Goldwater Care Gibson City

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide toileting assistance/incontinence care in a timely manner for two residents (R4, R12) of five residents reviewed for bowel and bladder in a sample list of 12. Findings Include: The facility's Call Light Policy, reviewed 2/2/18, states: Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. All residents who have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility at the bedside or another reasonably accessible location. All staff should assist in answering call lights. Nursing staff members shall go to the resident's room to respond to the call system and promptly cancel the call light when the room is entered. Bathroom call lights should be viewed as emergencies and given immediate attention. The facility's Incontinence Care Policy, reviewed 1/16/18, states:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate documentation of medications that was administered for 2 of 3 residents (R1,R2) reviewed for medication administration.Findings include: 1.R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Fibromyalgia, Morbid Obesity, Complex Regional Pain Syndrome, Major Depressive Disorder, HTN, Hypothyroidism, GERD, Anxiety Disorder and Barrett's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 15 cognitively intact and receives an opioid.R1's Physician Orders Sheet (POS) date documents Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams, give 1 tablet by mouth every 8 hours as needed for severe pain.R1's Controlled Drug Receipt Record/Disposition Form dated August 29, 2025, no time given, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.R1's Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' right to be treated in a dignified manner for three (R8, R9, and R10) of 12 residents reviewed for abuse in the sample list of 13. Findings include: The facility's Resident Rights policy dated 8/23/17 documents Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. The facility will not hamper, compel, treat differentially, or retaliate against a resident for exercising his/her rights On 5/8/25 at 10:45 AM R8 stated V3 Certified Nursing Assistant (CNA) is a b (expletive), she's just mean. R8 stated about six months or so ago V3 hit R8 in the stomach while rolling R8 in bed. R8 felt this was done intentionally and described V3 as being mean about it. V3 stated V1 Administrator and V2 Director of Nursing were notified. R8 stated 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 interview and record review, the facility failed to implement their Abuse Prevention and Reporting Policy. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13. Findings include: On 5/7/25 at 9:49am, V1 Administrator stated V1 was notified on 4/26/25 by V4 Certified Nursing Assistant (CNA) of R1 hitting and yelling at R2 but did not report the incident to the State Agency or do an investigation. On 5/7/25 at 10:59am, V6 R1's Representative stated V6 was not notified of the altercation between R1 and R2. On 5/7/25 at 1:21pm, V4 CNA stated V4 notified V1 Administrator on 4/26/25 of R1 yelling at R2 and hitting R2 in the back. There is no documentation in R1's medical record of the state survey agency or V6 being notified of the incident. There is no documentation in R2's medical record of the state survey agency or V10 R2's Representative being notified of the incident. The facility's Abuse Prevention and Reporting Policy (revised 10/24/22) documents the following: This facility affirms the right of our residents to be free 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 interview and record review, the facility failed to timely report an allegation of resident to resident physical and verbal abuse to the state survey agency. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample list of 13. Findings include: R1's Face Sheet dated 5/8/25 documents the following diagnoses: Dementia with agitation and behaviors and Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired. R1's Care Plan (current) documents R1 has a behavior problem and screams/curses at staff. This same record documents R1 is frequently verbally aggressive towards others and can have aggressive behaviors. A Progress Note dated 5/7/25 documents R1 still wearing the same clothing as the day before and R1 resistive to cares and very aggressive physically and verbally. R2's Face Sheet dated 5/8/25 documents the following diagnoses: Alzheimer's Disease. R2's MDS dated [DATE] documents R2 is severely cognitively impaired. A typed,…

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

Based on interview and record review, the facility failed to thoroughly investigate and document an allegation of resident-to-resident physical and verbal abuse. This failure affects two (R1 and R2) of 12 residents reviewed for abuse in the sample of 13. Findings include: The facility Abuse, Neglect and Exploitation Policy dated 12/5/22 documents the following: when suspicion of abuse or reports of abuse occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members and visitors in the area. Obtain witness statements. Document the entire investigation chronologically. Notify the attending physician and the resident's family/legal representative. Monitor and document the resident's condition, including the response to medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the interview and record review, the facility failed to provide timely call light response for four (R17, R38, R45, R206) of nine residents reviewed for call light response times in the sample list of 27. Findings include: On 3/25/25 at 9:00 am, R206 stated that R206 needed assistance from staff, and R206 was unsure why they took so long to come to R206's room. R206 stated sometimes R45 (R206's roommate) has to wait 45 minutes or more for staff to come and put R45 into bed. R206 stated that sometimes R206 will wheel down the hall to get staff to come and help R45. Facility Census documents R206 was admitted to the facility on [DATE] and has the following medical diagnoses: Acute Respiratory Failure with Hypoxia, Difficulty in Walking, Lack of coordination, Abnormal Posture, and Muscle Wasting and Atrophy. R206's Minimum Data Set (MDS) dated [DATE] documents R206's Brief Interview for Mental Status (BIMS) score of 8, moderate cognitive impairment, and needs moderate assistance with showers/bathing. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to provide numerous showers as scheduled for two (R45, R206) of three residents who were reviewed for showers in the sample list of 27. Findings include: 1. On 3/25/25 at 9:00am R206 was sitting in the wheelchair in R206's room, nails not trimmed and face not shaven. On 3/25/25 at 9:00 am R206 stated that R206 was admitted a couple of weeks ago and has only gotten one shower last week. R206 stated that staff do not cut R206's nails on that day or any other day; they are very long and need trimming. The Facility Census documents that R206 was admitted to the facility on [DATE] and has the following medical diagnoses: Acute Respiratory Failure with Hypoxia, Difficulty in Walking, Lack of coordination, Abnormal Posture and Muscle Wasting and Atrophy. R206's Minimum Data Set (MDS) dated [DATE] documents R206's Brief Interview for Mental Status (BIMS) score 8, moderate cognitive impairment and needs moderate assistance with showers/bathe. The Facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to utilize data to put a quality improvement program in place that would identify, intervene, and improve resident outcomes to address significant medication errors after learning of a significant medication error that resulted in resident harm. This failure has the potential to all 51 residents who reside in the facility. Findings include: The facility provided census dated [DATE] documents 51 residents reside in the facility. The facility Quality Assurance Performance Improvement Program Policy dated [DATE] documents that quality of care will be monitored and evaluated in areas of resident care and services at each quality meeting including but not limited to adverse resident events and medication errors. R1's census report dated [DATE] documents admission to the facility. R1's [DATE] physician order sheet documents Plavix (anticoagulant) 75 milligrams (mg) to be given daily. R1's [DATE] medication administration record documents that R1 was started on…

