Mattoon Rehab & Hcc

Based on observation, interview and record review the facility failed to maintain essential equipment to ensure a safe operating environment in a medication room. This failure has the potential to affect all 94 residents residing in the facility. Findings include:The facility daily census dated 9/14/25 documents 94 residents reside in the facility. 1.On 9/15/25 at 12:30 PM V8 Licensed Practical Nurse (LPN) disposed of R33's medication in the [NAME] hall nurses medication room. V8 LPN applied soap to her hands then turned the handles on the facility sink to turn on the water. No water flowed from either the hot or cold water sides. V8 LPN stated the nurses medication room should have a working sink for her to wash her hands when needed. V8 stated she works on another hall also and doesn't have time to 'run from hall to hall to find a working sink'. On 9/15/25 at 12:45 PM V6 Maintenance Director attempted to turn on the hot and cold sides of the water in the [NAME] hall nurses medication room. There was no water that flowed from either side. V6 Maintenance Director opened up the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent cross contamination of one (R66) resident's infected Diabetic Foot Ulcers out of two residents reviewed for skin conditions in a sample list of 41 residents.Findings include:R66's Minimum Data Set (MDS) dated [DATE] documents R66 as cognitively intact. This same MDS documents R66 requires moderate assistance from staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R66's Physician Order Sheet (POS) dated September 2025 documents a physician order to cleanse R66's Left Lateral Diabetic Foot Ulcer (DFU) with wound cleanser, apply Santyl (chemical debrider) 250 units/Gram to wound bed, cover with Calcium Alginate and dry dressing daily. This same POS documents a physician order to cleanse R66's Right Second Toe DFU with wound cleanser, apply calcium alginate and dry dressing daily. On 9/17/25 at 10:30 AM V20 Licensed Practical Nurse (LPN) completed wound care for R66's Left Lateral Foot Diabetic Foot…

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 prevent cross contamination during urinary catheter care for one (R29) resident out of two residents reviewed for catheter care in a sample list of 41 residents. Findings include:R29's Minimum Data Set (MDS) dated [DATE] documents R29 as cognitively intact. This same MDS documents R29 as requiring maximum assistance from staff for personal hygiene and is dependent on staff for toileting and dressing. On 9/16/25 at 2:10 PM V18 and V19 Certified Nurse Aides (CNA) completed urinary catheter care for R29. V18 CNA prepared a basin of soapy water for use in providing catheter care. V18 CNA did not rinse R29's front or rear perineal areas after washing with soapy water. R29 was incontinent of bowel. V18 CNA did not change gloves or perform hand hygiene after cleansing R29's front and rear perineal areas and before applying a new incontinence brief. R29 was wearing a urinary catheter leg drainage bag which was pulled taunt during positioning of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to properly maintain and store respiratory equipment. This failure has the potential to affect one of one residents (R3) reviewed for respiratory care on the sample list of 41. Findings Include: The facility's Tracheostomy Care policy dated [DATE] documents a replacement tracheostomy tube must always be available at the bedside. The same policy documents a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution must always be available at the bedside. The same policy documents an emergency tracheostomy set up should be kept at the resident's bedside. R3's Medical Diagnoses dated [DATE] documents R3 is diagnosed with Anoxic Brain Damage, Anxiety Disorder, Paraplegia, Dependence on Supplemental Oxygen, and Tracheostomy Status. R3's Physician Order Sheet dated [DATE] documents facility staff are to maintain suction set up, an emergency bag valve mask, and a replacement tracheostomy tube of equal size and one size down at R3'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, interview and record review the facility failed to ensure a medication error rate less than 5%. This error effects two (R33, R34) residents out of six residents reviewed for medication administration in a sample list of 41 residents. The facility medication error rate was 7.41% based on two medication errors out of 27 opportunities completed.Findings include:R33's Physician Order Sheet (POS) dated September 2025 documents a physician order starting 6/19/25 to administer Buspirone Hydrochloride (HCl) (Buspar) Oral Tablet 10 MG (Buspirone HCl) daily. R33's Electronic Medical Record (EMR) documents R33 resides in bed number two. R34's Physician Order Sheet (POS) dated September 2025 does not document a physician order for Buspar 10 mg. R34's EMR documents R34 resides in bed number one. R34's Nurse Progress Note dated 9/16/25 at 1:47 PM documents R34 received roommate's (R33) scheduled Buspirone 10 milligrams (mg) (9/15/25) at noon. On 9/15/25 at 12:39 PM R33's name plate outside her door showed R33's name with a 'D' next to it. R34's name plate outside the same…

