The Haven of Paris

Based on observation, interview and record review the facility repeatedly failed to maintain nebulizer respiratory equipment in a clean sanitary manner, change oxygen nasal canula and tubing in a timely manner, provide an oxygen humidification water bottle, failed to obtain an oxygen administration order, and failed to care plan respiratory status, interventions for the monitoring of oxygen administration, and for safe and sanitary practices for R43. The facility also failed to provide an oxygen humidification water bottle for (R64). These failures affected two of three residents (R43 and R64) reviewed for respiratory care and medication administration on the sample list of 30.Findings include: 1.R43's Physician Order Sheet (POS) dated 9/18/25, (time stamp at 10:27 am when copied, prior to an updated version), documents: Elevate head of bed to avoid shortness of breath when lying flat R/T (related to) COPD (Chronic Obstructive Pulmonary Disease), every shift. Start date 8/7/25.The same POS documents: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (milligrams/…

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 pharmacy instruction for the administration of physician ordered medication, for two of seven resident (R3 and R43) reviewed during medication observation. The facility had three medication errors, out of 32 opportunities, resulting in an 9.38 percent medication error rate.Findings include:1. R3's current Physician Order Sheet (POS) documents: Ferrous Sulfate Oral Tablet, Delayed Release 324 (65 FE (65 milligrams iron) MG (milligrams). Give 1 (one) tablet by mouth two times a day for Supplement.R3's same POS documents: Cefdinir Oral Capsule 300 MG (antibiotic). Give 1 capsule by mouth two times a day for leukocytosis, bacteremia for 10 Days. Give with or without meals. No iron/antacids within 2 hours.On 9/19/25 at 8:00 am V13, Licensed Practical Nurse administered R3's Iron, and Cefdinir at the same time, in direct contrast to the physician order and pharmacy directions on the prescription label. V13, Licensed Practical Nurse confirmed she had given Cefdinir antibiotic with Ferrous Sulfate and 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.

Based on observation, interview and record review the facility failed to store (R55's) Scheduled IV, Narcotic Controlled Substance in a locked refrigerator compartment to prevent the potential for drug diversion, and failed to ensure (R2 and R8's) opened, insulin injection pens were properly labeled, by the dispensing pharmacy with directions for safe administration. These failures affected three residents (R2, R8 and R55) reviewed during medication storage observation and are included on the sample list of 30.Findings include:1.) R55's current Physician Order Sheet (POS) documents the following: Lorazepam Intensol Oral Concentrate (Scheduled IV, Controlled Substance, liquid medication), two milligrams (mg) per milliliter (ml) (strength).Give 0.25 ml by mouth every 40 (facility typo clarified to be every four) hours as needed for Anxiety, Restlessness and Agitation (diagnoses) for 120 days, for end of life (Hospice care).On 9/18/25 at 12:20 pm V10, Licensed Practical Nurse (LPN) during medication storage observation, V10, LPN opened the South Hall medication room door. There 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 observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were utilized for residents with indwelling urinary catheters. This failure affects two residents (R1, R12) of five reviewed for infection control in the sample list of 30. Findings include:1. R1's diagnosis list (9/18/2025) documents diagnoses including Hemiplegia (paralysis of one side of the body), Hemiparesis (weakness on one side of the body), Epilepsy (brain disorder causing seizures), History of Traumatic Brain Injury, Parkinsonism (brain condition causing slow movements, stiffness, and tremors), Vascular Dementia with Agitation, Infection due to indwelling urinary catheter, and Sepsis (life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage).R1's Resident Assessment (8/20/2025) documents R1 has severe cognitive impairment. The same record documents R1 uses a wheelchair for mobility, is dependent on staff to complete activities of daily living, uses an indwelling urinary…

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 supply of a house-stock probiotic medication (to prevent antibiotic -associated diarrhea, and protect against Clostridium-difficle infection that can develop after antibiotic use,) for a resident (R43) currently on an intravenous antibiotic medication for Extended-Spectrum Beta-Lactamase (ESBL), (antibiotic resistant bacterial infection) of a wound. R43 is one of seven resident reviewed during medication administration, on the sample list of 30. Findings include:R43's current Physician Order Sheet (POS) documents the following: Florastor (Saccharomyces boulardii), (Yeast based, probiotic medication, that are ten times larger than bacterial based probiotic) Capsule 250 milligrams (mg) , Give one capsule by mouth, two times a day, for Prophylactic (to prevent disease).R43's same POS documents the following; Ertapenem (broad-spectrum antibiotic to treat serious bacterial infections) one gram (reconstituted in 100 milliliters of normal saline) intravenously, over a one hour period, give every 24 hours…

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

Based on observation, interview, and record review, the facility failed to provide a full-time director of nurses to oversee and coordinate nursing services provided within the facility. This failure has the potential to affect all 83 residents residing in the facility.Findings include:During the survey 8/19/25 through 8/22/25 there was no Director of Nursing (DON) in the building.On 8/19/25 at 10:10 am V1, Administrator/Abuse Prevention Coordinator stated V2, previous Director of Nursing's last day employed for the facility was Friday 8/15/25. V1 stated she has not hired a Registered Nurse for the DON position, nor does the facility have an Acting DON to provide oversite of the nursing services.The facility resident roster dated 8/19/25 documents 83 residents reside in the facility.

Based on interview and record review, the facility failed to notify residents Family Representatives/Power of Attorney of Physical Abuse allegations for five of nine residents (R3 - R7) reviewed for abuse on the sample list of 18. Findings include:1. R'4s/R3's IDPH resident to resident physical abuse investigation report dated 7/5/25 documents R3 smacked R4's face, and the Power of Attorney was notified, as the facility abuse prevention policy directs.On 8/22/25 at 10:13 am, V24, R3's Power of Attorney (POA)/Family Member reported the facility did call V24 on 7/5/25 and made it sound like another resident (R4) and R3 were just arguing. V24 said there was no mention of anything physical in that call.2. R4/R5 IDPH resident to resident physical abuse investigation report dated 6/21/25 documents R4 swatted R5's back, and the Power of Attorney was notified, as the facility abuse prevention policy directs. On 8/21/25 at 12:35 pm V28, R4's POA/Family Member had great difficulty hearing each question regarding R4's resident to resident altercations. V28, repeated the question regarding 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 protect residents' right to be free from witness, resident to resident physical abuse. This failure affects four of nine residents (R3, R4, R5 and R6), reviewed for abuse on the sample list of 18.Findings include:1.) R3's Minimum Data Set (MDS) dated [DATE] documents the following: R3's Brief Interview of Mental Status score of 00 (zero) out of a possible score of 15, which indicates severe cognitive impairment. The same MDS documents R3 has had Verbal behaviors directed towards others (e.g. screaming at others, threatening others, and cursing at others). These verbal behaviors occurred four to six days a week of the lookback period of the MDS assessment.The same MDS documents R3 also had other Behavioral symptoms not directed towards others: (e.g., smearing physical food or symptoms bodily such wastes, as or hitting or verbal/vocal scratching symptoms self, pacing, like rummaging , public sexual acts, disrobing in public, throwing or smearing food 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 interview and record review, the facility failed repeatedly to operationalize their abuse prevention policy by failing to notify the Ombudsman of abuse allegations. This failure affected seven of nine residents (R3 -R7) reviewed for abuse on the sample list of 18. Findings include:1. R'4s/R3's IDPH resident to resident physical abuse investigation report dated 7/5/25 documents R3 smacked R4's face, and the Ombudsman was notified, as the facility abuse prevention policy directs.2. R4/R5 IDPH resident to resident physical abuse investigation report dated 6/21/25 documents R4 swatted R5's back, and the Ombudsman was notified, as the facility abuse prevention policy directs. 3. R4/R6 IDPH resident to resident physical abuse investigation report dated 6/18//25 documents R4 grabbed R6's wrist, and the Ombudsman was notified, as the facility abuse prevention policy directs. 4. R7's IDPH report dated 8/19/25 documents R7 was handling rough by an unidentified nursing staff named ( V11, Nursing staff) causing a bruise to R7's arm, and the Ombudsman was notified, as the facility abuse…

