Arcadia Care Havana

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to protect one of three Residents (R1) reviewed for Verbal Abuse from a Facility staff perpetrator. Findings include:The Facility Abuse Prevention and Reporting Policy, dated 12/2025, documents: the Facility affirms the right of our Residents to be free from abuse; Facility prohibits abuse; establishes a resident sensitive and resident secure environment; and orienting and training employees on how to deal with stress.The Facility's Final Abuse Investigation Report, dated 12/22/25, documents, on 12/16/25 at approximately 6:00 pm, a verbal abuse altercation between R1 and V8 (Agency Certified Nursing Assistant/CNA). The Abuse Investigation Report also documents: R1 is a [AGE] year-old, has altered cognitive deficits (Brief Interview for Mental Status/BIMS-score 12/15) and admitted to the Facility with diagnoses including Right Femur Fracture and Chronic Obstructive Pulmonary Disease. V8 (Agency CNA) swore at R1 and disregarded R1's hip pain when…

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

Based on interview and record review, the Facility failed to provide a properly maintained transportation van causing safety risks for one of three Residents (R3) during transportation with weather risks (rain) and after sundown.Findings include:The Facility Transportation Driver Job Description, dated 7/2023, documents: is responsible for safety of Residents at all times; monitors Resident safety on the bus; responsible for general upkeep including conducting preventative maintenance, delivering vehicle to authorized service facility, maintains vehicle according to the requirement of the Facility, including completing all required paperwork; follow all safety procedures and protocol as dictated by local policy, federal and state regulations and standard practice; reports all hazardous conditions, defective equipment and incidents to the supervisor immediately; and maintains accurate activity and vehicle report logs.The Facility Grievance Tracking Logs, dated 12/2025 and 1/2026, document issues with headlights on 1/8/26. The Tracking Log does not document a date of resolution…

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

Based on observation, interview, and record review the facility failed to employ and schedule sufficient maintenance, custodial, laundry, and housekeeping staff to ensure the facility was kept clean and free of odors, to ensure the facility had a sufficient amount of clean linens, mechanical lifts, mechanical lift slings, to ensure the facility's clean utility rooms and all resident rooms were cleaned at least daily, and to ensure the facility's walls, floors, mechanical lifts, lights, window coverings, and toilets were kept maintained and in good repair. These failures have the potential to affect all 58 residents residing within the facility.Findings include:The Facility's Daily Census Log dated 1/15/26 documents there are 58 residents currently residing within the facility.The Facility's Assessment Tool dated 11/25 through 11/26 documents, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the facility assessment included the amount of direct care staff required daily to meet the needs of the residents, ensure there were an adequate amount of direct care staff to perform daily ADLs (Activities of Daily Living) to the residents, ensure residents received fresh ice water every shift, and ensure call lights were answered timely. These failures have the potential to affect all 58 residents residing within the facility.Findings include:The Facility's Daily Census Log dated 1/15/26 documents there are 58 residents currently residing within the facility.The Facility's Assessment Tool dated 11/25 through 11/26 documents, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents' toilets were clean and operable for four of ten residents (R4, R7, R8, R9) reviewed for safe, clean, comfortable, and homelike environment in the sample of 10.Findings include:The facility's Maintenance Director Job Description dated 3/2024 documents The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator to assure that our facility is maintained in a safe and comfortable manner. Essential Duties and Responsibilities: Repair facility/resident property as necessary.The Illinois Long-Term Care Ombudsman Program Residents' Rights Booklet, dated 11/2018, documents Your rights to safety: Your facility must be safe, clean, comfortable, and homelike.R4's Census List dated 9/26/25 through…

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

Based on record review and interview the facility failed to provide financial statements quarterly to residents and residents' representatives. This failure has the potential to affect all 44 residents residing within the facility. Findings include:The Resident Funds policy dated 3/2024 documents Guidelines: 5. The resident and/or resident representative is provided with a quarterly accounting report of his or her funds on deposit with the facility, and upon request.The Business Office Manager policy dated 7/2023 documents, Job duties: Prepare and mail statements.On 8/6/25 at 8:45 AM V7 (R1's Power of Attorney) stated, I have never received a copy of (R1's) financial statement from the facility.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, I worked for the facility from the day the company took over on 11/1/24 until I was terminated on 6/12/25. While I was there, I never provided the residents or residents' representatives with quarterly financial statements. I used to mail those for the prior company, but since I started with this company I did not have time to…

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

Based on record review and interview the facility failed to promptly provide a copy of the updated admission agreement/contract to all residents and/or residents' representatives upon change of facility ownership. These failures have the potential to affect all 34 residents residing within the facility upon change of ownership on 11/1/24.Findings include:The facility's Daily Census Report dated 11/1/24 documents 34 residents residing within the facility on 11/1/24. The Business Office Manager policy dated 7/2023 documents Business Office Manager Job Description Summary: The primary purpose of the Business Office Manager is to assist in the day-to-day accounting functions of the facility in accordance with current acceptable accounting and cost reimbursement principles relating to nursing facility operations, and as may be directed by the Administrator, Director of Finance, or Accountant. Ensure that resident admission contracts are signed and appropriately filed.V5's (Prior Business Office Manager's) Performance Improvement Plan dated 4/28/25 documents V5 was responsible for doing…

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

Based on record review and interview the facility failed to refund unused resident funds to a resident's representative within 30 days of the resident's death for one of three residents (R1) reviewed for resident funds in the sample of three.Findings include:The Illinois Department on Aging Centers for Medicare and Medicaid Understating Your Financial Rights Guidelines dated 7/12/21 document, Your financial rights: The nursing home must return funds with a final statement to the person or court handling your estate within 30 days after your death. R1's Hospital Record documents:R1 was transferred to the hospital from the facility on 6/21/25 and passed away while in the hospital on 6/23/25.R1's Resident Statement Landscape dated 11/5/24 through 6/12/25 documents R1 had 60.00 dollars each month deposited by SSA (Social Security Administration) into the facility's trust fund account for R1's personal use. R1's Resident Statement Landscape dated 8/1/25 documents R1 had 420.00 personal dollars left in the facility's trust fund account that R1 had not spent or used since 11/5/24.On 8/6/25…

