Alden Debes Rehab & Hcc

Based on interview and record review, the facility failed to ensure prescribed medications were acquired and provided for 1 of 3 residents (R1) in the sample of 3 reviewed for medication administration. Findings include:R1's admission Record dated 11/24/25 shows R1's diagnoses including End Stage Renal Disease, hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, asthma, left kidney malignant neoplasm, paroxysmal atrial fibrillation, generalized anxiety disorder, anemia, insomnia, dependence on renal dialysis, hypertension, pain in right and left knees, osteoarthritis of knee, dorsalgia (pain in the back), chronic kidney disease, left shoulder osteoarthritis, obesity, hypothyroidism, presence of an artificial right knee joint, non-pressure chronic ulcer of the right lower leg, and goiter.R1's current care plan provided by the facility shows R1 requires long term use of prophylactic antifungal medication (fluconazole) for care and management of chronic healing surgical wounds. It is to be provided per physician's orders.R1's Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer cardiac medications as prescribed to 1 of 3 residents (R1) with a heart arrhythmia, heart disease, kidney disease, and hypertension in the sample of 3 reviewed for medications.Findings include:R1's admission Record dated 11/24/25 shows R1's diagnoses include, but are not limited to, End Stage Renal Disease, Hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, asthma, left kidney malignant neoplasm, paroxysmal atrial fibrillation, generalized anxiety disorder, anemia, insomnia, dependence on renal dialysis, hypertension, pain in right and left knees, osteoarthritis of knee, dorsalgia (pain in the back), chronic kidney disease, left shoulder osteoarthritis, obesity, hypothyroidism, presence of an artificial right knee joint, non-pressure chronic ulcer of the right lower leg, and goiter.On 11/24/25 at 10:40 AM, V6, Licensed Practical Nurse (LPN), said staff kept reordering R1's medications and they weren't being delivered. V6 said they eventually figured out the pharmacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications were administered timely as ordered and scheduled for 4 of 5 residents (R58, R111, R184, R73) reviewed for medication administration in the sample of 63.Findings include:On 7/30/25 at 9:11 AM, the surveyor approached V11 (Agency RN (Registered nurse)) to observe medication administration. V11's medication cart was parked in the middle of the hall. R182 was seated in her wheelchair next to the medication cart and R58 was standing behind R182. V11 said she was preparing medications for R182. The surveyor waited while V11 administered the prepared medications to R182. R58 told V11 that he needed something for his stomach. V11 opened her computer to the Medication Administration Screen and numerous residents showed up in red. V11 stated, I know there's a lot of red on the screen. That's because they're considered late. R58 was red on the computer screen. V11 stated, I need to give you your morning medications and I'll see what you have for your stomach. While V11 prepared R58's medications he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent potential cross-contamination by failing to don the proper personal protective equipment (PPE) while providing high-contact resident care for residents requiring enhanced barrier precautions (EBP) and failing to remove gloves and perform hand hygiene after providing incontinence care. These failures affect 3 of 5 residents (R77, R160, R99) reviewed for infection control in the sample of 63. Findings include: 1. R77's admission Record, provided by the facility on 7/31/2025, showed diagnoses including, Hypertensive stage 5 Chronic Kidney Disease, or end-stage renal disease, dependence on renal dialysis, acute angle-closure glaucoma, type II diabetes mellitus, and heart failure. R77's care plans, provided by the facility on 7/31/2025, show R77 requires assistance from staff for transfers, experiences bladder and bowel incontinence, and requires enhanced barrier precautions (EBP) related to use and care of indwelling dialysis device.…

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