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

Based on interview and record review the facility failed to respond to call lights timely for five (R6, R7, R10, R9, R12) of 12 residents reviewed for call lights in the sample list of 17. Findings include: The facility's Resident Council Meetings dated 4/29/24, 5/28/24, and 6/24/24 document concerns of call light wait times on all shifts, including wait times of almost an hour on second shift. On 7/9/24 at 10:00 AM, R6 stated sometimes R6 waits awhile for R6's call light to be answered. On 7/9/24 at 10:25 AM, R7 stated R7 waits awhile for call lights to be answered due to the facility being short of staff. On 7/9/24 between 10:35 AM and 10:50 AM, R10 stated it takes a long time for staff to answer R10's call light, because staff are too busy, and this happens on any day and shift. On 7/9/24 at 10:44 AM, R9 stated R9 waits awhile with R9's call light on before staff provide help. On 7/9/24 at 12:58 PM, R12 stated R12 is the Resident Council President and long call light wait times is frequently mentioned in the council meetings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, Interview and Record Review the facility failed to serve meals at an appropriate or palatable temperature. This failure effects nine (R6, R7, R9, R10, R13, R14, R15, R16, and R17) of 17 residents reviewed for food on the sample list of 12. Findings include: The Policy titled In-Room Dining dated 2020 states Meals served in rooms may be periodically checked at the point of service for Palatable food temperatures. Food temperatures of hot foods on room trays the point of service are preferred to be at 120 degrees Fahrenheit or greater to promote palatability for the resident. If there is concern about the temperature or palatability of a meal, a new meal should be ordered from dining services. On 7/9/24 at 1:55 PM, there was a sign with posted meal times on dining room door that documented Breakfast at 7:00 AM, Lunch at 11:45 AM, and Dinner at 5:00 PM. On 7/9/24 at 12:00 PM, V17 Dietary Aide pushed a cart of uncovered meal trays to the assisted dining room and distributed the trays to half of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide showers as scheduled for one (R10) of seven residents reviewed for Activities of Daily Living in the sample list of 17. Findings: On 7/9/24 from 10:35 AM-10:50 AM, R10 stated residents are suppose to get showers/bed baths twice per week, but sometimes that doesn't happen. R10 stated the staff get too busy and forget, usually because they don't have enough staff. R10 stated R10's showers are scheduled for Mondays and Thursdays, and R10 did not get a shower yesterday (Monday). R10's Minimum Data Set, dated [DATE] documents R10 is cognitively intact and is dependent on staff for bathing/showers. The undated East Evening Showers list documents R10's showers are scheduled on Monday and Thursday evenings. R10's Shower Day Skin Inspections for June and July 2024 were requested. R10's shower documentation, provided by V2 Director of Nursing, documents showers on 6/6/24, 6/10/24, 6/13/24, 6/20/24 (refused), and 6/27/24. There are no documented showers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the Administrator and the Administrator failed to notify the State Agency timely of allegations of staff to resident abuse for two (R2, R3) residents. This failure affects all 60 residents residing in facility. Findings include: The facility undated policy titled 'Abuse, Neglect and Misappropriation of Resident Property' documents Reporting-Elder abuse is an unfortunate situation that must be reported. If you suspect or observe a resident being abused, discuss the situation with your supervisor immediately. The facility will ensure that all allegations of abuse, neglect, mistreatment including injuries of unknown source are reported immediately to the Administrator of the facility. The Administrator and/or other officials shall notify the State Agency. The facility Daily Midnight Census Report dated 6/30/24 documents 60 residents reside in facility. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. This same MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 abuse policy by not immediately suspending two alleged perpetrators after mental and physical abuse allegations were made by one resident (R3). The facility failed to protect two additional residents (R2, R6) from said perpetrators after R3's allegation was made. The facility also failed to assess R2 and R3 after abuse allegations were made against two alleged perpetrators. These failures affect three residents (R2, R3, R6) and have the potential to affect all 60 residents residing in the facility. Findings include: The facility undated policy titled 'Abuse, Neglect and Misappropriation of Resident Property' documents All residents shall be assessed immediately by the attending nurse upon notification of alleged abuse, neglect or mistreatment including employee inflicted injury. When incidents involve suspected abuse, neglect or mistreatment are reported the facility shall take the following steps: remove the employee immediately, staff is…

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

Based on interview and record review the facility failed to provide staff with Quality Assurance Performance Improvement (QAPI) training. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The Facility Daily Midnight Census Report documents 60 residents reside in facility. The Facility assessment dated Janurary 2024 documents the facility will provide QAPI training annually for all staff. On 7/3/24 at 1:15 PM, V25 Certified Nurse Aide (CNA) stated V25 has never heard of Quality Assurance Performance Improvement (QAPI) training. V25 CNA stated I have worked here (facility) for over eight years and never heard of QAPI training. They (facility) don't talk to us about that. On 7/3/24 at 2:15 PM, V1 Administrator stated the facility has not provided ongoing annual training on the topic of QAPI. V1 stated the facility is unable to provide documentation of QAPI trainings for staff for the last year.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide staff with Ethics training. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The Facility Daily Midnight Census Report documents 60 residents reside in facility. The Facility assessment dated [DATE] documents the facility will provide Ethics training annually for all staff. On 7/3/24 at 1:15 PM, V25 Certified Nurse Aide (CNA) stated V25 has never heard of Ethics training. V25 CNA stated I have worked here (facility) for over eight years and never heard of Ethics training. They (facility) don't talk to us about that. On 7/3/24 at 2:15 PM, V1 Administrator stated the facility has not provided ongoing annual training on the topic of Ethics. V1 stated the facility is unable to provide documentation of Ethics trainings for staff for the last year.

