Aperion Care Lincoln

Based on observation, interview, and record review, the facility failed to ensure a bath or shower was provided for 1 of 3 residents reviewed for bathing. (Resident C) Finding includes:On 9/23/25 at 1:39 P.M., Resident C's clinical record was reviewed. Resident C's diagnoses included, but were not limited to, type 2 diabetes mellitus without complications. The most recent Minimum Data Set (MDS) Assessment, dated 7/21/25, indicated Resident C was cognitively intact and required moderate assistance (staff do part of the work) for bathing. During an observation on 9/23/25 at 1:00 P.M., Resident C indicated that bathing had not been completed or bed linen hadn't been changed in weeks. Resident C had a very pungent sour smell, greasy hair, and long, soiled fingernails. The point of care (POC, a certified nurses aide charting system) indicated Resident C preferred bathing twice weekly in the evenings. Paper and electronic shower records were reviewed for the last 30 days, and indicated Resident C had not received or refused a bath or shower on the following dates: 8/26/259/12/259/19/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary treatment and services for 1 of 3 residents reviewed for behavior management. An incident with another resident was not documented, a resident's care plan was not updated following the incident, and behaviors were not monitored. (Resident B)Finding includes:In an anonymous interview, it was indicated that Resident B asked Resident T for sex and to see her breasts, and that Resident T was not capable of giving consent.During an interview on 9/23/25 at 1:10 P.M., Resident B indicated that he struggled with mental health disorders due to his time in the war. He indicated that he would like to move to a facility closer to his family.During an interview on 9/23/25 at 1:22 P.M., Resident T indicated that a male resident would open her door sometimes and then leave, but she did not know who it was or recall any specific encounters with any male residents.On 9/23/25 at 2:08 P.M., Resident B's clinical record was reviewed. Diagnoses included,…

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 proper storage of medications for 1 of 1 medication rooms reviewed. The medication room, treatment cart, and medication refrigerator were not locked. (First Floor Medication Room)Finding includes: On 9/23/25 at 1:04 P.M., the first floor medication room that contained the Emergency Drug Kit (EDK) was observed unlocked. Inside the room, the treatment cart and the refrigerator that contained insulin, suppositories, and other cold medication was observed unlocked. At that time, Qualified Medication Aide (QMA) 16 indicated that the medication room, treatment cart, and medication refrigerator were all supposed to be locked.On 9/24/25 at 2:27 P.M., the Administrator provided a current Medication Storage policy, revised 7/2/19, that indicated Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.This citation relates to Intake 2615731.3.1-25(m)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure dignity was provided for 1 of 1 observations of meal trays passed. Staff were observed to enter resident rooms without knocking or announcing themselves. ( room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Resident F) Finding includes: On 7/3/25 at 10:14 a.m., resident council minutes dated 5/29/25 were reviewed and included a complaint of staff not knocking or introducing themselves before entering the room. On 7/7/25 at 12:34 p.m., CNA 2 was observed to deliver lunch trays to room [ROOM NUMBER], 211, 213, 214, and 216. CNA 2 did not knock or announce herself before walking in the rooms. On 7/7/25 at 1:10 p.m., CNA 3 indicated before delivering a meal tray to a resident in their room, you should knock and let them know you have food for them. On 7/7/25 at 2:41 p.m., the Administrator provided the current policy on resident rights with a revision date of 4/23/18. The policy included but was not…

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

Based on observation, interview, and record review, the facility failed to provide food that was served at an appetizing temperature for 1 of 1 meal tested on unit 200. ( Unit 200, Resident F) Finding includes: On 7/3/25 at 8:55 a.m., Resident F indicated food was not always served hot, it was sometimes ice cold depending on what time it was delivered to her. On 7/7/25 food temperatures were taken on the 200 unit for the noon meal. The temperature of the herb roasted pork loin was 115, stuffing 85, peas 79. On 7/7/25 at 2:41 p.m., the Administrator provided the current guideline and procedure for monitoring food temperatures for meal service with a date of 2020. The guidelines included but were not limited to: Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at a palatable temperature .8. meals that are served on room trays may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 F (Fahrenheit) or greater to promote…

