Prairie Oasis

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to respond and resolve resident grievances in a timely manner. This failure affects one of six residents (R1) reviewed for grievances. Findings include: R1's face sheet documents in part R1 is a [AGE] year-old resident with a prior medical history including: hemiplegia affecting left side, type 2 diabetes mellitus, depression, hypothyroidism, and hypertension. Record review of grievances (5/5/2025, 7/3/2025, 11/11/2025) document, in part, concerns with R1 receiving showers. The grievance dated 11/11/2025 does not indicate if the grievance was resolved or unresolved, the complainant's response to the resolution or signature from the administrator. On 12/13/2025 at 10:27 AM, R1 stated R1 has complained about showers to R1's family members and staff and stated staff do not respond timely to concerns. R1 affirmed R1's family will also complain to staff about concerns and nothing gets resolved. R1 stated, I haven't had a shower in over a month. On 12/13/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an injury of unknown origin to the state survey agency within 2 hours for one (R3) of six residents reviewed for reporting. This failure resulted in R3 experiencing left arm pain and swelling and being transferred to the hospital and diagnosed with closed supracondylar fracture of the left humerus.Findings include:Record review of initial report to the state survey agency (12/12/2025) documents in part, that on 12/11/2025 at 10:10 AM, R3's left arm was observed swollen and painful to the touch. At 22:16, R3 returned from the hospital with a diagnosis of closed supracondylar fracture of the left humerus. The facsimile transmission for the initial report documents in part, that the reportable was faxed on 12/12/2025 at 3:30 PM. On 12/13/2025 at 3:45 PM, V1 (Administrator) affirmed V1 is aware of R3's fracture and that the facility does not know how R3 got the fracture. V1 explained, (R3) wasn't able to say what happened, (R3) just kept saying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record reviews, the facility failed to provide sufficient RN (registered nurse) coverage for the second quarter of 2025. Per PBJ (payroll based journal) requirements there should be an RN working 8 consecutive hours 7 days a week. This failure has the potential to affect all residents residing in the facility. Findings include:On 9/9/25 at 9:30 AM, there was signage posted at the main receptionist desk, dated 8/19/25, noting 'this facility did not meet the minimum staffing ratios required by law for the quarter ending March 31st, 2025.On 9/12/25 at 9:00 AM, V2 DON (director of nursing) stated that for 21 days during the second quarter PBJ report there wasn't an RN present for 8 consecutive hours 7 days a week.The facility's staffing sheets for January, February, and March were reviewed. Per V18 RN (registered nurse), V19 RN, V20 RN, V21 RN, and V22 RN time punches, the facility did not routinely have an RN present for 8 consecutive hours on New Year's Day, Saturdays, and Sundays:1/1/25 - RN time punch requested during survey but not made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to follow their recipe by not utilizing the appropriate serving size for zucchini, lettuce and cheese during lunch service. This has the potential to affect all 58 resident receiving regular diet. In addition, the facility, failed to provide pureed tortilla during lunch service for 20 of 20 residents receiving pureed diets.Findings include: On 9/9/25 at 11:49AM kitchen tray line observed with V13 (Cook). Lunch being served was beef taco on a tortilla with lettuce, cheese, onion and tomato with zucchini and refried beans. V13 said the mechanical soft diet is the same as regular but without lettuce. V13 observed using a tongs to serve the zucchini. No measurement or tools used for cheese, lettuce and tomatoes. V13 using gloved hand to place on cheese, lettuce and tomatoes the plates.Facility recipe for shredded lettuce with diced tomatoes and cheese documents to portion as garnish 1/2 cup of lettuce and tomato with tablespoon of shredded cheese.Facility recipe for seasoned zucchini documents to serve with #8 scoop to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the dishwasher was working to provide the correct sanitation solution during washing and utilized the dishes for the next meal service. In addition, the facility failed to follow their thawing policy by leaving raw pork on the stove top (that was off) and reaching a danger zone temperature of 60 degrees after being left out for over four hours. This has the potential to affect all 99 residents receiving meals.Findings include:On 9/9/25 at11:49Am, tray line observation conducted and facility using regular plates, silverware and cups for meal service.On 9/9/25 at 1:46PM, V14 (dietary aide) low temp/sanitizer dish washer checked. Chlorine test strip did not turn. V14 said it didn't work this morning when he checked and showed surveyor logbook. V14 said he informed another staff, but they continued to use dishwasher after breakfast and lunch service.On 9/12/25 at 11:04Am, V17 (dishwasher repairman) said he serviced facility dishwasher…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record reviews, this facility failed to ensure the call light cord was within reach for two residents (R59 and R63) out of three residents reviewed for call light accessibility in a sample of 104. Findings include:On 9/9/25 at 10:30 AM, R59's call light cord was observed dangling behind R59's bed. When questioned, R59 stated that R59 must lower the head of her bed to a flat position and stretch left arm above head and swing