Waters Of Georgetown, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a confidential interview, between 6/9/25 and 6/16/25, Staff 100 indicated there was only one CNA in each building. If a resident was a mechanical full body lift, sit to stand, or required two staff members for mobility/transfers or toileting, then they would have to call the nurse to come over and help, but sometimes there was a wait until they were free to come over. Some days were harder than others. Staff 100 indicated they had to make time to get all their work done, even on weekends. Showers were being given as they made sure they were. For the most part the villa cleaning got done, maybe not the full deep cleaning that was supposed to be done in 2 rooms every day. During a confidential interview between 6/9/25 and 6/16/25, Staff 101 indicated some [NAME] were harder out of all the [NAME] as there were residents who required a lot of care. There were several residents who required a full body mechanical lift to get up or to be put back to bed and that took two staff members to complete the task.…

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 schedule 8-hour consecutive RN coverage for 1 of 2 months reviewed. (June 2025). This deficiency had the potential to affect the 66 of 66 residents currently residing in the facility. Finding includes: Review of the May and June 2025 as worked nursing schedule on 6/13/25, the following days were missing an RN or had the RN only scheduled for 5 hours: - On 6/5/25, only 6.5 hours of consecutive RN coverage was worked. - On 6/6/25, only 5 hours of consecutive RN coverage was worked. - On 6/7/25, only 5 hours of consecutive RN coverage was worked. - On 6/8/25, no RN coverage was worked - On 6/13/25, no RN coverage was worked. During an interview with the Regional Director of Clinical Operations, on 6/13/25 at 12:30 p.m., she indicated she was aware there might be missing days of RN coverage. The Director of Nursing (DON) was a working DON who covered a Villa as necessary and was involved in all aspects of the facility. 3.1-17(b)(3)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During a confidential interview, between 6/12/25 and 6/16/25, Staff 100 indicated there was only one CNA in each building. If a resident required the use of a full body mechanical lift, sit to stand, or required two staff members assistance for mobility/transfers or toileting, then the nurse would be called to come over and help. Sometimes there was a wait until the nurse was free to come over. Some days were harder than others. During an confidential interview, between 6/9/25 and 6/16/25, Staff 101 indicated some [NAME] were harder because there were some residents who required a lot of care. There were five out of ten residents who required the use of a full body mechanical lift to get up or be put back to bed. The lift would require the assistance of two staff members. The nurses were usually called from another villa to help the CNA do the lift, watched the villa while the CNA toileted residents, or was giving showers. Sometimes there was a wait until staff were finished what they were doing before coming…

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 observation, the facility failed to ensure residents received respiratory care and maintenance for 4 of 4 residents reviewed for respiratory therapy. (Resident 3, Resident 38, Resident 54, and Resident 35) Findings included: 1. The record for Resident 3 was reviewed on 6/10/25 at 1:00 p.m. The resident's diagnosis included, but was not limited to, chronic respiratory failure. The current physician's order, dated 6/13/24, indicated for staff to always maintain the residents' oxygen at 3 liters per nasal cannula. The care plan, dated 6/13/24 and revised on 2/18/25, indicated the resident had Oxygen Therapy related to Ineffective gas exchange. The interventions included, but were not limited to, change the residents position every 2 hours to facilitate lung secretion movement and drainage, give medications as ordered by the physician, monitor for signs of respiratory distress and report to the physician, monitor for side effects and effectiveness, and oxygen via nasal cannula at 3 liters continuously. The current physician's order, dated 2/11/24, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow appropriate infection control guidelines related to complete surveillance documentation to analyze a pattern of know infectious symptoms and patterns. This had the potential to affect 66 of 66 residents residing in the facility. ([NAME] 2, 3, 4, 5, 6, 7, and 8) Findings include: The Quality Assurance Performance Improvement Meeting summary, dated 6/3/25, indicated the infection control book was not able to be located and the facility will continue to update the book for 2025. The Immediate Corrective Actions indicated Identified issue work on last 90 days continue to update. The review of the January 2025 updated Infection Control/Antibiotic Stewardship documentation, the following infections were documented: - 4 respiratory infections for residents. - 11 urinary tract infections (UTIs) for residents. - 4 skin infections for residents. The updated documentation lacked the date of onset, symptoms, culture date with results, re-culture 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 notify the physician and the resident's responsible party related to elevated blood surgar levels for 1 of 3 residents reviewed for notifications. (Resident 33) Findings included: The clinical record for Resident 33 was reviewed on 6/12/25 at 10:30 am. The resident's diagnoses included, but were not limited to atrial fibrillation, hypertension, edema, diabetes, right ankle wound, and unspecified dementia. The physician's order, dated 10/14/24, indicated the resident was precribed HumaLOG KwikPen Subcutaneous Solution (Insulin) Lispro with instructions for a sliding scale subcutaneously before meals and at bedtime. The sliding scale was as follows: Inject as per sliding scale: if resident's blood surgar (BS) level was 150 to 200 staff were to administer 2 units (U); 201 to 250, give 4U; 251 to 300, give 6U; 301 to 350, give 8U; 351 to 400, give 10U; for a BS grater than 400 give 10 units and call the physician. The physician's order, dated 10/14/24, indicated the resident was prescribed HumaLOG KwikPen Subcutaneous Solution…

