Parker Nursing & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident's were free from physical abuse for 2 of 3 residents (R1 and R2) reviewed for Abuse in the sample of 3. The findings include: R1's electronic face sheet accessed on 6/27/25 show R1 has diagnoses that include hemiplegia and hemiparesis affecting right side. Anxiety and delusional disorder. R1's facility assessment dated [DATE] show R1 is alert and able to verbalize his needs. R2's electronic face sheet accessed on 6/27/25 show R2 has diagnoses that include traumatic subdural hemorrhage, drug induced parkinsons, and anxiety disorder. R2's facility assessment dated [DATE] show R2 has no cognitive impairment with BIMS of-15 The Facility Reported Incident (FRI) as final dated 6/10/25 (date of incident as 6/6/25) documents, R1 and R2 were in the dining room at their separate tables. R2 began yelling towards the direction of R1's table. R1 came towards R2 making contact with R2's right forearm. R1 lost his balance fell backwards and hit his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow their policy and procedures for discharge planning for three residents (R1, R2, and R3) and unplanned discharge for three residents (R1, R4, and R5) of four residents reviewed for discharge in the sample of six. Findings include: The facility's undated, Unplanned Discharge policy and procedure, documents: Policy: For purposes of providing the safest discharge possible, the facility will advise residents of the risks of early, unplanned discharge, and provide appropriate referrals and discharge instructions whenever possible. Discharge Against Medical Advice (AMA) procedure documents to obtain and witness residents' signature on AMA form. If resident refuses to sign, consider AWOL (Absent Without Official Leave) procedure documents: Resident not returning from pass, LOA (leave of absence), or outside appointments as scheduled will be considered AWOL. Resident who leaves the facility with staff knowledge, without following proper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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's bed was in the low position and the mat was on the floor to prevent injury from falling out of bed. This applies to 1 of 3 residents (R3) reviewed for safety in the sample of 3. The findings include: R3's Incident Report dated 3/22/25 at 6:50AM states, Resident was lying on the floor next to the bed on his left side with his right arm underneath him. Blood noted to hand and when assessed it was from laceration to right eyebrow. When resident asked if he fell out of bed he nodded and said yes and was pointing at something he was reaching for a drink. The facility Final Investigation Report dated 3/22/25 states, Facility completed its investigation and it was determined thru multiple interviews with staff and resident that resident became impulsive and impatient, did not request for staff assistance when attempting to retrieve an item, subsequently fell and sustained an open area to the right eyebrow requiring sutures . R3's Progress Notes dated 3/22/25 at 7:37 AM state, Resident was laying on floor of…

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

Based on interview and record review the facility failed to provide evening snacks for seven of seven residents (R7, R8, R15, R28, R33, R45, R55) reviewed for evening snack provision in the sample of 32 residents. Findings include: The facility's HS (evening/hour of sleep) Snacks policy, dated 8/8/2024, documents the following: Snacks are available to residents to offer nourishment at HS. The Food & Nutrition department will send snacks to the nursing stations at HS. Residents may be offered snacks such as graham crackers, cookies, fig newtons, pudding, applesauce (according to the resident's diet order and/or preferences.). The Food & Nutrition department will maintain a system or snack list for labeling & delivering snacks to those residents that receive scheduled snacks as part of their plan of are/preference. Resident Council Meeting Minutes, dated 10/28/24, documents concerns that Snacks and Coffee are not being passed out. On 4/7/25 at 9:45am, during the Survey Group Meeting, every attending resident stated that evening snacks are not being given to residents very often. R7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one allegation of abuse was immediately reported to the facility abuse coordinator for one of one resident (R19) reviewed for abuse in the sample of 32. FINDINGS INCLUDE: The facility policy, Abuse Prevention Program, dated (revised) 01/2029 directs staff, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or an allegation of suspected abuse or neglect of a resident by a third party. Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about or suspect to the (facility) administrator. The facility form, Concerns, dated 3/23/25 and completed by V8/Social Services Director…

