Waters Of Castleton Skilled Nursing Facility, The

Based on interview and record review the facility failed to document thorough investigations for allegations of abuse for 1 of 5 residents investigated for abuse (Resident F).Finding include: The clinical record for Resident F was reviewed on 3/10/26 at 1:10 p.m. The resident's diagnosis included, but was not limited to, Down Syndrome (genetic condition resulting in distinct physical features, developmental delays, and mild-to-moderate intellectual disabilities). On 3/11/26 at 10:58 a.m., the Nurse Consultant (NC) provided a copy of the allegation of abuse investigation for Resident F for review. The investigation file contained an Incident Report, dated 12/27/25, that indicated Resident F had witnessed a verbal disagreement between Qualified Medication Aide (QMA) 10 and Certified Nursing Assistant (CNA) 11. The immediate action taken was to suspend QMA 10 and CNA 11 pending outcome of the investigation. The investigation file did not contain statements from QMA 10 or CNA 11 about the verbal disagreement. On 3/11/26 at 12:58 p.m., the NC provided a written statement from QMA 10,…

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 urinary catheter was available for resident use for 1 of 1 resident reviewed for urinary catheters. (Resident G)Findings include: The clinical record for Resident G was reviewed on 3/10/26 at 11:30 a.m. The diagnoses included, but were not limited to, paraplegia (paralysis of lower body) and neuromuscular dysfunction of bladder (loss of bladder control). An admission Minimum Data Set (MDS Assessment, dated 2/18/26, indicated Resident G was cognitively intact. A care plan, dated 2/7/26, indicated the resident had the potential for infection due to the need for intermittent self-catheterization (resident will insert a tube to empty his bladder) related to neurogenic bladder. A physician's visit note, dated 2/13/26, indicated Resident G wanted to be seen due to urgent request regarding catheter supplies.patient reports he is running low on straight catheters and requires an order to prevent running out. He verbalizes concern that without appropriate supply he would be forced to reuse catheters,…

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 new behaviors were documented in the clinical record and to ensure staff were monitoring and tracking behaviors for 1 of 5 residents reviewed for abuse and 1 of 5 residents reviewed for call light response (Resident B and Resident D).Findings include:1. The clinical record for Resident D was reviewed on 3/10/26 at 11:20 a.m. The resident's diagnoses included, but were not limited to, dementia (mental decline) and bipolar disorder (a chronic mental health condition causing extreme shifts in mood, energy, and activity levels). A physician's order, dated 4/24/25, indicated Resident D's behavior was to be monitored each shift for delusions/hallucinations, tearfulness, crying, verbal expressions of sadness, anger, yelling, cursing, insomnia, anxiety, skin picking, and physical aggression. A Quarterly MDS Assessment, dated 1/9/26, indicated the resident had moderately impaired cognition and had not displayed behaviors during the assessment period. A care plan, revised on 1/21/26, indicated Resident D had…

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

Based on observation, interview, and record review, the facility failed to ensure outdated items were discarded from the refrigerator timely, items were not open to air in the refrigerator, and the kitchen and kitchen equipment were clean with the potential to affect 50 of 51 residents residing at the facility.Findings include: On 12/9/25 at 9:45 a.m., the facility kitchen was observed with the Dietary Manager (DM). The walk-in refrigerator contained a silver pan of gelatin, dated 11/30/25, and a package of sliced cheese that was not sealed. The DM indicated the gelatin should be discarded and the cheese should have been wrapped completely and would be discarded. The kitchen floor had a film and did not appear to be clean. On 12/11/25 at 10:27 a.m., the facility kitchen was observed to have a dirty film and did not appear to have been mopped. On 12/11/25 at 12:35 p.m., the second-floor kitchenette was observed. The inside of the double-door refrigerator had dried food substances at the sides of the floor and a piece of fuzz stuck to the floor on the bottom of the interior…