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

Based on observation, interview and record review the facility failed to properly dispose of medications for one (R61) resident out of six residents reviewed for medication administration in a sample list of 41 residents. Findings include: R61's Physician Order Sheet (POS) dated September 2025 documents a physician order to administer Loratadine 10 milligrams (mg) daily. On 9/16/25 at 8:00 AM V16 Licensed Practical Nurse (LPN) prepared R61's medications for administration. V16 LPN dropped R61's Loratadine 10 milligrams (mg) directly onto the top of the medication cart. V16 LPN used her bare hand to pick up the dropped Loratadine and put it into the garbage can attached to the medication cart. V16 LPN replaced R61's Loratadine 10 mg. V16 LPN administered R61's medications without washing her hands or performing hand hygiene after disposing of R61's dropped Loratadine medication. On 9/16/25 at 8:10 AM V16 Licensed Practical Nurse (LPN) stated she should have used gloves to pick up R61's dropped Loratadine 10 mg. V16 LPN stated the facility has a bottle of chemical that is used for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise resident's care plans to accurately reflect resident's current status. This failure affects two residents (R1 and R3) out of the sample of three reviewed for falls. Findings include: 1. R1's Care Plan for Fall Prevention documents an intervention to Ensure personal items are in reach, initiated 3/10/23, and a second intervention to Make sure (R1) has mirror in reach, initiated 9/2/23. On 5/6/25 at 10:35 am, 11:00 AM, 12:55 PM, R1 did not have any personal items, including a mirror, in view in her room. On 5/6/25 at 1:45 PM, V4, Licensed Practical Nurse, stated R1 doesn't really have any personal items, and she hasn't seen R1 with a mirror in a long time. On 5/6/25 at 1:55 PM, V7, Registered Nurse, stated that R1 used to keep her purse, hairbrush, make up, and mirror with her in bed and would sit and do her make up and brush her hair. V7 further stated R1 hasn't been able to do that for a long time. 2. R3's Care Plan for Fall…

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 conduct safe transfers in accordance with a resident's care plan (R1), and failed to implement fall prevention interventions according to a resident's care plan (R2). These failures affect two residents (R1 and R2) out of the sample list of three reviewed for falls. Findings include: 1. R1's Fall Risk assessments dated 4/15/25 and 4/19/25 document R1 is at high risk for falls. R1's Nurses Progress Notes dated 4/15/25 document R1 experienced a fall in the facility. R1's current Care Plan for Fall Prevention documents an intervention for Staff re-educated to ensure they are using an appropriate number of staff during all transfers, initiated 11/3/22. This same Care Plan for Activities of Daily Living documents R1 requires two staff participation for transfers, initiated 9/30/20. On 5/6/25 at 3:46 PM, V8, Certified Nursing Assistant, stated R1 is not steady at all standing up. V8 stated when she transfers R1, she has R1 wrap R1's arms around V8's neck, and since R1 can not stand steadily, V8 has to do all the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent cross contamination during wound treatments for one of three residents (R3) reviewed for infected wounds on the sample list of three. Findings include: R3's current Diagnoses sheet documents the following: ) Lymphedema, Not Elsewhere Classified and Non-Pressure Chronic Ulcer of Unspecified Part Of Right Lower Leg With Unspecified Severity. R3's Minimum Data Set (MDS) dated [DATE] documents the following Brief Interview of Mental Status score of 15 out of 15, indicating no cognitive impairment. The same MDS documents R3 is at risk for pressure ulcers, and had two venous and arterial ulcers. R3's Physician Order Sheet (POS) dated 3/5/25 documents the following wound treatment orders: Wound Care: (L) calf: Cleanse w/ wound cleanser. Apply Santyl 250 UNIT/GM (gram)(Collagenase) ointment on wound bed followed by Calcium alginate (cut to fit) on wound bed. Cover with Superabsorbent dressing. Wrap with gauze wrap. Secure with tape. Change…

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 complete physician ordered pressure ulcer treatments for one of three residents (R2) reviewed for infected wound/pressure ulcers on the sample list of three. Findings include: R2's current Diagnoses Sheet documents the following: Acquired Absence Of Left Leg, Above the Knee, Acquired Absence Of Right Leg, Below the Knee, Peripheral Vascular Disease, and Pressure Ulcer Of Sacral Region Stage IV. R2's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment. The same MDS documents R2 has one Pressure Ulcer Stage III and one Pressure Ulcer Stage IV. R2's Physician Order Sheet (POS) dated 3/5/25 documents the following orders: Wound Care: (R) Trochanter wound (pressure ulcer Stage III): Cleanse with wound cleanser. Apply sureprep to periwound. Place Santyl in the wound bed. Loosely fill wound bed with Opticell gelling fiber. Cover 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 observation, interview, and record review the facility failed to keep resident call buttons in an easily accessible area for four of five at risk residents (R2, R3, R4, R5) reviewed for call button accessibility on the sample list of five. Findings Include: 1. R2's Medical Diagnoses List dated January 2025 documents R2 is diagnosed with Chronic Obstructive Pulmonary Disease, Dysphagia, Weakness, Dementia, and Difficulty Walking. R2's Care Plan dated May 2024 documents R2 is at risk for falls and staff should keep her call light within reach and encourage her to use it. R2 also has a communication problem related to Dementia and staff should make sure R2's call light is within reach and avoid isolation. R2 requires two person staff assistance for transfers and toileting. On 1/26/25 at 1:40 PM R2 was laying in her bed. She was the only person in her room. R2 was wearing oxygen by nasal cannula and a wheelchair was parked near her bed. R2's special touch pad call button was laying at the foot of her bed completely out of her reach. 2. R3's Medical Diagnoses List dated January…

