Countryside Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen therapy equipment was maintained and labeled according to facility policy, and failed to ensure oxygen safety signage was posted for residents receiving oxygen therapy for five (R1, R6, R12, R17, and R34) of five residents reviewed for oxygen therapy in the sample list of 28. Findings include:The facility's Oxygen Administration and Storage Policy revised 3/8/2022 documents to ensure staff follow guidelines for storage and use of oxygen. Staff are to label the tubing connected to the oxygen concentrator with time and date and to place an Oxygen in Use sign on the resident's door/door frame.1.On 1/12/26 at 10:40 AM, R1 was sitting in her room wearing oxygen. There was no oxygen sign on R1's door. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses which included Chronic Respiratory Failure with Hypercapnia, Depression, Atrial Fibrillation, Panlobular Emphysema, Chronic Obstructive Pulmonary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clean and disinfect a resident's wheelchair that had brown fecal matter smeared on the seat daily for one of four residents (R34) reviewed for dignity in a sample of 28. Findings Include:The facility's Resident Rights policy dated 11/5/2019 documents, It is the policy of this facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents as outlined by the State Department of Public Health, Centers for Medicare and Medicaid (CMS) and Joint Commission of Healthcare Organization (JCAHO). Recognizing that society is dynamic, and the rights of residents are continually evolving; we will strive to improve the quality of our care through a multi-disciplinary approach recognizing that each resident is an individual with unique needs.The facility's Cleaning and Disinfection of Resident Care Equipment dated 3/24/2023 documents, Purpose: to provide guidelines for disinfection in accordance 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.

Based on Interview and Record Review, the facility failed to ensure resident mail was delivered unopened for two of nine residents (R42, R47) reviewed for resident rights in the sample of 28.Finding include:The facility's Ombudsman Program Resident's Rights for People in Long Term Care pamphlet (undated), documents Your rights to privacy and confidentiality. Your facility must deliver and send your mail promptly. Your facility may not open your mail without your permission.On 1/13/26 at 10:20 AM, R42 and R47 both stated that sometimes mail is opened when delivered to them. R47 stated My mail was opened one time, and I went to (V1, Administrator in Training) about it. R42 stated They (staff) open my packages and envelopes all the time. They are not opened in front of me. R42 confirmed that she frequently gets packages that have been opened without her permission and that V8 (Social Service Director) is usually the one opening them. On 1/14/25 at 11:45 AM, V8 stated that she has opened mail with scissors prior to delivering the packages to resident rooms. V8 stated I do that, so I…

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

Based on Interview and Record Review, the facility failed to implement their abuse policy when an allegation of staff to resident physical/sexual abuse was received for one of two residents (R12) reviewed for abuse in the sample of 28.Findings include:The facility's Resident Right to Freedom from Abuse, Neglect and Exploitation policy, dated 10/16/23, documents The facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the facility (Associates). This same policy documents Associates must not use verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion against any resident. When the facility has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigate and document an allegation of staff to resident physical/sexual abuse for one of two residents (R12) reviewed for abuse in the sample of 28.Findings include:The facility's Resident Right to Freedom from Abuse, Neglect and Exploitation policy, dated 10/16/23, documents The facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical of chemical restraint not required to treat the resident's medical symptoms. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the facility (Associates). This same policy documents The facility will investigate any allegations made alleging abuse, neglect, and exploitation of residents and misappropriation of resident property. In response 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 provide the ombudsman an accurate notification of admission/discharges for one of two residents (R1) reviewed for discharge process in the sample of 28. Findings include:The Discharge/Transfer policy not dated documents Purpose To ensure that (the facility): I. Permits each resident to remain in the Facility unless the conditions that allow for transfer or discharge are met; II. Properly document resident transfers and discharges; III. Has a standardized discharge planning process that addresses residents' discharge goals and needs and involves residents and their interdisciplinary team; and IV. Transfers or discharges residents in a safe manner. Policy: Once admitted , residents have a right to remain in the Facility. Discharging a resident is a violation of the right unless the Facility can demonstrate that the conditions that allow for a transfer or discharge are met. To that end, it is the Facility's policy to permit each resident to remain in 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 Interview and Record Review, the facility failed to ensure a residents Minimum Data Set assessment (MDS) was completed accurately to reflect medications for one of three residents (R2) reviewed for Resident Assessment in the sample of 28. Findings include:The facility's Minimum Data Set (MDS) policy, dated 11/05/2019, documents its purpose is To provide guidance to conduct initially and periodically a comprehensive, accurate and standardized reproducible assessment of each resident's functional capacity through utilization of the MDS 3.0 Patient Driven Payment Model (PDPM) User's Manual.R2's MDS, dated [DATE], documents R2 is receiving an anticoagulant medication. R2's Medication Administration Record, dated 10/1/25-10/31/25, does not document an anticoagulant medication was administered.On 1/14/2026 at 1:00pm, V2 (Director of Nursing) confirmed that R2's medical record does not document R2 was taking an anticoagulant medication at the time of his assessment. V2 stated she does not recall R2 ever being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refer a resident to the PASRR (Preadmission Screening and Resident Review) State Agency to obtain a Level II PASRR after being diagnosed with Schizophrenia for one of five residents (R6) reviewed for Mental Illness in the sample of 28. Findings Include:The Pre-admission Screening and Resident review (PASRR) policy dated 2/2/24 documents This facility coordinates with the preadmission screening and resident review (PASRR) program to ensure that residents are appropriately placed in nursing homes for Long-Term Care. 4. Any level II resident who experiences a significant change in status will be referred promptly to the State mental health or intellectual disability authority for additional resident review. 5. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the State mental health or intellectual authority for a level II resident review.R6's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review, the facility failed to ensure residents with Mental Illness diagnoses were provided the required level two PASARR (Pre-admission Screening and Resident Review) upon admission to the facility for two of five residents (R2, R43) reviewed with PASARR in the sample of 28.Findings include: The facility's Social Service-Coordination with PASRR program policy, dated 2/2/24, documents This facility coordinates with the preadmission screening and resident review (PASARR) program to ensure that residents are appropriately placed in nursing homes for long-term care. All individuals with a mental disorder or intellectual disability who apply for admission to this facility will be screened in accordance with the state's Medicaid rules for screening. Recommendations, such as specialized services, from a PASRR level two determination and or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. 1. R43's current Care Plan, dated…

