Woodland Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were provided proper notice prior to an involuntary transfer or discharge for 1 of 4 residents reviewed for hospitalizations (Resident 49). Finding includes: A record review was completed for Resident 49 on 5/1/2025 at 11:32 A.M. Diagnoses included, but were not limited to: anxiety and depression. An admission Minimum Data Set (MDS) assessment, dated 3/13/2025, indicated Resident 49's cognition was mildly impaired and the resident was a current tobacco user. A review of Resident 49's census indicated she was discharged from the facility on 3/3/2025 and re-admitted to the facility on [DATE]. A Discharge assessment, dated 3/3/2025 indicated the resident was being discharged to (a local hotel name). A Physician's Order, dated 3/3/25 indicated to discharge the resident home with medications and discharge instructions. A review of a Nursing Progress note, dated 3/3/2025 at 11:25 A.M., indicated Resident 49 was informed due to her being 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 showers for 1 of 7 residents reviewed for ADL (Activities of Daily Living) care. (Resident 1) Finding includes: During an observation, on 4/30/2025 at 9:07 A.M., Resident 1 was noted to have a large amount of facial hair on her chin and her fingernails had a brown substance underneath them The record for Resident 1 was reviewed on 5/01/2025 at 1:25 P.M. Diagnosed included, but were not limited to quadriplegia, epilepsy, blindness, arthritis and non-Alzheimer's dementia. A Quarterly MDS (Minimum Data Set) assessment, dated 4/22/2025, indicated the resident had severe cognitive impairment and required extensive assist of 2 staff for bed mobility transfers, toilet use and showering. A current Care Plan, initiated on 12/7/2021, indicated Resident 1 required assistance with ADL's due to her cognitive deficits, arthritis, blindness, and quadriplegia. Interventions included, but were not limited to: I prefer to complete bathing with staff assist and prefer my showers Monday and Thursday evening. Resident 1'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 record review and interview, the facility failed to notify the physician of abnormal blood sugars for 1 of 1 resident reviewed for insulin usage. (Resident 3) Finding includes: During an interview, on 4/29/2025 at 11:25 A.M., Resident 3 indicated she had recently had an abnormally high blood sugar reading of over 300 mg/dL (milligram per deciliter). A record review was completed for Resident 3 on 5/1/2025 at 9:47 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, diabetes with polyneuropathy and acute kidney failure. A Quarterly Minimum Data Set (MDS) assessment, dated 12/23/2024, indicated Resident 3 was cognitively intact and received insulin injections. A current Care Plan, initiated on 4/9/2021 and revised on 10/6/2024, indicated Resident 3 had diabetes mellitus with a goal of Resident 3 would not exhibit signs of hypo/hyperglycemia. Interventions included, but were not limited to: administer medications as ordered by the physician and blood sugar monitoring as ordered by the physician. A Physician's Order, dated 11/13/2024, indicated Resident 3…

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 store respiratory equipment in a sanitary manor for 2 of 3 residents reviewed for respiratory care. (Resident 1 & 50) Findings include: 1. During an observation, on 4/30/2025 at 9:11 A.M., Resident 1's oxygen concentrator humidification bottle was dated 4/2/2025 and was not hooked up to the concentrator. The oxygen storage bag was dated 4/28/2025 and the nasal cannula tubing was not dated. The record for Resident 1 was reviewed on 5/1/2025 at 1:25 P.M. Diagnoses included, but were not limited to quadriplegia, blindness, arthritis, and non-Alzheimer's dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 4/22/2025, indicated the resident had severe cognitive impairment and required the use of oxygen. Resident 1's current physician orders included: - Oxygen at 2 Liters per minute per Nasal Cannula on continuous to keep oxygen saturation above 90%. - Change the oxygen tubing, and humidification bottle; clean oxygen filter, and inspect easy foam wraps (replace if soiled or missing), on the night shift…

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 attempt a gradual dose reduction of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 20) Finding includes: During an observation, on 4/30/2025 at 9:34 A.M., 5/1/2025 at 2:46 P.M. and 5/5/2025 at 10:24 A.M., Resident 20 was observed seated in the doorway of his room looking into the hallway A record review for Resident 20 was completed on 5/1/2025 at 10:40 A.M. Diagnoses included, but were not limited to: post-traumatic stress disorder (PTSD), major depressive disorder, alcohol dependence with alcohol-induced dementia and other sexual disfunction. A Quarterly Minimum Data Set (MDS) assessment, dated 4/14/2025, indicated Resident 20 had moderate cognitive impairment and received an antipsychotic and antidepressant medications. A current Care Plan, initiated on 1/25/2024 and revised on 10/6/2024, indicated Resident 20 was at risk for yelling and cursing at staff due to a history of these…