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

Based on observation, interview and record review the Facility failed to maintain a sanitary and orderly environment for Residents by failing to stock disposable hand towels and/or cloth hand towels/wash clothes in Resident restrooms for nine of nine Residents (R2, R3, R4, R7, R8, R9, R10, R11 and R12) and maintain clean and orderly Resident restrooms for two Residents (R1 and R7) of nine reviewed for clean and homelike environment in a sample of 12. Findings include: The Facility Resident Rights for People in Long-Term Care Facilities, revised 11/2018, documents: the Facility must provide services to keep your physical and mental health at the highest practical levels; and must be safe, clean, comfortable, and homelike. The Facility Housekeeper Job Description, revised 7/2024, documents: the primary purpose is to perform day-to-day activities of the Housekeeping Department in accordance with federal, state and local standards, guidelines and regulations; to ensure the Facility is maintained in a clean, safe and comfortable manner; and to coordinate housekeeping services with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility failed to follow Physician Orders to apply bilateral lower extremity compression stockings and provide basic activity of daily living nail care for one of five Residents (R2) reviewed for cares in a sample of 12. Findings include: The Facility Resident Rights for People in Long-Term Care Facilities, revised 11/2018, documents: must treat you with dignity and respect and care for Residents in a manner that promotes quality of life; provide equal access to quality of care regardless of diagnosis or condition; provide services to keep physical and mental health at highest practical levels; and receive services included in plan of care. The Facility's Certified Nursing Assistant/CNA Job Description, revised 7/2023, documents: to provide Resident of this Facility with nursing and personal care and to safeguard the health, safety and welfare of all Residents of the Facility in accordance with policies and procedures and applicable laws and regulations;…

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 have a Registered Nurse/RN for eight hours a day seven days a week. This has the potential to affect all 46 residents in the facility. Findings include: Facility Assessment, updated 3/1/25, documents Average daily census of 40. Facility resources needed to provide competent support and care for our resident population every day and during emergencies. Staff type; Nursing Services RN-1 on day shift. State PBJ/Payroll Based Journal Staffing Data Report, Quarter (October 1 - December 31, 2024) documents no RN hours on the following dates: 11/01 (FR/Friday); 11/02 (SA/Saturday); 11/03 (SU/Sunday); 11/09 (SA); 11/10 (SU); 11/16 (SA); 11/17 (SU); 11/23 (SA); 11/24 (SU); 11/30 (SA); 12/01 (SU); 12/07 (SA); 12/08 (SU); 12/14 (SA); 12/15 (SU); 12/21 (SA); 12/22 (SU); 12/25 (WE/Wednesday); 12/28 (SA); and 12/29 (SU). Facility daily staffing sheets for January thru March 2025 reviewed with no RN coverage for 1/11, 1/12, 1/25, 1/26, 2/8, 2/9, 2/22, 2/23, 3/8 and 3/9/25. V2 DON confirmed no RN coverage on those dates. 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 have a Certified Dietary Manager/CDM and failed to have certified staff. This has the potential to affect all 46 residents in the facility. Findings include: Facility Dietary Aid job description, copyright 2025, documents The dietary aid is responsible for aiding all food functions as directed/instructed and in accordance with established food policies and procedures. Essential Duties and Responsibilities: Ensure food is prepared in accordance with sanitary regulations. Facility Dietary Manager/DM job description, copyright 2025, documents The Dietary Manager is responsible for partnering with the Dietician to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, to assure that quality nutritional services are provided on a daily basis and that the Dietary Department is maintained in a clean, safe, and sanitary manner. Must possess Food Service Sanitation Manager…

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

Based on observation, interview, and record review, the facility failed to have sufficient staff during the meal service. This has the potential to affect all 46 residents in the facility. Findings include: Facility Assessment, updated 3/1/25, documents Average daily census of 40. Facility resources needed to provide competent support and care for our resident population every day and during emergencies. Staff type: Food and Nutrition Services (Director, support staff, Registered Dietician). Facility Dietary Aid job description, copyright 2025, documents The dietary aid is responsible for aiding all food functions. Facility Dietary Manager job description, copyright 2025, documents The Dietary Manager is responsible to assure that quality nutritional services are provided on a daily basis. Facility Cook job description, copyright 2025, documents The [NAME] is responsible to assure that quality food services is provided at all times. Facility Meal times and locations, undated, documents 7:30 AM small and main dining room; 11:30 AM small and main dining room; and 5:30 PM small 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 observation, interview, and record review, the facility failed to have a delivery, use-by date, or expiration date for Zucchini and loaves of bread. This has the potential to affect all 46 residents in the facility. Findings include: Facility Food and Supplies: Storage, copyright 2025, documents All foods will be covered, labeled, and dated. If there is no expiration date on the package or container, a use-by date must be written on the product. On 3/18/25 at 11:00 AM during the kitchen tour with V6 DM/Dietary Manager a bag of frozen zucchini had no date on it when received, use-by date, or expiration date; and multiple loaves of bread did not have a received, use-by date, or expiration date on them. At that same time V6 DM stated I thought the bread had a date on them, but I don't see one, and that bag of zucchini was taken out of the box today. I am on staff all the time to make sure they are dating when we get our deliveries and when they are opened. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a PASARR (Pre-admission Screening and Resident Review) Level I screening and/or Level II referral were completed for one (R2) of two residents reviewed for PASARR Screenings in the sample of 22. Findings include: The facility's Preadmission Screening and Annual Resident Review (PASARR) Policy and Procedure dated 3/2024 documents, It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASARR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD (Serious Mental Illness/Serious Mental Disorder)), intellectual disability (ID) or related condition. Based upon the Level I screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been…

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 activity of daily living/ADL assistance for hygiene/scheduled baths for one dependent resident (R4) of 16 resident's reviewed for Activity of Daily Living assistance in a sample of 22. Findings include: The Facility Bathing, Shower and Tub Bath Policy, revised 10/2024, documents: To ensure the residents cleanliness to maintain proper hygiene and dignity; shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested; and shower chair or bed, towels and wash cloths, body wash, shampoo, deodorant/antiperspirant, lotion and other toiletry items as requested by resident and residents clothing. R4's current Care Plan documents: (R4) requires staff assistant for Activities of Daily Living/ADL for bathing and grooming; assure resident that staff is plentiful and available for assist at any time;.maintain consistent routine to insure compliance and avoid confusion; monitor for…

