Vandalia Healthcare & Senior Living

Based on interview, observation, and record review, the facility failed to ensure the resident rooms and resident equipment were maintained in a state of good repair for 5 of 5 residents (R1, R2, R3, R4 and R12) reviewed for environment in a sample of 14. Findings include: 1. On 12/5/24 at 11:50AM, R1's bathroom was observed to have water leaking from the front of his toilet. R1's tiles behind his toilet were all laying on the floor away from the wall. R1's toilet was crooked and not positioned correctly and away from the wall. On 12/05/24 at 11:50 AM, R1 who was alert to person, place, and time, stated he knows the toilet leaks in the front and that the toilet is crooked. R1 said that he knows the tiles have fallen down behind the toilet as well. R1 said someone was supposed to be fixing it. 2. On 12/05/24 at 9:21AM, R2's bathroom toilet was observed was to not be secure to the floor and was easily moved around. R2's window sill in room had dust, dirt, debris along with cobwebs noted to top of the window. On 12/05/24 at 9:21AM, R2 who was alert to person, place, and time, stated he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to maintain safe water temperatures for 14 of 14 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for water temperatures in a sample of 14. Findings include: On 12/5/24 at 8:54 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method, and was accurate within +/_ 2 degrees Fahrenheit. 1. On 12/5/2024 at 9:12 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the handsink of the shared bathroom of R1 and R10, and registered 120.2 degrees Fahrenheit. On 12/5/24 at 9:12 AM, R1 who was alert to person, place, and time, stated the maintenance man told him a week ago the bathroom water temp was 118. R1 then stated the water is hot, but that it has never burned him. 2. On 12/5/2024 at 9:16 AM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken…

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

Based on observation, interview, and record review, the facility failed to have a full time Director of Nursing and to ensure Registered Nurse coverage 8 consecutive hours a day, seven days a week. This failure has the potential to affect all 33 residents who reside at the facility. Findings Include: The facility's Social Service Need Notice, dated 6/12/24, documents residents concern of the Administrator not being out on the floor more. V28 (Former Administrator) documented on this form, the Administrator does make daily rounds however is needing to do other things due to V2 (Director of Nursing/DON) being on the floor. On 7/29/24 at 12:09 PM and 7/30/24 at 12:13 PM, V2 (DON) was working the floor as a floor nurse and passing medications to residents. V2 was the only nurse on the unit both days at these times. On 7/30/24 at 12:13 PM, V2 stated V2 used to be the DON, but has not had any office time as DON for two months due to working 12 hour days, 3 days a week on the floor as a floor nurse. V2 stated V2 recently submitted V2's resignation from that position due to not having time…

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

Based on observation, interview, and record review, the facility failed to store and serve food in a safe and sanitary manner in accordance with professional standards. This has the potential to affect all 33 residents residing at the facility. Findings include: On 07/29/24 at 9:51 AM during the initial tour of the kitchen, there were three containers of thickened juice, one kiwi and strawberry flavored and two orange flavored, opened and in the refrigerator with no dates on them. There were two bags of cereal, one whole grain toasted oats and one bran flakes, that were opened with no dates on them. There was a bag of dried milk opened with no date on it. There were also two containers of liquid eggs opened with no dates on them and one package of lunchmeat ham opened with no date on it in the walk in cooler. On 07/29/24 at 9:51 AM during the initial tour of the kitchen, there was a scoop inside the sugar bin laying on top of the sugar and a scoop in the container of coffee laying on top of the ground coffee. On 07/29/24 at 11:35 AM during lunch service, V27 (Dietary) touched the…

