Envive Of Evansville

Based on observation, interview, and record review, the facility failed to ensure meals were served at a palatable temperature for 1 of 1 trays tested for temperature. (North Hall) Finding includes: On 1/17/25 at 10:46 A.M., Resident 118 indicated the food tasted bad and was cold. On 1/21/25 at 10:13 A.M., Resident 35 indicated the food temperature was never what it was supposed to be. Her hot foods were not hot and her cold foods were not cold. On 1/21/25 at 10:53 A.M., Resident S indicated the food was cold when she got it and hot plates were sometimes not used to keep it warm while delivering it to residents. On 1/23/24 at 12:45 P.M. a test tray was obtained. Food temperatures from that meal were: Cheeseburger 100.6 F (Fahrenheit) Sweet potato fries 87 F The food tasted lukewarm and the cheeseburger was observed to be pink in the middle of the meat. On 1/23/24 at 12:50 P.M., the Dietary Supervisor indicated that the burgers used were precooked. On 1/27/25 at 12:31 P.M., the Administrator provided a Food Temperatures policy, dated 2021, that indicated foods sent to the units for…

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

Based on interview and record review, the facility failed to ensure documentation was complete and accurate for 1 of 3 residents reviewed for discharge from Medicare Part A and 1 of 6 residents reviewed for falls. (Resident Z and Resident T) Attempts to contact the family were not documented and details of an injury from a fall were not documented accurately. Findings include: 1. During an interview on 1/17/25 at 9:45 A.M., the Administrator indicated Resident Z was scheduled to be discharged home on 1/15/25, but family failed to pick up the resident. The facility had attempted to call the resident's family, but they had not answered the phone. During an interview on 1/17/25 at 9:58 A.M., Resident Z'a family member indicated that Resident Z was at the facility short term for rehab and was due to be discharged soon. They were waiting on a phone call from the Social Services Director (SSD) to set a date for discharge but had not yet heard anything. On 1/17/25 at 10:45 A.M., Resident Z's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart…

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

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment during 7 random observations. Odor was present in the facility and puddles of fluid and debris were on the floor. (West Hall, East Hall, 500-hall, Pavilion Dining Room) Findings include: 1. On 1/16/25 at 9:23 A.M., an unattended rolling cart of trash sitting in front of East Hall nurses station had an odor consistent with bowel movement. 2. On 1/16/25 at 9:32 A.M., the 500-hall had a strong putrid smell. 3. On 1/16/25 at 9:35 A.M., the [NAME] Hall was noted to have an odor consistent with bowel movement. 4. On 1/16/25 at 12:37 P.M., the Pavilion dining room floor had a large puddle of fluid and dirty debris observed along the dining room floors. 5. On 1/21/25 at 8:00 A.M., the East Hall was noted to have an odor consistent with urine. 6. On 1/23/25 at 8:10 A.M., the East Hall was noted to have an odor consistent with urine. 7. On 1/23/25 at 10:41 A.M., the [NAME] Hall was noted to have an odor consistent with bowel movement. During an interview on 1/24/25 at 9:19 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Forms were provided following the end of Medicare skilled services for 1 of 2 residents who discharged from Medicare services and remained in the facility. (Resident Z) Finding includes: On 1/17/25 at 9:45 A.M., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed. The form indicated Resident Z received Medicare Part A Skilled Services starting 12/4/24. The form indicated the last covered day of Part A services was 1/14/25 and the resident remained in the facility. The form indicated Resident Z did not receive a SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Form because she was scheduled to be discharged home on 1/15/25 following the last covered day, but family failed to pick up the resident who remained in the facility. At that time, the Administrator indicated a SNF-ABN had not been issued to the resident. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's discharge was documented in the clinical record for 1 of 3 residents reviewed for discharge. (Resident 60) Finding includes: On 1/23/25 at 12:24 P.M., Resident 60's clinical record was reviewed. Resident 60 was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's Disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/5/24, indicated Resident 60 was moderately cognitively impaired, required substantial assistance from staff (staff does more than half of the work) for toileting and transfers, and was dependent on staff for bathing. A nutrition note created on 1/17/25 at 2:09 P.M., indicated Resident 60 was discharged with return not anticipated. The clinical record, including progress notes, assessments, and documents, lacked information regarding planning of a discharge, documents sent during discharge, where Resident 60 was discharged to, or when discharge occurred. During an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure social services were provided to meet a resident's mental and psychosocial needs for 1 of 1 residents reviewed for Preadmission Screening and Resident Review (PASARR). (Resident 61) Finding includes: On 1/22/25 at 2:14 P.M., Resident 61's clinical record was reviewed. Diagnoses included, but were not limited to, Wernicke's encephalopathy, alcohol use disorder, non-Alzheimer's dementia, seizures, anxiety, depression, and an unspecified psychiatric disorder. The resident was admitted to the facility on [DATE]. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/20/24, indicated the resident was cognitively intact, required supervision for all mobility tasks, and received antipsychotics, antianxiety medication, antidepressants, and anticonvulsants during the 7-day look back period. Physician orders included, but were not limited to: olanzapine (an antipsychotic medication) oral tablet 10 milligrams (mg) - 1 tablet at bedtime,…

