Transcendent Healthcare Of Boonville

Based on interview, and record review, the facility failed to ensure the physicans orders were thoroughly followed and documented when completed for 2 of 3 residents reviewed for nursing services related to wound care. Routine dressing changes and skin assessments were not completed per the physician's orders. (Resident F, Resident G) Findings include: 1. During record review on 5/21/25 at 9:15 A.M., Resident F's diagnoses included, but were not limited to peripheral vascular disease, morbid obesity, and lymphedema. Resident F's most recent admission MDS (Minimum Data Set) dated 3/12/25, indicated the resident had one unhealed venous ulcer. Resident F's physician orders included, but were not limited to, Right dorsal lateral foot: Cleanse with wound cleanser and pat dry, Apply collagen moistened with sodium chloride to wound bed. Cover with bordered foam dressing and apply three layer compression wrap every day shift, Monday, Wednesday, and Friday (started 5/9/25 and discontinued on 5/15/25), Right dorsal lateral foot: Cleanse with wound cleanser. Place collagen dressing as filler…

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 adequate pharmaceutical services were available to provide physician prescribed routine treatments for 1 of 3 residents reviewed for pharmaceutical services. A facility did not have a treatment on hand and could not provide proof that the treatment (ointment) had been delivered by the pharmacy. (Resident C) Finding include: During an interview on 5/21/25 at 12:50 P.M., Resident C indicated that he typically received his ordered medications, however he had not been receiving a routine hemorrhoid cream and had asked for multiple times. During record review, Resident C's diagnoses included, but were not limited to, anxiety, irritable bowel syndrome, and hypertension. Resident C's physician orders included but were not limited to; 2-BAD Cream Baclofen/Diltiazem/Amitriptyline topical: apply to hemorrhoids twice a day to reduce inflammation/pain related to rectal fissure (started 3/20/25). During an interview on on 5/21/25 at 1:00 P.M., the Assistant Director of Nursing (ADON) indicated Resident C's hemorrhoid cream 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 resident records were complete and accurate for 1 of 3 residents reviewed for elopement risks. Resident records contained no documentation of an elopement event, and the Medication Administration Records (MAR) was documented inaccurately. (Resident C) Findings includes: 1. During record review on 3/26/25 at 9:10 A.M., Resident C's diagnoses included, but were not limited to dementia, anxiety disorder, schizoaffective disorder, and heart failure. Resident C's most recent quarterly MDS (Minimum Data Set) assessment, dated 1/17/25, indicated the resident had severe cognitive impairment, could walk 10 feet with partial to moderate assistance, and could walk 50 feet with substantial to maximal assistance. A risk for elopement assessment completed 1/15/25 indicated Resident C was not at risk for elopement. Resident C's care plan included but was not limited to, resident at risk for elopement (initiated 3/24/25). Resident C's progress notes included, but were not limited to: (A previous note was dated 3/12/25 with no 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to facilitate care plan meetings with the resident and/or resident representatives for 5 of 6 random clinical records reviewed for care plan conferences and 1 of 5 residents reviewed for unnecessary medications. A newly admitted resident did not have an initial care plan conference and other residents care plan conferences were not held quarterly. (Resident 260, Resident 11, Resident 35, Resident 26, Resident 3, Resident 30) Findings include: 1. On 1/28/25 at 8:09 A.M., Resident 260's clinical record was reviewed. Resident 260 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), schizophrenia, and alcohol dependence with alcohol induced persisting dementia. Resident 260's clinical record lacked a care plan conference since admission. 2. On 1/27/25 at 1:11 P.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, COPD, dementia 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.

Based on observation, interview, and record review, the facility failed to ensure accuracy of assessments for 6 of 17 resident records reviewed during the survey. Minimum Data Set (MDS) assessments did not accurately reflect resident status. (Resident 31, Resident 20, Resident 6, Resident 23, Resident 30, Resident 40) Findings include: 1. On 1/23/25 at 9:25 A.M., Resident 31's clinical record was reviewed. Diagnoses included, but were not limited to, depression and anxiety. The most recent Quarterly MDS assessment, dated 12/9/24, indicated no cognitive impairment and diuretic use. The assessment indicated Resident 31 had not received an opioid or an antiplatelet. Current physician orders included, but were not limited to: Aspirin (an antiplatelet) 81mg (milligrams) once a day, dated 8/20/24. Oxycodone-Acetaminophen (an opioid) 7.5-325mg every 12 hours as needed for pain, dated 8/18/24. Resident 31's Medication Administration Record (MAR) for December 2024 indicated during the MDS look back period, a diuretic had not been given, aspirin was administered daily, 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 development and implementation of a comprehensive person-centered care plan for each resident for 4 of 17 residents reviewed for care plans. A resident lacked a care plan for antidepressant use, and current care plan interventions were not followed. (Resident 4, Resident 54, Resident 23) Findings include: 1. On 1/22/25 at 1:20 P.M., Resident 4 was observed lying in bed. A call light was observed lying on the floor just under the bed, out of the resident's reach. On 1/23/25 at 9:13 A.M., Resident 4 was observed lying in bed. A call light was observed lying on the floor beside the bed, out of the resident's reach. On 1/23/25 at 12:19 P.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, depression and schizophrenia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/12/25, indicated no cognitive impairment and no behaviors. Resident 4 required staff supervision with eating,…

