The Citadel at Saint Joseph Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was positioned safely to prevent a fall for 1 (R4) of 4 residents reviewed for falls in the sample of 23.The findings include:R4s admission record shows she was admitted to the facility on [DATE] with a primary diagnosis of congestive heart failure and a history of falling. The 12/16/25 quarterly resident assessment and care screening documents R4 to be cognitively intact. The same record shows R4 requires partial/moderate assist with rolling right to left. The helper lifts, holds or supports trunk and limb during the movement.R4s 11/30/25 care plan documents her to be a high risk for falls related to functional deficits.The facility's 2/5/26 incident report of a witnessed fall documents R4 fell out of bed during repositioning. She was lowered to the floor gently by the aide. On 3/04/2026 at 12:34 PM, R4 said she had rolled out of her bed about a month ago. The Certified Nursing Assistant (CNA) was repositioning her in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an indwelling catheter drainage bag was maintained below the level of the bladder for 1 of 3 residents (R31) reviewed for indwelling catheters in the sample of 23. The findings include:On 3/4/26 at 8:35 AM, V19 and V20 (Certified Nursing Assistants - CNAs) had the total lift in R31's room. They said they just got R31 up and were getting her ready for her dentist appointment. V20 left the room briefly and re-entered. R31 was seated in her electric wheelchair. V19 lifted R31's catheter drainage bag in the air to place it in the privacy bag. R31's catheter drainage bag was at the level of R31's shoulders (above the level of her bladder) and yellow urine was flowing back toward R31 in the tubing.On 3/4/26 at 12:34 PM, V21, V22, and V23 (CNAs) entered R31's room to transfer her to bed with the total lift. V22 and V23 applied R31's total lift sling to the mechanical lift. V22 said someone will need to hold R31's catheter. V22 removed 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 label open tube feeding, ensure a feeding tube dressing was intact, and check placement of a feeding tube prior to using the tube for 1 of 1 residents (R3) reviewed for enteral feeding in the sample of 23. The findings include:On 3/3/26 at 10:07 AM, there was an open bottle of tube feeding sitting on R3's dresser. There was 300 milliliters (ml) left in the bottle. The tube feeding was not labeled when it was opened.On 3/3/26 at 1:19 PM, R3 was laying in bed with his abdomen exposed. R3's feeding tube was slightly pulled out and there wasn't a dressing on his abdomen around the feeding tube. The dressing was twisted with bloody drainage and was hanging down on his tubing. V7 (Licensed Practical Nurse - LPN) was leaving his room and stated she was just cleaning up his room. At 1:24 PM, V7 was asked if she was returning to R3's room and she stated she had already given R3 his bolus of tube feeding at 11:00 AM and his medications had been given so she was done in his room. V7 stated his dressing around his feeding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 professional standards when starting an intravenous (IV) antibiotic for 1 of 1 resident (R38) in the sample of 23. The findings include:On 3/3/26 at 9:35 AM, V18 (Registered Nurse - RN) prepared to administer IV antibiotics to R38's PICC (peripherally inserted central catheter) line. V18 flushed R38's PICC line with 10 milliliters (ml) of Normal Saline (NS), clamped the PICC line and left the syringe attached to R38. V18 checked the IV antibiotic and stated, This is ampicillin 500 milligrams (mg) and we will run the 100 ml over 60 minutes. V18 opened the IV tubing and spiked the antibiotic. V18 primed the IV tubing with the antibiotic, clamped the white C-clamp and roller clamp. V18 removed the flush syringe from R39's PICC line, cleansed the site with an alcohol swab and attached the IV tubing. V18 opened the clamp on the PICC line site and the roller clamp on the IV tubing. The white C-clamp was still closed on the IV tubing. V18 said the next step was to put the tubing in the pump and set the rate.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have respiratory masks covered and stored in a manner to prevent any cross contamination for 3 of 3 residents (R3, R29, and R107) reviewed for respiratory care in the sample of 23.The findings include:1. On 3/3/26 at 10:07 AM R3 had a CPAP (Continuous Positive Airway Pressure) machine with a face mask sitting face down uncovered on the bedside table. The mask was dirty with white substances on the inside of the mask and some tan flakes. R3's nebulizer mask was uncovered on the bedside table, and the inside of the mask was dirty.On 3/3/26 at 2:25 PM, V3 (Assistant Director of Nursing - ADON/Infection Control Preventionist) stated respiratory masks are kept in little black bags next to the machines. This is done for sanitary reasons/infection control.R3's Face Sheet dated 3/4/26 showed diagnoses including hypoxic ischemic encephalopathy, asthma, critical illness myopathy, type 2 diabetes mellitus, obstructive sleep apnea, dysphagia, cognitive communication deficit, aphasia, spastic hemiplegia, gastroesophageal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose of a residents (R90) expired insulin pen, failed to store narcotics in a manner to prevent medication diversion for a resident (R80). These failures apply to 2 of 2 medication carts reviewed for medication storage.The findings include:On [DATE] at 1:34PM, surveyor reviewed medication cart belonging to V17's (Licensed Practical Nurse-LPN) assignment. R90's insulin aspart pen had an open date of 12/15 and an expiration date of 1/15. V17 stated, We try to keep an eye on the insulin pens to check expiration dates. (R90) hardly ever uses his sliding scale insulin so that's probably why we didn't notice it but it should have been discarded if it's been open for more than 28 days. V17 disposed of R90's insulin aspart pen and obtained a brand new one out of the medication room and stated, I don't know why we didn't replace it if there's a new one here that we should be using. R90's February and March medication administration records were…