arm side to side until she can reach the call light cord. On 9/9/25 at 1:05 PM, R63 was heard yelling out for help. When this surveyor entered R63's room, R63 was observed sitting in wheelchair positioned in the middle of room. R63's call light cord was observed wrapped in circular patterns on R63's nightstand which was about three feet behind R63. R63's call light cord was not within reach. On 9/9/25 at 1:10 PM, V6 LPN (licensed practical nurse) was observed clipping R63's call light cord to R63's clothing at the right shoulder. On 9/9/25 at 1:20 PM, V2 DON (director of nursing) stated that R59's call light cord is not long…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record reviews, the facility failed to have an appropriate diagnosis for the use of antipsychotic medications and failed to identify a specific behavior for the use of an antipsychotic medication. This failure affected one resident (R10) out of four residents reviewed for chemical restraints in a sample of 104.Findings include:Findings include:On 9/12/25 at 9:30 AM, V15 ADON (assistant director of nursing) stated that R10 is receiving Seroquel for agitation. When questioned if a resident is receiving psychotropic medication should there be a diagnosis and reason why medication is needed, V15 responded R10 is on hospice care and V15 can call the outside hospice company to see if their physician would like to add a diagnosis. When questioned if diagnosis should be determined before initiating a psychotropic medication, V15 did not respond.On 9/12/25 at 10:00 AM, when questioned if a dementia diagnosis is an appropriate diagnosis for a resident to receive a psychotropic medication, V2 DON (director of nursing) responded that she does not have anything to do with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their smoking at risk program policy and develop an at risk plan of care. This affects one of three (R56) residents reviewed for safe smoking care plan interventions. During survey tour from on 9/9/25 between hour of 11:17am -11:39am, R56 was observed with a cigarette lighter. R56 said it was his lighter for his cigarettes.9/9/25 V2 (Director of Nursing) said residents should not have cigarette lighters in their possession, it's the facility policy. V2 made aware R56 was observed with a cigarette lighter.9/12/25 at 12:27pm V2 (Director of Nursing) stated her expectation is the staff conduct and complete an accurate assessment of the residents. V2 said care plan are individualized, and the assessments drives the plan of care is developed for the residents. V2 said R56 does smoke. V2 said R56 care should have been updated accurately; to reflect he is at risk smoker.9/12/25 at 1:26pm V6 (LPN) said she only have two residents on the unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 successfully implement interventions to prevent resident (R17) from losing weight. This failure resulted in the resident experiencing a significant weight loss of 6 percent in one month and a significant weight loss of 11.3 percent within six months for one of seven reviewed for nutrition.Findings include:R17 was admitted to the facility on [DATE] with a diagnosis of type II diabetes, hypertension, anemia, severe protein caloric malnutrition, blindness category four to left and right eye.R17's weights documents: 9/5/25 65.2 pounds; 8/27/25 65 pounds; 8/20/25 66.6 pounds; 8/5/25 62.8 pounds; 7/3/25 66.8 pounds, 6/4/25 66.8 pounds, 5/28/25 66.8; 5/6/25 65 pounds, 3/5/25 70.2 pounds; 2/7/25 70.8pounds; 1/7/25 69 pounds and 12/6/24 71.4 pounds.R17's plan of care dated 6/7/24 documents: R17 receives a regular diet with thin liquids which I consume usually with a poor appetite. The resident may be at risk for weight loss related to: adjustment to 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 interviews and record reviews, the facility failed to have an appropriate diagnosis for the use of antipsychotic medications, failed to identify a specific behavior for the use of an antipsychotic medication. This failure affected one resident (R10) out of four reviewed for unnecessary medications in a sample of 104. Findings include:On 9/12/25 at 9:30 AM, V15 ADON (assistant director of nursing) stated that R10 is receiving Seroquel for agitation. When questioned if a resident is receiving psychotropic medication should there be a diagnosis and reason why medication is needed, V15 responded R10 is on hospice care and V15 can call the outside hospice company to see if their physician would like to add a diagnosis. When questioned if diagnosis should be determined before initiating a psychotropic medication, V15 did not respond. On 9/12/25 at 10:00 AM, when questioned if a dementia diagnosis is an appropriate diagnosis for a resident to receive a psychotropic medication, V2 DON (director of nursing) responded that she does not have anything to do with psychotropic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 set up a dental referral/appointment for one resident (R62) who required a tooth extraction for one of one reviewed for dental services.Findings include:R62 was admitted to the facility on [DATE] with a diagnosis of type II diabetes, dementia, hypertension, epilepsy, anxiety and weakness.On 9/9/25 at 10:59AM, R62 who was alert and oriented said he was having tooth pain for about week due to cracked tooth. R62 said he was supposed to see a dentist for removal but still not sure what is happening.Referral dated 9/5/25 documents: patient wants extraction of upper right premolar.On 9/12/25 at 9:48AM, V2(DON) said she was not aware of referral until she received the email on 9/11/25. V2 said she made the appointment on 9/11/25 for next week.