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

Based on observation and record review, the facility failed to investigate an allegation of abuse for one of one resident (R19) reviewed for abuse, in the sample of 32. FINDINGS INCLUDE: The facility policy,Abuse Prevention Program, dated (revised) 01/2019 directs staff, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. Upon learning of the report, the Administrator shall initiate an incident investigation. On 4/7/25 at 1:33 P.M., R19 stated, A while back, in the evening, I had a bad accident. I had loose stools and it was all over my clothes, the toilet, the floors and the walls. I was really embarrassed. One of the CNAs (I don't remember which one) said to me, 'Oh my lord, I have to clean up this shit.' It made me feel really bad. I didn't mean to do it. I can't help it. She told me I need to get up out of my chair and clean it up myself. The other two CNAs were laughing at me. On 4/7/25 at 2:33 P.M., V5/Licensed Practical Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a copy of the bed hold policy for residents discharging to the hospital, for two of four residents (R53 and R56) reviewed for bed holds, in the sample of 32. Findings include: The facility's Bed Hold policy, revised 11/28/2016, documents It is the policy of the facility to provide the Resident, Resident's family member and/or the Resident's legal representative, if applicable, in written form and/or by telephone conversation prior to transfer to a hospital or prior to a Resident beginning therapeutic leave, for a duration of 24 hours or longer; certain information regarding the Resident's facility bed status and how the bed will be held. A copy of the Bed Hold policy given to the Resident, Resident's family member and/or the Resident's legal representative will be placed in the Resident's record. This will be documented in the resident's record. R53's medical record documents that R53 was hospitalized on [DATE], 12/3/24 and 3/15/25. R53's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform a PASRR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for two of two residents (R19 and R54) reviewed for PASRR screening, in the sample of 32. Findings include: The facility policy, Guidelines For PASRR Process, dated 5/17/2023 documents, PASRR is a federally mandated process that requires all states to pre-screen all residents regardless of their payer source or age who are seeking admission to a Medicaid funded nursing facility. PASRR has three goals (including) To ensure residents receive the required services for mental illness. Residents who are confirmed to have Mental Illness are evaluated to determine the need for specialized services, and appropriate placement options are reviewed. 1. R19's (facility) Face Sheet documents that R19 was admitted to the facility on [DATE] with the following diagnoses: Generalized Anxiety Disorder, and Schizoaffective Disorder,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 restorative services were being provided for one of two residents (R9) reviewed for restorative and range of motion in a sample of 32. Findings include: The Facility's Range of Motion (ROM) Policy and Procedure, not dated, documents, The Restorative Nurse and/or Nurse Designee will complete a ROM (range of motion) risk assessment for all residents that are admitted to the facility to determine if they have any ROM deficits and/or are at risk for development of a reduction in their current ROM status. Residents that have been assessed to have a reduction in their ROM will be placed in appropriate ROM programming to increase ROM and/or to prevent further decrease in their ROM status. The facility acknowledges that some residents may develop deterioration in their ROM status due to the resident's clinical condition and the reduction in their range of motion is unavoidable. The Restorative Nurse will initiate tracking sheets to record the days/minutes that the ROM programming was completed. R9's…

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

Based on interview and record review the facility failed to provide medications as ordered for one of five residents (R40) reviewed for medication administration, in a sample of 32. FINDINGS INCLUDE: The (undated) facility's Drug Administration policy, documents, Medications are administered as prescribed, in accordance with good nursing principals and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the attending physician. R40's (hospital) After Visit Summary, dated 8/13/25 includes the following diagnoses: Suicidal Ideations and Major Depressive Disorder. This same form includes the following medication orders: Sertraline (Anti depressant) 100 MG (Milligrams) Take two tablets every day. R40's Medication Administration Record, dated August 13, 2024 through August 30, 2024 includes no nursing documentation that R40's prescribed Sertraline were added to R40's Medication Administration Record or administered from 8/13/24 through 8/28/24. On 4/8/25 at 2:38 P.M., V2/Director of Nurses confirmed that R40 did not…

