Goldwater Care Peoria Heights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure scheduled physician ordered medications were given for four of six residents (R1, R2, R7, and R9) reviewed for medications in the sample of 16.Findings include:The facility's Ordering and Receiving Non-Controlled Medications, dated 6/2024, documents Policy: Medications and related products are received from the pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. The facility's Medication Administration General Guidelines Policy, undated, documents Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). Administration: 2. Medications are administered in accordance with written orders of the prescriber.…

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 refund money owed to a resident's representative timely after the resident left the facility for one of three residents (R3) reviewed for resident funds in the sample of 16. Findings include:The Abuse policy dated 10/24/22 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Misappropriation of Resident Property means the…

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 resident falls were investigated and care planned, develop new interventions after falling, and ensure existing fall interventions were implemented for three of four residents (R1, R7, R9) reviewed for falls in the sample of 16.Findings include:The facility's Fall Prevention Program policy, dated 11/21/17, documents To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Components include Notification of physician, family/legal representative, care plan incorporates; identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures. Safety interventions will be implemented for each resident identified at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record review, the facility failed to complete physician ordered weights for two of three residents (R1, R9) reviewed for nutrition in the sample of 16.Findings include:The facility's Weights policy, dated 10/17/19, documents Each resident shall be weighed on admission and at least monthly thereafter, or in accordance with Physician orders or plan of care. Residents identified at nutritional risk may be weighed weekly or bi-weekly as per physician order or interdisciplinary team recommendation.1. R1's current Care Plan, dated 1/20/26, documents R1 was admitted to the facility on [DATE] with multiple diagnoses including Lung Cancer, Brain Cancer, Chronic Kidney disease, Failure to Thrive, Muscle Wasting and Atrophy, and Severe Protein-Calorie Malnutrition.R1's Medication Administration Record (MAR), dated 12/1/25-12/31/25, documents R1 had a physician order started on 12/4/25 for height and weight upon admission on e time for height and weight daily for seven days. This same record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a resident was free of significant medication errors for two of three residents (R4 and R6) reviewed for significant medication errors in the sample of 16. Findings include:The facility's Medication Administration General Guidelines Policy, undated, documents Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). Administration: 2. Medications are administered in accordance with written orders of the prescriber. Documentation (including electronic): 6. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (Example: the resident is not in the facility at scheduled dose time 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 to ensure physician ordered laboratory (lab) monitoring was completed and processed for one of three residents (R9) reviewed for laboratory monitoring in the sample of 16.Findings include:The facility's Facility Assessment tool, dated 11/1/25, documents the facility will employ or contract hire staff to provide competent support and care for their resident population on a daily basis and during emergencies to provide clinical laboratory services and diagnostic x-ray services.R9's Physician Order Summary (POS), dated 11/20/25-2/10/26, documents R9 was ordered the following labs on 12/23/25; CBC (Complete Blood Count) one time related to pressure ulcer of sacral region, CRP (C-reactive Protein) one time related to pressure ulcer of sacral region, Hemoglobin A1C one time for diabetes, Prealbumin one time related to pressure ulcer of sacral region stage four, and Sedimentation Rate one time related to pressure ulcer of sacral region. This same summary documents R9 was ordered the following labs on 12/30/25 and 1/13/26; CBC one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review, the facility failed to ensure a physician orbital x-ray (radiography imaging) was completed for one of three residents (R1) reviewed for x-ray imaging in the sample of 16.Findings include:The facility's Facility Assessment tool, dated 11/1/25, documents the facility will employ or contract hire staff to provide competent support and care for their resident population on a daily basis and during emergencies to provide clinical laboratory services and diagnostic x-ray services.R1's nursing progress notes, dated 12/28/25 at 12:45 PM, documents Resident had a witnessed fall 12/28/2025 at 12:00 PM. Location of Fall: hallway (R1) was wheeling himself in wheelchair and scooted himself out of chair. Resident statement (if applicable): Resident states I was trying come get help to go lay down. I hit my head.R1's nursing progress notes, dated 12/29/25 at 6:06 AM, documents Upon report this nurse and night shift nurse noticed resident had slight swelling and a bruised right eye…

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

Based on record review and interview, the facility failed to ensure their abuse policy was implemented when the facility failed to separate a visitor from a resident (R2) after an alleged altercation was reported for one of four residents (R2) reviewed for abuse in the sample of six.Findings include:On 12/5/25 at 2:19 PM V7/LPN (Licensed Practical Nurse) stated, The early morning of 12/3/25 I was the nurse for (R1) and (R2). Around 1:30 AM (R2) came to the nurse's station crying saying (V6/R1's family) was being mean to her. I didn't know (V6) was there at this time. I walked down to (R2's) room approached (V6) to find out what was going on. (V6) started cursing at (R2) saying Nobody cares about your def a. The situation started escalating, so I told (V6) that this was (R2's) home and that visiting hours were over at 8:00 PM and asked (V6) to leave. (V6) was agreeable at this point. (V6) gave (R1) a kiss and looked as if she was packing up her things to leave. (V6) stated at this time that (R1) and (R2) were switching rooms in the morning anyways and would no longer be roommates.…

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

Based on record review and interview the facility failed to report an allegation of visitor to resident verbal abuse to the state agency for one of four residents (R2) reviewed for abuse in the sample of six. Findings include:A written communication dated 12/3/25 at 3:39 AM from V7/LPN (Licensed Practical Nurse) to V1/Administrator documents, Resident abuse report. 1:30 AM (R2) approached nurses station crying that her roommate's daughter (V6) was being mean to (R2). (V7) entered (R2) rooms to assess situation. (V6/R1's family) stated, (R2) is just mad because she doesn't want me in here. (V7) replied this is (R2's) home as well as (R1's), but visiting hours are over at 8:00 PM. At this time (V6) was agreeable to leave but started to swear at (R2) saying things like yo deaf a! This nurse requested that (R2) and (V6) no longer interact with each other. This same written communication documents, (V6) exited the facility. At 2:15 AM (R2) approached (V7) again. Visibly upset and crying explaining that she now needed new bed lines because when she went to get into her bed, (R2's) 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 interview and record review the facility failed to address concerns voiced by residents during their resident council meetings. This failure has the potential to affect all forty-six residents who reside in the facility. The facility's Grievances policy dated 9/25/2017 documents the policy's purpose as to ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at this campus. All alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, will be immediately reported to the administrator and as required by state law. The facility's Grievances policy also documents All written grievances shall include: The date the grievance was received; a summary statement of the grievance; department assigned to investigate; steps taken to investigate the grievance; summary of the…

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

Based on interview and record review the facility failed to investigate an allegation of abuse for 2 residents (R10 and R11) of five residents reviewed for abuse in a sample of ten. The Facility's Abuse Prevention and Reporting policy dated 10/24/22 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and service by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. The Facility's Abuse Prevention and Reporting policy dated 10/24/22 documents the definition of abuse as: any physical or mental injury or sexual assault…

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 resident room temperatures were maintained at a safe and comfortable temperature of 71 degrees Fahrenheit or higher for 14 of 15 residents (R2-R15) reviewed for safe and comfortable environment in the sample of 17. Findings include: The facility's Maintenance Policy (undated) documents, Purpose: To ensure the building (interior and exterior), grounds, and equipment are maintained in a safe and operatable manner. Policy: It is the policy of the facility to provide a safe, accessible, effective environment of care that is consistent with its mission, services, and laws and regulations. The facility's Code White-Extreme Weather dated 9-22-22 documents, Purpose: To provide staff specific guidance and instruction on how to initiate an emergency code and steps to be taken to ensure the safety of residents and staff in the event of extreme weather/temperature related conditions. The facility will follow federal requirement to maintain facility temperatures between 71-80 degrees Fahrenheit. The Local…

