part but not limited to: lipoprotein deficiency, other disorders of plasma-protein metabolism, not elsewhere classified, unspecified glaucoma, legal blindness as defined in USA, unspecified hearing loss, right ear, essential hypertension, body mass index 19.9 or less, adult, pain in right foot. On 2/19/26 at 12:39 PM, R7 stated that when she returned from hospital to facility on 11/24/25 she did not find dentures in her room, afterwards R7 said she requested multiple times to speak with V1(Administrator) but the staff kept telling her V1 was on vacation. R7 said she was redirected to V10 (Assistant Administrator) but that V10 never followed up. R7 stated that she then spoke with V16 (Social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 working call light for one (R4) of five residents reviewed for call lights. This failure resulted in a delay of staff helping R4.Findings include: R4 is a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses not limited to End Stage Renal Disease, Heart Transplant Status, Depression, Unspecified, Type 2 Diabetes Mellitus Without Complications, Essential (Primary) HypertensionR4's care plan documents in part: Focus: dated initiated:12/31/2025 Goal: I (R4) will be free of falls through Date initiated: 12/31/25 Interventions: I would like staff to provide me a safe environment: even floors, free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls Date Initiated: 12/31/2025On 1/2/2026 at 12:41pm R4 was sitting in chair in his room alert, able to make needs known, dressed and groomed. As surveyor was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain resident's room temperatures within a comfortable range of 71-to 81- degree Fahrenheit. This affected seven of seven residents (R1 - R7) reviewed for comfort environment. Findings include: On 06/23/25 from 1:02pm to 1:45pm, during the facility tour with V8 (Maintenance Director) the following observation were made on the 100 unit hallway: room [ROOM NUMBER] temperature measured 81.3 degrees Fahrenheit room [ROOM NUMBER] temperature measured 81.5 degrees Fahrenheit, room [ROOM NUMBER] temperature measured 81.6 degrees Fahrenheit room [ROOM NUMBER] temperature measured 81.5 degrees Fahrenheit room [ROOM NUMBER] temperature measured 81.6 degrees Fahrenheit room [ROOM NUMBER] temperature measured 81.3 degrees Fahrenheit Unit 200 back hallway temperature measured 81.5 degrees Fahrenheit. On 06/23/25 at 1:12pm, both R3 and R4 are roommates and they both stated that their room is very hot, but the staff are aware of it, and they have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assure that the resident environment remains comfortable and homelike with cooling system in proper working order to maintain acceptable temperature within 71- to 81-degree Fahrenheit. This failure affected 100-unit and 200-unit wings in the facility. Findings include: On 06/23/24 at 9:45am, V4 (Assistant Maintenance Director) stated in part that the whole 100 units in the building was hot the AC (Air-conditioner) was not working well with the temperature outside very hot it became hard to keep the inside cool. V4 stated that there were 20 unit of the fans in the roof and two fan belts were broken. The vents are not producing enough cool air for circulation since the belt is broken. On 06/23/25 at 10:25am, V1 (Administrator) stated that she was made aware of this problem with the temperature on Sunday 06/22/25. During the facility tour observation starting at 1:02pm with V8 (Maintenance Director) the following observation made: 100-unit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to follow its side rail policy and assess residents for the need of side rails use and/or obtain consent prior to the use of side rails for four residents (R26, R150, R159, and R161) of seven in a sample of 49. Findings include: On 5/20/25 at 10:00 AM, R159 was observed to have raised upper quarter side rails on both sides of bed. R26 was observed to have upper 1/2 side rails on both sides of bed. R150 was observed to have raised upper quarter side rails on both sides of bed. R161 was observed to have upper 1/2 side rails on both sides of bed. On 05/21/25 11:17 AM V5 (restorative nurse) stated that all beds in this facility have bilateral upper side rails. V5 stated that all residents should have a side rail assessment completed on admission, quarterly, significant change, and annually. V5 was unable to locate a side rail assessment for R159, admitted on [DATE]. V5 stated that side rail consents are kept in a binder. On 5/21/25 at 3:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their medication labeling, Storage of medications and insulin administration policies by not discarding medication for discharge residents, ensuring open date and expiration dates were labeled on insulin pens, ( R80, R136, R33, R59, R172) of five of five residents reviewed for medication storage. Findings include: On [DATE] at 10:56am, V15 (nurse) said, when insulin has been opened, it must be dated with an open/ expiration date. Resident who are currently residing in the facility should be the only residents with medication on the cart. R80 was discharged . R80's insulin should have been discarded. R80's was observed with a lispro insulin bottle dispensed on [DATE] on the medication cart opened and not dated. R80 had two bottles addition bottles of lispro insulin dispensed on [DATE] on the medication cart opened and not dated. V15 (nurse) said, expired insulin must be discarded. On [DATE] at 8:36am, V17 (adon) said, resident 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 observations, interviews, and record review this facility failed to follow their infection prevention and control policy and perform appropriate hand hygiene before entering and after exiting resident room, failed to follow their infection control policy for donning appropriate PPE (personal protective equipment) prior to entering resident rooms in enhanced barrier precautions to perform resident care. This affected four of four (R26, R150, and R137) residents reviewed for infection control practices Findings includes: On 5/20/25 at 12:40 PM, V15 (nurse) was observed donning gloves and entering R150's EBP room. V15 was observed bringing R68's bedside table to R150's bedside. V15 was observed flushing R150's gastrostomy tube with water. V15 did not don a gown prior to providing care to R150. On 5/21/25 at 8:45 AM, V13 NP (nurse practitioner) and V14 NP donned gloves and entered an EBP resident room. V13 and V14 performed a new admission skin assessment on the resident. V13 and V14 assessed resident head-to-toe for any skin abnormalities. Neither donned a gown prior to…

