Arcadia Care Morton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to have enough staff to answer call lights, provide showers, provide incontinent care, clean residents' rooms daily, and prevent falls. The facility also failed to accurately report the number of staff that worked on the daily staffing report and failed to update the Facility Assessment Tool with the number of staff needed. This has the potential to affect all 83 residents residing in the facility.Findings include:The facility's Midnight Census Report dated 12/29/2025 documents 83 residents reside at the facility.The Facility Assessment Tool for 08/2025 through 08/2026 documents Requirement: Nursing facilities will conduct, document, and annually review a facility wide assessment, which includes both their resident population and the resources the facility needs to carry for their residents. Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent falls, investigate one fall, notify the Physician and Residents Representative of two falls, and failed to put interventions in place for two falls for one resident (R19) of five residents reviewed for accidents in the sample of 21. Findings include:The Fall Prevention Program revised 05/2022 documents Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines: The Fall Prevention Program includes the following components: Use an implementation of professional standards of practice. Immediate change in interventions that were successful. Notification of physician, family/legal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions/EBP or perform hand hygiene during indwelling urinary catheter care for 1 resident (R9) of 3 residents reviewed for catheter care in the sample of 21. Finding include:The Urinary Catheter Care policy revised 09/2020 documents Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Guidelines: 1. Disposable one-time use gloves shall be worn when emptying urinary drainage bags and when performing perineal care. 2. Hand hygiene shall be performed before and after touching any part of the urinary catheter drainage system.The Enhanced Barrier Precautions policy revised 12/2025 documents Statement of Purpose: Enhanced Barrier Precautions (EBP): recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status.…

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

Based on record review and interview, the facility failed to document all complaints and/or concerns voiced in resident council meeting. This failure has the potential to affect all 82 residents that currently reside in the facility.Findings Include:The Facility's Resident Council policy dated 02/2025 documents The purpose of the Resident Council is to allow the residents the opportunity to express their thoughts and ideas in a safe and confidential manor. Additionally, the council serves to promote improvement and control concerning the quality of life at the facility.The Facility's Grievances policy dated 09/2017 documents The purpose is to ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnish, the behavior of staff and of other residents, and other concerns regarding their stay at this campus. Grievances maybe filed orally (meaning spoken), in writing, or anonymously. Every effort shall be made to resolve all grievance in a timely manner, usually within 5 business days. On 11/20/25 R4…

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 adequate housekeeping services to keep the facility clean and free of odors. These failures have the potential to affect all 85 residents residing within the facility. Findings include:The facility's Daily Census form, dated 8/18/25, indicates that 85 residents are currently residing in the facility.The facility's Housekeeper policy revised 7/2023 documents the primary purpose of the housekeeper is to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and/or the Director of Environmental Services, to assure that our facility is maintained in a clean, safe, and comfortable manner. Ensure that work/cleaning schedules are followed as closely as practical. Clean floors including sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting…

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 promptly provide medical care for a resident promptly after a decline in condition for one of five residents (R2) reviewed for change in condition in a sample of nine. Findings include:The facility's Hospice Services, dated 10/2024, documents Guidelines: the facility shall honor the advance directives and care alternatives residents may desire when terminally ill and to afford residents with care that allows for dignity and comfort during the end stage of their lives. 2. The resident's advanced directives will be honored in all aspects of Hospice services. 9. Facility licensed personnel will be responsible to notify the Hospice Service Coordinator in the event of a change in the Hospice residence condition and prior to transfer of resident to another facility including an acute hospital.R2's admission Record, dated [DATE], documents R2 admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Benign Prostatic Hyperplasia with…

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

Based on observation, interview, and record review the facility failed to serve food that was visually appealing and palatable to residents. This failure has the potential to affect 78 residents in the facility who are prescribed oral intake. Findings include: Facility Matrix documents 80 residents reside in the facility. Two residents require feeding tubes and do not eat. On 2/18/25 at 11:35am, the lunch meal plating of beef stroganoff, steamed zucchini and chilled pears was observed being served from the kitchen and delivered to the residents in the dining room. During the plating of the food, the pears were in a designated separate bowl. The steamed zucchini was plated without being drained on the same plate as the beef stroganoff, and a moderate amount of standing zucchini water/liquid was mixed with the beef stroganoff causing the plated food to look moderately watery and unappetizing. R37, R39, R43, R52, and R71 did not eat served lunch and requested grilled cheese as an alternative. On 2/19/25 at 10:32am, R22 stated he does not like the food that is served. On 2/19/25 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.