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 development and completion of a baseline care plan within forty-eight (48) hours of admission for use of respiratory equipment, tracheostomy, and Enhanced Barrier Precautions (EBP) for 1 of 1 residents reviewed for respiratory care. (Resident 277) Finding includes: On 1/21/25 at 11:21 A.M., Resident 277's clinical record was reviewed. Resident 277 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia and tracheostomy. The admission Minimum Data Set (MDS) Assessment was in progress. Current physician orders included, but were not limited to, the following: Change oxygen tubing monthly and as needed (PRN), one time a day every four weeks on Sunday for Oxygen (O2) use and as needed for soiled or compromised, dated 1/15/25. Change humidifier/bubbler monthly and as needed (PRN), as needed for empty/compromised and change one time a day every four weeks on Sunday for routine oxygen, 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 record review and interview, the facility failed to ensure care plans were updated after a fall for 1 of 6 residents reviewed for falls. (Resident 8) Finding includes: On 1/21/25 at 3:19 P.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, chronic pain syndrome, spinal stenosis lumbosacral region, and age-related physical disability. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/13/24, indicated the resident was mildly cognitively impaired, required substantial to maximal help (staff does more than half) with dressing, required partial to moderate assistance of staff (staff does less than half) with transferring, and had one fall with injury since the prior assessment. Current physician orders included, but were not limited to: 1/4 side rails for mobility positioning every day and night shift to aide with bed mobility related to morbid (severe) obesity, dated 11/20/20. A current falls care plan, dated 12/12/17, indicated that Resident 8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure physician orders were followed for 2 of 5 residents reviewed for nutrition. (Resident 35 and Resident L) Findings include: 1. During an observation on 1/21/25 at 10:15 A.M., Resident 35's lower extremities were swollen. Resident 35 indicated she was supposed to wear compression stockings to reduce edema but staff had not put them on for her. On 1/21/25 at 1:37 P.M., Resident 35's clinical record was reviewed. Resident 35 was admitted on [DATE]. Diagnoses included, but were not limited to, renal failure and diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated Resident 35 was cognitively intact and required substantial assistance from staff (staff does more than half of the work) for toileting, bathing, and transfers. Current physician orders included, but were not limited to: Patient to wear stockings on bilateral lower extremities (Tubigrips size G) for edema reduction 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, observation, and record review, the facility failed to promote the prevention of pressure ulcer development through evaluation of clinical risk factors and implementation of interventions consistent with resident needs for 1 of 2 residents reviewed for facility acquired pressure injuries. (Resident G) Finding includes: During an anonymous interview, it was indicated Resident G had a decline in mobility since admission and was being left in the same position for long periods of time resulting in skin breakdown. During an observation on 1/23/25 at 8:57 A.M., Resident G was sitting in a recliner in the common area. The chair did not have a pressure reducing cushion for skin breakdown prevention. On 1/22/25 at 1:55 P.M., Resident G's clinical record was reviewed. Resident G was admitted on [DATE]. Diagnoses included, but were not limited to, dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/24/24, indicated Resident G was severely cognitively impaired, required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 1/22/25 at 1:55 P.M., Resident G's clinical record was reviewed. Resident G was admitted on [DATE]. Diagnoses included, but were not limited to, dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/24/24, indicated Resident G was severely cognitively impaired and required substantial assistance (staff do more than half the work) for bathing and transferring. A fall risk assessment, dated 1/15/25, indicated Resident G was a high risk for falls and had fallen multiple times in the past in the past three months. The care plan included, but was not limited to: I am at risk for falls/injury due to: impaired cognition related to dementia, history of falls, initiated 12/10/24, Interventions included: Assess for pain, Date Initiated: 12/13/24 call light is within reach, Date Initiated: 12/13/24 Ensure pathways are free of clutter, Date Initiated: 12/13/24 Keep personal items within reach, Date Initiated: 12/13/24 Physical therapy to eval (evaluate) and treat as indicated, Date Initiated:…