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

Based on observation, interview, and record review, the facility failed to have orders for a BiPAP/Bilevel Positive Airway Pressure machine and failed to label and change oxygen and nebulizers per their policy and orders for three (R30, R191, and R192) of five residents reviewed for oxygen in a sample of 22. Findings include: Facility Oxygen and Respiratory Equipment- Change/Cleaning, copyright 2025, documents The hand held nebulizer should be changed weekly and PRN (as needed). A clean plastic bag with a zip loc or draw string will be provided with each new set up and will be marked with the date the set up was changed. Nasal cannulas are to be changed once a week and PRN. A clean plastic bag with a zip loc or draw string will be provided to store the cannula when it is not in use. It will be dated with the date the tubing was changed. On 3/21/25 at 11:11 AM, V19 RN/Registered Nurse stated Night shift nurses are responsible for changing oxygen tubing and humidifiers out. We assist residents with cleaning their CPAP (Continuous Positive Airway Pressure)/BIPAP or make sure they are…

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 specialized rehab services after an order for one (R191) of one resident reviewed for Rehab Services in a sample of 22. Findings include: R191's hospital Physical Therapy notes, dated 3/4/25, documents Decline in functional mobility, poor functional mobility, and deconditioning. Discharge disposition: Nursing home for continued therapy. Frequency: 1-2 times/day on Monday through Friday. Duration: 2 weeks. Treatment plan to include the following: Gait training; mobility/transfers/strength/ROM (Range of Motion); education; family training; and balance activities. R191's medical record documents an admission date of 3/5/2025 (Wednesday), and a medical diagnosis of Polymyalgia Rheumatica and Congestive Heart Failure/CHF. R191's current care plan for March 2025 documents The resident is at risk for falls related to impaired mobility. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Pt evaluate and treat as ordered or PRN/as…

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

Based on observation, interview and record review the Facility failed to ensure that ongoing resident centered activity programs were being offered. This failure has the potential to affect all 40 Residents residing in the Facility. Findings include: Facility Resident Census Roster, dated 12/9/24, documents 40 Residents residing in the Facility. Facility Resident Rights Policy, revised 11/2018, documents: the Facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; must provide equal access to quality care; must provide services to keep your physical and mental health, at their highest practical levels; and you have the right to participate in social and community activities. The Facility Activity Director Essential Duties and Responsibilities/Job Description, revised 5/2023, documents: to provide ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial wellbeing of each Resident; and to develop and plan activities. On 12/10/24…

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

Based on interview and record review, the facility failed to have Resident Council Meetings for five of twelve meetings in the past year, this has the potential to affect all 36 residents who live in the facility. Findings: The document, Resident Council, no date, states, It is the policy of this facility to establish a Resident Council for the purpose of residents sharing in the planning and controlling of their lives. The Resident Council shall provide a setting where personal choices, opinions, concerns, interests and complaints can be openly discussed All decisions made by this council shall be made democratically and all residents shall be encouraged to participate in the council. The council shall meet at least once per month or more often of desired. The Resident Council shall communicate to the Administrator the opinions and concerns of the residents. The council shall review procedures for implementing resident rights and facility responsibilities and make recommendations for changes or additions. On 6/03/24 at 10:00 AM, a group meeting was held with R3,R14,R20 and R36.…

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 the facility had an adequate amount of wash clothes and towels and maintained a clean shower curtain. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Laundry policy and procedures (undated) documents, It is the policy of (the facility) that clean linens and clothing are available at all times to provide a clean sanitary environment for residents. Clean linens will be stored in clean linen rooms, and available for nursing use. The Housekeeper Job Summary (undated) documents Housekeepers are responsible for maintaining the facility in a clean, orderly and sanitary manner. Responsibilities: 1 Duties b) Deep clean assigned bath/shower rooms, each resident room and all other rooms or areas at least once each month or per the cleaning schedule or as directed. d) Bath/shower rooms are monitored for cleanliness and sanitation and the need for soap…

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 residents were aware of the process to submit grievances, and aware of who the facility grievance official is, and failed to develop and implement a resolution to monthly resident council complaints. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Resident Grievance/Complaints policy dated 11/1/17, documents Policy: It is the policy of (the facility) to actively encourage residents and their representatives to voice grievances and complaints on behalf of themselves or others without discrimination or reprisal. Grievances and/or complaints may be reported to the Administrator, any staff member, Resident Council and to State Agencies. All staff are required to report any and all grievances and complaints received from residents to the Social Service Director (SSD), who will serve as the grievance official. The grievance official will bring all…

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 an ongoing program of activities daily on the day and evening shifts designated to meet the resident's physical, mental, and psychosocial well-being of each resident, failed to develop comprehensive activity care plans, and failed to assess resident activity interests and goals quarterly. These failures have the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The facility's Activity Policy dated 7-11-06, documents It is the policy of the facility to provide a program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The program is under the direction of an Activity Director, who shall have a specific planned program of group and individual activities based upon the resident's…

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

Based on observation, record review, and interview the facility failed to employ a full-time Activity Director to plan, schedule, and implement an ongoing program of activities. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Activity Director policy (undated), Job Summary The Activity Director plans, schedules, and implements an ongoing program of activities designed to meet the physical, mental, and psychosocial needs of each resident. Residents are engaged in a meaningful, varied program of activities that meets the individual residents. The activities are conducted with individuals or in groups, according to the residents Plan of Care. The Activity Director completes the activity assessment for each resident and participates in developing the Interdisciplinary Care Plan. Responsibilities 1. Plan, organize and coordinate an activity program according to established policies. 2. Plan group and individual activities…