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 adequate supervision and an environment free of accident hazards for 1 of 3 residents reviewed for accidents and 2 random observations. Residents were keeping smoking supplies on their person, smoking unsupervised, and in undesignated areas. A dementia resident that was at high risk for falls had an extension cord in his room that was not secured down. (Resident 32, Resident 22, Resident 54) Findings include: 1. On 1/27/25 at 10:48 A.M. Resident 32 was observed punching in the code to exit the door from the dining room to the outside while lunch was being served in the dining room. The resident was observed seated in a chair on that patio, smoking a cigarette, without staff supervision. On 1/28/25 12:01 P.M., Resident 32's clinical record was reviewed. Diagnoses included, but were not limited to, nicotine dependence, diabetes mellitus type II, and polyneuropathy. The most recent Annual Minimum Data Set (MDS) assessment, dated…

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 and interview, the facility failed to ensure a sanitary and home-like environment for 2 of 2 halls, 1 of 1 shower rooms reviewed for environment, and 3 of 3 resident personal refrigerator temperature logs reviewed. Temperature logs were not completed for resident personal refrigerators, a call light was out of the wall, brown spots on the wall of resident's room, and cracked tiles along shower front and side wall, paint peeling on ceiling, and vent caked with dust in [NAME] Shower Room. (room [ROOM NUMBER], room [ROOM NUMBER]-A, room [ROOM NUMBER]-A, room [ROOM NUMBER]-B, room [ROOM NUMBER]-B, [NAME] Shower Room) Findings include: 1. On 1/21/25 at 9:23 A.M., the temperature log for room [ROOM NUMBER]-A resident refrigerator was observed to be filled out from 1/1/25 through 1/14/25 at 40 degrees. On 1/29/25 at 10:00 A.M., the temperature log for room [ROOM NUMBER]-A resident refrigerator was observed to be filled out from 1/1/25 through 1/14/25. There were two drink cups sitting 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 deliver mail to the residents on Saturdays. Eleven of eleven anonymous residents interviewed indicated they failed to get mail every Saturday. Finding includes: During an interview on 1/27/25 10:53 A.M., eleven residents unanimously indicated they did not receive mail on Saturdays during the resident council meeting. During an interview on 1/27/25 at 11:49 A.M., the Activity Director indicated mail should be delivered everyday. At that time, she indicated she delivered the mail during the week and every other weekend an assistant delivered the mail. She further indicated two weekends a month the mail was not delivered because the office was locked. On 1/28/25 at 11:50 A.M., the Administrator provided a current Mail policy, revised November 2010, that indicated, .Mail will be delivered to the resident within twenty-four (24) hours of delivery on premises . 3.1-3(s)(1)

Based on observation, interview and record review, the facility failed to revise resident care plans for 1 of 2 residents reviewed for a decline in activities of daily living (ADLs) and 1 of 3 residents reviewed for nutrition. A resident's ADL care plan was not revised with an ADL decline and a resident was receiving a diuretic but the care plan indicated she was not. (Resident 11, Resident 35) Findings include: 1. On 1/27/25 at 11:29 A.M., Resident 11 was observed in a Broda chair brought to the dining room by staff and was being fed her lunch by staff. On 1/27/25 at 1:11 P.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), dementia with behaviors, schizophrenia, edema, Parkinson's disease, and mild intellectual disorder. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 12/28/24, indicated Resident 11's cognition was not able to be assessed, she was totally dependent on staff for toileting, transfers, bed mobility, eating, and took a diuretic. Current physician's orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was given the appropriate treatment and services to maintain or improve his ability to carry out the activities of daily living for 1 of 2 residents reviewed for a decline in activities of daily living (ADLs). A resident's functional ability declined, the ADL Care Plan was not revised, and restorative therapy was not provided as recommended. (Resident 35) Findings include: On 1/27/25 at 10:48 A.M., Resident 35 was observed seated in a wheelchair by himself at a dining room table. On 1/28/25 at 11:39 A.M., Resident 35 was laying in bed with his eyes closed. On 1/27/25 at 8:19 A.M., Resident 35's clinical record was reviewed. Diagnoses included, but were not limited to, COPD, dementia with behaviors, and stroke. A Quarterly MDS assessment, dated 9/5/24, indicated Resident 35's cognition was severely impaired, supervision of staff for eating, substantial to maximum assistance of staff (more than half effort performed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 of 2 residents reviewed for dementia care. A resident didn't have a plan of care for dementia, safety risks were not identified, wandering behavior and interventions were not being documented and evaluated, and a daily routine was not established. (Resident 54) Finding includes: On 1/21/25 at 9:59 AM, Resident 54 was observed roaming in the East Hall and down the hall towards the dining room without eyeglasses. An ankle alarm was not observed. On 1/21/25 at 12:17 P.M., Resident 54 was observed roaming in the [NAME] Hall and in the dining room without eyeglasses. An ankle alarm was not observed. On 1/27/25 at 11:11 A.M., Resident 54 was observed walking into room [ROOM NUMBER] on the [NAME] Hall. He indicated to the Qualified Medication Aide (QMA) who 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 medications were administered appropriately for 1 of 5 residents reviewed for unnecessary medication use. A blood pressure medication was administered without adequate monitoring as well as given outside of ordered parameters, and an opioid pain medication was administered with excessive use. (Resident 6) Findings include: On 1/23/25 at 1:25 P.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, hypotension (low blood pressure), and chronic pain. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/8/25, indicated a moderate cognitive impairment, no behaviors, and use of an opioid. Current physician orders included, but were not limited to: Midodrine HCl 5mg (milligrams) three times a day related to orthostatic hypotension. Hold for systolic blood pressure greater than 120, dated 1/19/25. Midodrine HCl 5mg three times a day related to orthostatic hypotension (no parameters), dated 7/3/24 and discontinued 1/18/25. Norco (an opioid pain medication) 5-325mg every 8…

