Momence Meadows Nursing & Rehab

Based on interview and record review, the facility failed to investigate reported allegations of resident abuse, and subsequently failed to ensure residents were protected while the reported allegations were investigated. This applies to 3 of 3 residents (R1, R5, R9) reviewed for abuse. The findings include:1. On 12/19/25 at 2:32 pm, R9, who was alert and oriented, said that on 12/14/25, staff ripped his shirt and had their knee on his neck during a verbal altercation between R9 and the staff. R9 said that he told the CNA (Certified Nurse's Assistant) that night that they ripped his shirt, and he told the nurse that the CNAs had their knees on his neck. On 12/14/25 at 11:10 am, V5 CNA verified that R9 did tell her and show her that his shirt was ripped during the altercation. V5 said that R9 was sent to the hospital that night for his behaviors and she reported the incident to the Administrator and the DON. On 1/2/26 at 5:50 pm, V1 (Administrator) said that R9 did report that the staff ripped his shirt and the staff was being physically aggressive to him. V1 said that the incident…

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 a safe resident environment after a resident was able to obtain objects that could be used to threaten others. This applies to 2 residents (R1, R5) reviewed for safe environment. The findings include:On 1/2/25 at 9:57 am, R5, who was alert and oriented, said that on 12/7/25 she told the staff that R1 had a knife and held it to her neck and threatened her. R5 stated she was scared in the moment. On 12/27/25 at 2:30pm, V4 CNA (Certified Nurse's Assistant) said that 12/7/25 she worked the night of 12/7/25 and she heard R1 threatening R5 with a knife and R1 was standing over R5. V4 said that night, the staff found a knifes, a drill, a hammer, and lighters in R5's room. V4 said R1 also threatened to burn down the facility before she was discharged to the hospital that night. V4 said that the facility was trying to send her to jail, but she went to the hospital instead. On 12/31/25 at 11:09 am, V3 CNA said the next day on 12/8/25, V2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide care to a resident dependent on staff for ADL (activities of daily living). This applies to 1 of 3 (R5) residents reviewed for ADL care.The findings include:According to the Electronic Medical Record (EMR), R5 was admitted to the facility on [DATE], with multiple diagnoses including acquired absence of left leg above knee, cellulitis of groin, hidradenitis suppurativa, and pressure ulcer of sacral region, stage 3. R5's MDS (Minimum Data Set) dated June 5, 2025, showed R5 had mild cognitive impairment and required maximum assist with toileting hygiene, shower, and bathing. R5's Care Plan dated April 13, 2025, showed R5 has an ADL (Activity of Daily Living) self-care deficit and required staff assistance and showed that R5 is incontinent of bladder and bowel. Interventions include the CNA (Certified Nurse Aide) should check and change R5 every 2 hours and as needed.On August 25, 2025, at 12:40 PM, R5 was in bed with an empty urinal 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 interviews and record review, the facility failed to prevent resident to resident abuse. This applies to 2 of 5 residents (R2 and R3) reviewed for abuse in the sample of 10. The findings include: 1. FRI (Facility Reported Incident) report documents an incident of April 14, 2025, alleging that R1 made inappropriate contact with R2. The report indicates that immediate action taken: Residents were immediately separated. Body and pain assessments completed on R1 and R2. Police was notified. R1 was placed on 1:1 monitoring until sent out to the hospital for further evaluation. After interviewing staff and residents, it was discovered that R1 and R2 were waiting in the hallway to go out for smoke break but staff did not witness the incident. R2's EMR included diagnoses of End Stage Renal Disease; Chronic Obstructive Pulmonary Disease; Major Depressive Disorder, Recurrent; Unspecified Bipolar Disorder, Schizoaffective Disorder unspecified R2's admission MDS dated [DATE], showed that R2 was cognitively intact.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident was free from abuse for one of three residents (R3) reviewed for abuse in a sample of 3. This failure resulted in R3 being physically slapped by a staff member which caused R3 to experience emotional distress and led to R3 displaying increased agitation, aggression, and combative behavior. Findings include: R3's face sheet indicated that resident admitted to the facility on [DATE] and has a past medical history not limited to: cerebral infarction due to thrombosis, metabolic encephalopathy, bipolar disorder, personal history of physical injury and trauma, and tension-type headaches. R3's screening assessment for indicators of aggressive and/or harmful behavior dated 09/16/2024 revealed that R3 is at minimal risk for aggression with dementia, related interventions of re-orientation, re-assurance, emphasis on safety/security, and severe mental illness interventions of stress management/relief and harm reduction.…