Based on interview and record review, the facility failed to ensure continued competency for nurse aides for at least twelve hours per year including dementia training and resident abuse prevention training for four nurse aides (V3, V13, V14, V25). This has the potential to affect all 60 residents residing in the facility. Findings include: The facility's Facility Assessment Tool dated January 2024, documents all new employees must complete an orientation program covering abuse, neglect, exploitation, and Certified Nurse Assistants must receive at least 12 hours minimum of in-service training that include dementia management training and resident abuse prevention training. On 7/3/24 at 11:30 AM, V1 Administrator stated V1 does not have a log of staff training for abuse or dementia training. On 7/3/24 at 12:41 PM, V5 Human Resources stated she does not have training logs for dementia or abuse training for the last year for the staff for the on-boarding V5 completes for new hires. The facility's Daily Midnight Census dated 6/30/24, documents 60 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affects two of three residents (R1, R2) reviewed for abuse in the sample of three. Findings Include: The facility's undated Abuse Policy documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse includes hitting, slapping, pinching, and kicking. The Resident Abuse Investigation Form dated 4/11/24 documents after the evening meal on 4/11/24, R1 wandered into R2's room uninvited. R2 asked R1 to leave the room. R1 refused to leave. R2 attempted to move around R1's wheelchair and exit the room when R1 hit her causing a skin tear. R2 then hit R1 in retaliation. R2 called for help and staff came and separated the two residents. R1's Medical Diagnoses sheet dated April 2024 documents R1 is diagnosed with Alzheimer's Disease, Depression, Dementia, and Anxiety. R1's Minimum Data Set (MDS) dated [DATE] documents R1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain informed consent for surgical debridement of wounds from a resident's representative for one of three residents (R1) reviewed for wounds on the sample list of five. Findings include: R1's Order Summary Report dated 3/18/24 documents diagnoses including Age-Related Cognitive Decline, Atherosclerotic Heart Disease, Unspecified Osteoarthritis, Presence of Automatic (Implantable) Cardiac Defibrillator, Polyneuropathy, Difficulty in Walking, Heart Failure, Chronic Kidney Disease Stage 3, Chronic Atrial Fibrillation, Flaccid Neuropathic Bladder, Benign Prostatic Hyperplasia, Repeated Falls and Weakness. This Order Summary documents R1 was admitted to the facility on [DATE]. R1's admission Minimum Data Set, dated [DATE] documents R1 was moderately cognitively impaired. R1's Wound Physician Initial Wound Evaluation and Management Summary dated 1/19/24 documents wounds on R1's right buttock and sacrum. This Wound Evaluation documents R1 received Surgical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the resident's representative of wounds for one of three residents (R1) reviewed for wounds in the sample list of five. Findings include: The facility's Pressure Injury and Skin Condition Assessment policy with a Revised date of 1/17/18 documents, At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. R1's Order Summary Report dated 3/18/24 documents diagnoses including Age-Related Cognitive Decline, Atherosclerotic Heart Disease, Unspecified Osteoarthritis, Presence of Automatic (Implantable) Cardiac Defibrillator, Polyneuropathy, Difficulty in Walking, Heart Failure, Chronic Kidney Disease Stage 3, Chronic Atrial Fibrillation, Flaccid Neuropathic Bladder, Benign Prostatic Hyperplasia, Repeated Falls and Weakness. This Order Summary documents R1 was admitted to the facility on [DATE]. R1's Admission/re-admission Observation GG dated 1/12/23 at 3:25 PM by V3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete an initial wound assessment on admission and obtain treatment orders, failed to complete wound treatments as ordered and failed to complete pressure ulcer interventions as ordered and as stated in the facility policy for one of three residents (R1) reviewed for pressure ulcers in the sample list of five. Findings include: The facility's Pressure Ulcer Prevention policy with a Revision date of 1/15/18 documents, Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc. (etcetera) may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds. The facility's Pressure Injury and Skin Condition Assessment policy with a Revision date of 1/17/18 documents, A wound assessment will be initiated and documented in the resident chart 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to change and label oxygen tubing and humidifier bottles (R43, R45, R306), failed to properly maintain Continuous Positive Airway Pressure (CPAP) mask (R20) and failed to properly maintain and store nebulizer mask/tubing (R38). These failures affect five (R43, R45, R306, R20, R38) of five residents reviewed for respiratory care in the sample list of 37. Findings include: 1). On 2/4/24/23 at 9:06 AM, R43 had oxygen on at 4 liters per minute (LPM) via a nasal cannula and an oxygen concentrator in R43's room. The oxygen tubing was not dated as to indicate when it was changed, and the humidification container was not dated as to when it was applied. R43's Order Summary Report dated 2/6/24 documents diagnoses including Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Dependence on Supplemental Oxygen, and Chronic Atrial Fibrillation. R43's Physician Order Sheet (POS) dated 9/14/23 documents Oxygen at 4 liters per minute per nasal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in accordance with manufacturer's instructions and physician's orders for three (R37, R42, R256) of seven residents reviewed for medication administration in the sample list of 37. This failure resulted in four medication errors out of 31 opportunities, resulting in a 12.9 % medication error rate. Findings include: 1.) On 2/04/24 at 3:18 PM V8 Registered Nurse (RN) administered R37's Naproxen Sodium 220 milligrams (mg). The medication card contained a label to take this medication with meals. There was no food at R37's bedside when V8 administered the medication. At 3:23 PM V8 stated supper is served at 5:00 PM (over an hour after R37's medication administration.) R37's Physician's Order dated 12/31/23 documents Aleve (Naproxen Sodium) give 220 mg by mouth twice daily. R37's February 2024 Medication Administration Record (MAR) documents Aleve is scheduled twice daily at 8:00 AM and 4:00 PM. The Naproxen Sodium Manufacturer's Instructions revised July 2014 documents this medication may…