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 there was enough nursing staff to provide nursing services. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Facility Assessment Tool dated 8/18/2017, documents Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. The facility's Nursing Services policy (undated) documents, It is the policy of (the facility) to assure sufficient qualified nursing staff is available and on duty on a daily basis to provide nursing 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 observation, record review, and interview the facility failed to provide Registered Nurse/RN services eight hours daily and failed to employ a Director of Nursing (DON) to oversee the operation of the Nursing Department and ensure quality of care. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The facility's Nursing Services policy (undated) documents, Registered nurse services shall be available eight hours each day, seven days a week. The facility's Director of Nursing Job Description (undated) documents, Job Summary: To plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulation that govern our facility and as may be directed by the Administrator and the Medical Director to ensure the highest degree of quality care is maintained at all times. The facility's Facility Assessment Tool dated…

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

Based on observation, interview and record review, the facility failed to employ a Certified Dietary Manager. This has the potential to affect all 36 residents living in the facility. Findings: The job description for the Food Service Manager, dated 4/17, states, Manages all aspects of the Food Service Department in the facility including but not limited to Food Service personnel, food production, supplies and equipment. Manages nutritional care of all residents in the facility. The Responsibilities of the Food Service Manager are: Orders all supplies necessary for the proper and efficient running of the department making sure to remain within budget; Ensures that all residents are served diets as ordered by physician; Ensures that the menus are followed and appropriate substitutions are made and recorded. Follows Consultant Dietitian/Regional Dietitian recommendations that are reviewed and approved by Administrator; Takes necessary measures to ensure that all food served to residents has been prepared in a safe, sanitary manner while also maintaining the highest quality; Makes sure…

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: keep meat in the refrigerator overnight; date and label food that has been opened in both cold food and pantry storage; discard outdated food; use proper storage containers to prevent foods from contamination; maintain a clean kitchen; replace and maintain floor tiles; clean overhead vents and returns in both food preparation and dish room areas; repair and maintain walls and corners that have paint and plaster chipped away; date and label all food brought in from the outside for residents; keep 50 pound bags of salt (softener) off of the kitchen floor; close spaces between ceiling tiles and around pipes; keep boxes of paper supplies off of the floor; and keep the door to the outside closed. This has the potential to affect all 36 residents living in the facility. Findings: The document, Food from Outside Sources/Personal Food Storage, dated 4/17, states, All residents have the right to accept food brought to the facility by any visitors, however, the food must be handled in a way to ensure resident safety.…

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 administration failed to ensure ongoing resident complaints were resolved, to ensure residents had an adequate amount of linens, to ensure an ongoing program of activities were provided to the residents daily, to ensure a full-time Director of Nursing, Activity Director, and Dietary Manager were employed to manage and oversee everyday nursing, activity, and dietary services, to ensure the facility had sufficient nursing staff, to ensure the most up-to-date infection control practices were implemented, to ensure resident council meetings were provided monthly, to ensure large dietary appliances were in good repair and working order, to ensure all required QAPI (Quality Assurance and Performance Improvement) members met monthly, to ensure plans were implemented to correct and/or improve identified areas of concern, and ensure all CNAs (Certified Nursing Assistants) were provided annual required abuse, QAPI, and Dementia in-service training. These failures have the potential to affect all 36 residents residing within 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, record review, and interview the governing body of the facility failed to employ a licensed administrator to oversee and manage the everyday operations of the facility. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The Job Description Administrator (not dated), documents QUALIFICATIONS The Administrator must be qualified through a combination of education, experience, and training to manage a Nursing Facility. Knowledge of business administration, nursing care and human relations is necessary. He/she must hold, or be eligible for, a Nursing Home Administrators license in the State which he/she is practicing. ADMINISTRATOR QUALIFICATIONS: 1 Must have successfully completed all educational requirements as required by federal and state regulations. 2 Must possess a current, unencumbered Nursing Home Administrators license or meet the licensure requirements of the State. On 6-2-24 from 7:00 AM through 2:15…

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 develop and implement QAPI (Quality Assurance and Performance Improvement) plans to address the lack of follow-up to resident complaints, to address the lack of department heads including the Director of Nursing, Activity Director, and Dietary Manager, to address the lack of linens, to address the lack of an ongoing program of activities, to address the lack of sufficient nursing staff, to address the lack of education regarding QAPI, Dementia care and treatment, infection control practices, and abuse, to address the broken dietary equipment, to address the lack of resident council meetings, and the lack of required employees attending QAPI meetings. These failures have the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The document, Quality Assurance and Performance Improvement (QAPI), dated 1/10/24, states, This facility will utilize the principles of QAPI to align all…

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 have a Director of Nursing or the required number of members at the quarterly Quality Assurance Meetings. This has the potential to affect all 36 resident living in the facility. Findings: The document, Members of Quality Assessment and Assurance, no date, states, (Members): Administrator; Administrator in Training; Resident Care Coordinator; Social Services Director/Business Office Manager; Medical Director; Therapy and Pharmacy. The Quality Assurance quarterly sign-in sheets for the past twelve months were reviewed. A Director of Nursing was not present at any of the meetings. The 1/19/24 meeting had five members; the 10/19/23 meeting had four members; the 7/21/23 meeting had four members. On 6/06/24 at 12:45, V2/Administrator in Training stated, No, we didn't have a Director of Nursing to come to the Quality Assurance Meetings. The number of members able to attend the meeting signed the attendance sheets. The facility's Daily Census dated 6/2/24 documents 36 residents currently reside within the facility.

Based on observation, interview and record review, the facility failed to make repairs to several large appliances: the reach-in refrigerator; range oven; convection oven; outside freezer door; steam table; large hood and baffles. This has the potential to affect all 36 residents living in the facility. Findings: The document Maintenance and Environmental Policy and Guidelines, no date, states, It is of the utmost importance to provide a safe, organized facility that is conducive to providing the best care. A well maintained building is also important for creating safe work surroundings across all departmental staffing and their ability to effective and efficiently provide care to all residents. Requested work orders completed in an acceptable manner and time. On 6/02/24 at 9:35 AM, V12, [NAME] and V13, Dietary Worker, both stated, The convection oven doesn't work. It's been broken for months. We were told the part to fix it was too expensive. One of the two range ovens doesn't work right - it can be used as a warmer but won't get the temperature of foods up to the correct…

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

Based on record review and interview the facility failed to ensure direct care staff received annual Abuse and Prevention in-service training. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The facility's Annual Required In-Service policy dated 09/2017 documents staff should receive Abuse Prevention in-servicing annually. V7 (CNA/Certified Nursing Assistant), V11 (CNA), V16-V18 (CNAs), V22 (CNA), and V24-V34's (CNA's) In-Service Training Logs dated 6-1-23 through 6-2-24 do not include evidence of V7, V11, V16-V18, V22, and V24-V34 receiving annual Abuse training. On 6-6-24 at 9:30 AM V2 (Administrator-In-Training) stated, The staff have not received abuse training within the last 12 months.