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 the dignity of four (R1, R12, R13 and R14) of six residents reviewed for dignity from a total sample list of 15 residents. Findings include: 1.) The facility provided report to the State Agency dated 11/26/24 documents that on 11/19/24, R1 complained that he did not like the care provided to him by V15 Certified Nursing Assistant (CNA). The facility response documented that V15 CNA would not provide R1 with further care. R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact and that R1 is dependent on staff for activities of daily living. On 12/16/24 at 10:00AM, V15 CNA stated that he continues to provide care for R1, as directed by the nursing staff. On 12/16/24 at 1:00PM, R1 stated that V15 CNA still cares for him. R1 stated, They just do whatever they want. On 12/16/24 at 3:10PM, V1 Administrator stated that V15 CNA is not supposed to be providing care for R1 and that by doing so, R1's wishes are being disrespected. 2.) 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 complete a thorough investigation for one (R1) of six residents reviewed for abuse from a total sample list of 15 residents. Findings include: The facility provided Abuse Policy dated 12/2024 documents that the facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Steps in the investigation include completing a thorough investigation with two management level staff conducting interview with witnesses or other staff, residents or visitors who could have knowledge of the allegation and witnesses will be asked to assist with completing statements. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on and if the allegation occurred on a specific shift, all staff for the identified shift only will give a statement if indicated. The facility will immediately remove any alleged perpetrator from any further contact with any resident through suspension, pending the outcome 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide nail care for one of six residents (R1) reviewed for activities of daily living from a total sample list of 15 residents. Findings include: The facility provided report to the State Agency dated 11/26/24 documents that on 11/25/24 a bruise was found on R1's left middle finger and upon X-ray was fractured. The facility report documents the cause of the fracture was due to R1's cracked fingernail snagging his shirt causing the finger to be bent and fractured while R1 was dressed due to left side hemiplegia. R1's care plan dated 11/26/24 documents to keep R1's nails trimmed and short enough to prevent snagging on clothing. R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact and that R1 is dependent on staff for activities of daily living. On 12/12/24 at 11:45AM, R1's nails on both the right and left hands were nearly an inch past the end of the finger with food and brown matter underneath them. On 12/16/24 at 9:30AM,…

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 protect the residents' right to be free from verbal abuse by another resident and mental abuse by a staff member. This failure affected three of four residents (R1, R3, R4) reviewed for abuse in the sample of four. Findings Include: The facility's Abuse Prevention Program dated October 2022 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Abuse means the willful infliction of injury, intimidation or punishment resulting in physical harm, pain, or mental anguish. Verbal abuse is 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 an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm or saying things to frighten a resident. Mental abuse includes but is not limited to threats of punishment or deprivation.…

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 the services of a full-time Director of Nursing. This failure has the potential to affect all 90 residents residing in the facility. Findings include: On 08/14/24 at 9:05 there was no Director of Nursing (DON) present in the building to complete entrance paperwork. On 8/14/24 at 9:10 am V3, Registered Nurse/ Minimum Data Set/Care Plan Coordinator stated the facility does not have a full-time Director of Nursing. On 8/14/24 at 9:25 am V2, Regional Nurse completed the entrance paperwork for this survey. V2 stated V2 is not full time in the facility. V2 works in this facility on average two days a week, to help the facility in the absence of a full-time DON. On 8/15/24 at 11:45 am V6, Previous DON stated her last day working in the facility was 7/31/24. The facility 802 Matrix dated 8/14/24 document 90 residents are currently residing in the facility.

Based on observation, interview, and record review, the facility failed to revise a resident's care plan to reflect the actual health status after a change in residents condition. This failure affects one resident (R1) out of three residents reviewed for care plans on the sample list of 7. Findings include: R1's Diagnoses Sheet updated 5/14/24 documents R1's Primary, admission Diagnosis for Medical Management was Alcohol Abuse, Uncomplicated. R1's Care Plan updated 7/23/24 with the following interventions: (R1) is at risk for falls. Educate family to provide assistance with transfers and ambulation when out in the community. This same plan of care does not include any mention of the primary diagnosis of medical management Alcohol Abuse, Uncomplicated, or interventions to prevent future exacerbation. R1's SBAR (Situation, Background,Assessment, and Recommendation) note dated 7/22/2024 at 1:09 pm documents the following:Note Text: The resident is experiencing a change in condition. See SBAR assessment for further information and family/physician notification. The change in condition…

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 proper food storage order, failed to maintain dishwashing equipment to sanitize dish wares, and failed to maintain food contact equipment in a sanitary manner. These failures have the potential to affect all 99 residents residing in the facility. Findings Include: 1.) On 7/9/24 at 9:50 AM, in the facility's walk-in refrigerator, there was an opaque plastic tub with thawing raw pork sausage sitting on top of and in direct contact with thawing raw hamburger. On 7/9/24 at 9:50 AM, V3, Dietary Manager in Training, stated, Pork should be below hamburger. On 7/10/24 at 1:40 PM, V6, Dietary District Manager, stated, We follow the FDA (Food and Drug Administration) Code for food storage hierarchy. The current FDA Code (2017) documents on page 421, It is the intent of this code to require separation of raw animal foods based on anticipated microbial loads and food type in order to prevent cross-contamination. On page 558, this same FDA Code documents pork is a food associated with Trichinella species (worms)…