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

Based on observation, interview, and record review the facility staff failed to follow enhanced barrier precautions - EBP when providing care for a resident with a feeding tube for 1 of 3 residents (R3) reviewed for enhanced barrier precautions in the sample of 23.The findings include:On 3/3/26 at 1:24 PM, R3 was laying in bed with his dressing around his feeding tube twisted with bloody drainage. The dressing was down on the tubing and not secure to his abdomen. At 1:28 PM, V7 (Licensed Practical Nurse - LPN) and V9 (Certified Nursing Assistant - CNA) went into R3's room with gloves on but no gowns on. They repositioned R3 in the bed. V7 removed the old dressing from around R3's feeding tube, did site care, and placed a new dressing. V7 and V9 repositioned R3 in bed. V9 stated R3 was incontinent of bowel movement and said she needed to go and get help. When V9 returned to the room she had V8 (CNA) with her. V7, V8, and V9 were asked about EBP. V7 stated she did not know if R3 was on EBP. V8 stated that a gown, gloves, and face mask is to be worn with care of the feeding tube 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 honor resident preferences regarding menu items. This failure has the potential to affect all residents residing in the facility. The findings include:The facility's resident roster provided on 12/6/25 showed 77 residents reside in the facility.On 12/6/25 at 8:39 AM, V3 [NAME] stated bacon used to be provided for the residents prior to the current owners acquiring the building. (New corporation took ownership on 10/1/25.) V3 said, We used to make bacon all the time.I had four residents ask for it this morning.On 12/6/25 at 8:45 AM and 8:47 AM respectively, a walk-through of the facility's walk-in freezer and walk-in refrigerator showed no bacon.On 12/6/25 at 8:53 AM, V2 Dietary Aide stated We do have residents asking for bacon all the time, but we were told the company won't allow it. [V4] is the dietary manager, and he called the company, and they said no bacon. V2 stated R2, R3, R4, and R5 routinely ask for bacon.On 12/6/25 at 1:16 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents were treated in a dignified manner for 3 of 3 residents (R1-R3) reviewed for dignity in the sample of 5. The findings include: On 7/21/25 at 9:02 AM, R1 stated, I had a shower last Tuesday (7/15/25). The aide that was with me was on her cell phone the whole time we were in the shower. I don't remember her name. She answered her phone and talked through her earphones. I felt like she wasn't really paying attention to me. I wasn't important. R1's shower records showed R1 did receive a shower on 7/15/25 by V8 Certified Nursing Assistant (CNA). On 7/21/25 at 8:35 AM, R2 stated during her shower on 7/12/25, the CNA that gave her a shower was on her phone. She had her earphones in and her cell phone rang. She answered it (while she was in the shower with R2) and started talking. R2 stated, Why was my bath not more important than her phone call? She has a job because I need help. R2 stated she was unable to remember the name of the CNA that showered her on 7/12/25. R2's shower records showed R2 did receive a…

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

Based on interview and record review the facility failed to provide showers to a resident that required staff assistance to shower for 1 of 3 residents (R1) reviewed for activities of daily living (ADLs) in the sample of 5. The findings include: R1's current care plan showed R1 required staff assistance and supervision for showering or bathing. On 7/21/25 at 9:02 AM, R1 stated he's supposed to get at least two showers per week but sometimes he only got one shower per week or none at all. R1's shower records dated 5/1/25-7/21/25 were reviewed. R1's records showed R1 received a shower on 6/27/25. The records showed R1 was not offered and did not receive another shower until 7/11/25 (13 days later). On 7/21/25 at 12:21 PM, V2 Director of Nursing (DON) stated staff are to offer and/or provide a shower or bath to residents twice a week. V2 stated the facility did not have a policy on how often a resident is to be showered/bathed.

