Monmouth Rehab And Nursing

Based on interview and record review, the facility failed to ensure medical records were accurately documented with resident assessments for one of twelve residents (R48) reviewed for accurate documentation in a sample of 28.Findings include:The Charting and Documentation policy revised 11/5/19, documents medical record entries shall be made by the person providing or supervising/observing the service being documented. Narrative documentation/progress notes will be documented under the premise of charting by exception. It is anticipated that all routine care and services will be delivered within established standards of professional practice and regulatory guidance and may not be reflected in the medical record. Documentation will include information on assessment, notifications, interventions and evaluation including but not limited to incidents/accidents, change in condition, physician notification, responsible party notification, refusal of medication/treatment or recommendations, education provided, status updates/summaries as required. Transfer, discharge or leave of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure hospice communication was coordinated and the required documents were available and accessible to the facility staff for one resident (R6) reviewed for hospice care management in a sample of 28. Findings include:The Hospice Care policy revised 8/25/25, documents the facility will work in coordination with the contracted hospice agency to provide a safe continuum of care for the resident's end of life. The Hospice agency will participate in the residents' plan of care and provide services/supplies outside the general as needed procedures and be available 24 hours a day.R6 was admitted on [DATE] with diagnoses of Venous Insufficiency, Alzheimer's Disease, Dementia and Dysphagia. R6 elected Hospice Benefits on 9/24/25.R6's current Care Plan lacked specific Hospice responsibilities/interventions or that R6 was utilizing a self-adjusting and alternating pressure mattress.The Hospice binder located at the nurse's station included a Hospice Plan 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.

Based on interview and record review, the facility failed to ensure Influenza and Pneumococcal immunizations were offered to three of five residents (R6, R17, R37) reviewed for immunization compliance in a sample of 28.Findings include: The Influenza Vaccine policy revised 10/10/25, documents all residents will be given information on the importance of adult immunizations. Prior to administration each resident or resident's legal representative shall receive education regarding the risks, benefits and potential side effects of the immunization. Evidence of education is to be documented on the individual resident's medical record. Consent form must be signed prior to administration by the resident or responsible party after reviewing the vaccination information statement. The resident or responsible party may revoke consent by providing facility with a request in writing. Verbal consent is acceptable.The Pneumococcal Vaccination policy revised 10/28/24, documents prior to administration each resident or resident's legal representative shall receive education regarding the risks,…

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 COVID-19 vaccinations were offered to three of five residents (R6, R17, R37) reviewed for immunization compliance in a sample of 28.Findings include:The COVID-19 Vaccination policy dated 7/15/21, documents all residents are to be offered the COVID-19 vaccine unless the immunization is medically contraindicated. Residents and/or Residents Representatives are provided with education regarding the benefits and risks and potential side effects associated with vaccine. The medical record includes documentation that indicates the resident or resident's representative was provided education and accepts or refuses the vaccination.1.R6's immunization record does not document the COVID-19 vaccination was administered or refused.R6's Universal Vaccine Consent Form- Long-Term Care Facility signed by the resident's representative on 10/17/25, does not specify that vaccine information was given to the resident's representative nor the name of which vaccine is being consented for.2. R17's immunization record documents COVID-19…

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 maintain complete and accurate clinical records for two residents (R3, R5) of three reviewed for documentation out of a sample list of six.Findings include:The facility's Charting & Documentation Policy revised 11/5/2019. The purpose of this policy is to maintain a medical record to serve as a legal document that details the services provided to the residents, or any changes in the residents' medical or mental condition, through charting and documentation. Documentation will include information on assessment, notifications, interventions and evaluation including but not limited to: Incidents/ Accidents, Change in Condition, Physician Notification and Responsible party, education provided to resident and or responsible party.1. R5's electronic medical record contained no Nurse Progress Note or assessment regarding R5's elopement from the facility on 1/5/26.R5's care plan was updated on 1/6/26 for wander guard placement, and physician orders dated 1/6/26 documented the wander guard was placed. However, there was no…