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

Based on interview, and record review, the facility failed to ensure residents consistently received food that was palatable, properly prepared, and consistent with posted menus for three (R1, R2, and R3) of three residents reviewed for dietary services. This has the potential to affect all 47 residents residing in the building.Findings include:The facility's Resident Nutrition Status policy dated 11/1/2015 documents each resident shall receive the correct diet, with food preferences accommodated as feasible, and shall receive prompt meal service and appropriate assistance. The Facility's Resident Council Minutes dated 9 11/25 documents Residents say that Toast, grilled cheese, and cookies are too hard and burnt to eat. The Facility's Resident Council Minutes dated 10/9/25 documents a resident stated she was fed bloody chicken.The Facility's Resident Council Minutes dated 11/6/25 documented that a staff member reported witnessing bloody chicken being served again during lunch on 11/3/25. Residents stated they are not receiving what is posted on the menu and that food is often served…

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

Based on interview and record review the Facility failed to identify, reconcile, document and investigate a missing controlled substance drug for one of seven Residents (R5) reviewed for controlled substances in a sample of nine.Findings include:The Facility Registered Nurse Job Description, undated, documents: ensure that all nursing personnel assigned to you comply with the written policies and procedures established by the Facility; responsible for complying with Facility policies and procedures; cooperate with other Resident services when coordinating nursing services to ensure that Resident's total regimen of care is maintained; dispose of drugs and narcotics as required, and in accordance with established procedures; perform all tasks in accordance with established policies and procedures and as instructed by supervisor; documents accurately in Resident chart any significant changes in care and services; sign and date all entries made in the Resident medical record; charts nurses' notes in an informative, relevant, concise and descriptive manner that reflects the care provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare and serve palatable food. This failure has the potential to affect all 47 residents residing in the facility. Findings include: The facility's Daily Census dated 6/19/25 documents 47 residents currently reside within the facility. The facility's [NAME] Job Description, undated, documents, Job Summary: The primary purpose of this position is to prepare, serve, and maintain food safety with current federal, state, and local standards, guidelines, and regulations, facility established policies and procedures, and as directed by the dietary manager, to ensure on-going program of food safety and to assist with resident food preferences. Main Duties: Prepare foods in a safe and palatable manner that meets the appearance, taste, and quality expectations of the residents. The facility's 4/3/25 Resident Council Minutes document, Resident say the food is getting worse (eggs are burnt food is watery, food under/overcooked). On 6/20/25 between 11:50 AM through 12:30 PM the residents were served tuna patties. The…