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 timely discontinue an anti-psychotic medication as recommended by pharmacy and medial provider for 1 of 6 residents reviewed for unnecessary medications. (Resident 7) Findings include: The clinical record for Resident 7 was reviewed on 12/9/25 at 3:00 p.m. The resident's diagnoses included, but were not limited to, dementia. A physician order, dated 9/15/25, indicated Resident 7 was to receive 0.25 milligrams of risperidone at night for agitation. A November 2025 pharmacy recommendation for Resident 7 indicated the medical provider needed to provide justification for the usage of the 0.25 milligrams of risperidone at bedtime for agitation. The medical provider responded with discontinuation of the 0.25 milligrams of risperidone at bedtime for Resident 7 as of 12/4/25. The staff was to monitor the resident for worsening symptoms. A medical provider note, dated 12/4/25, indicated the pharmacy had reviewed Resident 7's medications. The recommendation indicated that the resident does not have appropriate diagnosis to support…

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 transfer form was sent with a resident who was transferred to an acute care hospital for 1 of 2 residents reviewed for hospitalization (Resident 2)Findings include: The clinical record for Resident 2 was reviewed on 12/10/25 at 11:00 a.m. The resident's diagnoses included, but were not limited to, Alzheimer's Disease and history of falling. An interview was conducted with Resident 2's Representative on 12/10/25 at 11:37 a.m. She indicated Resident 2 had been hospitalized for low blood sugar at the beginning of October. Resident 2's medical record did not include a transfer form for the resident being discharged to the hospital. Hospital records for Resident 2 were provided by the Nurse Consultant on 12/16/25 at 1:32 p.m. It indicated Resident 2 was brought in by Emergency Medical Services (EMS) and admitted to the hospital on [DATE]. The chief complaint was altered mental status. An interview was conducted with the Director of Nursing 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 interview and record review, the facility failed to ensure a care plan accurately reflected resident wishes regarding discharge and to ensure care plan meetings were held timely for 2 of 3 residents reviewed for discharge care plans, 1 of 1 resident reviewed for notification of change, and 1 of 3 residents reviewed for care plans (Resident 4, Resident 37, Resident 36, and Resident 20)1. The clinical record for Resident 4 was reviewed 12/12/2025 at 1:30 p.m. The medical diagnoses included, but were not limited to, diabetes and polyneuropathy. A Quarterly Minimum Data Set Assessment, dated 9/4/2025, indicated Resident 4 was cognitively intact, had no active discharge planning, and did not want to speak to someone about returning to the community. A discharge care plan, dated 8/31/2023 and revised on 11/8/2025, indicated Resident 4 wanted to discharge home. The interventions included, but were not limited to, for staff to offer support and encouragement as needed. A progress note, dated 6/19/2025, indicated Resident 4 wished to stay in the facility and not discharge to the…