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 the required Quality Assurance Performance Improvement (QAPI) meetings were being held quarterly and failed to ensure required members attended quarterly QAPI meetings. This failure has the potential to affect all 99 residents residing in the facility. Findings Include: The facility Long-Term Care Facility Application For Medicare and Medicaid dated 7/10/24 documents 99 residents residing in facility. The facility is unable to provide any documentation that the required quarterly QAPI meeting was held during the first quarter of 2024. The 2023 fourth quarter QAPI meeting sign in sheet, dated 2/23/24, does not document that an Infection Preventionist was present. On 7/10/24 at 2:40 PM V2 Director of Nursing said that they could not locate the minutes or sign in sheets for the 2024 first quarter QAPI meeting. On 7/10/24 at 2:20 PM V2 Director of Nursing confirmed that there was no Infection Preventionist in attendance at the 2/23/24, fourth quarter 2023 QAPI meeting. The undated Quarterly QAPI Committee Meeting Agenda…

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 establish a water management program including developing a risk assessment, ensuring that interventions to monitor control limits are met, and developing a method to audit the program to prevent the growth of Legionella and other water borne pathogens in the building's water systems. This failure has the potential to affect all 99 residents that reside in the facility. Findings Include: The facility Long-Term Care Facility Application for Medicare and Medicaid dated 7/10/24 documents that there are 99 residents who reside in the facility. The undated facility Water Management Program to Reduce Legionella Growth and Spread documents that each facility will complete a risk evaluation to identify if the entire building or parts of the building are at risk for Legionella growth and spread. Additionally, the facility will implement control measures to reduce spread, ensure that the program remains operational and audit the program monthly. The facility could not provide documentation of a Legionella prevention program including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to place call light devices within resident's reach for four of four residents (R14, R27, R77, R95) reviewed for call lights in the sample list of 49. Findings Include: R14's undated Face Sheet documents R14's diagnoses as: Repeated Falls, Unsteadiness of feet, Muscle Weakness, and unspecified Dementia. R14's Care Plan dated 3/20/24, documents R14 as having a non-traditional call light. R14's Minimum Date Set (MDS) dated [DATE], documents R14 is dependent and requires substantial/maximal assist with moving in bed, rolling, lying, sitting, chair bed transfers, toilet transfers, dressing, and personal hygiene. R14's Brief Interview for Mental Status (BIMS) dated 7/1/24, documents R14 is not cognitively intact. On 07/09/24 at 10:03 AM R14's call light was on the floor near the bed and not within R14's reach. R27's undated Face Sheet documents R27's diagnoses as: Fracture of Superior rim of right Pubis, subsequent encounter, Wedge compression…

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 thoroughly address multiple concerns of the resident council and facility grievances regarding laundry services. This failure effects 5 of 5 residents (R8, R15, R56, R78 and R81) who participated in Resident Council Meeting on the sample list of 49. Findings Include: Resident Council Meeting was held on 7/10/24 at 1:00 PM in the ADL (Activities of Daily Living) room. The Resident Council Members were R8, R15, R56 (Resident Council President), R78 and R81. During the meeting all five residents complained the facility did not return their personal items and clothing back in a timely matter. They also complained the clothes returned to them are not always clean and they appear as though they have not been washed. The Resident Council Meeting minutes dated 1/30/24, 2/27/24, 3/26/24, 4/25/24 and 6/28/24 under the section Laundry Issues/Concerns document complaints regarding the facility's laundry service. Specific complaints included issues such as the laundry taking a long time to be returned, clothes are put into…

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 a complete discharge summary for one of two residents (R101) reviewed for discharge on the sample list of 49. This past noncompliance occurred from 4/10/24-6/1/24. Findings Include: R101's Census Information dated 4/10/24 from the facility's EMR (Electronic Medical Record) documents R101 was admitted to the facility on [DATE] and was discharged on 4/10/24. R101's Medical Diagnosis sheet dated 2/14/24 in the EMR documents R101 is diagnosed with Metabolic Encephalopathy and Unspecified Convulsions. R101's Discharge summary dated [DATE] documents five separate sections with the following titles, Discharge Summary Recapitulation of Stay, Social Service Summary of Resident Stay, Clinical Summary of Resident Stay, Dietary Summary of Resident Stay and Activity Summary of Resident Stay. Of the five sections of R101's Discharge Summary only two sections were completed and the others were left blank. R101's Progress Note dated 4/10/24 documents R101 was…

