Signature Healthcare Of Bremen

Based on observation, record review and interview, the facility failed to implement effective behavior monitoring to prevent resident to resident altercations from recurring. (Resident 52) Findings include: 1. During an observation, on 2/12/2025 at 9:25 A.M., Resident 52 was crying at an activity. A record review for Resident 52 was completed on 2/13/2025 at 10:13 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, dementia with agitation, major depressive disorder, post-traumatic stress disorder and delusional disorder. A Quarterly Minimum Data Set (MDS) assessment, on 1/14/2025, indicated Resident 52 had severe cognitive impairment, no mood or behavior issues and was taking an antipsychotic, antianxiety and antidepressant medication. A Physician's Order, dated 11/7/2024, indicated behavior monitoring for pointing fingers at other residents and taking her clothing off. A Psychiatry Initial Consult note, dated 11/8/2024, indicated Resident 52 was observed pacing, restless, crying, confused and mildly agitated. Resident 52 was difficult for staff to redirect and…

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

Based on observation, interview and record review, the facility failed to ensure showers were provided for 8 of 17 residents reviewed for ADL's (Activities of Daily Living). (Residents H, J, L, C, N, P, M & Q) Findings include: 1. The record review for Resident H was completed on 10/31/2024 at 10:34 A.M. Diagnosis included, but were not limited to dementia, anxiety, need for assistance with personal care and dysphagia. A Quarterly Minimum Data Set (MDS) assessment, dated 8/21/2024, indicated Resident H resident was dependent on staff for showers. Shower documentation for Resident H, dated 10/1/2024 thru 10/31/2024, indicted the resident had only received a shower on 10/13/2024 and 10/19/2024. A current Care Plan, dated 9/13/2024, indicated the resident needed staff assistance with bed mobility, transfers and toileting. During an interview, on 11/1/2024 at 8:45 A.M., the Director of Nursing indicated the resident should have received two showers a week. 2. During an interview, on 10/30/2024 at 11:41 A.M., Resident J indicated he did not always receive a shower two times a week. A…

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

Based on observation, interview and record review, the facility failed to provide a continent resident timely assistance for toileting that resulted in an incontinence episode for 1 of 1 residents reviewed for toileting. (Resident C) Finding includes: During an observation, on 10/30/2024 at 12:20 P.M., Resident C was in a small dining room sitting in a reclining chair. The resident asked CNA 10, who walked by her, to take her to the bathroom. CNA 10 responded I'll see what your aides are doing now. At 12:21 P.M., the resident started to moan and stated Please help!, while trying to reposition herself in the reclining chair. Resident C was observed to bang her right hand down numerous times on the armrest of the chair while still moaning. CNA 10 observed to entered the dining room and asked Resident C,What's going on?, Resident C replied,I need to go to the bathroom. CNA 10 indicated Well, we are about to eat. Resident C indicated, I know but I have asked for ½ hour to go to the bathroom and they say I can't go by myself. CNA 10 left the dining room without assisting Resident C 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 record review and interview, the facility failed to notify the physician of an elevated heart rate and seizure activity and missed medications for 2 of 7 residents reviewed for pharmaceuticals. (Resident N and E) Findings include: 1. The record for Resident N was reviewed on 10/30/2024 at 11:45 A.M. Diagnoses included, but were not limited to: unspecified dementia, anxiety, depression, hypertension, diabetes mellitus, atrial fibrillation and chronic venous hypertension. Physician Orders for Resident N, dated 1/2/2024, included Eliquis (anticoagulant) 2.5 mg (milligrams) 1 tablet twice a day for atrial fibrillation (an irregular heart rhythm that begins in the heart's upper chambers or atria). A current Care Plan, reviewed 8/21/2024, indicated Resident N had a diagnosis of atrial fibrillation. Interventions included but were not limited to: observe for and report heart palpitations, irregular heartbeat and tachycardia (a heart rate that is faster than a hundred beats per minute), and notify physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to develop a care plan for seizures for 1 of 8 residents reviewed for medication. (Resident E) Finding includes: A record review for Resident E was completed on 10/30/2024 at 2:07 P.M. Diagnoses included, but were not limited to: Lennox-Gastaut syndrome (severe form of epilepsy), severe intellectual disabilities, autistic disorder and schizophreniform disorder. Resident E was admitted to the facility on [DATE]. A record review for Resident E was completed on 10/30/2024 at 2:07 P.M. Diagnoses included, but were not limited to: Lennox-Gastaut syndrome, severe intellectual disabilities, autistic disorder, schizophreniform disorder, and epilepsy. An admission Minimum Data Set (MDS) assessment, dated 8/23/2024, indicated Resident E had severe cognitive disability and received medications of an antipsychotic, antianxiety and antidepressant. He had an active diagnosis of seizure disorder Current Physician's Orders for medications to treat seizures…