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

Based on observation, interview and record review the facility failed to donn personal protective equipment during cares for two of 12 residents (R7, R27) reviewed for enhanced barrier precautions in a sample of 32. Findings include: The facility's Guidelines for Enhance Barrier Precautions-EBP, undated, documents that enhanced barrier precautions are defined as the use of PPE (personal protective equipment) gowns and gloves during high-contact resident care activities that generate opportunities for transfer of MDRO's (Multi-drug Resistant organisms) in the form of blood or body fluids, onto the hands and/or clothing of the rendering caregiver. This form also documents examples of High Contact Resident Care activities at which EBP is to be practiced are dressing care/changes/management of dressings, changing briefs and assisting with toileting. 1. R27's current Physician Order Sheet, documents to cleanse the right great toe with wound cleanser, then apply a medicated dressing and cover with bordered gauze daily. This form also documents Enhanced Barrier Precautions due to AV…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's Power of Attorney (POA) was notified post fall for one of three residents (R2) reviewed for falls. Findings include: The Facility Resident Census Roster and Facility Matrix/802, dated 3/11/25, were reviewed. The Census Roster documented 60 Residents resided in the Facility. Guidelines for Notification of Change in Residents Condition/Status/Treatment dated 6/29/24 documented the nurse will immediately notify the resident, their physician, and/or the resident's Responsible Party/POA for the following: a) An accident involving the resident, which results in injury and has the potential for requiring physician intervention. B) A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental, or psychosocial status in either life threatening conditions or a clinical complication. Guidelines for Incident/Accidents/Falls dated 6/30/23 documented residents who have an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were assessed after a fall per policy and interventions were implemented to prevent further falls for one of three residents (R2) reviewed for falls. Findings include: The Facility Resident Census Roster and Facility Matrix/802, dated 3/11/25, were reviewed. The Census Roster documented 60 Residents resided in the Facility. Guidelines for Incident/Accidents/Falls dated 6/30/23 documented residents who have an unwitnessed fall must have neurological checks started and continued per policy. Neuro checks will be initiated even if the resident states they did not hit their head in an unwitnessed (by staff) fall. Documentation of the physical and mental status of the resident(s) involved will be completed each shift (every 8 hours minimally) over at least 72 hours or until the resident's condition improves. Neuro checks will be completed after any head trauma as well as after any unwitnessed fall (even if the resident states they did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure documentation was accurate and completed per policy for one of three residents (R2) reviewed for falls. Findings include: The Facility Resident Census Roster and Facility Matrix/802, dated 3/11/25, were reviewed. The Census Roster documented 60 Residents resided in the Facility. The Guidelines for Nursing Documentation policy dated 5/17/23 documented 6. Be timely in your documentation. It is easy to forget details in the hustle of business. 7. Late notes happen. Should you need to document something out of time do it properly and in orderly manner by first documenting when you are making the late note, then detailing the actual time the event occurred. Never be deceptive and back-date or fake that you are writing at an earlier time. 8. Flow Charts need filled. Every organization has flow charts, do not leave them blank. Also, whenever an unusual event occurs remember to also go to the chart to document your findings. 9. Remember if you did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure wounds were cleansed and PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 3. The findings include: R1's face sheet printed on 2/6/25 showed diagnoses including but not limited to metabolic encephalopathy, Down syndrome, and early onset Alzheimer's disease. R1's February 2025 physician order report showed an order for: Cleanse wounds on buttocks and apply calcium alginate and dressing everyday shift for wound. The same report showed an order for: Transmission based droplet isolation related to: MRSA (Methicillin resistant staphylococcus aureus) of sputum every shift. The same report showed an order for: doxycycline hyclate (antibiotic) oral tablet 100 milligrams two times a day for 6 days. On 2/6/25 at 10:01 AM, R1 was observed from the hallway lying in bed. The room door was wide open, and a sign was posted on the door…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 give showers to three (R1, R2, and R3) of three residents reviewed for activities of daily living in a sample of three. Findings include: Facility Nursing and Rehabilitation Master Shower Schedule, updated 8/13/24, documents R1 gets a shower on Wednesday and Saturday 2-10 PM; R2 gets a shower on Tuesday and Friday 6-2 PM; R3 get a shower on Thursday and Sunday 2-10 PM. Facility Certified Nursing Assistant (CNA) job description, dated April 1, 2023, documents Essential Job Functions are to assist residents with daily bathing functions, and hair and nail hygiene needs. 1. R1's medical record documents she is moderately impaired for cognition. R1's grievance, dated 6/24/24, documents (R1) reported staff were not giving her a shower and response or resolution was staff educated, and resolved on 6/24/24. R1's current care plan documents I usually require extensive assistance and one person support for bathing and dressing. R1's online 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 ensure residents who required thickened liquids had access to fluids at night for two of four residents (R1, R2) reviewed for hydration on the sample list of 9. Findings Include: R1's May 2024 Physician Orders documents an order for Honey thick liquids. R2's May 2024 Physician Orders document an order for nectar thick liquids. On 5/2/24 at 5:32 am, V5, CNA (Certified Nursing Assistant), stated R1 and R2 both require thickened liquids. V5 stated the nurses ran out of thickener, therefore, neither R1 or R2 were able to have liquids during the night. V5 explained the thickener is kept in the kitchen and the kitchen is locked up at night, so if the nurse doesn't have thickener, then R1 and R2 don't get liquids. V5 stated R1 usually drinks all night long. On 5/2/24 at 5:45 am, R1 was lying in bed awake without any drinks available. There was 1 empty cup on R1's overbed table. At this time, V4, Agency RN (Registered Nurse), confirmed V4 does not have access to thickener in order to give R1 and R2 fluids, 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 non-pressure wound treatment was completed for 1 of 3 residents (R1) reviewed for quality of care in the sample of 4. The findings include: R1's Face Sheet shows R1 is a [AGE] year old male, with diagnoses including: end stage renal disease, methicillin resistant staphylococcus aureaus infection (MRSA), dependence on renal dialysis, type 2 diabetes mellitus with diabetic polyneuropahy, and excoriation (skin-picking) disorder. R1's Minimum Data Set assessment, completed 1/26/24, shows his cognition and memory are intact. R1's Care Plan shows he has had numerous self inflicted wounds due to picking at his skin. The Care Plan shows he currently has an open area to his left lateral leg and wound care treatments should be administered per physician orders. The facility provided skin and wound report shows R1 current has a non-pressure wound that is open on his left lateral shin, requiring a boarded foam dressing, and R1 had 3 other…

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

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for two (R11 and R12) of four residents reviewed for abuse in a sample of 31. Findings include: Facility Abuse Prevention Program, revised 3/26/12, documents, The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident. Investigation: All incidents, allegations or suspicions of abuse against a resident will be documented and will result in an abuse investigation. 1. R11's Final Abuse Report, dated 1/31/24, to the State Agency, documents the following: (R11) reported alleged inappropriate interaction with staff member (V18, Certified Nurse Aid/CNA) . After speaking with staff and resident the alleged inappropriate interaction with a staff member is unsubstantiated. Facility whole abuse investigation conducted by V8, Former Administrator, consists of the following: interviews with R11, V13, Licensed Practical Nurse/LPN, and V18, CNA. No other residents were interviewed regarding staff behaviors/interactions. Facility…