Based on observation, interview and record review, V8 (nurse) failed to sanitize or wash her hand during medication administration. This affected two of three (R3, R32) residents reviewed for hand washing during medication administration. Findings Include: On 9/10/25 at 9:00am, during medication pass, V8 (nurse) administered R3's morning medications, return to the medication cart and proceed to prepare R32's morning medications without washing her hands or using hand sanitizer. V8 said she was supposed to clean her hands after she gave R3 her medication and before she prepared R32's medication. V8 said she forgot to clean her hands in between residents. V8 said she will clean her hands now. On 9/12/25 at 12:30pm, V2 (DON) said hand hygiene should be performed in between resident during medication administration to prevent the spread of infections. V2 said hand sanitizer or soap and water should be used for hand hygiene. Hand Hygiene Policy no date documents: Hand hygiene shall be performed: before contact with a resident or resident's environment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their abuse policy by not keeping a resident (R2) with dementia free from being hit by a cognitively intact resident (R1) for one out of four residents reviewed for physical abuse in a total sample of six. Findings include: R1 is a [AGE] year old with the following diagnosis: cirrhosis and lymphedema. R2 is a [AGE] year old with the following diagnosis: type 2 diabetes, dementia, and Alzheimer ' s disease. On 6/25/25 at 3:13PM, R1 stated R1 pushed R2 up against a wall when R2 would not stop touching R1's personal items. R1 reported R2 had a habit of drinking R1's pop and taking R1's clothing. R1 stated R1 asked R1 to stop each time R2 would do this but R2 would not stop due to being confused. R1 reported telling the staff about this behavior but staff did nothing to help R1. R1 stated R1 had enough and pushed R2 against a wall and they started to hit each other in the face while wrestling. R1 reported moving to a different room when R1 got 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 provide adequate supervision and monitoring for residents. This failure affects six (R7, R8, R9, R10, R11, R12) out of twelve residents reviewed for supervision and monitoring. Findings include: On 04/26/2025, at 8:41 AM, R7 observed sitting in a wheelchair inside of the first-floor 100-unit dining room unsupervised and unattended. On 04/26/2025, at 8:57 AM, V7 (CNA) walked inside of the 100-unit dining room and stated she is responsible for caring for R7 today. V7 stated R7 should be monitored and supervised while sitting in the dining room but V7 can't watch everybody. V7 stated if residents are left unsupervised and no one is monitoring the residents, then residents could potentially fall or choke while eating. On 04/26/2025, at 1:17 PM, R8, R9, R10, R11, and R12 observed sitting inside of the first floor 300-unit dining room unsupervised and unattended. R8, R9, and R11 were sitting in wheelchairs. On 04/26/2025, at 1:18 PM, V2 (Director of Nursing/DON) walked inside the 300-unit dining room and walked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record reviews the facility failed to follow their policies for care planning and fall prevention by not ensuring care plans were developed based on assessments and individual needs; by not reviewing and updating care plans for appropriateness; and by not ensuring adequate personalized interventions were identified. This failure applied to two of four residents (R3 and R5) reviewed for care planning. Findings include: 1. R3 is a [AGE] year-old male with a diagnoses history of COPD, Heart Failure, Unspecified Convulsions, and Alcohol Abuse who was admitted to the facility 08/14/2024. R3's Fall Risk assessment dated [DATE] documents he is at high risk for falls. R3's Fall Risk Assessments dated 08/20/2024, 11/12/2024, and 12/29/2024 document his fall risk factors include diuretic medication, antiseizure medication, antihypertensive medication, psychotropic medication; occasional - frequent incontinence, inability to independently stand, requires hands on assistance to move from place 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 interviews and record reviews the facility failed to follow their policy and procedures for hydration by not ensuring a nutrition assessment was completed, not ensuring a hydration care plan was developed or interventions implemented, and not notifying the physician of abnormal labs related to hydration for a newly admitted resident assessed to be at risk for dehydration. This failure applied to one of four residents (R5) reviewed for hydration. Findings include: R5 is a [AGE] year-old male with a diagnoses history of Quadriplegia, Heart Failure, End Stage Renal Disease, Chronic Kidney Disease, Dependence on Renal Dialysis, Urinary Tract Infection, Metabolic Encephalopathy, Partial Paralysis following Stroke, and Dehydration (02/15/2025) who was admitted to the facility 01/31/2025. R5's Current Care Plan initiated 02/17/2025 documents he is at possible risk for dehydration with signs and symptoms related to a history of dehydration with interventions including: Encourage resident to drink all fluids…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record reviews, the facility failed to protect a resident with severe cognitive impaired from physical abuse and failed to develop care plan interventions in preventing abuse for two (R1 and R2) of four residents reviewed for abuse. Findings include: R1 is a [AGE] year old, male, admitted in the facility on 04/15/24 with diagnoses of Alzheimer's Disease, Unspecified; Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood disturbance and Anxiety. MDS (Minimum Data Set) dated 01/06/25 documented R1's BIMS (Brief Interview for Mental