Based on observation, interview, and record review the facility failed to maintain a residents dignity, by failing to dispose of and clean emesis from a basin from the resident's bedside. This applies to 1 of 1 residents (R2) reviewed for dignity in the sample of 63. Findings include:R2's admission Record (Face Sheet) showed an admission date of 4/24/23 with diagnoses to include heart bypass, morbid obesity, and diabetes type 2.R2's 6/6/25 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R2's 7/25/2025 Nurses' Note from 12:40 showed, Resident had another emesis occurrence. NP (Nurse Practitioner) came to assess. Ordered [nausea medication] 4mg (milligram) PO (by mouth) q4PRN (every four hours as need for pain).On 7/29/25 at 10:26 AM, R2 was asleep in bed. R2 was pale and she did not arouse to a door knock. R2 had a pink basin in front of her on the over-bed table. The basin had a approximately one cup of emesis in the basin. The emesis was chunky, dark brown, with round off-white pieces. 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 observation, interview and record review the facility failed to provide clearly defined target behaviors and failed to provide an appropriate indication for the use of an antipsychotic medication for two (R34, R55) residents with a diagnosis of Dementia of five residents in the sample of 63.Findings include:R55's Physician Order Summary Report indicates R55 was admitted to the facility on [DATE], with diagnoses including Vascular Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Unspecified Bipolar Disorder. This Order Summary Report indicates R55 has current orders for Seroquel (antipsychotic) 50mg (milligrams) in the morning related to Bipolar Disorder and Seroquel 25mg at bedtime for Bipolar Disorder. (Order date initiated 6/5/25)R55's Medical Diagnosis List indicates R55's diagnosis of Bipolar Disorder was initiated on 10/14/24 and Dementia diagnosis on 7/21/25.On 7/28/25 at 11:10am R55 was seen in bed. R55 stated he was too sick to talk.On 7/29/25 at 9:50am R55…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bed rails for assistance with bed mobility for 1 of 2 residents (R99) reviewed for activities of daily living (ADL's) in the sample of 63.Findings include:R99's electronic face sheet printed on 7/31/25 showed R99 has diagnoses including but not limited to heart failure, chronic kidney disease, dementia without behaviors, and history of falls.R99's facility assessment dated [DATE] showed R99 has moderate cognitive impairment and does not utilize side rails.R99's undated care plan showed, (R99) has an ADL functional performance deficit.cue resident to grasp side rail and pull self-up to a sitting position or to the side of the bed.R99's document titled, Side Rail Assessment dated 4/25/25 showed, Is the resident able to use a side rail to assist in bed mobility? Yes.the use of side rails is indicated and serves as an enabler to promote independence.R99's document titled, Side Rail Assessment dated 7/22/25 showed, Decision regarding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 signs and symptoms of nausea and vomiting were treated as ordered and failed to provide wound/skin care as ordered for 2 of 7 residents (R2, R99) reviewed for quality of care in the sample of 63. Findings include: 1. R2's admission Record (Face Sheet) showed an admission date of 4/24/23 with diagnoses to include heart bypass, morbid obesity, and diabetes type 2. R2's 6/6/25 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R2's 7/25/2025 Nurses' Note from 12:40 showed, Resident had another emesis occurrence. NP (Nurse Practitioner) came to assess. Ordered [nausea medication] 4mg (milligram) PO (by mouth) q4PRN (every four hours as need for pain). On 7/29/25 at 10:26 AM, R2 was asleep in bed. R2 was pale and she did not arouse to a door knock. R2 had a pink wash basin in front of her on the over-bed table. The wash basin had a approximately a cup…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 weights were completed as ordered for residents with weight loss for 2 residents (R95, R3) reviewed for nutrition and weight loss in the sample of 63. Findings include: 1. R95s admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including dysphagia (difficulty swallowing) diabetes mellitus, malignant neoplasm of the prostate (cancer) and gastric reflux. The 5/2/25 quarterly resident assessment and care screening shows R95 has moderately impaired cognitive skills for daily decision making. He requires supervision for eating and oral hygiene. The swallowing/nutritional status assessment documents him to be 64 inches in height and weigh 147 pounds. He has a mechanically altered diet. R95's July 2025 order summary report shows a diet order for no concentrated sweets, mechanical soft texture with nectar consistency fluids. The same report shows an order dated 7/23/25 to weigh three times a week 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 administer medications per physicians orders as scheduled. There were 9 medication errors out of 28 opportunities, resulting in a 32.1% medication error rate.This applies to 1 of 2 residents (R58) observed for medication administration.Findings include:On 7/30/25 at 9:11 AM, the surveyor approached V11 (Agency RN (Registered nurse)) to observe medication administration. V11's medication cart was parked in the middle of the hall. R182 was seated in her wheelchair next to the medication cart and R58 was standing behind R182. V11 said she was preparing medications for R182. The surveyor waited while V11 administered the prepared medications to R182. R58 told V11 that he needed something for his stomach. V11 opened her computer to the