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

Based on observations, interviews, and record reviews, the facility failed to follow its electronic monitoring policy and post signage regarding electronic monitoring in use on facility entry and the resident's room, failed to obtain informed consent from residents and resident representatives before initiating video monitoring and audio monitoring for residents. This affected two of two residents (R83 and R159) reviewed for resident rights in a sample of 49. Findings include: On 5/21/25 at 3:00 PM, an electronic monitoring device was observed by this surveyor and V2 DON (director of nursing) on R159's bedside refrigerator. V2 stated that this device was monitoring the refrigerator temperature. On 5/21/25 at 3:10 PM, R83 stated that R83 was not aware that there was electronic monitoring being done in R83 and R159's room. R83 stated that R83 did not understand what this surveyor and V2 DON were talking about regarding the electronic monitoring device. On 5/22/25 at 9:15 AM, R159 stated that she was not aware there was an electronic monitoring device on her bedside refrigerator. 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.

Based on observation, interview the facility failed to ensure the call light was in reach for a dependent resident. This affected one of three residents (R146) reviewed for call light accessibility. Findings include: On 5/20/25 at 11:41am R146 was observed resting in bed, R146 observed alert to person and able to communicate. R146 call light was observed hanging down to the floor on the left-hand side of the bed. R146 said she don't know where her call was, R146 was observed to feel around for the call light but not able to reach it. At 12:27pm R146 call light remains out of reach. On 5/23/25 at 9:52am V17 (Assistant Director of Nursing) said call lights should be in reach of the resident; the residents use the call lights to call for the Nurse assistant when they need something. Facility policy titled Call Light Policy with last revised date of 7/26/2024 denotes in part, it is the policy of this facility to ensure that there is prompt response to the residents call assistance. The facility also ensures that the call system is in proper working order.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, facility staff failed to accurately code a Minimum Data Set (MDS). This affected three of three residents (R130, R81, R43) reviewed for accurate assessment. Findings include: 1. On 5/20/25 R130 observed alert to person, place and time, R130 said she has not received dialysis in over two years. R130 said she has a new kidney, and she is not receiving dialysis. R130 said she has never received dialysis at the this Nursing home. Review of R130 MDS dated [DATE], section o for special treatment, procedures and programs, J1 denotes dialysis , performed while a resident of this facility and within the last 14 days. Yes is checked with an X. Review of R130 physician orders including discontinued orders, R130 does not have any orders for dialysis treatment. On 5/22/25 at 10:49am V22 (MDS Coordinator/RN) said the MDS assessment should be coded accurately, the MDS drives the plan of care and is also used for reimbursement. V22 said R130 does not received dialysis and has never…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plans reflect the patients care needs for safe transfer status to include mechanical lift. This affected one of eight residents (R52) reviewed for implementation of care plan interventions in the sample of 49 residents. The findings include: On 05/20/25 at 11:21 AM V9, Certified Nursing Assistant (CNA), assisted R52 into the resident bathroom in her wheelchair. V9 told R52 to stand to use the toilet. R52 hesitant and required verbal and physical cueing from V9 to stand. No gait belt was applied to R52 during the transfer onto the toilet. V9 stood and R52 assisted with removing the soiled brief. R52 turned with V9 assisting and sat on the toilet. V9 said I know how to transfer the resident with the care cards instruction. V9 said R52 is recovering from a hip fracture. On 5/21/25 at 9:48AM V5, Restorative Nurse, said transfer status for R52 prior to her fall on 5/1/25 was stand and pivot with 1 assist. V5 said currently R52 should be 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 observations, interviews, and record reviews, this facility failed to provide incontinence care/checks at least every two hours. This affected one of three (R150) residents reviewed providing incontinence care for dependent residents in the sample of 49 residents. Findings include: On 5/20/25 from 11:45 AM until 1:45 PM, continuous observation was made by this surveyor. There was noted to be a malodor coming from R150's room. During this time period, staff did not provide incontinence care or turning/repositioning for R150. On 5/20/25 at 12:40 PM, V15 (nurse) was observed entering R150's room to provide gastrostomy tube care. V15 exited R150's room without checking if R150 needing incontinence care. On 5/20/25 at 1:45 PM, R150 was observed to have a urine saturated brief on, the flat sheet under R150 was wet from R150's upper back down to her knees with a brown discoloration outlining it. When R150 was turned towards her left side, the mattress was wet with liquid pooled where buttocks was. R150's sacral pressure ulcer dressing was saturated with urine. On 5/20/25 at 1:45…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, records reviews the facility failed to follow the identified mechanical lift transfer status while transferring onto the toilet and failed to follow their policy and use a gait belt to perform a safe transfer from bed to wheelchair for one resident. This affected one of three residents (R52) reviewed for safety during staff assisted transfers. This failure resulted in R52 falling during the bed to wheelchair staff assisted transfer and sustaining an acute impacted right femoral fracture. The findings include: R52 cognition on 4/21/25 was 13 and on 5/8/25 her cognition score decreased to 8. Facility reported incident report for R52 dated 5/1/25 states R52 was lowered to the floor during a transfer and found to have right hip fracture requiring right hip pinning. On 05/20/25 at 11:21 AM V9, Certified Nursing Assistant (CNA), assisted R52 into the resident bathroom in her wheelchair. V9 told R52 to stand to use the toilet. R52 hesitant and required verbal and physical cueing from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow their oxygen therapy and administration policy by failing to ensure residents have physician orders for oxygen use and ensure the oxygen concentrator is in working order. This affected one of one (R18) resident reviewed for oxygen use. Findings include: R18 was admitted to the facility on [DATE] with a diagnosis of dependence on supplemental oxygen, heart failure and atrial fibrillation. On 5/20/25 at 11:40AM, R18 observed in bed with nasal cannula in place. R18 oxygen concentrator was off. Staff notified of concern. At 12:03PM, V17(ADON) assisted R18 with oxygen and attempted to turn on concentrator but concentrator began to beep and not working properly. V17 exchanged oxygen concentrator for a new one. V17 said she was not notified prior of any concern to the oxygen concentrator. On 5/21/25 at 1:42PM, V2 (director of nursing) said there was no order for R18's oxygen. The last order for oxygen was discontinued on 4/7/25 when R18…