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 served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Floors were soiled, food unlabeled. (Kitchen) Findings include: On 7/3/25 at 8:17 a.m., during observation of the kitchen the following was observed: 1. The walk in freezer contained partially used bags of breaded chicken, mixed vegetables, and garlic bread. The bags were unlabeled. 2. The floor behind the stove and deep fryer, stainless steel table that contained a sink had soil buildup and debris. On 7/3/25 at 8:21 a.m., the Dietary Manager indicated the floors under equipment are usually cleaned once a week. On 7/7/25 at 1:00 p.m., the floors were observed to still be soiled. The walk in freezer contained a box of fish squares that were open to air, unsealed. On 7/7/25 at 1:06 p.m., Dietary Aide 2 indicated when food is opened, it is put in a plastic bag with the open date and dated 30 days out. On 7/7/25 at 2:41 p.m., the Administrator provided the current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to maintain complete and accurate records, quarterly assessments were completed and documented in the clinical record. The Facility elopement risks were not documented in the clinical record. (Resident E) Finding includes: On 7/7/25 at 9:08 a.m., Resident E's clinical record was reviewed. Diagnoses included but were not limited to, unspecified dementia, unspecified severity, with other behavioral disturbance, cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident E's cognition was severely impaired, uses walker, once standing, the ability to walk at least 150 feet in a corridor or similar space, supervision or touching assistance, helper provides verbal cues or touching/steadying assistance as resident completes activity. Care plans were reviewed and included but were not limited to: Resident is at risk for elopement per elopement risk assessment, initiated 4/27/23, revision 8/22/24. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was stored in sanitary manner for 1 of 2 kitchen observations. Food containers were not labeled in the reach in refrigerator and dry storage. Findings include: On 4/3/25 at 10:35 A.M., the following was observed in the dry storage area: - One bag of [NAME] noodles with no open date - One bag of marshmallows with no open date On 4/3/25 at 10:57 A.M., the following was observed in the reach in refrigerator: - One container of orange juice without preparation date or use by date - One container of apple juice without a preparation date or use by date - One green container with orange colored fluid without a label, preparation date, or use by date - One pink container with brown colored fluid without a label, preparation date, or use by date - One clear container with purple colored fluid without a label, preparation date, or use by date - Two green colored containers with fluid, without a label, preparation date, or use by date -…

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

Based on interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The IP did not currently dedicate at least part time hours to the role of IP for 1 of 1 staff members reviewed for IP. Finding includes: On 4/9/25 at 9:30 A.M., the DON's employee file was reviewed. The employee file lacked a signed job description for the Infection Preventionist role. On 4/9/25 at 9:37 A.M., the DON indicated she was currently responsible for the infection prevention and control program in the facility. She indicated she also worked full time in the facility as the DON. On 4/9/25 at 12:14 P.M., the DON provided a current Infection Preventionist job description, dated 4/14/22, that indicated Reports to: Director of Nursing and/or Administrator . The role of the Infection Preventionist is to oversee the infection prevention and control program for the surveillance, investigation, prevention, and control of healthcare-associated infections and other infectious diseases. On 4/9/25 at 12:14 P.M., the DON provided a current Director of Nursing job…

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

Based on interview and record review, the facility failed to ensure care plan conferences were completed quarterly for 6 of 7 residents reviewed for care plan conferences. (Resident P, Resident S, Resident D, Resident N, Resident B, and Resident F) Findings include: 1. On 4/7/25 at 12:35 P.M., Resident P's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral palsy, diabetes mellitus, and major depressive disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/25/25, indicated Resident P was cognitively intact. The most current care plan conference was completed on 10/31/24. 2. On 4/4/25 at 12:40 P.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited, to dementia, repeated falls, and major depressive disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 2/20/25, indicated that Resident S had severe cognitive impairment. The most current care plan conference was completed on 11/14/24. 3. On 4/7/25 at 2:40 P.M., Resident D's clinical record was reviewed. Diagnoses included,…