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 communication between the wound clinic, and documentation of wound assessments for 1 of 7 residents reviewed for wounds. (Resident 33) Findings include: The record for Resident 33 was reviewed on 6/10/25 at 8:49 a.m. The resident's diagnoses included, but were not limited to, type II diabetes and abrasion to the right ankle. The physician's order, dated 4/22/25, indicated the resident was to have a betadine moistened dressing to the wound, and covered with gauze and Coban. The physician's order, dated 5/20/25, indicated staff were to apply a collagen sheet (endoform) to the resident's wound bed, covered with a superabsorbent silicone border dressing. Change the dressing every other day. The physician's order, dated 6/8/25, indicated staff were to cleanse the resident's wound to the right lower extremity with normal saline, apply a collagen dressing, cover with a non-adherent dressing, wrap with a gauze, and secure with Coban every 48 hours for the wound. Staff were to date the dressing after the treatment 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 record review and interview, the facility failed to ensure insulins were administered as prescribed for 2 of 19 residents reviewed for pharmacy services. (Residents 33 and 37) Findings included: 1. The record for Resident 33 was reviewed on 6/12/25 at 10:30 a.m. The resident's diagnoses included, but were not limited to edema, diabetes, right ankle wound, and unspecified dementia. The physician's order, dated 10/14/24, indicated staff were to administer the resident's Humalog per a sliding scale. The sliding scale for before meals and at bedtime was as follows: if the resident's blood sugar (BS) level was 150 to 200 mg (milligrams per deciliters) mg/dL, the staff were to administer 2 U (units) ; 201 to 250 mg/dL, administer 4 U; 251 to 300 mg/dL, administer 6 U; 301 to 350 mg/dL, administer 8 U; 351 to 400 mg/dL, administer 10 U; for a blood sugar level grater than 400 mg/dL, administer 10 units and call the physician. During the review of the June Medication Administration Record (MAR), on 6/16/25 at 1:00 p.m., indicated the following insulin administration times 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 record review and interview, the facility failed to ensure adequate supervision for a resident at risk for elopement for 1 of 5 residents reviewed for accidents hazards. (Resident B). Findings include: The record for Resident B was reviewed on 6/10/25 at 9:48 a.m. The resident's diagnoses included, but were not limited to, Alzheimer's disease and dementia. The care plan, dated 8/16/24 and revised on 5/23/25, indicated the resident was an elopement risk or wanderer, disoriented to place, impaired safety awareness, and a history of leaving a previous facility unsupervised. The interventions included, but were not limited to: assist in reorientation to the room and facility using verbal cues and reminders; the courtyard gate was to be locked with padlock; distract the resident from wandering by offering pleasant diversions, (conversation or offer snack) structured activities, food, conversation, television, and/or book; notify social services and/or the administrator for persistent attempts to leave the…