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

Based on observation, interview, and record review, the facility failed to provide an accessible call system for residents in the shower room or the community bathroom. This failure has the potential to affect all 33 residents residing at the facility. Findings include: On 07/29/24 at 1:35 PM, the hall bathroom/shower room on E-Hall was noted to have a call light box on the wall, but no pull cord was observed to be attached to the toggle switch. Thus, the call light near the toilet was not accessible as it could not be reached from the toilet or the floor without a pull cord. The shower stall in this bathroom/shower room also did not contain any call system. On 07/29/24 at 1:39 PM, the hall bathroom/shower room on the D-Hall was noted to have a call light box on the wall, but no pull cord was observed to be attached to the toggle switch. Thus, the call light near the toilet was not accessible as it could not be reached from the toilet or the floor without a pull cord. The shower stall did not contain any call system. On 07/29/24 at 2:17 PM, the hall bathroom/shower room on A-Hall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 at least 80 square feet per resident bed in multible occupancy resident bedrooms. This failure affects four (R7, R10, R15, R21) of four residents reviewed for environment in the sample of 27. Findings include: Observations on 8/1/2024 at 9:00 AM, revealed R7 resided in a room certified for double occupancy. This room contained two beds, a dresser, two bedside tables and one over the bed table and had limited area to move around inside the room. V4 (Maintenance Director) used a tape measure and measured R7's bedroom. The bedroom measured 136 inches by 151 inches which equals 142.61 total square feet, and equals 71.31 square feet per resident bed. Observations on 8/1/2024 at 9:10 AM, revealed R10 resided in a room certified for double occupancy. This room contained two beds, two bedside tables, one over the bed table, three trash cans, one isolation supply cart, one bedside commode and one dresser, and had limited area to move around inside the room. V4 used a tape measure to measure R10's bedroom. 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 promote resident independence and dignity while providing care by neglecting to explain a task prior to beginning and allowing the resident time to perform the task independently for one (R31) of six residents reviewed for resident rights in the sample of 27. Findings Include: R31's MDS (Minimum Data Set), dated 6/28/24, documents R31 has moderate cognitive impairments. On 7/29/24 at 10:48 AM, R31 stated, Yesterday {7/28/24} around 2:00 PM, a bigger girl was very rough with me during cares. R31 explained R31 is normally able to turn over in bed by herself with just a little help but this bigger girl was in a hurry to get her job done and just pushed me over hard and fast. R31 stated this action caused R31 to yell out What are you doing? R31 stated a man across the hall must have heard R31 yell because the man yelled back, What are you doing to her? R31 explained there was also a supervisor present. R31 thought the girl might have gotten fired, but then was back today {7/29/24}. R31 also stated the big girl made it known…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 honor resident choices regarding preferences for sleeping/waking schedules for one (R16) of one resident reviewed for Self-determination in a sample of 27. Findings include: R16's face sheet documents an admission date of 11/23/24, with diagnoses that include depression and insomnia. R16's Minimum Data Set (MDS), dated [DATE], documents chair/bed-to-chair transfer: the ability to transfer to and from a bed to a chair (or wheelchair) as Dependent designating: helper does all of the effort, resident does none of the effort to complete the activity .or, the assistance of two or more helpers is required for the resident to complete the activity. On 07/29/24 at 1:53 PM, R16 was alert to person, place, and time and stated the one thing he just does not agree with at the facility is they get him up too early, then he will just sit in his room. R16 stated sometimes they will take him to the dining room at 5:00 AM, and he will sit down there with nothing to do…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) Assessment for one (R4) of 12 residents reviewed for accuracy of assessments in the sample of 27. Findings Include: R4's ongoing weight log documents the following weights: 12/21/23 - 132 pounds and 6/1/24 - 111.4 pounds. This change in weight calculates as a 15.61% weight loss in six months. R4's Minimum Data Set (MDS), dated [DATE], does not document a significant weight loss. On 7/31/24 at 12:52 PM, V13 (MDS/Care Plan Coordinator) stated significant weight losses should be coded on the MDS. The facility Comprehensive Assessment/MDS Policy, dated 11/1/17, documents the facility shall make every effort to ensure the MDS is accurate. Should an inaccuracy in coding be found, the facility shall follow the instructions for amending the assessment found in the RAI (Resident Assessment Instrument) Manual.