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 medication storage areas were clean and free from loose medications and failed to ensure medications were labeled and dated when opened, during medication storage review in 2 of 2 medication carts reviewed. (medication cart 1 on 100/200 hall and Memory Care 400 medication cart). Findings include: 1. During a medication storage observation, on 5/2/2025 at 10:30 A.M., on the medication cart 1 with LPN 2 the following was observed: - An unopened tube of glucose for a discharged resident. - An opened and undated bottle of Milk of Magnesia. - An opened bottle of ant-acid tablets with no resident label on the container. - Fourteen loose pills in the medication cart. - An opened package of Albuterol inhalation vials with no resident identifier. The over flow medication cart had an unopened box of Omeprazole tablets with no resident identifiers on the box. During an interview, on 5/5/2025 at 10:48 A.M., LPN 2 indicated the medications should have been labeled and dated when opened, and there should be labels 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 a resident's call light was answered timely and care was provided to maintain her dignity for 1 of 4 residents who were reviewed for dignity. (Resident H) Finding includes: A record review was completed on 2/27/2025 at 10:40 A.M. for Resident H. Diagnoses included but were not limited to cerebral palsy, chronic obstructive pyelonephritis and morbid severe obesity. A Quarterly Minimum Data Set (MDS) assessment, dated 1/14/2025, indicated Resident H's cognitively intact, required substantial/maximal assistance for bed mobility and toileting, was dependent for transfers with a mechanical lift, and was always incontinent of her bowel and bladder. A current Care Plan, revised on 7/12/2019, indicated Resident H had an activity of daily living (ADL) self performance deficit and required extensive assistance of two staff members for personal hygiene, bed mobility and transfers. A grievance document, filed on 1/29/2024 by Resident H indicated she had filed a grievance due to having to wait an extended period 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, interview and record review, the facility staff failed to follow infection control procedures for a resident on Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for infection control. (Resident M) Finding includes: During an observation on 2/28/2025 at 5:20 A.M., CNA 7 and QMA 8 provided peri-care for Resident M, who had an indwelling urinary catheter. Both the CNA and the QMA entered the room and donned gloves but did not don gowns. There was a sign on the wall next to the door in the hallway for Resident M's room that indicated the resident was on Enhanced Barrier Precautions. During an interview on 2/28/2025 at 5:22 A.M., QMA 8 indicated staff never wore gowns for Resident M and she did not know the resident was on EBP even though he had a urinary catheter and a sign was present in the hall. CNA 7 also indicated, at the same time, she did not know the resident was on EBP isolation. A record review was completed on 2/28/2025 at 5:54 A.M. for Resident M. Diagnoses included, but were not limited to, hemiparesis and hemiplegia to right side,…

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, record review and interview, the facility failed to ensure showers were provided for 3 of 7 residents reviewed for ADL's (Activities of Daily Living). (Residents 53, E & F) Findings include: 1. During an interview, on 11/7/2024 at 10:54 A.M., Resident 53 indicated Sometimes I don't get any showers for 2 weeks. A record review for Resident 53 was completed on 11/12/2024 at 10:26 A.M. Diagnoses included, but were not limited to: chronic kidney disease, obesity, lymphedema, depression, and diarrhea. An Annual Minimum Date Set (MDS) assessment, dated 10/23/2024, indicated Resident 53 required substantial to maximum assistance for transfers, bathing and showering, was occasionally incontinent of bladder and frequently incontinent of bowels. A current Care Plan, initiated on 12/19/2023, indicated: The resident has an ADL Self Care performance deficit related to impaired mobility and recent hospital stay. BATHING: The resident is totally dependent on staff to provide a bath/Shower weekly and as necessary. ADL-Bathing shower/bed bath on Wednesday and Saturday after…