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 a resident free from sexual abuse. This applies to 1 of 6 residents (R1) reviewed for abuse. The findings include: On December 3, 2024 at 11:15 AM, V10 (Cook) stated she had been coming out of the hallway bathroom on 11/15/2024, when she witnessed R2 patting R1 above her right breast on the outside of her clothing. V10 stated R2 then slipped his hand down the neckline of and underneath R1's shirt to her left breast. V10 stated she knew R2 could feel her presence because he stopped and left. V10 stated at first she thought R2 was just checking on her, then she saw him slip his hand down her shirt. V10 stated R1 is nonverbal and blind and regardless of if she reacted or not, R1 cannot defend herself. V10's written statement from the facility's 11/15/2024 investigation showed she .saw [R2] sitting in the hallway near the small dining room. I saw [R2] touch [R1] by her right side of her chest. I saw him put his hand under her shirt close to her left breast. Then when [R2] saw me he hurried up and moved his…

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

Based on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness.This applies to 74 residents in the facility receiving dietary services. Findings include: On 11/14/24 4:36 PM, V2 DON (Director of Nursing) stated 74 residents were served from dietary services on 11/12/24. On 11/12/24 at 10:45 AM, the dry storage contained: A large bin of breadcrumbs with use by date of 7/28/24. A large bin of oatmeal with use by date of 11/9/24. A large bin of rice with use by date of 10/30/24. A large bin of flour with use by date of 9/18/24. A large bin of thickener with use by date of 7/9/24. A clear plastic bag with dry penne pasta open to air. Two clear plastic bags containing dry fettuccini pasta open to air. Dented cans in rotation for use: Diced beats 6lb (pounds) 8 oz (ounces). Diced carrots 6lb 9 oz. Three cans of diced potatoes 6lb 6oz. Two cans of chunk tuna 4.16lb. The facility policy Storge of Dry Foods / Supplies dated 9/18/23 states dry goods will be handled and stored to maintain the integrity of 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 provide a resident and/or his family/POA (Power of Attorney) the reason of transfer to the hospital in writing. The facility also failed to notify the ombudsman of the transfer.This applies to 4 of 4 residents (R7, R26, R38, R74) reviewed for discharge in a sample of 18. The findings include: 1. On 11/13/24 at 2:27 PM, V2 (DON-Director of Nursing) stated, We don't notify the ombudsman about the transfer to the hospital. We don't get the ombudsman involved in the discharge or transfer of a resident. We only notify the ombudsman if the resident is non-compliant with something, or we can't reach an agreement with the resident. We didn't give a written notice to (R74) and his POA at the time of discharge to the hospital or afterwards. We notified the POA by phone. If we can't reach the POA, then social services emails or gives them a written notice. There's nothing uploaded in the resident's chart regarding the written notice of discharge to the hospital 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide in writing to residents and their families/POA (Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 4 of 4 residents (R7, R26, R38, R74)) reviewed for discharge in a sample of 18. The findings include: 1. On 11/13/24 at 2:27 PM, V2 (DON-Director of Nursing) stated, We hold the bed for 10 days. That's guaranteed to the patient. We don't typically keep a copy of the bed hold notice. R74's face sheet shows an admission date of 9/9/24 to the facility. R74's progress notes document the following: On 9/19/24 at 10:30 AM, (R74) observed on floor positioned on buttock with against door in bedroom. No injuries no skin alterations. Resident noted being verbally aggressive towards staff. MD (Medical Doctor) notified. Received order to transfer to (Hospital) for CT (Computerized Tomography) scan and psych evaluation. Order carried out. DON (Director of Nursing) and family POA made aware. On 9/20/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain physician orders for residents to have medications at the bedside and failed to complete self-administration of medication assessments. This applies to 3 of 3 residents (R18, R38, R58) reviewed for medications in a sample of 18. The findings include: 1. On 11/13/24 at 11:34 AM, R58 was observed sleeping in her bed. Her Fluticasone Propionate nasal spray 50 MG (Milligrams) was inside a box labeled with her name on the dresser that belonged to her roommate (R18) behind her curtain. Surveyor asked (R18) if it was hers and if she ever used it. R18 just stared at Surveyor and smiled. V6 (RN-Registered Nurse/Wound Nurse) who was in the room stated that R18 was nonverbal. On 11/13/24 at 2:18 PM, V2 (DON-Director of Nursing) said, I currently don't have any residents that can self-administer any medications. Any meds (medications) at the bedside need an order from the doctor. The nurse also must do a self-administration of medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to change PICC (Peripherally Inserted Central Catheter) dressings.This applies to 1 of 7 residents (R75) reviewed for infection control in a sample of 18. Findings include: R75's face sheet showed R75 admitted to the facility on [DATE] with diagnoses that includes cellulitis of the right lower limb, diabetes mellitus, and cutaneous abscess of the foot. R75's MDS (Minimum Data Set) dated 10/29/24 shows she is cognitively intact. On 11/12/24 at 1:01 PM, R75 showed the surveyor the single lumen PICC line in her right upper arm. The PICC had a border gauze dressing in place that had drainage in the center of it. R75 stated the dressing had been in place 4 to 5 days and she had changed it herself. R75 stated the staff did not do the dressing changes on her PICC line. On 11/14/24 at 1:20 PM, R75 stated the dressing on her PICC line had not been changed. R75 showed the surveyor her PICC line had the same stained border gauze dressing, with more…

