Loft Rehab & Nursing Of Normal

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to answer call lights in a timely fashion for three of three residents (R2, R7, R10) reviewed for call lights in the sample list of eleven.Findings Include:Grievance logs dated October 2025, November 2025 and December 2025 all document residents having to wait extended times for help with various activities.Resident Council Minutes dated 12/3/25 document 13 residents attended the meeting and documented staff need to answer call lights quicker.R2's Medical Record reviewed 12/30/25 documents R2 admitted to the facility on [DATE] from a local hospital with Diagnoses of Weakness, Right Sided Hemiparesis, Cognitive Decline, B12 Deficiency, Back Pain, Right Lower Extremity Pain, Microscopic Hematuria, Diabetes Mellitus, Hypertension, Hyperlipidemia, Cerebral Vascular Accident, and Multiple Sclerosis. R2's medical record does not contain an admission assessment or admission note from a licensed nurse from time of arrival until discharge. On 12/30/25 at 10:20am…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide showers for three (R1, R3 and R6) of five dependent residents reviewed for activities of daily living out of a sample list of eleven.Findings Include:R1's current Medical Record documents R1's admission to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis Right Ankle and Foot, Weakness, Chronic Atrial Fibrillation, and Chronic Kidney Disease Stage Four. R1's Care Plan includes a focus regarding ADL deficits initiated 04/11/2025. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact.On 12/30/2025 at 9:42 AM R1 stated he received a bed bath last night with water staff retrieved from another area of the facility. R1 stated he had not received a shower or bed bath for approximately two weeks prior to last night's bed bath. R1 described his bed bath water as lukewarm. R1 stated the hot water has not been working for a couple of months and that the lack of hot water is the entire uptown hall. R1 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were complete and accurate for four of four residents (R1, R2, R6, R9) reviewed for documentation in the sample list of eleven.Findings Include:On 12/30/25 R2's Medical Record review of Hospital Notes documents R2 admitted to the facility on [DATE] (unknown time) from a local hospital with Diagnoses of Weakness, right sided hemiparesis, Cognitive Decline, B12 Deficiency, Back Pain, Right Lower Extremity Pain, Microscopic Hematuria, Diabetes Mellitus, Hypertension, Hyperlipidemia, Cerebral Vascular Accident, and Multiple Sclerosis. The facility medical record does not contain an admission assessment or admission note with a time of arrival from a licensed nurse from time of arrival until discharge later on 11/24/25. On 12/30/25 at 10:20am V4, R2's Family, stated that R2 was not seen or assessed by a nurse while being in the facility for five hours and wanted to leave. V4 stated V4 arranged for a transport to another local nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of three residents (R8 and R9) reviewed for abuse in the sample list of eleven.Findings Include:On 12/30/25 the facility provided an investigation file dated 12/2/25 documenting a physical incident occurred between two roommates/residents (R8, R9). The file documents staff responded immediately, intervening to stop the interaction and separate the residents.R8's Current Care Plan reviewed on 12/30/2025 documents R8's admission to the facility on 5/1/2025 with the following diagnoses: Metabolic Encephalopathy, Protein-Calorie Malnutrition, Anemia in Chronic Kidney Disease, and Dementia in other Diseases, Moderate, with Agitation.R8's Minimum Data Set, dated [DATE], documents R8 with a brief interview for mental status score of 14 indicating R8 is cognitively intact. R8's Care Plan dated 06/27/2025 addresses wandering without purpose and wandering into other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was properly supervised to prevent a fall for one (R3) of three residents reviewed for accidents on a sample list of five. Findings include:R3's Minimum Data Set (MDS) dated [DATE] documents that R3 was not able to complete the Brief Interview for Mental Status (BIMS) due to cognitive impairment.R3's admission fall risk assessment dated [DATE] documents R3 is at risk for falls.R3's Care Plan dated 10/23/25, documents that R3 is at risk for falls related to dementia, side effects of medication and a terminal condition.R3's Care Plan dated 10/30/25, documents that R3 is an elopement risk/wanderer related to R3 is disoriented to place and has impaired safety awareness.R3's progress notes document that on 11/20/25 at approximately 6:00 AM R3 was observed on the floor in R3's room.On 11/25/25 at 12:40 PM, V18 Certified Nurse Assistant (CNA) stated V18 sat right outside of R3's room the night of her unwitnessed fall. V18 stated V18 went on…

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

Based on interview and record review the facility failed to ensure a resident was kept free from a significant medication error for one (R3) of three residents reviewed for medication management on a sample list of five residents. Findings include:R3's Electronic Medical Record (EMR) contained a physician's order dated 10/22/25 documenting that R3 was to receive Haloperidol (HALDOL) two milligrams (mg)/ milliliter (ml) concentrate, take one ml by mouth every eight hours for agitated movements accompanied by emotional distress. R3's physician orders in R3's EMR dated 10/22/25 document an order for Haloperidol Lactate Oral Concentrate two mg/ml, give two ml by mouth every eight hours for agitation/restlessness.R3's October and November 2025 Medication Administration Record (MAR) documents that R3 received seventy-three incorrect doses of Haloperidol. R3's EMR contains a letter dated 11/20/25 documenting that V2 Assistant Director of Nursing (ADON) reported R3's Haloperidol medication error to Physicians Group. This letter documents that R3 was lethargic that day. On 11/25/25 at 12:02…