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

Based on interview and record review, the facility failed to ensure Qualified Medication Aides did not sign off on treatments completed, outside the scope of practice, for 4 of 4 residents reviewed for medical records. (Residents D, E, F and H) Findings include: 1. The clinical record for Resident D was reviewed on 5/15/25 at 3:33 p.m. The resident's diagnosis included, but was not limited to, a stage 4 Pressure ulcer (full-thickness tissue loss with exposure of bone, tendon, or muscle). The April and May 2025 treatment administration record indicated staff were to cleanse the resident's sacral wound with normal saline, apply collagen with normal saline fluffed gauze and cover with a bordered gauze twice daily at 10:00 a.m. and 10:00 p.m. The April and May 2025 treatment administration records indicated the treatment was signed as completed as follows: - On 4/28/25 at 10:00 a.m., the resident's wound treatment was signed by Qualified Medication Aide (QMA) 9 - On 5/01/25 at 10:00 a.m., the resident's wound treatment was signed by QMA 5 - On 5/02/25 at 10:00 a.m., the resident's wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the facility was adequately staffed to provide adequate care and safety for the residents. This deficient practice had the potential to affect 67 of 67 residents residing in the facility. Findings include: During an interview, between 3/24/25 and 3/27/25, Staff Member 11 indicated there was supposed to be an aide in every Villa but that did not always happen. When Staff Member 11 had two [NAME] to administer medications, Staff Member 11 would have to flip flop with the aide in Villa 3 which would leave the residents in Villa 1 alone with no staff in the building for approximately two minutes. There had, however been times when Villa 1 had been left unattended for 5 to 10 minutes. The way the facility staffed the [NAME] was not safe nor was it fair to the residents. During an interview, between 3/24/25 and 3/27/25, Certified Nurse Aide (CNA) 12 indicated the facility was currently short staffed. She had cared for residents that…

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 residents (Resident D, Resident F and Resident G) were monitored for medication side effects and failed to ensure treatments were completed for a resident (Resident L) for 4 of 4 residents reviewed for quality of care. Findings include: 1. The clinical record for Resident D was reviewed on 3/24/25 at 4:48 p.m. The diagnoses included, but were not limited to, diabetes, peripheral vascular disease and systemic lupus. The physician's order, dated 3/21/25, indicated to resident was to receive Eliquis (anticoagulant) 5 mg (milligrams) twice a day for DVT (deep vein thrombosis) prevention. The care plan, dated 1/11/24, indicated the resident was at risk for bleeding due to anticoagulant medication use and to observe for signs and symptoms of complications which included blood tinged or frank blood in urine, black tarry stool, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, petechiae, diarrhea, muscle/joint pain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure unavailable medications were not documented as administered for 1 of 6 residents (Resident E); failed to ensure resident medication administration records accurately reflected the administration of medications for 5 of 6 residents (Resident D, Resident G, Resident H and Resident M); and failed to ensure a resident's (Resident E and Resident L) medication administration record accurately reflected the administration of narcotic pain medication for 2 of 3 reviewed for documentation. Findings include: 1. The clinical record for Resident D was reviewed on 3/24/25 at 4:48 p.m. The resident's diagnosis included, but was not limited to, hypothyroidism. The physician's order, dated 4/18/24, indicated the resident was to receive Levothyroxine Sodium Tablet, 100 mcg (micrograms) daily at 6:00 a.m. The March 2025 medication administration record (MAR) lacked documentation of the administration of the medication on 3/6/25, 3/9/25, 3/12/25 and 3/16/25.…

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.

Based on interview and record review, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 of 3 residents reviewed for abuse. (Resident P) Findings include: The incident report, dated 3/24/25 at 10:30 a.m., indicated Resident P reported that she felt RN (Registered Nurse) 6 was sexually inappropriate during care. The clinical record for Resident P was reviewed on 3/26/25 at 2:57 p.m. The resident's diagnoses included, but were not limited to, diabetes, anxiety, insomnia and GERD (gastroesophageal reflux disease). The quarterly Minimum Data Set (MDS) assessment, dated 1/31/25, indicated the resident's cognition was intact. During an interview, on 3/24/25 at 3:11 p.m., Resident P indicated RN 6 had come to her room to give her evening medications. RN 6 asked Resident P if she needed something to help her sleep and Resident P told her if she had one prescribed. RN 6 responded I did not ask you that. RN 6 told Resident P that she loved her, she was beautiful and that she did not think Resident P was crazy. RN 6 rubbed Resident P's left arm and leg 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 Indwelling catheter care was provided for a resident and failed to ensure urine output was documented as ordered for 2 of 2 residents reviewed for Indwelling catheters. (Resident K and Resident L) Findings include: 1. The clinical record for Resident K was reviewed on 3/27/25 at 10:20 a.m. The resident's diagnosis included, but was not limited to, urinary retention. The care plan, dated 1/3/25, indicated the resident had an Indwelling catheter and staff were to provide catheter care every shift and document the resident's urine output every shift. The physician's order, dated 1/3/25, indicated to provided catheter care every shift. The physician's order, dated 2/26/25, indicated to record catheter output every shift for monitoring. The March 2025 medication administration (MAR) lacked documented urine output on the following dates and shifts: - On 3/3/25 and 3/4/25, there were no documented urine output on day shifts. - On 3/7/25 and 3/8/25, there were no documented urine output on night shifts. - On 3/10/25, 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 a resident's (Resident L) ostomy output was documented and care of the ostomy completed, as ordered by the physician for 1 of 1 resident reviewed for ostomy care. Findings include: The clinical record for Resident L was reviewed on 3/27/25 at 10:54 a.m. The resident's diagnosis included, but was not limited to, ostomy status. The care plan, dated 2/20/25, indicated the resident had an ostomy surgical site and staff were to administer the resident's treatments as ordered. The physician's order, dated 2/15/25, indicated to provide ostomy care and record any liquid output every shift. The resident's March 2025 treatment administration record lacked documentation of care provided and the resident's output on the following dates and shifts: - On 3/4/25, there was no output documented on day shift. - On 3/7/25 and 3/8/25, there were no output documented on night shifts. - On 3/10/25 through 3/12/25, there were no output documented on night shifts. - On 3/13/25, there was no output documented on day shift. - On 3/21/25,…