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 unnecessary use of psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. An antianxiety medication lacked a required gradual dose reduction (GDR) and an antipsychotic medication was given without an appropriate indication. (Resident 31, Resident 54) Findings include: 1. On 1/23/25 at 9:25 A.M., Resident 31's clinical record was reviewed. Diagnoses included, but were not limited to, depression and diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 12/9/24, indicated no cognitive impairment, no behaviors, and use of an antianxiety medication. The MDS indicated a Gradual Dose Reduction (GDR) had not been done due to no antipsychotic medications given. Current physician orders included, but were not limited to: buspirone HCl oral tablet 5mg (milligrams) twice a day for anxiety, dated 8/19/24. A pharmacy review note, dated 7/19/24, indicated there was a recommendation related to…

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

Based on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 1 of 1 medication carts observed. A medication cup with loose pills and a narcotic was observed in a medication cart. (Resident 17) Finding includes: During an observation on 1/21/25 at 8:45 A.M., the medication cart on the [NAME] Hall had a clear medication cup for Resident 17 with 10 loose pills in it. The loose pills included, but was not limited to, an oxycodone (narcotic) 10mg (milligram) tablet. At that time, Qualified Medication Aide (QMA) 7 indicated Resident 17 requested his pills and then left the hall. During an interview on 1/21/25 at 12:32 P.M., Registered Nurse (RN) 23 indicated if medications are prepared for a resident, and the resident is unavailable, the medications are placed in the medication cart because you can't put them back in the package. During an interview on 1/30/25 at 10:10 A.M., RN 23 indicated narcotics should be double locked in the medication cart. On 1/27/25 at 11:55 A.M., the Director of Nursing (DON) provided a current,…

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

Based on observation and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents observed for wound care and 1 of 2 residents with catheters. Staff did not change gloves after touching multiple items before starting wound care. One resident with a catheter did not have Enhanced Barrier Precautions in place. (Resident 26, Resident 3) Findings include: 1. On 1/22/25 at 1:16 P.M., Resident 26's clinical records were reviewed. Diagnoses included, but were not limited to disorder of bone density and structure, hereditary and idiopathic neuropathy, spinal stenosis, lumbar region with neurogenic claudication, achondroplasia, and neuromuscular dysfunction of bladder. The most recent Quarterly Minimum Data Set (MDS) assessment, date 11/14/24, indicated Resident 26 had severe cognitive impairment, required substantial/maximal assistance where the helper did more than half the effort with bed mobility and transfer, supervision with eating and was dependent for toilet…

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 the smoking policy was followed for 2 of 2 residents reviewed for smoking. Residents had their smoking supplies on their person, smoking assessments were not completed quarterly, smoking care plans were not revised, residents were smoking without staff supervision, and residents were smoking in undesignated area. (Resident 32, Resident 22) Findings include: 1. On 1/27/25 at 10:48 A.M. Resident 32 was observed punching in the code to exit the door from the dining room to the outside while lunch was being served in the dining room. The resident was observed seated in a chair on that patio, smoking a cigarette, without staff supervision. On 1/28/25 12:01 P.M., Resident 32's clinical record was reviewed. Diagnoses included, but were not limited to, nicotine dependence, diabetes mellitus type II, and polyneuropathy. The most recent Annual Minimum Data Set (MDS) assessment, dated 12/23/24, indicated Resident 32 was cognitively intact, supervision of one staff for bed mobility and transfers, needed partial 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 safe, sanitary, and homelike environment in 2 of 2 resident halls observed. Resident areas had holes in walls, floors were in disrepair, specimen collection hats were stored uncovered, resident trash receptacles were full, and odors were present during 2 of 2 days of the survey. (East Hall, [NAME] Hall, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Finding includes: 1. During an observation on 12/13/24 at 9:40 A.M., the flooring in front of the [NAME] Hall nurse's station near a wall mounted heating/air unit was cracked and uneven. During an observation and interview on 12/16/24 at 8:25 A.M., the Maintenance Director observed the uneven floor and indicated that the heating/air units had been leaking. The floor had already been repaired near the [NAME] Hall's nurse's station, but was not repaired well and that the floor was left uneven. 2. During an observation on 12/13/24 at 9:45 A.M., room [ROOM NUMBER]'s shared…