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

Based on observation, interview, and record review the facility failed to follow their pest control policy for four residents (R3, R5, R12, R13) reviewed for Pest Control in the sample list of 15 residents. On 7/24/25 at 12:38 PM V6 Housekeeper stated V6 has seen roaches in the hallways and resident rooms, which started around March or April, and is most prominent on the Downtown [NAME] hallway.On 7/24/25 at 1:18 PM V8 Certified Nursing Assistant stated over the past year V8 has noticed roaches on the walls in hallways and resident rooms, mostly on the downtown west hallway.On 7/24/25 at 1:08 PM R3 attempted to enter R3's room. V3 Licensed Practical Nurse redirected R3 away from his room and told him his room was just sprayed. R3's room and R5, R12, R13 had the doors closed with signs posted on the door indicating the room had been sprayed with pesticide treatment and required ventilation until 4:16 PM. At 1:11 PM R12 stated he has had a couple of roaches on the floor in his room. V3 stated V3 noticed bugs in the facility starting in October, and V3 has seen bugs in R12, R13, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow physician's orders for administration of eye drops for one of three residents (R3) reviewed for hygiene in the sample list of 15 residents.On 7/24/25 at 9:18 AM R3 was sitting in a wheelchair. R3's eyes were red with a small amount of yellow/white matter on the lower lids. R3 rubbed his eyes with his hands. At 1:03 PM R3's eyes had a small amount of matter on the lower lids.R3's Minimum Data Set, dated [DATE] documents R3 has severe cognitive impairment. R3's active diagnoses list includes ectropion of right and left lower eyelids (drooping of eyelids).R3's Progress Note, recorded by V12 Nurse Practitioner, dated 4/10/25 documents R3 continues to have ectropion and chronic blepharitis (inflammation) to bilateral eyelids, Systane Complete ophthalmic solution ordered, continue current management.R3's active Physician's Orders include an order dated 4/1/25 for Systane Complete Ophthalmic Solution apply one drop to each eye twice daily.…

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

Based on interview and record review the facility failed to follow their infection prevention, response, and reporting policy following a newly identified Covid positive resident. This failure has the potential to affect all residents who reside in the facility. Findings Include: The 5/6/25 facility Census document 108 residents reside at the facility. R7's current diagnoses list includes the following diagnoses: Repeated Falls, Malignant Neoplasm of Prostate, COVID-19, Pain in Unspecified Joint, Abnormalities of Gait and Mobility, Type 2 Diabetes Without Complications, Chronic Atrial Fibrillation, Lack of Coordination, Colostomy, Hyperlipidemia, Vitamin C Deficiency. R7's progress note dated 4/14/2025 at 11:16 AM documents (R7) Tested positive for Covid; Power of Attorney here and was notified. Stated family member had tested positive and helped resident move in facility (4/11/25). R7's progress note dated 4/14/2025 at 11:33 AM documents Fax sent to (APN/Advanced Practice Nurse) to report Covid positive results; chest congestion, cough. R7's progress note dated 4/14/2025 at 11:37…

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 document complete accurate assessments for one resident (R7) of three residents reviewed for documentation in a sample list of eight residents. Findings Include: R7's current diagnoses list includes the following diagnoses: Repeated Falls, Malignant Neoplasm of Prostate, COVID-19, Pain in Unspecified Joint, Abnormalities of Gait and Mobility, Type 2 Diabetes without Complications, Chronic Atrial Fibrillation, Lack of Coordination, Colostomy, Hyperlipidemia, and Vitamin C Deficiency. R7's progress note dated 4/11/25 at 7:30 PM documents R7 was admitted from the hospital emergency room following a fall at the assisted living facility where he lived on 4/11/25. R7's Nursing assessments on 4/11/25 and 4/12/25 do not indicate R7 was having any respiratory symptoms and documents R7 as negative for respiratory signs and symptoms. There are no head-to-toe assessments or respiratory assessments documented on 4/13/25, 4/14/25, or 4/15/25. R7's Electronic Medical record census report documents R7 left for the hospital 4/15/25. R7'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 the timeliness of laboratory services as ordered by a physician for one (R4) of one resident reviewed for laboratory services on the sample list of three. Findings include: The After Visit Summary (AVS) dated 7/25/24 documents R4 was diagnosed with a kidney stone. The same AVS documents that on 7/19/24 R4 was admitted to the hospital and underwent bilateral Percutaneous nephrolithotomy (PCNL) for removal of bilateral staghorn kidney stones. The same AVS documents that on 7/25/24 at 12:18 PM R4 was discharged from the hospital and returned to the facility. On 7/25/24 Discharge Instructions were printed and document an Inpatient AVS (After Visit Summary) was (Printed 7/25/2024). The AVS documents a 48-hour urine is to be collected two weeks after the operative procedure and sent to the laboratory under the discharge instructions. Two weeks postoperative is August 2, 2024, for the 48-hour urine collection date to start. The AVS also documents instructions for the facility to collect a urine culture in one month and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to revise care plans for two (R4 and R7) of three residents reviewed for care plan revision from a total sample list of 10 residents. Findings include: The facility provided Care Plan Revisions Upon Status Change Policy dated 1/25/23 documents that the comprehensive care plan will be reviewed and revised as necessary when a resident experiences a status change. 1.) R4's census sheet documents admission to the facility on [DATE]. R4's Minimum Data Set, dated [DATE] documents that R4 is cognitively intact. R4's Minimum Data Set, dated [DATE] documents that R4 requires a wheelchair for mobility. The facility provided transport schedule documents that R4 was transported on the following dates: 1/9/25, 1/23/25 and 1/28/25. On 2/3/25 at 9:40AM, R4 stated that due to her size and inability to wear shoes, she was unable to keep her feet on the pedals of the transport wheelchair, resulting in R4 sliding down in the wheelchair during transport. 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 assess for elopement risk, document the rational for application of an elopement notification bracelet, and re-apply an elopement notification bracelet after readmission from the hospital for one (R6) of three residents reviewed for elopement from a total sample list of ten residents reviewed. Findings include: The facility Elopement and Wandering Residents Policy revised 5/6/2024 documents that the facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazard and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. R6's current medical diagnosis record dated 2/4/24 documents R6 has Vascular Dementia, Repeated Falls, Panic Disorder, Depression and Parkinson's Disease. R6's Minimum Data Set (MDS)…

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

Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination of ice, failed to prevent the potential for physical cross-contamination of food, and failed to maintain sanitary food service equipment (sink) and floor areas. These failures have the potential to affect all 87 residents residing in the facility. Findings include: 1. On 10/6/2024 at 8:53AM, dark colored mildew growth was located inside of the dietary service ice machine along multiple sections of the plastic evaporator skirt. On 10/8/2024 at 2:10PM, V15 (Regional Dietary Manager) was present and reported the facility maintenance department was responsible for cleaning the machine. 2. On 10/6/2024 at 8:40AM, the kitchen three-basin sink sewer pipe was continuously dripping into a metal pan located on the floor below the sink. The pan was one-fourth full of discolored and opaque water. On 10/8/2024 at 1:31PM, the pipe leak and pan remained the same as above. 3. On 10/6/2024 at 8:41AM, the flooring surfaces throughout the dish line area of the kitchen were sticky…