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 residents received respiratory care services in accordance with professional standards of practice for 1 of 1 residents reviewed for respiratory care. The facility failed to date oxygen tubing, oxygen concentrator, and suction tubing, and place signs that indicated oxygen was in use. (Resident 277) Finding includes: On 1/21/25 at 9:17 A.M., Resident 277's oxygen tubing, suction tubing, and oxygen concentrator were observed without a label and date. There were no oxygen signs observed that indicated the resident received oxygen. Resident was observed to have a tracheostomy. During the observation of Resident 277's tracheostomy care on 1/22/25 at 8:34 A.M., the obturator for emergency tracheostomy use was not identified in the room. On 1/22/25 at 8:53 A.M., Resident 277's oxygen tubing, suction tubing, and oxygen concentrator were observed without a label and date. There were no oxygen signs observed that indicated the resident received oxygen. On 1/21/25 at 11:21 A.M., Resident 277's clinical record was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician orders and provide ongoing assessment of the resident's condition and monitoring for complications by completing pre-dialysis evaluations assessments for 1 of 1 residents reviewed for dialysis management. (Resident 35) Finding includes: On 1/21/25 at 1:37 P.M., Resident 35's clinical record was reviewed. Resident 35 was admitted on [DATE]. Diagnoses included, but were not limited to, renal failure and peripheral vascular disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated Resident 35 was cognitively intact and required substantial assistance from staff (staff does more than half of the work) for toileting, bathing, and transfers. Current physician orders included, but were not limited to: Do not obtain blood pressure in the left arm, Start date 10/8/24. Pre-Dialysis assessment to be completed prior to dialysis one time a day every Monday, Wednesday, Friday for pre-dialysis assessment; Start…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was assessed by a physician since admission for 1 of 1 residents reviewed for dialysis. (Resident 35) Finding includes: During an interview on 1/23/25 at 3:00 P.M., Resident 35 indicated she had not been assessed by a physician in the facility since admission. On 1/21/25 at 1:37 P.M., Resident 35's clinical record was reviewed. Resident 35 was admitted on [DATE]. Diagnoses included, but were not limited to, renal failure and peripheral vascular disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated Resident 35 was cognitively intact and required substantial assistance from staff (staff does more than half of the work) for toileting, bathing, and transfers. The clinical record, including assessments, progress notes, and documents, lacked assessment of Resident 35 by a physician in the facility since admission. During an interview on 1/24/25 at 11:39 A.M., the Administrator indicated she 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.