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 hold Quality Assurance (QA) and Improvement Committee Meetings. This failure has the potential to affect all 40 residents who currently reside in the facility. Findings Include: The Facility's Quality Assurance and Improvement Agenda dated 4/19/2019 documents that the following areas will be reviewed as a Quality Assurance Team at least every quarter: Resident Concerns, Consultant/Department Reports, Policy and Procedure Review and Updates, Nursing and Quality Improvement Information, Special Unit Report (if applicable), Dietary Report, Social Service Report, Activity Department, Housekeeping and Laundry, Quality Assurance Audits/Rounds, Surveys Compliance, Life Safety Concerns, Safety Issues/Risk Management, Personnel, Environmental Improvements Planned/Made during the Quarter, Census/marketing Recruitment. On 10/01/24 at 12:15 PM, V1 (Administrator in Training) stated I have no documentation of any QA meetings done prior to me coming in April 2024. I held one immediately upon hire because I did not see where it had been…

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

Based on record review and interview the facility failed to monitor infections. This failure has the potential to affect all 40 residents that currently reside in the facility. Findings Include: The Facility's Infection Control Surveillance and Monitoring policy dated 4/11/2022 documents It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. Monitoring of the day-to-day operation of the Infection Control Program will be conducted by the DON/ICP (Director of Nursing/Infection Preventionist). Included in the duties are: Investigation and implementation of controls to prevent infections in the facility, determine and direct the correct procedures necessary for the prevention of infections. This shall be done on an individual basis, applying the concepts of isolation per infection, follow up on documentation of, and reporting of infection to physicians, through direct, random inspections of the clinical record with respect to: 1) Isolation techniques initiated and followed, 2)…

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

Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program. This failure has the potential to affect all 40 residents that currently reside in the facility. Findings Include: The facility's Antibiotic Stewardship Program Protocol dated 12/12/18 states, Purpose: To improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished using the Core Elements. Core Elements for Antibiotic Stewardship: 1. Leadership Commitment: Demonstrates support and commitment for safe and appropriate antibiotic use. Accountability: Identify physicians, nursing, and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities. Action: Implement as least one policy or practice to improve antibiotic use. Tracking: Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic…

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

Based on record review and interview, the facility failed to notify the local Office of the State Long-Term Care Ombudsman and Residents/Residents' Representative in writing of resident Hospital Transfer/Discharge for five (R2, R6, R30, R34 and R291) of five residents reviewed for transfers and hospitalizations in the sample of 23. Findings include: Facility Transfer and Discharge Policy and Procedure, undated, documents that transfer or discharge documentation in the Residents clinical record shall be required. R2's Census List dated 10/1/24 documents a Hospital Paid Leave on 10/17/23, 2/26/24, 3/11/24, 4/5/24, 4/29/24, 6/4/24, 6/20/24, 7/10/24, 8/8/24 and 9/1/24. R6's Census List dated 10/1/24 documents a Hospital Paid Leave on 6/14/24 and 8/19/24. R30's Census List dated 10/1/24 documents a Hospital Paid Leave on 11/15/23, 12/20/23 and 7/3/24. R34's Census List dated 10/1/24 documents a Hospital Paid Leave on 9/20/24. R291's Census List dated 10/1/24 documents a Hospital Paid Leave on 8/24/24, 9/2/24 and 9/5/24. 1. On 10/1/24 at 12:10 pm, V9 (Social Service Manager) stated, I…

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 new/updated PASARR (Preadmission Screening and Resident Review) Level II for one (R30) of two residents reviewed for PASARR screenings in a sample of 23. Findings include: On 10/1/24 at 1:30 pm, V1 (Administrator) stated, I am unable to provide a PASARR Policy; we do not have a PASARR Policy. R30's Physician Order Summary Report, dated 10/1/24, documents an admission dated of 12/31/23 and medication orders (Venlafaxine Hydrochloride and Aripiprazole) for diagnoses including Major Depressive Disorder, Severe Psychotic Symptoms, Bipolar Disorder, Unspecified Psychosis and Delusional Disorder. R30's Notice of PASARR Level II Screen Outcome, dated 7/31/23, documents the date of Short-Term Approval ends on 10/29/23. The PASARR Outcome Explanation documents that this Level II evaluation is good within 90 calendar days of the Notice Date listed on the PASARR Level II Outcome and after that time, you must have an updated Level I and Level II before you to go to a Medicaid Certified Nursing Facility. On 10/1/24 at 1:30…

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 resident's prescribed medication was available for one (R1) of three residents reviewed for medication administration in a sample of three. Findings include: The facility's Medication Administration policy, revised 11/18/17, documents Procedure: 21. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Like medications are not to be Borrowed from one resident to another. R1's current Physician Order Sheet/POS documents an order for Zolpidem Tartrate Oral Tablet 10mg (milligrams) give one tablet by mouth at bedtime related to insomnia. R1's current Care Plan documents a focus of (R1) is on sedative/hypnotic therapy related to insomnia, with interventions including but not limited to Administer Sedative/Hypnotic medications as ordered by physician. On 7/9/24, at 12:36pm, R1 sat in his room and stated he did not receive his Ambien (Zolpidem) two or three times in June due to an ordering issue. R1 said I did not sleep well…

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

Based on observation, interview, and record review the facility failed to ensure residents had fresh water available between meals for six of seven residents (R2-R7) reviewed for hydration in the sample of seven. Findings include: The facility's Hydration policy dated 06/2006 documents, It is the policy of (the facility) that the facility will provide each resident with sufficient fluids to maintain proper hydration. Procedure: 1. Provide fluids (6-8 glasses per day) to residents during and in-between meals and during activities. 2. Provide fresh water and ice at the bedside except where contraindicated (example fluid restriction). 1. R2's current Physician's Orders document R2 has an order for thin liquids. On 5-13-24 at 10:15 AM R2 was sitting on the edge of his bed. R2 stated, We (residents) do not get served fresh ice water every shift. Whenever I need water, I have to get it myself out of the tap. The ice chest is locked up so I cannot get ice. A lot of residents cannot get themselves their own water. 2. R3's current Physician's Orders document R3 has an order for thin 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 record review and interview, the facility failed to ensure call lights were answered in a timely manner for one of three residents (R1) reviewed for call light response time in a sample of seven. Findings include: The Rehab (Rehabilitation) Resident Council Meeting Minutes dated 4/30/24 documents Slow call light reaction 2nd shift and 1st shift. On 5/13/24 at 10:20 AM, R1 stated I came the end of December (2023). Sometimes the call light can take hours to get answered. It's not all the time. It's usually worse on day shift because the aides are so busy doing stuff. On 5/14 24 at 11:15 AM, V14 (Agency Nurse) stated There is a wait time for the call lights to be answered. Nurses try to help as much as possible, but we have our duties too. Like, the night before (5/12-13/24) we had one aide in the whole building. Everyone called off. We tried to get staff called in, but we can only do what we can do. On 5/14/24 at 11:45 AM, V2 (Director of Nursing) stated call light response time has been an issue and filling vacant positions and getting CNA's (Certified Nurse Aides) trained…

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

Based on record review and interview, the facility failed to ensure staff provided care by assessing, evaluating, and providing immediate treatment of an acute condition for one of three residents (R1) reviewed for changes in condition in a sample of seven. Findings include: The Notification of Change in Resident Condition or Status policy dated 7/1/12, documents 1. The nurse supervisor/charge nurse will notify the residents attending physician or on-call physician when there has been e. A significant change in the resident's physical/emotional/mental condition; g. Refusal of treatment or medications; h. A need to transfer the resident to a hospital; j. Instructions to notify the physician of changes in the resident's condition; k. Onset of temperature of a temperature two degrees higher than baseline; l. Symptoms of any infectious process; 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The Nursing Documentation Guidelines policy, not dated, documents vital signs…