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 refund resident funds after residents discharged from the facility. This applies to 3 of 3 residents (R1-R3) reviewed for resident funds. The findings include: The facility's Admission/Discharge To/From Report shows that R1 was discharged on 2/13/24, R2 was discharged on 2/26/24, and R3 was discharged on 1/29/24 (all over three months earlier). R1's Resident Fund Statement from 12/30/23-3/29/24 shows a balance of $2,097.70 in her account. R2's Resident Fund Statement from 12/30/23-3/29/24 shows a balance of $120.08 in her account. R3's Resident Fund Statement from 12/30/23-3/29/24 shows a balance of $30.09 in his account. On 5/31/24 at 10:41 AM, V3 (BOM/Business Office Manager) said when R1 was discharged from the facility she went to the hospital and then from the hospital he believes that she was sent to another facility, but that facility never contacted V3 to transfer R1's funds over. V3 said he will try to find out where R1-R3 are currently residing and get their funds sent over. At 1:09 PM, V3 said he found out where…

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

Based on observation, interview and record review, the facility failed to follow the menu plan and serve residents with alternatives for food items refused. This applies to 11 of 11 (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R14) residents reviwed for meal service. The findings include: The facility's lunch meal for 5/15/24 listed Cuban style pork chop, red beans and rice, chocolate mousse, corn bread, margarine, and beverage. Their menu for lunch, or the substitute menu was not posted for the residents on the notice board in the hallway. After checking the temperature V4 (Cook) began to plate the food for the residents. During Lunch instead of chocolate mousse they served Banana Cream Pie. Corn bread was not available during lunch. By the end of serving R4 and R15 did not get, red beans and rice, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R14 did not receive Banana Cream Pie instead they were given [NAME] Crackers for dessert. On 5/21/24 dietary staff did not post the breakfast or lunch menu until 10:00AM and the menu in the kitchen and the menu posted in the hallway for the…

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

Based on observation, interview and record review, the facility failed to provide alternate food to meet residents need. This applies to 3 of 3 residents (R1, R6, and R15) reviewed for alternate food and nutritional adequacy in the sample of 15. R1's MDS (minimum data set) dated April 25, 2024, indicated R1 has a BIMS (brief interview of mental status) score of 15 and she is cognitively intact. On 5/21/24 at 9:30 AM, R1 stated during interviews that she is not getting the food alternatives because she did not order the item the previous day. R1 stated that during the lunch meal she did not get the item that was listed on the planned menu and she requested a vegetable salad. According to R1, the dietary staff refused to give R1 the vegetable salad that she wanted since the menu as planned was not served. R1 added that staff refused to give her the salad since she did not order the salad the previous day. R1 continued and stated that residents do not get a breakfast menu but whatever the kitchen wants to serve. On 5/21/2024, R6 stated during interview that dietary staff refused 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 notify a resident's POA (Power of Attorney) of the resident's change in condition. This applies to 1 of 3 residents (R1) reviewed for notification of changes. The findings include: R1's 12/04/23 progress notes from 3:14 PM showed R1 was difficult to arouse, had not eaten breakfast or lunch, had increased fatigue, and his pulse was elevated (116). The note showed R1's physician was notified and new orders were given for metoprolol tartrate and lab work. No documentation of POA being notified of change in condition. On 12/27/23 at 10:39 AM, V3 (LPN/Licensed Practical Nurse) said on 12/4/23 from 6:30 AM until 7:00 PM, she was the nurse for R1 for part of the shift. V3 said R1 was in his room with breakfast tray. V3 said R1 was not eating his breakfast. V3 said she spoke with R1 and R1 said he was not hungry. V3 said she offered R1 an alternative meal, but he refused. V3 said R1 seemed tired like he wanted to sleep in. V3 said at lunch time she noticed R1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who require ADL (Activities of Daily Living) assistance received grooming cares. This applies to 5 residents (R31, R33, R61, R36 & R230) reviewed for ADLs in the sample of 31. 1. On 12/19/23 at 1:57 PM, R61 was observed in the hallway in her wheelchair with the hair on the back of her head matted. R61's electronic health records showed that she is an [AGE] year old female with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, age-related osteoporosis, Alzheimer's disease, non-suicidal self-harm, and major depressive disorder. R61's care plan 1/9/23 showed, Self-Care Deficit with impaired Dressing and Grooming abilities . keeping nails short with no more than Extensive Assist time 1 Staff 6-7 days weekly . Special Note for ADL Care: may have fluctuations in . normal day to day ADL Assistance and Staff Support Needs due to . Chronic Disease Process and/or any Acute exacerbations. The Restorative…