3. On 1/22/25 at 10:27 A.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, stage three pressure ulcer. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/7/24, indicated Resident 13 had moderate cognitive impairment, was dependent on staff for all Activities of Daily Living (ADLs), and had two stage three pressure injuries. Physician orders included, but were not limited to: Resident requires the use of Enhanced Barrier Precautions related to chronic wound to reduce the risk of transmission of multidrug-resistant organisms (MDROs). Use personal protective equipment (PPE) precautions when providing prolonged direct resident care, dated 11/14/24. A stage three pressure ulcer to right posterior lateral calf care plan, dated 7/2/24, included an intervention for enhanced barrier precautions. A stage three pressure ulcer to left lateral lower leg care plan, dated 7/2/24, included an intervention for enhanced barrier precautions. A diabetic ulcer to left second toe care plan, dated 12/27/24, included an intervention for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received a written notice prior to a room change for 1 of 4 residents reviewed for resident rights. A resident was moved from the locked dementia unit to a different hall off the unit without prior or documented notification. (Resident B) Finding includes: During an observation on 10/21/24 at 9:00 A.M., Resident B was observed to have a room on the 500 hall. During record review on 10/21/24 at 10:30 A.M., Resident B's diagnoses included, but was not limited to, dementia with mood disturbance and agitation, anxiety, and major depressive disorder. Resident B's most recent quarterly Minimum Data Set (MDS) assessment, dated 10/8/24, indicated the resident had no cognitive impairment, and resided on the Pavilion (Memory) Unit in room [ROOM NUMBER] in bed 2. Resident B's physician orders included, but were not limited to, resident may reside on locked secured memory unit (dated 6/7/24). Resident B's progress notes 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 interview and record review, the facility failed to ensure staff immediately reported alleged resident to resident abuse to the Facility Administrator and the facility failed to include known relevant information for 1 of 1 allegations of abuse reviewed. Following documented alleged resident to resident abuse, the facility failed to report the allegation to the State Agency for 7 days. The reported incident did not contain all residents involved nor did it contain a detailed description of the incident. (Resident B, Resident K) Finding includes: During a review of State reportable incidents on 10/21/24 at 10:05 A.M., an incident report indicated that there was an allegation of inappropriate contact made by Resident B and an unidentified resident. The incident date and time was reported to be 10/15/24 at 9:01 A.M During a review of the facility's investigation of the incident on 10/21/24 at 2:35 P.M., an undated, untimed, typed document indicated that on 10/15/24 an investigation was initiated based on an allegation that Resident B had touched the breast of a female…

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

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent falls for 1 of 3 residents reviewed for falls. A resident's fall interventions were not in place. (Resident K) Finding includes: On 10/21/24 at 10:11 A.M., Resident K's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with psychotic disturbance, and repeated falls. Resident K's most recent Quarterly MDS (Minimum Data Set) Assessment, dated 9/21/24, indicated the resident's cognition was severely impaired, resident required extensive assist of 2 staff for bed mobility, transfers, toileting, and requried supervision with set up for eating. Resident K had 2 falls since the last assessment, one with injury. Resident K's physician's orders included, but were not limited to, the following: Fall mat at bedside while in bed every shift (ordered 8/1/24). Non-skid mat in front of toilet every shift (ordered 8/1/24). Motion sensor while in bed. Check functioning and placement every…

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

Based on observation, record review, and interview, the facility failed to provide an accurate updated Facility Assessment. The Facility Assessment lacked specific services for residents with Intellectual Disabilities, feeding tubes, tracheotomies and dialysis, and staffing numbers for all departments. Finding includes: On 11/28/23 at 8:14 A.M., the current [name of facility] Facility Assessment, dated 9/12/23, was reviewed. The document indicated staffing numbers varied, and it lacked specific resident population services for residents with Intellectual Disabilities, feeding tubes, dialysis, tracheotomies, and feeding tubes. On 12/5/23 at 9:33 A.M., the Administrator indicated there were no staffing numbers listed in the Facility Assessment, and that the services offered for residents were generalized. She further indicated services such as transportation for dialysis were implied. On 12/5/23 at 11:57 A.M., the Administrator provided a current Facility Assessment policy, dated 6/22. The policy indicated the purpose of the assessment is used to make decisions about direct care staff…