Medication Administration Screen and numerous residents showed up in red. V11 stated, I know there's a lot of red on the screen. That's because they're considered late. R58 was red on the computer screen. V11 stated, I need to give you your morning medications and I'll see what you…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 their Abuse Prevention Policy by failing to immediately remove the accused employee from resident contact for 1 of 3 residents (R1) reviewed for Abuse in the sample of 3. Findings include: The Facility's Abuse Policy dated 3/25 documents, 5. Protection of Residents. The facility will take steps to prevent mistreatment while the investigation is underway. c. Employee of this facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation has been reviewed by the administrator or designee. On 4/9/25 at 9:45 AM, V5 (Step daughter) and V6 (ex wife) said they were at the facility last Sunday 4/6/25. R1 told them that V7 (Certified Nurse Assistant CNA) had hit R1. V5 and V6 said they reported to V4 (Operations Manager) that Sunday, specifically telling V4 that R1 said he was hit by V7 (CNA). V5 said on Monday (4/7/25) she tried to get hold of the Director of Nursing (V2-DON) and left a message for V2 to call her back. V5 said she wanted to make sure…

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

Based on interview and record review the facility failed to report to the State Agency in a timely manner an allegation of Physical Abuse for 1 of 3 residents (R1) reviewed for Abuse in the sample of 3. The findings include: On 4/9/25 at 9:45 AM, V5 (R1's Step daughter) and V6 (R1's ex wife) said they were at the facility last Sunday 4/6/25. V5 and V6 said they reported to V4 (Operations Manager) that Sunday, specifically telling V4 that R1 said he was hit by V7 (CNA). On 4/9/25 at 11:12 AM, V4 (Operation Manager) said she was the Weekend Manager working last Sunday 4/6/25. It was after 3PM last Sunday 4/6/25. R1's step daughter (V5) and R1's ex wife (V6) informed her that R1 said V7 (CNA) was rough when taking care of R1. V4 said she reported the allegation to V3 (Assistant Administrator.) but did not report the allegation to V1 (Abuse Coordinator) On 4/9/25, V3 (Asst Administrator) said V4 did not report to her that R1's family (step daughter and ex wife) had an allegation of a CNA V7 being rough to R1 that Sunday. All V4 reported was that there was an issue going on at the…

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

Based on observation, interview, and record review the facility failed to ensure residents at risk for falls had their call lights within reach for 3 of 6 residents(R3, R5, R7) reviewed for safety in the sample of 8. Findings include: 1. On 2/5/25 at 10:02 AM, R3 was sitting up in a chair on the right side of the bed. R3's call light was clipped to the mattress on the left side of the bed (across the bed). R3 said she uses the call light when she needs help to go to the bathroom. R3's most recent Care Plan shows R3 is at risk for falls due to weakness and lists the intervention: promote placement of call light with in reach. 2. On 2/5/25 at 10:20 AM, R5 was sitting up in his wheelchair near the end of the bed watching TV. R5's soft touch call light was clipped to the head of the bed behind R5. R5's most recent Care Plan shows R5 is at risk for falls due to generalized weakness and lists the intervention: promote placement of call light with in reach. 3. On 2/5/25 at 10:49 AM, R7 was awake and sitting up in bed. R7's call light was coiled up, clipped to itself and hanging over 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 a resident remained free from resident-to-resident abuse for two of two residents (R30, R58) reviewed for abuse in the sample of 38. Findings include: R30's admission Record, provided by the facility on 6/27/24, showed he had diagnoses including schizophrenia, bipolar disorder, cataract-unspecified, and cognitive communication deficit. R30's facility assessment dated [DATE] showed he was cognitively intact, had behaviors that were not directed towards others, and had hallucinations. The assessment showed R30 needed supervision or touching assistance with walking. R58's admission Record, provided by the facility on 6/27/24, showed he had diagnoses including schizoaffective disorder, generalized anxiety disorder, metabolic encephalopathy (a brain condition caused by a chemical imbalance in the blood due to an illness or organ dysfunction), and cognitive communication deficit. R58's facility assessment dated [DATE] showed he had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff were documenting the resident's Physician, or Nurse Practitioner was notified when a resident's blood glucose levels were out of the parameters ordered by the physician for 1 of 1 resident (R133) reviewed for insulin medication use in the sample of 38. Findings include: R133's admission Record, provided by the facility on 