Based on observation, interview, and record review, the facility failed to follow physician orders for skin protection for one (R6) of two residents reviewed for standards of practice in the sample of 27. Findings Include: R6's July 2024 Physician Orders document an order for R6 to wear protective skin sleeves at all times related to being prone to skin tears. On 7/29/24 at 11:25 AM and 7/30/24 at 12:07 PM, R6 was sitting up in a reclining wheeled chair without the ordered protective skin sleeves in place. On 7/30/24 at 12:28 PM, V15 (Certified Nursing Assistants/CNA's) and V16 (CNA) both stated R6 is to wear protective skin sleeves at all times, and explained R6 isn't wearing them because they don't know know where they are. R6's Care Plan, last updated 7/24/24, documents R6 is supposed to have arm sleeve protectors in place at all times. On 7/30/24 at 1:39 PM, V13 (Minimum Data Set/Care Plan Coordinator) confirmed R6 is supposed to wear arm sleeve protectors at all times.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Deficiencies at this level require more than 1 Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to position a resident in an upright position and follow swallowing precautions per orders during meals to prevent choking episodes for one (R6) of 12 residents reviewed for dining on the sample list of 27. Findings Include: R6's Diagnosis Report, dated 7/31/24, documents a diagnosis of Dysphagia. R6's July 2024 Order Summary documents an order for swallow precautions and a Carbohydrate Controlled/No added Salt diet of pureed texture with pudding/extremely thick consistency liquids. R6's Care Plan, updated 7/24/24, documents R6 requires a pureed diet with pudding thick liquids and is dependent on staff assistance for feeding. R6 is to stay awake/alert during meals; staff are to provide small bites and alternate liquids and solids, monitoring for aspiration such as coughing, congestion, and watery eyes. R6's head of bed is to be elevated after meals. Along 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 provide necessary services consistent with professional standards of practice to prevent the worsening of pressure ulcers for one (R4) resident reviewed for pressure ulcer care in the sample of 27. Findings Include: The facility's Quality Assurance (QA) Weekly Skin Eval Documentation List, dated 7/26/24, documents R4 has a Stage III Pressure Ulcer to the lower right buttock. R4's Minimum Data Set (MDS), dated [DATE], documents R4 is at risk for pressure ulcers and has one Stage III Pressure Ulcer. R4's Care Plan, dated 4/25/24, documents R4 is at high risk for pressure ulcers according to R4's Skin Risk Assessment. This Care Plan was updated on 6/27/24, and documents R4 has a stage III pressure ulcer to the right lower buttock with an intervention to complete pressure ulcer treatments per physician orders. R4's Medical Record {computerized or paper} does not contain any pressure ulcer assessments. On 7/30/24 at 12:13 PM, V2 (Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess a resident after a fall and failed to implement interventions for one (R28) of eight residents reviewed for falls in a sample of 27. The findings include: R28's Face Sheet, dated 08/01/24, documents an admission date of 08/17/23, with diagnoses in part of unspecified dementia, vascular dementia, diabetes mellitus, major depressive disorder, anxiety disorder, brief psychotic disorder, intermittent explosive disorder, dementia in other diseases with other behavioral disturbance, pseudobulbar affect, unspecified lack of coordination, difficulty in walking, unsteadiness on feet, and muscle weakness. R28's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 8, which indicates R28 has moderate cognitive impairment. R28's MDS documents he is dependent for toileting, showering, and upper and lower body dressing. R28 requires substantial/maximal assistance with rolling left to right, sit to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a urinary catheter was secured in accordance with the plan of care, and failed to complete incontinence care and catheter care in accordance with standards of practice to prevent irritation and cross contamination for two (R6 and R32) of two residents reviewed for incontinence/catheter care in the sample of 27. Findings Include: 1. R6's Care Plan, dated 4/27/24, documents R6 has an alteration in bladder elimination which resulted in R6 having a Suprapubic Catheter being placed by an unidentified Urologist on 6/19/23 for Obstructive Uropathy. This care plan documents to complete catheter care and maintenance per orders and secure catheter to avoid tension. R6's July 2024 Physician Orders document an order for Suprapubic Catheter Care every shift. On 7/31/24 at 10:19 AM, V17 (Licensed Practical Nurse/LPN) entered R6's room to provide catheter care. V17 obtained an over bed table from R6's roommate, which had food crumbs/debris on it.