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 ensure physician ordered medications were administered for 2 of 10 residents whose medications were reviewed. (Residents J & L) Findings include: 1. The record for Resident J was completed on 10/31/2024 at 10:16 A.M. Diagnoses included: Parkinson's disease, dementia, neurogenic bladder and diabetes and pain in joints. Current Physician Orders for Resident J included: Hydrocodone (narcotic pain medication) 5/325 mg (milligrams) 1 tablet every 6 hours for pain at midnight, 6:00 A.M., noon and 6:00 P.M. Resident J's narcotic Controlled Drug Record for the Hydrocodone, dated October 2024, indicated he had not received the 4 scheduled doses on 10/25/2024 and the midnight dose on 10/26/2024. During an interview, on 11/1/2024 at 8:45 A.M., the Administrator indicated the resident should have received the medication. 2. The record for Resident L was completed on 10/31/2024 at 11:26 A.M. Diagnoses included, but were not limited to Alzheimer's disease, hypertension, depression, dementia and chronic cluster headaches. Resident L's…

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

Based on observation, interview and record review, the facility failed to ensure routine medications were available and dispensed according to physician's orders for 3 out of 8 residents reviewed for medication administration. (Residents M, L and C) Findings include: 1. The medical record for Resident M was reviewed on 10/30/2024 at 2:19 P.M. The diagnoses included but were not limited to: Alzheimer's disease, acute kidney failure, ventral hernia, urinary tract infection, frequent falls, depression, other artificial opening of the urinary tract, post-traumatic stress disorder, sepsis, neuromuscular dysfunction of the bladder, neurogenic bladder and obstructive uropathy. Physician Orders for Resident M included Mupirocin ointment 2% 1 application topically twice a day, dated 8/31/2024 until 10/30/2024, and Clonazepam 0.25 mg 1 tablet by mouth twice a day, dated 10/3/2024. The October MAR indicated Resident M did not receive Mupirocin as ordered on the following dates: 10/18/2024 Evening dose due to medication unavailable, 10/19/2024 Morning and evening doses due to medication…

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

Based on observation, record review and interview, the facility failed to ensure an antianxiety drug was not adiministered for an excessive duration for 1 of 8 residents reviewed for pharmaceutical services (Resident M). Finding includes: The medical record for Resident M was reviewed on 10/30/2024 at 2:19 P.M. The diagnoses included but were not limited to: Alzheimer's disease, acute kidney failure, ventral hernia, urinary tract infection, frequent falls, depression, other artificial opening of the urinary tract, post-traumatic stress disorder, sepsis, neuromuscular dysfunction of the bladder, neurogenic bladder and obstructive uropathy. Physician's Orders for Resident M included Ativan (an antianxiety medication) 2 mg 1 tablet by mouth twice a day as needed, initiated on 7/29/2024, and Clonazepam (an antianxiety medication) 0.25 mg 1 tablet by mouth twice a day, initiated on 10/3/2024. The PRN Clonazepam did not have a stop date for the medication use. A current Care Plan, reviewed 10/14/2024, indicated Resident M was at risk for drug related side effect due to psychotropic…

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

Based on record review and interview, the facility failed to ensure 1 of 7 residents reviewed for medication use was free from significant medication errors related to omissions and overdosing/underdosing of antiseizure medications. (Resident E) Finding includes: A record review for Resident E was completed on 10/30/2024 at 2:07 P.M. Diagnoses included, but were not limited to: Lennox-Gastaut syndrome, severe intellectual disabilities, autistic disorder, schizophreniform disorder, and epilepsy. An admission Minimum Data Set (MDS) assessment, dated 8/23/2024, indicated Resident E had severe cognitive disabilities and received medications of an antipsychotic, antianxiety and antidepressant. Physician's Orders for medications included, but were not limited to: -Clobazam (anti-seizure medication) 20 milligrams at bedtime starting 8/29/2024, given in the morning from 8/17/24-8/28/24. -Fycompa (anti-seizure medication) 30milliters equals15milligrams at bedtime starting on 8/ 817/2024. -Lamotrigine (anti-epileptic medication) 200 milligrams 2 tabs twice daily starting 8/17/2024.…