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

Based on interview and record review the facility failed to completed treatments as ordered for two of three residents (R1 and R2) reviewed for pressure ulcers in the sample list of 13. Findings include: The facility's Pressure Ulcer/Pressure Injury Prevention Policy with a revised date of March/2022 documents, If a PU/PI (Pressure Ulcer/Pressure Injury) is present, provide treatment to heal it and prevent the development of additional PU/PI's. 1.) R1's Order Summary Report dated 8/8/24 documents diagnoses including Type 2 Diabetes, Dementia and Pressure Ulcer Right Heel Unstageable. This Order Summary also documents an order dated 8/8/24 for the right heel, cleanse with normal saline, do not scrub or use excessive force, cover with a hydrophilic polyurethane non-adhesive dressing may slightly overlap on new skin, wrap with rolled gauze, change every day and as needed. R1's Treatment Administration Record (TAR) dated 7/1/24 through 7/31/24 documents the order for the right heel dressing change and the treatment is not signed out as completed on 7/25/24 and 7/31/24. R1's TAR 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 assess and monitor a Peripherally Inserted Central Catheter (PICC) for one of two residents (R5) reviewed for Intravenous Catheter medication administration on the sample list of 49. Findings Include: R5's Medical Diagnoses list dated July 2024 documents R5 is diagnosed with Bipolar Disorder, Depression, and Neuromuscular Dysfunction of Bladder. R5's Minimum Data Set, dated [DATE] documents R5 is cognitively intact. R5's Situation, Background, Assessment, and Recommendation (SBAR) and Communication Form and Progress Notes dated 7/6/24 documents R5 stated she has had Urinary Tract Infection (UTI) symptoms and R5 requested to go to the emergency room. R5 was sent to the emergency room. R5's Health Status Note dated 7/8/24 documents R5 returned from the hospital after being admitted with a Urinary Tract Infection. R5 returned to the facility with a PICC line and new orders to start intravenous antibiotics. R5's Physician Order Sheet (POS)…

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 reviewed the facility failed to manage a resident's pain by failing to obtain pain medication and administer pain medication for one of one resident (R83) reviewed for pain management in the sample list of 49. Findings Include: R83's undated Face Sheet documents R83's diagnosis as: Bilateral Primary Osteoarthritis of Knee. R83's Physician Order Sheet (POS) dated July 2024 documents Oxycodone-Acetaminophen oral tablet 5-325 milligrams two tablets by mouth every four hours for pain management. R83's Medication Administration Record (MAR) documents on 7/9/24 at 12:00 PM a dose was not given and to see progress note. On 7/9/24 at 4:00 AM the MAR documents a dose not given and to see progress note and the same was documented on 7/9/24 at 8:00 AM. On 7/9/24 at 2:34 PM V11 Licensed Practical Nurse (LPN) stated there was no Oxycodone available to be given to R83 this morning. V11 LPN stated she just found out this morning the medication was not available and placed a call to the doctor so V11 could get the order to the pharmacy. V11 stated there were three…

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 treatment for a newly developed skin wound for one (R1) of three residents reviewed for skin wounds in the sample list of three. Findings include: R1's Physician Order Sheet (POS) dated June 2024, documents R1's diagnoses as: Moderate Protein-Calorie Malnutrition, Muscle Weakness (generalized), other reduced Mobility, and Myasthenia Gravis without acute exacerbation. R1's Minimum Data Set (MDS) dated [DATE], documents R1 requires substantial/maximum assistance with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed transfers. R1's Nurse Skin Inspection Report dated 6/14/24, documents R1's skin is not clear and intact, has redness, bloody drainage, an open ulcer, and a circle placed on the body drawing indicating where these issues are seen (coccyx/sacrum/buttocks) area, signed by V7 Certified Nursing Assistant (CNA) and signed by V8 Licensed Practical Nurse (LPN). There is no documentation in R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect resident's rights to be free from physical abuse by another resident. This failure affects five (R3, R4. R5, R6, R7) residents of 12 residents reviewed for abuse in a sample list of 12 residents. Findings include: The facility policy titled 'Abuse, Prevention and Prohibition Policy' revised January 2024 documents each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. The facility prohibits mistreatment, neglect and abuse of residents. The facility Administrator will be designated as the Abuse Coordinator. If the Administrator is not available to address this role then the Administrator will designate a 'person in charge' in their absence to fulfill the role. The Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician 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 protect residents from physical abuse from another resident with known physical aggression, failed to investigate resident allegations of abuse by another resident and allegation of potential abuse by staff. These failures affect five (R5, R6, R7, R3, R1) residents out of 12 residents reviewed for abuse in a sample list of 12 residents. Findings include: The facility policy titled 'Abuse, Prevention and Prohibition Policy' revised January 2024 documents each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. The facility prohibits mistreatment, neglect and abuse of residents. The facility Administrator will be designated as the Abuse Coordinator. If the Administrator is not available to address this role then the Administrator will designate a 'person in charge' in their absence to fulfill the role. The Administrator will ensure a thorough investigation of alleged violations of individual rights and document…