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

Based on observation, interview, and record review, the facility failed to ensure the optometry plan of care was implemented for a resident with glaucoma for 1 of 1 resident reviewed for vision services ( Resident 17).Finding include: The clinical record for Resident 17 was reviewed on 12/9/25 at 11:45 a.m. The resident's diagnosis included, but was not limited to, glaucoma.An Eye Care Chart Note, dated 4/11/25, indicated Resident 17 had blurred vision in the right and left eyes. The assessment and plan was to treat her open-angle glaucoma in both eyes with brimonidine 0.1% dorzolamide 2% (medication to treat high eye pressure) eye drops 1 drop into each eye twice daily and latanoprost 0.0005% eye drop (medication to treat open-angle glaucoma) one drop in both eyes at bedtime.A physician's order, dated 4/26/25, indicated she was to receive brimonidine tartrate ophthalmic solution 0.2 % 1 drop into both eyes two times a day for glaucoma.The clinical record did not contain an order for latanoprost eye drops. A Quarterly Minimum Data Set (MDS) Assessment, completed 11/28/25, 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 interview, observation, and record review, the facility failed to address a resident's (Resident 26) pain by ensuring availability of pain medications and implementing other pain relief interventions for 1 of 1 resident reviewed for pain management. Findings include:The clinical record for Resident 26 was reviewed on 12/12/2025 at 1:30 p.m. The medical diagnoses included, but were not limited to, cancer and pneumonia.An admission minimum data set (MDS) assessment, dated 11/13/2025, indicated Resident 26 was cognitively intact, frequently had pain, utilized as needed pain medication, and the severity raised to a 9/10.A pain care plan, dated 11/23/2025, indicated that Resident 26 was at risk for pain and discomfort. The interventions included for staff to administer pain medications as ordered and the use of non-pharmacological relief of pain. During an observation and interview, on 12/09/2025 11:53 AM, Resident 26 was laying in bed. He was observed to be rubbing his right thigh frequently and having facial grimacing. Resident 26 indicated he was having pain at 8/10 and could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the availability of a resident's seizure medication for 1 of 6 unnecessary medications reviewed. (Resident 58)Findings include: The clinical record for Resident 58 was reviewed on 12/10/25 at 1:00 p.m. The resident's diagnoses included, but were not limited to, anoxic brain injury (brain deprived of oxygen), tracheostomy (airway in neck) and epilepsy. The resident was admitted to the facility on [DATE]. A physician's order, dated 12/9/25, indicated the resident was to receive 100 milligrams of lacosamide for seizures twice a day. The December 2025 Medication Administration Record (MAR) for Resident 58 indicated the following days and times the administration of 100 milligrams of lacosamide: -On 12/10/25 at 9:00 a.m. and 9:00 p.m., the medication was not available to be administered.-On 12/11/25 at 9:00 a.m. and 9:00 p.m., the medication was not available to be administered. -On 12/12/25 at 9:00 a.m., administered medication as…

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

Based on interview and record review, the facility failed to timely address a pharmacy recommendation to discontinue a resident's medications for 1 of 6 residents reviewed for unnecessary medications. (Resident 5) Findings include: The clinical record for Resident 5 was reviewed on 12/10/25 at 1:30 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD). A physician's order, dated 7/17/25, indicated Resident 5 was to receive 0.125 milligrams of hyoscyamine sulfate every 2 hours PRN (as needed). An October 2025 pharmacy recommendation indicated to discontinue unused PRN medications for Resident 5. The PRN 0.125 milligrams of hyoscyamine sulfate had not been used in the last 60 days. The pharmacy was recommending the medical provider to discontinue the medication. The medical provider as of 10/30/25 agreed to discontinue the medication. The November 2025 Medication Administration Record (MAR) indicated Resident 5 was able to receive 0.125 milligrams of hyoscyamine Sulfate every 2 hours PRN. A November 2025 pharmacy recommendation…