Status) score of 5 which means severe cognitive impairment. According to incident report dated 01/13/25, around 1:45PM, R2 was sitting at his own lunch table by himself when he suddenly jumped up and reached for R1's face with his fork in his hand. R1 had been sitting eating his lunch at his own lunch table which was located on the right side of R2. R1 and R2 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 replace a broken domestic water heater that provide hot water to resident's bathroom sinks and shower room. This affected eight of eight residents (R3-R6, R8-R11) reviewed for hot water and homelike conditions. Finding Includes: On 1/9/25 at 10:50am, V3 (maintenance director) said, We had an issues with the hot water for a few days. We have two hot water tanks that supply domestic water/ water to the resident's room and the three compartment sink in the kitchen. One of the two water tanks is broken. The other functioning water tank is having a work load stain. On 1/9/25 at 10:54am, V3 tested the water temperature from R8's - R11's bathroom sink after letting it run for 20- 30 seconds the water temped at 77 degrees F for all the sinks. R8-R11's bathroom sink water was cold to touch. R9 who was assessed to be alert and oriented to person, place and time, said her water has been cold for a while. R9 was informed the pilot light went out on the water heater. V3 said the water temperature should be 105 degree F to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record the facility failed to follow the plan of care for a dependent resident and ensure to provide two persons assist with transfer using mechanical lift for 1 of 1 resident (R2). R2 transferred using mechanical lift, R2 was subsequently observed with bruise over left eyebrow and swelling to right jaw. R2 was sent to hospital evaluation and diagnosed forehead contusion. Findings include: R2 face sheet shows R2 is a [AGE] year-old female, diagnosis of unspecified dementia, Alzheimer's disease, hypertension, heart disease, heart failure, presence of cardiac pacemaker, COPD, chronic kidney disease. R2 MDS dated [DATE] notes section C for cognition notes a score of 05 (cognitive impairment) section GG for functional status notes chair to bed transfer R2 is dependent, helper does all the effort. 12/10/24 at 12:59pm R2 observed awake, and alert. R2 observed to follow simple direction from V12 (CNA- certified Nursing Assistant). R2 was unable to interviewed by surveyor. R2 emergency room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the bed rails/side rails were in use and in the up position for one of three residents (R1). R1 hit her right eye on the bedrail. R1 observed with discoloration to right eye and redden sclera. This affects R1 reviewed for bedrail use. Findings include: R1 [NAME] data set dated [DATE] section C shows BIMS score of 15 (cognitively intact). Facility final report dated 12/10/24 notes, in part, resident was observed by staff with discoloration to the right eye and noted swelling. Small blood clot in the right eye. The resident stated she didn't fall, no one hit her, but stated she puts a mask on because her roommate was coughing a lot. The resident said she was sleeping on her right-side rail with the mask on her face and was rubbing her eye because it was itching, but no pain at the right eye. All responsible parties made aware. Resident son, Medical Doctor aware. Orders noted and carried out. Summary of investigative findings: resident received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their abuse policy by not immediately reporting an allegation of staff to resident physical abuse to the administrator and failing to report to the state agency within 2 hours for one of three (R1) residents reviewed for abuse. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis schizophrenia, bipolar disorder, major depressive disorder, and type II diabetes. R1 has a brief interview for mental status score of 12/15 which indicates cognitively intact. On 10/29/24 at 2:20PM, V3 (Nurse) said V4 (NP) reported to her on 10/28/24, that R1 had said when someone was cleaning, someone could have hit her eye. V3 said she informed the V2(DON) prior to leaving her shift at 300pm about concern. On 10/29/24 at 2:35pm, V4 (NP) said R1 saw her in the hallway and R1 mentioned that there was a possible situation with the person that was cleaning up the room but unclear what happened. R1 reported they hurt her but not sure where. V4 said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and record review, the facility failed to always have sufficient staff available to provide nursing services to meet the residents' needs in the facility. This has a potential to affect 105 residents currently residing in the facility. Findings include: On 10/21/2024 at 10:00 AM Surveyor was provided census showing 105 residents residing in the facility at this time. On 10/22/2024 at 10:28 AM Surveyor met with residents during resident council meeting where R7 said, There is long response time to call lights on the second and night shift. They (staff) come when they want to come. On 10/22/2024 at 11:40 AM Surveyor inspected unit 300, no staff was present in the nursing station or in the hallways. Surveyor noticed ongoing call light at 11:40 AM without response. Surveyor prompted V25 (Certified Nurse Assistant) at 12:00 PM to answer the call light. On 10/22/2024 at 11:50 AM Surveyor interviewed V25 (Certified Nurse Assistant) who said in summary, I feel like we don't have enough staff to monitor residents adequately. My assignments usually contain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify responsible parties and perform comprehensive assessment for a resident with an injury of unknown origin for one (R84) of two reviewed for abuse in the sample of 42. Findings include: R84 