Based on interview and record review the facility failed to follow up and obtain an ophthalmology appointment for a resident with vision loss for 1 of 3 residents (R1) reviewed for necessary care and services in the sample of 5. The findings include: R1's current care plan showed R1 was visually impaired which required him to wear eyeglasses. A physician order for R1, dated 12/17/24, showed, Ophthalmology consult and treatment as indicated. On 7/21/25 at 9:02 AM, R1 was seated in bed. R1 wore eyeglasses. R1 stated he felt like his vision had gotten worse recently even with wearing his glasses. R1 stated he had an appointment to see an eye doctor but the appointment was canceled. R1 stated he didn't know why the appointment had been canceled. R1 stated he had not been seen by an ophthalmologist and/or had his vision tested in over a year. The facility's resident outside appointment records dated 4/1/25-7/21/25 was reviewed. The records showed R1 had an appointment for an ophthalmology exam on 5/1/25 but the appointment had been canceled due to the ophthalmology office not accepting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 surgical incision was cleansed per physician's order for 1 of 3 residents (R1) reviewed for physician's orders in the sample of 5. The findings include: R1's medical record showed she was admitted to the facility on [DATE] with diagnoses to include fibromyalgia, atherosclerotic heart disease, surgical aftercare following cardiac surgery, myocardial infarction, presence of aortocoronary bypass graft, asthma with acute exacerbation, chronic pain syndrome, muscle wasting, muscle weakness, hypertension, major depressive disorder, obstructive sleep apnea, and hypokalemia. R1's facility assessment dated [DATE] showed she had no cognitive impairments and required partial to moderate assist with most cares. R1's acute care hospital discharge packet dated 5/27/25 showed . Wound Care Orders . Monitor your wounds for signs and symptoms of infection, including redness, swelling, drainage, and odor. If you notice these symptoms call your surgeon's office.…

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

Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician for one of six residents (R1) reviewed for medications in the sample of six. The findings include: R1's Face Sheet dated June 9, 2025 shows she was admitted to the facility with diagnoses including fibromyalgia, heart disease, myocardial infarction, presence of aortocoronary bypass graft, asthma, chronic pain syndrome, muscle weakness, hypothyroidism, major depressive disorder, mixed hyperlipidemia osteoarthritis, and generalized anxiety disorder. R1's Medication Record dated June 2025 shows levothyroxine ordered to be administered at 7:00 AM and an order for acetaminophen 500 mg (milligrams) one tablet by mouth four times per day. On June 9, 2025 at 9:18 AM, during the morning medication pass, V5 Licensed Practical Nurse (LPN) administered R1's levothyroxine that was ordered to be given at 7:00 AM and administered acetaminophen 500 mg two tablets instead of one tablet as ordered. On June 9, 2025 at 11:15 AM, R1 said that she has to take her levothyroxine at…