Based on record review and interview the facility failed to ensure direct care staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The facility's QAPI Plan policy dated 1-10-24 documents, Annual training will be provided to all staff utilizing the annual QAPI report to summarize goals, progress, and PIPs (Performance Improvement Projects). V7 (CNA/Certified Nursing Assistant), V11 (CNA), V16-V18 (CNAs), V22 (CNA), and V24-V34's (CNA's) In-Service Training Logs dated 6-1-23 through 6-2-24 do not include evidence of V7, V11, V16-V18, V22, and V24-V34 receiving annual QAPI in-service training. On 6-6-24 at 9:30 AM V2 (Administrator-In-Training) stated, The staff have never received QAPI in-service training.

Based on record review and interview the facility failed to ensure direct care staff received annual Dementia Care in-service training. This failure has the potential to affect all 36 residents residing within the facility. Findings include: The facility's Daily Census dated 6-2-24 documents 36 residents currently reside within the facility. The facility's Annual Required In-Service policy dated 09/2017 documents staff should receive Alzheimer's Dementia Management in-servicing annually. V7 (CNA/Certified Nursing Assistant), V11 (CNA), V16-V18 (CNAs), V22 (CNA), and V24-V34's (CNA's) In-Service Training Logs dated 6-1-23 through 6-2-24 do not include evidence of V7, V11, V16-V18, V22, and V24-V34 receiving annual Alzheimer's Dementia Management in-service training. On 6-6-24 at 9:30 AM V2 (Administrator-In-Training) stated, The staff have not received Alzheimer's Dementia Training within the last 12 months.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement services to maintain and/or improve range of motion limitations for four of four residents (R6, R16, R24, R35) reviewed for limitations in range of motion in the sample of 29. Findings include: The Range of Motion Protocol policy dated 9/08 documents Policy: It is the policy of the facility to provide range of motion exercises for residents who through assessment demonstrate the need for exercise to prevent functional decline in range of motion. Responsibility: Nursing Assistance and Therapy Aids monitored by Licensed Nurses and Therapists. Procedure: 2) Parts of the body on which range of motion exercises can be performed include all body joints or only those affected by disease process and may include the fingers, wrist, forearm, elbow, shoulder, toes, foot, ankle, knee, hip and trunk. 3) Range of motion exercises will be conducted as scheduled by nursing staff based on need determined by assessment of risks. 6) Perform the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide fresh water for four residents (R6, R7, R23, and R138) of 16 residents reviewed in a sample of 29. Findings include: The Hydration policy dated 6/06 documents It is the policy of (the facility) that the facility will provide each resident with sufficient fluids to maintain proper hydration. Procedure: 2. Provide fresh water and ice at the bedside except where contraindicated, example residents with fluid restrictions. The Hydration Policy dated 2/08, documents It is the policy of (the facility) to assess individual residents who are at risk for dehydration and to provide adequate fluids to all residents to maintain proper fluid balance, prevent skin breakdown, reduce infections and to maintain residents current level of function. 1. R6's current electronic medical record, documents R6 was admitted to the facility on [DATE] with diagnosis which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2…

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 implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling urinary catheters for 11 of 12 residents (R3, R6, R7, R8, R15, R18, R24, R32, R33, R36, and R138) reviewed for EBP in the sample of 29. Findings include: The Enhanced Barrier Precautions dated 7/13/23 documents Purpose: To reduce transmission of multi-drug-resistant organisms/MDRO (Multi-Drug Resistant Organisms). Enhanced Barrier Precautions should be used when contact precautions do not apply, for residents with any of the following: Open wounds that require a dressing change, Indwelling Medical Devices, Infection or colonized with a MDRO. Enhance Barrier Precautions require use of a gown and gloves during high contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended to use for care that occurs within a residence room when high contact resident care activities are bundled together. Outside of a resident's room, EBP should be followed…

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 cover a urinary catheter bag with a privacy bag and failed to provide a washcloth instead of a paper towel to use to wash the resident's face for two residents (R15, R23) of 16 residents reviewed for dignity in the sample of 29. Findings include: The Resident Rights Booklet dated 11/18, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must be safe, clean, comfortable, and homelike. 1. R15's current electronic medical record, documents R15 was admitted to the facility on [DATE] with diagnosis which included Neoplasm of Uncertain Behavior of Right Kidney, Alzheimer's Disease, Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Schizophrenia, and Altered Mental Status. R15's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status)…

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

Based on record review and interview the facility failed to prevent resident (R35) to resident (R19) verbal abuse for one of two residents (R19) reviewed for abuse in the sample of 29. Findings include: The facility's Abuse Prevention Program dated 11-28-16 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies. Verbal abuse in the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. R35's Progress Notes dated 4-1-24 at 1:23 PM documents, V5 (Social Service Director) Note Text: Writer overheard resident (R35) at bingo yelling at another resident (R19), Get out of here. No n*s allowed. I'm getting out of here too…

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

Based on record review and interview the facility failed to report an allegation of resident (R35) to resident (R19) verbal abuse to the state agency for two of two residents (R19 and R35) reviewed for abuse in the sample of 29. Findings: The facility's Abuse Prevention Program dated 11-28-16 documents, Verbal abuse in the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility must ensure that all alleged violations involving abuse are reported to the (State agency) immediately after forming suspicion but no later than two hour after forming suspicion. R35's Progress Notes dated 4-1-24 at 1:23 PM documents, V5 (Social Service Director) Note Text: Writer overheard resident (R35) at bingo yelling at another resident (R19), Get out of here. No n*s allowed. I'm getting out of here too many nrs in here. Writer spoke to resident that it is politically incorrect to use that term, and this is the other…