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to chronic kidney disease, stage 3; Cerebral Infarction; Unspecified Dementia; and Cognitive Communication Deficit. According to R84's MDS (Minimum Data Set) assessment dated [DATE], under section C, R84 has BIMS (Brief Minimum Data Set) score of 5 indicating severely impaired cognition. On 10/22/24 at 03:31 PM Surveyor interviewed V27 (Licensed Practical Nurse) who said in summary, I worked a day shift on 10/11/2024. V26 (CNA) reported to me that R84 has a black eye. I looked at R84, noticed the black eye (don't remember) which one. I checked her vital signs but didn't do any other assessment. I asked R84 what happened, but she wasn't able to tell me, R84 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 ensure staff was provided adequate abuse prevention education. This failure has a potential to affect 63 residents in the facility. Findings include: On 10/21/2024 at 10:00 AM Surveyor was provided census showing 36 residents residing in the unit 200 and 27 residents residing in the unit 300. Total residents for unit 200 and unit 300 is 63. 10/22/24 03:31 PM Surveyor interviewed V27 (Licensed Practical Nurse) who said in summary, I worked a day shift on 10/11/2024. V26 (CNA) reported to me that R84 has a black eye. I looked at R84, noticed the black eye (don't remember) which one. I checked her vital signs but didn't do any other assessment. I asked R84 what happened, but she wasn't able to tell me, R84 is confused. It looked like a fresh bruise. I didn't receive information about R84's injury in a hand off report and there was no progress note. I didn't notify the family or doctor. I created the progress note. Later on, V2 (DON) told me that, in similar case in the future, I should notify V2 (DON) and I received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report alleged abuse to the state regulatory agency within timely manner for one (R84) of two residents reviewed for abuse in the sample of 42. Findings include: R84 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to chronic kidney disease, stage 3; Cerebral Infarction; Unspecified Dementia; and Cognitive Communication Deficit. According to R84's MDS (Minimum Data Set) assessment dated [DATE], under section C, R84 has BIMS (Brief Minimum Data Set) score of 5 indicating severely impaired cognition. On 10/22/24 at 03:31 PM Surveyor interviewed V27 (Licensed Practical Nurse) who said in summary, I worked a day shift on 10/11/2024. V26 (CNA) reported to me that R84 has a black eye. I looked at R84, noticed the black eye (don't remember) which one. I checked her vital signs but didn't do any other assessment. I asked R84 what happened, but she wasn't able to tell me, R84 is confused. It looked like a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate alleged abuse for one (R84) of two residents reviewed for abuse in the sample of 42. Findings include: R84 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to chronic kidney disease, stage 3; Cerebral Infarction; Unspecified Dementia; and Cognitive Communication Deficit. According to R84's MDS (Minimum Data Set) assessment dated [DATE], under section C, R84 has BIMS (Brief Minimum Data Set) score of 5 indicating severely impaired cognition. On 10/22/2024 between 11:40 AM and 11:42 AM in separate interviews, R32 and R48 denied being interviewed in relation to the incident involving R84 prior to the surveyor's interview. R32 resides in the room that was adjacent to R84 and R48 resides in the room that was immediately across form R84's room around the time of the incident. On 10/22/24 at 03:31 PM Surveyor interviewed V27 (Licensed Practical Nurse) who said in summary, I worked a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders and failed to follow their policy for restorative programs by failing to obtain a physician order for a restorative device for 1 (R16) resident and failed to apply a splint/brace, or restorative device to prevent further contracture formation for 2 residents (R16 and R80) out of 3 residents reviewed for limited range of motion and rehabilitation. Findings include: 1. R80 is [AGE] years of age. Current diagnoses include but are not limited to Hemiplegia and hemiparesis following Cerebrovascular Disease Affecting Right Dominant Side. R80's MDS Minimum Data Set (Comprehensive Assessment) Section C Cognitive Status dated 10/09/2024 indicates a brief interview for mental status score of 13 out of 15. A score of 13-15 indicates no cognitive impairment. On 10/21/24 at 10:44 AM, R80 was alert and oriented and seated in her wheelchair in her room. R80 has limited range of motion to the right arm. R80 wasn't wearing a splint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent a cognitively impaired resident from sustaining an injury for one (R84) of two residents reviewed for accidents in the sample of 42. Findings include: R84 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to chronic kidney disease, stage 3; Cerebral Infarction; Unspecified Dementia; and Cognitive Communication Deficit. According to R84's MDS (Minimum Data Set) assessment dated [DATE], under section C, R84 has BIMS (Brief Minimum Data Set) score of 5 indicating severely impaired cognition. Absent are any care plans prior the incident (10/11/2024) to show R84 has a history of behavior related to bending over to take off shoes that would put her at risk to hit her face on the surface of the table. On 10/21/24 at 10:59 AM R84 observed with hematoma under left eye. Assigned nurse and CNA not aware how R84 obtained the injury. On 10/21/24 at 01:11 PM Surveyor interviewed V3 (Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an arbitration agreement to a resident/representative that provided 30 days after signing to rescind the agreement. This failure applies to 1 (R23) resident