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 provide a safe and sanitary environment for residents, staff, and the public for 11 random observations on 5 of 5 days. Offensive odors were detected in public hallways, alcoves and stairwells (throughout 100-unit hallways, in front of chapel, alcoves on 200 unit, outside of rooms [ROOM NUMBERS], Holy Family Nurses Station), dirty showers and resident room floors were observed. (Resident P and Resident D) Findings include: 1. On 4/3/25 at 9:30 A.M., during a random observation, the smell of urine was observed on the first floor outside of the chapel. 2. On 4/3/25 at 11:35 A.M., during a random observation the strong smell of urine was observed outside of room [ROOM NUMBER] and 113. 3. On 4/4/25 at 10:03 A.M., during a random observation, the strong smell of urine was observed in the hallway outside of the chapel. 4. On 4/7/25 at 8:50 A.M., during a random observation, the strong smell of urine was observed in the hallway in front of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents dependent on staff for ADLs (activities of daily living) were showered and hair was shampooed for 9 of 10 residents reviewed for ADL care. (Resident P, Resident S, Resident G, Resident D, Resident B, Resident N, Resident F, Resident L, and Resident U) Findings include: 1. During an interview on 4/4/25 at 9:03 A.M., Resident P indicated that she only got a shower once a week most weeks. She preferred a shower because staff didn't wash her hair when they gave her a bed bath. She indicated that she was told they were short staffed and sometimes didn't have time to get her up for a shower. She indicated that there was no one in the facility to cut her hair and that her family tried to fill that role. At that time, Resident P's hair was observed to be oily. On 4/7/25 at 12:35 P.M., Resident P's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral palsy, diabetes mellitus, and major depressive…

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 food that was served at palatable temperature for 1 of 1 trays tested for food temperature. Findings include: On 4/7/35 at 12:50 P.M., a hall tray was obtained on the 200 Unit. The following temperatures were observed: Carrots-115 degrees F During an interview on 4/7/25 at 12:45, the Dietary Manager indicated that the holding temperatures on the steam table should be 145 degrees F or higher. On 4/9/25 at 12:14 P.M., The Director of Nursing (DON) provided a current, non-dated policy Monitoring Food Temperatures for Meal Service. The policy indicated . food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures .serving/holding temperatures require 140 minimum when checked prior to meal service .meals that are served on room trays .prefer hot foods to be at 120 degrees F or greater for the palatability for the resident . This citation relates to Complaint IN00449780. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to accommodate a resident's choice of activity for 1 of 2 residents reviewed for choices. A resident's morning care was not completed in time for the resident to attend mass. (Resident P) Finding includes: On 4/4/25 at 9:05 A.M., Resident P indicated she wanted to go to mass, but staff didn't always get her up in time to go. Mass was scheduled daily in the facility at 11:00 A.M. On 4/7/25 at 12:35 P.M., Resident P's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral palsy and major depressive disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/24/25, indicated that Resident P was cognitively intact and was dependent on staff (staff does all of the effort) for toileting and bathing. The most current care plan conference was completed on 10/31/24. Care plans were reviewed and updated. A current preferences care plan, initiated 2/12/21, indicated that the resident preferred to get up for the day at 10:00 A.M. or as desired. A current self care deficit…

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 signed admission paperwork and resident rights and was provided a copy for 1 of 3 residents reviewed for new admissions. (Resident L) Finding includes: During an interview on 4/4/25 at 8:36 A.M., Resident L indicated she was unaware of her rights as a resident in the facility, and had not signed or received an admission packet. On 4/7/25 at 8:55 A.M., Resident L's clinical record was reviewed. Resident L was admitted on [DATE]. Diagnosis included, but was not limited to, malignant neoplasm. The most recent admission Minimum Data Set (MDS) assessment, dated 3/25/25, indicated Resident L was cognitively intact. An admission packet was signed 3/21/25 by the Social Services Director (SSD) and Resident L. During an interview on 4/8/25 at 1:53 P.M., Resident L stated the signature on the admission packet was not hers. During an interview on 4/9/25 at 9:19 A.M., the SSD indicated residents sign the admission packets electronically and 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 ensure clinical documentation was sent with a resident during a transfer for 2 of 2 residents reviewed for hospitalizations. (Resident B and Resident D) Findings include: On 4/7/25 at 9:24 A.M., Resident B's clinical record was reviewed. Diagnosis included, but was not limited to, hypertensive encephalopathy. The most recent Annual Minimum Data Set assessment, dated 1/3/25, indicated Resident B was moderately cognitively intact, required partial assistance from staff (staff do half of the work) for toileting and transfers, and required substantial assistance for bathing (staff do more than half of the work). Physician orders included, but were not limited to: Carvedilol oral tablet 12.5 mg (milligrams) give one tablet by mouth two times a day for hypertension; Start date 2/9/24 Isosorbide Mononitrate ER (extended release) oral tablet 60 mg give one tablet by mouth two times a day for paroxysmal atrial fibrillation; Start date 2/9/24 Lisinopril oral…