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

Based on observation, interview, and record review, the facility failed to ensure medications and syringes were stored safely and securely during a random observation during the survey. Discontinued medications along with an unsecured sharps container with unused syringes were stored in an unlocked conference room. (Resident J) Finding includes: During an observation on 12/13/24 at 12:30 P.M., a cardboard box that contained Resident J's medications included the following: Levofloxacin 500 mg (milligrams) - 19 tablets Vitamin D3 50,000 IU (International Unit) - 3 tablets 1 bag of Juven Oral Packets (nutritional supplement) - 20 packets Scopolamine Base Patch 1.5 mg - 1 patch An unsealed sharps container was also observed next to the box of medications. The container held 30 unused syringes that were accessible through an opening at the top of the box. During an interview on 12/13/24 at 12:35 P.M., the Director of Nursing (DON) indicated the medications would be removed from the conference room. During an observation at 1:40 P.M., the medications were no longer stored in the unlocked…

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

Based on record review and interview, the facility failed to electronically submit to CMS (Center for Medicare and Medicaid Services) required information regarding direct care staffing for Fiscal Quarter 4 from 7/1/23 thru 9/30/23. Findings Include: During an interview on 3/7/24 at 9:37 A.M., the Administrator indicated PBJ (Payroll-Based Journal) information was submitted by staff outside of the facility. On 3/8/24 at 2:13 P.M., the Administrator provided a copy of the [NAME] Report 1702S, Staffing Summary Report from 7/1/23 thru 9/30/23, which indicated No data returned for selected criteria. On 3/11/24 at 10:53 A.M., the Administrator provided an undated Reporting Direct Care Staffing Information (Payroll-Based Journal) policy which indicated .9. Direct care staffing is submitted on the schedule specified by CMS, but no less frequently than quarterly. 10. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter .

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with dignity for 3 of 3 residents reviewed for dignity and 2 random observations. Two residents had catheter bags that were not covered. A resident was walking down the hall with wet pants and another with debris on her face and shirt. A resident asked for breakfast tray to be removed but it was not. (Resident 203, Resident 27, Resident 29, Resident 101, Anonymous Resident) Findings include: 1. On 3/4/24 at 9:32 A.M., Resident 203 was observed laying in her bed with an uncovered catheter bag hanging on the left side of her bed with dark amber urine in it that was visible from the hallway. On 3/6/24 at 8:25 A.M., Resident 203 was observed laying in bed with an uncovered catheter bag hanging on the left side of her bed with light amber urine in it visible from the hallway. On 3/11/24 at 9:10 A.M., Resident 203 was observed laying in bed with an uncovered catheter bag hanging on the left side of her bed with light yellow urine in it visible from the hallway. On 3/5/24 at 12:56…

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 notice of transfer or discharge was given to residents or resident representatives for 7 of 9 residents reviewed for hospitalizations. The transfer discharge form was not completed. There was no documentation of a resident, representative, and the ombudsman receiving a notice of transfer or discharge at the time of hospitalization. (Resident B, Resident C, Resident E, Resident F, Resident G, Resident H, Resident J) Findings include: 1. On 3/5/24 at 1:01 P.M., Resident F's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 2/9/24 and returned back to the facility from the hospital on 2/11/24. Resident F's records lacked a notice of transfer/ discharge. On 2/9/24 at 5:45 P.M., a progress note in Resident F's clinical record indicated, Transfer/Discharge Information Late Entry: .How was notice of transfer/discharge and bed hold policy given? .in person . On 3/12/24 at 9:43 A.M., the MDS (Minimum…

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 bed hold policy was given to residents or resident representatives for 5 of 9 residents reviewed for hospitalizations. The bed hold form was not completed. There was no documentation of a resident or representative receiving a bed hold at the time of hospitalization. (Resident C, Resident E, Resident F, Resident G, Resident H, Resident J) Findings include: 1. On 3/5/24 at 1:01 P.M., Resident F's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 2/9/24 and returned back to the facility from the hospital on 2/11/24. Resident F's records lacked a bed hold policy. On 2/9/24 at 5:45 P.M., a progress note in Resident F's clinical record indicated, Transfer/Discharge Information Late Entry: .How was notice of transfer/discharge and bed hold policy given? .in person . On 3/12/24 at 9:43 A.M., the MDS (Minimum Data Set) Coordinator provided a bed hold policy form, dated 2/9/24 that was not filled out for…