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

Based on observation, interview, and record review, the facility failed to revise a comprehensive care plan for one (R54) of 19 residents reviewed for care planning in the sample of 31. Findings include: The facility's Comprehensive Care Plans policy and procedure, dated 12/2017, documents, The Comprehensive Care Plans will be reviewed and updated every quarter (90 days) at minimum. The facility may need to review the care plans more frequently based on changes in the resident's condition and/or newly developed health/psychosocial well-being issues. The facility MDS (Minimum Data Set)/Care Plan Coordinators and ancillary MDS staff will attend the department head meeting with in-depth review of the 24-hour report and will establish a new plan of care and/or make revisions to existing care plans to address any acute condition changes or exacerbation of chronic issues that may need revisions to the problem, goals and/or interventions. The face sheet for R54 includes the following diagnoses: Dementia, Alzheimer's Disease, Restlessness and Agitation, Obesity, and Adult Failure to Thrive.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview, the facility failed to ensure enteral feeding bottles were marked with the date/time that the bottles were changed/started for two of two residents (R11 and R37) residents reviewed for tube feedings, in a total sample of 31 residents. FINDS INCLUDE: Facility policy, entitled Guidelines for Enteral Feeding: Adult, dated 7/3/23, document, 3) Maximum formula hang time is Closed System 24 hours; and 5) Closed System-Closed system bottles and tubing must be changed every 24 hours for bolus feeding, resident may be disconnected by the licensed nurse and the tubing capped between feedings. Bottles/containers and feeding tubing must be changed every 24 hours. On 2/20/2024, at 10:45 AM., R37's enteral feeding bottle was not dated/timed. On 2/20/2024, at 10:45 AM, V5/Registered Nurse verified R37's enteral feeding bottle was not dated/timed and feeding bottle should be changed every 24 hours, and the date/time should be written on feeding bottle. 2. R11's February 2024 POS/Physician Order Sheet has an order for tube feeding to infuse via…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 address pharmacy medication recommendations for two (R31 and R49) of nine residents reviewed for psychotropic medications in the sample of 31. Findings include: The facility's undated Medication Regimen Review policy and procedure documents, The consultant pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities exist; The review of the medication regimen will include all medications currently ordered; The Pharmacist will report any apparent irregularities in writing to the attending physician, the director of nursing and the medical director. It is the responsibility of the facility to assure that each recommendation results in a written response by either the physician or nurse, as appropriate. On 2/22/24 at 2:30 PM, V3, ADON (Assistant Director of Nursing), stated, I honestly don't know who is supposed to oversee the psychotropic medications and gradual dose reductions. It used to be the DON (Director of Nursing) The Pharmacy emails 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 have appropriate indications for the use of antipsychotic/psychotropic medications, failed to identify target behaviors on the consent forms, and failed to attempt Gradual Dose Reductions for three residents (R1, R31, R49) of five residents reviewed for unnecessary psychotropic medications in the sample of 31. Findings include: Facility Policy/Psychotropic Drug Usage (undated) documents, If psychotropic drug therapy is required, the physician, facility staff and pharmacist will assist in choosing the most effective medication for the resident that has the fewest possible side effects, adverse drug reactions, and in the smallest effective dose. Antipsychotics are not to be used if one or more of the following are the only indication: Wandering, poor self-care, restlessness, impaired memory, anxiety, depression (without psychotic features), insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness or…