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 maintain a sanitary environment related to urine odors, dirty ceilings and walls and unpainted spackle in resident's rooms and related to gouges and unpainted spackle on the 400 unit hall walls. Findings include: 1. During an observation on 11/8/2024 at 11:06 A.M., a strong smell of urine was detected in room [ROOM NUMBER]. During an Environmental tour with the Maintenance Director (MD), Executive Director (ED) and the Director of Housekeeping (DH) on 11/14/2024 at 9:05 A.M., a strong smell of urine was detected in room [ROOM NUMBER]. During an interview on 11/14/2024 at 9:07 A.M., the DH indicated room [ROOM NUMBER] smelled of urine due to a urine soaked mattress. The DH indicated the resident brought his own mattress on admission and it was not cleanable. The DH indicated there had been conversations with the resident about replacing the mattress, but the resident refused. The DH indicated she did not have any documentation to indicate…

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 maintain an effective Pest Control Program related to an infestation of fruit flies. This had the potential to affect 68 of the 68 residents who reside in the facility. Finding includes: During an observation of room [ROOM NUMBER] on 11/7/2024 at 2:06 P.M., fruit flies were seen in the resident's room. During an observation of room [ROOM NUMBER] on 11/8/2024 at 11:06 A.M., fruit flies were seen in the resident's room. During an observation of room [ROOM NUMBER] on 11/8/2024 at 11:11 A.M., fruit flies were seen in the resident's room. During the Resident Council Meeting on 11/08/24 at 1:17 P.M., 5 out of 8 residents indicated fruit flies had been a problem for three months or longer. During a record review of the Pest Control binder on 11/8/2024 at 2:00 P.M., no documentation was located to indicate the facility had received any Pest Control visits/treatments related to fruit flies in the last three months. On 11/14/2024 at 8:45 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 record review and interview, the facility failed to notify the physician timely of changes for blood glucose readings outside of the ordered parameters for 2 of 3 residents reviewed for insulin usage (Resident 30 & M), for 1 of 2 residents reviewed for death (Resident H) and for 1 of 3 residents reviewed for accidents (Resident 12). Findings include: 1. A record review for Resident 30 was completed on 11/12/2024 at 9:33 A.M. Diagnosis included, but were not limited to Diabetes Type 2, Hepatitis B, depression, anxiety, and dementia. Resident 30's Physician Orders included, but were not limited to: Humalog (a rapid acting) insulin- inject subcutaneous before meals per sliding scale of blood sugar results- if 250 to 500 give 6 units and if over 400 call the MD. Use Freestyle meter for blood sugar levels and call the MD if the result is less than 60 or over 400. Lantus (long acting) insulin pen - inject 20 units subcutaneously two times a day. A current Care Plan, dated 12/3/2024 and revised 5/16/2024, indicated Resident 30 had a diagnosis of Type 2 diabetes with interventions…

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 4 of 4 residents reviewed for hospitalization. (Residents B, 52, 55, 69) Findings include: 1. A record review for Resident B was completed on 11/08/2024 at 2:32 P.M. Diagnosis included but were not limited to cerebral palsy, hydronephrosis, urogenital implants, and obstructive and reflux uropathy. A Nursing Progress Note, dated 6/19/24 at 11:45 A.M., indicated Resident B had returned from the hospital. The chart lacked documentation a transfer/discharge form was provided by the facility to the resident and/or the resident's representative for this transfer. In addition, the Ombudsman was not notified of the resident's transfer. A Nursing Progress note, dated 8/16/2024 at 12:00 A.M., indicated that Resident B was transferred to a local hospital for back and abdominal pain. The chart lacked documentation a transfer/discharge form was provided by the facility to the resident and/or the resident's representative for this transfer. In addition, the Ombudsman was not notified 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 record reviews and interview, the facility failed to provide a bed hold form for 4 of 4 residents reviewed for hospitalizations. (Resident 52, 55, 69 & B) Findings include: 1. A record review for Resident 52 was completed on 11/12/2024 at 1:56 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease (COPD), pneumonia and acute respiratory failure. A Quarterly Minimum Data Set (MDS) assessment, dated 9/17/2024, indicated Resident 52 was cognitively intact. A Nursing Progress Note, on 5/27/2024 at 4:05 A.M., indicated at 2:45 A.M. Resident 52 requested her lung sounds to be evaluated. Resident 52's lung sounds had scattered wheezing posteriorly and expiratory wheezing anteriorly. Resident 52 refused a nebulizer treatment or an as needed inhalation medication. Resident 52 indicated she felt she had bronchitis and needed an antibiotic and was offered for hospice to be called for further instruction. Resident 52 decided to emergency services for transfer and the nurse gathered Resident 52's transfer paperwork. A Nursing Progress Note, on 7/25/2024…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the environment was free from potential hazards for 1 of 4 halls. In addition, the facility failed to ensure interventions were in place to prevent burns for 1 of 3 residents reviewed for accidents. (Resident 12) Findings include: 1. During an observation of room [ROOM NUMBER] on 11/14/2024 at 10:00 A.M., Resident R's bed was pushed against the packaged terminal air conditioner (PTAC) (ductless, self-contained air conditioning unit for heating and cooling small areas). The top and front of the PTAC was warped and melted. The PTAC unit was plugged in but was turned off. Resident R was not in his room. An interview with Resident S, Resident R's roommate, was completed on 11/14/2024 at 10:02 A.M. Resident S indicated the PTAC melted at least five months prior. He indicated his roommate's comforter had been in front of the PTAC unit and due to excessive heat, melted the PTAC unit. He indicated the current Maintenance Director (MD) had…