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 a resident's rights were maintained for one of three residents (R2), reviewed for resident rights, in sample of 5. Findings include: The (undated) facility Resident Rights for People in Long Term Care Facilities form documents, As a long-term care resident in (State), you are guaranteed certain rights, protections and privileges according to state and federal laws. Your rights to safety: You must not be abused, neglected or exploited by anyone- physically, financially, verbally, mentally or sexually. Your facility must be kept safe, clean, comfortable and homelike. R2's current Minimum Data Set Assessment, dated 5/21/25 documents, Section C-Cognitive Patterns: 13:15 (Cognitively intact). R2's Nursing Progress Notes, dated 3/12/2025 at 9:38 P.M. document, (R2) was sitting in her room and (R1) entered (R2)'s room and was seen having a shoe in her hand and it appeared that (R1) struck (R2) on the shoulder. No injuries were noted, (R2) stated that she was not hurt but was fearful of (R1). R2's Nursing Progress Notes,…

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 protect two of two residents (R2 and R5) from physical abuse by another resident (R1), in a sample of five. FINDINGS INCLUDE: The facility policy, Resident Right to Freedom from Abuse, Neglect and Exploitation, dated October 16, 2023, directs staff, The facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation. The facility shall review altercations from resident to resident as a potential situation of abuse. Staff shall monitor for any behaviors that may provoke a reaction by residents or others which include Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects. 1. The facility form, Physical Aggression, dated 3/12/2025 at 6:50 P.M., documents, Staff member reported that when she entered (R2)'s room, she saw (R1) strike (R2) on the shoulder with a shoe. (R1) was redirected back to her room. (R1) was experiencing increased agitation and demanded that her daughter…

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 its abuse policy of immediately reporting abuse to the State Agency and investigating an allegation of resident-to-resident physical abuse for two separate occurrences, for three of three residents (R1, R2, and R5) reviewed for abuse in the sample of 5. Findings include: The facility policy, Resident Right to Freedom from Abuse, Neglect and Exploitation, dated October 16, 2023, directs staff, When the facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: Taking steps to prevent further potential abuse; Reporting the alleged violation and investigation within required timeframe's pursuant to Federal and State statutes and regulations; Conducting a thorough investigation of the alleged violation. 1. The facility form, Physical Aggression, dated 3/12/2025 at 6:50 P.M., documents, Staff member reported that when she entered (R2)'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 interview and record review, the facility failed to ensure two allegations of abuse were immediately reported to the State Agency for three of three residents (R1, R2, and R5) reviewed for abuse in the sample of 5. Findings include: 1. R2's Nursing Progress Notes, dated 3/12/2025 at 9:38 P.M. document, (R2) was sitting in her room and (R1) entered her room and was seen having a shoe in her hand and it appeared that (R1) struck (R2) on the shoulder. No injuries were noted and (R2) stated that she was not hurt but was fearful of (R1). POA (Power of Attorney), Administrator, MD (Medical Doctor) were all notified. On 6/30/2025 at 11:48 A.M., V1/Administrator confirmed the incident on 3/12/25 when R1 hit R2 with a shoe. V1 confirms that the incident was a potential abuse incident but states she did not do an abuse investigation nor notify the State Agency of a potential abuse incident. 2. R1's Nursing Progress Notes, dated 6/27/2025 at 9:37 A.M., document, (R1) was noted to be sitting in wheelchair with oxygen on self-propelling around nurses station area. When another resident…

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 and record review, the facility failed to investigate two allegations of abuse for three of three residents (R1, R2, and R5) reviewed for abuse, in the sample of 5. Findings include: The facility policy, Resident Right to Freedom from Abuse, Neglect and Exploitation, dated October 16, 2023, directs staff, When the facility has identified abuse, the Facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. The Facility will increase enforcement action, including, but not limited to: Conducting a thorough investigation of the alleged violation. 1. The facility form, Physical Aggression, dated 3/12/2025 at 6:50 P.M., documents, Staff member reported that when she entered (R2)'s room, she saw (R1) strike (R2) on the shoulder with a shoe. On 6/30/2025 at 11:48 A.M., V1/Administrator confirmed the incident on 3/12/25 when R1 hit R2 with a shoe. V1 confirms that the incident was a potential abuse incident but states she did not do an abuse investigation. 2. R1's Nursing Progress Notes, 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 implement fall precautions for one of three residents (R1), reviewed for falls, in a sample of 5. Findings include: The facility policy, Fall Reduction policy, dated (revised) November 5, 2019, directs staff, Purpose: To provide an environment that remains as free of accident hazards as possible. To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. Residents with a Fall Risk Assessment score greater that 10 should be considered to be at high risk for falling. Identified risk factors should be addressed in the resident's Care Plan to assure individualized interventions to reduce the risk are implemented. R1's facility admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Paroxysmal Atrial Fibrillation, Unsteadiness on Feet, Dementia, Anxiety, Chronic Respiratory…