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

Based on observation, interview, and record review, the facility failed to ensure local hospice service documentation was included in one (R49) of one resident reviewed for hospice services in the sample of 31. Findings include: The facility's undated Hospice policy and procedure, documents, Hospice Care consultants and the facility will communicate in a manner that will ensure collaboration of care. Hospice consultants will be notified and/or will communicate the following: A change in the resident's physical, mental, social, and emotional status; Any time that a revision of the resident's plan of care is warranted; Education/Counseling to the resident or family related to preventative care, medical problems, psychological problems, and spiritual problems; Serve as a nursing resource for consultation and education of the facility IDT (Interdisciplinary Team); and Serve as a resource to provide care to the resident. The current Order Summary Report for R49 documents a physician order, dated 10/7/23, Admit to (local Hospice), diagnosis early onset Alzheimer's disease with behaviors.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physical abuse for three (R3, R4 and R5) of four residents reviewed for abuse in a sample of nine. Finding include: The facility's Abuse Prevention Program, revised 01/2019, documents, Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. This policy also states VII. Prevention: The facility desires to prevent abuse, neglect, exploitation, misappropriation, and a crime against a resident by establishing a resident-sensitive and resident-secure environment. This will be accomplished by a comprehensive Quality Assurance Performance Improvement approach. This policy continues with Abuse and Crime Reporting Policy: This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 verify a Certified Nursing Assistant (V4) was certified before working alone on 12/8/23. This failure has the potential to affect all 54 residents in the building. Findings include: Facility Resident List Report,dated 12/28/23, documents 54 residents currently reside in the building. Facility Certified Nursing Assistant, dated 4/1/23, documents, Must have and maintain an active searchable Certified Nursing Assistant Certification in accordance with the state in which the facility resides. Facility clock in sheets for 12/8/23 documents V4 worked. V4's Health Care Worker Registry provided by V1, Administrator, documents V4 completed CNA/Certified Nurse Aid training on 12/7/23, and Competency Evaluation (certified) was completed on 12/12/23. On 12/28/23 at 10:55am, R3 was in bed in her room, alert and oriented and stated, On 12/8/23 (V4) provided incontinent cares to me. There was no other staff. On 12/28/23 at 12:00pm, R1 was in bed, alert and oriented and stated, On 12/8/23 (V4) provided me cares but was not certified until…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Facility Failures resulted in two deficient practices. A. Based on interview and record review, the facility failed to provide transportation to appointments for eight (R14, R2, R3, R1, R17, R16, R5, and R6) of nine residents reviewed for transportation/appointments in a sample of 17. B. Based on observation, interview, and record review, the facility failed to carry out resident's activities of daily living on 12/8/23. This failure resulted in a delay of residents getting out of bed, getting dressed, incontinent cares, every two-hour checks on residents were not done, and call lights couldn't be answered in a timely manner. This failure also resulted in R3 becoming tearful to staff, crying, and stating she feels like a burden. Findings include: A. Facility Vehicle Lift Policy, undated, documents, Resident will be secure and safe during use of transport vehicle, and never transport residents in electric wheelchairs or (reclining chairs); the residents must be transferred to standard wheelchairs before being put…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allow a resident to smoke for two (R1 and R3) of three residents reviewed for smoking in a sample of 17. Findings include: Facility Smokers in the Facility,, dated 1/4/23, documents R1 and R3 are smokers residing in the facility. Smoking times are 9:00am-9:15am; 1:15pm-1:30pm; 3:30pm-3:45pm; and 6:00pm-6:15pm. Facility Concerns form, dated 7/29/23, documents resident concerns because two residents were not getting up to go out and smoke. Facility Concerns form, dated 8/31/23 for R3, documents, (R3) was not up for the 3:30pm smoke break and she had asked the CNA's/Certified Nurse Aides to get her up for smoke break. Facility Resident Council Minutes, dated 12/18/23 documents, Smoke breaks are not getting done. On 12/28/23, 12/29/23, and 1/2/24, between the hours of 9am and 4pm, R1 and R3 did not get out of bed. On 12/28/23 at 12:00pm, R1 was in bed, alert and oriented, and stated, I vape, but there is not enough staff to get me out of bed, but I would like to. R1's electronic medical record documents R1 is a…

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

Based on interview and record review, the facility failed to provide showers on 12/8/23 for six (R7-R12) of six residents reviewed for showers on 12/8/23 in a sample of 17. Findings include: Facility Resident Shower Schedule, undated and provided as the current schedule by V1, Administrator, documents on 12/8/23 (Friday), R7-R12 are to get a shower on first shift. Facility Resident Rights pamphlet, undated, documents, The facility must care for you in a manner and environment that promotes your quality of life. Facility Certified Nursing Assistant, date April 1, 2023, documents, Assists residents with daily bathing functions. Facility Resident Council Minutes,, dated 9/19/23, documents, Residents are not getting showers on scheduled days. Facility Concerns form, dated 9/19/23, documents a resident stated her showers are not getting done. Facility Concerns form, dated 9/27/23, documents a resident did not have a shower in the past week. R7-R12's electronic record has no documentation R7-R12 were given showers on 12/8/23 first shift, as they are supposed to. On 12/28/23 at 1:05pm,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 catheter care for one (R2) of three residents reviewed for catheter cares in a sample of 17. Findings include: Facility Catheters policy, undated, documents, A resident who is incontinent of their bladder is to received appropriate treatment. R2's electronic medical record documents R2 diagnoses as Flaccid Neuropathic Bladder and Stage Three Kidney Disease. R2's current order summary report documents, Suprapubic catheter care every day and night shift. Cleanse area and apply dressing twice a day. 12/28/23 at 10:45am, R2 was alert and oriented, clean and in bed, and stated, Catheter site has only been cleaned once; I got my catheter because I have stage 3 kidney disease; and I have had my suprapubic catheter for five years. R2's catheter was at the edge of the bed draining amber urine. On 1/2/24 at 11:30am, V18, Ombudsman, stated, (R2) had a bad UTI/Urinary tract infection in October. R2's Treatment Administration Record, dated 10/1-10/31/23, has no documentation R2's catheter care was completed on…

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

Based on interview and record review, the facility failed to set up/reschedule a dental appointment for one (R1) of one residents reviewed for dental services in a sample of 17. Findings include: Facility Resident Rights pamphlet, undated, documents, The facility must care for you in a manner and environment that promotes your quality of life. Facility Director of Social Services, undated, documents, The director of Social Services is responsible for providing related social work services so that each resident may attain the highest practicable level of physical, mental, and psychosocial well-being. R1's Social Service Note, dated 5/23/23, documents, Resident added to dentist list for broken tooth. Dentist does not have a return date, continue to follow. R1's medical record has no documentation a dentist appointment is scheduled. Facility provided documentation R1 did have a dental appointment on December 4, 2023 that was canceled due to facility transportation issues, but has not been rescheduled. On 12/28/23 at 12:00pm, R1 was in bed, alert and oriented, quadriplegic, and stated,…