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 adequately label an over the counter medication stored in a medication cart for 1 of 1 medication cart reviewed (400 Unit). The facility also failed to monitor and maintain proper temperatures of a refrigerator where medications were stored for 1 of 1 medication refrigerators reviewed (Nurses Station 1). Findings include: 1. During an observation of the medication cart on the 400 Unit on 11/8/2024 at 11:45 A.M., an opened bottle of Tylenol and an open bottle of melatonin did not have any resident identifying information on the bottles. During an interview on 11/08/2024 at 11:48 A.M., LPN 24 indicated she was not able to identify whose Tylenol and melatonin were observed. She indicated over the counter medications should be labeled with the resident's name and room number. During an interview on 11/8/2024 at 11:51 A.M., the Director of Nursing (DON) indicated all medications should be labeled with the resident's name, prescriber name and dosage information. 2. During an observation of the nursing station 1…

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 1 of 2 unit pantries was maintained in a sanitary manner. This had the potential to affect 18 of 18 residents on the 400 unit. Finding includes: An observation of the 400 unit pantry was completed with the Dietary Director (DD) and the Executive Director on 11/13/2024 at 9:13 A.M. The following was observed: - A microwave with dried food splatter on the inside. - A wet white blanket with black and brown stains on the bottom of the cabinet underneath the sink. During an interview on 11/13/2024 at 9:15 A.M., the DD indicated the microwave was dirty and needed to be cleaned. She indicated the blanket was used to catch the dripping water from the leaking plumbing, but was not able to recall the last time the blanket had been changed. The ED indicated the blanket should not be used to absorb the leaking water and she had already notified maintenance about the leaking sink prior to the survey starting. A policy for maintaining the pantry and any cleaning checklists related to the pantry were requested but not…

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

Based on record review and interview, the facility failed to ensure pertinent transfer and resident clinical information was completed for neccessary hospital transfers for 1 of 4 residents reviewed for hospitalization. (Resident B) Finding includes: A record review for Resident B was completed on 11/08/2024 at 2:32 P.M. Diagnosis included but were not limited to Cerebral Palsy, hydronephrosis, urogenital implants, and obstructive and reflux uropathy. A Nursing Progress Note, dated 6/19/24 at 11:45 A.M., indicated Resident B had returned from the hospital. There was no documentation a physician's order was obtained prior to Resident B's transfer to the hospital. In addition, there was no documentation a transfer/discharge form or bed hold policy was provided to the resident and/or their representative for this transfer. A Nursing Progress Note, dated 8/16/2024 at 12:00 A.M., indicated Resident B was transferred to a local hospital for back and abdominal pain. The chart lacked a physician's order to send Resident B to the hospital and there was no documentation that a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to develop a comprehensive person-centered care plan for activities (Resident 54) and medication use (Resident 64) for 2 of 27 residents reviewed for care plans (Resident E) . Findings include: 1. During an observation, on 11/8/2024 at 9:45 A.M., Resident 54 was not observed in the morning reading activity. During an observation, on 11/8/2024, at 2:20 P.M., Resident 54 was observed walking in the activity room of the Dementia Unit and was non-responsive to questions from facility staff. Resident 54 was resistant to sit in the activity room despite staff encouragement and walked out of activity room. During an observation, on 11/12/2024, at 10:21 A.M., Resident 54 walked by the nursing station but was able to be re-directed to sit in a chair located in front of the nursing station intermittently. The record review for Resident 54 was completed on 11/12/2024 at 11:19 A.M. Diagnosis included, but were not limited to: Alzheimer's disease,…