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

Based on record review and interview the facility failed to obtain scheduled physician prescribed medications from the pharmacy for one of three residents (R2) reviewed for medication availability in the sample of seven. Findings include: The facility's Conformance with Physician Medication Orders policy dated 9-27-17 documents all medications, including cathartics, headache remedies, or vitamins, etc. (etcetera) shall be given as prescribed by the physician and at the designated time. This policy also documents the resident's attending physician shall be notified to promptly renew prescription order to avoid interruption of the resident's therapeutic regimen. R2's Order Summary Report dated 5-13-24 documents the following current medication orders: Order date 3-22-24: Atenolol 50 mg (milligrams) one tablet by mouth two times a day for the diagnosis of Hypertension. Order date 4-26-24: Zolpidem Tartrate 10 mg one tablet by mouth at bedtime daily for the diagnosis of Insomnia. R2's Medication Administration Records dated 5-1-24 through 5-31-24 document R2 did not receive his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Physical Therapy/Occupational Therapy (PT/OT) was provided per physician order for one of three (R1) residents reviewed for therapy services in a sample of seven. Findings include: The Admissions Policy, dated 10/2006, documents To admit and/or retain only those residents whose health care needs can be met through services of the facility and staff, in cooperation with outside resources under contract with the facility. Prior to admission, a thorough pre-screening of potential residents shall be done with the resident or guardian or responsible party determining appropriate placement. The Facility assessment dated [DATE] documents Resident support/care needs the facility provided various services for the residents we care for. The resident's care is based on their individual needs and preferences and are reflected in the individuals care plan. The care and services provided are broken down by category: Therapy PT, OT . On 12/21/23, R1's New…

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

Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for six residents (R5-R10) on the sample of residents reviewed for medication pass. This failure resulted in medication errors out of thirty-six opportunities for error, for a 22 percent medication error rate. Findings include: The facility's Medication Administration policy, revised 11/18/17, documents that medications must be prepared and administered within one hour of the designated time or as ordered. (I.e., Medication time is 9:00am, The medication can be administered as early as 8:00am and as late as 10:00am. Medication is ordered as daily then medication can be given during the day at resident's preference). On 4/22/24 at 12:40pm, V6, Registered Nurse, gave R7 his medications. V6 told R7 that his Fluticasone (steroid) 50 MCG (Microgram) nasal spray was not available. On 4/22/24 at 1:00pm, V6 gave R9 his Gabapentin (Nerve pain) 100mg (Milligrams) one tablet. R9's MAR documents to take Cranberry tablet daily, but V6 stated that the medication was 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 interview, and record review, the facility failed to provide required staff to assist and monitor residents during breakfast, failure to answer call lights timely, and failure to provide incontinent care for dependent residents. This failure has the potential to affect all 55 residents residing in the facility. Findings include: The Nurse Staffing policy (not dated) documents, It is the policy of (the facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by (the state agency). Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. The facility's Facility Assessment dated 8/18/2017, documents the average daily census is 55 residents. It does not include staffing requirements necessary…

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 their facility assessment to include the staffing requirements needed to care for the resident population and census. This failure has the potential to affect all 55 residents residing in the facility. Findings include: The facility's Facility Assessment dated 8/18/2017, documents the average daily census is 55 residents. It does not include staffing requirements necessary to meet the needs of the resident based on the resident population and census. On 3/20/24 at 9:59 AM, V14 (Resident Care Coordinator/Licensed Practical Nurse) stated that she took over staffing on 3/11/24. V14 said V14 was not shown how to figure what the staffing needs were and not given any tools to use. V14 was told to staff six Certified Nursing Assistants/CNAs on days, five CNAs on evenings and four CNAs on nights. On 3/21/24 at 9:50 AM, V1 (Administrator in Training) stated she does not know if there is a Facility Assessment that documents how the facility should staff. On 3/21/24 at 1:58 PM, V16 (Regional Director of Operations) stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide incontinent care for 4 residents (R1, R2, R3, R4) reviewed for incontinent care in a sample of four. Findings Include: The Perennial Cleansing policy dated 12/2017 documents, To eliminate odor; to prevent irritation or infection and to enhance residents' self-esteem. The Certified Nurse's Aide policy not dated documents the CNA job summary, Working under the direction of the staff nurses, the Certified Nurse's Aide (CNA) provides personal care and assistance to residents to assure their safety and comfort. Carries out basic hygiene measures including but not limited to the following: grooming, shaving, applying makeup, oral hygiene/dental care, cuts/cleans nails, fingers and toes, foot care, skin care, bathing/showering and cleaning incontinent residence. On 3/18/24 at 10:47 AM, V3 (Ombudsman) stated that on 3/4/24, R3 called at 8:00 AM and said he was wet and had not been changed since night shift. V3 called V4 (Ombudsman) and asked V4 to go…

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 develop and maintain policies and procedures for monthly drug regimen review and failed to act timely on pharmacy recommendations for eleven of eleven residents (R4, R13, R19, R23, R28, R31, R38, R39, R40, R41 and R42) reviewed for pharmacy recommendations, in a sample of 42. FINDINGS INCLUDE: On 2/17/2024 at 1:30 P.M. the facility forms, (Pharmacy) Consultation Report, dated January 23, 2024 and signed by V19/Registered Pharmacist for R4, R13, R19, R23, R28, R31, R38, R39, R40, R41 and R42 (addressing missing diagnoses for medication, verification of correct dosages of medications, laboratory tests required for medication monitoring, duplicate pain medication therapy, parameters for blood glucose levels) were unsigned by the physician, indicating incomplete. At that time, V2/Director of Nursing stated, I'm not sure what our (facility) policy is for the monthly drug reviews. I haven't seen the recommendations from January (2024). On 2/20/2024 at 12:00 P.M., V1/Administrator and V3/Administrator in Training stated they were…

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

Based on observation, interview and record review, the facility failed to perform the required nurse shift to shift controlled substance reconciliation for 31 of 31 residents, (R3, R4, R5, R8 and R11- R37) reviewed for controlled substances, in a sample of 42. FINDINGS INCLUDE: The facility policy, Controlled Substances, dated (reviewed) 3/16/23 directs staff, It is the policy of the facility that all drugs listed as Schedule II drugs are subject to specified handling, storage, disposal and record keeping. The drugs in Schedule II will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. These records shall be retained for at least one (1) year. On 02/15/24 at 9:18 A.M., a review of the facility East Hall narcotic Shift Verification of Controlled Substances Sheet for February 2024, for residents residing in the facility North East and East Wings, shows missing, nursing documentation, to confirm facility nurses performed the required shift to shift controlled substance reconciliation, on February 5, 6, 8, 9, 10, 11, 2024. On 9:20 A.M., a review…

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

Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for two residents (R5 and R12) on the sample of residents reviewed for medication pass. This failure resulted in two medication errors out of twenty- five opportunities for error, for an 8% medication error rate. FINDINGS INCLUDE: The facility policy, Medication Administration, dated (revised) 11/18/2017 directs staff, Medications must be administered to the right resident, right dose, right drug, right consistency, right time, right route and right documentation. If the medication is not available for a resident, call the Pharmacy and notify the physician when the drug is expected to be available. 1. R5's current Physician Order Sheet, dated February 2024 includes the following medications: Calcium 600 MG (milligrams) with Vitamin D 800 MG two tablets by mouth daily for supplementation and Oyster Shell Calcium 500 MG three tablets daily for supplementation. On 2/15/2024 at 9:18 A.M., V11/Licensed Practical Nurse prepared to administer medications for 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 prevent abuse for three residents (R1, R2 and R4) of three residents reviewed for abuse in a sample of five. Findings Include: The Abuse Prevention policy dated 10/19/07, documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its resident, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure the facility is doing all is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, or mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide incontinent care for two residents (R3, R5) of three residents reviewed for incontinent care in a sample of five. Findings Include: Certified Nurse's Aide Job Summary (not dated) documents that the Certified Nursing Aide/CNA provides care and assistance to residents to assure their safety and comfort. The CNA carries out basic hygiene measures includes cleaning incontinent residents. On 1/6/24 at 3:15 PM, V1 stated the facility does not have a policy on incontinent care. The facility was hacked a few months ago and lost all the policies. 1. R3's Medical Records documents R1 was admitted to the facility on [DATE] with a diagnosis of Unspecified Sequel of Cerebral Infarction, Perforation of Intestine (non-traumatic), Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Intervertebral Disc Degeneration, and Hypertension. R3's MDS (Minimum Data Set) dated 12/8/23 documents a BIMS (Brief Interview for Mental Status) Score of 15/15,…