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

Based on record review and interview the facility failed to offer bedtime snacks daily. This failure has the potential to affect all 47 residents residing in the facility. Findings include: The facility's Daily Census dated 6/19/25 documents 47 residents currently reside within the facility. The facility's Frequency of Meals policy and procedure dated 12/30/24 documents, Evening snacks will be offered routinely to all residents not on diets prohibiting bedtime nourishment. On 6/20/25 at 3:30 PM V2 (Director of Nursing) provided a list of residents with the diagnoses of Diabetes which included R2, R5, R6, R9, R10, R12, R13, R15, R18, R19, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, and R34. On 6/20/25 at 9:50 AM R1 stated, Staff do not offer me a bedtime snack. On 6/20/25 at 1:55 PM R6 stated, I would like a snack at bedtime. I never get one. On 6/20/25 at 2:55 PM R2 stated, I don't get a snack at bedtime. I am diabetic and want one. On 6/20/25 at 3:00 PM R21 stated, I never get offered a snack at bedtime. I have diabetes. On 6/20/25 at 3:10 PM R22 stated he never…

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

Based on observation, interview, and record review the facility failed to ensure the kitchen ovens were maintained and in operating condition. This has the potential to affect all 47 residents residing in the facility. Findings include: The facility's Daily Census dated 6/19/25 documents 47 residents currently reside within the facility. The facility's Maintenance Director Job Description, undated, documents, The primary purpose of this position is to maintain the orderly functioning of all equipment in the facility including the kitchen, laundry heating, air conditioning, and elevators as well as purchasing necessary supplies for repairs, maintenance, and emergencies within budgetary guidelines. Assure the proper maintenance and running condition of all equipment in the building including all kitchen appliances and machinery. Supervise repairs and routine maintenance of the building and all the departmental equipment. The facility's Equipment and Supplies policy and procedure dated 11/5/19 documents, Purpose: To ensure the facility provides and maintains routinely to meet the needs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 mechanical lift machines used to transfer dependent residents were safe and in good repair for five of five residents (R1, R4, R27, R38, and R39) reviewed for accidents in the sample of 38. Findings include: The Manufacturer's User Instruction Manual for the (Mechanical Lift) HPL700 dated 2024 documents, 9. Maintenance Schedule and Daily Checklist-Operate the hand control to confirm the boom raises and lowers satisfactorily. The Manufacturer's User Manual for the (Mechanical Lift) 450/600 dated 2022 documents, Caster Base: Inspect monthly for missing hardware. Inspect casters and axle bolts for tightness. Inspect casters for a smooth swivel and roll. On 6/21/25 at 11:30 AM V2 (Director of Nursing) provided a list of residents who use a mechanical lift for transfers which included R1, R4, R27, R38, and R39. ` On 6/21/25 at 9:50 AM V18 (CNA/Certified Nursing Assistant) was transferring R1 from the wheelchair to the bed using a mechanical lift model number HPL700. During this transfer, the mechanical lift…

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

Based on observation, interview, and record review the facility failed to ensure medications were stored in their original packaging until administered for 18 of 18 residents (R1, R2, and R8-R23) reviewed for medication storage in the sample of 38. Findings include: The facility's Administering Medication Policy and Procedure dated 10/15/2023 documents, Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Medications may not be prepared in advance. Medications that are removed from their original packaging and not immediately administered must be destroyed in accordance with facility policy. The facility's Storage, Labeling of Over the Counter Medication, Destruction and Disposal of Medication dated 11-9-21 documents, Purpose: To ensure that medications and biologicals are stored in a safe, secure storage and safe handling. Medications will be stored in the containers in which they are received. Transfer between containers is performed only by the issuing pharmacy. R1's Order Summary Report and MAR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 hand hygiene and apply new gloves between dirty to clean wound dressing changes and failed to apply pressure ulcer treatments as ordered by the physician for one of three residents (R1) reviewed for pressure ulcers in the sample of 38. Findings include: The facility's Wound Care policy and procedure dated 11/9/19 documents the following guidelines for wound care, 1. Verify Order. 2. Explain procedure to the residents. 3. Gather equipment. 4. Place items on a clean surface. 5. Hand hygiene. 6. DON (put on) PPE (Personal Protective Equipment). 7. Remove dressing to be changed and discard. 8. Remove gloves and discard, (perform) hand hygiene. DON new gloves. 9. Clean wound bed per order. 10. Remove gloves and discharge. 11. Place new dressing. 12. Remove gloves and discard. Hand hygiene. 13. Reposition resident and bed covers. 14. Call light within reach. 15. Remove unused supplies from overbed table and place in appropriate place. 16. Document treatment. The facility's Skin Prevention, Assessment, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBPs) and failed to change gloves and complete handwashing after performing catheter care for one of four residents (R1) reviewed for infection control practices in a sample of 38. Findings include: The facility's Enhanced Barrier Precautions Policy, date 10/28/24, documents Policy: It is this Facilities policy that EBPs are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. They are a strategy in nursing homes to decrease transmission of CDC (Centers for Disease Control and Prevention)-targeted and epidemiologically important MDRO's (Multidrug-Resistant Organisms) when contact precautions do not apply. EBP is used during high-contact care activities for residents with chronic wounds or indwelling medical device, regardless of MDRO status, in addition to residents who have an infection or colonization 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.