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 urinary catheter equipment was positioned and maintained in a sanitary manner for 1 of 2 residents reviewed for catheter use. (Resident J) Finding includes: During an observation, on 10/30/2024 at 11:41 A.M., Resident J's catheter tubing and urine collection bag was lying on the floor under his wheelchair. During an interview, on 10/30/2024 at 11:43 A.M., CNA 11 indicated the tubing and the drainage bag should not be on the floor. During an observation, on 10/31/2024 at 10:20 A.M., Resident J's urine collection bag was lying on the floor. During an observation, on 11/1/2024 at 9:10 A.M., Resident J was in the dining room with the urine collection bag lying on the floor. During an interview, on 10/30/2024 at 11:43 A.M., CNA 11 indicated the tubing and the drainage bag should not be on the floor. On 10/30/2024 at 11:59 A.M., Resident J was brought into the dining room with the urinary catheter tubing and drainage bag dragging on the floor. During an observation, on 10/30/2024 at 3:42 P.M., Resident J's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the physician of a removal of a PICC line (a peripherally inserted central catheter is a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) and resident discharge and failed to notify the physician of low blood glucose levels for 2 of 3 residents reviewed for physician notification. (Residents B & C). Findings include: 1. The record for Resident B was reviewed on 10/4/2024 at 10:49 A.M. Diagnoses included, but were not limited to, amputation of left lower leg, diabetes, hypertension, Bipolar disorder and infection of left lower stump. Resident B had been admitted on [DATE] and was discharged on 8/28/2024. Physician Orders for Resident B, dated 8/21/2024, included Vancomycin (antibiotic) 1.5 gram/250 ml (milliliter) intravenous. A Nursing Progress Note, dated 8/22/2024, indicated a PICC (peripherally inserted central catheter) was inserted in the resident's right upper arm. A Nursing…

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 ensure a transfer/discharge form was provided for 1 of 3 residents reviewed for transfer and discharge. (Resident C) Finding includes: A record review for Resident C was completed on 10/4/2024 at 10: 37 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, fracture of the neck, lumbar and thoracic vertebra and right humerus. A Nursing Progress Note, dated 7/13/2024 at 1:14 A.M., indicated at 12:23 A.M., Resident C was transferred a to local hospital. Resident C was found unresponsive by a CNA (Certified Nursing Assistant) and when assessed by the nurse, Resident C was found to be cold, clammy, and with pupils non-reactive to light, labored breathing and weak hand grips. Resident C's blood sugar was 49 mg/dL (milligrams per deciliter). A Nursing Progress Note, dated 7/13/2024 at 3:17 A.M., indicated Resident C returned from the hospital. A Nursing Progress Note, dated 7/22/2024 at 12:04 P.M., indicated Resident C's left abdomen was swollen and firm with bruising to the right arm and had increased pain…

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 ensure a bed hold form was provided for 1 of 3 residents reviewed transfer and discharge. (Resident C) Finding includes: A record review for Resident C was completed on 10/4/2024 at 10: 37 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, fracture of the neck, lumbar and thoracic vertebra and right humerus. A Nursing Progress Note, dated 7/22/2024 at 12:04 P.M., indicated Resident C's left abdomen was swollen and firm with bruising and the resident's right arm had increased pain and swelling. Resident C was transferred to the emergency department for evaluation and treatment. A Nursing Progress Note, dated 7/22/2024 at 5:18 P.M., indicated Resident C was admitted to the hospital. A Nursing Progress Note, dated 7/22/2024 at 5:19 P.M., indicated Resident C would be transferred to another hospital for surgery due to a large hematoma. There was no documentation a bed hol form was sent by the facility to the hospital or provided to Resident C's Power of Attorney (POA) for either transfer. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to write an order to send a resident to the emergency room or have adequate orders in place for diabetes management, for 1 of 3 residents reviewed for transfer and discharge. (Resident C) Finding includes: 1. A Nursing Progress Note, dated 7/13/2024 at 1:14 A.M., indicated at 12:23 A.M., Resident C was transferred a to local hospital. Resident C was found unresponsive by a CNA (Certified Nursing Assistant) and when assessed by the nurse, Resident C was found to be cold, clammy, their pupils were non-reactive to light, their breathing was labored and she had weak hand grips. Resident B's blood sugar was 49 mg/dL (milligrams per deciliter). A packet of sugar was administered to the resident with no change in her condition, except Resident C's blood sugar increased to 56 mg/dL. A Nursing Progress Note, dated 7/13/2024 at 3:17 A.M., indicated Resident C had returned from the hospital. The physician was notified, but an order was not written to send Resident C…