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 residents received mechanically altered diets, as ordered by the physician, for 3 residents randomly observed at meal service (Resident 25, Resident 31, and Resident 36).Findings include: 1 a. The clinical record for Resident 31 was reviewed on 12/11/25 at 12:55 p.m. The resident's diagnosis included, but was not limited to, dementia. A physician's order, dated 12/4/23, indicated she was to receive a mechanical soft, ground meat texture diet. 1 b. The clinical record for Resident 25 was reviewed on 12/11/15 at 12:55 p.m. The resident's diagnosis included, but was not limited to, dysphagia (inability to swallow). A physician's order, dated 7/31/24, indicated she was to receive a mechanical soft, ground meat texture diet. 1c. The clinical record for Resident 36 was reviewed on 12/9/25 at 2:20 p.m. The resident's diagnosis included, but was not limited to, dysphagia. A physician's order, dated 7/22/25, indicated she was to receive a mechanical soft, chopped meat texture diet with nectar thick liquids. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' medical records were accurately documented for the administration of a resident's seizure medication and for the administration of a resident's eye drops for 1 of 6 unnecessary medications reviewed, 1 of 1 resident reviewed for vision services, and 1 or 3 reviewed for potential communication concerns. (Resident 58, Resident 17, and Resident 26) Findings include: 1.The clinical record for Resident 58 was reviewed on 12/10/25 at 1:00 p.m. The resident's diagnoses included, but were not limited to, anoxic brain injury (brain deprived of oxygen), tracheostomy (airway in neck) and epilepsy. The resident was admitted to the facility on [DATE]. A physician's order, dated 12/9/25, indicated the resident was to receive 100 milligrams of lacosamide for seizures twice a day. The December 2025 Medication Administration Record (MAR) for Resident 58 indicated the following days and times the administration of 100 milligrams of lacosamide: -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 interview, observation, and record review, the facility should ensure the indwelling urinary catheter bag remains free of contact with the floor, that hand hygiene was performed prior to donning gloves, and that the hub of an insulin pen was disinfected prior to attaching the needle, for 1 or 1 residents reviewed for urinary catheters and 1 of 5 residents randomly observed during medication pass . (Resident 8 and Resident 1) Findings include:Findings include: 1.The clinical record for Resident 8 was reviewed on 12/11/2025 at 3:00 p.m. Medical diagnosis include, but were not limited to, a stroke. A Quarterly Minimum Data Set assessment, dated 11/11/2025, indicated Resident 8 was cognitively impaired and was frequently incontinent of bladder. A urological care plan, dated 11/12/2025, indicated Resident 8 had uropathy. Intervention included the use of a catheter. During an observation, on 12/09/2025 2:57 PM, Resident 8's indwelling urinary catheter bag was noted to be contacting the floor. During an observation, on 12/10/2025 1:21 PM, Resident 8's indwelling urinary catheter…

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 administer a resident's antipsychotic medication, as ordered; inform the physician/provider of the medication not having been administered; and implement and revise a resident's behavior care plan regarding refusal of care and medication for 1 of 3 residents reviewed for behavioral Health Services. (Resident B)Findings include:The clinical record for Resident B was reviewed on 10/28/25 at 2:42 p.m. His diagnoses included, but were not limited to: anxiety, paranoid schizophrenia, dementia, and depression. He was readmitted to the facility on [DATE] after a 20-day inpatient psychiatric hospitalization. The Inpatient Psychiatric Hospital Discharge Medication Reconciliation, dated 9/23/25, indicated staff were to administer the resident's Uzedy (atypical antipsychotic medication) 75 mg/0.21ml subcutaneously every 30 days at 9:00 am. His last administration was on 9/18/25 at 9:59 a.m.The facility physician's orders indicated to administer the…

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

Based on observation, interview, and record review, the facility failed to ensure a fall intervention was implemented timely after a fall event occurred and fall interventions were in place for 1 of 3 residents reviewed for accidents. (Resident D) Findings include: The clinical record for Resident D was reviewed on 4/16/25 at 11:30 a.m. The diagnoses included, but were not limited to, borderline personality disorder, bipolar disorder, schizoaffective disorder, generalized anxiety disorder, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 4/9/25, indicated Resident D was moderately cognitively impaired and had two or more falls since the last MDS assessment. A care plan, revised 4/14/25, indicated Resident D was at risk for falls related to incontinence and psychoactive drug use. The interventions included, but were not limited to, anti-roll backs to the wheelchair, initiated on 4/14/25, and encourage the resident to wear nonskid footwear and/or nonskid socks, initiated on 3/11/25. A progress note, dated 4/13/25 at 10:46 p.m., indicated Resident D…