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

Based on interview and record review the facility failed to provide a written, Notice of Medicare Non-Coverage notice, (NOMNC) for three (R51, R257, R258) of three residents reviewed for Medicare Non-Coverage notices from a total sample list of 37 residents. Findings include: The facility Skilled Nursing Facility Notices for Medicare/Medicare Advantage/Medicaid MCO Admissions-NOMNC policy dated 7/28/23 documents that the designated staff shall ensure that the required procedures are followed to remain compliant with the rules and regulations of distribution, follow-up and completion of the required skilled nursing facility notices as advised by Medicare/Medicare Advantage/MMAI plans. The facility social services designee will contact the patient/representative and review the Medicare (Part A) / Medicare advantage/MMAI letters no later than 48 hours before the last Medicare covered day with them. Additionally, the deadline to request a review, as well as what to do if the deadline is missed, and the telephone number of the (Quality Improvement Organization) QIO to request the appeal.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Sets (MDS) were accurate to include oxygen use for two (R20, R38) of five residents reviewed for respiratory care in the sample list of 37. Findings include: 1.) On 2/4/24 at 9:12 AM and 11:55 AM R20 was lying in bed wearing oxygen at 3 liters per minute (l/min) per nasal cannula. R20's Physician Order dated 9/1/23 documents to administer oxygen at 2 l/min continuously per nasal cannula. R20's January and February 2024 Medication/Treatment Administration Records (MARs/TARs) document daily use of oxygen and weekly changing of oxygen tubing and humidification bottles. R20's MDS dated [DATE] documents R20 does not use oxygen. 2.) On 2/04/24 at 8:59 AM R38 was wearing oxygen at 3 l/min per nasal cannula. R38's Physician Order dated 11/24/23 documents to administer oxygen at 3 l/min continuously. R38's December 2023 MAR documents daily use of oxygen and weekly changing of oxygen tubing and humidification bottles. R38's MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have quarterly care plan meetings for two (R20, R42) of two residents reviewed for care plan meetings in the sample list of 37. Findings include: 1.) On 2/04/24 at 11:52 AM R20 stated the facility doesn't have any meetings with R20 about R20's care. R20's Minimum Data Set (MDS) dated [DATE] documents R20 is cognitively intact and admitted on [DATE]. There are no documented care plan meetings in R20's medical record. 2.) On 2/04/24 at 8:50 AM R42 stated the facility doesn't have care plan meetings with R42. R42's MDS dated [DATE] documents R42 is cognitively intact and admitted on [DATE]. There are no documented care plan meetings in R42's medical record. On 2/06/24 at 9:41 AM V16 Social Services Director (SSD) stated V16 is responsible for scheduling care plan meetings and residents and their families are invited to attend the meetings. V16 stated care plans are documented in a plan of care note in the resident's record. V16 was unsure the frequency of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 grooming per resident preference for one (R42) of one resident reviewed for activities of daily living in the sample list of 37. Findings include: On 2/04/24 at 12:02 PM R42's hair was long down to R42's shoulders and R42's beard was long down to R42's chest. R42 stated R42 does not like to have long hair/facial hair, and prefers to keep it short/trimmed. R42 stated R42 has asked to have R42's hair cut/trimmed, but the facility doesn't have anyone here to cut R42's hair. R42's Minimum Data Set, dated [DATE] documents R42 is cognitively intact. R42's care plan dated 11/1/23 documents R42 requires substantial assistance of one staff person with personal hygiene. On 2/06/24 at 9:31 AM V15 Certified Nursing Assistant stated residents should be shaved twice weekly during showers and R42 is currently getting a shower. V15 stated we have straight razors available in the shower room to use. V15 was not sure if R42 has an electric razor and…

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

Based on interview and record review the facility failed to follow physician's orders for insulin and notify the physician that insulin was held for one (R38) of five residents reviewed for unnecessary medications in the sample list of 37. Findings include: On 2/04/24 at 9:02 AM R38 stated the other day my blood sugar was 100 so the nurse did not administer R38's insulin. R38 stated last night R38's blood sugar was 168, the nurse was worried that R38's blood sugar would bottom out and so R38's insulin was not given. R38's Care Plan dated 10/12/23 documents R38 has Diabetes Mellitus, receives insulin, and includes interventions for medication as ordered and to monitor/report any symptoms/signs of hypoglycemia (low blood sugar). R38's Physician Order dated 12/8/23 documents to give Novolog (short acting insulin) 30 units subcutaneously before meals. There are no ordered parameters to hold R38's insulin based on blood sugar results. R38's February 2024 Medication Administration Record (MAR) documents an entry to refer to the nursing notes on 2/2/24 at 5:00 PM, and R38's blood sugar was…

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

Based on observation, interview and record review the facility failed to provide wound care as ordered for one (R23) of two residents reviewed for wound care from a total sample list of 37 residents. Findings include: The facility Pressure Skin Condition Assessment & Monitoring- Pressure and Non-Pressure policy dated 6/8/18 documents that dressings will be performed based on physician orders. R23's physician order dated 2/5/23 documents that the treatment to the left and right buttocks will include packing the wounds with gauze soaked in antiseptic solution, covered with an abdominal dressing and a clear adhesive dressing over that and a skin protective wipe to the periwound twice daily. On 2/5/24 at 11:45AM, V7 Licensed Practical Nurse (LPN) provided R23's wound care treatments. Both left and right coccyx wounds were packed with antiseptic soaked gauze and a clear adhesive dressing was placed over the packing. No abdominal pad was used to cover the wounds and no skin protective wipe was used on the periwound, as ordered. On 2/6/24 at 2:25PM, V2 Director of Nursing stated, I would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restorative range of motion services for one (R42) of one resident reviewed for restorative services in the sample list of 37. Findings include: On 2/04/24 at 8:47 AM R42 stated R42 had a stroke that affected R42's left side and R42 received therapy, but after that the exercises stopped. R42 stated the Certified Nursing Assistants (CNAs) are too busy to provide range of motion exercises. R42 was lying in bed and had impaired movement of his left leg and arm. R42's Diagnoses dated 6/7/23 documents hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side. R42's Minimum Data Set (MDS) dated [DATE] documents R42 is cognitively intact, has one sided impaired range of motion to upper and lower extremity, and does not receive any range of motion restorative services. There is no documentation in R42's medical record that R42 receives range of motion services. R42's Occupational Therapy Discharge summary…