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 MDS (Minimum Data Set) Assessments were accurate for 6 of 23 residents reviewed for MDS Assessments. Medications were not accurately documented. (Resident E, Resident J, Resident 13, Resident 30, Resident 34, Resident 203) Findings include: 1. On 3/07/24 at 2:44 P.M., Resident 34's clinical record was reviewed. Resident 34 was admitted on [DATE]. Diagnoses included, but were not limited to, Type II diabetes mellitus with foot ulcer, chronic atrial fibrillation, major depressive disorder, chronic kidney disease, and dementia. The most current State optional, Quarterly MDS (Minimum Data Set) Assessment, dated 2/2/24 indicated Resident 34 had severe cognitive impairment, required total dependence of two for bed mobility, transfers and toilet use and total dependence of one for eating. The medications listed were insulin 7 days, antianxiety, anticoagulant, opioid, and hypoglycemic. Physician Orders included, but were not limited 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement person-centered care plans and interventions specific to resident needs for 4 of 18 residents reviewed for care plan development. An intervention for monthly weights was not followed, a care plan was developed with inaccurate diagnosis, care plans were not developed for residents on antiplatelets and antianxiety medication. (Resident J, Resident G, Resident 41, Resident 34) Findings include: 1. On 3/5/24 at 9:01 A.M., Resident J's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, anxiety, depression, and schizophrenia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 2/6/24, indicated cognitive status could not be obtained. Resident J had no weight loss or gain, and no swallowing or dental concerns. Resident J lacked current physician orders related to weights. A current risk for altered nutrition and hydration care plan dated 4/28/17 indicated, but was not limited…

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 2. On 3/4/24 at 8:32 A.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, hypertension and diabetes mellitus. The most recent quarterly MDS, dated [DATE], indicated Resident 13 was cognitively intact. Discontinued Physician's Orders included, but were not limited to, .Droplet Precautions x 7 days for positive influenza test start date 1/20/2024 .end date 1/26/2024. Current care plans included, but were not limited to, I am in contact/droplet isolation as I am positive for Influenza . dated 1/25/24. During an interview on 3/8/24 at 9:09 A.M., the DON (Director of Nursing) indicated the MDS Coordinator revised care plans. During an interview on 3/11/24 at 1:53 P.M., the MDS Coordinator indicated the isolation care plan should have been removed 7 days after Resident 13 was diagnosed with influenza. 3. On 3/5/24 at 1:01 P.M., Resident F's clinical record was reviewed. Diagnoses included, but were not limited to, seizure disorder, anxiety disorder, and heart failure. The most…

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

Based on observation and interview, the facility failed to ensure an ongoing activity program was in place for residents in 2 of 2 halls during the survey period. (West Hall and East Hall) Findings included: During an observation on 3/4/24 at 12:10 P.M., the activity calendar posted by the main dining room was for February 2024. During an observation on 3/4/24 at 12:22 P.M., Resident E had a February 2024 activities calendar hanging in her room. During a continuous observation on 3/7/24 from 10:20 A.M. to 10:35 A.M., 6 residents were seated in the dining room, 3 of them talking to each other, the others were seated alone. 3 residents were sitting in the living room area watching tv. According to the activity schedule, at 10:30 A.M., there should have been a Lucky Numbers activity. During an interview on 3/4/24 at 12:22 P.M., Resident 30 indicated he was bored most of the time because there were not enough activities. He indicated he would like to go outside the facility to other places and he indicated he did not know what activities were going on that day. During an interview on…

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

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 4 of 7 residents reviewed for accidents. Interventions were not implemented following falls, thorough assessments were not performed following unwitnessed falls, and assessments were not completed for a residents with an electronic cigarette. (Resident 7, Resident 31, Resident G, [NAME] Hall Treatment Cart) Findings include: 1. On 3/5/24 at 10:49 A.M., Resident 7 was observed lying in bed using an electronic cigarette. On 3/7/24 at 8:48 A.M., Resident 7's clinical record was reviewed. Diagnosis included, but were not limited to, Alzheimer's disease, dementia, and depression. The most recent MDS (minimum data set) Assessment, dated 12/23/23, indicated no cognitive impairment and no behaviors. Resident 7's clinical record lacked an order related to the use of an electronic cigarette. Resident 7's clinical record lacked a care plan related to the use of an electronic cigarette. Resident 7's clinical record lacked 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 provide an RN (registered nurse) for 8 consecutive hours, seven days a week, for 2 of 7 days reviewed. Findings include: On 3/7/24 at 9:27 A.M., the review of nurse staffing from 2/20/24 through 2/27/24 indicated there was no RN coverage for 8 consecutive hours on 2/24/24 and 2/25/24. There was an RN working for 6 hours from 12 A.M. until 6 A.M. and 6 P.M. until 12 A.M. on 2/24/24. There was an RN working for 6 hours from 12 A.M. until 6 A.M. and 6 P.M. until 12 A.M. on 2/25/24. During an interview on 3/11/24 at 11:01 A.M., CNA 18 indicated she was the scheduler. She indicated an RN should be here every day but was not certain how many consecutive hours they should be in the building. On 3/11/24 at 10:55 A.M., the Administrator provided an undated Staffing, Sufficient and Competent Nursing Policy which indicated, .3. A registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week . 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to ensure storage of food in a safe and sanitary manner for 2 of 2 kitchen observations. Open food items were observed unlabeled and open to air, debris was observed on the floor, and the window screen was observed damaged in the dishwasher area. Findings include: On 3/4/24 at 8:28 A.M., the following was observed in the kitchen: A pitcher of yellow substance was in the refrigerator with no label or date. A package of Canadian bacon was open to air with no label or open date in the refrigerator. A package of Canadian bacon was open and in a separate baggie with no label or open date. Slices of lunch meat were in a baggie in the refrigerator with no label or open date. A baggie of yellow cheese slices were in the refrigerator open to air with no label or open date. A baggie of white cheese slices were in the refrigerator with no label or open date. Shredded cheese was observed wrapped in cling wrap with no label or open date. The floor of the refrigerator was observed wet. A bag of meat patties were observed in…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention program for 1 of 2 residents reviewed for infections, 1 random observation, and 2 of 2 halls reviewed for water system management. Proper PPE (personal protective equipment) was not used to care for a resident with MRSA (Methicillin Resistant Staph Aureus-a skin infection), an uncovered catheter bag was dragging on the floor, and there was no program for monitoring the water system for the growth of Legionella (bacteria). (Resident 16, Resident 29, East Hall, [NAME] Hall) Findings include: 1. On 3/11/24 at 1:12 P.M., Resident 16's clinical record was reviewed. Diagnoses included, but were not limited to, MDRO (Multidrug-resistant bacteria) and diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 11/24/23, indicated Resident 16 had severe cognitive impairment. Progress nursing notes included the following: 2/23/24 at 2:07 P.M., .Late Entry: Note Text: Please obtain wound culture. 2/26/24 at 12:41 P.M., .Wound cultures results forwarded to MD…