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 interview and record review, the facility failed to report allegations of resident to resident physical abuse, staff to resident physical abuse, and injuries of unknown origin to the police department and physician, in accordance with the facility policy. This failure affected five of nine residents (R3-R7) reviewed for abuse on the sample list of 18.Findings include: 1. R'4s/R3's IDPH resident to resident physical abuse investigation report dated 7/5/25 documents R3 smacked R4's face, and the local police department and physician were notified. 2. R4/R5 IDPH resident to resident physical abuse investigation report dated 6/21/25 documents R4 swatted R5's back, and the local police department and physician were notified. 3. R4/R6 IDPH resident to resident physical abuse investigation report dated 6/18//25 documents R4 grabbed R6's wrist, and the local police department and physician were notified. 4. R7's IDPH report dated 8/19/25 documents R7 was handling rough by an unidentified nursing staff causing a bruise to R7's arm, and the local police department and physician 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 interview and record review, the facility failed to complete a thorough investigation by failing to interview families that are frequently in the facility, and other residents residing in the facility, that may have knowledge of alleged abuse. This failure had the potential to affect five of nine residents (R3- R7) reviewed for abuse on the sample list of 18. Findings include:R'4s/R3's IDPH resident to resident physical abuse investigation report dated 7/5/25 documents R3 smacked R4's face. The facility investigation determined this allegation to be unfounded, though no families or other residents were interviewed. 2. R4/R5 IDPH resident to resident physical abuse investigation report dated 6/21/25 documents R4 swatted R5's back. The facility investigation determined this allegation to be unfounded, though no families or other residents were interviewed. 3. R4/R6 IDPH resident to resident physical abuse investigation report dated 6/18//25 documents R4 grabbed R6's wrist. The facility investigation determined this allegation to be unfounded, though no families or other…

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

Based on interview and record review, the facility failed to timely review and revise care plans for four of nine residents ( R3, R4, R5, and R6) reviewed for abuse on the sample list of 18. Findings include: R'4s/R3's final IDPH resident to resident physical abuse investigation report dated 7/5/25 documents R3 smacked R4's face. The same report documents R3 and R4's care plan was reviewed/revised. R3's Care Plan dated as last revised 01/22/24 (twenty- four) with a target date of 01/10/25 (twenty -five) documents the following: (R3) has the potential for abuse/neglect due to invading other's space and property, rummaging through belongings or wandering in and out of other's spaces. She has a history of being physically abused, psychiatric diagnosis or manifestations, including delusions, paranoia and hallucinations, Underlying factors that increase vulnerability; including such as dementia, confusion, poor judgment, wandering and giving away personal property. (R3) will experience no present/future problems related to abuse/mistreatment/violation. Revision on: 01/22/2024, Target…

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 repeatedly to maintain complete and accurate medical records for one of nine residents ( R6) reviewed for abuse/injury of unknown origin on the sample list of 18.Findings include:R6's Physician Adult Health Exam, Routine Nursing Home Follow-Up. notes dated 2/20/25, 4/10/25, 4/17/25, 6/19/25 and 7/10/25 document R6 was assessed by V3, Medical Director (Physician). These notes were signed by V3, Medical Director. V3, MD documented R6 'Integumentary (skin)' assessments indicates R6 had left cheek and left, lower rib cage bruises on each of these assessment. On 8/22/25 at 1:10 PM V3, Medical Director reviewed R6's medical record documentation and said he now recognized his documentation was not accurate in V3, MD Nursing home visit notes that he documented on 2/20/25, 4/10/25, 4/17/25, 6/19/25 and 7/10/25. V3 confirmed R6 had a fall in December 2024 and continued with bruises in January but did not have bruising on the above mentioned dates. V3, MD acknowledged this was a documentation error. V3, MD also said V3, MD will add 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 record review and interview the facility failed repeatedly, to notify a provider of blood pressure measurements, that were below normal range, for one of three resident (R1) reviewed for change in condition on the sample list of three.Findings include:R1's Current Diagnoses List includes the following: Type II Diabetes with Other Specified Complications, Type II Diabetes With Other Diabetic Neurological Complications, Chronic Ischemic Heart Disease, Unspecified, Hypertensive Heart Disease With Heart Failure Presence Of Automatic Implantable Cardiac Defibrillator, Peripheral Vascular Disease Unspecified, Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris, Non-rheumatic Tricuspid Insufficiency, Acute Kidney Disease, Essential Hypertension, Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Unspecified Severity Without Behavioral Disturbance, Mood Disturbance and Anxiety, Encounter for Orthopedic Aftercare Following Surgical Amputation, Gangrene, Not Elsewhere…

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 report an Injury of Unknown Origin timely for one (R4) resident out of three residents reviewed for Injuries of Unknown Origin in a sample list of seven residents. Findings include: R4's undated Face Sheet documents medical diagnoses as Dementia without behaviors, Diabetes Mellitus Type II, Peripheral Vascular Disease (PVD), Heart Failure, Cardiac Arrhythmia's, and bilateral hearing loss. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 requires set up assistance for eating, supervision for oral hygiene, bed mobility, moderate assistance for personal hygiene, dressing, bathing, toileting, and transfers. R4's Notification to Physician dated 5/24/25 documents R4 was observed to have a 31.0 centimeter (cm) wide by 7.0 cm deep dark purple/pink bruise to Left Lower Abdomen. This same report documents (R4) is unable to say what happened. No fall or injury noted to area. R4's Initial Report 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 complete a thorough investigation of an Injury of Unknown Origin for one (R4) resident out of three residents reviewed for Injuries of Unknown Origin in a sample list of seven residents. Findings include: R4's undated Face Sheet documents medical diagnoses as Dementia without behaviors, Diabetes Mellitus Type II, Peripheral Vascular Disease (PVD), Heart Failure, Cardiac Arrhythmia's and bilateral hearing loss. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 requires set up assistance for eating, supervision for oral hygiene, bed mobility, moderate assistance for personal hygiene, dressing, bathing, toileting, and transfers. R4's Medication Administration Record (MAR) dated May 2025 documents R4 was administered Insulin subcutaneously in her Left Lower Quadrant (LLQ) six times out of the last 30 administrations. The other injection sites included Right Lower Quadrant (RLQ) and bilateral…

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 a resident was provided adequate assistance and safe equipment, to prevent a fall during a shower. This failure affects one of three residents (R3) reviewed for falls on the sample list of four. Findings include: R3's current diagnoses sheet documents the following: Type II Diabetes Mellitus With Diabetic Polyneuropathy, Personal History of Transient Ischemic Attack, and Cerebral Infarction Without Residual Deficit, Presence of Left Artificial Hip Joint, Unspecified Osteoarthritis, Unspecified and Essential Hypertension. R3's Minimum Data Set (MDS) dated [DATE] documents an admission date as 9/5/23 and that R3 has had one fall with no injury since admission/entry/reentry. The same MDS documents R3's Brief Interview of Mental Status score of 14 out of a possible 15, indicating no cognitive impairment. The same MDS documents R3 uses a walker for mobility and has no upper or lower extremity impairment in range of motion. The same 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to maintain a resident's complete and accurate medical record after a fall in the shower room. This failure affects one of three residents (R3) reviewed for falls on the sample list of four. Findings include: R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status score of 14, out of a possible 15, indicating no cognitive impairment. The (Facility) Fall Incident List log dated 01/01/25 - 05/05/25 documents R3 had a fall 2/18/25 at 9:00 pm. The same Fall List documents the fall occurred during transfer in the shower room, with R3 being lowered to the ground by staff member. R3's Fall risk assessment quarterly dated 2/13/25 documents a score of 10, at high risk for falls. There was no documentation of a fall risk assessment post R3's fall (documented on the above fall log) that occurred 2/18/25. R3's Fall Investigation report documents R3's fall occurred on 2/18/25 at 9:00 pm. The fall investigation is signed as investigated…

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 a resident's physician of signs of a wound infection. This failure affected one of three residents (R1) reviewed for Physician Notification on the sample list of three. Findings Include: The Acute Change of Condition policy dated 1/23/23 documents the facility will identify and treat residents with an acute change of condition. The nursing staff will collect pertinent details to report to the physician. The nursing staff will contact the physician based on the urgency of the situation. The physician will help identify and authorize appropriate treatments. R1's Medical Diagnosis List dated April 2025 documents R1 is diagnosed with Atherosclerotic Heart Disease, Diabetes Mellitus Type II, Dementia, and Local Infections of the Skin and Subcutaneous Tissue. R1's Physician Order Sheet dated April 2025 documents an order placed on 2/20/25 for staff to complete a daily foot check related to a history of skin impairment/ulcer, current skin impairments/ulcers, color, temperature, edema, and pedal pulses and notify the…