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 submit direct care staffing information to CMS (Centers for Medicare and Medicaid Services) for 1 of 1 quarters reviewed. (April, May, June, 2023) Finding includes: Failed to Submit Data for the Quarter and 1 Star Staffing Rating was triggered on the CMS PBJ (Payroll Based Journal) Data Report for Quarter 3 (April 1 - June 30, 2023). On 11/30/23 at 1:58 P.M., the Administrator indicated that she was aware that staffing information had not been submitted for the third quarter because the facility changed ownership in July and the information did not get submitted. She further indicated that was the reason for the 1 star staffing rating. On 12/4/23 at 1:06 P.M., the Administrator indicated there was no policy for direct care staffing information submission and the facility followed the federal guidelines.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain safe and secure storage of medications for 4 of 4 medication carts observed and 2 of 2 medication storage rooms observed. Loose pills were observed in medication carts, and refrigerator temperature logs were not filled out completely in medication rooms. (Southeast, Northeast, West, and Pavilion) Findings include: 1. On 12/5/23 at 8:52 A.M., the following was observed on the Northeast/Southeast Unit: The medication cart was observed with the following loose pills in the drawers: 1 small white round tablet with marking 20/15 1 small white round tablet with marking 12 on one side and T on the other 1 gray oval tablet with marking m10 1 white oval tablet with marking U on one side and 227 on the other At that time, Registered Nurse (RN) 12 indicated that any staff could clean out the medication carts, as it was not assigned to any certain person or shift. The refrigerator temperature logs from November/December in the medication…