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 safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 2 resident halls, 2 of 2 shower rooms, and 1 of 2 nurses stations. (East Hall, East Hall nurses station, [NAME] Hall) Findings include: 1. On 3/5/24 at 10:34 A.M., the [NAME] Hall shower room was observed with debris on the floor, the floor was observed to be sticky, a candy bar wrapper was on the floor with ants crawling around it, and a tissue, used glove, and four alcohol prep packages were observed on the floor. A used paper towel was observed on the top of the trashcan lid. The shower chair had a brown substance smeared in the seat. The area of the floor tile where it met the wall was observed with a black substance, and the ceiling had chipped paint. On 3/5/24 at 1:25 P.M., the [NAME] Hall shower room was observed the same, with an alcohol wipe on the floor of the shower area. On 3/14/24 at 9:18 A.M., the [NAME] Hall shower…

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 that were self administering medications were assessed for capability to self administer medications for 1 of 1 residents observed with medications in their rooms. (Resident F) Finding includes: During an observation on 3/4/24 at 9:39 A.M., Resident F was observed in bed and had a clear medication cup on her bedside table that had 7 circular tablets in it. At that time, the resident indicated staff left Tums in her room for her upset stomach. During an observation on 3/5/24 at 9:22 A.M., Resident F had an unlabeled albuterol sulfate inhaler on her bedside table. At that time, Resident F indicated she used the inhaler twice a day. On 3/5/24 at 1:01 P.M., Resident F's clinical record was reviewed. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/29/24, indicated Resident F had moderate cognitive impairment. Current diagnoses included, but were not limited to, heart failure, hypertension, anxiety disorder, and depression. A current Self Medication assessment, dated 2/26/24,…

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 appropriate parties were notified following a change in resident condition for 1 of 3 residents reviewed for nutrition and 1 random observation. The physician, Registered Dietician (RD), nor a representative were notified following a significant weight loss, and the physician was not notified of a resident's use of an electronic cigarette. (Resident 7, Resident J) Findings include: 1. During a random observation on 3/5/24 at 10:49 A.M., Resident 7 was observed lying in bed using an electronic cigarette. On 3/7/24 at 11:45 A.M., Resident 7 indicated her son used to bring her two electronic cigarettes per week, but that was too much, so she asked him to bring her less, and now received one per week. She indicated her roommate had recently moved out of the room, and she used her electronic cigarette to celebrate. She also indicated she never got out of bed, and used the electronic cigarette in bed. On 3/7/24 at 8:48 A.M., Resident 7's clinical record was reviewed. Diagnosis included, but were not limited…