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

Based on interview and record review, the facility failed to ensure a notice of transfer was provided to the ombudsman for 1 of 2 residents reviewed for hospital transfers. (Resident B) Finding includes: On 4/7/25 at 9:24 A.M., Resident B's clinical record was reviewed. Diagnosis included, but was not limited to, hypertensive encephalopathy. The most recent Annual Minimum Data Set assessment, dated 1/3/25, indicated Resident B was moderately cognitively intact, required partial assistance from staff (staff do half of the work) for toileting and transfers, and required substantial assistance for bathing (staff do more than half of the work). Resident B was transferred to the hospital on 6/25/24, 9/8/24, and 12/8/24. A list of transfers and discharges for June, September, and December 2024 sent to the ombudsman was requested, but failed to be provided. During an interview on 4/9/25 at 12:49 P.M., the Director of Nursing (DON) indicated there was no notification to ombudsman for June, September, or December 2024 transfers. On 4/9/25 at 12:14 P.M., the DON provided an undated policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a bed hold was provided upon transfer for 2 of 2 residents reviewed for hospitalizations. (Resident B and Resident D) Finding includes: 1. On 4/7/25 at 9:24 A.M., Resident B's clinical record was reviewed. Diagnosis included, but was not limited to, hypertensive encephalopathy. The most recent Annual Minimum Data Set assessment, dated 1/3/25, indicated Resident B was moderately cognitively intact, required partial assistance from staff (staff do half of the work) for toileting and transfers, and required substantial assistance for bathing (staff do more than half of the work). Resident B was transferred to the hospital on 6/25/24 and 12/8/24. The clinical record lacked documentation of a bed hold provided for the transfer to the hospital on 6/25/24. The clinical record lacked documentation of a bed hold provided for the transfer to the hospital on [DATE]. During an interview on 4/9/25 at 12:49 P.M. the Director of Nursing (DON) indicated there…

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

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) Assessment was completed accurately for 1 of 1 residents reviewed for weight loss. (Resident S) Finding includes: On 4/4/25 at 12:40 P.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, diabetes mellitus, and dysphagia. The most current Annual Minimum Data Set (MDS) Assessment, dated 2/5/25, indicated Resident S had severe cognitive impairment, required setup assistance from staff for eating, weighed 179 pounds (lbs), and had no weight loss. The most current Quarterly MDS Assessment, dated 2/20/25, indicated Resident S had severe cognitive impairment, required setup assistance from staff for eating, weighed 132 lbs, and had no weight loss. A review of the weights and vitals tab indicated Resident S was weighed on the following days: - 1/3/25 - 179.3 lbs standing - 2/18/25 - 131.7 lbs wheelchair (a 26.55% weight loss) On 4/8/25 at 2:51 P.M., CNA 18 weighed Resident S. The resident weighed 162.8 lbs including the wheelchair weight. 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 ensure Qualified Medication Aides (QMA) practiced within the QMA scope of practice for 2 of 5 residents reviewed for unnecessary medications. (Resident U and Resident P) Findings include: 1. On 4/7/25 at 12:29 P.M., Resident U's clinical record was reviewed. Diagnosis included, but was not limited to, type 2 diabetes mellitus. The most recent admission Minimum Data Set (MDS) assessment, dated 3/24/25, indicated Resident U was moderately cognitively intact. Physician orders included, but were not limited to: Hydrocodone-acetaminophen (pain medication) oral tablet 7.5-325 mg (milligrams) give one tablet by mouth every four hours as needed for pain for 30 days; Start date 3/18/25. The following days indicate a QMA administered Hydrocodone-acetaminophen 7.5-325 mg tablet without prior authorization from a nurse: - 3/24/25 7:02 P.M. - 3/28/25 9:37 A.M. - 3/29/25 3:41 P.M. 2. On 4/7/25 at 12:35 P.M., Resident P's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral palsy, diabetes mellitus, 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, record review, and observation, the facility failed to identify the potential for the development of pressure ulcers, perform routine skin checks, and follow the plan of care to promote wound healing for 2 of 2 residents reviewed for facility acquired heel wounds. (Resident F, Resident F) Findings include: 1. During an interview on 4/4/25 at 2:29 P.M., Resident N was observed to have a wound vac (a medical device that uses negative pressure to promote wound healing) on his right heel. Resident N indicated it started out as a blister and developed larger requiring surgical debridement and a skin graft. Resident N indicated the wound resulted in him staying in the facility longer than anticipated. On 4/4/25 at 12:48 P.M., Resident N's clinical record was reviewed. Resident N was admitted on [DATE] for therapy following a recent fracture surgery. Diagnosis included, but was not limited to, diabetes mellitus with diabetic polyneuropathy. An admission Minimum Data Set (MDS) assessment, dated…