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

Based on observation, record review, and interview, the facility failed to ensure food was served at palatable temperature for 1 of 1 trays tested for food temperature. Finding includes: On 12/1/23 at 8:00 A.M., a test tray was obtained from the Northeast/Southeast Hall. Food temperatures for that meal were as the following: Sausage -114 F Scrambled eggs - 133.7 F Milk - 39 F Orange Juice - 40 F The sausage tasted greasy, and the scramble eggs were bland. On 12/1/23 at 3:06 P.M., during the Resident Council meeting, anonymous residents indicated: The steam table broke last week, and the food has been cold. Thanksgiving dinner was cold. The food is not seasoned well. It is bland. I ask for the salad because I do not like the food. On 12/5/23 at 11:19, an anonymous resident indicated the temperature of the food varied each day. Breakfast was usually hot, but lunch and dinner vary greatly in temperature on various days. On 12/5/23 at 11:32 A.M., an anonymous resident indicated food temperature varied day to day. On 12/1/23 at 6:40 A.M., [NAME] 22 indicated the temperature of food 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 assessments were completed for residents that self administered medications for 2 of 2 random observations. A resident was observed self administering a breathing treatment, and a resident was observed self administering eye drops. (Resident 94, Resident 14) Findings include: 1. On 11/28/23 a 9:54 A.M., Resident 94 was observed sitting on the edge of her bed self administering a breathing treatment. Staff was not observed in the room. On 12/1/23 at 1:17 P.M., Resident 94's clinical record was reviewed. Diagnosis included, but was not limited to, respiratory failure. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 11/11/23, indicated no cognitive impairment. Current physician orders included, but were not limited to: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter) (Ipratropium-Albuterol) 1 vial inhale orally four times a day, dated 11/3/23. The EMR (electronic medical record) lacked an order for self administration of medications. The EMR lacked 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 interview and record review, the facility failed to ensure notification to the physician and family representative was completed following a change of resident condition for 1 of 6 residents reviewed for nutrition. The physician nor family representative was notified following a resident's significant weight loss. (Resident F) Finding includes: On 11/29/23 at 1:21 P.M., Resident F's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, hemiplegia/hemiparesis, anxiety and depression. The most recent admission MDS (Minimum Data Set) Assessment, dated 10/11/23, indicated a severe cognitive impairment and no swallowing or dental concerns. Weights included, but were not limited to, the following: 10/3/23 112.6 pounds 11/2/23 108.4 pounds 11/6/23 101.4 pounds Resident F experienced a 9.95% weight loss from 10/3/23 through 11/6/23. A current nutritional care plan included, but was not limited to, the following intervention: Monitor/record/report to MD (Medical Doctor) significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 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 interview and record review, the facility failed to ensure grievances were documented and resolved for 1 of 1 residents reviewed for misappropriation of property. (Resident S) Finding includes: During an anonymous interview on 12/4/23 at 3:05 P.M., it was indicated that an oral grievance was filed on 9/17/23 with Social Service Director (SSD) 7 in regard to Resident S's missing iPad. SSD 7 opened an investigation into the missing iPad, but was unable to locate the device, and indicated the facility would reimburse Resident S for the iPad. Reimbursement was never received. On 12/4/23 at 12:55 P.M., Resident S's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent annual MDS (Minimum Data Set) Assessment, dated 6/23/23, indicated Resident S had mild cognitive impairment. An inventory list, dated 1/24/23, indicated Resident S had one iPad/iPod. The clinical record lacked documentation related to the missing item or related grievance. On 12/5/23 at 10:18 A.M., SSD 7 indicated she was informed of Resident S's missing iPad and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's discharge was documented in the clinical record for 1 of 3 residents reviewed for discharge. (Resident S) Finding includes: On 12/4/23 at 12:55 P.M., Resident S's clinical record was reviewed. Resident S was discharged to the hospital on 9/13/23 and was anticipated to return. A Discharge return anticipated MDS (Minimum Data Set) Assessment was submitted on 9/13/23. A progress note, dated 9/14/23, indicated unwitnessed fall discussed in IDT (Interdisciplinary Team). Fall with major injury. Sent to ER (emergency room) for eval (evaluation) and tx (treatment). A progress note, dated 9/17/23, indicated Discharge Return Anticipated w. (with) ARD (Assessment Reference Date) 9/13/23 Section K completed on this date. A current discharge care plan, revised 8/10/23, indicated my d/c (discharge) plans are to stay here at [name of facility] for long term care. The clinical record lacked any documentation in regard to the outcome of Resident 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 the MDS (Minimum Data Set) Assessment was completed accurately for 2 of 2 residents reviewed for MDS discrepancy. (Resident 76, Resident 16) Findings include: 1. On 11/29/23 at 2:32 P.M., Resident 76's clinical record was reviewed. Diagnoses included, but were not limited to, personal history of transient ischemic attack, vascular dementia, and cognitive communication deficit. The most recent quarterly MDS Assessment, dated 10/13/23, indicated Resident 76 was unable to be assessed for cognitive function due to rarely or never being understood and received an anticoagulant during the 7 day look back period (10/7/23 - 10/13/23). Current physician orders included, but were not limited to: Aspirin (an antiplatelet) Tablet - Give 81 mg (milligrams) by mouth one time a day, dated 5/18/21. Physician orders lacked an order for an anticoagulant medication during the lookback period. 2. On 12/4/23 at 10:41 A.M., Resident 16's clinical record was reviewed. Diagnosis included, but was not limited to, Alzheimer's Disease. 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 interview and record review, the facility failed to ensure baseline care plans were completed for newly admitted residents for 2 of 8 residents reviewed for accidents. (Resident P, Resident T) 1. On 12/1/23 at 1:31 P.M., Resident P's clinical record was reviewed. admission date was 8/31/23. Diagnoses included, but were not limited to, Alzheimer's Disease, dementia, and anxiety. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 10/4/23, indicated a severe cognitive impairment, and one (1) fall with injury since the previous assessment on 9/8/23. A current risk for falls care plan was initiated 9/12/23. A Falls Risk Assessment was completed 8/31/23 that indicated high fall risk. The EMR (electronic medical record) lacked a baseline care plan related to falls. On 12/4/23 at 1:55 P.M., a handwritten 48-hour care plan for baseline functional abilities was provided, with effective date 9/1/23. The form lacked information related to risk for falls. The form was not in the resident's clinical…