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

Based on interview and record review the facility failed to complete weekly pressure wound assessments/measurements for one of three residents (R1) reviewed for Wound Assessments on the sample list of three. Findings Include: The Pressure Ulcer policy dated 8/31/23 documents it is the responsibility of the Charge Nurse or Designee to measure and document on the pressure areas weekly, monitor for healing progress, and ensure appropriate treatments are in use. Documentation of the pressure ulcer must occur upon identification and at least once a week until healed. The assessment is to include wound characteristics, presence of granulation tissue or necrotic tissue, treatment and response to treatment, prevention techniques used, and any updated for the physician or resident/family of any regression of the wound. The Director of Nursing or Designee is responsible to maintain a weekly wound log. R1's Medical Diagnosis List dated April 2025 documents R1 is diagnosed with Atherosclerotic Heart Disease, Diabetes Mellitus Type II, Dementia, and Local Infections of the Skin and Subcutaneous…

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 follow their bedbug prevention policy to ensure the identification and removal of bedbugs from the facility. This failure has the potential to affect all 82 residents who reside in the facility. Findings include: The facility provided bed board dated 4/1/25 documents 82 residents reside in the facility. The facility provided bedbug prevention and management of infestations policy dated 6/22/23 documents that if evidence of bedbugs is found, a specimen is to be collected and the pest control company notified. The Terminex Inspection Report dated 2/27/25 documents treatment for bed bugs in room [ROOM NUMBER]. On 4/1/25 at 9:00AM, V5 Licensed Practical Nurse stated that she recently saw a bedbug in room [ROOM NUMBER] and reported it to V12 Assistant Director of Nursing. On 4/1/25 9:15AM, V6 Certified Nursing Assistant (C.N.A.) stated that she was aware that someone had found bed bugs in R1 and R2's room, but did not believe that their room had been sprayed…

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 safe, clean and homelike environment for 28 (R1, R2, R3, & R7-R31) of 28 residents reviewed for a homelike environment from a total sample list of 31 residents. Findings include: On 4/1/25 at 9:23AM the south shower hall anti-room floor was sloping from the entry into the shower room to the exit door. When stood on, this floor was mushy in feel and it felt as though it could cave in or one could slide off of it, leaving one unsteady and at risk for falling. Additionally, the transition piece from old floor to new was not attached to the floor creating a potential trip hazard. On 4/1/25 at 9:35AM, V7 Certified Nursing Assistant was using the south shower to provide care to a resident. On 4/1/25 at 2:45PM, V2 Director of Nursing confirmed that south hall shower is used for south hall residents R1, R2, R3, & R7-R31. On 4/1/25 at 9:30AM, V3 Maintenance Director observed the south shower room and ante-room floors and stated that they are in need of repair and that the do not represent a safe or homelike…

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 that two (R4, R5) of three residents reviewed for physical abuse were free from physical abuse from a total sample list of 31 residents. Findings include: The facility abuse policy dated 1/9/24 documents that residents in the facility are to remain free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. R4's progress notes dated 3/11/25 documents an altercation between R4 and another unidentified resident documenting that R4 took that resident's walker away from them, requiring intervention by staff R4's progress notes dated 3/30/25 document an altercation between R4 and R5, both residents of the dementia unit. On 4/1/25 at 10:30AM, V1 Administrator confirmed that an initial reportable incident form had been submitted to the state agency on 3/30/25. On 4/1/25 at 11:00AM, V9 Certified Nursing Assistant (CNA) stated that she was at the facility working on 3/30/25 when R4 and R5 had their altercation. V9 CNA stated that she heard R4 and R5…

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 administer one (R4) resident's physician ordered Insulin for eight days and failed to notify R4's Physician of medication error out of three residents reviewed for Quality of Care in a sample list of ten residents. Findings include: R4's undated Face Sheet documents R4 admitted to the facility on [DATE] with medical diagnoses of Diabetes Mellitus Type II, Dementia, Pubis Fracture, Thyrotoxicosis, Hearing Loss, Lumbar Vertebrae Compression Fracture, Localized Skin Infection and Atherosclerotic Heart Disease. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. R4's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 1/21/25 and ending 1/28/25 to administer Levemir 100 units/milliliter (ml) give 18 units subcutaneously every bedtime for Diabetes Mellitus Type II (DM). This same POS documents a physician order starting 1/22/25-2/18/25 to monitor R4's blood glucose three times daily. This…

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 two (R4, R9) residents physician ordered diets, and failed to initiate a nutritional careplan for one resident (R4) out of three residents reviewed for Dietary Services in a sample list of ten residents. Findings include: R4's undated Face Sheet documents R4 admitted to the facility on [DATE] with medical diagnoses of Diabetes Mellitus Type II, Dementia, Pubis Fracture, Thyrotoxicosis, Hearing Loss, Lumbar Vertebrae Compression Fracture , Localized Skin Infection and Atherosclerotic Heart Disease. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 requires supervision with oral hygiene and eating. R4's Hospital Record dated 1/21/25 documents discharge instructions for R4 to receive a Diabetic diet. R4's Physician Order Sheet (POS) dated January 2025 documents a physician order starting: -1/22/25 and ending 2/17/25 for R4 to receive a Regular diet, Full Liquids…

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 a resident's change of condition to the nurse prior to obtaining a COVID-19 test and failed to ensure qualified staff conducted COVID 19 testing for one of three residents (R2) reviewed for a change in condition in the sample list of four. Findings include: R2's undated diagnoses list, documents a diagnosis of COVID-19. Per R2's Nursing Progress notes, on 12/25/24 at 1:42 PM, V10 Licensed Practical Nurse (LPN), documented R2's temperature as 98.2 degrees Fahrenheit. Per these same notes, on 12/25/24 at 9:00 PM, V8 LPN documented writer (V8) was notified by (a) CNA (Certified Nursing Assistant) (V11) that she (V11) COVID tested this resident (R2) because she (R2)was not acting right. Per CNA (V11) resident (R2) is COVID positive. CNA (V11) reported she (V11) notified on call nursing manager (V6). Writer (V10) notified on call provider of results at this time. These same nursing notes document on 12/25/24 at 9:36 PM, V8 LPN documented R2's temperature being 101.4 degrees Fahrenheit. On 1/9/25 at 11:37 AM, V8 LPN…