Based on observation, interview, and record review, the facility failed to ensure two large trash dumpsters are secured from pest and rodents, in that the lids of the trash dumpsters were not closed. This failure has the potential to affect all 80 residents residing in the facility. Findings include: Facility Policy, titled Trash Disposal, not dated, documents: The dietary department should dispose of trash appropriately and maintain the dumpster area for cleanliness and prevention of rodents. To prevent the spread of infection and deter pests and rodents. 2. The dietary department should ensure the dumpster lids are closed when disposing of trash and that no trash is on the ground surrounding the dumpster. The Department of Health and Human Services Centers for Medicaid and Medicare Services, Form 671-Long-Term Care Facility Application for Medicare and Medicaid, dated 2/18/25, documents 80 residents reside in the facility. On 02/19/25, at 11:01am, during follow-up tour, with V7/Regional Dietary Manager, the two trash dumpsters, located outside, had lids which were open, and one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to obtain a Pre-admission Screening and Resident Review (PASARR) and/or Level II Resident Reviews for three residents (R17, R32, R60) of six residents reviewed for diagnosed mental illness in the sample of 18. Findings include: The facility's Preadmission Screening and Annual Resident Review (PASARR) Policy dated 3/2024 documents: Annually and with any significant change of status, the facility will complete the PASARR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly. 1. R17 was admitted to the facility on [DATE]; R17 was diagnosed with Schizoaffective Disorder with diagnosis date of 2/4/23. R17 does not have a PASARR screening in her current electronic medical records, and there is no evidence that a PASARR was initiated at the time of R17's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the appropriate state mental health/intellectual disability authorities for newly diagnosed mental illness for two residents (R17, R60) of six residents reviewed for mental illness in the sample of 18. Findings include: The facility's Preadmission Screening and Annual Resident Review (PASARR) Policy dated 3/2024 documents: The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly. F. Coordination of Care: iv. The facility will refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for a level II review upon a significant change in status assessment to the State PASARR representative. 1. R17 was admitted to the facility on [DATE]; R17 was diagnosed with Schizoaffective Disorder on 2/4/23. 2. R60 was admitted to the facility on [DATE]; R60 was diagnosed with…

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

Based on observation, interview and record review the Facility failed to maintain intact right inner thigh and left inner ankle wound dressings for one Resident (R12) of 18 Residents reviewed for skin conditions in a sample of 30. Findings include: The Facility Skin Condition Assessment and Monitoring (Pressure and Non-Pressure) Policy, revised 6/2018, documents: to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented; non-pressure skin conditions will be assessed for healing progress and signs of complications or infection weekly; a skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission; dressings which are applied to wounds shall include the date of the licensed nurse who performed the procedure; the dressing will be checked daily for placement, cleanliness and signs/symptoms of infection; and a licensed nurse shall observe condition of wound incision daily, or with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an appropriate indication for use of antipsychotic medication for one of five (R83) with a diagnosis of dementia in a sample of 30. Findings include: The facility's policy titled Psychotropic Medication - Gradual Dosage Reduction, revised 2/2018 documents, To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice and are prescribed at the lowest therapeutic dose to treat such conditions. R83's admission Record documents that R83's date of admission to the facility was 11/25/24 and her diagnoses on admission include Dementia with other behavioral disturbance, Anxiety Disorder, Delusional Disorders, Depression, Dementia (mild) without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R83's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status…