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 as needed psychotropic medications were limited to 14 days for one (R4) of six residents reviewed for unnecessary medications in the sample of 27. Findings Include: R4's Pharmacy Consultation Report, dated 1/10/24, documents R4 received Lorazepam {Benzodiazepine} 0.5 mg (milligrams) BID (twice a day) and 1 mg every four hours as needed for anxiety. This report documents to please assess R4's medication dosage (s), condition, behaviors, and if clinically appropriate consider reducing a medication in modest increments. On 2/14/24, V18 (Physician) is documented to have declined this recommendation, however, did not document a resident specific rationale why this GDR (Gradual Dose Reduction) was not attempted. R4's July 2024 Physician Order Sheet documents an order received on 8/1/23 for Lorazepam {Benzodiazepine} 1 mg (milligram) every four hours as needed for Anxiety. R4's July 2024 MAR (Medication Administration Record) does not document R4 has received any as needed doses of Lorazepam. On 7/30/24 at 2:53 PM, V13,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 current standards and practices for infection control regarding handling of soiled linens, hand hygiene, Enhanced Barrier Precautions, and Contact Isolation Precautions to prevent the spread of infection. This failure affects 3 (R6, R13 and R32) of 3 residents reviewed for infection control on the sample list of 27. Findings Include: 1. R6's July 2024 Physician Orders document an order for a Suprapubic Catheter size 16 French and for Suprapubic Catheter Care to be completed every shift. R6's Care Plan, dated 7/24/24, documents R6 has a Suprapubic Catheter due to a diagnosis of Obstructive Uropathy and is on Enhanced Barrier Precautions (EBP). On 7/29/24 at 11:01 AM, R6 was sitting up in a reclining wheelchair in the room. There was no EBP signage hanging outside of R6's room, no Personal Protective Equipment (PPE) outside of R6's room, and no hamper or container inside of R6's room for PPE to be disposed into. On 7/31/24 at 10:19…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow the Influenza Immunization Policy to ensure an influenza vaccine was offerred/provided for one (R21) of five residents reviewed for Influenza Immunizations in the sample of 27. Findings include: R21's Care plan documents an admission date of 10/06/22, and diagnoses including: frontotemporal neurocognitive disorder, dementia, Alzheimer's disease, major depressive disorder, anxiety disorder, and muscle weakness. R21's Physician Order Sheet documents an order dated 11/27/23 of Immunization: may have annual flu vaccine with consent unless contraindicated with an order status of active. R21's current medical record contained a section titled, Immunizations, and under the category labeled Influenza is documented the date of 10/20/22. On 07/30/24 at 10:10 AM, V1 (Administrator) stated she printed off a list of all the current immunizations for all the residents. V1 provided this list and it was titled, Covid Vaccine. This document has a column titled, Influenza and documents R21's most current influenza vaccination 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 interview and record review, the facility failed to follow physician's orders to administer anti-anxiety medication as ordered for 1of 5 (R4) residents reviewed for physician orders in a sample of 12. Finding include: R4's admission record, dated 4/03/24, documents R4 was admitted to the facility on [DATE], with diagnoses of Cerebral infarction, Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side, Alzheimer's disease with late onset, unspecified dementia, unspecified severity with agitation, Chronic Kidney Disease, Anemia, Hypertension, Morbid obesity, hyperlipidemia, Major depressive disorder recurrent, anxiety, Gastroesophageal reflux disease, Post Traumatic Stress Disease, Atrial Fibrillation, and pain. R4's Minimum Data Set (MDS), dated [DATE], documents in Section C a Brief interview for mental status a score of 13, which indicates R4 is cognitively intact. Section D documents under mood little interest or pleasure in doing things present 2-6 days in a 14-day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 determine that drug records were in order, and an account of all controlled drugs were maintained and periodically reconciled for 1of 5 (R4) residents reviewed for controlled substances in a sample of 12. Findings include: R4's admission record, dated 4/03/24, documents R4 was admitted to the facility on [DATE], with diagnoses of Cerebral infarction, Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side, Alzheimer's disease with late onset, unspecified dementia, unspecified severity with agitation, Chronic Kidney Disease, Anemia, Hypertension, Morbid obesity, hyperlipidemia, Major depressive disorder recurrent, anxiety, Gastroesophageal reflux disease, Post Traumatic Stress Disease, Atrial Fibrillation, and pain. R4's Minimum Data Set (MDS), dated [DATE], documents in Section C a Brief interview for mental status a score of 13, which indicates R4 is cognitively intact. Section D documents under mood little interest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 coverage was provided by a Registered Nurse (RN) 8 hours a day, 7 days a week. This has the potential to affect all 36 residents living in the facility. The findings include: The facility schedules for 11/01/23 to 12/20/23 were reviewed, and documents no RN coverage for Saturday 11/11/23, Saturday 11/25/23, Sunday 11/26/23, Saturday 12/02/23, Sunday 12/03/23, Sunday 12/10/23, Saturday 12/16/23, and Sunday 12/17/23. On 12/18/23 at 2:25 PM, V1(Administrator) stated they currently don't have enough Registered Nurses to staff 8 hours a day 7 days a week. V1 said she does have 3 Registered Nurses at this time. V1 said they did hire another Registered Nurse, but is waiting for her license approval in Illinois. V1 confirmed the facility was without Registered Nurse coverage on the dates documented on the schedule (11/11/23, 11/25/23, 11/26/23, 12/2/23, 12/3/23, 12/10/23, 12/16/23, and 12/17/23). The facility Census Report, dated 12/18/23, documents a census of 36 residents.