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

Based on observation, interview, and record review, the facility failed to follow fall protocol, revise care plans, and follow interventions to reduce the risk of falls for 2 of 2 residents reviewed for falls. (Resident D and Resident S) Findings include: 1. During a confidential interview during the survey, it was indicated that Resident D had fallen a lot while attempting to self toilet because when he pushed his call light no one came to help him to the bathroom. On 4/4/25 at 1:26 P.M., Resident D was observed sitting by himself in his wheelchair in his room eating. The call light was wrapped around the bed rail and was not clipped to or within reach of the resident. There was not a dycem in his wheelchair. The resident was wearing socks without nonskid bottoms. Non skid strips were not observed anywhere in the resident's room. On 4/7/25 at 2:40 P.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, epileptic seizures, wedge compression fracture of unspecified lumbar vertebra, repeated falls, unsteadiness on feet, and weakness. The…

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

Based on observation, interview, and record review, the facility failed to provide nutritional care and services including failure to identify significant weight loss, failure to notify the physician of significant weight loss, and failure to be reviewed by the Registered Dietician for 1 of 1 residents reviewed for weight loss (Resident S). Finding includes: On 4/4/25 at 12:40 P.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, diabetes mellitus, and dysphagia. The most current Annual Minimum Data Set (MDS) Assessment, dated 2/5/25, indicated Resident S had severe cognitive impairment, required setup assistance from staff for eating, weighed 179 pounds (lbs), and had no weight loss. The most current Quarterly MDS Assessment, dated 2/20/25, indicated Resident S had severe cognitive impairment, required setup assistance from staff for eating, weighed 132 lbs, and had no weight loss. The most recent care plan conference was completed on 11/14/24. The care plan was reviewed and updated. A current nutritional status care plan, revised…

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 physician orders were followed and a resident's nutritional feedings were administered for 1 of 1 residents reviewed for tube feedings. A resident's enteral nutrition refusals were not documented, and feeding equipment was not changed daily. (Resident G) Finding includes: On 4/3/25 at 11:44 A.M., Resident G was observed sitting in her wheelchair in her room. Jevity (tube feeding) formula, dated 4/2/25, was observed in the room but was not hooked up to the resident. A syringe was observed hanging in a bag and was dated 4/1/25. On 4/4/25 at 1:24 P.M., the enteral nutrition was observed turned off in Resident G's room. Resident G was not in her room at that time. A syringe was observed hanging in a bag and was dated 4/1/24. On 4/7/25 at 11:37 A.M., the enteral nutrition was observed turned off in Resident G's room. Resident G was not in her room at that time. The feeding tube was wrapped around the pole and there was no cap on the end of the tubing. On 4/8/25 at 10:57 A.M., the enteral nutrition was…

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

Based on observation, record review, and interview, the facility failed to ensure infection control practices were implemented for 2 of 3 residents observed for care. Gloves were not changed and hand hygiene was not performed. (CNA 23, RN 28, RN 7) Findings include: 1. On 4/8/25 at 10:42 A.M., incontinence care was observed for Resident 22. CNA 23 sanitized with hand sanitizer and donned gloves while RN 28 only donned gloves. CNA 23 gathered supplies with the gloves on, turned the resident to the right side, and removed the resident's sweatpants and soiled brief. CNA 23 provided incontinence care using three wash cloths and turned the resident to the left side, then RN 28 completed the incontinence care with two more washcloths. RN 28 removed the soiled gloves and washed hands with soap and water. CNA 23 utilized the same gloves to place barrier cream on Resident 22. CNA 23 wiped the gloved hands with the barrier clean inside the clean incontinence brief and then put the clean incontinence brief on Resident 22. 2. During an observation of wound care on 4/9/25 at 11:40 A.M., RN 7…