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

Based on observation, interview and record review the facility failed to administer medications as ordered. There were 34 opportunities with eight errors resulting in a 23.53% error rate. This applies to one of seven Residents (R12) observed in the medication pass. Findings include: Facility Medication Administration Policy, revised 1/2025, documents: Licensed Nurse may prepare, administer and record administration of medications; documentation of medication administration is recorded on the Medication Administration Record; and medications must be administered in accordance with a Physician's order. R12's Medication Administration Details, dated 2/18/25, documents Physician Orders for medications to be administered at 8:00 am (Leftunomide 20 milligram/mg one tab by mouth; Glipizide 10 mg one tab by mouth three times a day; Furosemide 20 mg one tab by mouth; Lantus SoloStar 30 units Subcutaneous/SQ two times a day; Oxybutynin Chloride ER 10 mg one tab by mouth; MVI with minerals one tab by mouth; Omeprazole 40 mg one tab by mouth; and Lefluonomide 20 mg one tab by mouth). 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 perform hand hygiene after providing care, when removing contaminated gloves and touching contaminated gloves for one Resident (R51) and failed to follow their policy on Enhanced Barrier Precautions for two residents (R35, R64) of 18 reviewed for Infection Control in a sample of 30. Findings include: Facility Hand Hygiene/Handwashing Policy, revised 3/2023, documents: hand hygiene means cleaning your hands by using either handwashing with soap and water or alcohol based hand sanitizer; perform hand hygiene after direct contact with patient's intact skin, after contact with body fluids or excretions, mucous membranes, non-intact skin or wound dressings; after contact with inanimate objects, before glove placement and after glove removal. An Enhanced Barrier Precautions policy last revised 03/2024 documents, Enhanced Barrier Precautions (EBP): recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high contact resident care activities regardless of their…

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

Based on interview and record review, the facility failed to notify in writing, and maintain a copy in the medical record notification to the Ombudsman and resident/resident representatives of residents that were reviewed for notices before transfers. This failure has the potential to affect all 70 Residents residing in the Facility. Findings include: Facility Bed Hold and Return to Facility policy, revised 9/17/17, documents To ensure that residents and/or resident representatives are notified of a transfer from the facility. On 4/11/24 at 1:21 PM, V2 RN/Registered Nurse DON/Director of Nursing was unable to provide any documentation the Ombudsman or resident/resident representative was notified of resident transfers. On 4/12/24 11:08 AM, V15 SSD/Social Services Director stated I only notify the Ombudsman if residents discharge out of the building but not if they transfer to the hospital. I do not notify the resident/resident representative in writing of transfers. I did not know I needed to do that. Facility Application for Medicare/Medicaid, dated 4/9/24, documents 70 Residents…

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

Based on interview and record review, the facility failed to notify in writing, and maintain a copy in the medical record notification of the bed hold policy to the resident/resident representatives of residents that were reviewed for bed-holds. This failure has the potential to affect all 70 Residents residing in the Facility. Findings include: Facility Bed Hold and Return to Facility policy, revised 9/17/17, documents To ensure that residents and/or resident representatives are notified of the facility bed-hold policy and conditions for return to facility upon admission and at the time of a transfer from the facility. On 4/11/24 at 1:21 PM, V2 RN/Registered Nurse DON/Director of Nursing was unable to provide any documentation the resident/resident representative was notified of the bed-hold policy. On 4/12/24 at 11:00 AM, V2 DON stated We have told the staff to send the bed hold with the residents at the time of discharge. They are to make a copy and then it be put in the residents record but that has not been done yet. On 4/12/24 at 11:09 AM, V18 RN stated I have not documented…

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

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions. This has the potential to affect all 70 residents in the facility. Findings include: Facility Enhanced Barrier Precautions/EBP, revised 4/8/24, documents Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employees targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices, infection or colonization. Indwelling medical device examples include: Central lines, urinary catheters, feeding tubes, and tracheostomies. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. Facility provided a form, untitled and undated, documenting ten residents that consist of having wounds, feeding tubes, urinary catheters, ostomies, ESBL/Extended-Spectrum Beta-Lactamase Escherichia Coli and Klebsiella, and central lines. Facility email to…