Based on interview and record review the facility failed to notify family, physician, and Illinois Department of Public Health/IDPH of an injury for one of three residents (R1) reviewed for quality of care in the sample of three. Findings include: The Accident and Incident Investigation policy dated 4/3/24 documents To ensure all accidents, incidents and allegations of abuse involving residents, visitors, or employees are investigated and reported to the facility administration. Procedure 4. The assigned nurse or nursing supervisor shall complete an assessment and provide medical interventions as warranted. 5. Reporting of incident, accident and abuse to state and federal agencies shall be in compliance in accordance with agency guidelines. 7. The assigned nurse or nursing supervisor shall: b. As determined notify the attending physician or medical director of the occurrence. c. Follow the physician orders as instructions for rendering care. f. Date and time the physician/responsible party notification. The Reporting policy dated 11/6/24 documents Policy: Incident report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 correctly enter and follow a physician's order for one resident of three residents (R1) reviewed for steroid injections in the sample of three. Findings include: The Administering Medication policy dated 10/15/23 documents Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: 3. Medications shall be administered according to physician's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. 20. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's attending physician or…

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

Based on record review, observation and interview, the facility failed to employ a Dietary Manager with the appropriate competencies and skill to carry out the functions of Food Service Director. This failure has the potential to affect all 46 residents currently residing in the facility. Findings include: The facility's Resident Roster dated 11/19/24 documents 46 residents reside in the facility. The facility's job description for Food Service Director documents the following :Qualifications: 1. Bachelor of Science degree in Foods and Nutrition from an accredited college or university. 2. Graduation from a course in food service supervision which meets the established by the American Dietetic Association or graduate of another course in foods service supervision with ninety (90) or more hours in classroom instruction with on-the-job counseling by a dietician. On 11/19/24 at approximately 9:15am there was no Food Service Certification available or posted in the Dietary Manager's office. On 11/19/24 09:15am V9 (Dietary Manager) stated she did not have a Dietary Management Certificate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and interview, the facility failed to ensure appropriate infection control practices were utilized in the Laundry Room, failed to ensure Legionella Risk Assessments were conducted annually and accurately with the designated team members, and failed to utilize Enhanced Barrier Precautions during a wound treatment for one (R1) of two residents reviewed for wound care in a sample of 24 residents. These failures have the potential to affect all residents who reside in the facility with a current census of 46 residents. Findings include: 1. The Handling Linens and Laundry policy, dated 11/1/15, documented to wash hands after handling soiled linen and before handling clean linen, consider all soiled linen to be potentially infectious and employees sorting or washing linens shall wear a gown/apron, gloves and if aerosolization occurs, a mask. The Hand Hygiene Policy, dated 11/1/15, documented Procedure and Implementation 1. Roll down paper towel. 7. Wipe hands dry with a clean single use paper towel. 8. Turn off the water with a paper towel and dispose…

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

Based on observation, interview and record review the facility failed to ensure a resident ingested his medications for one resident (R2) of 24 residents reviewed during a routine medication pass observation. Findings Include: The Facility's Administering Medication policy dated 3/19/2020 documents the purpose of the policy and procedure is to ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. The Facility's Administering Medication policy also documents Medications will remain secured in a locked cabinet/cart unless in direct view of the individual administering the medication. Self administration of drugs is permitted when approved by the attending physician and the interdisciplinary care planning team. R2's Medication Administration Record for November 2024 lists his medications scheduled at 7:00 AM as Famotidine 20 mg (milligrams), Lacosamide 50 mg, Pregabalin 100 mg, Levetiracetam 750 mg, Topiramate 100 mg, Oyster Shell Calcium 1500 mg, Potassium Chloride (Extended Release), Vitamin D3-50, and Acetaminophen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a completed discharge summary for one (R48) of one resident reviewed for discharge in a total sample of twenty four. Findings Include: The Facility's Transfer/Discharge policy dated 11/05/2023 documents The interdisciplinary team and or physician, in consult with the resident or his/her Power of Attorney for healthcare, may recommend transfers or discharges. Information vital for discharges to home include: a. Interdisciplinary discharge summary. R48's Interdisciplinary Discharge Summary for resident dated 10/16/2024 is filled out for Nursing Service Summary. The following areas on the Interdisciplinary Discharge Summary are blank : medications, social service summary, dietary service summary, activity service summary and rehab service summary. On 11/21/24 at 1:30 PM V2 (Director of Nursing) confirmed R48's Discharge summary dated [DATE] was incomplete.