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

Based on record review and interview the facility failed to investigate an allegation of resident (R35) to resident (R19) verbal abuse for two of two residents (R19 and R35) reviewed for abuse in the sample of 29. Findings: The facility's Abuse Prevention Program dated 11-28-16 documents, Internal Investigation of Allegations and Response: 1. Once the administrator or designee receives and allegation of abuse the administrator will appoint a person to take charge of the investigation. The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident. R35's Progress Notes dated 4-1-24 at 1:23 PM documents, V5 (Social Service Director) Note Text: Writer overheard resident (R35) at bingo yelling at another resident (R19), Get out of here. No nrs allowed. I'm getting out of here too many nrs in here. The facility's Abuse Investigations dated 3-1-24 through 6-2-24 do not include an abuse investigation regarding the alleged verbal abuse between R35 to R19 that occurred on 4-1-24. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a PASRR (Pre-admission Screening and Resident Review) Recommendations Care Plan for one resident (R15) out of 16 reviewed for Care Plans in a sample of 29. Findings Include: The Comprehensive Care Plan dated 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. The following procedures shall be utilized in the development and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to obtain a level one PASRR (Pre-admission Screening and Resident Review) for one resident (R21) and failed to obtain a level II PASRR for two residents (R3 and R15). These failures have the potential to affect three of 16 residents (R3, R15, and R21) reviewed for pre-admission screenings in the sample of 29. Findings include: The admission Policy (undated) documents Prior to admission, a thorough pre-screening of potential residents shall be done with the resident or guardian or responsible party determining appropriate placement. 1. R3's Plan of Care documents R3 was admitted to the facility on [DATE]. R3's PASRR Level I Screen Outcome dated 12-14-23 documents, Level I Outcome: Refer for Level II Onsite. Rationale: A PASRR Level II evaluation must be conducted. That evaluation will occur as an onsite face-to-face evaluation. R3's Medical Record does not include evidence of the facility obtaining R3's PASRR Level II. On 6-4-24 at 12:30 PM V2…

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 develop a Wound Care Plan for one resident (R24) out of 16 reviewed for Care Plans in a sample of 29. Findings Include: The Comprehensive Care Plan dated 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. The following procedures shall be utilized in the development and maintenance of care plans. 3. Components of the CPC (Comprehensive Care Plan) may include: a. Care Plans Summary/Participation…

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 document justifiable behaviors or diagnosis to warrant the use of an anti-psychotic medication for one of one resident (R27) reviewed for anti-psychotic medication use with the diagnosis of Alzheimer's Disease in the sample of 29. Findings include: The Psychotropic Medication Policy dated 11/28/17, documents Policy: It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: 4. Without adequate indication for its use. Definition of a Psychotropic Medication: Medication that is used for or listed as used for antipsychotic, antidepressant, antimonic, antianxiety, behavior modification, or behavior management purposes. Definition of Antipsychotic Drug: A neuroleptic drug that is helpful in the treatment of psychosis and has a capacity to ameliorate thought disorders.7. Any resident receiving such medications shall have a psychiatric diagnosis or documented evidence of maladaptive behavior, which can be considered harmful to themselves or others,…

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 physician ordered therapy services were provided for 1 resident (R1) of 3 residents reviewed for physical/occupational therapy. Findings include: R1's Minimum Data Set/MDS assessment dated [DATE] documents that R1 has a BIMs (Brief Interview for Mental Status) of 14 (cognition intact), had orthopedic surgery and was getting Occupational Therapy and Physical Therapy. On 3/8/24 at 12:03 PM, V5 (Assistant Director of Nursing) stated there is no therapy being done in the facility. It stopped in the middle of February. R1 admitted on [DATE] for a right femur fracture for therapy. R1 did not get to complete her therapy because therapy quit coming to the facility. On 3/8/24 at 1:15 PM, V2 (Administrator in Training) stated that therapy stopped coming to the facility near the middle of February 2024. V4 (Social Service Director) went and told R1 that R1's therapy was going to be discontinued. The facility does not have a Therapy policy. On…

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

Based on observation, interview, and record review the facility failed to provide activities daily for the residents. This failure has the potential to affect all 40 residents in the facility. Findings include: The Activity Policy dated 9/17 documents It is the policy of (the facility) to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interest and the physical, mental, and psychosocial well-being of each resident. The program is under the direction of an Activity Director, who shall have a specified planned program of group and individual activities based upon the resident's needs and interest. Residents shall have the opportunity to contribute to planning, preparation, conducting, clean up and critiquing of programs. There were no residents observed doing any activities during this survey (1/12-1/16/24). On 1/13/24 at 8:20 AM, V2 (Administrator in Training/AIT) stated that there is not an Activity Director. The last one that was hired worked for three days and quit. We (the facility) try to do Bingo two times a week.…

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

Based on record review and interview, the facility failed to provide requested Medical Records for 1 resident (R1) of 3 residents reviewed for records requested in the sample of 13. Findings include: The Resident Rights Handbook dated 11/18 documents Your facility must allow you to see your records within 24 hours of your request (excluding weekends and holidays). You may purchase a copy of part or all of your records at a reasonable copy fee within two working days of your request. On 1/13/24 at 8:20 AM, V2 (Administrator in Training/AIT) stated V6 (R1's Power of Attorney) requested R1's medical records about a month ago. The request was sent to the Corporate Office, and V2 is waiting for the approval. V6 was told we (the facility) are having some system problems because we were hacked, but he will get the records. On 1/12/24 at 4:06 PM, V6 (R1's Power of Attorney) stated I asked (V2/AIT) for (R1's) Medical Records in November and haven't heard anything more about getting them. An Electronic E-Mail sent by V2 dated 1/16/24 at 11:40 AM, documents that V6 requested R1's complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide the correct size (disposable briefs) for 3 residents (R3, R5, and R9) of 7 residents reviewed for supplies in the sample of 13. Findings include: The Resident Rights Handbook dated 11/18 documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. 1. R3's Minimum Data Set assessment dated [DATE], documents R3 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact) and is always incontinent of bowel and bladder. On 1/12/24 at 2:23 PM, R3 stated there have been several times the facility has run out of disposable briefs in her size. It's because they don't order far enough ahead. When they run out, I'm given disposable underwear. I don't like them because they are too small, and tight across my stomach and they leak. 2. R5's Minimum Data Set assessment dated [DATE], documents R5 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact) and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide assistance for transportation to medical appointments for 1 residents (R8) of 6 residents reviewed for transportation needs in the sample of 13. Findings include: The Transportation Protocol (not dated) documents Protocol for the facility regarding transportation requests for outside vendor appointments. The social service director will assist residents in arranging transportation to appointments and outside excursions. If other arrangements cannot be made the facility will provide transportation as the schedule allows. The residents receiving hemodialysis will take precedence of the facility van transports. The Resident Rights Handbook dated 11/18 documents The facility must provide services to keep your physical and mental health, at their highest practical levels. R1's current Medical Record, documents R1 was admitted to the facility on [DATE] with diagnoses which included Other Psychoactive Substance Dependence with Psychoactive Substance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide assistance for transportation to dental appointments for 1 residents (R2) of 6 residents reviewed for dental service needs in the sample of 13. Findings include: The Transportation Protocol (not dated) documents Protocol for the facility regarding transportation requests for outside vendor appointments. The social service director will assist residents in arranging transportation to appointments and outside excursions. If other arrangements cannot be made the facility will provide transportation as the schedule allows. The residents receiving hemodialysis will take precedence of the facility van transports. The Resident Rights Handbook dated 11/18 documents The facility must provide services to keep your physical and mental health, at their highest practical levels. R2's Minimum Data Set assessment dated [DATE], documents R2 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact). On 1/13/24 at 4:00 PM, R2 stated I missed…