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 permanently affix a narcotic lock box in a medication room for three of three residents (R68, R72, R40), reviewed for medication storage in the sample list of 41. Findings include: 1.) R68's Order Summary dated 10/9/24 documents an order for Morphine Sulfate (Concentrate) Oral Solution 20 mg (milligrams)/ml (milliliters) (Morphine Sulfate), give 0.25 ml by mouth every 6 hours as needed for pain with a start date of 6/2/2024. 2.) R72's Order Summary dated 10/9/24 documents an order for Morphine Sulfate Oral Solution 20 mg/ml give 0.25 ml by mouth every 6 hours as needed for pain, SOB (shortness of breath) with a start date of 7/03/2024. 3.) R40's Order Summary dated 10/9/24 documents an order for Morphine Sulfate ER (extended release) Oral Tablet 15 mg, give 1 tablet by mouth every 12 hours for pain with a start date of 8/26/2024. 4.) R40's Order Summary dated 10/9/24 documents an order for Hydrocodone/Acetaminophen 5/325 mg oral tablet, give 1 tablet by mouth every 8 hours as needed for Pain - Severe with a…

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

Based on interview and record review, the facility failed to ensure arbitration agreements provide for the selection of an arbitration venue convenient to both parties. This failure has the potential to affect three residents (R83, R137, R187) of five reviewed for arbitration agreements on the sample list of 48. Findings include: On 10/9/2024 at 12:06 PM, V3 (Social Services Director) reported R83, R137, and R187 all signed arbitration agreements upon admission to the facility. The facility arbitration agreements signed by R83 on 8/16/2024, R137 on 9/29/2024, and R187 on 8/30/2024 do not include any language providing for the selection of an arbitration venue convenient to both parties. The contract documents the arbitration will occur in the county where the facility is located unless the parties mutually agree otherwise.

Based on observation, interview, and record review, the facility failed to maintain homelike room conditions for a resident room. This failure affects one resident (R61) of 24 reviewed for clean, comfortable, homelike environment in the sample list of 48. Findings include: On 10/6/24 at 10:05AM, R61 was resting in bed. Large areas of wallpaper above R1's headboard were peeling free from the wall surface. Multiple sections approximately 4 in width were torn free from the wall surface and dangling from the wall. A section of paper approximately four feet tall was curling free from the wall. On 10/9/2024 at 12:36PM the wall remained as above. R61 was present and reported the wall had been in disrepair since R61 admitted to the facility. V18 (Certified Nurse Aide) was present and reported R61's bed had been positioned too high and was hitting the wall. R61's census sheet (printed 10/9/2024) documents R61 first began living in R61's current room on 3/23/2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for a hearing-impaired resident (R73). This failure impacts one of one resident reviewed for impaired hearing in the sample list of 41. Findings include: On 10/07/24 at 10:23 AM R73 observed sitting in his room at the bedside without the television on, looking around. R73 stated I need my hearing aids, I can't hear. On 10/07/24 at 10:25 AM R12 stated R73 cannot hear, and staff must talk loud to him. On 10/07/24 at 10:27 AM V9 and V10 Certified Nursing Assistants stated R73's hearing aid broke a day or 2 after the resident admitted . On 10/08/24 at 11:47 AM V13 Certified Nursing Assistant stated there is a white board at the bedside the staff use to communicate with R73. V13 then shows white board and uses it to communicate with R73 to introduce surveyor to resident. On 10/08/24 at 1:24 PM V14 Care Plan Coordinator confirmed R73's care plan does not address R73's hearing…

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 complete pressure ulcer treatments as ordered and failed to implement pressure relieving interventions for two of two residents (R138, R142) reviewed for pressure ulcers in the sample list of 41. Findings include: 1.) R138's Order Summary dated 10/7/24 documents diagnoses including Malignant Neoplasm of Prostate, Secondary Malignant Neoplasm of Brain, Secondary Malignant Neoplasm of Bone, Traumatic Subdural Hemorrhage with Loss of Consciousness Status Unknown and Pressure Ulcer of Sacral Region. This Order Summary documents an order dated 9/12/24 for the Unstageable pressure wound due to Necrosis of the Sacrum, cleanse with normal saline, pat dry, apply thin layer of medical honey to the wound bed, cover with a bordered gauze dressing, change daily and as needed. This Order Summary also documents an order for pressure relieving boots to the bilateral lower extremities when in bed to offload pressure, document non-compliance every shift with a start date of 9/12/24. On 10/6/24 at 9:26 AM, R138 was in bed in his…

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

Based on observation, interview, and record review the facility failed to check placement of a Gastrostomy tube (g-tube) prior to administering medications and prior to administering feeding for one of one resident (R138) reviewed for Gastrostomy tubes in the sample list of 41. Findings include: R138's Order Summary dated 10/7/24 documents diagnoses including Unspecified Protein-Calorie Malnutrition, Pneumonitis Due to Inhalation of Food and Vomit, Dysphagia, Metabolic Encephalopathy, Malignant Neoplasm of Prostate, Secondary Malignant Neoplasm of Brain, Secondary Malignant Neoplasm of Bone and Traumatic Subdural Hemorrhage with Loss of Consciousness Status Unknown. R138's Order Summary dated 10/7/24 documents an order for nothing by mouth with a start date of 9/4/24. This Order Summary documents orders to flush the enteral tube with 30 milliliters of water pre/post medication administration and 5-10 milliliters of water between each medication with a start date of 10/1/24. This Order Summary also documents an order to flush the enteral tube with 125 milliliters of water before and…

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

Based on observation, interview, and record review the facility failed to place a resident in Enhanced Barrier Precautions for one of 24 residents (R142) reviewed for infection control in the sample list of 41. Findings include: R142's Nurses Note dated 10/3/24 documents R142 has a pressure ulcer on R142's Coccyx with Serosanguineous drainage. On 10/6/24 at 2:35 PM, R142 was in her room and there was no Enhanced Barrier Precaution (EBP) sign posted on her door or near her door. On 10/7/24 at 10:07 AM, V4 Registered Nurse and V5 Certified Nursing Assistant entered R142's room to complete the pressure ulcer dressing change. V4 and V5 did not don a gown prior to completing the dressing change. V4 and V5 had to open R142's incontinence brief to complete the treatment and R142's pressure ulcer was open and greater than a stage 1 pressure ulcer. On 10/7/24 at 10:47 AM, R142's room does not have an EBP sign on the door and there is no indication that staff should don PPE prior to providing care. On 10/8/24 at 12:47 PM, V19 Infection Preventionist confirmed that residents with pressure…