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

Based on observation, interview, and record review the facility failed to ensure residents know who the Grievance Officer is, failed to provide a private area for resident council meetings, and failed to provide a response, action or rationale for Resident Council concerns for five (R17, R22, R34, R41, and R65) of five residents reviewed during Resident Council meeting in the sample of 31. Findings include: The facility's Grievance policy and procedure, revised 9/25/17, documents Purpose: To ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their status at this campus. Contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency, and State Long-Term Care Ombudsman program or protection and advocacy system shall be posted in prominent locations throughout the facility and/or provided to residents…

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 accurately code visual status for one (R12) of 20 residents reviewed for accurate resident assessments in a sample of 31. Findings include: On 4/9/24 at 9:30 AM, in R12's room above the head of R12's bed had a sign that documents (R12) is legally blind- please introduce yourself, place call light in resident's hand, and have bed controls in reach. At that same time, R12 stated he can see shadows but not details. R12's MDS/Minimum Data Set, dated [DATE], documents under Vision - Highly Impaired. R12's MDS/Minimum Data Set, dated [DATE], documents under Vision - Adequate. On 4/10/24 at 2:00 PM, V5 Licensed Practical Nurse/LPN verified R12 was visually impaired, and visitors needed to introduce themselves to the resident when entering the room. On 4/12/24 at 12:00 PM, V12 LPN Careplan Coordinator verified R12 was visually impaired, and should be documented as so on his MDS.

Based on observation, interview, and record review, the facility failed to develop a vision careplan for one (R12) of 20 residents reviewed for careplans in a sample of 31. Findings include: Facility Comprehensive Care Plan policy, revised 11/17/17, documents To develop a comprehensive careplan that directs the care team and incorporates the resident's services that are to maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 4/9/24 at 9:30 AM, in R12's room above the head of R12's bed had a sign that documents (R12) is legally blind- please introduce yourself, place call light in resident's hand, and have bed controls in reach. At that same time, R12's three drawer dresser next to his bed had a cassette in a tape player with headphones for books on tape, R12 stated he can see shadows but not details, and staff was observed in the room and heard identifying themselves and telling the resident where things are in his room and on his meal trays. On 4/10/24 at 2:00 PM, V5 Licensed Practical Nurse/LPN verified R12 was visually impaired and…

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

Based on observation, record review and interview, the facility failed to revise a Comprehensive Care Plan for two residents (R52, R62) of 20 residents reviewed for Care Plan revision in a sample of 31. Findings includes: The facility's Comprehensive Care Plan dated 11/17/17 documents: To develop a Comprehensive Care Plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan should be revised on an ongoing basis to reflect changes for the resident and the care that the resident is receiving. 1. The current Care Plan for R52 documents R52 is oxygen dependent continuously. The Order Summary Report…

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

Based on observation, interview, and record review the facility failed to ensure shower and nail care were performed for one (R125) of two residents reviewed for activities of daily living in the sample of 31. Finding include: The facility's Certified Nursing Assistant policy and procedure, dated 5/2/2017, documents The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential duties and responsibilities include: Provide assistance in personal hygiene by giving bedpans, urinals, baths, backrubs, shampoos, and shaves; and assisting with travel to the bathroom; helping with showers and baths. Document actions by completing forms, reports, logs, and records. The facility's Bathing-Shower and Tub Bath policy and procedure, revised 1/31/18, documents To ensure resident's cleanliness to maintain proper hygiene and dignity. A shower, tub bath or bed/sponge bath will be offered according to resident's preference two times per week or according to the…