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

Based on observation, interview, and record review, the facility failed to properly secure urinary catheter tubing and drainage bags to ensure hygenic storage (R306, R256), intervene for a leaking urinary catheter, and provide hygenic catheter care (R23). R306, R256, and R23 are three of three residents reviewed for catheters in the sample list of 35. Findings include: 1.) On 2/4/24 at 9:24am, R306 was seated in a recliner in R306's room sleeping. R306's urinary catheter tubing and collection bag were resting on the floor next to R306's recliner. V4 Certified Nursing Assistant (CNA) entered R306's room and asked R306 if R306 needed anything, and left the room, leaving the catheter bag and tubing on the floor. On 2/5/24 at 9:26am, V4 Certified Nursing Assistant (CNA) acknowledge that R306's urinary catheter bag and tubing should not be on the floor, and should be secured inside a dignity bag. On 2/5/24 at 9:40am, V1 Administrator stated, R306's catheter bag should be in a dignity bag, and the bag and tubing should not be laying on the floor. V1 said, staff should of secured it 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 medications were labeled with resident's name and opened date for two (R29, R43) of two residents reviewed for medication storage in the sample list of 37. Findings include: On 2/05/24 at 10:02 AM, the 200 medication cart was reviewed with V7 Licensed Practical Nurse (LPN). There were two bottles of Dorzolamide Timolol Maleate 22.3 milligrams (mg)/6.8 mg per milliliter eye drops. These bottles were not in boxes and did not contain a pharmacy label with a resident name. V7 stated R29 is the only resident on this medication cart who has an order for this medication. V7 confirmed the bottles were not labeled with a resident's name and opened date. This cart contained R43's Budesonide Formoterol Fumarate 160-4.5 MCG/ACT (microgram per actuation) inhaler that contained a label with a dispensed date of 10/27/23. There was no opened date on the medication box or inhaler and this was confirmed with V7. R29's Physician Order dated 1/9/24 documents Dorzolamide Hydrochloride Ophthalmic Solution give one drop 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 administer pneumococcal vaccines for two (R36 and R38) of five residents reviewed for vaccines in a sample list of 37 residents. Findings include: The facility Influenza and Pneumococcal Policy dated 4/21/22 documents that each resident or the resident's representative will be provided education regarding the benefits and potential side effects of the immunization. Each resident is offered a pneumococcal immunization per Centers for Disease Control (CDC) recommendations unless the immunization is medically contraindicated or the resident has already been immunized and a second pneumococcal vaccine will be offered only when necessary according to the CDC guidelines. The medical record will include documentation that indicates that the resident either received or did not receive the pneumococcal immunization due to medical contraindications or refusal. 1. The facility provided authorization and release for Pneumococcal Vaccine documents that on 11/10/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report a resident fall to the physician and resident representative for one (R6) of three residents reviewed for falls in the sample list six. Findings include: R6's Minimum Data Set, dated [DATE] documents R6 has severe cognitive impairment. R6's Nursing Note dated 10/8/2023 at 11:11 PM documents nurse (V8 Registered Nurse (RN)) heard R6 yelling out and found two nurses (V18 RN and V19 Licensed Practical Nurses) in R6's room helping R6 who was lying on the floor. This note documents R6 was found holding onto R6's bedrail yelling, with R6's lower body on the floor. The nurses assisted R6 to the floor and R6 had no injuries. R6's nursing notes do not document that R6's Power of Attorney (V17) and physician were notified of R6's fall. R6's Witnessed Fall Report dated 10/8/23 at 10:00 PM documents R6's fall. The section titled Agencies / People Notified is blank and this report does not document the physician and R6's representative were notified of R6's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide showers as scheduled for three (R1, R3, R4) of four residents reviewed for showers in the sample list of six. Findings include: 1.) R1's undated census documents R1 admitted to the facility on [DATE] and discharged on 10/1/23. R1's Minimum Data Set (MDS) dated [DATE] documents R1 requires extensive assistance of two staff for transfers, and bathing did not occur during the review period. R1's Care Plan dated 10/1/23 documents R1 has an activity of daily living self performance deficit related to impaired mobility and includes an intervention that R1 is usually dependent on staff for bathing transfers. R1's electronic documentation for bathing dated 10/17/23 documents showers were given on 9/23/23 and 9/27/23, and R1 refused shower on 9/30/23. On 10/17/23 at 4:04 PM, V2 Director of Nursing stated showers are scheduled to be given at least twice weekly for all residents and are documented in the resident's electronic medical record and on paper…

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

Based on interview and record review, the facility failed to obtain and implement urinary catheter orders and document urinary output for one (R1) of two residents reviewed for urinary catheters in the sample list of five. Findings include: The facility's Urinary Catheter Care policy with a revision date of 2/14/19 documents the following: Catheter drainage bags will be emptied one time on each shift or as needed. This policy does not discuss documenting urinary output. R1's Electronic Medical Records (EMR) document R1 resided at the facility from 8/19/23 through 8/29/23. R1's Progress Note dated 8/26/23 documents R1 had an indwelling urinary catheter placed in the emergency department on 8/26/23. R1's August Physician Orders does not document an order for an indwelling urinary catheter. R1's EMR does not contain any documentation of R1's urinary output. On 9/1/23 at 10:08 am, V5 R1's Representative stated R1 was sent to the hospital on 8/26/23 for abdominal pain and a urinary catheter was placed. V5 stated V5 visited R1 on 8/27/23 at 8:30 am and R1's urinary collection bag was full…

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

Based on interview and record review, the facility failed to complete treatments as ordered by the physician and failed to complete wound assessments for one of three residents (R1) reviewed for accidents on the sample list of four. Findings Include: On 8/15/23 at 2:10 pm, R1 stated R1 had sustained a three inch V shaped laceration on R1's left leg a couple of weeks ago, requiring 18 sutures. R1 stated R1's legs were not wrapped at the time, as ordered, which might have prevented the laceration because those elastic bandages are thick. R1's Progress Notes dated 8/1/23 at 9:38 am, documents R1 was noted to have a skin tear to the left lower extremity. First Aide was administered and R1 was sent to the hospital. At 7:35 pm, the Progress Notes documents R1 returned to the facility with sutures. R1's August 2023 Physician Order Sheet documents an order initiated on 7/29/23 to wrap BLE (Bilateral Lower Extremities) with rolled gauze and then an elastic bandage, for edema, with instruction to apply on day shift and remove at night. R1's August 2023 TAR (Treatment Administration Record)…