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, observation and record review, the facility failed to ensure sufficient staff was available to meet the needs of residents. This failure has to potential to affect all 55 residents currently residing at the facility. Findings include: The facility's Nurse Staffing policy (undated) documents the following: It is the policy of (facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident. Nursing staff shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the (State Agency). Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day, and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time by Registered Nurses. Registered Nurses and Licensed Practical Nurses employed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to provide oversight and leadership to Administrator in Training and nursing staff to ensure implementation of its policy and procedures regarding pressure ulcers, staffing, assessments, care plans, and employee education. In addition, Administrator in Training is practicing without any type of license. These failures have the potential to affect all 55 residents residing at the facility. Findings include: The facility's Administrator Job Description documents the following: Job Summary: The Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting and the physical management of the facility, residents & equipment in a way that the purpose of the facility shall be maintained in accordance with all established practices, policies, laws, and applicable State Regulations. The administrator will manage and conduct the business of the facility in the manner that protects the facility…

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

Based on observation and interview, the facility failed to ensure call lights were answered in a timely manner for two of five residents (R5 and R9) reviewed for call lights in the sample of nine. Findings include: On 12/11/2023 at 10:45 AM, V15 (Regional Administrator) verified facility does not have a policy regarding call light response times for staff to access. 1. On 12/12/2023 from 11:28 AM to 12:01 PM, R9's call light was observed to be on during this time. At 11:51 AM, V10 CNA (Certified Nursing Assistant) entered R9's room, shut R9's call light off, and then exited R9's room and left the hallway. At 11:52 AM, R9 was lying in bed covered up with a bed sheet. R9 stated, (V10) CNA came in and shut my call light off and said she would be right back. This happens all the time. Sometimes the staff member forgets to come back. I have had my call light on for around 25 to 30 minutes. I used the bed pan to have a bowel movement and needed assistance getting off the bed pan and cleaned up. It hurts and causes me pain to sit on a bed pan this long, but it is a constant thing. It takes…

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, observation and record review, the facility failed to revise a care plan after a resident fall for one of three residents (R3) reviewed for falls in the sample of nine. Findings include: The facility's Fall Prevention policy (revised 11/10/18) documents the following: Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. R3's Fall Investigation (dated 12/08/23) documents R3 fell while trying to transfer himself off the toilet. This same investigation documents the following fall prevention intervention was implemented after R3's fall: Placed Call Don't Fall sign in (R3's) bathroom. R3's current care plan has no mention of the fall prevention intervention that was implemented after R3's 12/08/23 fall. On 12/13/23 at 03:10 PM, V2 (Director of Nursing) stated R3's care plan has not been updated with the fall prevention intervention from R3's 12/08/23 fall. V2 then added that due to the facility currently not…

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

Based on observation, interview, and record review, the facility failed to ensure showers were completed as scheduled and hygiene assistance was provided to a dependent resident for one of four residents (R7) reviewed for ADL (Activities of Daily Living) assistance in the sample of nine. Findings include: The facility's Bath/Shower Policy dated 1/2018 documents, Policy: To ensure adequate hygiene needs are met. A bath/shower is scheduled for all resident in the facility at least weekly. Responsibility: All nursing personnel. The facility's Shaving-Male or Female Policy undated documents, Policy: Resident will be free of facial hair- male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the care plan. Responsibility: All nursing assistants, monitored by the charge nurse. The facility's A.M. (Morning) Policy, undated, documents Policy: A.M. care will be given to all residents daily. Responsibility: All Nursing Assistants. Equipment: 7. Nail clippers, orange stick. 8. Razor, shaving cream, basin of warm water. Procedure: 12. Provide…

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 the services of a registered nurse, as required. This failure has the potential to affect all 59 residents currently in the facility. FINDINGS INCLUDE: Facility Nursing Schedule staffing sheets, dated 11/4/2023 document no Registered Nurse in the facility for 8 hours out of 24 hours, on that day. On 11/29/2023 at 1:15 P.M., V2/Director of Nursing stated, We don't have many RN's (registered nurses) on staff. At that time, V2/Director of Nurses confirmed no Registered Nurses were present in the facility on 11/4/2023. The facility Room Roster/Census, dated 11/29/2023 confirms 59 residents currently reside in the facility.

Based on observation, interview and record review, the facility failed to remove soiled PPE (Personal Protective Equipment) and apply clean PPE upon exiting the facility COVID-19 Unit, failed to apply the correct PPE upon entrance into the facility COVID-19 Unit and failed to ensure a COVID-19 positive resident exited the facility COVID-19 Unit with correct PPE. These failures have the potential to affect all 59 facility residents. FINDINGS INCLUDE: The facility policy, COVID-19 Control Measures, dated (revised) 5/19/2023 directs staff, To prevent transmission of the COVID -19 Virus and to control outbreaks. Healthcare workers must use proper PPE (Personal Protective Equipment) when exposed to a resident with suspected or confirmed COVID-19. The Healthcare worker must wear an N95 respirator, eye protection, gown and gloves. Soiled (contaminated) PPE must be removed, disposed of, hand hygiene performed and a clean N-95 mask reapplied upon exit from a COVID-19 Unit. On 11/29/2023 at 8:59 A.M., V11/Medical Records/Receptionist exited the facility COVID-19 Unit wearing a soiled,…

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

Based on observation, interview and record review, the facility failed to keep medications secure for thirteen residents (R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15 and R16) of fifteen residents reviewed for medication storage, in a sample of 16. FINDINGS INCLUDE: The facility policy, Procurement and Storage of Medications, dated (reviewed) 11/6/18 directs staff, All medications, except those requiring refrigeration, shall be kept in the locked medicine room or locked medication cart. On 11/29/2023 at 8:40 A.M., four gold/tan-colored plastic tubs with 120 different medication punch cards for 13 facility residents (R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15 and R16) were present, unattended, on top of nurse's station counter, readily accessible to any resident or facility staff. Multiple residents, including R1, R2 and R3 walked/wheeled past the unsecured medications, as well as V3/SSD (Social Survives Director), V4/Maintenance Director, V8/Housekeeping Supervisor, V11/Medical Records/Receptionist, V7/Licensed Practical Nurse, V12/Registered Nurse and V13/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.

Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for three residents (R2, R6 and R7) on the sample of residents reviewed for medication pass. This failure resulted in four medication errors out of twenty- seven opportunities for error, for a 14.81% medication error rate. FINDINGS INCLUDE: The facility policy, Medication Administration, dated (revised) 11/18/2017 directs staff, Medications must be administered to the right resident, right dose, right drug, right consistency, right time, right route and right documentation. If the medication is not available for a resident, call the Pharmacy and notify the physician when the drug is expected to be available. 1. R2's current Physician Order Sheet, dated November 2023 includes the following medication: Pregabalin (Lyrica) Oral Capsule Give 75 mg (milligram) by mouth one time a day for nerve pain. On 11/29/2023 at 9:33 A.M., V13/Licensed Practical Nurse (LPN) prepared to administer medications for R2. After adding Baby Aspirin one tablet, Orphenadrine ER 100 MG…

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, observation and record review, the facility failed to ensure that sufficient staff was available to meet the needs of residents. This failure has to potential to affect all 54 residents currently residing at the facility. Findings include: The facility's Nurse Staffing policy (undated) documents the following: It is the policy of (facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. Nursing staff shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the (State Agency). Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day, and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time by Registered Nurses. Registered Nurses and Licensed Practical Nurses…