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 provide dressing changes for a PICC (a peripherally inserted central catheter is a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) site for 1 of 3 residents reviewed. (Resident D) Finding includes: The clinical record for Resident E was reviewed on 10/4/2024 at 11:00 A.M. The diagnoses included but not limited to: osteomyelitis, alcohol abuse with withdrawal, psychoactive substance abuse, malnutrition, methicillin-resistant staphylococcus aureus (MRSA) infection and patient non-compliance. The Physician Orders, included, but were not limited to: PICC line dressing changes every week. A Nursing Progress Note, dated 5/8/2024, indicated Resident D arrived at the facility with a PICC line in place. The May 2024 Medication Administration Record indicated Resident D received a PICC line dressing change on 5/17/2024, 5/24/2024, 5/31/2024 and 6/4/2024. A current Care Plan, initiated on 5/8/2024, indicated Resident D had a Peripherally Inserted Central Catheter 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 interview and record review, the facility failed to ensure a resident was transferred, as ordered. (Resident C) Finding includes: On 6/11/24 at 12:46 P.M., a review of the clinical record for Resident C was conducted. The resident's diagnoses included, but were not limited to; heart failure, end stage renal disease, insulin dependent diabetic and right hip fracture (prior to admission-due to a fall at home) and malnutrition. An Activities of Daily Living (ADL) Care Plan, dated 4/3/24, indicated the resident had a self care deficit related to impaired physical functioning and medical conditions. The interventions included, but were not limited to: .provide the amount of assistance resident needs for completion of ADL care, dated 4/26/24, resident is non-weight bearing to right lower extremity . A Care Plan related to health related complications - hip fracture with complications of pressure ulcer, falls and pain, dated 4/3/24 had interventions including but not limited to .assist resident to T & R [turn…

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 honor resident preferences related to bathing choices, for 1 of 3 residents reviewed for choices. (Resident 48) Finding includes: During an interview, on 3/6/2024 at 2:47 P.M., Resident 48 indicated she received a shower every other week, and did receive bed baths, but would like a shower weekly at a minimum. A record review for Resident 48 was completed on 3/11/2024 at 8:48 A.M. Diagnoses included, but were not limited to: quadriplegia, rheumatoid arthritis, and atrial fibrillation. A Care Plan, dated 1/18/2024 and updated 2/23/2024, indicated Resident 48 was limited in physical mobility, bedfast all or most of the time related to quadriplegia and muscle spasms, a required extensive assistance to full dependence on staff for mobility, transfers, toileting, and eating. A Social Service Initial History, dated 1/22/2024 at 9:40 A.M., indicated Resident 48 preferred to have a bathing performed in the morning three times a week. An admission Minimum Data Set (MDS) assessment, dated 1/25/2024, indicated Resident 48 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 record review and interview, the facility failed to ensure a complete written notice of transfer or discharge was provided, for 2 of 3 residents reviewed for hospitalization. (Residents 23 and 49) Findings include: 1. The record for Resident 23 was reviewed on 3/8/2024 at 9:03 A.M. Diagnoses included, but were not limited to: malignant neoplasm of the right breast, generalized anxiety disorder, dementia with behavioral disturbance, delusional disorders, schizophrenia (7/18/2023), major depressive disorder, post traumatic stress disorder (PTSD), restless leg syndrome, and insomnia. The record indicated the resident had no family or guardian and was her own responsible person. The Nursing Progress Notes for February 2024 indicated the resident had displayed episodes of daily mood instability, delusional behaviors, at times expressed suicidal ideation and had attempted to exit the building. The resident was discharged to an inpatient psychiatric hospital on 2/28/2024. There was no written notice of…

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

Based on observation, record review and interview, the facility failed to ensure a written notice of the bed hold policy form was provided, for 3 of 3 residents reviewed for hospitalization. (Residents 23, 48 and 49) Findings include: 1. The record for Resident 23 was reviewed on 3/8/2024 at 9:03 A.M. Diagnoses included, but were not limited to: malignant neoplasm of the right breast, generalized anxiety disorder, dementia with behavioral disturbance, delusional disorders, schizophrenia (7/18/2023), major depressive disorder, post traumatic stress disorder (PTSD), restless leg syndrome, and insomnia. The record indicated the resident had no family or guardian and was her own responsible person. The Nursing Progress Notes for February 2024, indicated the resident had displayed episodes of daily mood instability, delusional behaviors, at times expressed suicidal ideations and had attempted to exit the building. The resident was discharged to an inpatient psychiatric hospital on 2/28/2024. There was no written notice of discharge or transfer located in the clinical record. During 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 observation, record review, and interview, the facility failed to ensure a comprehensive, person-centered care plan for activities was developed, for 1 of 3 residents reviewed for activities. (Resident 42) Finding includes: During the initial tour of the facility, on 3/6/2024 between 9:45 A.M. - 11:00 A.M., Resident 42 was observed seated in a high back wheelchair in the unit lounge. He was seated behind three large broda-type recliner chairs. The television in the room was turned on, but the volume was not very loud. Resident 42 was noted to be fiddling with the looped strap of the mechanical lift pad that was underneath him. Resident 42 was observed on 3/7/2024 from approximately 8:30 AM. - 11:14 A.M. He was in his wheelchair and was either located in the hallway across from the nurse's station or in the day lounge behind the large broda-type recliner chairs. The resident was noted to alternate between wakefulness and sleeping. Other than the television on a low volume in the day lounge, there was no activity provided to Resident 42. Resident 42 was observed on 3/8/2024…