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

Based on interviews and records reviewed the facility failed to develop and implement protocols and a system to monitor antibiotic use for one resident with a history of Clostridium difficile currently on antibiotics. This failure affected one of eight (R28) residents reviewed for infection control practices. Findings include: On 5/21/25 1:21PM V3, IP (Infection Prevention) Nurse, said R28 was removed from contact isolation for C-Diff because there were no symptoms. Symptoms would include loose stools or abdominal cramping. There have been no reports that he has 3 loose stools or cramping. Consistency for c-diff stool can be putty, loose, runny, or slimy. Stool putty like should be reported. R28 Is on antibiotics currently and the floor nurse are responsible to monitor him. There should be an antibiotic assessment or progress notes to show the documentation of the assessment. On 5/21/25 2:01PM V3 said They (nurses) are not documenting the assessments for R28. V3 said we should be doing it, I expect it, but we don't have a policy for them to document when on antibiotics. V3 said they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that the resident was provided a clean homelike environment for one residents (R7) reviewed for home like environment. Findings include: On 5/20/25 at 11:15am R7 was observed resting in bed, there was dry substance on the tube feeding machine, thick dry substance was observed on the floor, numerous dry substances observed on the wall (flowing down the wall), dry substance observed on the bed side table, and dark substance observed on the bed framing. At 3:00pm dry substance remains on the floor, walls, machine and bed framing. On 5/21/25 at 10:56am dry substance remains on the floor, walls, machine and bed framing. On 5/21/25 at 11:20am R7 was observed resting in bed, R7 said she received a bed bath today, R7 said she is dry, and not soiled. R7 pillowcase was observed with a wet yellow/brown stain, smelled of urine. R7 said the aide did not change her bed linen today. R7 said she doesn't know if the sheets have the same stains as the pillowcase. R7 agreeable for observation of checking her bed sheets. V23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document in residents electronic health record and notify family regarding a resident's fall. This failure affected one resident (R4) out of eight residents reviewed for quality of care. Findings include: R4 was [AGE] years old with diagnosis but not limited to: Senile Degeneration Of Brain, Shortness Of Breath, Dysphagia, Difficulty In Walking, Muscle Wasting And Atrophy, Muscle Wasting And Atrophy, Gerd, Hypertension , Conversion Disorder With Seizures Or Convulsions, History Of Falling, Dependence On Renal Dialysis, Raynaud's Syndrome Without Gangrene. On 3/29/25 at 9:32 am V12 (Fall Nurse) said R4 on 3/19/25 had fall. V12 said, R4 was transferred to bed 30 minutes prior to the fall and the bed was in low position. V12 said, during rounds R4 was observed lying next to her bed on the floor, she was a hospice resident, she was not sent out to the hospital as there was no need for hospital admission. V12 said, the protocol for falls is V12 herself need…

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

Based on interview and record review, the facility failed to follow the Abuse and Neglect Policy by not reporting an allegation of rough handling to the Administrator immediately for one of three residents (R1) reviewed for Improper Nursing Care on the total sample list of three. Findings include: On 12-3-24 and 10:00 AM and 11:25 AM, surveyor told V1 (Director of Nursing) and V2 (Assistant Director of Nursing) about allegations of night shift staff rough handling R1. No further follow up was mentioned by V1. On 12-5-24 at 9:57 AM, V17 (Administrator) said if she receives a concern of rough handling, she will send state reportable and begin investigation immediately. V17 said she was not aware of rough handling allegation received on 12-3-24. V17 said she will send state reportable and begin investigation immediately. On 12-5-24 at 9:15 AM, V1 (Director of Nursing) said when there is an allegation of rough handling, V1 said she would immediately report this concern to V17 (Administrator). V1 said she did not report this incident (on 12-3-24) however she will immediately tell…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility protocol to safely operate a full body mechanical lift by failing to use 2 staff persons when transferring a patient to a wheelchair from bed. This affected one of three resident (R1) reviewed for mechanical lift. This failure resulted in the full body mechanical lift tipping onto the floor and R1 falling to the floor, while still hooked by the sling to the lift. findings include: R1 incident report dated 11/1/24 states writer heard R1 yelling help. Writer observed R1 on the floor with the full body mechanical lift on the floor next to the resident. R1 complained of lower back pain, rated 10. R1's diagnosis include but are not limited to Encounter for Orthopedic Aftercare, Heart Failure, Atrial Fibrillation, Peripheral Vascular Disease, Chronic Kidney Disease, End Stage Renal Disease, Pain in Left hip, Displaced Fracture of Left Femur. On 11/8/24 at 10:13AM V8, R1's family, said R1 said the facility called me about 7:30AM. V8 said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to ensure one resident's (R3) money was managed from her monthly portion paid to the facility. The facility collected a balance of $5,504.06 from R3's facility managed account and did not present an itemized record of services for the amount taken. This failure affected 1 of 3 residents reviewed for finances. The findings include: R3's diagnosis include but are not limited to Cerebral Infarction, Depressive Disorder, Diabetes, Heart Disease, and Dementia. R3 died on [DATE] and had resided at the facility since 2016. R3 was [AGE] years old. Facility Abuse Report dated [DATE] states V19 (R3's POA), called and spoke to V13, Business Office Manager (BOM), regarding the trust account for R3 on [DATE]. V13 disclosed the amount in R3's account of $840.94. V19 said the amount should be more and V13 explained that in February 2023 the amount of $5504.06 should be applied to the balance of $6636.72. V19 states she never signed anything. Facility investigation…