of 1 reviewed for arbitration agreements. Findings include: R23 is [AGE] years of age. Current diagnoses include but are not limited to Cerebral Infarction. R23 has a POA Power of Attorney in place due to her current cognition to make decisions on her behalf. Findings include: On 10/22/24 at 01:30 PM, R23's arbitration agreement dated 11/11/2022 was reviewed which indicates: This agreement may be cancelled by any signatory within seven (7) days of its execution. Said cancellation must be delivered to the facility in writing. On 10/22/24 at 01:34 PM, interview with V11 Family Member regarding R23's arbitration agreement cancellation within seven (7) days of its execution signed on 11/11/2022. V11 said, I can't say I'm familiar with what it said. On 10/24/24 at 09:17 AM, V1 was inquired 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 interviews and record reviews the facility failed to follow their policy and procedures for fall prevention by not using all possible methods for identifying risk factors for falls, not implementing personalized and effective interventions, not ensuring new interventions were implemented with each fall, and not providing adequate supervision for residents at risk for falls. This failure applies to two of five residents (R1 and R4) reviewed for falls. Findings include: 1. R1 is a [AGE] year-old female with a diagnoses history of Paranoid Schizophrenia, COPD, Schizoaffective Disorder, Bipolar Disorder, Recurrent Severe Major Depressive Disorder, and Lymphedema who was admitted to the facility 09/19/2023. R1's Risk Management Fall Incident Report dated 09/08/2024 documents she was observed sitting on her bathroom floor after an unwitnessed fall and reported when the incident occurred, she was self-toileting. R1's current care plan initiated 12/18/2023 documents she is at risk for falls related to requiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and records reviewed the facility failed to provide incontinence care at every 2 hours. This affected one of three R1 residents reviewed for incontinence care. Findings include: R1's diagnosis include but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction, Seizures, Diabetes, Hypertension, Atrial Fibrillation, Aphasia, Weakness, Major Depressive Disorder. On 5/28/24 at 10:35AM R1 was in the dining room since approximately 10:25AM. At 11:33AM R1 was observed leaving the dining room by self-propelling in her wheelchair. R1 sat in the hall across from the nurses' station. At 11:51AM staff observed to return R1 to the dining room. On 5/28/24 surveyor remained in the dining room observing R1. At 12:35PM R1 was feeding herself lunch. At 1:05PM R1 was still in the dining room. R1 had not been checked or assisted with toileting. The surveyor ended direct observation of R1 in the dining room at 2:10PM. R1 had not been seen checked or toileted since observation began…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews, and records reviewed the facility failed to carry out physician orders to include dietary changes and a doppler study. This affected three of three residents (R1, R7, and R3) reviewed for physician orders. The findings include: 1.R1's diagnosis include but not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction, Seizures, Diabetes, Hypertension, Atrial Fibrillation, Aphasia, Weakness, Major Depressive Disorder. R1's cognitive patterns assessment dated [DATE] documents she has difficulty in new situations only related to daily decision making. On 5/28/24 at 12:20PM V1, Dietary Manager, said mechanical and ground diets look like ground meat. V1 pointed to R10's meat served on her dish. The surveyor observed it looks like ground meat with gravy on it. R1 has Salisbury steak in front of her, on her plate, not cut up. R1 was feeding herself the meal. At 12:30PM V3, Medical Records, observed cutting up Salisbury steak for R1. At 12:35PM V10, Director of Nursing, 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 interviews and records reviewed the facility failed to ensure one resident with a diagnosis of Dementia, remained free of antipsychotic medication without an appropriate diagnosis. This affects one of three residents (R2) reviewed for unnecessary medication. The findings include: R2 has diagnosis including but not limited to Encephalopathy, Malignant Neoplasm, Altered Mental Status, Type 2 Diabetes, Chron's Disease, Unspecified Dementia, Bipolar Disorder, Depression, and anxiety disorder. On 5/29/24 at 1:18PM V6, RN, said R2 can ambulate independently with a walker. V6 said R2 is confused, and we need to redirect her. V6 said R2 does not have violent behaviors, she needs redirection, has confusion and is forgetful. V6 said to give psychotropic medications we must have verbal and written consent in place. V6 said the Assistant Director of Nursing or Director of Nursing is responsible to give consent unless the doctor comes after hours and orders the medications. V6 said, I assume the consent is obtained,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and records reviewed the facility failed to protect one resident (R1) from being exploited by a staff person who offered her personal care services and the costs for that care and then discharged R1 into her care. This affected one of three (R1) residents reviewed for exploitation. This failure resulted in R1 being discharged to the care of V1 (social worker) without consent or the family's knowledge. The findings include: R1 is [AGE] years old with diagnosis including, but not limited to Congestive Heart Failure, Metabolic Encephalopathy, Pleural Effusion, Hypertension, Cerebral Infarction, Diabetes, Need for Assistance with Personal Care, Weakness, Dementia and History of Transient Ischemic Attack. R1 was admitted to the facility on [DATE] and discharged on 12/21/23. Records indicated