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

Based on interview and record review, the facility failed to provide wound/skin treatments and failed to perform weekly skin checks. This applies to 4 of 5 (R4, R3, R1, R5) residents reviewed for improper nursing care in the sample of 6. The findings include: 1.) R4's Face Sheet showed she had skin infections, morbid obesity, and congestive heart failure. On 5/27/25 at 12:50 PM, R4 said she may only receive her leg wound care one to two times per week, depending on the staff that are working. R4's 5/26/25 Wound Evaluation and Management Summary report showed she had a non-pressure wound to the left thigh measuring 0.3 centimeters (cm) by 0.7 cm by 0.2 cm deep. The wound report showed a second non-pressure wound to her right knee measuring 4.4 cm by 5.3 cm by 0.7 cm deep. The wound report showed another non-pressure wound to R4's left thigh measuring 0.5 cm by 1.9 cm by 0.1 cm. R4's April 2025 Treatment Record (Treatment Administration Record, TAR) showed weekly skin checks were not documented as being done on 4/6/25, 4/20/25, and 4/27/25. R4's April 2025 TAR showed three separate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify and report the diversion of a resident's controlled substance. This applies to 1 of 3 residents (R5) reviewed for controlled substances in the sample of 6. The findings include: R5's May 2025 Medication Record (Medication Administration Record, MAR) showed an order for lorazepam (anxiety treatment medication) liquid 2 milligrams per milliliter (ml). The MAR showed 0.25 milliliters should be given under the tongue every four hours as needed for restlessness. R5's Lorazepam Controlled Drug Receipt/Record/Disposition Form (Count Sheet) showed the pharmacy delivered 30.0 ml of lorazepam on 3/28/25. The count sheet showed from 3/28/25 to 5/16/25, 8 doses of lorazepam at 0.25 ml were given. The count sheet showed, on 5/17/25 at 6:00 AM, the count was correct(ed) from 28.0 mls available to 24.0 mls available (a discrepancy of 4 mls). The count showed two nurses signed off on the correction. The count sheet showed, as of 5/27/27, no lorazepam had been dispensed since the correction on 5/17/25. On 5/27/25 at 11:19 AM, V3…

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

Based on observation, interview, and record review, the facility failed to provide treatments for a pressure wound. This applies to 1 of 5 residents (R2) reviewed for wound care in the sample of 6. The findings include: R2's Face Sheet showed she had a stage four pressure injury above her buttocks. On 5/29/25 at 9:25 AM, V5 Wound Care Nurse provided R2's ordered wound care. The wound appeared to be the size as described in R2's 5/26/25 wound note. The wound bed was red and not actively draining. V5 provided wound care and applied a dressing. R2's April 2025 Treatment Record (Treatment Administration Record, TAR) showed an order for twice-daily wound care treatments for her stage four pressure injury. The TAR showed the evening treatments on 4/29/25 and 4/30/25 were not documented as being done. R2's May 2025 TAR showed her pressure injury wound care order carried over from April 2025. The TAR showed her evening 5/10/25 wound care treatment was not documented as being done. On 5/27/25 at 2:20 PM, V5 Wound Care Nurse stated the purpose of wound care treatments was to promote healing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an accurate disposition of controlled substances, failed to have procedures in place to accurately measure controlled substances, and failed to maintain an accurate log of controlled substances. This applies to 1 of 3 residents (R5) reviewed for controlled substances in the sample of 6. The findings include: 1. R5's May 2025 Medication Record (Medication Administration Record, MAR) showed an order for lorazepam (anxiety treatment medication) liquid 2 milligrams per milliliter (ml). The MAR showed 0.25 milliliters should be given under the tongue every four hours as needed for restlessness. R5's Lorazepam Controlled Drug Receipt/Record/Disposition Form (Count Sheet) showed the pharmacy delivered 30.0 ml of lorazepam on 3/28/25. The count sheet showed from 3/28/25 to 5/16/25, 8 doses of lorazepam at 0.25 ml were given. The count sheet showed, on 5/17/25 at 6:00 AM, the count was correct(ed) from 28.0 mls available to 24.0 mls available (a discrepancy of 4 mls). The count showed two nurses signed off 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 ensure pureed Swiss steak was a smooth, uniform texture that does not require chewing for 4 of 4 residents (R2, R35, R52, R78) reviewed for pureed diets in the sample of 18. The findings include: The facility provided list of residents on a pureed diet shows that R2, R35, R52, and R78 receive a pureed diet. On 12/9/24 at 11:28 AM, V11 (Cook) began pureeing the Swiss steak for lunch. V11 said the texture she is looking for with the pureed products is a consistency similar to mashed potatoes. V11 ran the food processor for a few short minutes before using a spatula to put the pureed Swiss steak into a steam table pan. The pureed Swiss steak appeared slightly chunky while V11 was transferring the product from the food processor into the steam table pan. V11 did not taste test the pureed Swiss steak when finished. On 12/9/24 at 1:12 PM, facility provided test tray of pureed Swiss steak, pureed broccoli, pureed mashed potatoes, and pureed bread pudding was reviewed. The pureed Swiss steak was gritty with small…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 spatula and food processor components were washed and sanitized in a manner to prevent cross-contamination for 4 of 4 residents (R2, R35, R52, R78) reviewed for pureed diets in the sample of 18. The findings include: The facility provided list of residents on a puree diet shows that R2, R35, R52, and R78 receive a pureed diet. On 12/9/24 at 11:28 AM, the facility had approximately six food processor pitchers, two food processor lids, and three food processor blades for use at the puree station. On 12/9/24 at 11:28 AM, V11 (Cook) started to puree the Swiss steak for lunch. When V11 finished the Swiss steak, V11 placed the food processor pitcher with the blade and lid into the sink adjacent the puree prep station. V11 ran hot water into the pitcher and grabbed the spatula and ran it underneath the running hot water. V11 then grabbed a new food processor pitcher, blade, and lid and started to puree the mashed potatoes for lunch. When finished with the mashed potatoes, V11 used the spatula that was run…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 treat a resident in a dignified manner for 1 of 18 residents (R9) reviewed for dignity in the sample of 18. The findings include: R9's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including parkinsons, chronic obstructive pulmonary disease, contusion of left ankle, and generalized anxiety disorder. R9's Care Plan with an admission date of May 28, 2021 shows R9 has emotional and spiritual distress due to hopelessness and lack of family support. R9's Care Plan dated February 9, 2022 shows to approach resident warmly and positively and in a calm manner, calmly talk with resident and offer reassurance prior to initiating cares. On December 9, 2024 at 10:14 AM, R9 went into her room and was asking to go into her bed. R9 was moaning and saying Oh my God. R9's moans were audible from across the hall. At 10:44 AM, V8 CNA (Certified Nursing Assistant) walked into R9's room and stood at the foot of R9's bed. 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.