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

Based on interview and record review, the facility failed to follow their notification for change in condition policy by failing to notify the family and physician following a fall for one resident (R1) for one of three residents reviewed for falls. Findings include: R1's fall risk evaluation dated 8/17/24 under cognition documents: Under history documents resident just had a fall. Under narrative documents: While I (V18) was getting report the CNA came and told myself and the morning nurse (V14)that the patient was sitting on the floor. We went into the patient's room and he was sitting between the bed and the wall with his back against the wall. He stated that he was trying to go to the bathroom and couldn't find his urinal. On 9/25/24 3:31PM, V14 (Nurse) who was assigned to R1 on 8/17/24 morning shift denied making any notifications to the family, doctor or falls coordinator related to R1's fall on 8/17/24. On 9/25/24 at 12:38PM, V18 (Nurse) said recalls assisting V14 (nurse) for fall on 8/17/24. V18 she did not notify anyone of the fall and V14 was responsible for notifications.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview, the facility failed to follow physician orders for no-pressure wound treatment for one resident. This affected one of three residents (R4) reviewed for non-pressure wound orders. Findings include: R4 was admitted to the facility on [DATE] with a diagnosis of type II diabetes, hidradenitis suppurativa acquired absence of right and left leg below the knee amputations. R4's Minimum Data Set, dated [DATE] documents a brief interview for mental status score of 15/15 which indicates cognitively intact. Under section GG under roll left to right documents substantial/ maximal assistance which indicates helper does more than half the effort to complete the activity. R4's braden scale dated 9/23/24 documents a score of nine which indicates high risk for skin breakdown. On 9/25/24 at 12:47pm, V12 (restorative aide) said, she gave R4 a shower on 9/24/24 before lunch which was around noon. R4's dressing to the right arm pit came off during the shower. V12 said, she notified V7 (wound care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent financial abuse and theft for one resident (R1) in a sample of 8 residents reviewed for abuse. Findings include: Facility's reportable documents in part: R1 is a female resident with a BIMs (Brief Interview of Mental Status) score of 12/15. Diagnosis including Osteoarthritis of the knee, obstructive sleep apnea, depression, pulmonary hypertension, and difficulty in walking. R1 reported on 6/17/2024 that her purse was missing. R1 reported, her purse missing to V3, (Activity Director). V3, then went and told V16 Assistant Administrator. V16 then went and spoke with R1 and she then explained, that when she woke up on Saturday morning that she could not find her purse. V16 filed an initial reportable. Notified the police. After carefully searching the unit R1 purse was found in another resident's room nightstand. After thorough Investigation, staff, and resident interviews, and after carefully searching the unit R1 purse was found in another…