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

Based on observation, interview and record review, the facility failed to properly store raw poultry to prevent cross contamination. The facility also failed to ensure food preparation equipment was disposed of/replaced when worn, cracked or broken and failed to ensure hand hygiene was performed after removing gloves and donning new gloves during food preparation. These failures have the potential to affect all 54 residents residing in the facility. Findings include: On 2/14/23 at 9:15am, the kitchen equipment storage shelving contained a green cutting board that was extremely worn with deep marks. On 2/14/23 at 9:35am, the cooler in the main area of the kitchen had a laminated undated Proper Food Storage sheet that documents raw poultry is to be placed on the bottom shelf and that raw foods which require higher cooking temperatures must be stored below or separately from foods requiring lower cooking temperatures to prevent cross contamination. This sheet documents the cooking temperature of raw poultry of 165 degrees Fahrenheit (F) and ground beef and pork products cooking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 infection control surveillance program that tracks/analyzes/monitors resident and employee illnesses to identify any trends and patterns, and failed to conduct surveillance of staff and resident COVID-19 (Human Coronavirus Infection) infections during an outbreak. This failure has the potential to affect all 54 residents residing in the facility. The facility also failed to ensure staff removed or disinfected personal protective equipment after the care of a COVID-19 positive resident (R15) and prior to caring for COVID-19 negative resident (R25), failed to conduct symptom monitoring and vital signs every four hours for COVID-19 positive resident (R28), and failed to ensure staff wore eye protection during a COVID-19 outbreak for R12. Findings include: On 2/14/23 at 8:35 AM there was a sign dated 2/8/23 posted at the facility entrance that documented the facility currently had COVID-19 positive cases and was in outbreak status. The undated COVID-19 positive staff list documents V11 Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 urine and wound cultures were obtained to ensure appropriate use of antibiotics. This failure has the potential to affect all 54 residents residing in the facility. Findings include: The facility's undated Antibiotic Stewardship Protocol documents: Antibiotic Stewardship is part of the Infection Prevention and Control Program and includes a committee consisting of the Medical Director, Director of Nursing, Infection Preventionist, and consulting pharmacist. The committee will review/monitor infections, antibiotic usage, hospital antibiograms, and patterns of antibiotic resistant organisms. Diagnostic testing will be used in accordance with physician's orders. The antibiotic risk management tools include to review the appropriateness of antibiotic administration and review of cultures and laboratory results. The Infection Preventionist will review whether tests, including cultures, were completed and whether the antibiotic ordered was appropriate based on the sensitivity report. The facility's Infection Control Logs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify residents and resident representatives after two COVID-19 confirmed cases and provide cumulative updates. This failure has the potential to affect all 54 residents residing in the facility. Findings include: On 2/14/23 at 8:35 AM there was a sign dated 2/8/23 posted at the facility entrance that indicated the facility had COVID-19 positive staff cases and was in outbreak status. This sign did not document a cumulative total of COVID-19 positive staff/residents. This same sign remained posted on 2/15/23 and 2/16/23 at 8:20 AM. On 2/14/23 at 9:35 AM R28 stated R28 recently tested positive for COVID-19, and R28 has not received any communication from the facility regarding the total number of positive staff or residents. On 2/14/23 at 9:40 AM R22 stated the facility has not provided information to R22 regarding the number of COVID-19 positive cases. There is no documentation in R28's and R22's medical records that the facility informed them or their representatives of COVID-19 positive cases 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents (R35, R38, R51, R23, R50, R255, R4, R18, R19, R39, R48, R42, R34, R30, R8, R29, R45) who had close contact exposure to COVID-19 (Human Coronavirus Infection) and employees were tested for COVID-19 during an outbreak in accordance with facility policy. This failure has the potential to affect all 54 residents residing in the facility. Findings include: The facility's COVID-19 Testing & Response Plan revised 1/5/23 documents: Asymptomatic residents and HCP (Health Care Personnel) with a close contact or higher-risk exposure with someone with SARS-CoV-2 (COVID-19) should have a series of three viral tests for SARS-CoV-2 infection unless they have recovered from COVID-19 in the prior 30 days. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an employee was fully vaccinated for COVID-19 (Human Coronavirus Infection), and develop a policy for employee COVID-19 vaccination that includes a process for medical and religious exemptions, and additional precautions to mitigate the spread of COVID-19 for unvaccinated staff. This failure has the potential to affect all 54 residents residing in the facility. Findings include: The facility's COVID-19 Vaccination Policy dated 11/14/22 documents staff can work if they have received at least the first dose of a two dose series, and they must receive the second dose on schedule in order to be allowed to continue to work. Staff are exempt from this requirement if they have an approved medical or religious exemption, or if COVID-19 vaccination is temporary delayed when recommended by the Centers for Disease Control and Prevention (CDC). A line list should be used to ensure all staff and newly hired staff COVID-19 vaccination status is accounted for. The facility's Employee COVID-19 Vaccination spreadsheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to act, follow-up, and resolve concerns discussed in the resident council meetings for four of four residents (R8, R50, R49, and R42) reviewed for resident council on the sample list of 46. Findings include: On 2/15/23 at 10:00 AM, during the group meeting, R8, R50, R49, and R42 stated the resident council meets once a month. When asked about concerns brought forth during the resident council meetings, R8, R50, R49, and R42 stated the snack cart is still a problem. They stated the staff are supposed to take it around and offer a snack and they don't do it. They stated at 2:00 PM, the staff don't always come to the activity room to offer a snack which they are supposed to do. They stated there is never a CNA (Certified Nursing Assistant) in the big dining room to help them. The dietary staff pass the trays and the CNAs are supposed to help them after the trays are passed. They stated call lights are a huge problem. R42 stated it took 62 minutes for the staff to answer R42's light. R50 stated it has taken an hour…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plans were developed and implemented for five residents (R2, R12, R26, R35, R44) reviewed for care plans on the sample list of 46. Findings include: The facility's Resident Assessment and Care Planning policy dated November 2017 documents the facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs as well as preferences for care and goals. This polciy documents this comprehensive care plan is person centered. 1. R35's Face Sheet dated 2/16/23 documents R35's diagnoses including Dementia. R35's Progress Notes dated as follows document: 1/18/23 at 11:02am, R35 was yelling at staff and made R35's roommate upset. 1/20/23 at 10:43pm, R35 displayed multiple aggresive and threatening behaviors throughout the nightshift anytime staff and residents talked with R35. 1/24/23 at 11:12am, R35…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigate falls, determine the root cause of falls, implement interventions add interventions to resident's care plans for four of four residents (R6, R47, R13, R24) reviewed for falls in the sample list of 46. Findings include: The facility's Fall Assessment and Management Policy with a revised dated 4/2019 documents, The potential for falls will be care planned when appropriate, based on the results of the Fall Risk Assessment. The interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the resident. Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. Post fall assessment - immediately after fall: A licensed nurse will immediately assess the resident after a fall. Risk Watch Occurrence report (facility's investigation) is initiated within the shift that the fall occurred. Care planning after a fall. 1. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store respiratory tubing and equipment in a sanitary manner, failed to obtain a physician's order for oxygen, and failed to date tubing and humidification bottle for four of four (R23, R43, R44, and R18) residents reviewed for respiratory equipment on the sample list of 46. Findings include: 1. On 2/14/23 at 9:53 AM, R23's BIPAP (Bilevel positive airway pressure) tubing and mask were not bagged and lying on a table in the room. On 2/16/23 at 1:00 PM, V2 Director of Nursing stated that all respiratory tubing and equipment should be bagged when not in use. 2. On 2/14/23 at 9:53 AM, R43's oxygen tubing and nasal cannula was laying on the floor unbagged. On 2/16/23 at 1:00 PM, V2 Director of Nursing (DON) stated that all respiratory tubing and equipment should be bagged when not in use. 3. R44's Hospital Discharge Instructions dated 12/24/22 document R44's diagnoses including Pneumonia. These orders document R44's medication orders including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 attempt alternatives prior to the use of bed rails and accurately complete a side rail assessment for five of five residents (R23, R24, R38, R44, and R2) reviewed for bed rails on the sample list of 46. Findings include: The facility's side rail policy with a revision date of 1/10/2018 documents, Prior to the use of bed rails the facility will document assessment of use. 1. On 2/14/23 at 9:53 AM, R23 was lying in bed, there were bed rails up on both sides of the bed. R23's bed rail assessment dated [DATE] does not document interventions attempted prior to the use of the bed rails. On 2/16/23 at 10:13 AM V2 Director of Nursing stated siderails should have prior alternative interventions that were attempted and documented on the bed rail assessment. 2. On 2/15/23 at 9:25 AM, R24 was lying in bed. A bed rail was up on both sides of the bed. R24's bed rail assessment dated [DATE] documents R24 does not have bed rails on the bed. On 2/16/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify targeted behaviors and nonpharmacological interventions attempt psychotropic medication reductions, document a rationale for not attempting medication reductions, develop a psychotropic medications care plan, and complete timely psychotropic assessments for five of five residents (R8, R38, R45, R6, and R49) on the sample list of 46. Findings include: 1. R8's Medications Administration Record for 2/1/23 through 2/28/23 documents an order with a start date of 8/5/22 for 2.5 milligrams (mg) of Abilify (antipsychotic) everyday at 8:00 AM, an order with a start date of 6/11/21 for 20 milligrams of Celexa (antidepressant), an order with a start date of 5/25/22 for 10 milligrams of Buspar (anxiolytic) three times a day. R8's psychotropic medication assessment dated [DATE] documents R8 has a diagnosis of Bipolar Disease and is receiving Abilify 2.5 mg every am, Celexa 20 mg every am and Buspar 10 mg twice a day. This assessment does not document which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in accordance with Physician's Orders and manufacturer's recommendations for two of three residents (R105, R22) reviewed for medication administration in the sample list of 46. The facility had 4 medication errors out of 26 opportunities resulting in a 15.38% (percent) medication error rate. Findings include: The Medication Administration policy dated 1/11/10 documents, Policy: It is the policy of this facility to accurately administer medication following physician's orders. Missed doses of medication may occur at points in time related to lack of availability by suppliers, drug recalls, etc. In such cases, the facility will notify the contracted back up pharmacy or resident family (in cases where the family is the provider of these medications, such as is common with some insurance and VA {Veterans Administration} medications) for provision to the facility. 1.) R105's Order Summary dated 2/15/23 documents an order for Sucralfate oral tablet 1 GM (Gram), give one tablet by mouth two…