R1 left the faciity on [DATE]. On 12/13/23 R1's Cognitive Assessment score is 10, moderately impaired and on a Cognitive Assessment from 12/21/23 R1 is described to have memory problems and difficulties making…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and records reviewed the facility failed to follow their practice and obtain a signature to ensure resident was signed out to the responsible person upon discharge. This affected one of three residents (R1) reviewed for discharge summary. This failure resulted in R1 being discharged to the facility social worker (V1) instead of the family. Findings include: R1 is [AGE] years old with diagnosis including, but not limited to Congestive Heart Failure, Metabolic Encephalopathy, Pleural Effusion, Hypertension, Cerebral Infarction, Diabetes, Need for Assistance with Personal Care, Weakness, Dementia and History of Transient Ischemic Attack. On 1/6/24 at 10:39AM V4, R1's family, said V1, Former Social Service Director, took my dad from the facility. V4 said V5, R1's family, called V4 and told V4, V5 had taken R1 to dinner and R1 told V5 that they were going to take R1 out of the facility, and R1 did not want to go. V4 said V5 told her at 2:00PM on 12/21/23, R1 called V5 and said he was in a van 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 ensure a resident was safely discharged into the community with a family member by allowing facility staff V1 (social service) to discharge the resident (R1) into her private care. This affected one of three residents R1 reviewed for safe discharge. This failure resulted in R1 being discharged into care of V1 without the facility's or family's knowledge. The findings include: R1 is [AGE] years old with diagnosis including, but not limited to Congestive Heart Failure, Metabolic Encephalopathy, Pleural Effusion, Hypertension, Cerebral Infarction, Diabetes, Need for Assistance with Personal Care, Weakness, Dementia and History of Transient Ischemic Attack. R1 was admitted to the facility on [DATE] and discharged on 12/21/23. R1 was admitted to the facility on [DATE] from the hospital. R1 was discharged home on [DATE] and returned 11/17/23 to the facility from home due to concerns related to his medication. Records indicated R1 left the faciity on [DATE].…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, intervention, and record review the facility failed to label medications with names, opened and use by dates; store medications that require refrigeration in the refrigerator, and maintain the correct count for Schedule II medications in two of two medication carts. This failure has the potential to affect 11 residents reviewed for medication storage in the sample of 22. Findings include: On [DATE] at 3:10 PM the medication cart on Unit 300 contained 18 Vancomycin 125 mg (milligram) capsules in unit dose packaging in the cart with no label. V26 (LPN-Licensed Practical Nurse) said, I don't have anybody on antibiotics. I don't know why that's here. All meds should have a label. R1 Timolol 0.5% eyedrops, open and no opened date. Lispro insulin pen opened [DATE] and expired date [DATE] written on label. Opened Insulin Aspart/Protamine Insulin mixed with no opened or use by date. Two unopened Lispro pens in the cart, not refrigerated. V26 (LPN) said, That shouldn't be on the cart. R74 Two opened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assistance with shaving is provided to resident who is unable to carry out the task to maintain good personal hygiene for one of two residents (R58) reviewed for activities of daily living (ADL) in a sample of 22. Findings include: On 12/13/2023 at 10:16AM during observation, R58 was observed with thick facial hair covering the side of his cheek extending to his chin area, and thick mustache. At 10:25AM, R58 was observed with V25 (Certified Nursing Assistant/CNA) with the same appearance. On 12/13/2023 at 10:25AM, V25 stated she was aware R58 had thick facial hairs but the razor in the facility is not efficient enough to be used to shave R58's facial hairs, so V25 waits for the barber to come in and ask to cut it down a little before V25 can shave it completely. On 12/14/2023 at 11:50AM, V2 (Director of Nursing) said it is expected for nursing staff to offer shave every ADL care is provided to residents, and if the razor is not efficient to be used, nursing staff should let her know. V2 said she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent deterioration of pressure ulcer upon admission and failed to follow manufacturer recommendation in using low air loss mattress to resident with stage 4 pressure ulcer. The facility also failed to update the wound care plan. This deficiency affects one (R342) of three residents in the sample of 22 reviewed for Pressure Ulcer Management. Findings include: On 12/13/23 at 12:18PM, Observed R342 lying in bed wearing disposable adult brief, on low air loss mattress with flat sheet and cloth pad over the mattress. Showed observation to V10 Wound care Nurse. V10 said R342 should only be on pads or flat sheet over the low air loss mattress, no multi layers of linen. On 12/13/23 at 12:29PM, Observed V19 Wound care Physician perform wound care with V10 Wound care Nurse and V20 CNA. V19 said R342 has stage 4 pressure ulcer that measures 15.1cm x 16cm x 2cm with undermining 6cm at 6 o'clock. 