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 adequate safety measures were in place to prevent accidents for 1 of 3 residents reviewed for falls. This deficient practice resulted in Resident B obtaining injuries that resulted in medical intervention. (Resident B) Finding includes: On 3/18/25 at 9:23 a.m., Resident B indicated a staff member was transferring her from bed to a shower chair, the Hoyer(mechanical lift) tipped over and fell on top of her. Resident B indicated the staff member had started pulling the Hoyer lift closer to herself, all of a sudden it tipped over and fell on her, causing injury to her right knee, bruising, she felt like it broke her little toe, she had low back pain at times. Resident B indicated the staff member protected her and sustained a few injuries herself, there was only one staff member who transferred her, another staff had asked if she needed help and was told no. Resident B was unsure of staff names. On 3/18/25 at 10:10 a.m., Resident B's…

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

Based on interview and record review, the facility failed to ensure grievances were documented and resolved for 3 anonymous residents interviewed and 9 of 9 residents who attended Resident Council. Findings include: 1. In an anonymous interview, a resident indicated a complaint was made to the Social Services Director (SSD) in January 2024 about a housekeeper who had been disrespectful to the resident. The resident indicated they didn't want the housekeeper to clean their room anymore. At that time, the resident indicated the complaint was never followed up on, and the housekeeper still cleaned their room, but they don't talk to each other. 2. In an anonymous interview, a resident indicated a complaint was made to the Administrator about a staff member who spoke harshly to them about the use of a call light. The resident indicated the Administrator followed up with them about the call light, but not about the behavior of the staff member. 3. In an anonymous interview, a resident indicated the procedure to file a grievance was to write it down on a piece of paper and give it to 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 interview and record review, the facility failed to develop and implement care plans for 2 of 3 residents reviewed for urinary tract infections and 3 of 5 residents reviewed for unnecessary medications (Resident 9, Resident 26, Resident 17, Resident 30, and Resident 32). Findings include: 1. On 2/27/24 at 1:06 P.M., Resident 9's clinical record was reviewed. Resident 9 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Multiple Sclerosis, epilepsy, and schizoaffective disorder. The most recent Annual MDS (Minimum Data Set) Assessment, dated 12/4/23, indicated Resident 9 was severely cognitively impaired and required extensive assistance from two staff members for toileting. Physician orders included, but were not limited to: Keppra (anticonvulsant) Tablet 1000 MG (milligrams) - Give 1 tablet by mouth two times a day for seizures related to epilepsy, start date 3/5/2020. Cranberry Tablet 450 MG - Give 2 tablets by mouth at bedtime for urinary supplement, start date…

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

Based on observation and interview, the facility failed to provide proper storage of medications in 1 of 3 medication carts and 1 treatment cart observed. Loose pills and unlabeled medications were found in the medication and treatment carts. (Holy Name Medication Cart and JJ Nurses Station) Findings include: 1. On 2/28/24 at 8:15 A.M., the following was observed in the Holy Name Medication cart: 1 large brown pill 1 large white pill The following, found at the same time, were marked with [resident name] but lacked an open date or label: 1 bottle of stool softener 1 bottle of Donepezil 1 bottle of acetaminophen 500 mg (Milligrams) 1 bottle of calcium 1 bottle of daily fiber 1 bottle of women's multivitamin 1 bottle of powdered laxative 2. On 2/28/24 at 8:27 A.M., the following was observed in the treatment cart in the JJ Nurses Station: 1 bottle of Tuberculin Solution with an open date of 11/22/23 and an expiration date of 2/25, lot number 66059 1 tube of pain relief cream with [resident name] that lacked an open date or label 1 bottle of powdered laxative that lacked a resident…

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 food was stored, labeled, and dated properly in accordance with professional standards for food service for 2 of 2 kitchen observations. Finding includes: On 2/26/24 at 9:22 A.M., an initial tour of the kitchen was conducted. The following items were observed: In the reach-in refrigerator: a clear plastic container with a green lid contained a white liquid; not labeled with contents or date A sour cream container with soup inside; not labeled with contents or date 1 opened can of dessert topping; no date 1 red drink pitcher with no date or contents label, and 1 red drink pitcher with a prep date 2/23/24 and use by date 2/25/24 2 blue drink pitchers; not labeled with contents or date In the walk-in freezer: a gallon plastic Ziploc bag labeled spaghetti sauce dated 12/20/23 and use by 6/2/23 1 opened bag of pepperonis with a manufacture expiration date 12/17/23 In the dry storage area: 1 dented can stewed tomatoes 2 dented cans…