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

Based on observation, interview and record review, the facility failed to label foods being thawed inside the refrigerator. This failure has the potential to affect all 159 residents currently residing in the facility. Findings include: On 05/14/2024 at 10:15AM during initial kitchen tour with V4 (Dietary Manager), the refrigerator was observed with unlabeled food thawing. V4 verified and identified the food as chicken breast, ham, turkey, ground beef, and a pitcher of orange juice. On 05/14/2024 at 10:20AM V4 said that the food thawing should all be labeled. On 05/15/2024 at 10:19AM Informed V1 (Administrator) of above observation made. V1 said that the expectations of food being thawed referred to facility policy. Review of facility policy with section entitled Food Safety/ Thawing and Food Handling Standards and Procedures on Labeling Processes developed on 05/08/2023 indicated the following: Policy: Thawing Ensure food is only thawed using one of these four approved methods: 1. In refrigerators operating at <40F (<4C) 2. Under cold running water that's <70F (<21C) ensuring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 exercise the right of the resident representative to choose a Long-Term Care Facility of their choice in one of four (R329) residents reviewed for residents right in a sample of 32. Finding includes: On 5/17/2024 at 09:52 AM, V37 (R329's daughter) said that V37 is the surrogate decision maker for her mother. V37 said that her mother was admitted to the facility for physical therapy only after a hospitalization. V37 said that her mother needed a permanent long term care facility when discharged . V37 said that V37 requested for her mother to be transferred to an assisted living Facility. V37 said that her mother was transferred to another long term care facility without her permission. V37 said that her mother was not happy at that facility and she followed up with having V44 (representative from the assisted living facility ) to come to the long term care facility to assess her mother through the assistance of someone she knew. V37 said that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure implementation of pressure ulcer prevention interventions and manufacturer recommendation for using low air loss mattress for resident with Stage 4 pressure ulcers. This deficiency affects one (R48) of three residents in the sample of 32 reviewed for Pressure Ulcer Prevention and Treatment Management. Findings include: On 5/15/24 at 10:24AM, Observed R48 lying in bed with LAL (low air loss) mattress. R48 has flat sheet and thick bath blanket folded in quarters over the LAL mattress. Called V5 Unit Manager and showed observation made. V5 said that R48 has pressure ulcers on sacral and bilateral heels. V5 said that R48 should only be on flat sheet over the mattress. Surveyor asked V5 to see the bilateral feet of R48. Observed bilateral heels with dressing but no heel protectors to off load heels. Bilateral heels on pillows, not elevated off from bed. R48 is admitted on [DATE] with admitting diagnosis listed in part but not limited to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate restorative services consistent to resident's functional need is provided to a resident with a limitation of range of motion to both upper extremities. This deficiency affects one (R30) of three residents in the sample of 32 reviewed for Restorative Nursing Program. Findings include: On 5/14/24 at 11:15AM, Reviewed list of residents on Braces /Splint program presented by V5 Unit Manager. V5 said that R30 is on bilateral hand splint to prevent contractures. Surveyor and V5 went to R30's room. Observed R30 lying in bed without bilateral hand splint. R30 has bilateral wrist hand and elbow flexion contractures. Observed 1 hand splint on top of bedside drawer. V5 Unit manager searched for the other hand splint but unable to locate. R30 said that she has only using left hand splint. R30 said that she has cannot move both of her hands/arms without assistance. On 5/14/24 at 11:28AM, V6 Restorative Nurse said that she ensures…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure ongoing assessment and implementation of catheter care to resident with indwelling urinary catheter. This deficiency affects one (R48) of three residents in the sample of 32 reviewed for Catheter Care Management. Findings include: On 5/15/24 at 10:24AM Observed R48 lying in bed with Low air loss mattress. Observed indwelling catheter with brownish, yellow-colored sediments attached