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 privacy for one (R5) resident during incontinence care out of three residents reviewed for incontinence care in a sample list of 16 residents. Findings include: The facility policy titled Resident Rights revised 7/11/22 documents employees shall treat all residents with kindness, dignity and respect. R5's undated Medical Diagnosis List documents R5's medical diagnoses as Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant side, Parkinson's disease, Paroxysmal Atrial Fibrillation, Seizures and Vascular Dementia. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as severely cognitively impaired. This same MDS documents R5 is dependent of staff for toileting, dressing, bathing, personal hygiene and requires maximum assistance for bed mobility and transfers. On 12/12/24 at 1:30 PM, V8, Certified Nursing Assistant (CNA), assisted R5 to the toilet. V8 applied gloves and walked R5 from his wheelchair 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 honor two (R11, R16) resident's right to refuse treatment out of three residents reviewed for electronic monitoring device systems in a sample list of 16 residents. Findings include: The facility policy titled Wandering/Elopement Policy revised 3/13/24 documents the facility will not use an (electronic monitoring device) on a resident who is able to give consent based on cognitive level without further assessment to protect the resident's right to personal autonomy. 1.) R11's undated Face Sheet documents R11 as his own responsible party. This same face sheet documents R11's medical diagnoses as Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right dominant side, Diabetes Mellitus Type II, Asthma, Vascular Dementia without behaviors, Bipolar Disorder, Anxiety, Depression, Seizures and Adjustment Disorder with Depressed Mood. R11's Minimum Data Set (MDS) dated [DATE] documents R11 as cognitively intact. This same 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an allegation of mental abuse of one (R9) resident by a staff member to the Physician, Ombudsman and State Agency timely. These failures affect one (R9) out of three residents reviewed for abuse in a sample list of 16 residents. Findings include: The facility policy titled Abuse Policy revised 1/9/24 documents the Administrator and/or designee is the Abuse Coordinator for this facility. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment. It is the responsibility of all facility staff to ensure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staffs responsibility to report any allegation or witnessed abuse immediately to the Administrator (Abuse Coordinator). The facility will report all allegations of abuse timely to the proper authorities 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 prevent cross contamination during incontinence care and failed to provide timely incontinence care for one (R12) resident out of three residents reviewed for incontinence care in a sample list of 16 residents. Findings include: The undated facility policy titled Handwashing/Hand Hygiene documents staff will use an alcohol based hand rub before moving from a contaminated body site to a clean body site during resident care. R12's undated Face Sheet documents medical diagnoses of Aphasia following Cerebral Infarction, Adult Failure to Thrive, Hypertension and Right Hand Contractures. R12's Minimum Data Set (MDS) dated [DATE] documents R12 as severely cognitively impaired. This same MDS documents R12 as being dependent on staff for transferring, bed mobility, toileting, dressing bathing and personal hygiene. On 12/13/24 at 11:15 AM, V31, Certified Nursing Assistant (CNA) assisted R12 to R12's dining room table. On 12/13/24 from 11:15 AM-12:50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain safe functioning equipment. These failures affect two residents (R3, R5) out of three residents reviewed for equipment in a sample list of 16 residents. Findings include: 1.) R3's undated Face Sheet documents medical diagnoses of Morbid Obesity, Chronic Respiratory Failure, Diabetes Mellitus, Chronic Pain, Combined Systolic and Diastolic Heart Failure, and Chronic Obstructive Pulmonary Disease (COPD). R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. This same MDS documents R3 is dependent on staff for transfers using a total body mechanical lift. On 12/13/24 at 2:10 PM, V29 and V30 Certified Nursing Assistant (CNA) assisted R3 from her wheelchair to her bed using a total body mechanical lift. V30 CNA exited R3's room stating the total body mechanical lift broke during R3's transfer. V30 stated R3 was in the sling and had been raised up in the air over R3's bed when the total body mechanical lift would…

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 a resident's (R8) right to be free from verbal and physical abuse by another resident (R1), and failed to protect a resident's (R1) right to be free from verbal abuse by a staff member. These failures affects three (R1, R8, R9) of nine residents reviewed for abuse in the sample list of nine. Findings include: The facility's Abuse Policy dated 1/9/24 documents the facility affirms the right of its residents to be free from abuse; physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment; and verbal abuse is the use of oral, written or gestured language including willful disparaging and derogatory terms to residents or families or within their hearing distance. 1.) On 11/20/24 at 12:27 PM R8 stated around 7:00 PM, R8 and R9 were outside in the smoking tent when R1 came towards R8, R1 grabbed R8's right arm tightly and pulled R8's arm, and R1 yelled move out, get out of here. R8 stated R8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to complete skin assessments and provide hygienic wound care for one of three residents (R1) reviewed for wound care from a total sample list of eight residents. Findings include: The facility provided Pressure Ulcer Policy dated 8/31/23 documents that nurses are to complete skin assessments daily for residents deemed high risk for skin breakdown. When a pressure ulcer is identified, the area will be assessed, a skin assessment completed and physician's orders will be obtained. The physician is to be notified when a pressure ulcer develops, when there is lack of improvement of the wound over time, and when there are signs of wound deterioration. R1's skin assessment dated [DATE] documents R1 is at high risk for skin breakdown. R1's October medical record does not document daily skin assessments. R1's Physician Order dated 10/15/24 documents instructions for staff to cleanse R1's sacrum wound with normal saline, pat dry, and apply foam and 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 observation, interview, and record review the facility failed to provide a working resident room call light, resulting in a fall for one (R5) of three residents reviewed for falls from a total sample list of eight residents. Findings include: The facility Accidents and Incidents Policy dated 9/7/23 documents that the facility will complete an investigation to determine the root cause of a fall and then implement appropriate interventions to prevent future falls. R5's incident report dated 10/11/24 at 10:25PM documents that R5 was witnessed getting up to go to the bathroom and lost his balance and fell. The root cause was documented as resident impulsivity, drowsiness and gait imbalance. Resident was reminded to use his call light and to use a urinal instead of getting up. The intervention was bed pads placed on the floor next to R5's bed. On 10/17/24 at 11:00AM, R5 stated, I keep falling because my call light doesn't work half the time and I get tired of waiting! I told them when I fell that it didn't work. On 10/17/24 at 11:02AM, R5's call light was pressed three times 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 provide hygienic perineal and catheter care for one (R1) of three residents reviewed for perineal and catheter care from a total sample list of eight residents. Findings include: The facility provided, undated, Perineal Care Procedure documents that woman's perineal cleansing begins separating the labia and washing downward, front to back and if the resident has an indwelling catheter, to gently wash the juncture of the tubing from the urethra down the catheter about three inches. After cleaning the front, then wash and dry the rectal area. The facility provided, Indwelling Catheter Care policy dated 10/7/22 documents that the facility shall maintain and care for urinary catheters to prevent catheter-associated urinary tract infections and adhere to the best nursing practice standards. R1's care plan dated 8/23/24 documents that R1 is at high risk for urinary tract infections due to an indwelling urinary catheter and a stage four wound on her sacrum. R1's progress notes document three urinary tract infections…

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

Based on interview and record review the facility failed to develop a pressure ulcer care plan for one (R1) of four residents reviewed for pressure ulcers on the sample list of four. Findings include: R1's Nursing Note dated 9/15/2024 at 2:23 PM, documents R1 has an open area to the left buttock. This note documents the pressure ulcer as superficial with a measurement of 1.2 centimeters (cm) in length. R1's Wound Assessment written by V3 Nurse Practitioner dated 9/25/24 documents an assessment of R1's pressure ulcers. This assessment documents a stage three pressure ulcer to the left buttock measuring 0.9 cm by 0.3 cm by 0.2 cm., a stage three pressure ulcer to the right buttock measuring 0.3 cm by 0.3 cm by 0.2 cm, and moisture associated skin damage to the intergluteal cleft. This assessment documents the start date of these areas as 9/15/24. This assessment documents instructions to offload as tolerated. R1's care plan with a start date of 4/28/24 does not document a care plan for R1's pressure ulcers. On 10/4/24 at 2:20 PM, V2 Director of Nursing stated that R1's care plan…

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 potential cross contamination during a pressure ulcer dressing change for R2 and R3 and failed to complete effective hand washing in a contact isolation room for two of two residents (R2, R3) reviewed for infection control in the sample list of three. Findings include: The facility's undated Handwashing/Hand Hygiene policy documents, This facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc. {etcetera}) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. The facility's undated Hand Washing Procedure documents, Washing Hands 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off 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 prevent the potential for cross-contamination and foodborne illness, by failing to maintain the facility commercial can opener and commercial plate warmer/storage wells in a sanitary manner, free of food-like debris and rust. The facility also failed to maintain dishware and glassware in a clean, sanitary manner free from dust, paint and caulking chips. The facility also failed to wear hair covering while preparing food. These failure affects all 85 residents residing in the facility. Findings include: 1.) On 07/21/24 at 07:55 am, during the initial kitchen tour of the facility, V4, Cook/ Dietary Assistant was plating residents food. V4 had a full, thick, black beard. V4 did not have on a beard/hair cover on. V4 stated I did not know I was suppose to cover my beard. 2.) On 07/21/24 at 8:05 am, during the same initial kitchen tour, in the dishwasher area of kitchen, there were four trays, with approximately 36 plastic drink glasses on each tray. The drink glasses on each of the four trays were stuck together…

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 have the required documentation in their Facility Assessment. This failure has the potential to affect all 85 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE], does not include the following required documentation: types of diseases listed for services, department and job structure listed,overall acuity listed, competencies to provide the level and types of care needed for residents, ethnic cultural factors that may affect care, and personnel and the education and/or training and any other competencies related to resident care. On 7/24/24, at 11:38 AM, V1 Administrator stated this is what we have (for the Facility Assessment) (which did not include the above listed information). The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 7/22/24, documents there are 85 residents residing in the facility.