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

Based on interview observation and record review, the facility failed to post signage with indication to maintain isolation precautions for a resident with suspected Shingles, failed to apply PPE (personal protective equipment) prior to entering a resident's room with isolation precautions in place for Shingles and a resident with Enhanced Barrier Precautions in place for two of six residents (R1 and R2) reviewed for improper nursing care in the sample of six. This failure has the potential to affect all 54 residents residing in the facility. Findings include: According to the CDC (Centers for Disease Control and Prevention), In 2019, CDC introduced a new approach to the use of personal protective equipment called Enhanced Barrier Precautions (EBP). This new approach recommends gown and glove use for certain residents during specific high-contact resident care activities associated with MDRO (multi drug resistant organisms) transmission. CDC interim guidance recommends EBP as a strategy in nursing homes to interrupt the spread of novel or targeted MDROs (e.g., carbapenem-resistant…

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 revise a care plan with a new fall prevention intervention following a fall for one of three residents (R4) reviewed for falls in the sample of six. Findings include: The facility's Fall Prevention policy (revised 11/10/18) documents the following: Report all falls during the morning Quality Assurance Meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. R4's Fall Investigation (dated 10/22/23) documents R4 was sent to a local hospital for evaluation and treatment after she was found on the floor next to her bed on 10/22/23. R4's Progress Note (dated 10/23/22) documents the following regarding R4's 10/22/23 fall: IDT (Interdisciplinary Team) Note: QA (Quality Assurance) team met this morning to discuss resident's unintentional change of plane. Resident fell out of bed while reaching for call light. Care plan reviewed and updated. Glow in the dark tape placed on call light for resident to see at night. R4's Current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to conduct a fall risk assessment and ensure the assessment was thoroughly completed, as directed in their Fall Prevention policy, for one of three residents (R4) reviewed for falls in the sample of six. Findings include: The facility's Fall Prevention policy (revised 11/10/18) documents the following: Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Conduct fall assessments on the day of admission, quarterly, and with a change in condition. R4's Face Sheet (undated) documents R4 was admitted to the facility on [DATE]. R4's medical record documents R4's most recent Fall Risk Assessment was completed on 05/14/23, the day R4 was admitted to the facility. This assessment documents a score of 9 (10 points or more equals High Risk Score). This assessment is compiled of the following criteria: Age; Elimination;…

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 activities to meet the needs and interests of all the residents. This had the potential to affect all 45 residents residing within the facility. Findings include: The Facility's Activity Director Job Summary (undated) documents, The Activity Director plans, schedules, and implements an ongoing program of activities designed to meet the physical, mental, and psychosocial needs of each resident. Residents are engaged in a meaningful, varied program of activities that meets the individual residents. The activities are conducted with individuals or in groups, according to the resident's plan of care. The Activity Director completes the activity assessment for each resident and participates in developing the interdisciplinary care plan. Responsibilities: 1. Plan, organize, and coordinate an activity program according to established policies. 2. Plan group and individual activities designated to restore self-care and well-being and…

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

Based on observation, interview, and record review, the facility failed to employ a full-time Activity Director. This failure had the potential to affect all 45 residents residing in the facility. Findings include: The Facility's Activity Director Job Summary (undated) documents, The Activity Director plans, schedules, and implements an ongoing program of activities designed to meet the physical, mental, and psychosocial needs of each resident. Residents are engaged in a meaningful, varied program of activities that meets the individual residents. The activities are conducted with individuals or in groups, according to the resident's plan of care. The Activity Director completes the activity assessment for each resident and participates in developing the interdisciplinary care plan. Responsibilities: 1. Plan, organize, and coordinate an activity program according to established policies. 2. Plan group and individual activities designated to restore self-care and well-being and geared to the individuals needs and interest. 3. Develop and appropriate plan of activities for and visit…

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, interview, and observation the facility failed to employ a full time Director of Nursing (DON) to oversee nursing services and failed to ensure a Registered Nurse (RN) worked at least eight hours daily. This failure has the potential to affect all 45 residents residing within the facility. Findings include: The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility. The facility's Director of Nursing Job Description undated documents, Job Summary: To plan, organize, develop, and direct the overall operation of our nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times. Qualifications: 3. Must possess a current, unencumbered, active license to practice as a registered nurse in this state. The facility's Nurse Staffing policy (undated) documents, It is…

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 food substitutions of equal nutritive value. This had the potential to affect all 45 residents residing in the facility. Findings include: On 07/17/23 at 01:29 PM R196 was alert sitting on the side of his bed. Clean well kempt. R196 stated, We don't get any kind of choices if we don't like the meal they are serving except grilled cheese, peanut butter and jelly, or lunch meat sandwiches. Normally it's only lunch meat sandwiches. On 07/18/23 at 08:43 AM, R197 stated, I've never been offered any kind of substitute since I've been here. I just take what they've given me. On 07/18/23 at 09:31 AM, R195 was alert sitting up in his bed. R195 stated, I'm of Islamic religion, and I'm not able to have any food with any kind of pork or pork product in it. However, the kitchen doesn't care. They send me things all the time with pork in it. When I tell them I can't eat what they are serving, all I get for a substitute is a grilled cheese sandwich. Tell me that a grilled cheese sandwich is a nutritive exchange for the protein.…

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, interview, and observation the facility failed to label and date 21 containers of mixed fruit and 12 deli-meat sandwiches when prepared and stored in the refrigerator. These failures have the potential to affect all 45 residents who reside within the facility. Findings include: The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility. The facility's Refrigerator and Freezer Storage policy dated 10/2009 documents, It is the policy of (the facility) that any item to be placed in the refrigerators and freezers must be covered, labeled, and dated with a date-marking system that tracks when to discard perishable foods. Procedure: 2. [NAME] container with name of item. [NAME] the date that the original container is opened or date of preparation. On 07/17/23 at 10:14 AM there were 21 small containers with lids that contained mixed fruit and 12 deli-meat sandwiches located inside a two-door refrigerator. These containers of fruit and sandwiches were not labeled or dated when prepared.…

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

Based on observation, interview, and record review the facility failed to employ a full-time Administrator to manage, plan, organize, staff, direct, coordinate, report, and provide physical management to the facility. This failure has the potential to affect all 45 residents residing within the facility. Findings include: The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility. The facility's Job Description Administrator dated and signed by V1 (Administrator-In-Training) on 11-21-22 documents, Job Summary: The Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting, and the physical management of the facility, residents, and equipment in a way that the purpose of the facility shall be maintained in accordance with all established practices, policies, laws, and applicable State Regulations. The Administrator will manage and conduct the business of the facility in a manner that protects the facility license and certification at all…

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 Governing Body failed to be consistently involved in the management and operation of the facility, failed to implement policies related to facility operations and resident care, including, Accommodation of Needs, Comfortable Homelike conditions, MDS (Minimum Data Set) assessments and care plans being completed timely and accurately, Psychotropics, Activities, Pressure Ulcers, Significant Weight Loss, Significant Medication Errors, Smoking supervision, Staffing, Medication storage, Incontinence Care, and Infection control. The Governing Body failed to ensure Director of Nursing and Activity Director responsibilities were completed. This failure has the potential to affect all 45 residents residing in the facility. Cross reference to F558, F584, F636, F637, F638, F655, F656, F657, F679, F680, F686, F689, F690, F692, F695, F727, F732, F758, F760, F761, F806, F812, F825, F867, F868, and F880. Findings include: The facility's Corporate Compliance & Ethics Program Overview (5/2021) documents Corporate's management staff (Directors,…