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 safeguard one (R1) resident personal bank account entrusted to facility for billing purposes by withdrawing money from R1's account without R1's permission. This failure affects one (R1) out of three residents reviewed for resident funds in a sample list of four residents. Findings include: R1's Electronic Medical Record (EMR) documents R1 was admitted to facility on 10/18/2023 and discharged from facility on 8/19/24. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1's Automatic Payment Authorization Agreement dated 3/6/2024 documents the facility has the authority to withdraw $6,673.44 monthly from R1's personal banking account. R1's Durable Power of Attorney (DPOA) for Finances dated 1/26/2023 documents V3 as R1's designated DPOA for finances. The facility untitled document dated 9/13/24 documents a refund of $6,673.44 to R1's personal debit card. On 9/13/24 at 12:00 PM V4 Business Office Manager (BOM) stated R1 did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a clean and homelike environment. This failure affects 36 residents (R4 through R39) reviewed for environment cleanliness on the sample of 39. Findings include: On 8/16/24, during a general environmental tour beginning at 10:05 AM and concluding 11:45 AM, environmental conditions including all of the following were noted. room [ROOM NUMBER]-bathroom floor was noted with heavy accumulations of ground in dirt and debris extending out from the floor to wall junction approximately six inches. The ground in dirt could be rubbed off with a piece of dry toilet paper. The surface of the vinyl flooring was worn to the point that the manufactured printed finish was worn through, and the dull gray underlying material was visible, creating a slippery surface. There were heavy scuff marks and worn off paint on the bathroom doors and radiant heater cover. Behind the head of bed number 2, there was a section of wallpaper approximately 24 inches…

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 document timely and specific actions following receipt of resident grievances. This failure has the potential to affect all 85 residents in the facility. Findings include: Facility Resident Council Minutes (8/2/2023) document resident concerns of CNA's (certified nurse aides) on phones. Facility Resident Council Minutes (9/6/2023) do not document any resolution of the above concern beneath the Old Business section of the minutes where staff indicate whether or not resident concerns were resolved satisfactorily. On 9/19/2023 at 1:41 PM, V3 (Activities Director) reported the facility did not document the required investigative process the facility used to investigate the grievance, a summary of pertinent findings or conclusions regarding the concern, a statement about whether the facility substantiated the allegation or not, or the date a written decision was issued for the resident complaint of CNA's on phones. The facility Resident/Family Grievance Policy and Procedure policy (1/1/2020) documents: All grievances,…

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 sanitary kitchen pantry floor areas. This failure has the potential to affect all 85 residents in the facility. Findings include: On 9/17/2023 at 8:17AM, the kitchen pantry where dry goods, canned goods, and single service items were stored for resident use floor areas were excessively soiled and had accumulations of tape, cardboard, dishes, drinking straws, plastic wrap, and single serve condiments. Dark accumulations of grease and dirt were accumulated along the pantry baseboards and lower portions of food storage racks. On 9/18/2023 at 10:15AM, the pantry remained as above. On 9/20/2023 11:28AM, the pantry areas remained as above. V10 (Dietary Manager) was present and reported dietary staff will clean the floors. The facility Resident Census and Conditions of Residents report (9/17/2023) documents 85 residents reside in the facility.

Based on interview and record review, the facility failed to complete required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 85 residents in the facility. Findings include: On 9/19/2023 at 1:59PM, V1 (Administrator) provided two QAA attendance sheets (April and July 2023) for the previous year's QAA meetings. V1 reported being unsure if the facility had completed additional QAA meetings during the previous year. The facility Quality Assurance and Performance Improvement (QAPI) policy (12/2/222) documents: The Quality Assessment and Assurance (QAA) Committee shall be interdisciplinary and shall meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. The facility Resident Census and Conditions of Residents report (9/17/2023) documents 85 residents reside in the facility.

Based on interview and record review, the facility failed to document resident infections and antibiotic treatments as required, failed to ensure antibiotic prescriptions were limited to residents meeting nationally recognized surveillance criteria, and failed to document residents' responses to antibiotic therapy. This failure affects R23, R27, R62 and has the potential to affect all 85 residents in the facility. Findings include: The facility's Antibiotic Stewardship Program policy with a revision date of 12/22/22 documents the following: The Infection Preventionist coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. Reassessment of empiric antibiotics is conducted after 2-3 days for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. Monitoring of antibiotic use. The facility antibiotic stewardship binder (January-September…

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 employee a full time Infection Preventionist per the Facility Assessment. This failure has the potential to affect all 85 residents who reside at the facility. Findings Include: The Facility assessment dated [DATE] documents the facility will have a full time DON (Director of Nursing), ADON (Assistant Director of Nursing), MDS (Minimum Data Set)/Care Plan Coordinator, and Infection Preventionist Nurse, all separate positions. On 9/25/23 at 11:20 AM, V1 Administrator stated V2 DON was the Infection Preventionist until taking over as DON on 8/28/23, so V2 is currently doing both jobs, as the facility does not have a separate Infection Preventionist. V1 confirmed the Facility Assessment documents the Infection Preventionist and DON will be separate positions. The Facility Resident Census and Conditions of Residents Form dated 9/17/23 documents there are 85 residents who reside at the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely complete comprehensive MDS's (Minimum Data Set's) for four of 44 residents (R40, R139, R17, R48) reviewed for resident assessments on the sample list of 47. Findings Include: The facility Resident Assessment Policy dated 9/12/19 documents the facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS (Centers for Medicare and Medicaid Services). 1. R40's ongoing Census documents R40 was admitted to the facility on [DATE]. As of 9/18/23, R40 does not have a completed comprehensive MDS (Minimum Data Set). On 9/18/23 at 12:43 PM, V11 MDS/Care Plan Coordinator confirmed R40's Comprehensive admission MDS has not been completed yet and stated, it should be completed within 14 days after admission. 2. R139's ongoing Census documents R139 was admitted to the facility on [DATE]. As of 9/18/23, R139 does not have a completed…