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 post isolation signs for Personal Protective Equipment (PPE), and failed to follow infection control guidelines for pericare, hand hygiene, and wound care. This applies to 5 residents (R3, R7, R31, R59, R230) reviewed for infection control practices in a sample of 31. The findings include: 1. On 12/19/23 at 1:32 PM, R3 was observed in his room with a personal protective equipment (PPE) box at the door side and no isolation posting/signage or stop sign at the door side to indicate the type of isolation and the PPEs visitors should wear to enter the room. R3's 11/21/23 Minimum Data Set showed he has severely impaired cognition. On 12/20/23 at 10:51 AM, there were still no signs showing staff and visitor to put on proper PPE (personal protective equipment) before entering the room. At 11:22 V8 (R3's sister-in-law) was observed going into R3's room without any PPE. At 11:50 AM, V8 stated, I visit R3 every day, and I took him to Bingo last Thursday, and nobody ever mentioned to me to wear a gown. I was told R3 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 observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications and obtain physician orders for residents' medication to be at the bedside. This applies to 2 residents (R31 & R68) reviewed for bedside medication in a sample of 31. Findings include: 1. On 12/19/23 at 10:20 AM, a cup containing 2 pills, 1 white and round, and 1 white and oval was observed on R31's bedside table next to a cup of water. R31 was in her bed asleep. At 11:39 AM the medications were observed gone and R31 said she thought she had taken the medications herself. On 12/21/23 at 9:21 AM, V2 DON (Director of Nursing) said that medication should not be left at the resident bedside and that no residents in the facility can administer medications by themselves. V2 said that residents should be assessed to see if they are competent before administering medication to themselves. V2 said that if medications are left at the bedside someone else can take the medications. R31's electronic record did not show an order for self-administration 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 have the call lights accessible to dependent residents. This applies to 2 of 2 residents (R9 and R36) reviewed for accommodation of needs in a sample of 31. The findings include: 1. On 12/19/23 at 10:41 AM, R9 was in bed asleep. R9 did not have a call light cord attached to the wall. R9 did not have any other methods of notifying staff of needing assistance. On 12/20/23 at 09:08 AM, R9 was in bed sleeping. R9 again did not have a call light cord attached to the wall, or any other methods of notifying staff of needing assistance. On 12/20/23 at 2:20 PM, R9 was in bed sleeping. R9 still did not have a call light cord or any other methods of notifying staff. R9's face sheet showed her dianoses include dementia, blindness, diabetes, weakness, congestive heart failure, hypertension, gait and mobility abnormalities, mixed conductive and sensorineural hearing loss. R9's MDS (MDS/Minimum Data Set) dated 12/05/23 showed R9 required…

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 a home-like environment for residents. This applies to one resident (R56) reviewed for homelike environment in a sample of 31. The findings include: On 12/19/23 at 10:53 AM, during the initial tour rounds, R56's floor was dirty, had food, candy on the floor by the bedside and the trash can was overflowing with garbage in the trash can and on the floor, there were several empty bottles of water. On 12/20/23 at 10:17 AM, R56's floor was still dirty with food and candy, and the trash can was still overflowing with garbage. R56 said she told housekeeping staff yesterday that her floors were dirty and that the trash can needed to be emptied, but the housekeeping staff did not show up yesterday nor this morning. R56 said that housekeeping staff does not come to their rooms everyday to clean or sweep the floors, and she does not have access to a broom so she can sweep. R56 said it does not feel like home to her and does not like it that…

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 prevent a resident-to-resident assault. This applies to two residents (R32 and R49) reviewed for abuse in a sample of 31. The findings include: On 12/19/23 at 2:06 PM, a scab was observed under R49's left eye near the bridge of his nose. R49 stated his previous roommate had punched him in the face. On 12/21/23 at 3:50 PM, V2 DON (Director of Nursing) stated R32 hit R49 in the face and the two residents were separated. R32 was moved to another room. R32 MDS (Minimum Data Set) dated 12/19/23 documents R32 has physical and verbal behavioral symptoms of aggression directed towards others. R32's behavior occurs one to three days per week. Nursing progress note for R49 dated 12/18/23 at 4:49 AM documents R49 being hit by R32. On 12/21/23 at 4:01 PM, V1 stated R32 and R49 were immediately separated and R32 was sent to the hospital for evaluation after the altercation. V1 stated the final report of resident-to-resident abuse will be completed on 12/22/23. The facility's initial report and submission of the incident…