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 narcotic medication was administered per the physician orders, narcotic medication was readily available for use, and intravenous (IV) antibiotics were obtained to be administered as ordered by the physician for 2 of 3 residents reviewed for medication use. (Resident C and Resident D) Findings include: 1a. The clinical record for Resident C was reviewed on 4/16/25 at 10:47 a.m. The diagnoses included, but were not limited to, osteomyelitis (infection of bone), pressure ulcer of sacral region, paraplegia, and muscle spasm. Resident C was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) assessment, dated 3/6/25, indicated Resident C was cognitively intact, had one injection, utilized antianxiety medication, antibiotic medication, and opioid medication. A care plan for IV medications, revised 3/7/25, indicated Resident C was on IV antibiotics related to osteomyelitis. A physician order, dated 2/28/25, indicated to administer…

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 gradual dose reduction (GDR) was conducted instead of abruptly discontinuing an antidepressant medication and antianxiety medication for 1 of 3 residents reviewed for unnecessary medications. (Resident B) Findings include: The clinical record for Resident B was reviewed on 4/16/25 at 9:30 a.m. The diagnoses included, but were not limited to, stroke, dementia, anxiety disorder, alcohol abuse, and depression. The resident was admitted on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 1/17/25, indicated Resident B was cognitively impaired. A long-term care facility discharge medication summary, date of discharge 1/7/25, indicated Resident B received the following psychotropic medications: Start date: 10/21/24 - 0.5 milligrams of lorazepam (antianxiety/benzodiazepine) twice a day, Start date: 8/3/24 - 5 milligrams of Zyprexa (antipsychotic) three times a day, and Start date: 12/16/24 - 100 milligrams of sertraline (antidepressant)…

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 honor a resident's right for dignity to 2 of 5 residents reviewed for timely response to call lights and 1 of 1 resident reviewed for incontinence care by offering an incontinence brief. (Resident C and Resident F) Findings include: 1. In an interview with Resident C on 3-31-25 at 1:46 p.m., she indicated the minimum amount of time it took to get her call light answered was typically 30 minutes and this reflected all shifts, but especially night shift. She indicated she had been a resident of the facility for over five years. The clinical record of Resident C was reviewed on 3-31-25 at 12:05 p.m. Her most recent Minimum Data Set assessment, dated 3-15-25, indicated she was cognitively intact. 2. In an interview with a family member of Resident F on 4-1-25 at 2:46 p.m., she indicated earlier in the day, the resident had activated the call light to request toileting assistance. She added the call light had been on for about 20 minutes when she (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 A. Based on interview and record review, the facility failed to ensure the attending physician and family were notified in a timely manner of a significant weight loss in less than 30 days for 1 of 2 residents reviewed for gastric feedings. (Resident G) B. Based on interview and record review, the facility failed to ensure the attending physician and family were notified in a timely manner of a new open area to a resident's neck for 1 of 2 residents reviewed for notification of change in condition. (Resident D) Findings include: A. During an interview on 4-1-25 at 3:56 p.m., with a family member of Resident G, she indicated during the previous night, she had spent the night in Resident G's room, at his request. She explained Resident G had several strokes during 2024, resulting in significant paralysis and an inability to swallow safely, thus causing him to require a feeding tube. The clinical record of Resident G was reviewed on 4-2-25 at 1:46 p.m. His diagnoses included, but were not limited to,…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 of 5 residents reviewed for bathing and hygiene care needs. (Resident B) Findings include: The clinical record of Resident B was reviewed on 3-31-25 at 10:12 a.m. His diagnoses included, but were not limited to, pneumonia, unspecified cirrhosis of liver, unspecified abnormalities of gait and mobility, cognitive communication deficit and general muscle weakness. His admission Minimum Data Set (MDS) assessment, dated 12-12-24, indicated he was moderately cognitively impaired, required moderate assistance from staff for bathing or showering, and supervision from staff for hygiene care. In an interview with a family member of Resident B on 3-31-25 at 11:15 a.m., he indicated Resident B received very few showers while at the facility. A comprehensive care plan was not located in Resident B's clinical record for assistance with activities of daily living (ADL's) or specifically for bathing and hygiene care needs. In an interview on 4-1-25 at 9:40 a.m. with the Director of Nursing (DON), he…