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 and implement plans of action through their Quality Assurance and Assessment (QAA) Committee to address a lack in providing meaningful activities, providing equal nutritive value food substitutes, employing a full-time activity director and Director of Nursing, employing at least eight hour of registered nurses daily, and ensuring MDS (Minimum Data Set) Assessments were completed timely. These failures have the facility to affect all 45 residents residing within the facility. Findings include: The facility's Quality Assurance Plan (undated) policy documents, (The facility) works to continuously improve the way residents are cared for, safety, and operations within the facility through the Quality Assurance process. Quality assurance activities are to be completed continuously and objectively to provide a comprehensive review of the facility's activities. The purpose of the Quality Assurance Plan is: To help identify problems or potential problems. To provide information upon which corrective action can…

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

Based on record review and interview the facility failed to ensure the Infection Preventionist and Director of Nursing (DON) attended all quarterly QAA (Quality Assessment and Assurance) meetings. These failures have the potential to affect all 45 residents who reside within the facility. Findings include: The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility. The facility's List of Quality Assessment and Assurance (QAA) members (undated) and provided on 7-17-23 at 10:45 AM by V1 (Administrator-In-Training) documents the DON and Infection Preventionist (V2) should be members of the QAA committee. The facility's QAA Meeting Attendance Forms dated 7-20-22, 10-26-22, 1-12-23, and 4-25-23 do not include attendance of a Director of Nursing or Infection Preventionist. 07/19/23 09:36 AM V1 (Administrator In Training) stated, A Director of Nursing did not attend any of the Quality Assessment and Assurance (QAA) meetings from 7-20-22 through 4-25-23. An Infection Preventionist did not attend the QAA…

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.

These failures resulted in two deficient practices. A. Based on record review and interview the facility to monitor and test for Legionella and other opportunistic waterborne pathogens within the facility's water system. This failure has the potential to affect all 45 residents residing within the facility. B. Based on observation, interview and record review, the facility failed to perform hand hygiene and a glove change between cares for one of 16 residents (R30) reviewed for infection control in the sample of 37. Findings include: A. The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility. The facility's Annual Risk Assessment (undated) and Legionella Policy and Procedure (undated) does not include any evidence of the facility testing their water system for Legionella or other opportunistic waterborne pathogens. On 07/19/23 at 03:05 PM V12 (Maintenance Director) stated, I am not aware of the facility testing for Legionella. I do not test the water for Legionella.B. The facility's Standard…

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, interview, and observation the facility failed to follow their water temperature policy to maintain water temperatures between 100 to 110 degrees Fahrenheit for five of 37 residents (R5, R14, R33, R42, R96) reviewed for water temperature in the sample of 37. Findings include: The facility's Water Temperature Control policy (undated) documents, It is the policy of (the facility) to maintain water temperature available to residents between 100- and 110-degrees Fahrenheit (F). On 7-19-23 at 12:25 PM V12 (Maintenance Director) tested R42's bathroom sink water temperature using a thermometer after the water was running for five minutes. The water was cold to touch and tested at 76 degrees F. On 7-19-23 at 12:35 PM V12 tested R5's, R14's, R33's, and R96's bathroom sink water temperature using a thermometer after the water was running for two minutes. The water was cold to touch and tested at 72 degrees F. On 7-19-23 at 11:20 AM R96 stated, My sink water has been cold for months. The CNA's (Certified Nursing Assistants) wash me up with freezing cold water. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for a smoker, a resident receiving hospice services, and within 21 days of admission to the facility for four of 15 residents (R9, R23, R195, R196) reviewed for care plans in the sample of 37. Findings include: The facility's Comprehensive Care Planning policy, dated 7/20/22, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining resident strengths, needs, goals, life history and preferences to develop a comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The following procedures shall be utilized in the development and maintenance of care plans: The Comprehensive Care Plan (CCP) shall be…

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, interview, and observation the facility failed to date multi-dose insulin pens once opened for four of eight residents (R2, R13, R39, R198) reviewed for insulin medication storage in the sample of 37. Findings include: The facility's Procurement and Storage of Medications policy dated 03/2017 documents, All medication containers shall be labeled with the date opened by the person breaking the container seal. On 07/18/23 at 11:35 AM R2's open Lantus Insulin Flexpen100 u (units) per ml (milliliter), R13's open Lantus Insulin Flex pen 100 u per ml, R39's open Lispro Insulin Kwik pen 100 u per ml, and R198's open Novolin R Insulin Flex pen three ml/100 u per ml were all located in the top drawer of the east hallway medication cart. These same insulin pens for R2, R13, R39 and R198 were opened and not labeled with the date the insulin pens were opened. On 07/18/23 at 11:41 AM V5 (LPN/Licensed Practical Nurse) stated, All insulin pens should be dated when opened.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a wheelchair to a resident (R197) who was dependent on a wheelchair for mobility for one of two residents (R197) reviewed for accommodation of needs in the sample of 37. Findings include: The Facility Assessment Tool, dated 3/29/23, documents, Other medical diagnoses or conditions may be considered for admission. For other possible admissions or continuing care decisions the QA (Quality Assurance) team will meet and identify any new needs or resources needed to provide care and support for the person. QA will make the decision that appropriate care can or cannot be provided to the individual and the services required are within the scope of the license for the facility. Once the decision is made the appropriate department will obtain the needed resources (training, equipment, etc.). On 07/18/23 at 08:43 AM, R197 was lying in bed. R197 stated, I was in the hospital for six weeks for the infection in my foot. I was home and took…

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 comprehensive admission and annual MDS (Minimum Data Set) assessments for 7 of 23 residents (R4, R11, R12, R18, R27, R195, R196) reviewed for MDS completion in the sample of 37. Findings include: The facility's Comprehensive Assessment/MDS policy, dated 11/1/17, documents, It is the policy of the facility to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining resident strengths, needs, goals, life history, and preferences to develop a comprehensive plan of care for each resident with the goal of attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The policy also documents, Each resident residing in this facility for a full 14 days shall have a MDS initiated by the 13th day after admission, and a RAI (Resident Assessment Instrument) completed by the 14th day after…

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 complete a significant change minimum data set assessment for a resident admitted to hospice for one of 23 residents (R9) reviewed for significant change in the sample of 37. Findings include: The facility's Comprehensive Assessment / Minimum Data Set (MDS) policy, dated 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining resident strengths, needs, goal, life history and preferences to develop a comprehensive plan of care for each resident with the goal of attaining or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This same policy documents The MDS shall be re-evaluated according to the following schedule. c. Significant change in status- The interdisciplinary team shall determine the presence or absence of significant change based on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a quarterly MDS (Minimum Data Set) assessment for three of 23 residents (R1, R23, R24) reviewed for MDS completion in the sample of 37. Findings include: The facility's Comprehensive Assessment/Minimum Data Set (MDS) policy, dated 11/1/17, documents, The MDS shall be re-evaluated according to the following: Quarterly-within 92 of previous ARD (Admission, Review, and Dismissal)/MDS. 1. R1's MDS Assessment Lookup (printed 7/20/23) documents R1's admission MDS assessment was dated 2/6/23 the next Quarterly assessment was dated 5/22/23. On 7/20/23 at 10:05 AM, V7 (Minimum Data Set Coordinator/MDS) confirmed that R1's quarterly MDS assessment was not completed on 5/22/23. 2. R23's MDS Assessment Lookup (printed 7/20/23) documents R23's admission MDS assessment was dated 4/2/23. This is the last assessment documented. On 7/20/23 at 10:05 AM, V7 (Minimum Data Set Coordinator/MDS) confirmed that R2's has no quarterly MDS assessment after R23's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a baseline care plan within 24 hours of admission for one of one resident (R197) reviewed for baseline care plans in the sample of 37. Findings include: On 07/18/23 at 08:43 AM, R197 was lying in bed. R197 stated, I was in the hospital for six weeks for the infection in my foot. I was home and took care of myself before that happened, and that is my goal to get back home. However, with being in the hospital for so long, I'm not able to walk. I came here with the understanding that I would be doing therapy to get back home. R197's Hospital Discharge information, dated 7/8/23, documents, Diagnosis Problem List: Principal physical deconditioning. R197's Order Summary report, dated 7/19/23, documents R197 was admitted to the facility on [DATE]. R197's Care Plan Detail, dated 7/20/23, has no documentation of an initial baseline care plan being completed for R197. 07/19/23 11:19 AM, V7 (MDS-Minimum Data Set/Care plan Coordinator)…