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 comprehensive care plans to include a urinary catheter, antidepressant medication, anticoagulant medication, CPAP (Continuous Positive Airway Pressure), and seizure disorder for four (R64, R1, R20, R37) of 18 residents reviewed for care plans in the sample list of 47. Findings include: 1.) On 9/17/23 at 8:23 AM R64 had a urinary catheter that was draining clear yellow urine. R64 stated the facility replaces R64's catheter monthly and as needed, and R64 has had one urinary tract infection since R64 admitted to the facility. R64's Minimum Data Set (MDS) dated [DATE] documents the use of an indwelling urinary catheter. R64's Order Summary Report dated 9/17/23 documents an order dated 6/14/23 for size 18 french indwelling urinary catheter, check placement/functioning every shift, and replace as needed. R64's Nursing Note dated 5/16/2023 at 9:27 PM documents R64's admission summary including that R64 admitted to the facility with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise comprehensive care plans to reflect the resident's current needs/condition and failed to conduct care plan meetings with residents and resident representatives for four of 44 residents (R40, R72, R78, and R75) reviewed for care plan revisions and meetings on the sample list of 47. Findings Include: The facility's Care Planning, Resident Participation Policy dated 9/12/19 documents the facility supports the resident's right to be informed of and participate in his or her care planning and treatment. The facility will notify the resident and/or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care. The facility will encourage and assist the resident and/or resident representative to participate in choosing care and treatment options. In the case of a resident who has impaired decision-making ability, the facility will,…

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 tube feeding at the ordered rate, timely follow up and implement dietitian recommendations for tube feeding rate and water flushes, document routine checks of tube feeding placement and residual volumes, and record tube feeding, and water flush volumes administered for one (R286) of two residents reviewed for gastrostomy tubes in the sample list of 47. Findings include: On 9/17/23 at 9:13 AM and at 12:19 PM R286 was lying in bed with Osmolite 1.0 cal infusing at 76 ml/hr. On 9/17/23 at 12:19 PM V13 Registered Nurse stated R286's feeding rate should be 75 ml/hr and not 76 ml/hr. At this time V13 adjusted R286's tube feeding rate from 76 ml/hr to 75 ml/hr. The feeding pump indicated 886 ml of feeding had been infused. V13 stated tube feeding pumps are cleared and the amounts are recorded on the Treatment Administration Record (TAR). R286's Order Summary Report dated 9/17/23 documents Osmolite 1.0 rate 75 ml/hr continuously with 125 ml water flush every six hours initiated on 9/16/23. There is 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 observation, interview and record review, the facility failed to perform suctioning of a tracheostomy under sterile conditions and according to facility policy, failed to have an ambu bag at the bedside for a resident with a tracheostomy, and failed to prevent potential contamination of a BiPAP Machine for four of four residents (R44, R75, R20, R286) reviewed for respiratory care on the sample list of 74. Findings Include: The Facility CPAP/BiPAP Cleaning Policy dated 9/1/20 documents it is the policy of this facility to clean CPAP/BiPAP equipment in accordance with current CDC (Centers for Disease Control) guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection. Clean the mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. 1.) R44's ongoing Diagnosis Listing documents the following: Malignant Neoplasm of the Larynx, Tracheostomy, Chronic Respiratory Failure with Hypoxia. R44's Care Plan dated Care Plan 9/8/23 documents…

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 obtain informed consent for an antidepressant for one (R1) of five residents reviewed for unnecessary medications in the sample list of 47. Findings include: R1's Minimum Data Set, dated [DATE] documents R1 has moderate cognitive impairment. R1's Order Summary Report dated 9/21/23 documents orders for Sertraline Hydrochloride 75 milligrams (mg) by mouth daily for depression, initiated on 7/23/23. R1's September 2023 Medication Administration Record documents Sertraline is administered daily as ordered. There is no documented consent for the use of Sertraline in R1's medical record. On 9/21/23 at 2:44 PM V11 Care Plan/Minimum Data Set Coordinator stated psychotropic medications can't be administered unless there is documented verbal or signed consent. On 9/21/23 at 3:18 PM V2 Director of Nursing stated there is no documented consent for R1's Sertraline. The facility's Use of Psychotropic Drugs policy revised 12/20/22 documents residents and 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 provide an Advanced Beneficiary Notice upon resident discharge from Medicare Part A services. This failure affects two residents (R24, R78) of three reviewed for beneficiary protection notifications in the sample list of 47. Findings include: R24's and R78's Beneficiary Protection Notification Review form (undated) documents the facility initiated R24's and R78's discharge from Medicare Part A services prior to R24 and R78's use of all covered Medicare benefit days. The same record documents R24 and R78 were only provided a Notice of Medicare Non-coverage and did not receive the required Advanced Beneficiary Notice of Non-Coverage. On 9/21/2023 at 3:15PM, V27 (Corporate Business Office Manager) reported R24 and R78 were not provided an Advanced Beneficiary Notice of Non-Coverage upon discharge from Medicare Part A services.