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

Based on observation, interview, and record review, the facility failed to keep a door closed and move a COVID-19 positive resident to a private room for one (R4) of three residents reviewed for infections in a sample of 17. Findings include: Facility Post Public Health Emergency, revised 5/23/23, documents, The facility will follow CDC/Centers for Disease Control guidelines. Residents with suspected or confirmed COVID-19 infection will be placed in a single person room. R4's electronic medical record documents R4 tested positive for COVID-19 on 12/26/23, and was in a room with a roommate. Facility resident roster, dated 12/28/23, documents R4 is still in his room with a roommate. On 12/28/23 at 1:10pm, R4 was in the secured unit in a double room with his roommate, who was not COVID-19 positive, had contact and droplet precaution signs on the door indicating the door was to remain closed and to wear an N95 mask or higher. At that same time, R4's door was open, and R8 and R9 were ambulating in the hallway past R4's doorway. On 1/2/24 at 1:30pm, R4's room door was open and on…

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

Based on interview and record review, the facility failed to have a certified Infection Preventionist. This failure has the potential to affect all 54 residents residing in the facility. Findings include: Facility Resident List Report, dated 12/28/23, documents 54 residents currently reside in the building. Facility Infection Preventionist, undated, documents Responsible for the Infection Prevention Program. Qualifications: Completion of training on infection prevention. Facility paperwork documents on 12/8/23 the facility was in a COVID-19 outbreak status. V6's employee file does not have her certificate as an IP/Infection Preventionist. Training for IP provided documents 15 of the required 23 IP modules were completed. On 12/28/23 at 2:20pm, V6, LPN/Licensed Practical Nurse/IP stated There was COVID-19 in our building for December 2023. I have completed the 15 modules; did not know their were 23 modules. I don't have my Infection Preventionist certificate. Before helping as an Infection Preventionist, I worked on the floor as a staff nurse. At that same time, V6 verified 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.

Based on interview and record review, the facility failed to ensure residents were free of misappropriation of property for two of four residents (R4 and R5) reviewed for misappropriation of property in the sample of seven. Findings Include: The facility's Drug Diversion-Reporting and Response policy, undated, documents the following: It is the practice of the facility to provide guidelines for the identification, reporting and investigation of suspected drug diversion by any employees, residents, or visitors. Drug diversion is the intentional and without proper authorization, using or taking possession of a prescription or a non-prescription medicine or biological from the supply intended for use by the facility staff for the facility residents. Examples of Drug Diversion: A. Medication Theft, B. Using or taking a medication without a valid order or prescription, C. Forging or modifying a prescription, D. Using or taking possession of a medication that was to be returned or destroyed. Controlled Substances: Medications classified as Schedule 1 through Schedule V by the Federal Drug…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from involuntary seclusion for one of one residents (R1) reviewed for involuntary seclusion in a sample of seven. Findings include: The facility's Abuse Prevention Program, Abuse and Crime Reporting, revised 03/1/21, documents, The facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals. This form also documents that Involuntary Seclusion is separation of the resident from other residents or from his or her room or confinement to his or her room (with or without roommates) against the resident's will, or the will or the resident's legal guardian or representative. R1's Minimum Data Set, dated [DATE], documents R1 is severely cognitively impaired. R1's current care plan documents R1's comprehensive assessment reveals a history of…

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

Based on interview and record review, the facility failed to report an allegation of involuntary seclusion to the Administrator immediately for one of six residents (R1) reviewed for abuse in a sample of seven. Findings include: The facility's Abuse Prevention Program, revised 3/1/21, documents, Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment, or a crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report to to the Administrator. The facility's Incident Investigation form, dated 11/3/23, documents, The allegation of of inappropriate behavior by a staff member is found to be substantiated. The Staff (V3/CNA/Certified Nursing Assistant) had admitted to holding the door closed while (R1) was in the room. (V3) has been terminated. On 11/20/23 at 8:45 AM, V1 stated the incident happened on 10/20/23, but was not reported to her until 10/31/23. V1 stated V19, Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish a system for the reconciliation of controlled drugs for two of four residents (R4 and R5) reviewed for controlled drugs in a sample of seven. Findings Include: The facility policy named, Controlled Substances, with no date, documents, To maintain individual records of receipt and distribution of all controlled drugs in sufficient detail to enable an accurate reconciliation. Controlled substance shall be securely stored, and precautionary measures taken to prevent misuse. 6.) Records shall be maintained by authorized nursing personnel of all scheduled II drugs administered. 7.) An individual Schedule II record in the form of a declining inventory will be initiated when the schedule II drug is delivered to the facility. 8.) Change of shift counts will be conducted by authorized nursing personnel to reconcile drug availability. R4's Controlled Drug and Receipt Record/Disposition Form, dated 10/27/2023, documents R4 received 30ML(milliliter) of Morphine Sulfate Solution 100MG/5ML. Take 0.25ML (5MG) (milligrams) every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 deliver resident mail for seven (R1 through R5, R10, and R11) of seven residents reviewed for resident rights in the sample of 17. This failure has the potential to affect all 63 residents residing in the facility. Findings include: The facility's undated Resident Rights policy and procedure, documents, Mail - You have the right to send and promptly receive your mail unopened and have access to writing supplies you have requested. On 8/29/23 at 3:40 pm, R1 stated his family member sent his birth certificate to the facility, and the facility held it until the last day to give it to him. R1 stated he kept asking for it, and the facility staff would not give it to him, and he needed it to be able to get his apartment. R1 stated V3 BOM (Business Officer Manager) was at the facility last Sunday, and he approached her again and asked if he had any mail, and he wanted his birth certificate, and V3, BOM, stated it might be in the pile of mail on her desk. V3, BOM, later Sunday night, brought him his mail and said she found in the…