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 ensure for resident rights regarding personal property for one (R1) of three residents reviewed from a sample list of 12. Findings include: The facility provided Abuse Prevention and Prohibition Policy, revised date 1/2024 documents that residents have a right to personal property in the facility. The facility provided Resident's Rights for People in Long Term Care Facilities, revised date 3/2017, documents that resident's have a right to privacy. The facility provided grievance dated 5/3/24 documents that R2 complained that V11 CNA was going through R1's drawers when he thought that they were both asleep. On 5/8/24 at 10:30AM, R1 stated, (V11 CNA) went through my drawers and I don't like that. On 5/8/24 at 10:45AM, R2 stated, I caught that guy going through her drawers when he thought that we were asleep. We don't want him in here anymore, going through our drawers. He said he was getting washcloths. On 5/9/24 at 3:33PM, V11 CNA said that he did open R1's drawers to get the rags out and that he didn't ask her if it was ok 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 interview and record review the facility failed to implement their abuse policy for one (R1) of twelve residents reviewed for abuse from a total sample list of 12. Findings include: The facility abuse policy revised date 1/2024 documents that each resident has the right to be free from abuse and that the facility's abuse prohibition program includes screening, training, prevention, identification, investigation, protection and reporting/response. Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violation of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in thru allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress except to meet with the administrator as apart of the investgation. The person identified in the allegation of abuse will have no contact with resident or other employees during 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 report allegations of physical and potential sexual abuse timely to the State Agency for three (R1, R6, and R7) of 12 residents reviewed for abuse from a total sample list of 12 residents. Findings include: The facility policy titled 'Abuse, Prevention and Prohibition Policy' revised January 2024 documents each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. The facility prohibits mistreatment, neglect and abuse of residents. The facility Administrator will be designated as the Abuse Coordinator. If the Administrator is not available to address this role then the Administrator will designate a 'person in charge' in their absence to fulfill the role. The Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Initiate an investigation including initial reporting to all required agencies. The facility Administrator or designee who is made aware of any allegation of abuse or neglect shall report to the State…

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 protect a resident's right (R2) to be free from sexual abuse by another resident (R1). This failure affect two (R2, R1) of three reviewed for abuse on the sample list of 16. This past non-compliance occurred 03/03/24 (date of the incident) to 03/07/24 (facility plan completed to address non-compliance). Findings include: The facility final report to the state agency, dated 3/7/24, submitted by V1, Administrator/Abuse Prevention Coordinator. This final report was regarding a 3/03/24 allegation of sexual abuse, R2 by R1. The final report documents the following: V3,Certified Nursing Assistant witnessed R1 touch R2's crotch area. The facility final report concluded that R1 had inappropriate physical contact by with R2. R1's medical record documents R1 has been on 1:1 observations since immediately after the event occurred on 3/3/24. R1's Current Diagnoses Sheet documents the following: Other Frontotemporal Neurocognitive Disorder, and Dementia in 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 interview and record review the facility failed to promote the right to respect and dignity during cares for one (R7) of three residents reviewed for improper nursing care on the sample list of nine. Findings include: R7's incident report dated 1/31/24 at 4:35 PM documents, V18 Certified Nurse's Assistant reported that V6 Certified Nurse's Assistant was extremely rude to R7 for no reason while providing cares. On 2/6/24 at 3:08 PM, V18 stated on the afternoon of 1/31/24, V6 was assisting V18 with transferring R7 into bed. V18 stated R7 likes the privacy curtain shut when receiving cares even if the door is shut. V6 stated R7 asked V6 to close the curtain and V6 grabbed the curtain and flung it forcefully when closing it. V18 stated after that, R7 asked what was wrong and V6 got upset and said, can we just get this done? V18 stated we got R7 into bed using the mechanical lift. V18 stated V18 asked R7 to roll toward the door to tuck the mechanical lift sling under R7. V18 stated V18 then rolled R7 and then asked R7 to roll back the other way and before R7 was able to turn, V6…

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 physician ordered medications and notify the physician when medications were on backorder for one (R1) of three residents reviewed for resident injury on the sample list of nine. Findings include: R1's Hospital Discharge Orders dated 1/13/24 includes an order for Valacyclovir 500 milligrams two tablets once a day for viral infection and an order for Liraglutide 18 milligrams per 3 milliliters, inject 1.8 milligrams subcutaneously one time a day for Diabetes. R1's Medication Administration Record dated January 2024 does not document that R1 received the Valacyclovir on 1/13/24, 1/14/24, or 1/15/24. This record does not document that R1 received the Liraglutide from 1/13/24 through 1/17/24. On 2/6/24 at 11:20 AM, V2 confirmed that R1's Valacyclovir was not given on 1/13/24, 1/14/24, or 1/15/24. V2 stated it was backordered and their pharmacy was unable to obtain it. V2 stated the facility did not contact any other pharmacy and the physician was not notified. V2 confirmed that the Liraglutide was not given from 1/13/24…

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 observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment for two (R2, R8) of four residents reviewed for cleanliness from a total sample list of four. Findings include: The facility provided Five Step Daily Room Cleaning and Seven Step Daily Bathroom Cleaning forms dated 10/25/16 document that the most important area of a patient's room to disinfect is the floor. This is where most air-borne bacteria will settle and so it needs to be sanitized daily. A proper mop and germicide solution should be used to disinfect the bathroom floor with the proper amount of solution dwell time, working outward from the room. The facility provided grievance log identifies complaints of the lack of cleanliness of resident rooms and bathrooms on October 26, 2023, 11/20/23 and 11/28/23 with a response to the identified grievance on 11/28/23 as a denial of the floors being dirty by V7 Housekeeping Supervisor. On 12/27/23 at 8:00AM, the facility smelled strongly of urine upon entry. No residents were present in the entryway. On…