Based on interview and record review, the facility failed to provide resident privacy while performing personal cares. This failure affects two residents (R33, R50) of 44 reviewed for privacy in the sample list of 47. Findings include: On 9/19/2023 at 11:14 AM, R50 reported an unknown staff member recently performed personal cares for R50's roommate (R33) on third shift while the staff member was talking on their personal cell phone, while on speaker mode. R50 reported the staff member was going room-to-room while talking on their cell phone on speaker mode. R50 reported having a difficult time sleeping and the staff member was disruptive to R50's sleep. R33's electronic medical record (undated) documents R33 has been R50's roommate since March of 2023. Facility Resident Council Minutes (8/2/2023) document resident concerns of CNA's (certified nurse aides) on phones. The facility Promoting/Maintaining Resident Dignity policy (12/5/22) documents: staff providing care to residents should maintain resident privacy and not talk to other people while performing a task for a resident 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 interview and record review the facility failed to provide written bed hold notification for one (R1) of three residents reviewed for hospitalizations in the sample list of 47. Findings include: On 9/18/23 at 9:36 AM V34 (R1's Power of Attorney) stated the facility did not provide written notification of bed hold when R1 was hospitalized on [DATE]. R1's Nursing Note dated 9/13/23 at 2:59 PM documents the facility was notified that R1 was transferred to the hospital from the dialysis center. R1's Nursing Note dated 9/15/23 at 6:00 PM documents R1 readmitted to the facility. There is no documentation in R1's medical record that R1 or V34 were provided written notice of R1's transfer to the hospital and bed hold notification. On 9/21/23 at 11:30 AM V2 Director of Nursing stated there was no documentation of written bed hold/transfer notification provided for R1's transfer (on 9/13/23) since R1 was transferred to the hospital from dialysis. V2 stated the nurse should have followed up with dialysis to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed to include the use of an anticoagulant for one (R20) of five residents reviewed for unnecessary medications in the sample list of 47. Findings include: R20's April 2023 Medication Administration Record documents R20 received Eliquis (anticoagulant) 5 milligrams (mg) by mouth twice daily, initiated on 3/1/23. R20's September 2023 MAR documents R20 received Eliquis 5 mg twice daily, initiated on 6/12/23. R20s MDS dated [DATE] and MDS dated [DATE] do not document that R20 receives an anticoagulant daily. On 09/21/23 at 2:44 PM V11 Care Plan/MDS Coordinator stated V11 has been the Care Plan/MDS Coordinator since April 2023. V11 reviewed R20's orders, April MDS, and July MDS. V11 confirmed R20's April MDS and July MDS are inaccurate and should document R20's daily anticoagulant use. The facility's Resident Assessment - RAI (Resident Assessment Instrument) policy dated as revised 12/19/23…

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

Based on observation, interview, and record review the facility failed to ensure a baseline Care Plan was completed accurately to include the use of a urinary catheter for one (R64) of one resident reviewed for urinary catheters in the sample list of 47. Findings include: On 9/17/23 at 8:23 AM R64 had a urinary catheter that was draining clear yellow urine. R64 stated the facility replaces R64's catheter monthly and as needed, and R64 has had one urinary tract infection since R64 admitted to the facility. R64's Order Summary Report dated 9/17/23 documents an order dated 6/14/23 for size 18 french indwelling urinary catheter, check placement/functioning every shift, and replace as needed. R64's Nursing Note dated 5/16/2023 at 9:27 PM documents R64's admission summary including that R64 admitted to the facility with an indwelling urinary catheter size 18 french and 30 cubic centimeter balloon. R64's Baseline Care Plan dated 5/16/23 documents R64 as continent of urine and indwelling catheter is not marked under the section for bowel/bladder appliances. On 9/20/23 at 1:07 PM V11 Care…

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 services to a resident requiring extensive assistance with transferring from a wheelchair. This failure affects one resident (R139) reviewed for Activities of Daily Living assistance on the sample list of 47. Findings Include: R139's MDS dated [DATE] documents R139 is alert and oriented and requires extensive assistance of one staff for transfers. On 9/17/23 at 11:30 AM, R139 was sitting up in a wheelchair and stated staff got R139 up around 7:00 am for breakfast and refuse to lay R139 down until after lunch. On 9/17/23 at 1:30 PM, R139 remains sitting up in the wheelchair in R139's room. R139 stated staff still have not laid R139 down after requesting to be laid down several times. On 9/18/23 at 9:54 AM, R139 was sitting up in a wheelchair in R139's room. R139 stated R139 has been up since 7:00 am again and R139's buttocks is hurting really bad, so R139 has requested to be laid down. On 9/18/23 at 11:10 AM, R139 was lying in bed.…

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 safely store an oxygen cylinder for one of two residents (R9) reviewed for oxygen on the sample list of 47. Findings Include: On 9/17/23 at 9:42 AM, an oxygen cylinder was lying across a wheelchair seat in R9's room, unsecured. At this time, V4 LPN (Licensed Practical Nurse) stated the oxygen cylinder was for R9 who was hospitalized a few days ago. V4 also stated the oxygen cylinder isn't supposed to be like that, it should be secured. V4 then exited R9's room without securing the oxygen cylinder. R9's ongoing Census documents R9 was hospitalized on [DATE]. The facility Oxygen Safety Policy dated 9/15/22 documents oxygen storage locations shall be in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors or gates that can be secured against unauthorized entry. Cylinders will be properly chained or supported in racks or other fastenings (sturdy portable carts, approved stands) to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to monitor and record fluid intake and implement dialysis recommendations/orders for one (R1) of one resident reviewed for dialysis in the sample list of 47. Findings include: R1's Hemodialysis Communication Forms document the following: On 8/4 dialysis session was stopped two hours early due to R1's complaint of pain and includes instructions to administer R1's PRN (as needed) pain medications and Lorazepam as prescribed prior to dialysis sessions to lessen shortening of sessions. On 8/9 R1's dialysis session ended one hour and twenty minutes early due to diarrhea. On 8/18/23 R1 was saturated with stool, was brought back to the facility for incontinence care, and the dialysis center requested R1 return for R1's dialysis treatment. On 8/21/23 dialysis instructed to give Loperamide prior to dialysis appointments. On 9/18/23 dialysis instructed to hold Calcium Acetate and Sevelamer under the section titled New Orders. R1's Order Summary Report dated 9/21/23…

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 document a medical necessity for prescribing antibiotic medications. This failure affects three residents (R23, R27, R62) of three reviewed for unnecessary antibiotics in sample list of 47. Findings include: The facility's Antibiotic Stewardship Program policy with a revision date of 12/22/22 documents the following: Antibiotic use protocols: All prescriptions for antibiotics shall specify the dose, duration, and indication for use. Reassessment of empiric antibiotics is conducted after 2-3 days for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. R23's Electronic Medical Record (EMR) documents V17 Nurse Practitioner (NP) prescribed an order for Nitrofurantoin (Antibiotic) 100 milligrams (mg), take one capsule by mouth twice a day for a urinary tract infection (UTI) for seven days on 8/22/23. R23's August Medication Administration Record (MAR) documents R23 completed the prescribed antibiotic course. R23's McGeer Criteria for…