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

Based on observation, interview, and record review the facility failed to have orders for indwelling catheter care and to record catheter output for two (R12 and R275) of five residents reviewed for indwelling catheters in a sample of 31. Findings include: Facility Urinary Catheter Care policy, revised 2/14/19, documents To establish guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. Routine hygiene (cleansing of the meatal surface during daily bathing or showering) is appropriate. Catheter drainage bags will be emptied one time on each shift. 1. On 4/09/24 at 2:19 PM, R12 was in bed with his catheter on the right side of the bed draining clear amber urine. At that same time, R12 stated he has had his catheter for a while. On 4/10/24 at 2:00 PM, and 4/11/24 at 10:30 AM, R12's catheter was at the side of bed draining clear amber urine. On 4/12/24 at 9 AM, R12 was up in a reclining chair with his catheter at the edge of the reclining chair draining clear amber urine. R12's current Order Summary Report, dated 4/11/24, has no orders 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 observation, interview and record review the Facility failed to perform hand hygiene, wear proper Personal Protective Equipment/PPE (N95 masks, gowns, face shields and gloves), failed to keep garbage and linen off the floor, failed to keep COVID positive room doors closed; failed to follow dining room tray procedures, failed to have accessible PPE available for isolation rooms, and failed to have dedicated isolation waste disposal receptacles available. This failure has the potential to affect all 76 Residents residing in the Facility. Findings include: Facility Linen Handling, revised 12/28/21, documents To ensure the proper handling of linens and to prevent the spread of infection. Every effort will be made to ensure that soiled articles do not come into contact with the floor. Facility Infection Control Interim COVID-19 Policy revised 7/24/23, documents: to educate staff on current infection control and standard precautions and proper Personal Protective Equipment/PPE selection, use, donning/doffing…

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 toilet paper for R8, clean hallways on B wing affecting R1, R2, R3, R4, R7, and R8, clean resident rooms for R7 and R8, and ensure housekeepers were hired and in the facility for six of nine residents reviewed for a clean environment in a sample of ten. Findings include: Facility Isolation Room Cleaning-Housekeeping, revised 1/19/18, documents Collect all trash and put in a garbage bag. Clean and disinfect room, and mop room. Facility Housekeeping Supervisor, dated 3/23/17, documents The primary purpose of the housekeeper is to perform day to day activities of housekeeping to assure that our facility is maintained in a clean, and comfortable manner. Clean, wash, sanitize, and/or polish fixtures, ledges, room heating/cooling units, bathroom fixtures, etc. Clean floors to include sweeping, dusting, damp/wet mopping and disinfecting. Discard waste/trash into proper containers and reline trash receptacle with plastic liner. Facility…

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

Based on observation, interview, and record review, the facility failed to answer call lights in a timely manner. This failure had the potential to affect all 77 residents residing within the facility. Findings include: The facility's Call light policy, dated 2/2/18, documents, Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered. Procedure: Answer light (signal) promptly. The facility's Resident Council minutes, dated 3/2/23, documents, Nursing-Call lights are not being answered in a timely matter. The facility's Resident Council minutes, dated 5/4/23, document, Nursing: Call lights not being answered in a timely manner. On 9/11/23 at 2pm, flooring had been removed on the A hallway for rooms 11-18 (R11-R14, R21-R25) The doorway of each room had tape across the door, and the contracted workers 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 maintain a clean comfortable homelike environment. These failures had the potential to affect all 77 residents residing within the facility. Findings include: The facility Housekeeper Cleaning Checklist, no date but provided by V18 (Housekeeping Supervisor) documents, Each task is to be initialed when completed. Checklist is to be turned into supervisor at the end of each shift with the date and signature on bottom of page. Sweep and mop floor in resident room. Every room is to be swept and mopped daily. Windowsill and top of air conditioning unit is to be wiped off. Any linen that is not at the foot of the bed is to be taken to the soiled utility room. The facility's Housekeeping Cleaning Schedule, no date, documents, Purpose: To establish a schedule which ensures the building and equipment is maintained in a clean and sanitary manner. All items may be cleaned more frequent if necessary. Daily: Resident room floors; Lobbies and hallways; Front entry; Corridors (spray buff twice a week). Weekly: Air…