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 Registered Nurse services eight hours daily. This failure has the potential to affect all 42 residents residing in the facility. Findings include: The facility's Midnight Census Report dated 12/4/23 and provided by V1 (Administrator in Training) documents 42 residents currently reside within the facility. The facility's Nursing Services policy (undated) documents, It is the policy of (the facility) to assure sufficient qualified nursing staff is available and on duty on a daily basis to provide nursing and related serviced to attain or maintain each resident's highest practical physical, mental, and psychosocial well-being as determined by resident assessment and plans of care. Nursing services shall be provided on a 24-hour per day basis. Registered nurse services shall be available eight hours each day, seven days each week, except when waived by proper authorities. The facility's Nurse Schedule dated 11/10/23-11/30/23 documents the facility had no Registered Nurse (RN) coverage on 11/19/23, 11/23/23, 11/24/23 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review, the facility failed to develop a comprehensive care plan for four of eight residents (R4, R7, R8, R9) reviewed for care plans in the sample of 10. Findings include: The facility's Comprehensive Care Planning policy, dated 11/1/17, documents It is the policy of (The facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The Resident Assessment Instrument (RAI) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. The Comprehensive Care Plan (CCP) shall be developed within 7 days of the completion…

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 respond to resident call lights in a timely manner for three of seven residents (R3, R10, R11) reviewed for call lights in the sample of 10. Findings include: 1. The facility's resident council minutes, dated November 2023, documents Complaints: Resident complained that call lights are not being answered in a timely manner, causing residents to start yelling. R11's Grievance/ Complaint Report, dated 11/2/23, documents R11 complained that staff are not answering call lights in a timely manner, therefore causing residents to start yelling. This same report documents Method of correction or disposition of complaint or grievance: Let (R11) know that at times CNA's (Certified Nursing Assistants) are in other rooms when call lights are going off. 2. On 12/4/23 at 10:00 AM, R10's call light was observed to be alarming and continued for 25 minutes from 10:00 AM-10:25 AM. At 10:30 AM R10 stated It typically takes them 30 minutes or so to answer my light. 3. On 12/4/23 at 10:05 AM, R3's call light was observed to be…

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

Based on record review and interview the facility failed to provide Registered Nurse/RN services eight hours daily. This failure has the potential to affect all 38 residents within the facility. Findings include: The facility's Midnight Census Report dated 11-7-23 documents 38 residents currently reside within the facility. The facility's Nursing Services policy (undated) documents, It is the policy of (the facility) to assure sufficient qualified nursing staff is available and on duty on a daily basis to provide nursing and related serviced to attain or maintain each resident's highest practical physical, mental, and psychosocial well-being as determined by resident assessment and plans of care. Nursing services shall be provided on a 24-hour per day basis. Registered nurse services shall be available eight hours each day, seven days each week, except when waived by proper authorities. The facility's Nurse Schedule dated 10-1-23 through 10-31-23 documents the facility had no RN coverage on 10-1-23, 10-7-23, 10-8-23, 10-14-23, 10-15-23, 10-21-23, and 10-22-23. On 11-7-23 at 11:30 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent misappropriation of resident property for 2 residents (R1 and R2) of 3 residents reviewed for abuse in a sample of four. Findings include: The facility's Abuse Prevention Program policy, dated 11/28/16, documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This policy also documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 1. R1's Initial Incident Report sent to the (State Agency) dated 9/20/23, documents [AGE] year-old male, cognitive score of 15 (cognition intact), alleges missing debit card 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 report an allegation of misappropriation of resident property to the local law enforcement for 1 resident (R1) of 3 residents reviewed for abuse in a sample of 4. Findings include: The facility's Abuse Prevention Program policy, dated 11/28/16, documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This policy also documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. External Reporting of Potential Abuse: Initial reporting of allegations. The facility must ensure that all alleged violations involving…

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 obtain blood glucose orders, failed to follow physician orders for obtaining blood glucose levels in a timely manner, and failed to document blood glucose orders, for one (R2) resident reviewed for physician orders in a sample of three. Findings include: The facility's Glucose Monitoring Policy, Dated 3/17/23, documents: Purpose: To monitor resident's blood glucose to assist in the development of an appropriate medication and treatment regime for resident's with a metabolic disorder caused by an imbalance between insulin supply and demand. R2's Diagnosis Report, Dated 8/2023, documents: Type 2 Diabetes Mellitus without complications. R2's 8/24/23 Progress Note documents: Situation: Accucheck's; Background: Resident's friend/V21 reports (R2) has a history of (Diabetes Mellitus) after arriving today and finding out about (R2's) fall yesterday, (V21 Friend to R2) thought this might be related. Per (V16 Medical Director), Please check…