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 provide bathing and/or showering care for 1 of 5 residents reviewed for bathing and hygiene care needs. (Resident B) Findings include: The clinical record of Resident B was reviewed on 3-31-25 at 10:12 a.m. His diagnoses included, but were not limited to, pneumonia, unspecified cirrhosis of liver, unspecified abnormalities of gait and mobility, cognitive communication deficit, and general muscle weakness. His admission Minimum Data Set (MDS) assessment, dated 12-12-24, indicated he was moderately cognitively impaired, required moderate assistance from staff for bathing or showering and supervision from staff for hygiene care and it was very important, for him to be able to choose what manner of bathing he received, such as tub bath, shower, bed bath or sponge bath. In an interview with a family member of Resident B on 3-31-25 at 11:15 a.m., he indicated Resident B received very few showers while at the facility. In an interview on 4-1-25 at 11:04 a.m., with the MDS Coordinator, she indicated It looks like I overlooked…

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 receiving continuous enteral (gastric) feedings received feedings as ordered and a significant weight loss occurring in less than 30 days was identified and timely interventions related to the weight loss were conducted for 1 of 2 residents reviewed for gastric feedings. (Resident G) Findings include: During an interview on 4-1-25 at 3:56 p.m., with a family member of Resident G, she indicated during the previous night, she had spent the night in Resident G's room, at his request. She explained Resident G had several strokes during 2024, resulting in significant paralysis and an inability to swallow safely, thus causing him to require a feeding tube. She indicated sometime between 2:00 a.m. and 4:00 a.m., on 4-1-25, the continuous feeding had run out and it had not been resumed prior to her leaving the facility later that morning at 8:20 a.m. She indicated the nursing staff informed her the reason the feeding was not resumed 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 interview and record review, the facility failed to thoroughly document information regarding the identification of a newly identified open area and information regarding notification of a change in condition to the family regarding the new open area for 1 of 2 residents reviewed for tracheostomies (trach). (Resident D) Findings include: The clinical record of Resident D was reviewed on 4-1-25 at 11:01 a.m. It indicated his diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, tracheostomy status and dysphagia. His most recent Minimum Data Set (MDS) assessment, dated 1-25-25, indicated he was severely cognitively impaired, was nonverbal, nonambulatory, and was dependent on staff for all activities of daily care. It indicated he had a feeding tube and a tracheostomy, which required oxygen support and tracheostomy care, including suctioning. It indicated he did not have any pressure ulcers, but did have an open area to his feet and moisture associated skin damage. In an interview on 4-2-25 at 12:30 p.m. with…

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 have a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This had the potential to affect 49 of 49 residents in the facility. Findings include: The Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of the 2024 Federal Fiscal Year indicated the facility had no RN coverage hours on the following dates: 4/7/24, 4/20/24, 4/21/24, 5/4/24, 5/5/24, 5/18/24, 5/19/24, 5/27/24, 6/1/24, 6/2/24, 6/15/24, 6/16/24, and 6/30/24. On 10/3/24 at 10:20 a.m., the Administrator provided the Daily Nursing Schedule for the above dates. They, along with the time sheets for RN 9 provided by the Director of Nursing (DON), on 10/4/24 at 10:45 a.m., indicated there was no RN coverage on Saturday, 4/20/24, and Sunday, 4/21/24, but the schedule and time sheets did verify RN coverage for 4/7/24, 5/4/24, 5/5/24, 5/18/24, 5/19/24, 5/27/24, 6/1/24, 6/2/24, 6/15/24, 6/16/24, and 6/30/24. An interview was conducted with the Staffing Coordinator (SC) and the DON on 10/3/24 at 11:28 a.m. The SC…