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.

Based on interview and record review, the facility failed to ensure a resident's (Resident H) scheduled narcotic was administered, as ordered by the physician, for 1 of 3 residents reviewed for medications errors. Findings include: The clinical record for Resident H was reviewed on 3/27/25 at 9:59 a.m. The resident's diagnoses included, but were not limited to, depression, anxiety and age-related osteoporosis. The care plan, dated 3/7/25, indicated the resident was at risk for pain and to administer medications as ordered. The care plan, dated 3/7/25, indicated the resident had an anxiety disorder and to give anti-anxiety medication as ordered by the physician. The physician's order, dated 3/19/25, indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication) 10-325 mg (milligrams) every 6 hours at 6:00 a.m., 12:00 p.m., 6:00 p.m. and 12:00 a.m. for pain. The physician's order, dated 3/6/25, indicated the resident was to receive Xanax (narcotic anti-anxiety medication), 1 mg every 6 hours at 6:00 a.m., 12:00 p.m., 6:00 p.m. and 12:00 a.m. for anxiety.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility failed to provide a resident-centered activities program to support residents in their choice of activities for 4 of 4 residents reviewed for activities (Residents B, C, D, and E). This had the potential to affect 63 of 63 residents that reside in the facility. Findings include: During an observation and interview on 12/30/24 at 10:40 a.m., Villa 6 was observed to have one resident in the common area and no activities present. License Practical Nurse (LPN) 6 indicated she was not a regular employee. There was one aide working with her and she did not know anything about resident scheduled activities. During an observation on 12/30/24 at 10:47 a.m., Villa 2 was observed with one resident in the common area and no activities present. During an interview with QMA 3, she indicated she was the only staff member in the Villa. There was no time for activities when you are trying to get everything done. During an observation and interview on 12/30/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure each Villa/unit was staffed with the appropriate staff to ensure the resident received care and services in a timely manner related to bathing, toileting, behavior/supervision, and resident-centered activities. This deficient practice had the potential to affect 63 of 63 residents residing in the facility. Findings include: During an observation on 12/30/24 at 10:20 a.m., the facility had a total of 8 [NAME] (independent building that housed up to 10 residents in each unit). The facility was laid out like a small subdivision, with two roads and the individual [NAME] each had a kitchen, living room, laundry, and resident bedrooms. There was sidewalks and grass lawns between each Villa. The staff had to walk outside to get from one Villa to the other. Villa 2 had ten residents that required bathing assistance and one resident that required two staff members assistance with a mechanical lift; Villa 3 had ten residents that 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.

Based on record review, observation, and interview, the facility failed to ensure a resident's plan of care was revised for 1 of 4 residents reviewed for behaviors and exit-seeking. (Resident E ) Findings included: The record for Resident E was reviewed on 12/31/24 at 8:30 a.m. The residents' diagnoses included, but were not limited to unspecified sequelae of cerebral infarction; unspecified dementia, psychotic disturbance, mood disturbance, and anxiety; Muscle weakness (generalized); Difficulty in walking, not elsewhere classified, aphasia (a language disorder that affects a person's ability to understand and express written and spoken language); and need for assistance with personal care. The admission Minimum Data Set (MDS) assessment, dated 10/10/24, indicated the resident's cognition was severely impaired. The resident's mobility was impaired on one lower extremity. A progress note, dated 12/01/24 at 8:08 p.m., indicated the resident was in bed yelling out I want sex. The note indicated the nurse tried to redirect the resident and was unsuccessful. A progress note, 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 interview, record review and observation, the facility failed to ensure residents who were dependent on staff for activities of daily living received the care and services needed related to incontinence care and bathing for 2 of 4 residents reviewed for Activities of Daily Living. (Residents D and E) Findings include: 1.a. The clinical record for Resident D was reviewed on 12/31/24 at 11:30 am. The resident's diagnoses included, but were not limited to, flaccid hemiplegia affecting the right dominant side, muscle weakness, transient cerebral ischemic attack, unspecified, and unspecified abnormalities of gait and mobility with lack of coordination. The Quarterly Minimum Data Set (MDS) assessment, dated 10/27/24, indicated the resident's cognition was mildly impaired. The resident's mobility was impaired on one side of his upper and lower extremities. He required maximal staff assistance with personal hygiene/bathing. The care plan, dated 1/22/24 and revised on 4/19/24, indicated the resident was…