Based on interview and record review, the facility failed to ensure they had a Registered Nurse (RN)working 8 hours a day, 7 days a week. This failure has the potential to effect all 36 residents residing at the facility. Findings Include: The Resident Census and Conditions of Residents form, dated 8/28/23, documents 36 residents reside at the facility. On 08/29/23 at 11:20 AM, V1 (Administrator) stated they do not have RN coverage 8 hours a day, 7 days a week. V1 stated, V2 (Director of Nurses) is a Registered Nurse, and is at the facility for any skilled nursing that requires an RN. V1 stated they run continuous ads and are attempting to recruit RN's, but they are in a small rural area, and have to compete with larger areas that are just 30 minutes from the facility. V1 stated they have had interviews, but the RN's do not accept the position once it is offered. The untitled nursing schedules, dated June 2023, July 2023, and August 2023, documents there was no Registered Nurse working on 6/4, 6/11, 6/12, 6/17, 6/18, 6/24, and 6/25, 7/1, 7/2, 7/9, 7/15, 7/16, 7/22, 7/23, 7/29, 7/30,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received the education addressing the benefits and risks and/or had the opportunity to receive the 20-valent pneumococcal conjugate vaccine (PCV20 or Prevnar 20) for 4 of 5 (R3, R6, R16, and R31) residents reviewed for immunizations in the sample of 33. Findings Include: 1.R6's admission Record, with a print date of 8/31/23, documents R6 is [AGE] years old and was admitted to the facility on [DATE], with diagnoses that include heart failure, chronic obstructive pulmonary disease, diabetes, pancreas and kidney transplants, anemia, and pneumocystis. R6's MDS (Minimum Data Set), dated 7/28/23, documents a BIMS (Brief Interview for Mental Status) score of 12, which indicates R6 has a moderate cognitive impairment. R6's facility undated Immunization Record documents R6 was administered an unidentified pneumococcal immunization on 11/14/16. On 08/31/23 at 3:13 PM, V2 (Director of Nursing/DON) stated she didn't know what type of pneumonia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the required 80 square feet of floor space per resident for 9 of 9 (R5, R8, R14, R17, R18, R20, R21, R24, R32, and R137) residents reviewed for room size in the sample of 33. Findings Include: On 8/29/23 beginning at 3:03 PM, V7 (Maintenance Director) and V8 (Maintenance Assistant) measured all the resident rooms located on A and B hall that didn't meet the required 80 square feet (sq. ft.) of floor space per resident. The measurements were as follows: rooms [ROOM NUMBER] measured 140 (inches) x 151 which equals 146.81 sq. ft. which indicates 73.40 sq. ft. per resident. rooms [ROOM NUMBERS] measured 141 x 152 which equals 148.83 sq. ft. which indicates 74.42 sq. ft. per resident. rooms [ROOM NUMBERS] measured 142 x 152 which equals 149.88 sq. ft. which indicates 74.94 sq. ft. per resident. room [ROOM NUMBER] measured 148 x 152 which equals 156.22 sq. ft. which indicates 78.11 sq. ft. per resident. room [ROOM NUMBER] measured 149 x…

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