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 provided with activities designed to meet their interest and their physical, mental, and psychosocial well-being for 1 of 4 residents reviewed for activities (Resident 54). Finding includes: During an observation, on 11/8/2024 at 9:45 A.M., Resident 54 was not observed in the morning reading activity. During an observation, on 11/8/2024, at 2:20 P.M., Resident 54 was observed walking in the activity room of the Dementia Unit and was non-responsive to questions from facility staff. Resident 54 was resistant to sit down in the activity room despite staff encouragement and walked out of activity room. During an observation, on 11/12/2024, at 10:21 A.M., Resident 54 walked by the nursing station but was able to be re-directed to sit down intermittently. The record review for Resident 54 was completed on 11/12/2024 at 11:19 A.M. Diagnosis included, but were not limited to: Alzheimer's disease, dementia, anxiety,…

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 physician orders for extra fluids were discontinued timely. This deficient practice resulted in the resident developing bilateral lower extremity edema requiring the use of diuretic medication. (Resident M) Finding includes: A record review for Resident M was completed on 11/12/24 at 11:23 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, congestive heart failure and vascular dementia. An Annual Minimum Data Set (MDS) assessment, dated 9/11/2024, indicated Resident M had a severe cognitive deficit and received insulin and diuretic medication. Current Physician's Orders, dated 7/19/2024, indicated to encourage Resident M to consume an additional 240 milliliters of fluids every shift for 72 hours. The Medication Administration Record (MAR), from 7/19/2024 through October 2024, indicated Resident M continued to receive 240 milliliters of additional fluids three times a day. A Physician's Progress Note, dated 7/16/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident with impaired vision received the appropriate follow-up care for 1 of 1 residents reviewed for communication (Resident 35). Finding includes: A record review for Resident 35 was completed on 11/12/2024 at 3:21 P.M. Resident was admitted on [DATE]. Diagnoses included but were not limited to: multiple sclerosis, depression, chronic obstructive pulmonary disease, dementia, anxiety, abnormal weight loss, mood disorder, muscle weakness and hypertension. A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 35 had moderate cognitive impairment, had impaired vision and required corrective lens. A Physician's order, dated 11/21/2022, indicated the resident could be seen by an optometrist as needed. Resident 35's current Care Plan, reviewed on 9/12/2024, indicated the resident had impaired visual function. Interventions included but were not limited to: the resident will wear his glasses and adjust the tone of voice when…

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, interview and observation, the facility failed to ensure physician ordered medications were available for 3 of 24 residents whose medications were reviewed. (Residents E, L and M) Findings include: 1. A record review for Resident E was completed on 11/12/2024 at 10:59 A.M. Diagnoses included, but were not limited to: encephalopathy, diabetes, anxiety, and depression. Resident E's current Physician Order's included the following: Atorvastatin Calcium 20 mg (milligram) give 1 tablet at bedtime for high cholesterol. Esomeprazole Magnesium 20 mg give 2 tablets before breakfast (to decrease stomach acids). Ezetimibe 10 mg give 1 tablet one time a day (lower cholesterol). Metformin 500 mg 2 tablets two times a day (anti diabetic). Risperdal (antipsychotic) 2 mg give 1 tablet two times a day for psychosis. Sitagliptin 100 mg (anti-diabetic) 1 tablet every day for diabetes. Veozah 45 mg every day (to reduce moderate to severe vasomotor symptoms due to menopause). The September Medication Administration Record (MAR) indicated Resident E had not received the following…

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 infection control practices were followed related to glove use and handwashing during perineal and catheter care for 1 of 2 residents observed for catheter care. (Resident 50) Finding includes: During an observation, on 11/14/2024 at 11:02 A.M., Certified Nursing Assistant (CNA) 23 was observed to provide incontinence/catheter care to Resident 50. She used a washcloth and cleaned the urinary catheter and tubing. CNA 25, with the assistance of LPN 19, then turned the resident over to his right side. CNA 23 cleansed the smear of feces from her buttocks and LPN 19 applied a barrier cream to his buttocks. Without changing her gloves, or washing her hands, CNA 23 obtained a clean bed pad and clean brief and placed them under the resident and pulled the resident's shirt down in back. The resident was then rolled over and his brief was fastened in the front. CNA 23 moved Resident 50's arms and pillows, then repositioned the resident up in bed. She placed a clean sheet over the resident, and lastley CNA 23 put…