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 hold food on a steam table at safe temperatures with the potential to affect 48 of 49 residents residing at the facility. Findings include: On 10/4/24 at 12:41 p.m., the lunch service was observed in the facility's main kitchen with Facility [NAME] (FC) 1. FC 1 indicated he was serving the room trays. The steam table contained a serving pan of mixed vegetables and a serving pan of [NAME] fish filets. The temperature of the mixed vegetables was obtained at 121.8 degrees Fahrenheit (F). The temperature of the [NAME] fish fillets was obtained at 107 degrees F. FC 1 indicated the temperature of the mixed vegetables, and the [NAME] fish filets should have been at least 135 degrees F. On 10/4/24 at 12:48 p.m., the lunch service was observed in the facility's upstairs kitchenette. FC 2 indicated he was finishing the upstairs dining room's food service. The steam table contained a serving pan of French fries. The temperature of the French fries…

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 administer medications and collect urine samples as ordered, to timely schedule a follow-up appointment for a resident who was admitted with a healing leg fracture, and timely implement dietary recommendations for a resident with a feeding tube for 1 of 1 resident reviewed for mobility, 1 of 1 resident reviewed for feeding tubes, and 3 of 5 residents reviewed for unnecessary medications. (Resident 11, Resident 29, Resident 30, Resident 42, and Resident 95) Findings include: 1. The clinical record for Resident 42 was reviewed on 10/3/24 at 1:18 p.m. The diagnoses included, but were not limited to, fracture of the lower femur (thighbone) and depression. She was admitted to the facility on [DATE]. A physician's progress note, dated 9/10/24, indicated Resident 42 had recently admitted to the facility. She had a previous stay at another rehabilitation facility following a right femur fracture on 7/26/24. An admission Minimum Data Set (MDS)…

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 5 of 5 residents medical records included documentation that indicated the resident or resident representative was provided education regarding the benefits and potential risks associated with the 2023-2024 COVID-19 vaccine; whether the COVID-19 vaccine was administered to the resident; or whether the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal for 4 of 5 residents reviewed for COVID-19 immunization. (Residents 11, 18, 20, 24, and 30) Findings include: The clinical records for Residents 11, 18, 20, 24, and 30 were reviewed on 10/3/24 at 11:48 a.m. Resident 11 was admitted to the facility on [DATE]. Resident 11's clinical record indicated he was last administered the COVID-19 vaccine on 7/7/22. There was no information in his clinical record that indicated Resident 11 or Resident 11's representative was provided education regarding the benefits and potential risks associated with the 2023-2024…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's dignity was maintained by not sitting down while assisting a resident with eating for 1 of 1 resident randomly observed during dining. (Resident 2) Findings include: The clinical record for Resident 2 was reviewed on 10/7/24 at 11:00 a.m. The diagnoses included, but were not limited to, dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 7/10/24, indicated cognitive impairment. An Activities of Daily Living (ADL) care plan, revised 12/22/23, indicated she needed assistance with eating. An observation was conducted of Resident 2 in the dining room on 10/7/24 at 12:35 p.m. The resident was observed sitting at a table in the dining room. Certified Nursing Assistant (CNA) 1 was standing next to the resident's table assisting the resident with eating her meal. An interview was conducted with the Nurse Consultant (NC) on 10/7/24 at 3:30 p.m. She indicated CNA 1 should have been sitting while assisting Resident 2 with her meal. A resident rights policy was provided by the NC on 10/8/24…

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 timely address a resident's grievance for 1 of 1 resident reviewed for choices. (Resident 11) Findings include: The clinical record for Resident 11 was reviewed on 10/3/24 at 9:00 a.m. The diagnoses included, but were not limited to, stroke. A quarterly Minimum Data Set (MDS) Assessment, dated 9/12/24, indicated Resident 11 was cognitively intact. An interview was conducted with Resident 11 on 10/3/24 at 9:41 a.m. He indicated he had been storing a Tupperware container that contained his tea pot and tea bags in a cabinet in the dining room for years. He was told a couple of days ago; he no longer was allowed to do that anymore. He had to store the Tupperware container in his room and take it back-an-forth from his room to the dining room every meal. It made it difficult. He was never given a reason why he could no longer store the container in the dining room. The resident had told everyone he was not happy about it. He had worked really hard to be able to use his crutches, but now he had to get back in the wheelchair. He…