Based on interview and record review the facility failed to trend the facility's monthly infections. This failure has the potential to affect all 85 residents residing in the facility. Findings include: The facility did not provide an Infection Control Surveillance and Monitoring Policy and no documents were provided for how the facility trends monthly infections to prevent further infection throughout the facility. The facility's Resident Infection Control and Antimicrobial Log dated 1/15/24 - 7/16/24, does not document the summary for total number of infections or the type of infections. There is no doucmented log for the identified pattern/trend and interventions. This log does not document a summary for the infections during these months. On 7/23/24 at 10:30 AM, V2 Director of Nursing/Infection Preventionist, stated V2 has not completed the trending for the facility's infections for this time frame. The facility's The Long Term Care Facility Application for Medicare and Medicaid dated documents there are 85 residents residing in the facility.

Based on interview and record review, the facility failed to development and implement a facility-wide antibiotic stewardship program. This failure has the potential to affect all 85 residents residing in the facility. Findings include: On 7/22/24, the facility was asked to provide their Antibiotic (ATB) Stewardship Policy and program. On 7/23/24 at 10:30 AM, V2 Director of Nursing (DON) stated V2 does not have the information requested regarding an Antibiotic Stewardship Program which includes standards, policies and procedures, that are current and based on the facility assessment and national standards. V2 also stated there is no log for staff who have infections or illnesses, there is no documentation of ongoing analysis of surveillance data and documentation of follow-up activity in response, and no ongoing review for ATB stewardship program. The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 7/22/24 documents there are 85 residents residing in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain consent for psychotropic medication use for five of five residents (R46, R55, R44, R36, R68) reviewed for psychotropic medications in the sample list of 29. Findings include: 1.) R46's Order Summary Report dated 7/23/24 documents orders for Abilify (antipsychotic) 10 milligrams (mg) by mouth once daily, started 6/1/24 and Clonazepam (antianxiety) 0.5 mg by mouth three times daily, started 6/20/24. There are no documented consents for these medication dosages in R46's electronic medical record (EMR). R46's EMR only contains Informed Consent for Psychotropic Medication forms dated 4/15/24 for Abilify 2 mg daily and 5/5/23 for Clonazepam 0.5 mg daily. On 7/24/24 at 10:45 AM-11:15 AM V2 Director of Nursing confirmed R46's Abilify and Clonazepam dosages were increased in May and June 2024. V2 stated the floor nurses are responsible for obtaining and documenting psychotropic medication consents upon admission, with new orders, and with any increase in…

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 protect the resident rights' to be free from verbal abuse by a visitor and another resident. These failures affect five of seven residents (R17, R55, R31, R40, R77) reviewed for abuse on the sample list of 29. Findings include: 1.) R17's Minimum Data Set (MDS) dated [DATE] documents R17's Brief Interview of Mental Status (BIMS) score as 15 out of a possible 15, indicating no cognitive impairment. R55's MDS dated [DATE] documents R55's BIMS score as two out of a possible 15, indicating severe cognitive impairment. R17's Allegation of Abuse Note dated 07/21/24 at 2:58 pm documents the following: Resident was observed to yell out spontaneously in the dining room. This was noted to be loud and little alarming. Resident Description: This resident responded to another resident who yelled out loudly in the dining room. This resident was observed to loudly state shut the hell up. Resident did state that yes I did say that to him. When asked about…

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 transcribe pressure ulcer treatment orders onto the Treatment Administration Record, document wound dressing changes, notify the physician of a dislodged wound graft, implement pressure relieving interventions, assess wounds weekly, and prevent cross contamination during wound treatment administration for residents. Theses failures affect three of three residents (R14, R46, R230) reviewed for pressure ulcers in the sample list of 29. Findings include: The facility's Pressure Ulcer Identification, Prevention and Treatment policy dated 8/31/23 documents the charge nurse/designee is responsible for pressure ulcer and document pressure ulcer measurements weekly. This policy includes the use of support services to prevent pressure ulcers including pressure redistribution/offloading. The weekly pressure ulcer assessments should include characteristics, tissue type, treatment, preventative measures, and physician and resident representative…

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 Failures at this level required more than one deficient practice statement. A. Based on interview and record review the facility failed to implement fall prevention interventions to prevent falls/injuries for one of three residents (R39) reviewed for falls in the sample list of 29. Findings include: a. The facility's Fall - Clinical Protocol with a revised date of March 2018 documents, A comprehensive assessment (Fall Risk Assessment) will be completed on each resident at Admission, Readmission, Quarterly, after a suspected change in condition and after an incident of concern. R39's Care Plan with an initiated date of 10/19/21 documents diagnoses including Cerebral Infarction without Residual Deficits, Hemiplegia and Hemiparesis, Paraplegia and Vascular Dementia. This Care Plan documents R39 has a self care deficit as evidenced by needing extensive assistance with ADLs (Activities of Daily Living) related to CVA (Cerebral Vascular Accident), Impaired Decision Making, Pain and Weakness with an intervention 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 interview and record review the facility failed to develop a policy for medication regimen reviews (MRRs), repeatedly failed to maintain pharmacy recommendation documentation, and follow up on pharmacy recommendations for three of five residents (R46, R55, R70) reviewed for unnecessary medications in the sample list of 29. Findings include: 1.) R46's Electronic Medical Record (EMR) includes MRRs dated 3/18/24 and 4/24/24 that document recommendations were made by the pharmacist. There is no documentation in R46's EMR, as of 7/24/24, what specific recommendations were made or that these recommendations were reported to R46's physician. R46's Pharmacist Recommendation form dated 12/29/23 documents: Resident (R46) hospitalized recently with AMS (altered mental status), Confusion and Lethargy and is receiving the following narrow therapeutic index medication (last Valporic Acid Level on file dated 3-2023; no Ammonia Level on file): Divalproex DR Tablet 500 mg (milligrams) PO (by mouth) BID (twice daily) for Bipolar. Recommend drawing Valporic Acid and Ammonia Levels to monitor…

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 complete psychotropic medication assessments, ensure appropriate diagnosis or behaviors to warrant the use of an antipsychotic, attempt gradual dose reductions (GDRs), and identify/track specific targeted behaviors for five of five residents (R55, R70, R36, R46, R68) reviewed for psychotropic medications in the sample list of 29. Findings include: 1.) R46's Order Summary Report dated 7/23/24 documents orders for Abilify (antipsychotic) 10 milligrams (mg) by mouth once daily started 6/1/24, Clonazepam (antianxiety) 0.5 mg by mouth three times daily started 6/20/24, Geodon (antipsychotic) 40 mg twice daily started 6/16/24, and Divalproex Sodium (mood stabilizer) 500 mg twice daily started 9/1/23 for Bipolar. There are no documented psychotropic medication assessments for these medications in R46's electronic medical record prior to 7/23/24. R46's May and June 2024 Medication Administration Records (MARs) document Abilify was increased from 2 mg daily to 5…

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 repeatedly failed to administer an antibiotic as ordered for one of one resident (R73) reviewed for following Physician's Orders in the sample list 29. Findings include: The facility's Physician Medication Orders policy with a revised date of April 2010 documents, Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. On 7/21/24 at 12:09 PM, V43 R73's family stated that the facility did not administer R73's Vancomycin as it was ordered by the hospital. V43 stated that they gave the wrong dose of Vancomycin and then switched to a lower dose too soon. R73's hospital discharge orders dated 7/4/24 documents orders for Vancomycin (antibiotic) 50 mg (milligrams)/ml (milliliters) oral solution, take 10 mls (500 mg total) by mouth every 6 hours for 1 day. Then Vancomycin 100 mg/ml oral solution, take 5 mls (500 mg total) by mouth every 6 hours for 10 days, start on 7/5/24. Then…

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 offer residents Influenza and Pneumococcal immunizations annually or upon admission and failed to provide educational material and consents for these vaccinations. This failure has the potential to affect all 85 residents residing in the facility. Findings include: R17 has no documented Influenza, Pneumococcal, or COVID vaccines being offered or given, no consents, and no documented pre-vaccine education. R18 has no documented Influenza, Pneumococcal, or COVID consents and no documented pre-vaccine education. R21 has no documented vaccinations given or offered, no consent forms, and no documented pre-vaccine education. R49 has no consents for Influenza, Pneumococcal, or COVID vaccines and no documented pre-vaccine education. R56 has no documentation given or offered for Influenza, Pneumococcal, and COVID vaccines and no documented pre-vaccine education. On 7/23/24 at 10:30 AM, V2 Director of Nursing/Infection Preventionist, stated V2 does not have the information requested regarding updated immunization information,…