Based on observation, interview and record review, the facility failed to ensure residents were transported to appointments as needed for one (R17) of three residents reviewed for transportation, failed to assess, document and provide appropriate treatment for a fungal infection for one (R8) of three residents reviewed for non-pressure skin impairments and failed to utilize a wheelchair positioning cushion for one (R8) of 14 residents reviewed for positioning in a total sample of twenty four. Findings Include: 1. The Transportation of Residents policy, dated 11/1/15, documented the facility will assist the resident in making transportation arrangements to and from the source of a service if the resident needs assistance. The Transportation calendar dated November 2024 documented R17 had a dental appointment on 11/19/24 at 11:15 AM. On 11/19/24 at 9:30 AM, R17 stated he was supposed to have a dentist appointment today at 11:15 AM, although, it was canceled due to the facility not having transportation staff available. On 11/20/24 at 11:32 AM, V5 (R17's family member) stated R17 had…

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

Based on record review and interview the facility failed to identify triggers for PTSD (Post Traumatic Stress Disorder) and develop and care plan interventions related to PTSD for one (R31) of two residents reviewed for PTSD in a total sample of twenty four. Findings Include: R31's current medical record includes a Trauma Informed Care Screen, dated 2/26/24, documents R31 answered Yes when asked if he has experienced traumatic events. This trauma screen also documents R31 answered Yes when asked if has had nightmares about the event(s) and if (he) has tried hard not to think about the event(s), and if R31 went out of (his) way to avoid situations that reminded (him) of the event(s). The section of R31's Trauma Informed Screen, titled Potential Trigger(s) that May Cause a Reaction from Trauma Event is left blank, with no potential triggers documented nor interventions for the triggers. R31's current Careplan does not include PTSD triggers, nor interventions for R31's PTSD triggers. R31 declined to be interviewed. On 11/22/24 at 10:15am V19 and V21 RNs/Registered Nurses stated R31 has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the antibiotic stewardship program accurately monitored infections and antibiotic use per policy for three of three residents (R7, R17, R25) reviewed in a sample of 46 residents. Findings include: The Infection Prevention and Control Program Standards policy dated 11/1/15 documented the Antibiotic Stewardship Committee will assess residents for infection using standardized tools and criteria, assess and reassess appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports and/or changes in the clinical status of the resident, will develop and maintain a system to monitor antibiotic use which includes a review of antibiotics prescribed to residents upon admission or transfer to the facility or an antibiotic prescribed by a practitioner who is not part of the facility's staff. 1. The Hospitalization record documented R7 was admitted to the hospital with a diagnosis of acute urinary tract infection (UTI) on 11/3/24.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement post fall interventions for one (R1) of three residents reviewed for falls in the sample list of four. Findings include: R1's plan of care dated 8/30/24 documents R1 was admitted to the facility on [DATE]. R1's fall risk assessment dated [DATE] documents R1 has a history of multiple falls and is at high risk for falls. R1's fall investigation report dated 9/19/24 documents R1 slipped in room while self-ambulating at 5:30 PM. This report documents a new intervention of requesting therapy. R1's fall investigation report dated 9/25/24 documents R1 fell attempting to change undergarment at 9:50 AM. This report documents a new intervention to order physical and occupational therapy. R1's plan of care documents a new fall intervention dated 9/25/24 for physical and occupational therapy to evaluate and treat for strengthening. R1's fall investigation report dated 10/21/24 documents R1 fell in the dining room at 11:00 PM. R1's plan of care documents a…