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 its Fall Prevention Policy, failed to monitor, and failed to ensure fall prevention safety precautions were in place and followed to prevent a fall for one (R2) of three residents reviewed for falls; these failures resulted in R2 falling and sustaining a soft tissue hematoma to his forehead. Findings include: The facility's Fall Prevention Policy, Dated 11/10/18, documents: Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. All staff must observe residents for safety. If residents with a high risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. R2's Fall Risk assessment dated [DATE] documents: R2's Fall Risk Assessment score: 14. (10 points or more equal high fall risk score). R2's Fall Analysis Log, Dated August 2023, documents: Date of Incident 8/23/23:…

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 interview and record review the facility failed to provide documented proof of 12 hours of Certified Nursing Assistants training in a twelve-month period. This includes Dementia Management, Abuse Prevention, and Impaired Cognition Training for Certified Nursing Assistants. This has the potential to affect all 40 residents living in the facility. Findings: The document, Abuse Prevention Program Policy, dated 11/28/16, states, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by (including) dementia management and resident abuse prevention. During orientation of new employees, the facility will cover staff obligations to prevent and (how to) immediately report abuse. Additional training (will also include) Dementia Management and Resident Abuse Preventions. Annually, each covered individual (staff) will receive a review of this training. The Facility Assessment, updated 12/27/22, states, The purpose of this assessment is 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 that a resident's Practitioner Order for Life-Sustaining Treatment (POLST) was transferred to the current Physician order sheet for one of sixteen residents (R11) reviewed for advance directives in the sample of 29. Findings include: The facility's Advance Directive policy, dated [DATE], documents The Patient Self Determination Act states that individuals have the right to make their own decisions, and to formulate advance directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. This facility shall take all steps necessary to comply with state and federal legislation relating to advance directives. Any decision made by the resident shall be indicated in the chart in the manner easily understood by all staff. Advance directives specifying full code/ Attempt Resuscitation/CPR…

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 immediately report an allegation of misappropriation to the state agency and local law enforcement for one of sixteen residents (R7) reviewed for abuse in the sample of 29. Findings include: The facility's Abuse Prevention Program policy, dated 11/28/16, documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This policy also documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. External reporting of potential abuse: Initial reporting of allegations. The facility must ensure that all alleged…

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 immediately report an allegation of misappropriation to the state agency and local law enforcement for one of sixteen residents (R7) reviewed for abuse in the sample of 29. Findings include: The facility's Abuse Prevention Program policy, dated 11/28/16, documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This policy also documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. External reporting of potential abuse: Initial reporting of allegations. The facility must ensure that all alleged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident in COVID-19 isolation was offered an activities program to meet their assessed needs which affected two of 16 residents (R18, R33) reviewed for activities in a sample of 29. Findings include: An Activity Policy dated 9/2017 states, It is the policy of (this) facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial wellbeing of each resident. The program is under the direction of an Activity Director, who shall have a specific planned program of group and individual activities based upon the resident's needs and interests. 1. R18's Minimum Data Set (MDS) assessment dated [DATE] documents that R18 is rarely or never understood. R18's MDS documents a staff assessment indicates R18 is moderately cognitively impaired. This assessment documents that R18's preferences for customary routines and activities…

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

Based on observation, interview, and record review the facility failed to ensure a wound treatment was applied as per physician's order, and hand hygiene was performed before applying a clean dressing for one of two residents (R3) reviewed for pressure ulcers in a sample of 16. Findings include: An Aseptic Wound and Skin Treatment Procedure policy dated 3/16/23 gives as its purpose, To prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore, and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures, and to promote resident comfort. In addition, this policy documents for staff to replace soiled dressings in the following order: wash hands, put on clean gloves, clean the wound as ordered, remove the soiled gloves and place in a bag, wash hands again, apply clean gloves, then apply the wound treatment and a clean dressing as ordered by the physician. A (Facility) Weekly Wound Tracking log dated 4/24/23 documents R3 has a stage 3 pressure ulcer to R3's right thigh which measures…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received individualized treatment and services based on their physician's order, comprehensive assessment, and Range of Motion Assessment to maintain, improve, or prevent further decrease in range of motion for three of four residents (R3, R33, R21) reviewed for range of motion in a sample of 29. Findings include: The facility's Range of Motion Program (ROM) Protocol, states It is the policy of (the facility) to provide Range of Motion exercises for residents who through assessment demonstrate the need for exercise to prevent functional decline in range of motion. 1) The Interdisciplinary team will identify those residents in need and consider the resident's age, diagnosis, prognosis, current joint condition, functional ability and any mobility restrictions. 2) Parts of the body on which range of motion exercises can be performed include all body joints or only those affected by disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the Care Plan and assist a resident while ambulating for one resident (R31) of two residents reviewed for falls in a sample of 29. Findings include: The facility Fall Prevention policy dated 11/10/18, documents To provide the resident safety and to minimize injuries related to falls; decreases falls, and still honor each resident's wishes/desires for maximum independence and mobility. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. R31's Face Sheet dated 5/3/23, documents R31 is [AGE] years old and was admitted to the facility on [DATE]. R31's Minimum Data Set assessment dated [DATE], documents that R31 has osteoporosis, severe cognitive impairment, uses a walker on the unit, is not steady and is only able to stabilize with human assistance needing the assistance of one staff. R31's Nurses Notes dated 2/5/23 at 12:15 AM, documents that a noise was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, Interview and Record review, the facility failed to ensure an oxygen humidity bottle contained liquid, complete physician ordered oxygen tubing and humidifier changes, clean an oxygen concentrator and CPAP (Continuous Positive Airway Pressure) equipment and care plan a CPAP for two of two residents (R4, R5) in the sample of 29. Findings include: 1. The facility's Oxygen Therapy policy, dated 3/2019, documents Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Procedure: Change oxygen tubing/mask/cannula/and or tracheostomy mask on a weekly basis. Date tubing changes and document on the treatment sheet. If humidification is indicated, date pre-filled bottles when changed. If using unfilled humidifier bottles; empty, rinse and refill daily with distilled water, and wash with soap and water as needed. Humidifier changes and cleaning is to be documented on the treatment sheet at the time of occurrence. R5's Current Physician Order…

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