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

Based on interview and record review, the facility failed to implement their Abuse Prevention policy and procedures after report of an allegation of verbal abuse for one (R2) of four residents reviewed for abuse in the sample of 17. These failures have the potential to affect all 63 residents residing in the facility. Findings include: The facility's Abuse Prevention Program policy and procedure, revised 1/2019, documents, Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following Procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. This policy includes the acronym S-T-R-I-I-P-P and is defined as Screen -Train-Report-Identify-Investigate-Protect-Prevent to ensure all areas of Abuse Prevention are covered. This same policy documents: Alleged abuse is to be reported immediately to the…

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

Based on interview and record review, the facility failed to report a verbal allegation of abuse for one (R2) of three residents reviewed for abuse in the sample of 17. This failure has the potential to affect all 63 residents residing in the facility. Findings include: The facility's undated Resident Rights policy and procedure documents, Abuse - You have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. Staff Treatment - The facility must implement procedures that protect you from abuse, neglect or mistreatment, and misappropriation of your property. In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials. All alleged violations must be promptly and thoroughly investigated and the results reported to appropriate agencies. Corrective action must be taken. The facility's Abuse Prevention Program, revised 01/2019, documents, The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or…

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

Based on interview and record review, the facility failed to investigate a reported allegation of verbal abuse for one (R2) of three residents reviewed for abuse in the sample of 17. This failure has the potential to affect all 63 residents currently residing in the facility. Findings include: The facility's Abuse Prevention Program, revised 1/2019, documents, Verbal Abuse: Any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. Investigation: All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will be documented. All incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. Once the Administrator or in the absence of the Administrator the DON (Director of Nursing) determines that there is an…

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

Based on interview and record review, the facility failed to be administered in a manner to ensure implementation of the facility's Abuse Prevention Program Policy and Procedures and in a manner that provides oversite and leadership to the residents and staff. V1 (Administrator in Training) failed to respond to reported allegations of abuse and misappropriation. These failures affected three of nine residents (R50, R58, and R60) reviewed for abuse in the sample of 11 and have the potential to affect all 57 residents residing in the facility. Findings include: The facility's Abuse Prevention Program Policy and Procedure, revised 1/2019 states, Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following Procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. This policy includes the acronym…

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

Based on observation, interview, and record review, the facility failed to revise a care plan with the proper transfer technique following an incident for one of three residents (R2) reviewed for resident injury in the sample of 3. Findings include: The facility's Incidents/Accidents/Falls policy, no date available, documents, Based on the results of the Incident/Accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place. R2's Point of Care Task list, dated 8/7/23, documents R2's transfer status is extensive assist of two staff members using a stand aid. R2's Incident report, dated 6/6/23, documents, (R2) was being transferred with sit to stand lift. (R2's) legs gave out. He scraped shin area 8 x 1 cm (centimeter). R2's Falls & Accident/Incident Resident Management Review, dated 6/7/23, documents, As a result of the accident/incident (6/6/23), the plan of care has been updated to decrease potential or future falls: Hoyer (mechanical lift). R2's current care plan, provided by V1…

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

Based on observation, interview, and record review, the facility failed to transfer a resident (R1) using a mechanical stand aid (Sit to Stand) according to their plan of care that resulted in a fall, and failed to lock a wheelchair and mechanical stand aid during a resident (R1) transfer for one of three residents (R1) reviewed for falls in the sample of three. Findings include: The facility's Sit to Stand Lift policy and procedure, dated 10/10/11, documents, Purpose: To assure that all residents are assessed to require extensive high assistance in transfer are transferred safely with no injury to resident or care handler. Utilizing the lift-Lifting the resident: If the resident is being lifted from a mobile chair make sure to apply the brakes on the chair. Lowering the resident: Move the lift close to the chair or the bed so that the back of the resident's knees almost touch the seat of the chair or the bed. Apply the brakes on the casters of the lift. Press the 'down' button using the hand controller until the resident is comfortably sitting. R1's care plan, dated 6/26/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility knowingly failed to have enough staff to accommodate the needs of the residents in the facility as evidenced by multiple complaints by residents, staff, and resident council minutes, where residents are not getting call lights answered, toileting, grooming, and smoking needs met for seven of ten residents (R1, R3, R4, R5, R6, R8, and R10) reviewed for issues related to staffing, in a sample of ten. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The Facility Assessment Tool, dated 7-20-23, documents, Staffing Plan: Below describes general staffing plan to ensure that we have sufficient staff to meet the needs of the resident at any given time. Licensed nurses two for each 12 hour shift. Certified Nursing Assistants/CNAs Day shift: 5-7, 1 restorative aid; PM shift: 5-7, Night shift: 4. The facility's Staffing Strategies During Shortage policy, dated December 2021, documents, Policy: When staffing…