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

Based on interview and record review the facility failed to develop a plan of care for the use of an antipsycotic medication, implement behavioral interventions, and limit a prn (as needed) antipsychotic medication to 14 days. This failure had the potential to affect one (R1) of three residents reviewed for medications in the sample list of four. Findings include: The facility's Psychotropic Medication Policy with a revision date of 11/2917 documents the care plan will identify target behaviors and will address the problem, approaches and goals to address the behaviors. This policy documents the Behavioral Tracking sheet will be implemented to ensure behaviors are monitored. This policy documents PRN orders for antipsychotic medications have a time limit of 14 days and if the physician or prescribing practitioner wishes to write a new order, they must first evaluate the resident to determine if the new order for the PRN is appropriate. R1's Preadmission Screening and Resident Review (PASRR) screen dated 8/2/24 documents R1 does not have a history of Mental Illness. R1's physician…

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

Based on interview and record review the facility failed train dietary staff on safe food handling or any other type of dietary specific training. This failure has the potential to affect all 49 residents who reside in the facility. Findings Include: The Facility's Diet Aid job description dated 10/2016 documents diet aids must have passed the Food Protection Manager exam or be willing to take the course approved by the facility is in. and Must receive food handler training within 30 days of employment. The Facility's Dietary Staff Schedule lists the following people work in the kitchen V4 (Dietary Manager), V11 (Day Cook), V14 (Day Cook), V15 (Evening Cook), 16 (Evening Aide), V5 (Day Aide), V12 (dishwasher), and V13 (Evening Aide). On 7/24/24 at 11:00 AM V5 (Dietary Aide) stated I have not been trained on anything in the kitchen. (V7/Previous Dietary Manager) did not like questions, he would just tell me to get it done. (V7) also didn't follow the menu or order the correct groceries, so I usually did not have a recipe to follow. I was just doing my best. On 7/24/24 at 12:45 PM V1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 adequate staffing in their dietary department. This failure has the potential to affect all 49 residents who reside at the facility. Findings Include: On 7/24/24 at 10:00 AM V4 (Dietary Manager) stated she took the dietary manager position over on July 1, 2024, after V7(Previous Dietary Manager) was terminated. V4 stated that she had been a dietary aide since June 2023. V4 reports that the schedules were usually done on paper and then thrown away. V4 stated there was no consistency to anyone's schedule, a lot of times people had to work alone and that wasn't right. It's too much to do with just one person. On 7/24/24 at 1:00 PM V5 (Dietary Aid) stated I have had no training and prior to (V4/Dietary Manager) taking over, I worked by myself most nights, so meals were always late. I had no idea what I was doing. V5 confirmed that V7 (Previous Dietary Manager) wrote schedules on a notebook piece of paper and threw it away when it was finished. On 7/24/24 at 12:45 PM V1 (Administrator in Training) stated (V7/Previous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent misappropriation of property for 1 resident (R1) of 3 residents reviewed for misappropriation of property in the sample of 4. The Findings include: Abuse Prevention Program policy dated 11/28/2016, 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 includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a residence belongings or money without the residence consent. The Final Investigation Report dated 4/8/24 at 8:34 PM, sent to the (State Agency) documents Upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform and document the food cooling process of a hazardous food. This failure had the potential to affect all 40 residents residing in the facility. Findings include: The facility's Food Cooling log, dated 3/18, documents, It is the policy of the facility that TCS (Time Temperature Control for Safety) foods will be cooled properly to prevent the outbreak of food borne illness. Hot foods will be cooled to 70 degrees F (Fahrenheit) or below within the first two hours, the food needs to be thrown out or reheated on time only to 165 degrees F for 15 seconds. The cooling process will start over, using an alternate method to cool from what failed initially. If the food does not reach 70 degrees F or below the second time, the food item must be discarded. Use the Food Cooling Log for temperature monitoring and recording. On 10/15/23 at 09:19 AM, The facility cheese/egg refrigerator had a storage container of barbeque chicken with no label or date. On 10/15/23 at 09:25 AM, V5 (cook) confirmed the storage container…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and record review, the facility failed to label, and date opened food items in the kitchen, monitor food temperatures, monitor the sanitizer levels of the dishwasher prior to washing dishes, and monitor refrigerator freezer temperatures. This has the potential to affect all 40 residents residing in the facility. Findings include: The facility's Storage policy, dated 10/2020, documents, It is the policy of the facility that food shall be stored on shelves in areas that provide the best preservation. Food shall be stored at the proper temperature and for appropriate lengths of time to protect quality of food and food cost. Shelves in all areas shall be kept at least 6 off the floor and 18 from the ceiling to allow for proper ventilation and sanitation. Store leftovers in covered, labeled, and dated containers under refrigeration or frozen. When using only part of a product, the remaining product should be in the original package or airtight container and labeled and dated. The facility's Equipment Temperatures policy, dated 9/2008, documents, It is the…