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 promote dignity following meals for one of 28 residents (R132) reviewed for dignity in the sample list of 29. Findings include: On 7/21/24 at 9:07 AM R132 was lying in bed with a washcloth on R132's chest. R132's washcloth had a half dollar sized brown lump of pureed food and R132's mouth was covered in dried food debris. R132's dentures showed a red food/drink substance between R132's teeth and on R132's chin. On 7/21/24 at 9:10 AM R132 stated R132 did not like to be in this condition and R132 needed staff help to get cleaned up. On 7/23/24 at 12:13 PM R132 was sitting in the dining room being fed by staff. R132 had white whipped cream dripped down R132's shirt. On 7/23/24 at 12:48 PM R132 was sitting in a wheelchair in R132's room wearing the same soiled shirt. On 7/23/24 at 1:52 PM R132 was in bed wearing the same shirt which contained smears of whipped cream. R132's ongoing diagnoses list includes Dementia, right sided Hemiparesis/Hemiplegia, and Lymphedema. R132's Care Plan dated 7/9/24 documents R132…

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 required Medicare Beneficiary Notices to residents whose Medicare Part A coverage was ending. This failure affects two residents (R78 and R384) out of three reviewed for beneficiary notices on a sample list of 29. Findings include: 1. R78's Beneficiary Protection Notification Review form (undated) documents R78 was admitted to the facility under Medicare Part A coverage on 4/16/24. This same form documents R78's last day of coverage under Medicare Part A was 5/14/24. R78's Nurses Progress Notes dated 5/6/24 documents, IDT (Interdisciplinary Team) met with (R78), husband, and daughter. Discussed care and no issues and (R78's) progress in healing and going home. Family would like (R78) to be discharged on May 14th (5/14/24). R78's Beneficiary Protection Notification Review did not include any type of a notice for Medicare non-coverage (NOMNC). On 7/23/24 at 1:17 PM, V25, Business Office Manager, stated, (R78) left the facility to go home voluntarily so I didn't give her any notice. I am not the person who normally…

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 restraint reduction interventions, and failed to have consents and assessments for the use of body pillow restraints, for one of one resident (R61) reviewed for restraints in the sample list of 29. Findings include: On 7/23/24 at 10:12 AM, 10:30 AM and 10:45 AM R61 was seated in a wheelchair outside, participating in a group activity. A soft lap cushion was across R61's lap and threaded through the arm rests of R61's wheelchair. There there were no foot pedals on R61's wheelchair. On 7/23/24 at 11:40 AM V19, Certified Nursing Assistant (CNA) pushed R61 in a wheelchair from R61's hallway, into the dining room and up against a table. R61's soft lap cushion was in place. At 11:43 AM V19 confirmed V19 was R61's assigned CNA. V19 stated V19 had not provided any cares for R61 prior to transporting R61 to the dining room. V19 stated R61 was with R61's spouse earlier this morning and then has been outside participating in activities. V19…

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 resident's required discharge summary and recapitulation of stay. This failure affects one resident (R78) out of one reviewed for discharge on a sample list of 29. Findings include: R78's Nurses Progress Notes dated 4/16/24 documents R78 was admitted to the facility on this date (4/16/24). R78's Nurses Progress Notes dated 5/14/24 document R78 was discharged to home from the facility on this date (5/14/24). R78's electronic medical record did not include a discharge summary nor a recapitulation of stay. On 7/23/24 at 10:00 AM, V1, Administrator, looked through R78's computer record and stated, There is a form available in system but I do not see one was made (completed) for (R78). On 7/24/24 at 2:50 PM, V2, Director of Nursing, after searching the electronic and paper medical records for R78 stated, There was no discharge summary.

Based on observation, interview and record review the facility failed to prevent tension to male urethra during urinary catheter care by failing to remove the catheter tubing from a residents leg mounted anchor during care and failed to stabilize catheter tubing during cleansing for one of one resident (R73) reviewed for catheter care in the sample list of 29. Finding include: The facility's Indwelling Catheter Care policy with a revised date of 10/7/22 documents, Purpose: To provide guidance to facility staff on the care of residents with an indwelling (urinary) catheter within the facility to prevent catheter-associated urinary tract infections. R73's Order Summary Report dated 7/22/24 documents diagnoses including Hydronephrosis with Renal and Ureteral Calculous Obstruction, Obstructive and Reflux Uropathy, Dementia, Alzheimer's and Unspecified Urethral Stricture. This Order Summary does not document orders for Urinary Catheter Care. On 7/23/24 at 10:30 AM, V27 and V28 Certified Nursing Assistants (CNAs) prepared to perform Urinary Catheter care for R73. R73 was laying 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.

Based on observation, interview and record review the facility failed to implement post-fall interventions for two of three residents (R2 and R3) reviewed for falls on the sample list of three. Findings include: 1.) R2's Incident note includes R2's fall investigation, and Interdisciplinary Note (IDT) dated 5/20/24, documents R2 had an unwitnessed fall in the bathroom. The IDT note documents the root cause of the fall was R2 did not lock R2's wheelchair when he stood up to go to the bathroom. The same IDT note documents the following intervention: Anti rollback will be added to his wheelchair for added safety. R2's Care Plan dated, last revised 6/3/24, documents the following fall intervention: 5/21/24 will apply anti roll back to wheelchair. On 6/12/24 at 3:20 am V11, Certified Nursing Assist (CNA) entered R2's room. R2 was seated in his recliner. R2's wheelchair was locked and within resident reach. R2's wheelchair did not have an anti rollback attachment on R2's wheelchair. R2 stated R2 does not know that his wheelchair had been modified. On 6/12/24 at 3:29 pm V12, Licensed…

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 report a resident incident to the physician for one (R1) of three residents reviewed for skin injuries in the sample list of six. Findings include: On 5/14/24 at 9:41 AM R1 stated there used to be sandpaper textured nonskid strips on the floor of R1's room. R1 stated this past Friday (5/10/24) V5 Certified Nursing Assistant (CNA) was helping R1 to transfer and get ready for R1's shower. R1 stated V5 rushed R1 and did not apply R1's shoes before the transfer. R1 stated the dressing on R1's foot slid down and R1's right heel wound rubbed against the nonskid floor strips causing the wound to bleed. R1 stated the nurse had to put a new dressing on it. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1's Wound Assessment and Plan dated 5/8/24 documents R1's right heel Stage Three pressure ulcer measured 3 centimeters (cm) long by 2.4 cm wide by less than 0.1 cm deep, had 100% granulation tissue, and minimal drainage. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to properly transfer a resident (R1). R1 is one of six residents reviewed for accidents/incidents in the sample list of six. Findings include: On 5/14/24 at 9:41 AM, R1 stated there used to be sandpaper textured nonskid strips on the floor of R1's room. R1 stated this past Friday (5/10/24) V5 Certified Nursing Assistant (CNA) was helping transfer R1 and get R1 ready to shower. R1 stated V5 rushed R1 and did not apply R1's shoes. R1 stated the dressing on R1's foot slid down, R1's right heel wound rubbed against the nonskid floor strips causing the wound to bleed, and the nurse had to put a new dressing on it. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact and R1 requires partial/moderate staff assistance when moving from sitting to standing and for bed to chair transfers. R1's Care Plan dated 6/16/23 documents R1 has a self care deficit related to Cerebrovascular Accident diagnoses and requires assistance of two staff 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 implement Enhanced Barrier Precautions (EBP) for one (R1) of three residents reviewed for skin injuries in the sample list of six. Findings include: R1's Physician Order dated 4/16/24 documents to cleanse the right heel wound, apply Collagen, cover with an abdominal pad, and wrap with gauze every evening shift. R1's Physician Order dated 1/11/24 documents EBP due to wound. R1's Wound Assessment and Plan dated 5/8/24 documents R1's right heel Stage Three pressure ulcer measured 3 centimeters (cm) long by 2.4 cm wide by less than 0.1 cm deep, had 100% granulation tissue, and minimal drainage. On 5/14/24 at 9:41 AM there was a sign posted on R1's doorway that instructed Enhanced Barrier Precautions and to wear a gown and gloves when providing high contact cares. There was a cart outside of R1's doorway that contained Personal Protective Equipment. On 5/14/24 at 11:27 AM V7 Licensed Practical Nurse entered R1's room without applying a gown. V7 applied gloves and removed R1's right heel wound dressing that had 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 interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affected one of three residents (R2) reviewed for abuse in the sample of three. Findings Include: The facility's undated Abuse Prevention Policy documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, and kicking. The Verification of Incident Investigation/Administrative Summary dated 1/25/24 documents on 1/25/24 at 10:40 AM R1 physically assaulted R2. V7 Therapy Staff witnessed the incident. V7's statement dated 1/25/24 documents V7 witnessed R1 standing up and out of his wheelchair (no alarm sounded). R1 grabbed a blanket and wrapped it around R2's neck. V7 yelled for help, the residents were separated and R1 was removed from the area. R1 was sent to the emergency…