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

Based on interview and record review, the facility failed to follow physician orders for changing a residents indwelling catheter every 30 days. This failure affects one (R6) of three residents reviewed for indwelling catheters from a total sample list of three. Findings Include: The facility (Indwelling) Catheter Insertion policy dated 01/2017 and (Indwelling) Catheter Removal Policy dated 01/2017 indicates that the nurse will verify the order for the procedure. R6's physician order sheet documents that on 10/29/23, V19 physician ordered an indwelling catheter change for R6 every 30 days and as needed. R6's progress note dated 10/29/23 indicates that R6's indwelling catheter was removed and a new indwelling catheter was inserted as directed by the physician. R6's medical record does not include another indwelling catheter change until 12/10/23. R6's progress notes dated 12/10/23 documents an indwelling catheter change for R6, 12 days after the order required. On 12/27/23 V2 was interviewed. V2 Director of Nursing said that there was an order on 10/29/23 for R6 to have indwelling…

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 clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 83 residents residing in the facility. Findings include: On 9/12/2023 at 9:45AM, V18 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V18 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. The Resident Census and Conditions of Residents report (9/12/2023) documents 83 residents reside in the facility.

Based on observation, interview, and record review the facility failed to prevent the potential for physical cross-contamination of food. This failure affects all 83 residents residing in the facility. Findings include: On 9/12/2023 at 12:18PM, the kitchen table-mounted can opener had an accumulation of metal shavings where the opener makes contact with cans being opened. The receiving base of the opener was soiled with accumulations of food debris. On 9/14/2023 at 11:55AM, the can opener remained as above. V19 (Dietary District Manager) was present and reported we just need to clean it (the can opener). 09/15/23 at 11:15AM, V18 (Dietary Manager) reported food prepared by the dietary service is available for all facility residents to eat. The Resident Census and Conditions of Residents report (9/12/2023) documents 83 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the hallway handrails were securely fastened to the walls. This failure has the potential to affect all 83 residents residing in the facility. Findings include: On 9/12/23 at 2:22 PM, the section of handrail between resident rooms [ROOM NUMBERS] was loose and easily moveable over 1 inch. The section of handrail between resident rooms [ROOM NUMBERS] was completely unattached on one end and the rail would raise to a near vertical position. The section of handrail next to the ice machine on the resident 200 hallway was loose and easily moveable over 1 inch. On 9/12/23 at 2:31 PM, V5, Maintenance Director, stated, I don't have any system for checking the handrails on a routine basis. After checking the section of handrail between resident rooms [ROOM NUMBERS], V5 stated, I ran up here and tightened that one after I was told someone saw you checking them. V5 stated that the section of handrail between resident rooms [ROOM NUMBERS] was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain the cleanliness of resident living quarters and bathrooms by failing to ensure residents had clean toilets to use and the disposing of soiled incontinence briefs in resident room garbage cans for five (R52, R61, R63, R69, R279) of five residents reviewed for dignity in a sample list of 43 residents. Findings include: 1. R61's Minimum Data Set (MDS) dated [DATE] documents R61 as cognitively intact. R52's Minimum Data Set (MDS) dated [DATE] documents R52 as moderately cognitively intact and requires staff assistance for toileting. On 09/12/23 at 10:24 AM R61 stated I share a bathroom with (R52). (R52) uses a riser on the toilet and has Diarrhea three to four times per day. The staff never clean the (fecal material) off of the riser and don't take the riser off of the toilet so when I have to go to the bathroom, I have to sit on (R52's) riser with (fecal material) all over it. The staff never take out my dirty diaper either. When 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 and/or administer Pneumococcal Conjugate Vaccine (PCV) 20 or PCV 15 timely and failed to monitor vaccination status for four (R16, R20, R22, R34) residents out of five residents reviewed for immunizations in a sample list of 40 residents. Findings include: Facility Pneumococcal Vaccination Log dated April 2023 and June-August 2023 do not include R16, R20, R22 nor R34. 1. R16's undated Face Sheet documents an admission date of 4/22/13 and date of birth as 7/26/44. R16's Electronic Medical Record (EMR) documents medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Malignant Neoplasm of Large Intestine and history of COVID-19. R16's Immunization Record Sheet documents R16's last Pneumococcal vaccination was Pneumococcal Conjugate Vaccine (PCV) 13 administered on 4/23/21. There is no record of R16 being offered or receiving a Pneumococcal vaccination after that date. No consents, documentation or education regarding Pneumococcal vaccinations were documented in R16's Electronic Medical Record (EMR). 