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

Based on observation, interview and record review the facility failed to store medications separately from food. This failure affects 20 residents (R26, R1, R12, R44, R47, R43, R19, R28, R5, R22, R30, R10, R25, R50, R46, R17, R45, R33, R35, R51) with medications in the refrigerator. Findings include: On 2/15/23 at 3:46 PM, V15 Registered Nurse completed the medication storage room tour. At this time there was pudding, applesauce, gelatin, individual thickened water, nutritional shakes, beer, wine, juice and whiskey in the medication refrigerator. In this same refrigerator were medications for specific residents and stock medications for back up supply. There was also Influenza vaccine vials and Tubersol vials in this same refrigerator with the food and drinks. On 2/16/23 at 8:58 AM, V7 Corporate Field Nurse supplied a list of items in the medications refrigerator. This list documents the refrigerator contains Lorazepam (antianxiety) concentrate for R26, R1, R12, R44, R47 and R43, Levemir (insulin) and Novolog (insulin) for R19, Latanoprost eye drops for R28 and R5, Trulicity…

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

Based on observation, interview and record review, the facility failed to serve residents meals as per the dietary spreadsheet. This failure affects seven residents (R9, R15, R21, R28, R48, R51, R255) reviewed for dietary food service on the sample list of 46. Findings include: The facility's Week 2 Wednesday Diet Spreadsheet documents residents requiring Low Concentrated Sweets (LCS) diets portion sizes to be served at the noon/lunch meal including the following: 1 square piece of Lasagna 8 ounce scoop of tossed salad with dressing 1/2 slice of Garlic Bread 1/2 square Chocolate Peanut Butter Cake. The facility's Diet Type Report dated 2/14/23 documents R9, R15, R21, R28, R48, R51 and R255's current diet types which include LCS. On 2/15/23 starting at 12:00pm, the facility served R9, R15, R21, R28, R48, R51 and R255's lunch meals which included a full slice of Garlic Bread and a full square of cake to each resident listed. On 2/16/23 at 2:10pm, V4, Dietary Manager (DM) stated the facility is to follow the dietary spreadsheets for each diet type, including serving sizes. V4 stated V4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer influenza and pneumococcal vaccinations, obtain/track resident influenza and pneumococcal vaccination information and document the information in the resident's medical record for four (R255, R50, R48, R6) of five residents reviewed for immunizations in the sample list of 46. Findings include: The facility's undated list of resident influenza and pneumonia vaccine status documents the following: R255's and R6's influenza and pneumococcal vaccine information is blank and does not document if they have received influenza or pneumococcal vaccines, or that they were offered and refused. R50 and R48 refused the influenza vaccine and there is no documentation listed for the pneumococcal vaccine. 1.) R255's Census dated 2/15/23 documents R255 admitted to the facility on [DATE]. R255's medical record does not document that R255 was offered the influenza and pneumococcal vaccines or R255's vaccine history/information. 2.) R50's Census dated 2/15/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 offer a COVID-19 (Human Coronavirus 2019) primary and booster vaccines, and obtain resident COVID-19 immunization information for four of (R255, R50, R48, R6) of five residents reviewed for immunizations in the sample list of 46. Findings include: On 2/14/23 at 8:35 AM there was a sign dated 2/8/23 posted at the entrance of the facility documenting the facility currently has COVID-19 positive cases and is considered to be in outbreak status. The facility's list of resident COVID-19 vaccination status documents R255, R50, R48, and R6 are not up to date on COVID-19 vaccination, and R48 and R50 declined the COVID-19 vaccine. This list does not document COVID-19 vaccination information for R255. 1.) R255's Census dated 2/15/23 documents R255 admitted to the facility on [DATE]. R255's medical record does not document that R255 was offered the COVID-19 vaccine or R255's COVID-19 vaccine history/information. 2.) R50's Census dated 2/15/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inspect bed rails to identify areas of entrapment, failed to ensure bed rails were secured to the bed frame, and failed to ensure the mattress fit securely against the side rails for five of five residents (R23, R24, R38, R44, and R2) reviewed for bed rails on the sample list of 46. Findings include: 1. On 2/14/23 at 9:53 AM, R23's was lying in bed. There were side rails up on both sides of the bed. On 2/16/23 at 11:18 AM, V25 Maintenance Assistance stated R23's bed and rails have not been inspected for areas of entrapment. 2. On 2/15/23 at 9:25 AM, R24 was lying in bed. A Side rail was up on both sides of the bed. The side rails are loose and move freely when shook back and forth. There is a six inch gap between the mattress and the side rails. On 2/16/23 at 12:05 PM, V25 Maintenance Assistant inspected R24's bedrails. At that time, V25 confirmed the side rails were loose and not tightly secured to the bed frame. V25 the gap between the rail and mattress was 3 inches. 3. On 2/15/23 at 9:30 AM, R38 was lying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately record a resident's preference for life-sustaining treatment in the medical record for one resident (R6) and failed to obtain a Qualified Practitioner's signature for a resident's POLST (Practitioner Order for Life-Sustaining Treatment) form for one resident (R49). This failure affects two (R6, R49) of three residents reviewed for advance directives in the sample list of 46. Findings include: The facility's Advance Directive policy with a revised date of 11/2022 documents, All residents will be given information regarding Advance Directives upon admission, in accordance with the Self Determination Act. Advance Directives include but are not limited to: Power of Attorney for Health Care, Living Will, IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST), Medically Administered Nutrition including feeding tubes. The IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) is an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written notification/acknowledgement of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage for three of three residents (R18, R24, R52) and failed to document acknowledgement of Notice of Medicare Non-Coverage for one of three residents (R18) reviewed for beneficiary protection notification on the sample list of 46. Findings include: 1. R18's Notice of Medicare Non-Coverage (NOMNC) dated 2/9/23 does not document a signature of acknowledgement of the notice by R18 or V28, R18's Family. R18's Skilled Nursing Advance Beneficiary Notice of Non-coverage (SNFABN) dated 2/9/23 does not document R18 or V28's signature of acknowledgement of the notice. 2. R24's Census documents R24 admitted to the facility on [DATE] with Medicare Part A benefits and a payor change on 2/2/23. This Census documents R24 remains in the facility. R24's NOMNC documents R24's skilled services end date of 2/1/23. The facility was unable to find…