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 assess a chronic wound and report changes to the physician for 1 of 3 residents reviewed for wound care. (Resident B) Finding includes: On 12/1/23 at 8:42 A.M., Resident B was observed to have a wound on her right shin. It had a thick crusty surface, was raised in the middle, and was red around the edges. At that time, the DON (Director of Nursing) measured the wound at 6cm (centimeters) x (by) 6cm. On 12/1/23 at 1:04 P.M., Resident B's clinical record was reviewed. Diagnosis included, but was not limited to, neoplasm of uncertain behavior of skin. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 11/10/23, indicated the resident was not cognitively impaired, required extensive assistance of 1 staff for transfers and toileting, and had no skin conditions. Physician orders included, but was not limited to: Please complete weekly skin assessment under assessment tab one time a day every Tue, dated 10/17/2023. A current ADL (activities of daily living) care plan, revised 9/14/22, indicated I…

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 residents received necessary respiratory care and services in accordance with professional standards of practice for 3 of 3 residents reviewed for respiratory care. The facility failed to date tubing and label humidification bottles, and lacked a care plan for oxygen for a resident on oxygen. (Resident 30, Resident 271, Resident 83) Findings include: 1. On 11/28/23 at 10:28 A.M., Resident 30 was observed in his room sitting in a wheelchair wearing oxygen (O2) at 2 L (liters) via nasal cannula. There were no visible dates on the tubing, concentrator, and humidification bottle. On 11/29/23 at 1:14 P.M., Resident 30 was observed sitting in a wheelchair wearing portable O2 at 2 L. The tubing lacked a dated label. On 11/29/23 at 12:54 P.M., Resident 30's clinical record was reviewed. Diagnoses included, but were not limited to, Pulmonary Fibrosis and dyspnea unspecified. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 11/4/23, indicated the resident was cognitively intact, needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to store and prepare food under sanitary conditions related to kitchen equipment and undated and expired dry goods for 2 of 2 observations. Findings include: The kitchen tour occurred between 8:51 A.M. and 11:40 A.M. on 11/27/23. During that time, the following was observed: In the dry storage area: 1 large can of spaghetti sauce dented 1 unlabeled can White powder on cans of apricot preserve Flour not dated when opened Bins not labeled Open box of Cheez-its not dated Open box of Fudge Rounds and [NAME] Buddies not dated when opened 3 bags of fried crisp onions with best by date of [DATE] 3 bag of blue diamond almond sliced with best by June 13 23 3 bags of almonds with best by date of April 13 23 Bag of elbow macaroni open not dated Bag of open egg noodles not dated Box of powdered sugar not dated Brown sugar opened and not dated Box of marshmallows with used by date of May 19 23 Bag of shredded coconut wrapped unable to read open date Hot…

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

Based on observation, interview, and record review, the facility failed to ensure the proper use of protective equipment to prevent the development and transmission of communicable diseases and infections in 1 of 2 residents reviewed for transmission based precautions and 1 of 3 residents reviewed for wound care. (Resident 99, Resident 10) Findings include: 1. On 12/04/23 at 3:37 P.M ., Social Services Director (SSD) 7 was observed coming out Resident 10's room with all of her PPE (Personal Protective Equipment) on and removed it in the hallway. The trash cans and hazardous waste containers were also observed in the hallway outside of the residents room. On 12/4/23 at 3:39 P.M., SSD 7 indicted that she was trained to remove the PPE outside the room. On 12/4/23 at 3:42 P.M., CNA (Certified Nursing Aide) 31 was observed coming out of Resident 10's room after removing her PPE inside the room with her used PPE in a plastic trash bag, and disposed of the bag in the containers outside of the room. On 12/4/23 at 3:45 P.M., CNA 31 indicated PPE equipment should be removed in the room 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.