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

Based on observation, record review, and interview, the facility failed to ensure care plan meetings were conducted timely, for 1 of 4 residents reviewed for care plan meetings. (Resident 35) Finding includes: During an interview on 3/6/2024 at 10:53 A.M., Resident 35's spouse indicated she had not been invited to a care plan meeting in a long time. She could not recall the last time but, did know that one was not held this year. A record review was completed on 3/8/2024 at 2:00 P.M. The resident's diagnoses included, but were not limited to: aphasia following cerebral infarction, peripheral vascular disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and left foot drop. The last documented care plan meeting in the electronic medical record indicated it was completed on 8/9/2023. A Care Plan for Activities of Daily Living Functional/rehabilitation status, dated 10/26/2023, included an intervention to invite the Resident and his family to care plan meetings. During an interview on 3/11/2024 at 10:39 A.M., the Social Service Director…

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

Based on observation, interview, and record review, the facility failed to ensure ADL (activities of daily living assistance was provided, related to grooming and personal hygiene, for 2 out of 3 dependent residents reviewed for Activities of Daily Living. (Residents 22 & 35) Findings include: 1. During an observation on 3/6/2024 at 11:40 A.M., Resident 22 was in her bed. She had long jagged fingernails on both hands with a brown substance under them, and long facial hair under her chin. During observations on 3/7/2024 at 8:45 A.M., on 3/8/2024 at 9:31 A.M., and on 3/11/2024 at 8:49 A.M., Resident 22 was seated in the dining room eating her breakfast. Her fingernails were still long and jagged with a brown substance under them, and she still had long facial hair under her chin. A record review for Resident 22 was completed on 3/8/2024 at 1:30 P.M. The resident's diagnoses included, but were not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Quarterly Minimum Data Set (MDS) assessment,…

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

Based on observation, record review, and interview, the facility failed to provide a person-centered activity program for 1 of 3 residents reviewed for activities. (Resident 42) Finding includes: During the initial tour of the facility, on 3/6/2024 between 9:45 A.M. - 11:00 A.M., Resident 42 was observed seated in a high back wheelchair in the unit lounge. He was seated behind three large broda- type recliner chairs. The television in the room was turned on, but the volume was not very loud. Resident 42 was noted to be fiddling with the looped strap of the mechanical lift pad that was underneath him. Resident 42 was observed on 3/7/2024 from approximately 8:30 AM. - 11:14 A.M. He was in his wheelchair and was either located in the hallway across from the nurse's station or in the day lounge behind the large broda-type recliner chairs. The resident was noted to alternate between wakefulness and sleeping. Other than the television on a low volume in the day lounge, there was no activity provided to Resident 42. Resident 42 was observed on 3/8/2024 8:30 A.M., seated in his wheelchair…

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 provide transportation to essential medical appointments as scheduled for 1 of 2 residents reviewed for range of motion and failed to identify and monitor a bruising for 1 of 3 residents reviewed for non-pressure related skin conditions. (Residents 35 & 22) Findings include: 1. On 3/6/2024 at 10:00 A.M., a family member who was standing in hallway, was overheard complaining that her husband had missed appointments in the past, and she was worried there was no transportation set up for the next week for his scheduled appointments. During an interview and observation on 3/6/2024 at 11:15 A.M., Resident 35's spouse indicated he had missed an appointment in January 2024. The appointments, scheduled every 12 weeks, were for Botox injections to his left leg, which was helping him. During an interview, on 3/11/2024 at 9:21 A.M., Resident 35 indicated he had missed his appointment in January and as a result,, had increased pain in his leg and felt his progress in moving his knee had slowed. He indicated in the past, the…