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 honor a resident's right to privacy during wound treatments administered by facility staff and agents. This failure affects one resident (R4) out of one reviewed for privacy on the sample list of 43. Findings include: R4's Electronic Medical Record including Census Details and Minimum Data Set List, document R4 was admitted to the facility 1/7/23, and did have prior stays at the facility. R4's Physician Order Sheet documents R4 is prescribed 3 separate wound treatments to the left posterior calf, middle to lower left leg, and left ankle. On 9/12/23 at 12:15 PM, R4 was seated in her own room while V7, Licensed Practical Nurse/ Wound Nurse, and V11, Advanced Practice Nurse/ Wound Care, administered R4's leg wound treatments. V7 was holding R4's fully exposed left leg up in the air while V11 conducted measuring, Picture taking, debriding, and dressing applications. R4's room door was wide open, exposing R4 to the hallway where V4, Maintenance/ Housekeeping Assistant, was working. On 9/12/23 at 12:20 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to complete, encode, and transmit a Minimum Data Set Assessment within the required timeframes. This failure affects two residents (R9 and R278) out of two reviewed for Minimum Data Set completion on the sample list of 43. Findings include: 1. R9's Minimum Data Set (MDS) List (undated) documents a quarterly MDS with an assessment reference date (ARD) 8/18/23. This MDS List documents the completion was 10 days overdue, and the status as In Progress. R9's MDS assessment dated [DATE] documents sections A, G, GG, H, I, J, L, N, O, P, and S were in progress, not completed, and there were 265 questions remaining unanswered. On 9/12/23 at 3:59 PM, V20, MDS Coordinator, stated, I have been off work for 3 weeks and I know I have about 4 MDS's I need to get done. They are supposed to be completed within 14 days after the ARD. 2. R278's undated Face Sheet documents an admission date of 8/12/23. This same Face Sheet documents medical diagnoses of Malignant Neoplasm of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement post-fall prevention interventions as documented on a resident's plan of care. This failure affects one resident (R27) out of five reviewed for accidents on the sample list of 43. Findings include: The facility's Fall Occurrence Log dated from 5/12/23 to 9/12/23 documents R27 experienced eight falls in the four month period. R27's Medical Record documents R27's Fall Risk Assessments, 33 total assessments, dated from 8/11/21 through 9/7/23, with 32 of these assessments documenting R27 is a high risk for falls. R27's fall risk assessment dated [DATE] was incomplete, with R27's fall history and high-risk medications sections not completed and documented low risk. R27's Care Plan for high risk for falls and history of falls dated as initiated 5/22/17, with revisions through 9/7/23, document post fall interventions including placing a call don't fall sign in R27's room, initiated 4/29/22, and placing non-skid strips in front of R27'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, interview and record review the facility failed to properly date and store oxygen tubing and nebulizer tubing for three (R12, R31, R128) residents out of four residents reviewed for respiratory care in a sample list of 43 residents. Findings include: 1.) R12's undated Medical Diagnosis List documents medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Dependence on Supplemental Oxygen. On 09/12/23 at 11:42 AM observed R12 wearing Oxygen on 2 liters per nasal cannula. R12's Oxygen nasal cannula tubing was undated. R12's nebulizer tubing was dated 8/28/23. Observed R12's nebulizer tubing was laying on top of R12's bedside dresser with the face mask directly touching the contaminated top of the dresser. On 9/12/23 at 11:45 AM R12 stated I am on oxygen 24/7. I can't go without it at all. I know they (staff) are supposed to change that tubing and humidifier every week but I have to beg them to do it. Sometimes I forget. I really should not have to remind them. They (staff) should just do it but some of these girls (nurses) are just lazy and need 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 obtain a physician response from a pharmacist recommendation for a medication irregularity. This failure affects one resident (R33) out of five reviewed for unnecessary medications on the sample list of 43. Findings include: R33's Note to Attending Physician, prepared by V21, Consultant Pharmacist, dated 7/8/23 documents a request for the attending physician (V22, Medical Director) to provide a medical rationale for R33 receiving prescriptions for more than one anti-depressant medication, Mirtazapine and Sertraline. This form had four optional prepared responses requiring a checkmark from V22. This form had no documented response from V22. R33's Note to Attending Physician dated 9/5/23 documents the same request for V22 to provide a medical rationale for R33 receiving prescriptions for more than one anti-depressant medications, Mirtazapine and Sertraline. This form had the same four optional prepared responses requiring a checkmark response from V22. On 9/13/23 at 1:29 PM, V2, Director of Nursing, stated, I just started…

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

Based on observation, interview and record review the facility failed to properly store medications for three (R16, R20, R34) residents out of three residents reviewed for medication storage in a sample list of 43 residents. Findings include: 1. R20's Physician Order Sheet (POS) dated September 2023 documents physician orders for Pantoprazole 20 milligrams (mg) daily at 8:00 AM, Docusate Sodium 100 mg daily at 8:00 AM, Duloxetine Hydrochloride (HCL) Delayed Release (DR) 30 mg daily at 8:00 AM and Gabapentin 300 mg daily at 8:00 AM. On 09/12/23 at 11:56 AM observed R20 sitting up in bed with the bedside table across R20's lap. Observed whole pills in a medicine cup with applesauce sitting on bedside table. No staff were present in R20's room at time of observation. On 9/12/23 at 11:58 AM R20 stated They (staff) do that all the time. (V9) Licensed Practical Nurse (LPN) brought them in earlier. Sometimes other residents walk in and out of my room but nothing has happened yet. Ill take them with my lunch. On 9/12/23 at 12:10 PM V9 Licensed Practical Nurse (LPN) stated R20 has not 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.