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

Based on record review and interview, the facility failed to provide a resident with a pneumococcal vaccination timely for 1 of 5 residents reviewed for vaccinations. (Resident 11) Finding includes: Resident 11's record review was completed on 11/12/2024 at 11:01 A.M. Diagnoses included but were not limited to: multiple sclerosis, anxiety disorder, cerebral infarction, bipolar disorder, hemiplegia and hemiparesis of left side and cerebral aneurysm. Resident 11 had received the Prevnar 13 (pneumococcal vaccine) on 3/15/2023. A document titled, Influenza/pneumococcal/Covid Vaccine/Booster Immunization Consent or Refusal indicated the resident wanted to be given the pneumococcal vaccine(s). Resident 11 signed the document on 10/30/2023. A document titled, Influenza/pneumococcal/Covid Vaccine/Booster Immunization Consent or Refusal indicated the resident wanted to be given the pneumococcal vaccine(s). Resident 11's Power of Attorney/Guardian gave verbal consent for the pneumococcal vaccine on 10/24/2024. During an interview on 11/13/2024 at 10:20 A.M., the Clinical Nurse (CN) 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.

Based on record review and interview, the facility failed to provide consented vaccinations for 1 of 4 residents reviewed for immunizations. (Resident 101) Finding includes: A record review for Resident 101 was completed on 12/26/2024 at 10:27 A.M. Diagnoses included, but were not limited to: acute kidney failure, congestive heart failure and bradycardia. A Quarterly Minimum Data Set (MDS) assessment, dated 12/12/2024, indicated Resident 101 had moderate cognitive impairment. The assessment indicated Resident 101's COVID-19 vaccinations were not up to date. admission documents, dated 11/14/2024, indicated consent was given for the COVID-19 booster. Documentation could not be located in the electronic medical record of the vaccination having been administered. A policy for the COVID-19 vaccination was requested on 12/27/2024 at 3:23 P.M. Policies were not provided by the facility. During an interview, on 12/27/2024 at 4:00 P.M., the Director of Nursing (DON) indicated residents or resident representatives that gave consent for vaccinations should have the vaccine ordered immediately…

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 1 of 1 residents who required dialysis, received assessment/monitoring for complications prior to and/or after their dialysis treatments, according to the facility policy and the resident's plan of care. (Resident D) Finding includes: On 9/4/24 at 11:04 A.M., a review of the clinical record for Resident D was conducted. The resident's diagnoses included, but were not limited to; End Stage Renal Disease requiring dialysis and diabetic A Care Plan, undated, indicated the resident required hemodialysis, at the Dialysis Center, on Tuesdays, Thursdays and Saturdays related to renal failure. The interventions included, but were not limited to: leave for dialysis at 8:00 A.M., first shift to obtain a weight, vitals signs and record in dialysis binder, upon return obtain post weight and vital signs, resident to take dialysis binder to dialysis center, monitor labs, monitor for peripheral edema, monitor/document any sign/symptoms of infection to access site (fistula). Review of the August 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received adequate supervision and the facility's elopement policy was followed for a resident with a traumatic brain injury with cognitive deficits, who was transferred off facility property, to a physician's office appointment, (Resident B) Finding includes: During an interview on 6/13/24 at 12:45 P.M., a Van Driver indicated he transported Resident B to an office building located next to an acute care hospital in a nearby city on 6/5/24 for a 10:00 AM appointment. During the ride the resident was quiet until he reached the (neighboring city name) and began to talk and point out familiar places and indicated this was his old stomping grounds. The van driver parked in front of the building and assisted the resident into the building to the specific physician's office and checked him in with Receptionist 1. The van driver told the receptionist he would be back, he had to park the van. When the van driver returned to the…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, served and delivered in a sanitary manner in 1 of 1 kitchens. This had the potential to affect 67 of 67 residents who consumed food from the kitchen. Findings include: During an observation of the kitchen on 5/13/2024 at 7:42 A.M., with [NAME] 16, the following was observed: the freezer had a bag of waffles, a bag of pancakes, 2 pizzas, a bag of broccoli, a bag of hamburger patties, 4 bags of cereal and a bag of chicken strips that were all undated and opened. the prep counter had crumbs and a grease like substance on top the storage bins were dirty with dried crumbs stuck to the lid the delivery cart had dried food particles and crumbs covering the top the dishwasher was dirty on the top and covered with crumbs the cooler had an undated bowl of fruit and salad. During an interview, on 5/13/2024 at 8:07 A.M., [NAME] 16 indicated the items should have been dated and /or thrown out if expired and the counters, storage bins, delivery cart and dishwasher should have been cleaned…