60% tissue granulation, 5% bone, 15% ligament and 20 %…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that residents with limited mobility and contractures are evaluated and provided treatment to prevent further development of contractures. This deficiency affects one (R82) of three residents in the sample of 22 reviewed for Restorative Program. Findings include: On 12/12/23 at 11:40AM, Observed R82 lying in bed with flexion contractures on right hand. Showed observation to V4 Restorative Nurse. V4 said that R82 does not use splint/brace, she does not need it. On 12/13/23 at 11:50AM, Review R82's medical records with V13 Therapy Director. V13 said that resident is screened upon admission or referral from the nursing. Screening is done to see if the resident will benefit from therapy services such as PT/OT/ST except for hospice or respite care. V4 said that R82 was screened on 6/7/23. It was recommended for her to be re-screened at later date due to inability to participate related to impaired cognition. But no follow up was done. V4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's mouth was clear and free from food residual after feeding a resident who is on aspiration precaution. This deficiency affects one (R35) of three residents in the sample of 22 reviewed for Resident safety. Findings include: On 12/12/23 at 12:45PM, V21 CNA and V22 CNA said R35 ate less than 10% for breakfast and lunch. R35 needs assistance and encouragement during meals. R35 is holding her food in her mouth or spitting it out. Both said V24 Speech Therapist fed R35 for lunch. On 12/12/23 at 12:50PM, Observed R35 sleepy in recliner chair alone in her room, leaning to left side her both legs where stuck at the space of leg rest on the right side of the recliner chair. R35's mouth was open with white colored liquid food pooling over her mouth. R35 opened her eyes when called, but nonverbal and dozing off. R35 is confused and needs total care with ADLs. R35 did not have food protector over her chest, her lunch tray was on…

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

Based on observation, interview and record review, the facility failed to follow physician order for oxygen dosage for one of three residents (R24) reviewed for oxygen therapy in a sample of 22. Findings include: On 12/13/2023 at 10:18AM during observation, R24 was observed with nasal cannula connected to oxygen concentrator regulated at 5 liters. During record review, order dated 11/14/2023 indicated R24's order for oxygen was at 2 liters via nasal cannula continuously. On 12/14/2023 at 11:50AM during observation with V2 (Director of Nursing), R24 was again observed with nasal cannula connected to oxygen concentrator regulated at 5 liters. On 12/14/2023 at 12:00AM during record review with V2, order dated 11/14/2023 indicated R24's order for oxygen was at 2 liters via nasal cannula continuously. V2 stated that the oxygen concentrator should be regulated at 2 liters. V2 also said she expects the nursing staff to follow the physician order for all oxygen use. R24's Order Summary Report dated 12/13/2023 indicated R24's admission dated of 10/29/2023, diagnoses not limited to chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications as ordered for two residents (R13 and R41) of six residents reviewed for medication administration in the sample of 22. Findings include: 1. On 12/13/23 at 9:04 am R41 was scheduled to receive Keppra 500 mg. V27 (LPN-Licensed Practical Nurse) was not able to locate Keppra 500 mg in the medication cart or the convenience cabinet. R41 did not receive Keppra. On 12/13/23 at 11:00 AM V27 (LPN) said, I called R41's doctor and he didn't give any new orders. He said to give the Keppra when it gets here. I called the pharmacy, and they are going to deliver it stat (immediately). It should be here this afternoon. This surveyor asked what could result from a missed or a late dose, V27 said she could have a seizure. On 12/14/23 at 10:21 AM V28 (LPN) said, I got report that the Keppra was on order. I should have given it when it came in. The meds arrived about 10:00 PM. I didn't check the meds. It was pretty busy last night. I didn't give the Keppra. I should have marked why it wasn't given but 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow it policy on infection control by ensuring nebulizer mask was properly stored in a plastic bag and not left open to air. The facility also failed to ensure that isolation gown was removed when coming out of an isolation room. This failure affected two of two residents (R25 and R29) observed for infection control in a sample of 22. Findings include: 1. On 12/12/2023 between 11:35AM to 11:45AM during observation, V14 (Lab Technician) was observed coming out of R25's room after drawing blood who is on contact precautions for MDRO (Multiple Drug Resistance Organism) of urine without removing any of her PPE (Personal Protective Equipment) gown, gloves, and mask. V14 removed her gloves outside of the room, walked to another room while holding the specimen in her hand, then removed her gown and put it in her bag. A sign outside the door of read, Contact/Droplet Precautions and How to safely remove PPR example 1 and 2. On 12/12/23 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 records review the facility did not provide scheduled maintenance to essential equipment according to manufacturer's recommendations. This failure contributed to one of the mechanical lifts not being available to provide the necessary assistance to R1 (1 of three residents interviewed R1,R7 and R8) , so that he could attend to his daily routine including dialysis. R1 is a [AGE] year-old male whose diagnosis includes diabetes mellitus due to underlying condition with chronic kidney disease, acute (congestive) systolic heart failure, end stage renal disease, malignant neoplasm of right kidney, acute kidney failure, unspecified, dependence on renal dialysis, encounter for orthopedic aftercare following surgical amputation, encounter for change or removal of surgical wound dressing. Weakness, unspecified, unsteadiness on feet, unspecified osteoarthritis, unspecified site. On 11/03/23 at 11:30 AM surveyor toured the facility and encounter V3 (maintenance director) in the hallway…

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