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 thoroughly investigate alleged mental abuse and failed to suspend alleged perpetrators. This failure has the potential to affect all 74 residents residing in the facility. Findings Include: 1. On 1/7/24 at 1:00 PM V11 Certified Nurse's Assistant (CNA) stated on 12/15/23 at approximately 9:20 AM V11 observed V14 CNA standing right behind V9 CNA, rubbing on V9's bottom when V9 was assisting R4 with a shower. V11 is unsure if R4 understood what was going on but V11 stated R4 could see both V9 and V14. V11 stated she did not report this to V1 Administrator. 2. On 1/7/24 at 11:06 AM V4 Registered Nurse (RN) stated on 1/2/24, V5 CNA and V11 CNA called her to R3's room. R3 reported to V4 that two female CNAs had been kissing in his room and doing sexual things in front of him on three different occasions. V4 stated R3 appeared very upset and uncomfortable with the situation. V4 stated she immediately reported R3's allegations to V1 Administrator. V4 stated V1 told her the situation was being handled, she shouldn't believe rumors…

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 one incident of potential mental abuse immediately to the Administrator and failed to report two incidents of potential mental abuse to the State Survey Agency. This failure affects three of four residents (R2, R3, R4) reviewed for abuse in the sample of four. Findings Include: 1. On 1/7/24 at 1:00 PM V11 Certified Nurse's Assistant (CNA) stated on 12/15/23 at approximately 9:20 AM V11 observed V14 CNA standing right behind V9 CNA, rubbing on V9's bottom when V9 was assisting R4 with a shower. V11 is unsure if R4 understood what was going on but V11 stated R4 could see both V9 and V14. V11 stated she did not report this to V1 Administrator. 2. On 1/7/24 at 11:06 AM V4 Registered Nurse (RN) stated on 1/2/24, V5 CNA and V11 CNA called her to R3's room. R3 reported to V4 that two female CNAs had been kissing in his room and doing sexual things in front of him on three different occasions. V4 stated R3 appeared very upset and uncomfortable with the situation. V4 stated she immediately reported R3's allegations to V1…

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

Based on observation, interview, and record review, the facility failed to properly store nutritional supplement. This failure has the potential to affect all 74 residents residing in the facility. Findings include: On 12/28/2023 at 11:35AM, eight cases of nutritional supplement were stacked on the floor against the East hallway wall across from a bathroom entrance. Two boxes were opened, and one bottle of supplement was resting on top of the stacked boxes. The East hallway is a common corridor open to all staff, resident, and visitor use. The hallway is not under visual supervision by staff. On 12/29/2023 at 11:05AM, the above nutritional supplement remained on the floor of the East hallway of the facility. On 1/4/2023 at 2:02PM, V9 (Licensed Practical Nurse) reported the facility maintenance staff delivered the above nutritional supplement to the nursing floors and nursing staff hadn't placed the boxes into the nursing storage room yet. On 1/5/2024 at 2:12PM, V9 reported the nutritional supplement stored in the East hallway on 12/28/2023 and 12/29/2024 is available for any…

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

Based on interview and record review, the facility failed to ensure required personnel attended the facility's Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 74 residents in the facility. Findings include: On 1/4/2024 at 2:21PM, V14 (Business Development) provided four attendance sheets (January 9, 2023; April 10, 2023; June 26, 2023; September 25, 2023) documenting attendees at the facility's quarterly QAA meetings during the previous year. The June 26, 2023, and September 25, 2023, attendance sheets do not document the facility Medical Director (V16) was present for those QAA meetings. V14 reported the facility has had difficulty getting V16's schedule to work with attending the facility's QAA meetings. V14 denied V16 attended the June or September QAA meeting remotely. The facility QAA attendance sheet (June 26, 2023) documents: (V16) - phone review - unable to attend. The facility Midnight Census Report (12/29/2023) documents 74 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a resident's room at a comfortable temperature. This failure affected one of three residents (R62) reviewed for comfortable room temperatures on the sample list of 74. Findings Include: R62's Medical Diagnoses list dated January 2024 documents R62 is diagnosed with Acute and Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Heart Failure, Anemia, Anxiety, and Pain. R62's Minimum Data Set, dated [DATE] documents R62 is completely cognitively intact. R62's Transfer Evaluation dated 12/5/23 documents R62 requires a mechanical lift and staff assistance for transfers and mobility. R62's Care Plan dated 11/29/23 documents R62 requires assistance with transferring, toileting, dressing, personal hygiene, bathing, and bed mobility. On 1/3/24 at 2:30 PM R62's room temperature measured between 61 - 65 degrees Fahrenheit by the State Agency thermometer. R62 was sitting in the hallway in her wheelchair…

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 showers to dependent residents. This failure affected three of three residents (R8, R9, R62) reviewed for showers on the sample list of 74. Findings Include: The facility's Bathing Policy dated 4/25/22 documents showers must be offered per resident preference at least twice per week and documented when completed. On 1/3/24 at 1:50 PM the North Hall shower room's temperature measured 56 degrees Fahrenheit by the State Agency thermometer. On 1/3/24 at 1:52 PM the South Hall shower room's temperature measured 51 degrees Fahrenheit by the State Agency thermometer. 1. R8's Medical Diagnoses list dated January 2024 documents R8 is diagnosed with Cerebral Palsy, Autonomic Neuropathy Disease, Post Traumatic Stress Disorder, Anxiety, Insomnia, Pain in Right Knee, and Chronic Pain. R8's Minimum Data Set, dated [DATE] documents R8 is completely cognitively intact. R8's Transfer Evaluation dated 12/28/23 documents R8 requires a mechanical lift…

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 interviews the facility failed to provide Resident Council with responses, actions, and rationale taken regarding their concerns for the months of August, September, and October 2023. This failure affects five residents (R4-R8) reviewed for lack of staff. Findings include: Resident Council Meeting minutes document the following: -August 17, 2023, documents the meeting was called to order at 10:30 AM. Resident Council Minutes discuss old business, new business, and all departments of the facility. The department about CNA's (certified nursing assistant) state the residents have concerns with call lights not being answered and concerns with not receiving showers timely. -September 20, 2023, documents the meeting was called to order at 11:10 AM. All departments were discussed. Council members stated Nursing department concerns are with medication pass times and receiving medication. The CNA department once again states they have an issue in receiving showers. -October 25, 2023, documents the meeting was called to order at 11:05 AM. In discussing the…

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

Based on interview and record review, the facility failed to provide adequate supervision in conducting and documenting visual checks of a resident with a known history to initiate an unwitnessed exit from the facility. This failure affects one resident (R1) out of a sample of three reviewed for a risk of unwitnessed exits. Findings include: R1's Census Detail dated 10/4/23 documents R1 was admitted to the facility 5/6/22. R1's Nursing Progress Notes dated 4/26/23 documents R1 had received placement of an (electronic alarm monitoring device) on his right ankle. R1's Elopement Risk Assessments dated 4/26/23 document R1 had a change in status from not being a risk for elopement to a moderate risk beginning 4/26/23. Subsequent Elopement Risk Assessments dated 5/8/23 and 5/31/23 document R1 continued as a moderate risk for elopement. On 10/4/23 at 11:55 am, V11, Social Services Director, stated, Around April (2023) (R1) started verbalizing to me that he wanted out of here, and that kind of statement triggers me to do a new elopement assessment. R1's Nursing Progress Notes dated 5/3/23…