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 date and store oxygen equipment as ordered for two of three residents (R1 and R4) and failed to administer oxygen at the prescribed rate for (R4), reviewed for oxygen, in a sample of 5. Findings include: The facility policy, Oxygen Administration and Storage, dated (revised) March 8, 2022, directs staff, To ensure staff follow safety guidelines and regulation for storage and use of oxygen. Verify provider's order for the procedure. Turn on oxygen and set flow rate to prescribed amount. Label the tubing connected to the oxygen cylinder with time and date. The nasal cannula or mask should be changed weekly or when soiled. Nasal cannula should be stored in a manner to prevent touching the floor when not in use. The humidifier bottle is to be labeled with the date of application and changed weekly if refillable. 1. R1's facility admission Record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Paroxysmal…

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 an entrapment assessment for bedrails prior to bedrails being applied to a bed as a fall intervention for one (R1) of three residents reviewed for bed rail assessments out of a sample list of three. Findings include: The facility's Side Rail Assessment Policy revised 11/5/24 documents bedrails are considered restraints; this includes full and half bed rails. The only time a bed rail can be used in the facility is after an evaluation for appropriateness and a Side rail assessment has been completed prior to applying bedrails. Consideration for the resident's cognitive ability to understand the use of bed rails also needs assessed. If determined side rails are appropriate the maintenance needs to determine prior to application that side rails are compatible with the bed and that safety is not compromised. On 6/17/25 at 9:30 AM, R1 was lying in R1's bed with R1's eyes closed. Metal half rails are up on side of the bed. R1's current…

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 These failures resulted in two deficient practices. A. Based on record review and interview the facility failed to provide adequate supervision to prevent two cognitively impaired residents from exiting the facility without staff supervision for two of three residents (R4 and R7) reviewed for elopements in the sample of seven. B. Based on record review and interview the facility failed to implement two staff for transfers as indicated in the resident's plan of care to prevent falls for one of three residents (R2) reviewed for falls in the sample of seven. Findings include: A. The facility's Elopements Policy dated 12/2007 documents, It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. 1. R4's MDS (Minimum Data Set) assessment dated [DATE] documents R4 is severely cognitively impaired. R4's Elopement assessment dated [DATE] documents,(R4) is cognitively impaired and independently mobile. (R4) has a desire to leave the facility 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 record review and interview the facility failed to ensure that resident's met the standards for infections for 2 residents (R4 and R23) and the facility failed to have standards in place for residents who were experiencing infection symptoms but did not meet the standards to be infections. The facility also failed to educate health care providers about Antibiotic Stewardship. This failure has the potential to affect all 40 residents who reside in the facility. Findings Include: The Facility's undated The Core Elements of Antibiotic Stewardship for Nursing Homes documents Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven Core elements which are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to provide appropriate indication for use of antipsychotic medications, attempt gradual dose reductions, and limit the use of as needed psychotropic medications to 14 days for four of five residents (R5, R16, R19, R26) reviewed for unnecessary medications in a sample of 26. Findings include: The facility's policy titled Psychotropic Medication Use, reviewed 01/2017, documents, Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. Residents who are admitted from the community or transferred from the hospital and who are already receiving psychotropic medications will be evaluated for the appropriateness and indications for use. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or…

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

Based on record review and interview the facility failed to allow one resident (R11) to choose her own doctor of 12 residents reviewed for choices in a total sample of 26. Findings Include: The Illinois Long-Term Care Ombudsman Residents' Rights for People in Long Term Care Facilities documents You have the right to choose your own doctor. R11's Nurse's Notes dated 7/21/24 at 5:45 PM documents Resident told this nurse that she did not want to be seen by (V10/Doctor) any longer. On 12/19/24 at 8:45 AM R11 confirmed that she did not want (V10) as her doctor. I just don't care for him. R11 stated I have told them (facility staff) but (V10) still comes to see me. I don't like him. On 12/19/24 at 9:00 AM V4 (Social Service Director) confirmed that all residents can pick their own doctor and that no one had notified V4 that R11 wanted to switch doctors.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents electronic medical records and care plans matched the Physician's Order for Life-Sustaining Treatment (POLST) for Cardio-Pulmonary Resuscitation (CPR) code status for three of five residents (R4, R6, R22) reviewed for Advanced Directives in the sample of 26 residents. Findings include: The Advanced Directives policy reviewed 2/2021 documented the facility will gather information about whether or not the resident has executed an advanced directive and place this information in the medical record. The plan of care for each resident will be consistent with the resident's treatment preferences and/or advanced directives. The resident has the right to refuse treatment and will not be treated against his or her own wishes. If the resident or representative refuses treatment, the facility will document specifically what the resident is refusing. Advanced directives are written instructions for healthcare relating to the provisions of health…