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 revise a care plan for the use of an antipsychotic medication for one of four residents (R10) reviewed for antipsychotics in the sample of 37. Findings include: The facility's Psychotropic Medication policy, dated 6/17/22, documents, Any resident receiving any psychotropic medication will have certain aspects of their use and potential side effects addressed in the resident's care plan at quarterly. The care plan will identify target behaviors causing the use of psychotropic medications. The care plan will address the problem, approaches, and goals to address these behaviors. On 07/19/23 at 10:38 AM, R10 was aimlessly self-propelling himself in the hallway. R10 was pleasantly confused, smiling, and not displaying any behaviors. R10's Order Summary Report, dated 7/19/23, documents R10 has an order to receive Seroquel (antipsychotic) 25 mg (milligrams) half tablet (12.5 mg) by mouth in the evening for the diagnosis of dementia. R10's Psychotropic care plan, dated 5/15/23, documents, R10 requires use of…

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

Based on observation, interview and record review, the facility failed to obtain an appropriate treatment order upon development and progression of a pressure ulcer for one of one resident (R30) reviewed for pressure ulcers in the sample of 37. Findings include: The facility's Decubitus Care/ Pressure Areas policy, dated 1/2018, documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. The facility's Skin Condition Monitoring policy, dated 3/16/23, documents, It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. R30's Skin Only Evaluation, dated 7/12/23, documents at 6:25 PM V23 (R30's Physician) was notified R30's skin contained bruising on the coccyx measuring 12 centimeters (cm) by 12 cm. This evaluation documents, Deep red and Purple bruising on coccyx, (V23) contacted at 6:30 PM. R30's Nursing Progress Note, dated 7/16/23, documents at 1:09 PM, Red non-blanchable area present to…

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

Based on observation, interview and record review the facility failed to supervise smoking residents and keep smoking materials in a safe place for three of three residents (R3, R23, R95) reviewed for smoking in the sample of 37. Findings include: The Safe Smoking and Vaping Policy dated 10/27/22, documents, The facility works to provide appropriate care for residents keeping safety and comfort in mind. Residents may have the desire to smoke/vape and accommodations will be provided as the facility deems appropriate. The Smoking Policy (not dated) documents, It is the policy of (the facility) smoking is only permitted outside the facility according to the following guidelines. There will be no smoking inside the facility by either resident or staff. Guidelines 2. Residents must always be accompanied by a staff member to smoke and may not keep his/her own smoking materials. On 7/18/23 at 9:32 AM, R3 and R95 were sitting on a bench in front of the facility smoking. There were no staff supervising the residents. On 7/19/23 at 11:48 AM, V9 (Ombudsman) stated she has seen residents out…

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 cleanse a resident's perineal area during incontinence care for one of one resident (R30) reviewed for incontinence care in the sample of 37. Findings include: The facility's Perineal Cleansing policy, dated 12/2017, documents, To eliminate odor; to prevent irritation and to enhance resident's self-esteem. This same policy documents Procedure: Female without catheter. 4. Wet washcloth with cleansing agent chosen. 5. Wash pubic area including upper and inner aspect of both thighs and frontal portion of perineum. a. Using long strokes from the most anterior down to the base of the labia. b. After each stroke refold the cloth to allow use of another area. 6. Follow same sequence for rinsing area, if applicable. 7. Place soiled items in plastic bag. 8. Dry thoroughly. R30's Current care plan, dated 1/13/23, documents R30 has an Alteration in Bowel and Bladder elimination as related to incontinence. On 7/19/23 at 3:20 PM, V6 (Registered Nurse) and V2 (Licensed Practical Nurse/ Resident Care Coordinator) went 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 provide a physician ordered supplement, obtain a weight upon admission, and obtain weekly weights following admission for one of two residents (R195) reviewed for weight loss in the sample of 37. These failures resulted in R195 having a significant weight loss of 11.2 lbs. (pounds)/6% in one month. Findings include: The facility's Resident Weight Monitoring policy, dated 9/08, documents, New admission weight is obtained within 24 hours of admit. All new admissions and readmissions will be weighed weekly for at least four weeks. If the monthly weight shows a significant change (i.e., 5% +/- in 30 days, 7.5%+/- in 90 days, or 10% +/- in 180 days) the resident will be re-weighed. On 07/18/23 at 09:31 AM, R195 was alert sitting up in his bed. R195 stated he is of Islamic religion and is not able to have any food with any kind of pork or pork product in it. R195 stated, However, the kitchen doesn't care. They send me things all the time with…

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

Based on observation, interview and record review, the facility failed to ensure oxygen tubing and oxygen humidity were dated for one of one resident (R30) reviewed for oxygen administration in the sample of 37. Findings include: The facility's Oxygen Therapy policy, dated 3/2019, documents Oxygen is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. 13. Change oxygen tubing/mask/cannula/ and/or tracheostomy mask on a weekly basis. Date tubing changes and document on treatment sheet. R30's current care plan, dated 3/16/23, documents, (R30) requires the use of Oxygen related to diagnosis of COPD (Chronic Obstructive Pulmonary Disease) and SOB (Shortness of Breath). On 7/17/23 at 10:50 AM, R30 was in her room sitting in high-back wheelchair with Oxygen on via nasal cannula at four liters and connected to a humidity bottle. R30's Oxygen tubing and humidity bottle were both undated. On 7/19/23 at 9:15 AM, R30 was in her room lying in bed sleeping. R30 had Oxygen on via nasal cannula at 4 liters and connected to a humidity bottle. R30's…

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

Based on observation, interview, and record review, the facility failed to document justification to warrant the use of an antipsychotic, monitor for behaviors, perform a gradual dose reduction, and complete an AIMs (Abnormal Involuntary Movement) assessment for two of three residents (R10, R12) reviewed for antipsychotics in the sample of 37. Findings include: The facility's Psychotropic Medication policy, dated 6/17/22, documents, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: Without adequate indications for its use. Any resident receiving such medications shall have a psychiatric diagnosis or documented evidence of maladaptive behavior, which can be considered harmful to themselves or others, destructive to property, or if emotional problems exist which cause the resident frightful distress. Residents who use antipsychotic drugs hall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Reductions shall be attempted at least…

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

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for two of two residents (R9, R10) reviewed for medication errors in the sample of 37. Findings include: The facility's Medication Administration policy, dated 11/18/17, documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. The facility's Adverse Drug Reactions and Medication Discrepancy policy, dated 11/6/18, documents, It is the policy of the facility that adverse drug reactions and drug errors are to be reported to the resident's physician, documented in the nursing notes and documented in the Adverse Drug…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident understood the arbitration agreement and failed to inform a resident of their ability to rescind the agreement for one of three residents (R197) reviewed for arbitration in the sample of 37. Findings include: R197's Order Summary Report, dated 7/19/23, document that R197 was admitted to the facility on [DATE]. On 07/18/23 at 10:53 AM R197 stated, I did my admission contract with (V11 Social Services Director) She went over arbitration with me, and I signed the arbitration agreement. However, she did not explain to me that I was giving up my rights to legal action. If I had known that I would have never signed it. I want to revoke that now! She never told me I could revoke it either. R197's Agreement to Resolve Disputes by Binding Arbitration, dated 7/8/23, documents that R197 signed the contract himself as well as V11. On 07/20/23 at 10:08 AM, V11 (Social Service Director) stated, I do the (admission) contract and the arbitration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Care Planning Meetings were held with residents and their representatives for nine (R4, R11, R15, R23, R30, R31, R32, R37 and R47) of 12 residents reviewed for care planning meetings in a sample of 26. Findings include: The Facility Comprehensive Care Planning Policy, revised 11/1/17, documents: the Care Plan Conference shall be held as necessary to communicate major revisions to the Comprehensive Care Plan and minimally with every Comprehensive Minimum Data Set/MDS completed; the Facility shall make an effort that the conference be attended by a representative from each discipline involved in resident care; be attended by the Resident unless the Resident is incapable of understanding the proceedings or chooses not to attend; be attended by a representative of the Resident's choice; serve as a means of communication among disciplines and resident/representative; provide a setting to discuss the Resident's condition, medications, progress, lack of…