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 observations, interviews, and record reviews, the facility failed to ensure medications were completely flushed through a gastrostomy tube, and failed to ensure alcohol was dry before obtaining a blood glucose value. This applies to 2 residents (R3, R72) reviewed for quality of care in a sample of 31. Findings include: 1. On 12/20/23 at 10:51 AM, V12 (Nurse) was observed preparing R3's medications for administration via R3's gastric tube (G-tube). V12 crushed up 6 medications and put them in individual cups: 81mg Aspirin, 10mg Lisinopril, 1mg Benztropine, 600mg Guaifenesin , 5000 IU Vitamin D 125mg, 20mg Baclofen V12 checked for placement in R3's G-tube and then began administering his medications. V12 was observed placing the crushed medications in the syringe, in its powdered form, then would add 20 to 25cc of water in the syringe. V12 did not dilute the medications with water prior to placing them in the syringe. V12 did this with all 6 of the medications. After V12 gave the last crushed medication,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents' toenails were cut, and failed to protect the feet of a resident with circulatory problems. This applies to 2 of 10 residents (R36, R49) reviewed for foot care in a sample of 31. The Findings include: 1. On 12/19/23 at 9:40 AM, R49 was observed ambulating with a walker and wearing non-skid socks. R49 was being escorted outside by V4 PTA (Physical Therapy Assistant) On 12/19/23 at 2:06 PM, R49 stated because of the bandages on his feet, his shoes did not fit. R49 stated the staff offered him double-socks to wear. R49 stated he was never offered any other footwear to accommodate his bandages. On 12/20/23 at 11:07 AM, V5 (Wound Nurse) stated R49 did not have any special equipment for his feet. At 11:36 AM, long and overgrown toenails and crusty white substance were noted on R49's feet and legs. On 12/20/23 at 11:45 AM, V6 (Wound Physician) stated he had not been informed that R49 was unable to wear his shoes with the…

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

Based on observation, interview and record review, the facility failed to ensure anti-contracture devices were applied as ordered. This applies to 1 resident (R72) reviewed for anti-contracture devices in a sample of 31. The findings include: On 12/19/23 at 10:18 AM, R72 was in bed. R72's left hand was closed and in a fist position. R72 was not wearing a hand splint. R72 said she wears a splint to her left hand when the staff applies it. On 12/20/23 at 08:53 AM, V14 (CNA/Certified Nursing Assistant/Restorative) said she did not apply left hand splint to R72 yesterday because she was busy doing weights. V14 said the floor CNAs can apply splints as well, but they did not apply it yesterday. V14 said R72 should have the splint applied every day due to the left-hand contracture. On 12/21/23 at 09:45 AM, V15 (Restorative LPN/Licensed Practical Nurse) said R72's PROM (Passive Range of Motion) and splint application is scheduled every day during morning care, between 6:30 AM -7:30 AM, prior to breakfast. V15 said R72's splint is removed before lunch, at 12 PM. V15 said she did not know why…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's room was free of trip hazards. This aplies to 1 of 31 residents (R69) reviewed for environmental risk in a sample of 31. The findings include: On 12/19/23 at 11:28 AM, surveyor tripped on broken floor tile in R69's room. The broken tile located in the pathway between R69's bed and bathroom door. R69 was observed standing from his wheelchair and unsteadily walking into the bathroom. R69's medical record shows he diagnoses of dementia, seizures, and weakness. R69's MDS (Minimum Data Set) dated 9/18/23 shows he has moderate cognitive impairment. R69 requires staff supervision / touch assistance with walking and transfers. On 12/20/23 at 1:51 PM, V3 Maintenance Director stated he was not aware of the broken tile. V3 stated he and V12 (Psychiatric Services Director / Social Services) are assigned to do guardian angel rounds on that unit. V3 stated he did not do his assigned rounding on the unit. V3 stated nursing staff are able to submit repair request through the computerized system or the…