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

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants were provided with Dementia training yearly. This failure has the potential to affect all 40 residents residing in the facility. Findings include: The facility's Facility Assessment Tool, dated 9/12/23, documents the facility is equipped to care for residents with multiple diagnoses including but not limited to Alzheimer's and Dementia. This tool also documents Staff training and competencies are required for all departments upon hire and annually. General training topics (this is not an inclusive list): Dementia and behavioral de-escalations/redirecting techniques. Required in-service training for nurse aides. In-service training must (see mandatory in-service list). The facility's Annually Mandated In-services sheet, dated 2022, documents a training category of Alzheimer's Dementia Management. The date scheduled, start and end time and presenter are all blank. The facility's Annually Mandated In-services sheet, dated 2023, documents a training category of Alzheimer's. The date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent resident to resident physical abuse for two of two residents (R20, R25) reviewed for abuse in the sample of 23. Findings include: The facility's Abuse policy states This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. R25's Nurses Notes dated 8/13/23 at 4:10 p.m. and documented by V7 (Registered Nurse) states (R25) got aggravated by another resident (R20) sitting on her preferred chair in the dining area thus (R25) started kicking, hitting, and dragging (R20), who called for help and never fought back. (The staff) intervened by separating them and 15-minute checks commenced, and other due protocols observed. V2's (Director of Nursing) handwritten witness statements (date unknown) document the following: Incident in the (dining room) Sunday 8/13/23 at 4:10 p.m. (between R25 and R20). V7/Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an incident of physical abuse to the State Agency for two of two residents (R20, R25) reviewed for abuse in the sample of 23. Findings include: The facility's Abuse policy dated 11/28/16, states The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime are reported immediately to the administrator or the facility and to other officials in accordance with State law through established procedures. The report must be made not later than 24 hours after forming the suspicion. The Administrator or designee is then responsible for forwarding a final written report of the results of the investigation to the (State Agency) within five working days of the reported incident. R25's Nurses Notes dated 8/13/23 at 4:10 p.m. and documented by V7 (Registered Nurse) state (R25) got aggravated by another resident (R20) sitting on her preferred chair in the dining area thus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a comprehensive care plan for the use of an anticoagulant, use of insulin, a UTI (Urinary Tract Infection), and a new fracture/pain for two of 13 residents (R6, R30) reviewed for care plans in the sample of 23. Findings include: The facility's Comprehensive Care Planning policy, dated 7/20/22, 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. 1. On 10/16/23 at 09:11 AM, R6 was alert lying in bed with oxygen on at 2 L/min (Liters/minute). R6 stated she has been feeling bad, and she thinks it's because of the new antibiotic she was 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 observation, interview, and record review, the facility failed to implement new interventions following a fall with a fracture for one of three residents (R30) reviewed for falls in the sample of 23. Findings include: On 10/15/23 at 11:10 AM, R30 was alert, but drowsy lying in bed with oxygen on at 4 L/min (liters/minute). During conversation, R30 would fall asleep while talking, and then wake up quickly with an immediate grimace each time. R30 stated, I fell a few days ago. I was walking with my walker to the bathroom, and my walker got caught on my oxygen tubing. It pulled me back and I fell onto my bed and the footboard of my bed. I instantly felt cracks and had lots of pain. I went to the ER (Emergency Room), and they said I have rib fractures. R30 had to stop speaking several times due to the pain it was causing her to speak and each breath she took. R30's Quality Care Reporting Form, dated 10/8/23, documents that R30 fell on [DATE] at 9:45 a.m. in her room. A Facility Reported Incident, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document justification for the increase of an antipsychotic, and document behaviors to warrant the use of an antipsychotic for one of five residents (R30) reviewed for psychotropics in the sample of 23. Findings include: The facility's Psychotropic Medication Policy, dated 7/12/22, documents, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drugs used: In an excessive dose, including in duplicative therapy; without adequate indications for its use. The policy also documents, The facility may not justify the use of a drug prescribed outside these guidelines solely on the basis of 'the doctor ordered it.' The rationale must be based on sound risk benefit analysis of the resident's symptoms and potential adverse effect of the drug. On 10/15/23 at 11:10 AM, R30 was alert, but drowsy lying in bed with oxygen on at 4 L/min (liters/minute). During conversation, R30 would fall asleep…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dental services were provided to a resident for one of one resident (R30) reviewed for dental services in the sample of 23. Findings include: The facility's Ancillary Services Policy, dated 9/27/17, documents, It is the policy of the facility to offer access to necessary routine and emergency dental, ophthalmology, and audiology services to maintain resident dental, ophthalmic, and audiology health. Residents are required to receive an oral inspection annually. A consultant licensed Dentist is retained by the facility and shall be responsible for: Providing consultation to physicians and providing services relative to dental matters; Assuring dental services are available to all residents. When dental problems arise (including lost or damaged dentures) the facility will make a referral to the Dentist within three business days. On 10/15/23 at 11:10 AM, R30 was alert lying in bed. R30 had no upper teeth and one tooth on the bottom of her mouth. R30 stated, I've been asking to go to the dentist ever…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff a full-time Licensed Administrator. This failure has the potential to affect all 40 Residents residing in the Facility. Findings include: Facility Resident Roster, dated 8/18/23, documents 40 Residents residing in the Facility. Facility Job Description Administrator, undated, documents: The Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting and the physical management of the Facility, Residents and equipment in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations. The Administrator will manage and conduct the business of the Facility in a manner that protects the Facility license and certification at all times. The major goal of the Administrator is to provide an atmosphere in which Residents may achieve their highest physical, mental and social wellbeing; the Administrator is responsible for directing day-to-day functions of the Facility…