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 misappropriation of medications for 1 of 1 residents reviewed for missing medications. A finding of missing controlled substances was not reported to the State Survey Agency. (Resident J) Findings include: On 3/5/24 at 9:01 A.M., Resident J's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, anxiety, depression, and schizophrenia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 2/6/24, indicated cognition status could not be obtained. Resident J had received antipsychotic, antianxiety, antidepressant, antibiotic, diuretic, and opioid medications. Current physician orders included, but were not limited to, the following: Clonazepam 0.5 mg (milligram) at bedtime for anxiety, dated 1/30/24. Resident J's MAR (medication administration record) for January 2023 indicated clonazepam 0.5 mg was administered on 1/25/24 by Qualified Medication Aide (QMA) 25 during a hospitalization when the resident was not in the facility. On 3/11/24 at 9:50 A.M., 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 perform a thorough and complete investigation of an alleged incident for 1 of 1 residents reviewed for missing medications. A finding of missing medications was not thoroughly investigated after being reported to the facility. (Resident J) Findings include: On 3/5/24 at 9:01 A.M., Resident J's clinical record was reviewed. admission date was 6/2/23. Diagnosis included, but were not limited to, dementia, anxiety, depression, and schizophrenia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 2/6/24, indicated cognition status could not be obtained. Resident J had received antipsychotic, antianxiety, antidepressant, antibiotic, diuretic, and opioid medications. Physician orders included, but were not limited to, the following: Clonazepam 0.5 mg (milligram) at bedtime for anxiety, dated 1/30/24 (current order). Resident J's MAR (medication administration record) for January 2023 indicated clonazepam 0.5mg was administered on 1/25/24 by Qualified Medication Aide (QMA) 25 while the resident was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to do a comprehensive assessment of residents and that residents received appropriate treatment and care in accordance with professional standards of practice for 3 of 9 residents reviewed for hospitalizations. A resident's weight and height were not accurately assessed, a resident's skin assessments were not completed, and a resident was not given Lasix (diuretic) as ordered and was hospitalized for weight gain. (Resident E, Resident 3, Resident G) Findings include: 1. On 3/6/24 at 10:58 A.M., Resident E's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, dysphagia, stroke, right side hemiplegia (paralysis of one side of the body). The most recent Quarterly MDS Assessment, dated 2/16/24, indicated Resident E's cognition was moderately impaired, was totally dependent on 2 staff for bed mobility, transfers, toileting, and an extensive assist of 1 staff for eating and no weight gain.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services to promote healing in 1 of 2 residents reviewed for pressure ulcers. A resident's wound culture was not collected timely, the wound vac (wound therapy using vacuum assisted closure) was not documented as physician ordered, and the wound was left open to air. (Resident E) Finding includes: 1. During an observation on 3/13/24 at 1:35 P.M., the Wound Nurse was going to change Resident E's pressure wound dressing on her right buttock. When the wound nurse pulled resident's pants and brief down, the wound did not have a dressing on it, was open to air, and the brief was saturated. On 3/6/24 at 10:58 A.M., Resident E's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, dysphagia, stroke, right side hemiplegia (paralysis of one side of the body). The most recent Quarterly MDS Assessment, dated 2/16/24, indicated…

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 necessary behavioral health monitoring to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 2 of 3 residents reviewed for behavior. Behavior monitoring was not accurately completed, and a care plan was not developed after behaviors observed. (Resident G, Resident H) Findings include: 1. On 3/5/24 at 1:17 P.M., Resident G was observed sitting in her room. At that time, she indicated she had recently fallen in the bathroom. Resident G initially indicated she had slipped on the bathroom floor, then later in the interview indicated she had fallen when a resident came into the bathroom while she was using it and pushed her. On 3/5/24 at 1:50 P.M., Resident G's clinical record was reviewed. Diagnosis included, but were not limited to, epilepsy. The most recent Annual MDS (Minimum Data Set) Assessment, dated 3/5/24, indicated…

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 medically-related social services were provided to residents for 1 of 2 residents reviewed for dental services and 1 of 1 resident leaving the building. Staff was unsure if a resident had dentures or not for Resident 14 and Resident 41 was assisted to leave the building without first verifying there was a physician order to leave, to leave with medication. (Resident 14, Resident 41) Findings include: 1. During an interview on 3/4/24 at 10:13 A.M., Resident 14 indicated someone took her dentures. On 3/5/24 at 1:27 P.M., Resident 14 was observed talking with other residents without her dentures while in the dining room. On 3/11/24 at 8:57 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, dementia without behavioral disturbance. The most recent Quarterly MDS Assessment, dated 2/1/24, indicated Resident 14's cognition was moderately impaired and an extensive assist of 1 staff for bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate dispensing and administration of medications for 1 of residents reviewed for hospitalizations. A resident's controlled medications were documented as given during a hospitalization, and after a change to the order resulting in missing doses. (Resident J) Findings include: On 3/5/24 at 9:01 A.M., Resident J's clinical record was reviewed. admission date was 6/2/23. Diagnosis included, but were not limited to, dementia, anxiety, depression, and schizophrenia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 2/6/24, indicated cognition status could not be obtained. Resident J had received antipsychotic, antianxiety, antidepressant, antibiotic, diuretic, and opioid medications. Physician orders included, but were not limited to, the following: Clonazepam 0.5 mg (milligram) at bedtime for anxiety, dated 1/30/24 (current order). Clonazepam 0.5 mg three times a day for anxiety, from 8/16/22 through 1/30/24. A hold was put on…