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

Based on observation, interview, and record review, the facility failed to ensure sanitary storage/containment of respiratory equipment when not in use, and failed to ensure that a resident could use their BiPAP (Bilevel Positive Airway Pressure) as ordered by the physician. This applies to 2 of 2 residents (R42 and R56) reviewed for use of respiratory equipment in a sample of 31. The findings include: 1. On 12/19/23 at 10:45 AM, R42's BiPAP (Bilevel Positive Airway Pressure) machine was on the nightstand. The BiPAP mask was on top of the machine and not contained. On 12/20/23 at 09:09 AM R42's BiPAP mask was still on top of the BiPAP machine and not contained. R42 stated she is supposed to use the BiPAP machine every night but is currently not using it because the mask does not fit. R42 said she informed the nurses that the mask does not fit. On 12/21/23 at 01:15 PM R42's BiPAP mask continued to be on top of the machine and not contained. On 12/21/23 at 11:21 AM, V2 (DON) said all BiPAP masks while not in use should be in a plastic bag or some covering to prevent contamination. V2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to maintain temperature logs, label food items, and discard outdated food items. This applies to 2 residents (R10 & R6) reviewed for personal food storage in a sample of 31 residents. The findings include: 1. On 12/19/23 at 10:53 AM, R60 did not have a thermometer, or a temperature log for the personal refrigerator in the room. R60's refrigerator contained a pack of lunch meat that was opened and did not have a date on it. On 12/21/23 at 12:58 PM, R60's refrigerator still did not have a thermometer or a temperature log. The opened lunch meat continued to be not dated. R60's face sheet showed R60 was admitted to the facility on [DATE]. 2. On 12/19/23 at 12:15 PM, R10 did not have a thermometer, or temperature log for the personal refrigerator in the room. On 12/20/23 at 11:55 PM, R10's refrigerator still did not have a thermometer or a temperature log. R10's face sheet showed R10 was admitted to the facility on [DATE]. The facility's Refrigerator policy…

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 daily feeding tube site care. This applies to 2 of 3 residents (R2, R4) reviewed for feeding tubes in a sample of 17. Findings include: On 11/7/2023 at 12:10 PM, V2 (Director of Nursing) confirmed care and cleansing of the feeding tube site is completed daily and documented on the Treatment Administration Record (TAR). V2 stated if the care is not documented and signed off as completed on the TAR it is considered not done. 1. On 10/30/2023 at 1:30 PM, V5 (Nurse), provided R2's bolus feeding. R2's feeding tube did not have a dressing present and the skin surrounding the the feeding tube had moderate amount of dried drainage present. R2's Physician Order Summary Report dated 11/8/2023 documents R2 with an order dated 11/26/2022 to cleanse the feeding tube site and cover with a dressing every day. R2's September and October Treatment Administration Record does not document R2's feeding tube site care being provided every day as ordered. 2. On 10/30/2023 at 11:50 AM, R4's continuous tube feeding 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 prevent employee to resident mental abuse. This applies to 1 of 16 residents (R1) reviewed for abuse in a sample of 16. The findings include: R1's admission Record dated 11/3/2023 documents R1 was admitted on [DATE] with diagnoses to include major depression, cocaine dependence, opioid dependence, suicide attempt, self harm sharp glass, restless, agitation, violent behavior and anxiety. An Initial facility Incident Report, dated 10/26/2023, documents on 10/25/2023 V5 (Nurse) used inappropriate language in the presence of R1. On 11/1/2023 at 11:28 AM V2 (Director of Nursing/DON) stated, R1 had alleged she was raped early morning 10/25/2023, was transported to hospital, and returned a few hours later. After she returned, R1 was hallucinating and packing her bags saying she was leaving. Orders were received from a nurse practitioner for R1 to be directly admitted for a psychiatric evaluation. On 10/26/23 at 1:15 PM, R1 sat on her bed in her…

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 immediately report an allegation of abuse to the Administrator or designee. This applies to 1 of 16 residents (R1) reviewed for abuse reporting in a sample of 16. Findings include: The facility Abuse Prevention Program policy dated 1/2019 documents it is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This policy documents employees are required to immediately report any incident, allegation or suspicion of potential abuse or mistreatment they observe, hear about, or suspect to the Administrator. In the absence of the Administrator, reporting can be made to the DON (Director of Nursing). An Initial facility Incident Report, dated 10/26/2023, documents on 10/25/2023 V5 (Nurse) used inappropriate language in the presence of R1. On 10/26/23 at 1:15 R1 stated, .I just don't know if I feel safe though, they just started hollering at me. R1 said that the staff that cared for her the previous night just started hollering at her and…