Based on observation, interview and record review the facility failed to safely transfer a resident by using a gait belt for 1 of 18 residents (R36) reviewed for safety in the sample of 18. The findings include: R36's Care Plan shows, Gait belt with all transfers .Transfers with assist of 1 person. On 12/9/24 at 1:01 PM, V18, Certified Nursing Assistant (CNA) brought R36 to his room. V18 positioned R36's wheelchair next to his bed. V18 assisted R36 to a standing position by lifting under his arm. V18 instructed R36 to turn while she guided his hips with her hands to the appropriate position to get into bed. V18 did not apply a gait belt on R36 during the transfer from his wheelchair to the bed. On 12/10/24 at 1:53 PM, V19 (CNA) said that R36 is a one person assist for transfers and staff should use a gait belt and his walker for the transfer. On 12/10/24 at 1:53 PM, V2 (Director of Nursing) said that gait belts should be use with all transfers for the resident's safety if they start to fall. The facility's Restorative Nursing-Transfer Program Policy revised on 12/2017 shows, Use…

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

Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 37 opportunities with 4 errors resulting in a 10.81 % error rate. This applies to 1 of 3 residents (R2) observed in the medication pass. The findings include: 1. R2's December Medication Administration Record (MAR) showed that R2 had an order for Diltiazem 30 milligrams (mg) to be given at 8:00 AM for hypertension. There was no hold parameters on the order. On 12/10/24 at 8:30 AM, V10 (Licensed Practical Nurse) administered R2's morning medications. R2's blood pressure was 160/75 and her pulse was 58. V10 did not administer R2's Diltiazem. V10 stated that she was going to hold R2's Diltiazem because her pulse was less than 70. R2's clinical records were reviewed on 12/11/24 and did not contain any documentation that the physician was notified that R2's Diltiazem was held on 12/10/24. 2. R2's December MAR shows an order for Timolol Maleate 0.5 % eye drops-one drop to left eye every morning at 8:00 AM due to changes in retinal vascular appearance. On 12/10/24 at…