6/27/24, showed he had diagnoses including type II diabetes mellitus, schizoaffective disorder-depressive type, encephalopathy (a broad term for any brain disease that alters brain function or structure. Declining ability to concentrate, memory loss, personality changes, seizures, and twitching are common symptoms). R133's diagnoses also included generalized anxiety disorder, and adult failure to thrive. R133's facility assessment dated [DATE] showed he had moderate cognitive impairment and receives hypoglycemic medications including insulins. The assessment showed R133 did not have behaviors. R133's Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care was provided for a resident's right hand contracture and nails for 1 of 1 residents (R32) reviewed for activities of daily living in the sample of 38. Findings include: On 6/25/24 at 9:59 AM, R32 was sitting up in a low bed with a mat on the floor to her right side of the bed. R32's right hand was contracted with a long, slightly curved thick nail on her right thumb. R32 stated staff do not clean her right hand. R32 stated her nails hurt and were cutting into her hand. On 6/26/24 at 7:51 AM, R32 was in bed and V9 CNA (Certified Nursing Assistant) was providing morning care and incontinence care for the resident. R32's right hand was contracted with a long, slightly curved thick nail on her right thumb. V9 stated R32's nail was so thick that it is hard to cut that nail. V9 stated she did not think regular nail clippers would cut the nail. V9 stated the nurse's have to cut R32's nails. V9 stated R32's right hand is contracted and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's dressings were in place for a resident (R20) with venous stasis ulcers. This applies to 1 of 6 residents reviewed for skin conditions in the sample of 38. Findings include: R20's electronic face sheet printed on 6/27/24 showed R20 has diagnoses including but not limited to venous insufficiency, Parkinson's disease with dyskinesia, non-pressure chronic ulcer of other part of left lower leg, alcoholic cirrhosis, bipolar disorder, peripheral vascular disease, and heart failure. R20's physician's orders dated 10/2/23 showed, (multipurpose support bandage): apply knee high to bilateral lower extremities in the morning and remove at bedtime. R20's facility assessment dated [DATE] showed R20 has no cognitive impairment. R20's care plan dated 9/25/23 showed, (R20) has actual alterations in skin integrity related to venous stasis to left lower extremity and peripheral vascular disease. (R20) is also noted to pick at her skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services to prevent a resident's Range of Motion from declining. This applies to 1 of 1 resident (R23) reviewed for Range of Motion in a sample of 38 residents. Findings include: R23's Facesheet shows her diagnoses to include hemiparesis (muscle weakness or partial paralysis) and hemiplegia (full paralysis) affecting her left side following a cerebral infarction in January of 2022. R23's Careplan shows she requires Activities of Daily Living (ADL) assistance secondary to her cerebral infarction. The intervention dated 1/24/22 shows the facility is to provide ROM to affected extremities as ordered. R23's 5/9/24 MDS (Minimum Data Set) shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) of 15. On 06/26/24 at 11:23 AM, R23 was in bed, with her left arm bent and her elbow close to her body. R23's hand was close to her neck. Her left hand had a rolled up washcloth in it. On 06/26/24 at 11:23 AM, R23 said, the facility is not providing Range of Motion (ROM) therapy, and she has lost…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to safely transfer a resident using a mechanical lift. This applies to one of one residents (R71) reviewed for safety in the sample of 38. Findings include: The facility face sheet for R71 shows she was admitted to the facility with diagnoses to include morbid obesity, osteoarthritis, and congestive heart failure. The facility assessment dated [DATE] shows R71 to be cognitively intact and is dependent on staff for transfers. The care plan dated 6/5/24 shows R71 requires the use of a mechanical lift for transfers. The interventions include to provide two staff assistance for transfers. On 6/26/24 at 10:45 AM, R71 was sitting in her room and a bruise was observed to her right eye. R71 said she was being transferred from her bed into her recliner by one CNA (Certified Nursing Assistant). R71 said as she was being lowered into the recliner , the CNA was at the end of the lift controlling the lift. R71 said it happened quickly when the arm 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 observation, interview and record review the facility failed to ensure there were physicians orders for a suprapubic catheter and it's care. This applies to 1 of 1 resident (R5) reviewed for catheters in a sample of 38 residents. Findings include: R5's 3/29/24 Nurse Practitioner