inside the lining of the catheter tubing. The urinary drainage has privacy bag. Called V5 Unit Manager/Infection Coordinator and showed observation made. V5 assessed R48's indwelling catheter tubing. Noted the entire catheter tubing from the urinary catheter connectors down to the urinary drainage bag has brownish, yellow-colored sediments attached inside the lining of the catheter tubing. V5 said that indwelling catheter care is rendered every shift to prevent catheter associated urinary tract infection. Any changes in color of the urine or formulation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate use of Personal Protective Equipment (PPE) during high contact care activities on a resident with urinary catheter and on Enhanced Barrier Precaution (EBP). This facility also failed to perform hand hygiene before donning new pair of gloves after incontinence care. These failures affect 2 of 5 residents (R137, R140) reviewed for infection control in a sample of 32. Findings include: 1. On 5/15/2024 at 01:44 PM observed V30 (Certified Nursing Assistant/CNA) without gloves on while emptying R140's urinary catheter bag. R140 on Enhanced Barrier Precaution (EBP) On 5/15/2024 at 01:45 PM V30 stated he should used gloves while emptying the catheter bag. On 5/15/2024 at 02:03 PM V5 (Infection Control Nurse) said staff should use gown and gloves when emptying the catheter bag and must do handwashing after the task. On 5/15/2024 at 02:25 PM V2 (Director of Nursing/DON) said gown and gloves must be worn while emptying the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based Based on interview and record review, the facility failed to follow their policies regarding indwelling urinary catheter care by failing to identify and promptly treat a catheter related laceration for one resident (R1). This failure applies to one (R1) of one resident reviewed for catheter care. Findings include: R1 is [AGE] years old and admitted to the facility 3/2/24 with diagnoses that included hypertension, diabetes type II and acquired absence of great toe. According to progress notes dated 3/4/24, nursing staff utilized a bladder scanner on R1, and it was determined that R1 was retaining urine. Subsequently, an order was placed for R1 to receive an indwelling urinary catheter to maintain emptying of bladder. According to the Physician's Order Sheet, on 3/4/24, an order was placed for 16F (French) indwelling catheter and included separate orders for changing the catheter and drainage bag as needed, however, the order set did not include instructions that would prompt nursing staff to perform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policies by not documenting catheter care and cleaning every shift (R1 and R3) failed to ensure a care plan was in place for residents with indwelling urinary catheters (R1 and R4). This failure applied to three (R1, R3 and R4) of four residents reviewed for catheter care. Findings include: R1's progress notes dated 3/4/24 documents, nursing staff utilized a bladder scanner on R1, and it was determined that R1 was retaining urine. Subsequently, an order was placed for R1 to receive an indwelling urinary catheter to maintain emptying of bladder. The electronic health record reviewed for R1 did not include any documentation for care plan and focused interventions for urinary catheter care. Point of care reports provided by the facility does not document perineal care was provided every shift from 3/6/24 to 3/18/24. An order to provide catheter care every shift and care plan for urinary catheter was initiated 3/20/24 during this survey after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were transferred in a safe manner for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of 18. The findings include: On 2/9/24 at 9:49 AM, R3 was sitting in her wheelchair outside her room near the nurse's station. A mechanical lift sling was not positioned under R3. On 2/9/24 at 9:57 AM, V15, Certified Nursing Assistant (CNA), said she got R3 dressed and out of bed this morning. V15 said she used a one person pivot to transfer R3 from her bed to her wheelchair. On 2/9/24 at 2:15 PM, V21, Restorative Aide, said R3 is supposed to be transferred with a mechanical lift. V21 said R3 cannot stand and pivot to be transferred at this time. On 2/9/24 at 2:30 PM, V16, Registered Nurse/Unit Manager, said staff leave the sling (pad), under the resident after using the mechanical lift to transfer them. R3's Minimum Data Set (MDS) dated [DATE] shows R3 did not attempt to come to a standing position from sitting…