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 maintain an effective pest control program related to gnats in residents rooms and in common areas in the facility in 1 of 4 units observed for environment. (200 Hall). Finding includes: On 5/16/2024, from 1:48 P.M. through 2:36 P.M., an environmental tour was conducted with the Administrator and the Maintenance Director. The following observations contained the following concerns: - room [ROOM NUMBER] the bathroom had 3 gnats. During an interview with Resident 32, on 5/16/2024 at 1:33 P.M., he indicated he has had concerns about gnats being in his room and had complained to staff about them. A pest control invoice was received on 5/17/2024, and indicated the last pest management was on 4/17/2024, and was due next on 5/17/2024, then scheduled monthly. On 5/16/24 at 2:45 P.M., the Director of Housekeeping indicated there was no policy regarding environmental cleaning. On 5/16/24 at 2:57 P.M., the Housekeeping Supervisor provided an untitled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the responsible party of a transfer to the emergency room for 1 of 3 residents reviewed for transfer and discharge. (Resident D) Findings include: On 12/18/23 at 10:18 A.M., the clinical record for Resident D was reviewed. Resident D was admitted to the facility on [DATE] with the most recent readmission date of 3/16/23. The resident's diagnoses included, but were not limited to, a history of stroke, gastrostomy (tube in the stomach for feeding), hemiplegia (partial paralysis), hemiparesis (partial weakness), aphasia (loss of ability to speak), and intracranial abscess (infected area in the brain). The Quarterly Minimum Data Set (MDS) assessment, dated 10/23/23, indicated Resident D rarely or never understood others and rarely or never made himself understood. Resident D had severe cognitive impairment, was not ambulatory, was dependent on others for all activities of daily living, and required a feeding tube for all nutrition. Progress Notes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the correct clinical information was provided to a receiving hospital that was necessary to meet a resident's needs and ongoing care, for 1 of 3 residents reviewed for transfer and discharge, (Resident D). Finding includes: On 12/18/23 at 10:18 A.M., the clinical record for Resident D was reviewed. Resident D was admitted to the facility on [DATE] with the most recent readmission date of 3/16/23. The resident's diagnoses included, but were not limited to, a history of stroke, gastrostomy (tube in the stomach for feeding), hemiplegia (partial paralysis), hemiparesis (partial weakness), aphasia (loss of ability to speak), and intracranial abscess (infected area in the brain). The Quarterly Minimum Data Set (MDS) assessment, dated 10/23/23, indicated Resident D rarely or never understood others and rarely or never made himself understood. Resident D had severe cognitive impairment, was not ambulatory, was dependent on others for all activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent the misappropriation of narcotics for 3 of 4 residents reviewed who were being administered narcotics. (Resident G, Resident F and Resident K) Findings includes: During an interview, on 8/3/23 at 1:58 P.M., LPN 4 indicated approximately 2 weeks ago Resident G had a missing Controlled Drug Record and the resident had approximately 10-12 tables left on the drug card. LPN 4 implied LPN 3 had wasted them and there were no other witnesses. LPN 4 indicated Resident F had requested a pain pill from her on July 16th and she explained to him it was to early to have a dose, since he had one a 6:00 A.M. The resident indicated to her he had never received a pain pill at 6:00 A.M. on the morning of July 16th. 1. On 8/4/223 at 10:15 A.M., a review of the clinical record for Resident G was conducted. The record indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: unspecified pain 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 establish and/or maintain a system that accounted for, periodically reconciled and ensured the disposition of all controlled drugs, related to incomplete and inaccurate documentation of narcotic medications for 3 of 4 residents reviewed who were administered narcotic medications. (Resident G, Resident F and Resident K) Findings include: 1. On 8/4/223 at 10:15 A.M., a review of the clinical record for Resident G was conducted. The record indicated the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: unspecified pain and dementia with anxiety. The Physician Orders indicated the resident was to be administered Hydrocodone-Acetaminophen 5/325 milligrams (mg). Order stated to give 1 tablet, by mouth, every 4 hours as needed for pain. The start date was 6/14/23 with a stop date of 6/29/23, then updated on 6/29/23 to continue order until 7/13/23. The July 2023 MAR indicated the resident 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.