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

Based on interview and record review the facility failed to ensure a resident received the correct insulins as ordered by an endocrinologist for 1 of 1 resident (R2) reviewed for significant medication errors in the sample of 18. The findings include: On 12/9/24 at 9:25 AM, R2 said that the facility did not transcribe her insulin orders right from her endocrinology appointment a few months ago. R2's After Visit Summary (AVS) from her endocrinologist dated 9/24/24 shows, The following issue was addressed: Type 1 diabetes mellitus with polyneuropathy .Please change basaglar (long-acting insulin) dose to 10 units in the morning and 16 units in the evening. Adjust the meal time novolog (short-acting insulin) dose to 10 units with meals and continue the sliding scale R2's September MAR shows that on 9/24/24 an order was placed for: Insulin Glargine (long-acting insulin) 20 units in the AM and Insulin Lispro (short-acting insulin) 16 units in the evening. R2's MAR shows that she received the insulins until it was discontinued on 9/30/24. R2's September MAR shows that on 9/24/24 an order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care to a resident with dementia in a manner to prevent escalating agitation for 1 of 3 residents (R4) reviewed for dementia in the sample of 6. The finding include: On 9/11/24 at 10:52 AM, V22 (R4's POA - Power of Attorney for Healthcare) said there was an incident on July 13, 2024 with R4 and four facility staff members in the bathroom. V22 said she hates to use the word abuse, but feels that the facility staff could use more dementia care training. V22 said she was not present during the incident, but was notified by her sister (V21) that was present. V22 said she is an administrator at another facility and CNA (Certified Nursing Assistant), V22 said she is well-versed in Dementia Care and didn't feel like sending four people in to assist with care was appropriate. V22 said R4 is slow to respond, needs time to understand the instructions provided, and gets agitated when too many people are giving instructions and getting loud…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, treat, and document areas of skin damage to a resident's inner thigh and left knee. This applies to 1 of 3 residents (R1) reviewed for skin alterations in a sample of 4. The findings include: On 7/31/24 at 10:30 AM V4 and V5 (Certified Nursing Assistants/CNAs) assisted R1 with perineal care. R1 was very particular with care and resistant to anything suggested to her. V5 stated, (R1) usually allows us to change her one time per shift. R1 stated, That is my choice. Because of this, V4 and V5 used a liner inside of the diaper. R1 stated she was last changed on night shift and her brief and liner were saturated with urine. One bed pad under her was also wet with urine. R1 stated that she does not like to be woken up at 2:00 AM to be changed and she would rather be left alone. R1's wet brief was removed and her skin was washed with skin cleanser and water. There was a foam patch on her coccyx that was swollen with urine, one on her left anterior thigh that also appeared saturated and another on her outer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication choice was followed for 1 of 3 residents (R1) reviewed for medications in the sample of 3. The findings include: On 5/21/24 at 9:19 AM, R1 was asleep in her bed. On 5/21/24 at 10:30 AM, V2 (Director of Nursing/DON) said R1's current Physicians Orders (POS) contain orders for melatonin 3 mg (milligrams) every evening scheduled and also melatonin 3 mg PRN (as needed). V2 (after reviewing the printed POS in R1's chart) said this POS was printed on 5/14/24 and the family wrote on it not to give R1 the PRN dose of medication unless requested by the family. V2 said she was not sure what nurse printed or went over the medications with R1's family or if the Nurse Practitioner (NP) or Doctor was notified. V2 said currently R1 is still getting scheduled melatonin 3 MG daily. On 5/21/24 at 11:03 AM, V6 (R1's Power of Attorney/Emergency Contact) said on 5/14/24 she went over R1's medication list (POS) with the nurse on duty and wrote on the list to not give the scheduled melatonin and 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 interview and record review the facility failed to treat residents in a dignified manner during care. This applies to 3 of 3 resident (R1, R2, and R3) reviewed for dignity in a sample of 3 residents. The findings include: R1's Face Sheet shows her diagnoses includes, Vascular Dementia with behavioral disturbances, anxiety, depression, type 2 Diabetes Mellitus and difficulty walking. R2's Face Sheet shows her diagnoses includes, anxiety disorder, depression, chronic pain, and weakness. She is assessed to have a moderate fall risk according to her 3/19/24 [NAME] Fall Risk Screening. R2 is cognitively intact according to her Brief Interview of Mental Status. R3's Face Sheet shows her diagnoses includes, arthritis, cellulitis of the lower extremeties, and muscle weakness. She is assessed to have a moderate fall risk according to her 12/5/23 [NAME] Fall Risk Screening. R3 is cognitively intact according to her Brief Interview of Mental Status. On 4/23/24 at 8:30 AM, V1 (Administrator) said, she investigated…