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

Based on observation, interview, and record review the facility failed to accurately document the administration of a controlled medication on a resident's Medication Administration Record and Controlled Drug Administration Form for 1 of 3 residents (R15) reviewed for controlled medications in the sample of 18. The findings include: R15's Medication Administration Record (MAR) for January 2024 documents an order for Hydromorphone (narcotic pain medication) 1 milligram/milliliter (mg/ml)-2 ml by mouth every 4 hours as needed for pain. R15's MAR documents that she received two- 2 ml doses of hydromorphone on 1/24/24 and one- 2 ml dose of hydromorphone on 1/25, 1/26, 1/29, 1/30 and 1/31/24. R15's February MAR documents that she received two-2 ml doses on 2/1/24 and 2/7/24 and received one- 2 ml dose on 2/2, 2/3, 2/4, 2/5, 2/8 and 2/9/24. (17-2 ml doses total) R15's Controlled Drug Administration Record documents that 60 ml of hydromorphone was delivered to the facility on 1/22/24. R15's Controlled Drug Administration Record documents that she received three-2 ml doses of hydromorphone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident's plan of care related to falls was carried out accordingly and failed to ensure that staff were aware of resident fall risk status in order to implement fall risk interventions, for a resident assessed to be at high risk for falls. This failure applied to one (R1) of three residents reviewed for falls. Findings include: R1 is [AGE] years old and admitted to the facility 11/15/23 with diagnoses that include Dementia, Cerebral infarction, and Adult Failure to Thrive. Hospital records on admission to the facility indicated that R1 was admitted to the hospital on [DATE] and treated for weakness, decreased oral intake, and was admitted for Failure to Thrive. While in the hospital R1 was considered to be at high risk for falls, and cognition was assessed with findings of poor attention/concentration, poor judgment, poor safety awareness and short term memory loss. Per record review, R1 is in the facility for short term…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to complete an accurate MDS regarding the skin condition of resident for one of six sampled residents (R3) Findings include: Per R3's face sheet, resident admitted to the facility on [DATE] with a stage 4 pressure ulcer of the sacral region. R3's hospital documentation dated 07/07/2023 indicated post debridement measurement to sacral region pressure ulcer as 13 x 16 centimeters (cm). No depth to wound is documented. R3's skin evaluation assessment dated [DATE] completed by V11 (Wound Care Nurse) indicated resident has an alteration in skin integrity, and a pressure ulcer to his sacrum that measured in centimeters at 14.00 x 17.00 x 2.00 (length x width x depth) and staged at IV (four). Assessment indicated air loss mattress in use by R3 but no physician order found for this mattress type. R3's admission assessment signed by V8 (Licensed Practical Nurse) on 07/12/2023 indicated resident admitted to facility on 07/10/2023. On page 8 of same 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.