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

Based on observation, interview, and record review the facility failed to provide Restorative Rehabilitation program for four (R19, R31, R37 and R47) of four residents reviewed for restorative services in the sample of 26. Findings include: The facility's undated Restorative Care/Nursing Rehabilitation policy and procedure documents, Restorative nursing focuses on what the resident is able to do. Interventions are focused on promoting the resident's ability to attain his/her maximum functional potential. The goals are to create independence, reduce the level of assistance required, and increase level of dignity. The Program Qualifiers include Quarterly note written by a Licensed Nurse including progress, participation and response/tolerance to each program . Nurse aides are trained in the techniques that promote resident involvement in the task . Interventions are carried out or supervised by the nursing staff . Provided for at least 15 min (minutes) per day. 1. Quarterly MDS (minimum data set) assessment for R31, dated 6/8/22, documents R37 is receiving restorative nursing programs…

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 had enough clothing for daily living for one (R38) of 26 residents reviewed for dignity in a sample of 26. Findings include: Facility Residents' Rights for People in Long-Term Care Facilities, revised 11/18, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health at their highest practical levels. Facility Social Service Director, no date, documents The Social Service Director responsibilities: general duties a. Provide consultation to members of our staff, community agencies, etc. in the efforts to solve the needs and problems of the resident. R38's medical record documents R38 was admitted to the facility on [DATE], cognitively intact, and walks independently. R38's medical record Inventory of Personal Effects, dated 5/24/22, documents the following; house slippers,…

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 and comprehensive care plan for two (R31 and R37) of 12 residents reviewed for care planning in the sample of 26. Findings include: The facility's Comprehensive Care Planning policy and procedure, revised 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being. 1. On 8/10/22 at 1:30 pm, V18 Hospice CNA (Certified Nursing Assistant) stated she comes to the facility to provide cares for R31 weekly. On 8/11/22 at 9:46 am, V9 and V10 CNA's provided incontinence care to R31 and blood was visible on the washcloth V10 CNA was cleansing…

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 shave and provide nailcare for one (R15) of 12 reviewed for grooming in a sample of 26. Findings include: Facility Residents' Rights for People in Long-Term Care Facilities, revised 11/18, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health at their highest practical levels. On 8/10/22 at 3:45 pm, R15 was in the activity room in a manual wheelchair, and alert and oriented. R15 had a long gray and black beard and moustache, and yellow long thick fingernails. R15 stated I want my nails clipped to at least half of what they are now, and I asked to be shaved a week ago and it was never done. On 8/11/22 at 9:00 am, R15 still had long fingernails, moustache and beard. On 8/11/22 at 9:10 am, V11 Certified Nurse Aid/CNA stated I am taking care of (R15) and I plan on shaving him today. As part of our job, we do shave and clip nails, and his fingernails need done.…

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 treat reddened and excoriated abdominal skin folds for one (R32) of 12 residents reviewed for skin care in a sample of 26. Findings include: Facility Preventative Skin Care Policy, revised 1/2018, documents: that the Facility is to provide preventative skin to keep the resident clean, comfortable, well groomed and free from pressure ulcers; that staff on every shift and as necessary will provide skin care; and a thin layer of body lotion/skin protestant may be applied as a protective barrier to areas exposed to incontinence. Facility Pressure Sore Prevention Guidelines, revised 11/2012, documents: to provide adequate interventions for prevention of pressure ulcers for residents who are identified as High or Moderate risk for skin breakdown; weekly skin checks for Moderate to High Risk for skin breakdown; and any resident at risk for skin breakdown will be noted on the Treatment Sheet and signed off by the Nurse and a brief weekly narrative will be completed describing the resident's skin condition on the back…

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 supervise and ensure a resident signed out prior to leaving facility for outing for one (R37) of 12 residents reviewed for supervision in the sample of 26. Findings include: The undated, Facility Sign Out Policy, documents If a resident leaves the facility grounds either with family or on their own to go for a walk, shopping, etc., it is the policy of the facility that either the Responsible Party or the Resident MUST sign out at the nurse's station and sign in when they return to the facility. The Sign Out/Acceptance of Responsibility for Leave of Absence for R37 documents last time R37 signed out of the facility was on 7/7/22. On 8/10/22 at 10:09 am, 11:20 am, 2:00 pm, and 3:10 pm, R37 was not seen in the facility. On 8/10/22 at 1:00 pm, V15 Receptionist stated R37 did not tell her she was leaving for the day and (V14) does not know where R37 is. On 8/10/22 at 3:10 pm, V14 RN (Registered Nurse) stated (R37) is not here and (V14 RN) doesn't know where (R37) is. On 8/10/22 at 3:12 pm, V2 DON (Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to monitor and document the assessment of the dialysis graft site for two (R19 and R99) of two residents reviewed for dialysis in a sample of 26. Findings include: Facility Dialysis Policy, revised 1/2002, documents: the normal thrill and bruit of the graft will be absent and the thrill is to be checked every shift and recorded on the treatment sheet. R19's current Care Plan documents: that R19 has Chronic Kidney Disease and receives dialysis on Tuesday, Thursday and Saturday. The Care Plan also documents to monitor the bruit and thrill daily and notify the Medical Director of changes to auditory assessment of the site. R19's Treatment Administration Record/TAR, dated 7/1/22 through 8/11/22, documents that R19 admitted to the facility on [DATE]. The TAR does not document assessment of the dialysis graft for bruit and thrill. On 8/11/22 at 2:50 pm, V7 (Assistant Director of Nursing/Restorative Nurse) stated We used to check (R19) for bruit and thrill but…

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 schedule a dental appointment, for dentures, for one resident (R47) of 12 reviewed for dental services in a sample of 26. Findings include: Facility Resident Rights, revised 11/2018, documents the facility must: treat you with dignity and respect and must care for you in a manner that promotes your quality of life; provide equal access to quality care regardless of diagnoses, condition or payment source; and provide services to keep your physical and mental health at their highest practical levels. R47's Social Service Progress Notes, dated 12/23/21, documents that a message was left with V12 (R47's Sister) for a dental assessment. No further documentation was noted. On 8/10/22, at 9:42 am, R47's teeth were missing. No dentures were present. On 08/09/22, at 10:46 am, V12 (R47's Sister) stated, I asked about getting my brother dentures over a year ago and I still do not think that he has ever gotten them, and I have never heard anything about them since. On 8/11/22, at 10:22 am, V4 (Social Service Director)…

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

Based on observation, interview, and record review, the facility failed to have a working cold faucet, fix a leaking hot water faucet, and fix a leaking toilet for three (R38, R40, and R46) of 12 residents reviewed for environmental concerns in a sample of 26. Findings include: Facility Maintenance Person, no date, documents The Maintenance Person maintains all building, equipment, systems and grounds in good, safe, and presentable condition. Regularly inspects and maintains plumbing systems. Maintains the building in good, safe repair. On 8/11/22 the facility was unable to provide any maintenance repair/request logs. 1. At the end of the Northwest hallway R38 and R46's bathroom were connected/shared. R38 and R46's toilet appeared to be leaking onto the floor, and the floor was wet in front of the toilet into the main entrance of the bathroom. The toilet was elevated off the ground and secured to the back wall where water appeared to be running down the back of the wall and the floor every time the residents flushed the toilet. The back wall was pulling away from the floor trim,…

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.