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 provide sufficient staff to care for dependent residents. This failure has the potential to affect all 77 residents residing in the facility. Findings include: The facility Assessment Tool, dated 6/7/23, documents, Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Staff: Licensed Nurses providing direct care: Day shift: 3, Night shift 2. CNA (Certified Nursing Assistants), Restorative Aides providing direct care: Day shift: 6-8, Evening shift: 6-8, Night shift: 4. The facility's Resident Council minutes, dated 3/2/23, documents, Nursing-Call lights are not being answered in a timely matter. The facility's Resident Council minutes, dated 5/4/23, document, Nursing: Call lights not being answered in a timely manner. On 9/11/23 at 8:50 a.m., one nurse and three CNAs were working on each side of the facility. One CNA was also assigned to care for a 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, interview, and record review, the facility failed to have a staff member dedicated to the Infection Preventionist role. This had the potential to affect all 77 residents residing in the the facility. Findings include: On 9/11/23 at 8:50 a.m., the facility's main entry door held a sign stating that the facility had COVID-19 positive cases within the facility. The facility's COVID-19 Resident Line Listing, no date provided by V1 Administrator on 9/11/23, documents that R3 tested positive for facility acquired COVID-19 on 8/22/23, and R6 tested positive on 8/24/23. The facility COVID-19 Staff Line Listing, no date provided by V1 on 9/11/23, documents that V12 (Certified Nursing Assistant) tested positive for facility acquired COVID-19 on 8/30/23. During this survey, 9/11, 9/13, 9/14, 9/18, and 9/19/23, no dedicated Infection Preventionist was present within the facility. On 9/13/23 at 8:35 a.m., V1 stated, We do not have an Infection Preventionist in the facility at this time. Our last Infection Preventionist quit 9/6/23. The Centers for Medicare and Medicaid…

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 respect a resident's dignity by providing adult incontinent briefs for eight of eight residents (R7, R8, R9, R11, R15, R16, R18, R19) reviewed for dignity in the sample of 32. Findings include: The facility's Dignity policy, dated 4/23/18, documents, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's lifestyle and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. The state Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, no date available, documents, Your rights to dignity and respect: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your…

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

Based on observation, interview, and record review, the facility failed to ensure the resident mechanical lifts were maintained in a safe operating condition. This had the potential to affect all 19 residents (R2, R3, R7-R18, R28-R32) who require the use of a mechanical lift for transfers in the sample of 32. Findings include: The facility's Transfers-Manual Gait Belt and Mechanical Lifts policy, dated 1/19/18, documents, In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents. Guidelines: Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Mechanical lift equipment shall undergo routine maintenance checks by the nursing and maintenance staff to…

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

Based on interview and record review the facility failed to prevent misappropriation of property for 7 residents (R1, R2, R3, R4, R5, R6, and R7) of 9 reviewed for misappropriation of property in the sample of 11. The Findings include: Abuse Prevention and Reporting policy dated 11/28/2016, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, 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 observation, interview and record review the facility failed to ensure residents were provided with a dignified dining experience for nine of 84 residents (R54, R22, R36, R31, R58, R62, R15, R64, R82) reviewed for dignity while dining in a sample of 84. Findings include: A Dignity policy dated 4/23/22 states, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality, and Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. A Dining Room Standards policy (undated) states, The community will ensure that an attractive, cheerful dining room is maintained with comfortable sound, lighting, furnishings, temperature and adequate space. On 11/28/22, 11/29/22, 11/30/22 between 11:15a.m. to 12:30p.m. R31, R22, R36, R15, R64, R54 were seated in their wheelchairs in the hallway outside their rooms lined up one in front of the others with tray tables placed in front of each 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 observation, record review and interview, the facility failed to provide ROM (Range of Motion) programming for residents with limited ROM, for four of 11 residents (R13, R76, R39, R74) reviewed for limitations in ROM, in a sample of 30. Findings include: The facility policy, titled Passive Range of Motion Exercises (no date), documents 1) Residents will be assessed for their need of passive range of motion (PROM) per the functional Limitation in Range of Motion assessment. 2) If the resident is recommended for a PROM program, trained nursing staff will provide the range of motion exercises as outlined under Range of Motion Technique. 3) Active Range of Motion (AROM) is provided when the resident performs the movement and the staff provides instructions on range completion. Active Assistive Range of Motion (AAROM) is provided when the muscle is too weak to complete the entire range and resident and staff work together. Passive Range of Motion (PROM) is provided by the staff with no assist form the resident. The facility policy, titled Restorative Nursing Program (revised…