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

Based on observation, interview, and record review the facility failed to post signage and implement transmission-based precautions during nebulizer administration for one (R286) of two residents reviewed for tracheostomy in the sample list of 47. Findings include: On 9/18/23 at 9:53 AM R286 was lying in bed. R286 has a tracheostomy and R286's nebulizer was administering. There was a sign (turned backwards with instructions facing the door) on R286's door indicating Nebulizer Treatment/BIPAP (Bilevel Positive Airway Pressure/CPAP (Continuous Positive Airway Pressure) in process; wear a well fitted mask, eye protection, and gloves upon entering; keep the door closed and window open for 60 minutes after administration. On 9/18/23 at 9:58 AM V39 Licensed Practical Nurse stated this is V39's first time working on R286's hallway and V39 was unsure of the precaution's signage posted on R286's door. V39 stated V39 wore a surgical mask and gloves to setup/administer R286's nebulizer treatment. V39 confirmed the sign on R286's door was not turned to indicate R286's nebulizer was…

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

Based on record review, observation and interview the facility failed to ensure food was protected from potential cross contamination, failed to ensure food was stored in a manner to assure sound condition, safety, and quality, and failed to maintain food contact surfaces in a clean, sanitary condition. These failures have the potential to affect all 81 residents residing in facility. Findings include: The facility Census and Condition Report dated 12/14/22 documents 81 residents residing in facility all or most of whom consume food prepared in the facility kitchen. 1.) On 12/13/22 at 10:40 am V27 [NAME] wore disposable gloves while touching raw hamburger patties. V27 cook wearing the same gloves then picked up a plastic lid laying on floor and placed lid on container of rice. V27 wearing the same gloves continued to cook the raw hamburger patties on the flat top oven touching V27's contaminated gloves to the raw hamburger patties. 2.) On 12/13/22 at 9:20 am food was not protected in the facility walk in refrigerator. There was an opened bag of yellowed broccoli with tan liquid that…

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

Based on observation, interview and record review, the facility failed to ensure the facility employed a licensed administrator. This failure affects all 81 residents residing in the facility. Findings include: On 12/14/22 at 11:15 am, V4 Human Resources Director/Acting Administrator (HR Director) stated V4 is the HR Director for the facility and is not a Licensed Nursing Home Administrator (LNHA). V4 stated V4 has not started taking the LNHA classes. On 12/16/22 at 8:52 am, V2 Director of Nursing stated the facility does not have an administrator at this time. V2 stated the facility has not had an administrator employed since 9/16/22. The facility provided an undated employee roster, and no administrator is documented on this roster. The Resident Census and Conditions of Residents Report dated 12/14/22 documents the facility has 81 residents in house.

Based on record review, observation and interview the facility failed to prevent the spread of COVID-19 by not following their COVID-19 testing policy for one (R66) resident, failed to wear Personal Protective Equipment (PPE) while providing care for two COVID-19 positive residents for one resident (R58, R60 ), failed to properly dispose of contaminated Personal Protective Equipment (PPE) for one resident (R58) and failed to ensure contaminated linen and garbage from COVID-19 positive residents was disposed of properly. These failures affected four residents (R20, R58, R60 and R66) out of 17 residents reviewed for infection control in a sample list of 32 residents. Findings include: 1.) R66's undated Face Sheet documents End Stage Renal Disease (ESRD), History of COVID-19, Chronic Respiratory Failure, Congestive Heart Failure and Protein Calorie Malnutrition. R66's Nurse Progress Note dated: -11/10/22 at 5:15 pm documents (R66) returned to facility. (R66) demanded to see nurse as soon as possible. (R66) wanted a pain pill for a pain level of 10 in (R66's) back. (R66) refused dinner…

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, observation and interview the facility failed to ensure dignity was maintained by failing to allow residents to eat in the dining room and failed to provide appropriate plates and cutlery during meal service. These failures affected four residents (R13, R24, R52 and R53) of seven residents reviewed during dining on the sample list of 32. Findings include: On 12/14/22 at 10:40 am the facility main dining room was not set-up to provide meal services. The main dining room was cluttered with numerous cardboard boxes, a bare Christmas tree, ornaments and residents' laundry strewn across the chairs. V1, Regional Clinical Support, Registered Nurse (RN) stated all residents that are positive for Covid-19 and the other resident that are negative for Covid-19, all dine in their rooms. On 12/15/22 between 8:30 am-9:00 am breakfast meals were being served room to room, to residents down each hall of the facility by unidentified staff. Resident (unidentified) meals were served in styrofoam containers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess a resident's ability to self-administer medications for one of one resident (R66) reviewed for self-administration of medication on the sample list of 32. Findings Include: The facility policy Resident Self-Administration of Medication dated 07/01/2021 documents the following: Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines: 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary…

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 operationalize their abuse prevention policy by failing to prevent resident to resident verbal and mental abuse, failing to recognize a resident-to-resident altercation as potential abuse and failing to report an allegation of abuse immediately to the state survey agency. These failures affect two of four residents (R10 and R53) reviewed for abuse on the sample list of 32 residents. Findings include: The facility policy Abuse, Neglect and Exploitation dated 06/08/20 documents the following: Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians,…

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

Based on interview and record review the facility failed to report an allegation of verbal and mental abuse immediately to the state survey and certification agency. This failure affects two of four residents (R10 and R53) reviewed for abuse on the sample list of 32 residents. Findings include: On 12/15/22 during the group meeting between 10:45 am and 11:45 am, R53 stated R53's roommate, R10 called R53 a jackass last evening 12/14/22 and R10 said R10 was going to bash (R53's) head in and kick (R53's) butt. R53 also stated staff were notified and R10 was moved to another room. R53 also stated My roommate (R10) scared me. I was afraid to go to sleep. R10's Mood and Behavior Note dated 12/14/2022 at 6:42 pm documents Note Text: Resident's roommate (R53) (complained of) resident (R10) made threatening statements to her including physical violence. Resident (R10) removed from her (R10's) current room and moved to an empty room on the hallway for the evening. Nurse manager on call notified via phone call. On 12/15/22 at 12:00 pm V1, Regional Clinical Support, Registered Nurse confirmed…