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

Based on observation, interview, and record review, the facility failed to ensure a splint and brace were applied as ordered, for 1 of 2 residents reviewed for limited range of motion. (Resident 35) Finding includes: During an interview and observation on 3/6/2024 at 11:15 A.M., Resident 35 and his spouse indicated he did not wear a splint on his left hand and ankle. He indicated when he was in therapy, they used to put splints on, but no one put them on him currently. During an interview and observation on 3/7/2024 at 10:52 A.M., Resident 35's left ankle was contracted inward, resting against the footboard of the bed. He and his wife indicated staff used to put on a brace (to his left ankle) but had stopped when his therapy had ended. Staff were also not applying any splints to his hand. During an interview and observation on 3/11/2024 at 9:30 A.M., Resident 35 was not wearing any splint or brace. He indicated he had not worn a hand splint or ankle brace during the past weekend. A record review was completed on 3/8/2024 at 2:00 P.M. for Resident 35. His diagnoses included, but were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a Physician's Order for the use of a Foley (indwelling urinary catheter) catheter, for 1 of 2 residents reviewed for urinary catheters. (Resident 26) Finding includes: During an interview on 3/7/2024 at 10:45 A.M., Resident 26 indicated she had a Foley catheter when admitted to the facility. A record review was completed on 3/11/2024 at 10:16 A.M. Resident 26 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to: multiple sclerosis, overactive bladder, and constipation. A Hospital Progress Note, dated 3/12/2024, indicated Resident 26 possibly had a neurogenic bladder. An admission Observation, dated 1/16/2024 at 10:29 P.M., indicated Resident 26 was incontinent of urine with the inability to recognize to void, and had an indwelling urinary catheter in place. An admission Minimum Data Set (MDS) assessment, dated 1/23/2024, indicated Resident 26 was incontinent of bladder. A Nurse's Note, dated 2/5/2024 at 1:44 P.M.,…

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

Based on observation, interview, and record review, the facility failed to address a Registered Dietitian's (RD) recommendations timely, related to significant weight loss, for 1 of 3 reviewed for nutrition. (Resident 22) Finding includes: A record review for Resident 22 was completed on 3/8/2024 at 1:30 P.M. The resident's diagnoses included, but were not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. An RD Progress Note, dated 8/28/2023, indicated Resident 22 had a significant weight loss in 30 days of 6.6%. She consumed a regular diet and ate an average of 50% of her meals with some refusals documented. Resident 22's weights were as follows: 8/25/2023 - 125.4 pounds (#), 7/26/2023 133#, 6/2/2023- 132.6#, 5/4/2023- 128#, and 1/3/2023- 120#. The RD recommendations, on 8/28/2023, were to add fortified foods with the meals and to continue monitoring intakes, labs, weight, skin, and medications. An RD Progress Note, dated 9/17/2023, indicated Resident 22 continued to have a significant…

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

Based on observation, record review, and interview, the facility failed to ensure the physician responded to pharmacy recommendations timely, for 1 of 5 residents reviewed for unnecessary medication use. (Resident 2) Finding includes: During the initial tour of the facility, on 3/6/2024 between 9:45 A.M. - 11:00 A.M., Resident 2 was observed lying in his bed asleep. The resident was noted to be very thin with severely contracted wrists. The clinical record for Resident 2 was reviewed on 3/8/24 at 10:23 A.M. Diagnoses included, but were not limited to: Spastic quadriplegic cerebral palsy, insomnia, major depressive disorder, recurrent, generalized anxiety disorder, bipolar disorder and depression. The current Physician's Orders for medications for Resident 2 included the following: - aripiprazole tablet (an antipsychotic medication) 20 mg (milligrams) tablet, one tablet once a day, and aripiprazole 5 mg, one tablet once a day. There were instructions to give the two tablets together to equal 25 mg of aripiprazole to treat the resident's Bipolar disorder. - citalopram tablet (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 follow a Physician's Order for the use of Ativan (anti-anxiety medication), and limit an Ativan as needed (prn) order to 14 days, for 1 of 5 residents reviewed for unnecessary medications. (Resident 49) Finding includes: A record review for Resident 49 was completed on 3/8/2024 at 8:55 A.M. Diagnoses included, but were not limited to: generalized anxiety, major depressive disorder, malignant neoplasm, and hemiplegia of the non-dominant left side. An admission Minimum Data Set (MDS) assessment, dated 2/2/2024, indicated Resident 49 was cognitively intact. He received an antidepressant and anti-anxiety medications. Resident 49 had moods of feeling down, depressed, or hopeless for 12-14 days of 14 days reviewed; trouble falling asleep or sleeping too much for 12-14 days of 14 days reviewed; feeling tired or having little energy for 12-14 days of 14 days reviewed; trouble concentrating on things, such as newspaper or watching television for 12-14 days of 14 days reviewed; and moving or speaking slowly that other people could…