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 The facility's failures resulted in two deficient practice statements. Based on observation, record review and interview, the facility failed to provide feeding and dressing assistance to one of two residents (R13) reviewed for Activities of Daily Living, in a sample of 30. Findings include: The Electronic Medical Record documents R13 has the current diagnoses of Cerebral Infarction, Lack of Coordination and Spastic Hemiplegia affecting the Right Dominant Side. Minimum Data Set assessments, dated 7/01/22 and 9/30/22, document R13 requires the physical assistance of one person while eating and extensive assistance of two staff for dressing. A Plan of Care, dated 9/30/22, documents (R13) has an (Activities of Daily Living) self-care performance deficit (related to) history of Cerebral Infarction resulting in right dominant side spastic hemiparesis and instructs staff under Eating: (R13) requires supervision, set up, and assist with task. On 11/28/22, at 1:23 pm and at 3:02 pm, R13 was sitting up in bed wearing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure abnormal blood glucose readings were reported to the physician and clarify hospital medication discharge instructions for a resident with Type II Diabetes Mellitus, for one of six residents (R39) reviewed for Insulin administration , in a sample of 30. Findings include: The facility policy, titled Physician/Family Notification - Change in condition (revised 11/13/18), documents Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient and effective manner. The policy further documents that the facility staff are to notify the Physician or Nurse Practitioner when there is A need to alter treatment significantly (i.e., a need to discontinue and existing form of treatment due to adverse consequences, or to commence a new form of treatment). The Electronic Medical Record documents R39 was admitted to the facility on [DATE] with the diagnosis 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 observation, record review and interview, the facility failed to ensure staff supervised a resident with Dysphasia (difficulty swallowing) while eating, for one of four residents (R13) reviewed for supervision in a sample of 30. Findings include: The Electronic Medical Record documents R13 has the current diagnoses of Dysphagia following Cerebral Infarction and Spastic Hemiplegia affecting the Right Dominant Side. Minimum Data Set assessments, dated 7/01/22 and 9/30/22, document R13 requires supervision for eating. A Plan of Care, dated 9/30/22, documents (R13) has an (Activities of Daily Living) self-care performance deficit (related to) history of Cerebral Infarction resulting in right dominant side spastic hemiparesis and instructs staff under Eating: (R13) requires supervision, set up, and assist with task. The Plan of Care also instructs staff to Monitor/document/report (as needed) any (sign/symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. A Nurses…

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 urinary drainage tubing from an indwelling catheter was not secured to a leg band and failed to ensure an indwelling catheter drainage bag was in a dignity bag for one of two residents (R57) for indwelling catheters in a sample of 30. Findings include: The facility's Urinary Catheter Care Policy revised 2-14-19, documents, Indwelling catheters may be secured to prevent trauma and tension. According to R57's Electronic Face Sheet R57 has diagnoses of Traumatic Brain Injury, Quadriplegia, Aphasia, Hemiplegia of left side, pressure ulcer of sacral region, infection and inflammatory reaction due to indwelling urethral catheter, Epilepsy and Schizophrenia. R57's MDS/Minimum Data Set assessment dated [DATE], documents R57 has severely impaired cognition, requires extensive assist of two staff for bed mobility for ADL's/Activities of Daily Living, has Functional limitation in Range of Motion on both sides of upper and lower extremities,…

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 a therapeutic diet with supplements as ordered for one of three residents (R62) reviewed for nutrition in a sample of 30. Findings include: A Diet Orders policy (undated) states, Each resident will have a diet order prescribed by the physician (or Registered Dietitian where allowed by State and Federal Guidelines) and documented in the health Record. A Nutritional Intervention Program policy (undated) states, Residents identified as needing additional nutrition interventions will be started on the NIP (Nutritional Intervention Program) Program. This policy states that residents to be included in the program have had a significant weight loss over one, three or six months; have had a significant change in food intake or had a significant weight change upon readmission. In addition, this policy states interventions to address residents' nutritional needs include adding health shakes, double portions, supplemental foods such 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.