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

Based on observation, interview, and record review, the facility failed to ensure resident call devices were responded to in a timely manner, failed to ensure resident smoking times were abided by, and failed to ensure residents felt safe and comfortable to speak with State Agency for seven of ten residents (R1, R2, R3, R5, R6, R8, and R10) reviewed for Resident Rights in a sample of ten. Findings include: The facility's Resident Council Minutes, dated 7-18-23, documents the following: Everything has gotten worse! Call lights still not being answered in a timely matter. (V1, Administrator) told the receptionist residents have to go to her office first before they can talk to State. They need to address that. It is illegal to say that they can't talk to state and visitors who are staff not to visit. Need 6-8 o'clock smoke break. Evening smoke breaks are not getting done. Call lights are being shut off before the problem is being resolved. 1. The facility's Call Light policy, undated, documents Policy: It is the policy of the facility to have a system in place to allow the staff to…

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

Based on interview and record review, the facility failed to ensure residents felt safe and comfortable when reporting any complaint to the facility for two of three residents (R3 and R6) reviewed for grievances in a sample of ten. Findings include: The facility's Grievances/Complaints/Missing Property policy/procedure, undated, documents, Policy: It is the policy of the facility to see that the residents and their responsible parties are made aware upon admission and as indicated of the resident's right to express a complaint or a grievance orally, or in writing at any time. This complaint or grievance may also be done anonymously. The facility's Resident Rights policy, undated, documents, Grievances - You may voice grievances concerning your care without fear of discrimination or reprisal. On 7-25-23 at 2:36pm, R3 sat in her room and made the following statements: I got left on the bedpan for two hours last week. I feel neglected. It's ridiculous. I don't care anymore if they want to retaliate. On 7-27-23 at 8:55am, R6 was sitting in a reclining chair by the patio door. R6 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident showers as scheduled for one of one resident (R3) of three residents reviewed for activities of daily living in a sample of ten. Findings include: The facility's Activities of Daily Living/ADL (Activities of Daily Living) (Routine Care) policy, undated, documents, Policy: Residents are given routine daily are and HS (at bedtime) care by a CNA (Certified Nursing Assistant) or a Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day, evening and night as care planned and/or as needed .ADL care of resident includes: Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care, appropriate skin care (as indicated and as per care plan) as well as encouraging participation in physical, social and recreational activities. The facility's Certified Nursing Assistant Job Description, undated, documents, The Certified Nursing Assistant provides each assigned resident with routine daily…

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

Based on observation, interview, and record review, the facility failed to ensure incontinent residents received incontinence care in a timely manner for two of three (R3 and R4) residents reviewed for incontinence care in a sample of ten. Findings include: The facility's Incontinent Care policy, undated, documents, Policy: It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care. Frequency depends on bladder diary results and/or routine minimal q (every) two hour checks as well as care planning. The facility's Certified Nursing Assistant Job Description, undated, documents, C. Role Responsibilities - Personal Nursing Care: 8. Keep residents dry (i.e. change gowns, clothing, linen, etc., when it becomes wet/soiled. And 11. Assists residents with bowel and bladder functions (i.e., take to bathroom, offer bedpan/urinal, portable commode etc.). 1. R3's Minimum Data Set/MDS assessment, dated 4-25-23, documents R3 is moderately cognitively impaired,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility policy for resident smoking times for three of three residents (R1, R3, and R6) reviewed for smoking in a sample of ten. Findings include: The facility's Smoking Policy, dated 2-8-21, documents, 12. The facility will determine designated smoking locations and times, however this will also be acceptable to the Resident Council, with any changes needing to have their input and agreement. The facility's Resident Smoking Times posted on the patio door throughout this survey documents the resident smoking times as 9:00am-9:15am, 1:15pm-1:30pm, 3:30pm-3:45pm, 6:00pm-6:15pm. 1. R1's current Care Plan includes a focus of (R3) likes to smoke r/t (related to) hx (history of) smoking with interventions including I have been shown the designated smoking area and will be assisted to and from the designated area at break times if needed. On 7-25-23 at 10:00am, R1 sat in R1's room and stated the 6pm smoke break gets canceled all the time. 2. R3's current Care Plan includes a focus of (R3) likes to smoke r/t…

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