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

Based on observation, interview and record review, the facility failed to complete skin assessments and assess and document a blood filled blister to the left hand little finger for one of one resident (R15) reviewed for skin alterations/edema on the sample of 46. Findings include: R15's Order Summary Report documents an order dated 1/4/23 to complete weekly skin checks and document if a wound is present. This order documents to document in R15's Progress Notes after completing the wound assessment. On 2/15/23 at 3:30pm, R15 was observed in the hall in R15's wheelchair and noted to have a dark, fluid filled circular skin alteration to R15's left hand little finger. R15's Electronic Medical Records (EMR) do not document R15 has this skin alteration. R15's EMR does not document an evaluation/assessment/measurements of this skin alteration. R15's Electronic Medical Records do not document weekly skin assessments as ordered. On 2/16/23 at 12:30pm, V2, Director of Nursing (DON) stated the facility does not have documentation of skin assessments weekly as ordered. V2 stated the facility…

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

Based on observation, interview, and record review the facility failed to complete weekly pressure ulcer assessments, ensure a wound dressing was dated and intact, perform hand hygiene and prevent cross contamination during a pressure ulcer treatment for one resident (R26) reviewed for pressure ulcers in the sample list of 46. Findings include: R26's Diagnoses List dated 2/15/23 documents R26 has Paraplegia, Moderate Protein-Calorie Malnutrition, and Stage IV Pressure Ulcer of the Left Buttock (5/10/22). R26's Hospice Plan of Care dated 1/25/23 documents R26 has a diagnosis of Stage IV Pressure Ulcer of the Right Buttock as of 10/21/22. R26's February 2023 Treatment Administration Record (TAR) documents an order to cleanse left and right gluteal wounds with Wound Cleanser, pack with Sodium Chloride 0.9 % moistened 4 x 4 sterile gauze or gauze roll, cover with abdominal dressing and a transparent adhesive dressing twice daily on dayshift and evening shift and as needed. This TAR documents orders to check to ensure the dressing is intact and not saturated every shift/three times per…

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

Based on observation, interview, and record review the facility failed to provide a frozen nutritional supplement as ordered for two residents (R2, R12) reviewed for nutrition in the sample list of 46. Findings include: 1. R2's undated weight log documents R2 weighed 120.2 lbs (pounds) on 10/13/22, 110.4 lbs on 11/10/23 (8.15% loss in one month), 109.6 lbs on 12/6/22, 108.2 lbs on 1/2/23, and 107.4 lbs on 2/1/23 (10.65% loss in 4 months.) R2's February 2023 Medication Administration Record (MAR) documents a frozen nutritional supplement is ordered to be given three times daily at 8:00 AM, 12:00 PM, and 4:00 PM. R2's Nursing Notes dated 12/26/22 at 12:45 PM documents R2's physician was notified of R2's weight and gave orders to increase R2's nutritional supplement to three times daily. R2's Nursing Note dated 1/10/23 at 10:08 AM documents R2's physician was notified of R2's weights and new orders given to increase the frozen nutritional supplement to three times daily. R2's Nutrition Notes document on 1/24/2023 at 3:58 PM documents R2 was evaluated by a registered dietitian and…

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

Based on interview and record review, the facility failed to ensure orders for hospice services were transcribed to residents Physician's Orders in the Electronic Medical Record and failed to ensure facility care plans were comprehensive for hospice services. These failures affect two of five residents (R26, R44) reviewed for hospice on the sample list of 46. Findings include: 1. R44's Hospice admission Orders/Initial Plan of Care documents R44 was admitted to hospice care on 1/4/23. R44's Physician's Orders dated do not document an order for hospice in R44's Physician's Orders. R44's Care Plans dated 2/14/23 document the hospice company used, but no details on how to contact them or to see R44's hospice plan of care. R44's Care Plans do not document resident specific interventions related to R44's hospice/facility coordination of cares. On 2/15/23 at 10:52 AM V3 Assistant Director of Nursing stated the resident's hospice company is listed on the nurse report sheets, which we are currently out of. The hospice company/contact information and order should be listed on the physician's…

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