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

Based on observation, record review, and interview, the facility failed to ensure residents were safe from falls with the use of motion sensor alarms, testing of alarms, and prompt attention for 2 of 7 residents reviewed for falls. (Residents 20 and 5) Findings include: 1. During an observation on 6/24/24 at 11:25 a.m., Resident 20 appeared confused and was sitting at the dining table near the staff. The record for Resident 20 was reviewed on 6/25/24 at 1:42 p.m. The resident's diagnoses included, but were not limited to, displaced fracture of the right humerus, fracture of the second lumbar vertebra, unsteadiness on her feet, dementia, abnormalities of her gait and mobility, osteoporosis, and a need for assistance with her personal care. The admission MDS (Minimum Data Set) assessment, dated 10/24/23, indicated the resident was moderately cognitively impaired. She required supervision or touching assistance for toileting and partial to moderate assistance for showers. The resident had impairment to one side and used a walker. The nurse's note, dated 10/21/23 at 9:10 p.m., indicated…

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

Based on observation, interview and record review, the facility failed to ensure a resident's (Resident B) plan of care was updated for 1 of 3 residents reviewed for care plans. Findings include: The clinical record for Resident B was reviewed on 4/15/24 at 2:30 p.m. The resident's diagnoses included, but were not limited to, dementia, depression and anxiety. On 4/15/24 at 11:30 a.m., during an observation the resident was observed resting in bed with her eyes closed. She was covered with 4 blankets and a sheet. The care plan, originally dated 6/17/22 with a revision on 1/29/24, indicated the resident had an actual skin impairment of a rash to the lower back. The interventions included, but were not limited to, for staff to assist the resident to turn and reposition every 2 hours, educate resident/family/caregivers of causative factors and measurements to prevent skin injury, provide good nutrition and hydration and complete treatments as ordered. The progress note, dated 2/19/24 at 12:54 a.m., indicated the resident had a rash to both sides of her lower back and the nurse…

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 (Residents D, E and F) were provided appropriate care for 3 of 5 residents reviewed for Activities of Daily Living. Findings include: 1. The clinical record for Resident D was reviewed on 12/28/23 at 1:11 p.m. The diagnoses included, but were not limited to, diabetes, cognitive communication deficit and depression. The quarterly MDS (Minimum Data Set) assessment, dated 11/29/23, indicated the resident's cognition was intact. She required partial to moderate assistance with bed mobility and substantial/maximal assistance with bed mobility. The care plan, dated 4/17/23, indicated a self-care deficit and required staff assistance with personal hygiene, bed mobility and up to total assistance with transfers. The written statement for Resident D, dated 12/7/23, indicated CNA (Certified Nurse Aide) 6 was mean and plopped her in the bed and would not check on her during the night. He squeezed her arms tight when he helped her up and it hurt. He seemed miserable to have to help her and did not appear to like his…

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 an ongoing activity program to meet the interest of and support the physical, mental, and psychosocial well-being of the residents for 6 of 6 resident observations. This deficient practice had the potential to affect all 65 residents residing in the facility. (Residents 24, 28, 35, 47, 50, and 45) Findings include: 1. The record for Resident 24 was reviewed on 4/24/23 at 10:08 a.m. The diagnoses included but were not limited to dementia, anxiety disorder, and major depressive disorder. The Quarterly MDS (Minimal Data Set) assessment, dated 3/8/23, indicated the resident was moderately intact cognitively. The care plan, dated 12/21/21 and revised on 8/19/22, indicated Resident 24 would actively participate in activities of interest, his family visited a lot, he enjoyed playing games with the group and watched his television daily, he enjoyed coloring and the activity department would supply coloring pages and colored pencils as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6. The record for Resident 16 was reviewed on 4/24/23 at 10:08 a.m. The diagnoses included but was not limited to rheumatoid arthritis. The nurse's note, dated 5/28/22 at 8:14 p.m., indicated the resident asked how much of her Humira was left when the nurse gave the resident her injection. The nurse indicated that was the resident's last dose in the refrigerator. Resident 16 indicated that her family member just brought some in and she should have a whole new box. The nurse rechecked in the refrigerator but did not find any. The nurse proceeded to check in the nurse's office and on the counters. She found the Humira box stuffed in a corner of the office above the refrigerator. She notified the resident who then notified her family member. The residents family member placed a call to the pharmacy to ask if the Humira injection was still good. Resident 16 and her family member were upset because the medication was not refrigerated when it was brought to the facility. The Annual MDS assessment, dated 11/16/22,…