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

Based on observation, interview, and record review, the facility failed to employ sufficient staff to carry out the functions of food service. This has the potential to affect all the residents who eat by mouth from the facility. The findings include: On 9/20/23 Facility data sheet indicated facility has 79 residents. Two of their residents are NPO (Nothing By Mouth) and do not consume food from the kitchen. On 9/20/23 surveyor entered the facility Kitchen at 10:56 AM. V5 (Cook), and V6 (Dietary Aide) were the only staff members working in the kitchen. The kitchen floor was not clean and a box of buttermilk biscuits was sitting directly on the floor. The freezer floor was noted with a box of scrambled egg mix sitting directly on the freezer floor. On top of the scrambled eggs, eleven boxes of food items were found stacked on top of each other. One box of ready-to-serve fresh-cut produce, fresh shelled eggs, another box of broccoli cuts were also sitting directly on the freezer floor. Three boxes of opened and unlabeled items were also directly on the floor. On 9/20/23 at 10:56 AM,…

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

Based on observation, interview, and record review the facility failed to ensure food on the menu was served as posted. This has the potential to affect all the residents who consume food from the facility kitchen. The findings include: The 9/20/23 Facility Data Sheet showed the facility census was 79 residents. Two residents are on NPO (Nothing by Mouth) status. On 9/20/23 surveyor entered the Facility Kitchen at 10:56 AM. On 9/20/23 at 10:56 AM, V5 (Cook) stated V11 (Kitchen Manager) is the supervisor he hasn't been here for a while. The facility's lunch menu for 9/20/23 showed Meatballs with Tomato Sauce, Spaghetti Noodles, Italian Blend Vegetables, Garlic Texas Toast, with Strawberry Blondies for dessert. Instead on 9/20/23 during lunch, the Kitchen served mashed potatoes, turkey stew, a bun, and apple sauce. On 9/20/23 at 11:00 AM, V5 (Cook) stated I don't have Meatballs and I don't have Strawberry Blondies .I have substituted turkey stew with mashed potatoes and applesauce. At 11:15 AM, V5 stated the food that is needed is not being ordered. V5 stated there was a food delivery…

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 a physician's medication order. This applies to 1 of 3 residents (R1) reviewed for medication administration. The findings include: R1's Face Sheet showed his diagnoses included anxiety disorder and violent behavior. R1's June 21, 2023 MDS (Minimum Data Set) showed R1 was moderately cognitively impaired. On August 11, 2023 at 9:38 AM, R1 stated that recently an agency nurse (V5) prepared some medication in a syringe and gave it to R1 under R1's tongue. R1 stated the resident in the same room with him (R2) received morphine for his pain. R1 stated the nurses had never given him any medication under his tongue before, so R1 asked the nurse what the name of the medication was. R1 stated the nurse told him it was morphine. R1 stated the morphine made him throw up twice and his bed was wet from the vomit. R1 stated he also felt some constipation for three or four days. R1 stated V5 does not work at the facility every day and he does not know her name. On 8/11/23 at 2:19 PM, V3 (Registered Nurse/Infection Preventionist)…

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 check for safe food temperatures and failed to provide palatable foods. This applies to 83 residents who receive meals from the kitchen. Three residents do not eat food from the kitchen due to receiving nutrition via a gastrostomy tube. Findings include: 1. On March 14, 2023, the food temperatures for lunch were not checked. On March 15, 2023, at 10:47 AM, the food temperature log was reviewed. During review, several dates were not filled out for breakfast and lunch, including February 27, 2023, February 28, 2023, March 1, 2023, March 2, 2023, March 4, 2023, March 5, 2023, March 7, 2023, March 8, 2023, March 9, 2023, and March 10, 2023. On March 15, 2023, at 10:55 AM, V7 (Cook) said he did not put the temperatures in the log and forgot to do it. On March 17, 2023, at 1:16 PM, V17 (Cook/Dietary Aide) said the cook was supposed to fill out the log and temperatures should be done because there is a risk for residents to get a foodborne illness. On March 17, 2023, at 9:27 AM, V16 (Dietician) said the food…