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 ensure an anticoagulant medication was continued upon readmission after hospitalization, for 1 of 5 residents reviewed for medication use. (Resident 48). Finding includes: During an interview on 3/6/2024 at 2:57 P.M., Resident 48's husband indicated Resident 48 was to be receiving Heparin (anticoagulant) related to a hospitalization for blood clots. A record review was completed on 3/11/2024 at 8:48 A.M. Diagnoses included, but were not limited to: quadriplegia, rheumatoid arthritis, fibromyalgia, and history of deep vein thrombosis and pulmonary embolism. An admission Minimum Data Set (MDS) assessment, dated 1/25/2024, indicated Resident 48 was receiving an anticoagulant. A Physician's Order, dated 1/18/2024, indicated Resident 48 received Heparin (anticoagulant medication) 5,000 units per milliliter twice daily from 1/18/2024-2/9/2024. A Hospital Progress Note, dated 2/8/2024, indicated lifelong anticoagulation would be needed per hematology. A Physician Progress Note, dated 2/14/2024, indicated Eliquis would be needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide accommodations for 1 of 1 resident reviewed for resident rights. (Resident B) Finding includes: A clinical record review was completed on 2/14/2023 at 2:00 P.M. Diagnoses included, but were not limited to: osteoporosis with current pathological fracture, right femur, Attention-deficit hyperactivity disorder, and [NAME]-Danlos syndrome. A Significant Change Minimum Data Set (MDS) Assessment on 1/16/2023 indicated Resident B was cognitively intact. She had verbal behavioral symptoms directed towards others that significantly disrupted care or the living environment for 1 to 3 days of the 14-day assessment period. She was occasionally incontinent of bladder and always continent of bowel. She was able to make herself understood and understand others. The assessment indicated it was very important for Resident B to take care of her personal belongings and to have snacks available between meals. A Nurse's Note on 11/2/2022 at 4:48 P.M., by the…

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

Based on observation, interview, and record review the facility failed to ensure care plans were in place for 1 of 22 Residents reviewed for care plans. (Resident 27) Finding includes: A clinical record was reviewed for Resident 27 on 2/14/2023 at 9:43 A.M. Diagnoses included, but not limited to: anxiety disorder, dementia, lack of coordination and difficulty walking. A skin event was initiated on 2/2/2023 for a skin tear to the peri-area. A Physician Order, dated, 2/2/2023, indicated apply antibiotic ointment, skin tear to peri-area until healed, once a day. Resident 27's medical record indicated no skin integrity or an acute care plan for the skin tear was in place. During an interview, on 2/14/2023 at 12:58 P.M., the MDS Nurse indicated that she does not see a care plan for skin integrity or for the skin tear on 2/2/2023 and there should have been one. On 2/16/2023 at 8:03 A.M., the Director of Nursing provided a policy titled, Comprehensive Care Plans, revised on 7/19/2018, and indicated the policy was the one currently used by the facility. The policy indicated .A…

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

Based on observation, interview and record review, the facility failed to ensure the care plan was revised for 1 out of 22 residents reviewed for care plans. (Resident 27) Finding includes: A clinical record was reviewed for Resident 27 on 2/14/2023 at 9:43 A.M. Diagnoses included, but not limited to: anxiety disorder, dementia, lack of coordination and difficulty walking. During an observation, on 2/9/2023 at 2:35 P.M., the resident was awake in bed, her bed was next to the wall and a bed bolster along the side you would exit the bed, a hoyer pad was sitting in a broda chair. A Physician Order, dated 1/25/2023, indicated utilize mechanical lift for transfers every shift, day, evening, night. Resident 27's medical record did not indicate she was using a bed bolster on her bed. During an interview, on 2/14/2023 at 10:23 A.M., the Director of Nursing indicated the bed bolster was used to define the edges of the bed. She did not see any documentation for the bed bolster in the medical record or when it was initiated and there should have been. The bed bolster was put in place as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the physician for blood sugars indicated in an order for less than 100 milligrams per deciliter for 1 of 3 residents reviewd for insulin administration. (Resident 157) Finding includes: During an initial interview on 2/10/2023 at 11:22 A.M., Resident 157 indicated he received insulin injections. A clinical record review was completed on 2/13/2023 at 9:14 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, generalized anxiety, and hypertension. An admission Minimum Data Set (MDS) Assessment on 1/20/2023 indicated Resident 157 received insulin injections for 7 days of the 7 days look back period. Physician Orders indicated Resident 157 received: 1. Lantus U-100 Insulin (insulin glargine) solution 100 units/milliliter with 45 units injected subcutaneously daily. 2. Lispro 300 units/3 milliliter with 12 units injected subcutaneously before meals. 3. Humalog 300 units/3 milliliter sliding scale to be injected subcutaneously as…