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 and standards were followed in 2 of 2 residents observed during care and 3 of 3 residents observed during medication administration. Hand hygiene was not performed correctly and vital sign equipment was not cleaned between residents. (Resident 32, Resident 8, Resident 29, Resident 21, and Resident 26) Findings include: 1. On 2/28/24 at 6:45 A.M., during a medication pass for Resident 32, LPN (Licensed Practical Nurse) 7 was observed entering the room without performing hand hygiene. LPN 7 took a temperature of 97 degrees Fahrenheit using a digital temporal thermometer and administered medications. Upon completion, LPN 32 left the room without hand sanitizing or cleaning the equipment after usage. 2. On 2/28/24 at 7:15 A.M., during a medication pass for Resident 8, LPN 8 was observed taking a blood pressure of 152/74 for the resident, and did not clean equipment after usage. 3. On 2/28/24 at 7:51 A.M., during a medication pass for Resident 29, LPN 8 was observed taking 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 ensure the admission Minimum Data Set (MDS) Assessment was completed timely within 14 days of admission for 1 of 2 new admission residents reviewed. (Resident 135) Finding includes: On 2/26/24 at 2:39 P.M., Resident 135's clinical record was reviewed. Resident 135 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) Assessment, dated 2/1/24, indicated it was still in process and not completed. During an interview on 3/4/24 at 10:16 A.M., the MDS Coordinator indicated the MDS Assessment was not completed within 14 days of admission. A policy was requested but not provided. The MDS Coordinator stated the facility follows RAI (Resident Assessment Instrument) Manual guidelines that indicate For the admission Assessment, the MDS Completion Date must be no later than 13 days after the Entry Date. 3.1-31(d)(1)

Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 1 of 5 residents reviewed for unnecessary medications. (Resident 23) Finding includes: On 2/27/24 at 2:27 P.M., Resident 23's clinical record was reviewed. Diagnosis included, but was not limited to, atrial fibrillation. The most recent quarterly MDS Assessment, dated 12/18/23, indicated Resident 23 was cognitively intact and did not receive an anticoagulant during the 7-day look back period. Current physician orders included, but were not limited to: Eliquis (an anticoagulant) Tablet 5 MG (milligrams) - Give 5 mg by mouth two times a day for blood thinner related to atrial fibrillation, dated 8/17/23. The December 2023 MAR (medication administration record) indicated Resident 23 received Eliquis twice daily in December. On 2/29/24 at 2:20 P.M., the MDS Coordinator indicated that the Eliquis should have been coded as an anticoagulant on the 12/18/23 quarterly MDS Assessment and was overlooked. At that time, the MDS Coordinator indicated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a base line care plan for 1 of 2 residents reviewed for dementia care, respiratory care, and antipsychotic medications. (Resident 85) Finding includes: On 2/28/24 at 10:20 A.M., Resident 85's clinical record was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia in other diseases classified elsewhere, unspecified severity with other behavioral disturbances, and chronic obstructive pulmonary disease with exacerbation. Physician orders included, but were not limited to: Aricept (a cognition-enhancing medication) Oral Tablet 5 MG (Milligrams) (Donepezil Hydrochloride), Give 1 tablet by mouth at bedtime related to dementia in other diseased classified elsewhere, unspecified severity with other behavioral disturbances, dated 2/23/24. Buspirone (an antianxiety medication) HCl Oral Tablet 5 MG (Buspirone HCl). Give 1 tablet by mouth two times a day related to anxiety disorder, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was properly labeled and oxygen services were provided according to physician order for 2 of 2 residents reviewed for respiratory care. (Resident 85, Resident 17) Findings include: 1. On 2/26/24 at 10:48 A.M., Resident 85 was observed lying in bed with oxygen that lacked a label or date on the tubing and humidification bottle. There was also no storage bag observed anywhere in the room. On 2/28/24 at 11:15 A.M., Resident 85 was sitting in a wheelchair with oxygen on, the tubing and water bottle were not dated. There was no oxygen tubing storage bag present. On 2/29/24 at 2:06 P.M., Resident 85's oxygen tubing was observed to be in an undated, unlabeled storage bag. On 2/28/24 at 10:20 A.M., Resident 85's clinical record review was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease with acute exacerbation and acute 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 interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A resident's as needed antianxiety medication was ordered for greater than 14 days. (Resident 17) Finding includes: On 2/27/23 at 11:01 A.M., Resident 17's clinical record was reviewed. Diagnoses included, but were not limited to, major depressive disorder and post-traumatic stress disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 12/11/23, indicated Resident 17 was cognitively intact and received an antianxiety medication during the 7-day lookback period. Current physician orders included, but were not limited to: Klonopin (an antianxiety medication) Oral Tablet 1 MG (milligrams) - Give 1 tablet by mouth every 24 hours as needed for anxiety, dated 1/26/2024 with no stop date indicated. The January 2024 MAR (medication administration record) indicated Resident 17 received PRN (as needed) Klonopin on 1/26. The February 2024 MAR indicated Resident 17 received PRN Klonopin on 2/8, 2/21,…