notes shows his diagnoses to include a neurogenic bladder, anxiety, agitation, and paranoia. On 6/26/24 at 8:53 AM, R5 was sitting in the wheelchair with his urine bag on his lap. On 6/27/24 at 11:45 AM, V2 DON (Director of Nursing) said, R5 came back from the hospital in March of 2023 and his catheter orders were never re-wrote. V2 said they re-wrote them today. V2 said there should be an order from the Physician or Nurse Practitioner for those things, and the order for care should be on the TAR (Treatment Administration Record) to remind staff it should be done, and to document that it was done. R5's POS (Physician Order Sheet) shows no orders for the suprapubic catheter or the care of it prior to 6/26/24. R5's Care Plan shows he requires the use of an Indwelling Supra pubic Catheter related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident with significant weight loss was assisted and encouraged with meals. The facility failed to ensure a residents supplement intake was accurately documented for 1 of 1 residents (R93) reviewed for significant weight loss in the sample of 38. Findings include: The Weight Log for R32 showed: 12/1/23 - 118.4 pounds; 1/4/24 - 123.6 pounds; 2/2/24 - 12:39 pounds; 3/8/24 - 117.5 pounds; 4/4/24 - 110.7 pounds; 5/4/24 - 111 pounds; and 6/5/24 - 108.6 pounds. R32 had a 7.5% significant weight loss from March 2024 to June 2024. On 6/26/24 at 8:09 AM, R93 was sitting on the side of her bed with her breakfast tray on the over the bed table in front of her. R93 had an egg, sausage, and cheese sandwich, fortified hot cereal in a bowl with a lid on it, milk, coffee and juice. On 6/26/24 at 12:42 PM, R93 was laying on her back in bed with her lunch sitting on the tray table next to her. R93 stated she ate the meat and cheesecake from her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 remove contaminated gloves after providing incontinence care and failed to place soiled linen in a plastic bag. This failure applies to two of seven residents (R32 and R74) reviewed for infection control in the sample of 35. Findings include: 1. The facility face sheet for R74 shows he was admitted to the facility with diagnoses to include hemiplegia after a stroke and congestive heart failure. The facility assessment dated [DATE] shows him to have severe cognitive impairment and is dependent on staff for all activities of daily living. On 6/25/24 at 11:07 AM, V4 Certified Nursing Assistant (CNA) and V5 CNA were observed providing incontinence care to R74. As V4 was providing care and removing soiled linens from R74, she was throwing the linen onto a chair in the room. When V4 was finished providing incontinence care, she did not remove her gloves, and assisted R74 with putting on a clean gown and turning him side to side to place 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 the required personal protective equipment was worn for a resident on contact isolation precautions and failed to ensure enhanced barrier precautions were implemented for 4 of 35 (R9, R110, R117, R118) residents reviewed for infection control. Findings include: 1. R110's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to osteomyelitis left ankle and foot, sepsis due to Methicillin resistant staphylococcus aureus infection (MRSA), type 2 diabetes mellitus. R110's physicians order sheet printed 8/8/23 showed isolation: contact precautions related to staph sepsis. R110's minimum data set (MDS) printed 8/8/23 showed he has no cognitive impairment and requires assistance of 2 staff for cares. R110's care plan printed on 8/8/23 showed (R110) is with isolation precautions: contact related to staph and sepsis with draining wounds. Monitor isolation supplies and replenish as needed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 weights were monitored for a resident with congested heart failure for 1 of 35 residents (R110) in the sample of 35. The Findings Include: R110's face sheet printed on 8/8/23 showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic diastolic congestive heart failure, end stage renal disease, hypertensive heart, and chronic kidney disease with heart failure and with stage 5 chronic kidney disease or end stage renal disease. R110's physicians order sheet (POS) printed on 8/8/23 showed to check weights x4 every shift on Wednesday for screening for 4 weeks. R110's after visit summary dated 7/11/23 showed for your congestive heart failure to check your weight every day. R110's minimum date sheet dated 7/18/23 showed no cognitive impairment and requires the assistance of two (2) staff for cares. R110's weight summary printed on 8/8/23 showed R110 was weighed from 7/12/23 to 8/3/23 five (5) time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to safely transfer residents at risk for falls for two of 35 residents (R140, R217) reviewed for safety in the sample of 35. The findings include: 1. R217's admission Record shows she was admitted to the facility on [DATE] with diagnoses including right femur fracture, polyosteoarthritis, other abnormalities of gait and mobility, muscle weakness, unsteadiness on feet, and history of falling. R217's MDS (Minimum Data Set) dated August 2, 2023 shows R217 is not cognitively intact and requires extensive assistance with transferring. R217's Fall Risk assessment dated [DATE] shows R217 is at risk for falls. R217's Care Plan initiated August 2, 2023 shows [R217] has an ADL (Activities of Daily Living) performance deficit related to displaced intertrochanteric fracture of right femur, polyosteoarthritis, chronic obstructive pulmonary disease, history of falling, other forms of dyspnea. [R217] is noted to not follow his weight bearing status. 