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

Based on record review and interview, the facility failed to notify the physician when a resident developed a firm to the touch raised area in a recent surgical incision of a hip fracture for 1 of 6 residents reviewed for physician notification. (Resident 17) Finding includes: The record for Resident 17 was reviewed on 4/24/23 at 9:53 a.m. The diagnoses included, but were not limited to, displaced intertrochanteric fracture of left femur, fracture of the left upper end of left tibia, muscle weakness, age-related osteoporosis, and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 3/24/23, indicated the resident was severely cognitively impaired, required extensive assistance of two staff members' for bed mobility and transfers, required one staff member's assistance to ambulate in room, her balance was unsteady which required staff to help stabilize, she had one fall since her admission, and she had one side lower extremity impairment in functional range of motion. On 2/7/23, the physician gave an order for the resident to be non-weight bearing on the left leg. 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 record review and interview, the facility failed to ensure a preventative device was placed timely to prevent the development of a pressure ulcer during the review of 1 of 4 pressure ulcers reviewed. (Resident 20) Findings include: The record was reviewed for Resident 20 on 4/20/23 at 9:49 a.m. The diagnoses included, but were not limited to, need for assistance with personal care, muscle weakness, contractures of the left and right ankles, osteoarthritis, dementia, polyneuropathy, type 2 Diabetes Mellitus, and intervertebral degeneration. The Interdisciplinary note, dated 12/8/22 at 11:31 a.m., indicated the resident returned to facility in 2019. She had a history of impaired skin and had fragile skin to the coccyx. The Quarterly MDS (Minimum Data Set) assessment, dated 2/2/23, indicated the resident was cognitively intact. She required extensive assistance of two staff for bed mobility, transfers, toileting and personal hygiene. The care plan, dated 2/4/22 and last revised on 5/27/22, indicated the resident had the potential for pressure ulcer development related to her…

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 physicians' orders were transcribed accurately to pharmacy for timely administration for 2 of 7 residents reviewed for significant medication errors. (Residents 50 and 34) Findings include: 1. The clinical record for Resident 50 was reviewed on 4/25/23 at 10:00 a.m. The diagnoses included, but were not limited to difficulty in walking, need for assistance with personal care, methicillin resistant staphylococcus aureus infection, retention of urine, and BPH (benign prostatic hyperplasia). The care plan, dated 2/10/22, indicated the resident had a diagnosis of BPH. The interventions indicated to provide intermittent catheterization per the MD (medical doctor) order, to notify the MD of concerns or changes PRN (as needed), and to provide a urology consult as needed. The Quarterly MDS (Minimum Data Set) assessment, dated 5/19/22, indicated the resident was cognitively intact. He required limited assistance of one person for bed mobility 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 record review and interview, the facility failed to ensure the residents were COVID-19 tested in accordance with their policy for 2 of 23 residents reviewed for COVID testing. (Residents 43 and 17) Findings include: 1. The clinical record for Resident 43 was reviewed on 4/24/23 at 10:13 a.m. The diagnoses included, but were not limited to, Parkinson's disease, personal history of COVID-19, and dysphagia. The Quarterly Minimum Data Set (MDS) assessment, dated 2/15/23, indicated the resident was alert and oriented. On 1/10/23, a new physician's order was received for COVID testing every 24 hours as needed. The Nurse's note, dated 3/1/23 at 6:33 a.m., indicated the resident no longer had nausea, vomiting or loose stools. The nursing note, dated 3/2/23 at 3:48 a.m., indicated the resident had intravenous fluids running although was taking fluids well. The clinical record lacked documentation of the resident having been COVID tested when experiencing symptoms. During an interview on 4/24/23 at 11:33 a.m., Unit Manager, indicated if a resident was experiencing any symptoms…

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.