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

Based on record review and interview the facility failed to report an in injury of unknown origin to the state reporting agency for one resident (R192) of two reviewed for accidents in a total sample of 26. Findings Include: The Facility's Abuse,Prevention and Prohibition policy dated 2021 documents The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. such reports may also be made to the local law enforcement agency in the same manner. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the administrator. The person made aware of allegations of abuse or neglect or the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than 2 hours after the allegation is made if the events that cause the allegation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document the assessment for a resident receiving hospice services in the Minimum Data Set (Minimum Data Set/MDS-a federally mandated assessment) for one of two residents (R3) reviewed for hospice services in the sample of 26 residents. Findings include: The MDS/Minimum Data Set documented R3 was admitted on [DATE] with the diagnoses of Traumatic Brain Injury, Mood Disorder, Anxiety Disorder, Dementia and Major Mood Disorder. A physician's order dated 3/27/23 ordered to admit R3 to hospice services. R3's record included a notice of admission to hospice services effective 3/27/23. The care plan dated 9/27/24 documented R3 had hospice services. The quarterly MDS dated [DATE] and 9/27/24 Section O 0110: Special Treatments, Procedures, and Programs documented R3 was not on hospice services. On 12/18/24 at 1:45 PM, V5 (Licensed Practical Nurse/LPN, Care Plan/MDS Coordinator) stated R3 elected hospice services on 3/27/23 and currently remained on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure hospice coordinated communication and the plan of cares were available and accessible to facility staff. This deficiency affects two of two residents (R3, R29) reviewed for Hospice care services in the sample of 26 residents. Finding include: The Hospice service agreements documented a copy of the plan of care will be furnished to the facility at the time of admission and when updated, of all cares provided, physician orders, election of benefits form, advanced directives, physician certification and recertification of terminal illness, a list of names and contact information for hospice personnel and hospice medication information specific to each hospice patient. 1. R3's admission Record documented R3 was admitted to the facility on [DATE] with diagnoses of intracranial injury with loss of consciousness, mood disorder, anxiety disorder and dementia. An active physician's order to admit R3 to hospice was dated 3/27/23. The Hospice…

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 four of four Certified Nurse Aides/CNA reviewed (V17, V18, V19, V20) in a total sample of four completed the required 12 hours of education per year. This failure has the potential to affect all 41 residents residing in the facility. Findings include: The Facility Assessment 2024-2025 documented the facility cares for residents with associated dementia symptoms, such as Parkinson's disease, Alzheimer's disease and residents with Psychiatric/Mood Disorders, The Facility Assessment documented Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training. Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurse aids providing services to individuals with cognitive impairments, also address the…

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

Based on interview and record review, the facility failed to ensure an allegation of neglect was reported to the State Agency for one of three residents (R1) reviewed for neglect in the sample of three. Findings include: The facility's Abuse, Prevention and Prohibition Policy (reviewed 2021) documents the following: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator. The person made aware of allegations of abuse or neglect or the Administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. If the event that caused the allegation do not involve abuse and do not result in serious bodily injury, these will be reported to the Administrator immediately and to State Survey Agency no later than 24 hours. On…

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

Based on observation, interview and record review, the facility failed to ensure staff hair was covered during the plating of food, while in the kitchen, and failed to date opened food items, to ensure use before expiration. These failures have the potential to affect all 39 residents currently residing in the facility. FINDINGS INCLUDE: The facility policy, Personal Hygiene and Appearance Nutrition Services, dated (revised) January 2018, directs staff, To support food safety practices and to maintain compliance with Federal, State and Local regulations governing food safety. Hair nets or hair coverings shall be worn while in the kitchen or storage areas. The facility policy, Dietary Food Storage, dated November 2007, directs staff, All food shall be stored according to regulatory guidelines governing food safety and sanitation and within established facility guidelines, as follows: Leftovers shall be labeled and dated. On 11/20/23 at 9:34 A.M., during a tour of the facility kitchen, with V3/Dietary Manager a five-pound plastic container of opened potato salad (approximately 1/2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for the use of an indwelling urinary catheter, side rails, the diagnosis of Diabetes Mellitus with the use of Insulin, antidepressants, and anticoagulants for five of 14 residents (R6, R11, R32, R35, R36) reviewed for care plans in the sample of 45. Findings include: The facility's Comprehensive Person-Centered Care Plans policy, dated 2016, documents, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The facility's Using the Care Plan policy, dated 2006, documents, The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. The facility's Proper Use of Side Rails policy, dated 1/2017, documents, The use of side rails as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide Active and Passive Range of Motion programming for residents with limited range of motion for two of two residents (R3, R6) reviewed for functional limitations in range of motion in the sample of 45. Findings include: The facility's Resident Mobility and Range of Motion policy dated 07/2017 documents, Resident with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 1. R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 has a limitation in ROM (Range of Motion) to one lower extremity. This same MDS documents R3 has not…