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 skin integrity assessments while an AFO (ankle foot orthotic) was in place to prevent the development of pressure ulcers for 1 of 2 residents reviewed for skin conditions. (Residents 33) Finding includes: On 2/10/2023 at 9:25 A.M., Resident 33 was observed sitting in his wheelchair in his room with an orthopedic sandal on his left foot. He indicated at this time during an interview, he has two sores on his heel and ankle. He indicated the staff took away his AFO when they determined the AFO was causing skin damage. A clinical record review was completed on 2/14/2023 at 10:27 A.M. Diagnoses included, but were not limited to: Parkinson's disease, chronic obstructive pulmonary disease (COPD), and emphysema. An Annual Minimum Data Set (MDS) Assessment on 12/6/2022 indicated Resident 33 had an unstageable deep tissue injury. He required extensive assistance with two or more staff members for dressing. A Braden Scale was completed on 11/17/2022. The score indicated Resident 33 was at mild risk for skin…

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

Based on record review, observation, and interview, the facility failed to provide the prescribed supplementation for a resident with significant weight loss and document consumption of prescribed supplementation for 1 of 4 residents reviewed for nutrition. (Resident 1) Finding includes: A clinical record review was completed on 2/13/2023 at 11:22 A.M. Diagnoses included, but were not limited to: Spastic quadriplegic cerebral palsy, bipolar disorder, and chronic obstructive pulmonary disease. An admission Minimum Data Set (MDS) Assessment on 12/20/2022 indicated Resident 1 had moderate cognitive impairment. He required extensive assistance with one staff member for eating. He had no weight loss and had an unstageable pressure ulcer present on admission. A Dietician note on 10/13/2022 indicated Resident 1's current body weight was 91.5 pounds. He had a body mass index of 16.28. He was prescribed Boost High Protein shakes daily, and a new order for health shakes three times daily with meals was obtained. The Dietician Note then indicated, .Will recommend to discontinue health shake…

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

Based on observation, record review, and interview, the facility failed to properly store the resident's C-PAP (continuous positive airway pressure) mask for 1 of 2 residents reviewed for respiratory devices. (Resident 33) Finding includes: During an observation on 2/9/2023 at 10:14 A.M. and 2:25 P.M., Resident 33's C-PAP mask was lying across his made bed. On 2/10/2023, the C-PAP mask was placed in the upper nightstand drawer without any protection. During an interview, Resident 33 indicated the mask and tubing for the C-PAP does not get cleaned regularly. On 2/13/2023 the C-PAP mask was observed lying across the C-PAP machine on the nightstand. A clinical record review was completed on 2/14/2023 at 10:27 A.M. Diagnoses included, but were not limited to: Parkinson's disease, chronic obstructive pulmonary disease (COPD), and emphysema. An Annual Minimum Data Set (MDS) Assessment on 12/6/2022 indicated Resident 33 had a non-invasive mechanical ventilator. A Care Plan developed on 2/12/2021, and revised on 12/20/2022, indicated Resident 33 had a diagnosis of COPD, emphysema, and…

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

Based on observation, interview, and record review the facility failed to ensure food and beverages were dated/labeled and store pots, mixing bowls, and colanders in a sanitary manner. Findings include: During a brief tour of the kitchen on 2/9/2023 between 9:35 and 9:55 A.M., observed in the walk- in refrigerator 4 dessert cups with fresh fruit uncovered, sausage gravy, brown gravy, scrambled eggs, cinnamon rolls, applesauce in containers with no date/label, 2 open gallons of chocolate milk and quart of lactose free milk undated, one pound of butter half gone wrap in plastic and dry parmesan cheese open in plastic bag undated. During an interview, on 2/9/2023 at 9:53 A.M., the Dietary Manager indicated that anything that is opened needs to be labeled with the date open and the date it expires. During another tour of the kitchen on 9/16/2023 at 8:55 A.M., observed pots, mixing bowls and colanders on a bottom open shelf approximately 8 inches from the floor not inverted, with visible crumbs, grit and dust when hand swept across the shelf. During an interview, on 2/16/2023 at 8:57…

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.