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

Based on observation, interview, and record review, the facility failed to serve food at an appetizing temperature for 1 of 1 lunch trays tested. (East Hall) Finding includes: On 3/8/24 at 12:29 P.M., a lunch tray was obtained from the East Hall with the following temperatures: Beef stroganoff: 120.6 degrees Fahrenheit Green beans: 104.1 degrees Fahrenheit At that time, Licensed Practical Nurse (LPN) 21 indicated residents would normally complain about the breakfast temperatures, but not as often for lunch. On 3/8/24 at 1:35 P.M., the Kitchen Manager indicated hot foods should be served to residents at 165 degrees Fahrenheit or higher, but may lose 20 degrees or so coming down the hall. On 3/13/24 at 12:48 P.M., a current non-dated Food and Nutrition Services policy was provided and indicated Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking in to consideration the preferences of each resident The policy did not indicate serving temperatures of foods. 3.1-21(a)(2)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain accurate medical records on 3 of 27 residents reviewed. (Resident 41, Resident G, Resident J) Findings include: 1. On 3/05/24 at 1:27 P.M., Resident 41's clinical records were reviewed. He was admitted on [DATE]. Diagnosis included, but was not limited to cerebral infarction, chronic embolism and thrombosis of bilateral lower extremities, chronic pain due to trauma, depression, atherosclerotic heart disease of native coronary artery. The most current State optional, Quarterly MDS Assessment, dated 1/29/24, indicated Resident 41 was cognitively intact, and needed extensive assistance of one for bed mobility, transfer, eating and toilet use. Progress Notes included, but was not limited to the following: 3/4/2024 1:34 P.M. Social Services Note Note Text: [Resident's name] went to NS [Nurse's State] to request CNA [Certified Nursing Assistant] call him a cab so that he can go to Bowling Green, Kentucky [101 miles away]. CNA notified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's call lights were properly functioning and in reach for 3 of 21 residents reviewed in the sample. Call lights were on the floor, out of reach for the resident and not functioning. (Resident 46, Resident 203, Resident E, room [ROOM NUMBER]) Findings include: 1. During an observation on 3/4/24 at 12:23 P.M., Resident 46 was in bed, and her call light was on the floor. CNA (Certified Nurse Aide) 18 walked by the call light to drop off a meal tray and failed to pick the call light up and place it in the resident's reach. During an observation on 3/5/24 at 9:10 A.M., Resident 46 was observed in bed and her call light was on the floor. During an observation on 3/6/24 at 8:38 A.M., LPN (Licensed Practical Nurse) 21 administered medication to Resident 46. At that time, Resident 46's call light was on the floor and LPN 21 failed to place it in reach of the resident. During an observation on 3/6/24 at 8:57 A.M., LPN 21 walked by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ADL (activities of daily living) care to 1 of 1 residents observed for ADL care. (Resident B) Finding includes: On 12/5/23 at 12:25 p.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, weakness generalized, chronic kidney disease, stage 3, diabetes mellitus. A quarterly MDS (Minimum Data Set) assessment, dated 8/20/23, indicated cognition intact, bathing total dependence. Care plans were reviewed and included, but were not limited to, [name] has an ADL self-care performance deficit r/t fatigue, impaired balance, weakness, date initiated 3/22/3. Interventions included but were not limited to, provide a sponge when full bath or shower cannot be tolerated, date initiated 3/22/23. On 12/6/23 at 9:33 a.m., CNA 1 and CNA 2 were observed to provide morning ADL care to Resident B. CNA 1 and CNA 2 removed Resident B's soiled brief, cleaned stool off Resident B's peri area and buttocks, put a new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment or notify the physician of suspected deep tissue injury for 1 of 3 residents reviewed for pressure wounds. (Resident C) Findings include: On 12/6/23 at 9:00 a.m., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus due to underlying condition with diabetic polyneuropathy, chronic kidney disease, stage 4 (severe), unspecified multiple myeloma. An admission MDS (Minimum Date Set) assessment, dated 10/17/23, indicated Resident C's cognition was intact, self care- resident needed partial assistance from another person to complete activities, skin - no unhealed pressure, no deep tissue injury, not marked for diabetic foot ulcers. Care plans were reviewed and included, but were not limited to: [name] has an ADL (Activities of Daily Living) self-care performance deficit r/t activity intolerance, fatigue, impaired balance, SOB (shortness of breath), date initiated 10/10/23.…

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 failed to ensure infection control practices were done for 1 of 3 resident's observed for care. Hand hygiene was not done and gloves were not changed. (Resident B) Finding includes: On 12/5/23 at 12:25 p.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, weakness generalized, chronic kidney disease, stage 3, diabetes mellitus. A quarterly MDS (Minimum Data Set) assessment, dated 8/20/23, indicated cognition intact, bathing total dependence. Care plans were reviewed and included, but were not limited to, [name] has an ADL self-care performance deficit r/t fatigue, impaired balance, weakness, date initiated 3/22/3. Interventions included but were not limited to, provide a sponge when full bath or shower cannot be tolerated, date initiated 3/22/23. On 12/6/23 at 9:33 a.m., an observation of morning ADL care was observed by CNA 1 and CNA 2 for Resident B. CNA 1 performed hand hygiene, donned gloves, took off the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints for 1 of 1 residents reviewed for restraints. A resident was placed in a new wheel chair that restricted mobilization and was strapped into the wheelchair without documented clinical rational for the need of the wheelchair with straps, assessments, or a plan of care for the use of restraints. (Resident C) Finding includes: During an observation on 9/19/23 at 9:20 A.M., Resident C was sitting in front of the [NAME] hall's nurse's station in a Tilt-in-Space wheelchair. Resident C was wearing a lap belt and foot straps that were wrapped around both ankles. During record review on 9/19/23 at 11:00 A.M., Resident C's diagnoses included, but were not limited to, cerebral palsy, epilepsy, abnormal posture, unspecified convulsions, schizophrenia, major depressive disorders, anxiety, and mild intellectual disabilities. Resident C's most recent quarterly MDS (Minimum Data Set) assessments, dated…

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.