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

Based on observation, interview, and record review, the facility failed to treat 3 residents (R14, R60, R79) with dignity during mealtime. This applies to 3 of 3 resident's reviewed for dignity outside of the sample. The findings include: On 2/6/24 at 11:33AM, V24 (Certified Nursing Assistant) was sitting at a lunch table with R14, R60, and R79. V24 was eating pizza and drinking her own personal drink. R14 stated, Oh, that pizza looks really good. I wish I could have some. All residents at the table had not been served their lunch meal. V24 continued eating her pizza until she identified the surveyor in the dining room. V24 then left the dining room with her pizza and drink and did not return until after the 3 residents had been served their noon meal. On 2/8/24 at 12:16PM, V2 (Director of Nursing) stated, Staff should not eat at the table with resident's due to this being a dignity concern. This is completely unacceptable, especially because the residents did not receive the same meal and hadn't received their food. Staff are never allowed to eat at the table when assisting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare a resident for discharge resulting in the resident exhausting his medication supply prior to his appointment with his primary physician. This applies to 1 of 3 residents (R80) reviewed for discharge in the sample of 21. The findings include: R80's Face Sheet showed an admission date of 12/23/23 and a discharge date of 1/23/24. The Face Sheet showed diagnoses to include respiratory failure, diabetes type 2, heart failure, and cellulitis (skin infection.) R80's Nurse's Note from 1/23/24 at 7:43 PM showed R80 was sent home with his mother and his remaining medications. (Note was authored by V20 Registered Nurse.) On 2/06/24 01:25 PM, V34 R80's Power of Attorney/Mother stated R80 was released at 3:00 PM on Tuesday and he was not given any medications for Wednesday. V34 stated R80 and herself were not aware R80 would not have enough medications to get R80 through until his doctor's appointment. V34 stated, R80 could not be seen by his primary doctor until the following Monday. V34 stated, R80 was able to get his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform a restorative assessment following a change in condition for a resident, failed to ensure a call light was available for a resident with a history of falls and failed to update a resident's care plan with updated fall interventions. These failures apply to 1 of 7 residents (R16) reviewed for falls in the sample of 21. The findings include: R16's electronic face sheet printed on 2/8/24 showed R16 has diagnoses including but not limited to dementia, diabetes, depression, hypertension, and hyperlipidemia. R16's facility assessment dated [DATE] showed R16 has severe cognitive impairment, utilizes a walker, requires set-up assistance for transfers and ambulation, and has a history of falls. R16's care plan dated 2/11/23 showed, Impaired mobility due to weakness .wheelchair for mobility leave foot pedals off as she likes to move her chair with her feet (discontinued: not using wheelchair), independent with walker. R16's care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident had care orders for an indwelling catheter for 1 of 2 residents reviewed for catheters in the sample of 21. The findings include: R66's face sheet shows he was re-admitted to the facility on [DATE]. The 1/28/24 admission assessment documents R66 to have an indwelling catheter. On 2/6/24, R66 was observed to be lying in bed with an indwelling catheter drainage bag hanging on the edge of the bed. On 2/6/24 at 11:17 AM, R66 said he has had the catheter for a while but does not know why. He denied any issues or concerns related to the catheter. R66's February 2024 physician order sheet was reviewed and has no order for the indwelling catheter, any care orders, the size of the catheter or when it would be changed. On 2/8/24 at 8:52 AM, V12 LPN (Licensed Practical Nurse) said when a resident returns from the hospital with a catheter, we get orders when getting report from the hospital. We would get when it was inserted and why…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify a resident (R57) was utilizing a BiPap (bi-level positive airway pressure) machine and failed to store a resident's BiPap mask in a sanitary manner for 1 resident (R57). The findings include: R57's electronic face sheet printed on 2/8/24 showed R57 has diagnoses including but not limited to cerebral infarction, obstructive sleep apnea, dyspnea, and chronic kidney disease. R57's facility assessment dated [DATE] showed R57 has no cognitive impairment and uses a non-invasive mechanical ventilator. R57's care plan dated 1/26/23 showed, (R57) has the potential for impaired gas exchange related to sleep apnea and requires continuous use of oxygen and/or CPAP (continuous positive airway pressure). 11/9/23 care plan reviewed continues to use CPAP when sleeping. No signs or symptoms of respiratory distress noted. Keep same plan of care. Change tubing and bubblers per protocol or as ordered. R57's physician's orders dated 1/26/23 showed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 label insulin pens with an open date and discard date. This applies to 1 of 1 resident (R70) reviewed for medications in the sample of 21 and one resident (R53) outside of the sample. The findings include: 1. R70's Physician Orders showed an active order since at least 1/17/24 for 11 units of long-acting insulin to be given daily. On 2/07/24 at 4:12 PM, V22 Licensed Practical Nursing (LPN) opened the medication cart for R70's unit. R70's insulin pen was not labeled with the date it was opened or discarded. The insulin pen showed there were approximately 80 units of insulin remaining. V22 stated the pen had been opened and used. On 2/07/24 at 4:27 PM, V2 Director of Nursing, stated she had seen R70's insulin pen and it was not labeled with an open date or discard date. V2 said the insulin pen had to be discarded because it was not known when it had been opened. V2 stated insulin pens need to be discarded within 28 days of being opened per manufacturer instructions. The facility's Procedure: Insulin Administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wear personal protective equipment (PPE) into a COVID-19 positive resident's room. This applies to 1 of 5 residents (R8) reviewed for infection control in the sample of 21 and 1 resident (R4) outside of the sample. The findings include: 1) R4's electronic face sheet printed on 2/8/24 showed R4 has a current diagnosis of COVID-19. On 2/8/24 at 9:15AM, V29 (Dietary Aide) was collecting R4's room tray. V29 entered R4's room with only a surgical mask and no additional PPE on. V29 exited R4's room with her meal tray unwrapped and set it on the community cart. V29 stated, I didn't know she was on isolation. I am supposed to wrap the tray in a plastic bag. I'm not sure why I need to do that though. I should have been wearing more PPE I guess but I don't know what all I'm supposed to wear. 2) R8's electronic face sheet printed on 2/8/24 showed R8 has a current diagnosis of COVID-19. R8's facility assessment dated [DATE] showed R8 has no cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refusing the COVID-19 vaccine did not receive it for 1 of 1 resident (R6) reviewed for immunizations in the sample of 10. The findings include: R6's face sheet showed a [AGE] year old female admitted to the facility on [DATE]. R6's diagnosis included arthritis, hypertension, dysphagia, neuropathy, atrial fibrillation, and a history of falling. On 11/7/23 at 10:15 AM, V7 R6's power of attorney (POA) said R6 received a COVID booster after a refusal was signed. V7 said V2 Director of Nursing (DON) called her on 11/2 or 11/3/23 to notify her. I was so mad I couldn't remember her name (DON). At 10:33 AM, V2 said she was notified by V3 Quality Assurance Director that R6 received the vaccine and should not have. It was my first day here and I was asked to notify the POA. V2 said V3 was notified by the pharmacy of the error. R6 was the only resident identified as receiving the vaccine who had refused. On 11/7/23 at 11:31 AM, R6 was seated in…