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 maintain a urinary drainage bag below the level of the bladder for two of eight residents (R143, R211) reviewed for catheters in the sample of 35. The findings include: 1. R143's Order Summary Report dated August 8, 2023 shows he was admitted to the facility on [DATE] with diagnoses including generalized anxiety disorder, post-traumatic stress disorder, history of falling, acute kidney failure, muscle weakness, urinary retention, and neuromuscular dysfunction of bladder. On August 7, 2023 at 10:47 AM, R143 was lying in his bed. V5 (Certified Nursing Assistant/CNA) repositioned R143 in bed and lifted his urinary drainage bag over R143's body to move it to the other side of the bed. V5 lifted R143's urinary drainage bag above the level of his bladder. There was urine in the tubing and in the urinary drainage bag. R143's Care Plan initiated April 8, 2023 shows, [R143] requires the use of an indwelling catheter. Position collection bag below…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pain management for a resident complaining of pain for one of 35 residents (R211) reviewed for pain in the sample of 35. The findings include: R211's Order Summary Report dated August 7, 2023, shows he was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, urinary tract infection, weakness, dysphagia, anxiety disorder, malignant neoplasm of prostate, encounter for palliative care, and bladder neck obstruction. The report shows and order for morphine sulfate 5 mg by mouth every three hours as needed for pain management/respiratory symptoms. On August 7, 2023 at 10:53 AM, V5 and V6 CNAs (Certified Nursing Assistants) provided incontinence care to R211. R211 said he had pain to his kidneys. R211 said Ow with each movement that V5 and V6 did. R211's MAR (Medication Administration Record) dated August 1, 2023-August 31, 2023 shows R211 did not receive any pain medication on August 7,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor a resident's food preference. This applies to 1 of 35 residents (R89) reviewed for preferences in the sample of 35. The findings include: On 8/7/23 at 10:06 AM, R89 said he had not been receiving a grilled cheese sandwich with lunch as requested. R89 said he ordered a grilled cheese sandwich for lunch on 8/7/23 and hopes to receive it. R89's diet card from 8/7/23 shows a handwritten gc for lunch. On 8/9/23 at 8:24 AM, V2 (Assistant Administrator/Dietary Manager) said certified nursing assistants or activity aides will go around with a weekly menu and ask residents what they would like to eat for meals. That information is given to the kitchen and then written onto the diet cards for the corresponding days and meals. V2 said that when a resident requests a grilled cheese sandwich, it will show up on the diet card as gc. V2 said if the diet card shows gc then a grilled cheese sandwich should have been served. On 8/7/23 at 12:51 PM, R89 was served spaghetti with meatballs, green beans, and garlic bread. R89…

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

Based on interview and record review the facility failed to ensure a resident was evaluated for occupational and physical therapy needs after returning from a hospital stay. This applies to 1 of 8 residents (R62) reviewed for therapy in the sample of 35. The findings include: R62's face sheet shows she has diagnoses including acute and chronic respiratory failure, pneumonia, and cellulitis. On 8/7/23 at 10:24 AM, R62 said she had a recent episode where she passed out and was sent to the hospital. She said she woke up and had a breathing tube in. R62 said she recovered and was sent back to the facility. R62 was asked if she was receiving any physical therapy after returning and she said she had received therapy at the facility in the past but nothing recently. R62's nursing progress notes show she was sent to a local emergency room on 6/25/23 due to vomiting, shortness of breath and decreased oxygen saturation levels and was admitted to a local community hospital with a diagnosis of respiratory failure. Nursing progress notes show R62 returned to the facility on 6/30/23. A physician…

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