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 medical records were accurate for 1 of 2 residents reviewed for hospitalizations. Dates of indwelling catheter changes were incorrectly documented. (Resident 21) Finding includes: On 2/29/24 at 11:19 A.M., Resident 21's clinical record was reviewed. Resident 21 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease, obstructive and reflux uropathy, and acute kidney failure. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 1/17/24, indicated Resident 21 was cognitively intact, had an indwelling catheter, and was always incontinent of bowel and bladder. Physician orders included, but were not limited to: Change indwelling catheter 16fr (French) 10ml (milliliters) Q (every) month and PRN (as needed) every day shift every 30 day(s) for catheter change, dated 12/10/23. Change indwelling catheter 16fr 10ml Q month and PRN every day shift starting on the 11th and ending on the 12th…

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 honor rights of the residents. The chapel was closed and residents were restricted to certain areas of the facility for 6 of 6 days of the survey. (Resident 37) Findings include: On 7/25/22 at 9:15 a.m., the chapel on the 100 unit was observed to have a chain and padlock attached to both entry doors with a sign that stated Due to being in outbreak status related to COVID -19 the Chapel will be CLOSED until further notice! On 7/26/22 at 8:44 a.m., the same was observed. On 7/27/22 at 8:33 a.m. the same was observed. On 7/28/22 at 10:10 a.m., the same was observed. On 7/29/22 at 8:45 a.m., the same was observed. On 07/26/22 at 9:22 a.m., Resident 37 indicated the facility had chains on the doors to the chapel, mass was not being offered, residents were told to stay on the floor where they resided, they thought the chains were extreme and residents in the facility were upset about it. On 7/27/22 at 10:29 a.m., an anonymous resident interview…

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 plan of care was implemented to address the resident's medical and physical needs for 1 of 2 residents reviewed for pressure ulcers. A resident did not receive weekly skin assessments, and a dressing was not changed per the physician's order. (Resident 11) Finding includes: On 7/28/22 at 10:28 A.M., Resident 11's clinical record was reviewed. The most recent significant change MDS (minimum data set) Assessment, dated 5/13/22, indicated Resident 11 was currently receiving hospice services, was at risk for pressure ulcers, and a had a moderate cognitive impairment. Current physician's orders included, but were not limited to, the following: Cleanse on and around below coccyx, apply med honey and cover with foam dressing, once a day, dated 7/14/22 Weekly skin assessments, dated 1/31/22 A current risk for skin impairment care plan, dated 1/27/22, indicted interventions, but were not limited to, weekly skin assessments, dated 1/27/22. Weekly skin assessments were completed on the following dates from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide showers/baths for 2 of 3 residents reviewed. Residents were not given showers or baths. (Resident C, Resident D) Findings include: 1. On [DATE] at 10:41 a.m., Resident C indicated she was not getting a shower twice a week, the staff turned her side to side and cleaned her up. On [DATE] at 9:05 a.m., Resident C's clinical record was reviewed. Resident C had diagnoses that included, not limited to, Hypertension, chronic kidney disease stage 3, spondylolistheses, multiple sites in spine. An MDS (Minimum Data Set) quarterly assessment dated [DATE], indicated C's cognition was intact, physical help in part of bathing, one person assist. Care plans were reviewed and included, not limited to, Resident preferences for daily care and care planning include: Shower: 2x weekly, bathing time of day: no preference, revision on [DATE]. Bathing documentation was revived for June and July of 2022 and contained the following: 6/3- bed bath 6/7- bed bath 6/14- bed…

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