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

Based on observation, interview and record review the Facility Owners and Chief Executor Officers failed to be consistently engaged and involved in the management and operation of the Facility. The Facility Owners and Chief Executive Officers failed to establish and implement policies related to Facility operations and management of the Facility. The Governing Body has the responsibility to monitor the facility for the appointment of a Licensed Administrator. The Governing Body failed to ensure that the facility investigate and report accidents to the local State Agency, updates the Facility Assessment, provide Psychiatric services for Psychiatric Residents and monitor the Quality Assurance/QAPI meetings. This failure has the potential to affect all 40 residents residing in the facility. Findings include: Resident Census and Conditions Report, dated 8/18/23, documents that 40 residents reside in the facility. The Facility Assessment Tool, dated 6/20/22, documents on page 20: to establish a process for updating the assessment in one year or earlier if there are substantive changes;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 annually update the Facility Assessment. This failure has the potential to affect all 40 Residents residing in the Facility. Findings include: The Facility Census Roster, dated 8/18/23, documents that 40 Residents reside in the Facility. The Facility Assessment Tool, dated 6/20/22, documents on page three, the update date of the Assessment, as 6/20/22. The Facility Assessment Tool, dated 6/20/22, documents on page 20: to establish a process for updating the assessment in one year or earlier if there are substantive changes; and that the Administrator or Designated individual assigns a person to lead the Facility Assessment process; reviews the Regulation for the Facility assessment requirements; the leader identifies and invites team members to be on the Assessment team, including Administrator, Representative of the Governing Body, Medical Director and Director of Nursing. On 8/18/23, at 8:45 am, upon entrance during the request for policies and documents, V2 (Director of Nursing/DON) stated, I am not sure where to the…

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

Based on interview and record review, the Facility failed to conduct quarterly Quality Assurance/QA meetings with the required staff consisting of the Medical Director, Administrator, Director of Nursing and Infection Preventionist. This failure has the potential to affect all 40 residents residing in the facility. Findings include: Facility Resident Census Roster, dated 8/18/23, documents 40 Residents residing in the Facility. The Facility Assessment Tool, dated 6/20/22, documents on page three as the most recent update of QAA/QAPI (Quality Assurance and Performance Improvement) as 6/20/22; the Facility determines equipment, supplies and physical environment by review of Resident medical records and quarterly Quality Improvements; the areas QAPA Initiatives/Performance Improvement Project; and what trends identified in the Facility Assessment suggest areas where we need to improve the quality of our care. Facility QAPI Plan, undated, documents that services provided to residents are implemented at the Interdisciplinary Team level, ensuring that the individual resident's needs 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide person centered treatment for Behavioral Health Services for one (R1) of three Residents reviewed for Mental Health Disorders, in a sample of three. Findings include: Facility Psychiatric Contracted Behavioral Health Source Agreement, dated 6/23/22, documents: the purpose of this agreement services shall include psychiatric evaluation and medication management, psychological evaluation and testing therapy and counseling sessions; shall provide licensed Psychiatrists, Psychologists, Nurse Practitioners and other mental health care professionals; Facility shall provide the Contracted Behavioral Health Source with appropriate referrals for services; and each party shall comply with the Federal, State and Local laws, rules and regulations. The Facility Assessment Tool, dated 6/20/22, documents: the purpose of the Assessment is to determine what resources are necessary to care for Resident's competently during both day-to-day operations…

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