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

Based on interview and record review, the facility failed to ensure an employee was immediately removed from resident care pending the investigation of an allegation of missing medications for 1 of 3 residents (R1) reviewed for missing medications. The findings include: On 11/1/23 at 9:02 AM, V3 Interim Assistant Director of Nursing (ADON), said on 10/28/23 at around 8:30 PM, V4, Licensed Practical Nurse (LPN), could not find two Fentanyl (narcotic/opioid pain medication) patches. V3 said V4 called her that evening, but her phone was out of range, and she did not hear about the incident until the next morning (10/29/23). V3 said she went to the facility, took V4's statement and suspended V4 pending the investigation. On 11/1/23 at 11:41 AM, V4 said she was working on 10/28/23 and prepared two Fentanyl patches for R1. V4 said she dated and initialed the patches, then was interrupted to assist with the pharmacy delivery. V4 said she thought she put the patches in the drawer in the medication cart, but when she returned, she could not find the patches. V4 said she looked everywhere 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 ensure a resident was free from a significant medication error. This applies to 1 of 3 residents (R2) reviewed for medication administration in the sample of eight. The findings include: R2's face sheet shows she is a [AGE] year-old female with diagnosis including congestive heart failure, unspecified dementia, chronic obstructive pulmonary disease, hypertension, and major depressive disorder. R2's Incident Report dated 10/3/23 documents R2 was given another resident (R7's) methadone (opiate) 10 mg (milligrams) two tablets around 8:00 PM. V3 (LPN) was training V5 (RN) on medication administration. V3 handed a cup of pills to V5 and told her the name and the room number, but V3 told her the wrong room number. On 10/10/23 at 9:00 AM, R2 was observed in her room sitting in her wheelchair. She was alert to herself, but not oriented to time or place. When asked if she was in the hospital recently, she said no. R2 and R7's room were located next…

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