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 store frozen foods in an order to protect from cross-contamination, failed to maintain kitchen equipment in a sanitary manner, and failed to maintain a kitchen appliance to operate as designed for sanitation. These failures have the potential to affect all 69 residents residing in the facility. Findings include: 1. On 6/13/23 at 10:05 AM, inside the facility's chest style freezer, there was a re-sealable plastic bag of raw/uncooked chicken breast fillets stored directly on top of a cardboard box containing cheese ravioli. This raw chicken was also over the top of a cardboard box of bread dough. On 6/13/23 at 10:05 AM, V4, Dietary manager, stated, (V5, Dietary Aid) just put those (chicken fillets) in there this morning because the reach-in freezer wasn't getting cold enough. V4 picked up the bag of frozen chicken and placed it off to the side of the freezer chest among other bags of meats. 2. On 6/13/23 at 10:09 AM, inside the facility's reach-in freezer, there was a plastic bag of raw/ uncooked pork sausage…

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 conduct one of four required quarterly Quality Assurance Committee meetings and failed to include required members such as the Director of Nursing and the Infection Preventionist. These failures have the potential to affect all 69 residents residing in the facility. Findings include: The Center for Medicare and Medicaid Services [NAME] Report 003D Provider History Profile dated 6/7/23 documents the facility's most recent prior annual survey was conducted 4/15/22. The facility's Quality Assurance (QA) quarterly meeting sign-in sheets, provided by V1, Administrator, on 6/13/23 document three QA meetings held by the facility since the most recent prior annual survey. These meetings were held at the facility on 10/3/22, 1/9/23, and 4/10/23. These meeting sign-in sheets did not include the signatures of the facility's Director of Nursing nor Infection Preventionist. On 6/14/23 at 12:57 PM, V1 Administrator reviewed the three QA sign-in sheets and confirmed there was not a Director of Nursing nor Infection Preventionist in…

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 label and date residents' medications when opened. This failure affects four residents (R13, R30, R38, R41) reviewed during medication storage on the sample list of 34. Findings include: 1.) On 6/14/23 at 12:58 PM, V15, Registered Nurse (RN) opened the top drawer of the south hall medication cart. V15, RN confirmed the medication cart drawer contained two opened, undated, Insulin cartridge pens that belong to R30. R30's opened Lispro and Lantus Insulin cartridge pens were not dated when they were opened. R30's Physician Order Summary Report (POS) sheet dated 6/16/23 documents the following active order: Insulin Lispro (1 Unit Dial) Solution Pen-injector 100 UNIT/ML (milliliter) Inject 10 unit subcutaneous before meals for DM II (Diabetes Mellitus Type II) hold for BS (blood glucose level) < (less then) 90, call office if s/s (signs or symptoms of) hypoglycemia. The same POS documents the following: Lantus SoloStar Subcutaneous Solution…

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 offer, administer and/or obtain declinations for Pneumococcal Conjugate Vaccination (PCV) 13, 15 or 20 and/or Pneumococcal Polysaccharide Vaccine (PPSV) 23 for four residents (R26, R28, R33, R60) out of five residents reviewed for Vaccinations in a sample list of 34 residents. Findings include: The facility policy titled 'Pneumococcal Vaccine' revised October 2019 documents all residents will be offered Pneumococcal vaccines to aide in preventing Pneumonia/Pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal…

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 the dignity of one (R26) resident was maintained by not providing timely incontinence care, grooming/personal hygiene, and bed linens for a resident. This failure affects one (R26) resident reviewed for dignity in a sample list of 34 residents. Findings include: On 6/13/23 at 10:30 AM R26 observed with two-inch-long chin whiskers walking in hallway on Dementia Unit. On 6/13/23 at 12:10 PM R26 observed sitting at dining room table eating lunch meal. R26 observed with dozens of two-inch-long grey hairs on chin. R26 observed taking a bite of mashed potato that dropped onto chin whiskers. R26 observed trying to pull a piece of potato out of R26's chin hair. On 6/14/23 at 9:30 AM R26 observed walking in hallway with other residents nearby. R26 observed with dozens of two-inch-long chin hairs. On 6/15/23 at 12:05 PM R26 observed to have dozens of two-inch-long chin hairs while eating lunch with other residents who shared the same dining…

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 privacy during a resident's Insulin administration. This failure affected one of 13 residents (R219) reviewed for privacy during medication administration on the sample list of 34. Findings include: On 6/14/23 at 5:10 PM, R219 observed laying in the first bed closest to the opened bedroom door. R219 was in full view of co-resident, staff, and visitors. V15, Registered Nurse (RN) raised R219's shirt, exposing R219's full abdomen. V15, RN administered Insulin Lispro Injection Solution Pen 100 units per milliliter, 17 units subcutaneous into R219's left lower abdomen. On 6/14/23 at 5:17 PM, R219 stated I like the door closed. I didn't like that when she (V15, RN) left it (bedroom door) wide open like that. She did it so fast, I didn't have time to say anything. On 6/14/23 at 5:40 PM V15, RN stated I should have closed his (R219) door, before I gave the insulin. I don't know why I left it open like that. Just being watched by 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 observation, interview, and record review the facility failed to develop a Comprehensive Care Plan for two of twenty residents (R43, R49) reviewed for Comprehensive Care Plans in the sample list of 34. Findings include: 1. On 6/13/23 at 12:20 PM R43 was sitting in her wheelchair in her room eating pureed food. On 6/13/23 at 12:20 PM R43 stated she just started eating solid food again last month after a year of being solely on tube feedings after her stroke. R43 stated sometimes she feels the food gets stuck because she eats too fast and sometimes she gets choked up but she always gets it down. On 6/16/23 at 1:24 PM V3 Regional Clinical Nurse confirmed Care Plans need to be updated and be specific to each resident's needs. V3 confirmed R43 has Dysphagia and was recently switched from tube feedings to pureed food. V3 confirmed Dysphagia and related diet order and eating precautions/interventions should be on R43's Care Plan. R43's Physician Order Sheet (POS) dated June 2023 documents R43 is diagnosed with Cerebral Infarction, Dysphagia, and Protein Calorie Malnutrition. The…

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

Based on observation, interview, and record review, the facility failed to ensure wound treatments and dressing changes were completed as ordered per the physician and per the resident's plan of care for a resident with Lymphedema and open skin wounds. This failure affects one resident (R6) out of two reviewed for skin conditions on the sample list of 34. Findings include: On 6/13/23 at 10:00 AM, R6 was laying in bed supine with gauze dressing wraps on both legs from the toes to the knees. On 6/13/23 at 10:00 AM, R6 stated, I do have some wounds because I have Lymphedema. My legs are supposed to be wrapped on Wednesdays and Saturdays but sometimes the nurses aren't doing it. On 6/15/23 at 11:18 AM, V20, Registered Nurse, stated, (R6) has not refused any care from me and I have not heard of (R6) refusing any cares. V20 further stated, (R6's) leg wraps get changed on Wednesdays and Saturdays after (R6's) bed bath on evening shift because (R6) is adamant about getting the wraps changed after (R6's) bed bath. V20 continued stating, It really isn't possible to overlook or ignore the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide palatable protein during breakfast and failed to have a substitute available for resident consumption. This failure affects one on five residents (R49) reviewed for nutrition on the sample list of 34. Findings include: On 6/15/23 at 8:40 AM, V15, Registered Nurse (RN) entered R49's room. R49 voiced a complaint (R49) hard sausage, that is burnt, (R49) can't even cut it. V15, RN confirmed R49's sausage was burnt when V15, RN unsuccessfully attempted to cut R49's charred sausage with a fork. V19, Certified Nursing Assistant (CNA) stated The kitchen said the facility is completely out of sausage. V15, RN directed V19, CNA to check with the kitchen on alternate menu items available. On 6/15/23 at 8:44 AM V19, CNA returned from the kitchen stated to V15, RN that V19, CNA was told by the kitchen staff (unidentified), there is no more sausage and there are no alternatives to replace the sausage served. V19, CNA then entered R49's room 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.