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 warm and clean environment. This applies to 8 residents (R241, R53, R46, R21, R240, R51, R32, and R66) reviewed for homelike environment in a sample of 25. The findings include: 1. On 3/14/23 at 11:37 AM, R241 was observed in her room wearing a t-shirt, sweater, winter coat and winter hat. R241 said she was cold and there is no heat in here. R241 had winter gloves laying on her bed and said she wears those when she gets really cold. On 3/14/23 at 3:00 PM, R241 was observed in the hallway wearing winter coat, hat, and gloves and said she was colder now than she was earlier. On 3/15/23 at 9:43 AM, R241 was observed in her room wearing a winter hat, gloves and a fleece coat. 2. On 3/14/23 at 11:07 AM, R53 was observed in her room wearing two nightgowns and said she was cold and that facility staff told her they were going to caulk around her window two weeks ago, but had not done that yet. On 3/15/23 at 9:36 AM, R53 was lying in bed with two nightgowns on and four blankets on top of her. R53 said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure privacy for residents by leaving residents' urinary catheter drainage bags in view of passersby. This applies to 2 of 2 residents (R13 and R23) reviewed for catheter care in a sample of 25. Findings include: 1. R13 is a [AGE] year-old female with mild cognitive impairment as per Minimum Data Set (MDS) dated [DATE]. On 3/15/23 at 2:07 PM, R13 was observed in her bed sitting at the bedside with an indwelling catheter drainage bag which was visible to roommates and visitors. 2. R23 is a [AGE] year-old male with moderate cognitive impairment as per MDS dated [DATE]. On 3/15/23 at 11:42 AM, R23 was observed in his bed with a urinary catheter drainage bag visible to his roommate and visitors. On 3/15/23 at 10:16 PM, V2 (Director of Nursing - DON) stated, We don't have any specific policy on privacy bag with urinary catheter bag. A privacy bag should be around the urinary catheter bag, especially with roommates.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow Physician Orders for a pressure ulcer treatment and failed to follow clean technique during pressure ulcer dressing changes. This applies to 1 of 2 residents (R9) reviewed for pressure ulcers in a sample of 25. Findings include: 1. R9 is a [AGE] year-old male with intact cognition as per Minimum Data Set (MDS) dated [DATE]. R9's March 15 2023 Order Summary Report showed his diagnoses included pressure-induced deep tissue damage of his left and right heels and showed to perform treatments to both wounds daily. On 3/14/23 at 1:40 PM, during wound care, R9 stated, The facility is not following the physician's order to change my left leg dressing daily. I am not getting a wound dressing change every day. I refused wound dressing change only one day, and that was because of the way the wound care nurse was interacting (rude) with me. R9's February and March Treatment Administration Record (TAR) showed R9's wound dressing changes were…

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

Based on observation, interview, and record review, the facility failed to obtain orders for providing PICC (Peripherally Inserted Central Catheter) line care, and failed to change a PICC line dressing. This applies to 1 of 1 residents (R66) reviewed for intravenous access care in a sample of 25. Findings include: On March 14, 2023, at 11:00 am, R66's left upper arm PICC line was dressed in gauze and clear transparent dressing. The dressing was dated 3/1/23 (13 days earlier). R66 stated his PICC line dressing should have been changed. R66's March 2023 Physician Orders showed a March 1, 2023 order for a PICC line insertion. On March 14, 2023, at 5:53 pm, Physician Orders were entered for PICC line dressing change to left upper extremity every day shift Tuesday and as needed (13 days after R66's PICC line was placed). On March 16, 2023, at 9:23 am, V2 DON (Director of Nursing) stated the RNs (Registered Nurse) do the central line dressing changes. V2 stated central line dressings should be changed every seven days and as needed, and stated R66's PICC line dressing should have 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to manage a resident's pain for a wound dressing change. This applies to 1 of 2 residents (R9) reviewed for pain management in a sample of 25. Findings include: R9 is a [AGE] year-old male with intact cognition as per Minimum Data Set (MDS) dated [DATE]. R9's March 15 2023 Order Summary Report showed his diagnoses included pressure-induced deep tissue damage of his left and right heels and showed to perform treatments to both wounds daily. On 3/14/23 at 1:23 PM, V3 (Wound Care Nurse) and V4 CNA (Certified Nursing Assistant) provided a left heel wound dressing change. R9 was not assessed for pain. V4 raised R9's left leg up and held it six inches above the mattress. V3 then removed the old dressing with drainage and cleansed the wound with wet gauze. R9 vocalized, it hurts .it hurts. V3 continued with the dressing change and did not ask R9 about his pain. On 3/14/23 at 2:15 PM, V3 stated, I didn't assess R9 for pain because I know he 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 interview and record review, the facility failed to document when a resident's narcotic pain medication was administered. This applies to 1 of 2 residents (R9) reviewed for pain medication administration in a sample of 25. Findings include: R9 is a [AGE] year-old male with intact cognition per Minimum Data Set (MDS) dated [DATE]. Record review on the narcotics log sheet indicates that 23 doses of Norco 10/325 milligrams were pulled from R9's locked narcotics box from 3/9/23 to 3/15/23. R9's March 2023 Medication Administration Record (MAR) showed that only three doses were documented as administered. On 3/16/23 at 11:20 AM, V2 (Director of Nursing - DON) stated controlled medications, including Norco, should be documented on the Narcotics log when they pull that medication from the Narcotics box, and then must be documented on the eMAR after administering it. The facility provided policy and procedure on Controlled Substance (undated) documents: Records shall be maintained by authorized nursing…

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.