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 a Preadmission Screening and Resident Review (PASARR) screening was completed for two (R41 and R59) out of two residents reviewed for PASARR screenings in a sample list of 32 residents. Findings include: The facility policy titled 'Resident Assessment -Coordination with PASARR Program revised 12/11/22 documents the following: All applicants to this facility will be screened for serious mental disorders and intellectual disabilities and related conditions in accordance with the state's Medicaid rules for screening. 1. R41's undated Face Sheet documents an admission date of 12/1/18. R41's Physician Order Sheet (POS) dated December 1-31, 2022, documents medical diagnoses of Psychosis not due to a substance, Dementia, Schizophrenia, Anxiety Disorder, Depressive Episodes and Bipolar Disorder. R41's Electronic Medical Record (EMR) does not document a PASARR screen. On 12/15/22 at 2:00 pm V15 Business Office Manager stated facility does not have any documentation of a PASARR. V15 stated We (facility) do not have a PASARR…

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, observation and interview, the facility failed to ensure R43's surgical wound dressing and diabetic ulcer dressing were changed daily as the physician ordered. The facility also failed to maintain documentation of R43's weekly wound measurements. These failures affected one of three residents (R43) reviewed for wounds on the sample list of 32. Findings include: R43's Hospital General Information note dated 9/7/22 documents R43 was admitted to the hospital for surgery. Procedure: Amputation Left Transmetatarsal (partial foot). R43's Treatment Administration Record (TAR) documents a physician order dated 11/04/22 as follows: Wound Left Transmetatarsal Amputation Site: cleanse with wound wash, pat dry, apply Medihoney paste then apply nonbordered sterile gauze and wrap with (gauze wrap) daily. every day shift. The same TAR documents a physician order dated 10/21/22. Wound #7-Left Calcaneus (heel): cleanse with saline wash, pat dry, place silver alginate in wound bed, cover with non-bordered…

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, observation and interview the facility failed to prevent cross contamination during pressure sore treatments for one (R20) resident out of three residents reviewed for pressure ulcers in a sample list of 32 residents. Findings include: R20's undated Face Sheet documents medical diagnoses of Paraplegia, Neoplasms of Urinary Bladder, Neuromuscular Bladder, Chronic Obstructive Pulmonary Disorder (COPD), Major Depressive Disorder and Chronic Pain. R20's Minimum Data Set (MDS) dated [DATE] documents R20 as being moderately cognitively impaired. This same MDS documents R20 as requiring extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. R20's Physician Order Sheet (POS) dated December 1-31, 2022, documents a physician order to Cleanse Left Posterior Lateral Ankle pat dry, apply Calcium Alginate, foam and gauze roll every other day, cleanse Right Heel pressure site, pat dry and apply Calcium Alginate border foam daily, and cleanse Right…

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, observation and interview the facility failed to implement a post fall intervention for a resident (R75) at high risk for falls with a history of falls. R75 is one of two residents reviewed for falls/accidents on the sample list of 32. Findings include: R75's Minimum Data Set (MDS) dated [DATE] documents the following: R75's Brief Interview of Mental Status scores 3 out of a possible 15, indicating severe cognitive impairment. The same MDS documents R75 requires extensive assistance of two person for transfers and has had two no injury falls prior to this assessment. R75's (Formal) Fall Scale assessment dated [DATE] documents the following: R75 has a history of falls, has a fall score of 50 and is at high risk for falls with a score above 45. R75's Fall Interdisciplinary Team Note dated 11/15/2022 07:36 am documents the following: Time of fall: 1730 (5:30 pm) Date of fall: 11/11/2022 V/S: see vitals flowsheet Activity at time of fall: w/c (wheelchair) reaching for something off the floor…

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, observation and interview the facility failed to prevent cross contamination during urinary catheter care for (R20) and failed to measure urinary output in accordance with facility policy for (R69). R20 and R69 are two of two residents reviewed for indwelling urinary catheters on a sample list of 32 residents. Findings include: 1.) R20's undated Face Sheet documents medical diagnoses of Paraplegia, Neoplasms of Urinary Bladder, Neuromuscular Bladder and personal history of Urinary Tract Infections. R20's Minimum Data Set (MDS) dated [DATE] documents R20 as being moderately cognitively impaired. This same MDS documents R20 as requiring extensive assistance of two people for bed mobility, transfers, dressing, toileting and personal hygiene. R20's Physician Order Sheet (POS) dated December 1-31, 2022, documents a physician order to cleanse R20's Suprapubic Urinary Catheter with soap and warm water, rinse, pat dry and apply new drain sponge twice per day and as needed. On 12/15/22 at 9:30 am…

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

Based on record review and interview the facility failed to include a Care Plan for Renal Dialysis and failed to ensure Renal Dialysis communication was completed and documented with each Renal Dialysis session for R287, one of two residents reviewed for Renal Dialysis in a sample list of 32 residents. Findings include: 1.) R287's undated Face Sheet documents an admission date of 5/14/22. This same face sheet documents R287's medical diagnoses of Congestive Heart Failure (CHF), Aphasia, Altered Mental Status, End Stage Renal Disease, Vascular Dementia and Dependence on Renal Dialysis. R287's Physician Order Sheet (POS) dated December 1-31, 2022, documents a physician order starting 5/17/22 for renal dialysis three times per week on Mondays, Wednesdays and Fridays. R287's Care Plan does not include a focus area, goal, nor interventions for Renal Dialysis. R287's Electronic Medical Record (EMR) does not document Renal Dialysis communications for each dialysis session outside of facility. On 12/15/22 at 2:30 pm V1 Regional Clinical Support Nurse stated We (facility) know there is a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent a significant medication error by failing to follow the physician ordered time of administration, directives for clinical staff to administer medication, and by failing to follow the medication administration policy to observe resident consumption of medication. These failures affected one of ten residents (R66) observed during medication administration in the sample list of 32. Findings Include: R66's Physician Order Summary Report Sheet (POS) dated 12/16/22 documents the following diagnoses: Hypertensive Chronic Kidney Disease With Stage Five Chronic Kidney Disease or End Stage Renal Disease and Dependence on Renal Dialysis. The same POS documents the following physician ordered medications: Apixaban (anticoagulant/blood thinner) Tablet 2.5 milligram (mg) by mouth, two times a day, for (the) prevention of unwanted clots in the veins. Calcium Acetate (phosphorous binder to prevent absorption from diet, into the blood stream),…

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.