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

Based on observation, interview, and record review, the facility failed to ensure an indwelling urinary catheter drainage bag was kept below the level of the bladder and off the floor for one of two residents (R35) reviewed for indwelling urinary catheters in the sample of 45. Findings include: The facility's Urinary Catheter Care, dated 2014, documents, The purpose of this procedure is to prevent catheter associated urinary tract infections. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Be sure the catheter tubing and drainage bag are kept off the floor. R35's Physician's orders, dated 11/20/23, document that R35 has an order for a 16 French 10 milliliter indwelling urinary catheter. On 11/20/23 at 09:54 AM, R35 was sitting up on a shower chair in his bathroom following a shower. V6 and V10 (Both CNAs-Certified Nursing Assistants) were dressing R35. R35's indwelling urinary catheter drainage bag was lying on the floor next to R35's shower chair.…

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 attempt less restrictive interventions, obtain an informed consent, obtain a physician order, and perform a risk of entrapment assessment for the use of side rails for one of one resident (R11) reviewed for side rails in the sample of 45. Findings include: The facility's Proper Use of Side Rails policy, dated 1/2017, documents, The use of side rails as an assistive device will be addressed in the resident care plan. Less restrictive interventions that will be incorporated in care planning. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. The risks and benefits of side rails will be considered for each resident. Consent for side rail will be obtained from the resident or representative. On 11/20/23 at 11:28 AM, R11 was alert sitting up in her recliner. R11's 1/2 side rail was in an upright position on the right side of R11's bed. R11 stated, They just put that on my bed. I didn't ask for it. I don't use it for anything but to clip my…

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

Based on interview and record review, the facility failed to develop a Dementia plan of care for one of two residents (R35) reviewed for Dementia care in the sample of 45. Findings include: R35's electronic diagnoses, dated 11/21/23, documents that R35 has the diagnosis of Vascular Dementia. R35's Current Care plan, printed 11/20/23, has no documentation of a comprehensive care plan addressing R35's diagnosis of Vascular Dementia. On 11/22/23 at 10:17 AM, V7 (Care plan Coordinator) confirmed there is no Dementia plan of care for R35.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document a diagnosis and target behaviors to warrant the use of an antipsychotic and perform behavior monitoring for two of two residents (R4, R35) reviewed for antipsychotics in the sample of 45. Findings include: The facility's Psychotropic Medication Use policy, dated 1/2017, documents, Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Tourette's Disorder; e. Huntington Disease. Diagnoses alone do not warrant the use of psychotropic medication. The staff will observe, document, regarding the effectiveness of any…

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 speech therapy services to one of one resident (R35) reviewed for specialized therapy services in the sample of 45. Findings include: The Facility Assessment, dated 8/31/23, documents, Services and Care Offered: Therapy-PT (Physical Therapy), OT (Occupational Therapy), Speech/Language, Respiratory, Music, Art, management of braces, splints. On 11/20/23 at 10:08 AM, R35 was alert sitting up in his bed. R35 had a gastrostomy tube capped off coming from his stomach. R35 stated, I don't like the ground meat or the thickened liquids. They are awful! I'm supposed to be getting speech therapy, but the lady is never here. So how am I supposed to get better. R35's Swallow Study, dated 7/7/23, documents, Today R35 reports that he has had a g-tube for about a year following a CVA (Cerebrovascular Accident). Patient/caregiver concerns: Patient would like for his diet to be upgraded. Therapy Diagnosis: Oropharyngeal Dysphagia. Medical Diagnosis: Dysphagia. R35 referred to Speech Therapy with deficits noted…

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.