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 Minimum Data Set (MDS) assessment was correctly completed, related to falls for 1 of 3 residents reviewed for falls. (Resident B) Findings include: The clinical record of Resident B was reviewed on 1-25-24 at 12:12 p.m. It indicated she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, unspecified encephalopathy, diabetes, rheumatoid arthritis, depression, high blood pressure, unspecified signs and symptoms of cognitive function, general muscle weakness and unspecified protein-calorie malnutrition. Her admission MDS assessment, dated 10-9-23, under section J, indicated the facility was unable to determine if she had any falls or fractures in the 6 month period prior to her admission to the facility. It indicated she had sustained no falls from the time of her admission through the assessment reference date (ARD) of 10-9-23. A review of the clinical record from the date of admission and through…

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 grievances reported were addressed that included resolutions. This had a potential to affect 6 of 6 resident council members and 1 of 1 residents reviewed for food. (Resident's 4, 13, 14, 22, 31, 35, 44) Findings include: 1. The May, June, and July 2023 Resident Council Minutes were provided by the Executive Director on 8/7/23 at 11:01 a.m. The May and June 2023 Resident Council Minutes indicated the council had concerns with alternative food choices that are not listed on the menu. The staff were not asking the residents what they would like to eat. The council minutes did not include resolutions to the concerns addressed in May or June. The July 2023 Resident Council Minutes did not include resolutions to the concerns addressed in May or June. A resident council meeting was conducted on 8/07/23 at 11:29 a.m. Resident 4, Resident 22, Resident 14, Resident 44, Resident 13, and Resident 35 attended the meeting. The council 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 the residents were able to file a grievance anonymously. This had a potential to effect 48 of 48 residents that reside in the facility. Findings include: A resident council meeting was conducted on 8/07/23 at 11:29 a.m. Resident 4, Resident 22, Resident 14, Resident 44, Resident 13, and Resident 35 attended the meeting. The council indicated the residents have to report to a staff person to file a grievance or a concern. They are unable to file a grievance anonymously. An interview was conducted with the Activities Director on 8/11/23 at 8:43 a.m. She indicated the residents notify the staff when he or she has a grievance or a concern needed to be addressed. The staff fill out a paper and turn it in to Social Services Director (SSD). An observation was made with the SSD on 8/11/23 at 8:43 a.m. An observation was made of the copy room with the SSD on the 1st floor. The grievances forms were located in a folder on the wall. The SSD indicated the staff fill them out for the residents. A resident with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely report an allegation of abuse to the Administrator; notify a resident's representative of the initiation and progress of an abuse investigation; and include pertinent information regarding an alleged victim of an abuse allegation and ensure accurate and detailed description in their state reporting for 3 of 5 residents reviewed for abuse. (Residents 20 and 37 and 40) Findings include: 1. The clinical record for Resident 37 was reviewed on 8/7/23 at 3:00 p.m. Her diagnoses included, but were not limited to, vascular dementia. She resided on the memory care unit of the facility until 6/29/23. The 5/26/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 5, indicating she was severely cognitively impaired. The 6/29/23, 7:18 p.m. nurses note, recorded as a late entry on 7/6/23, read, Writer notified sister [name of sister] and provider about the incident that occurred same day. Sister…

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 timely create a baseline care plan for 1 of 1 resident reviewed for care planning (Resident 200). Findings include: The clinical record for Resident 200 was reviewed on 8/7/23 at 10:07 a.m. The Resident's diagnosis included, but were not limited to, hypertension and anxiety. He was admitted to the facility on [DATE]. A Nursing Progress Note, dated 7/29/23 at 7:30 a.m., indicated Resident 200 was alert and oriented to person, place, and time and able to make all needs and wants known. During an interview on 8//7/23 at 10:07 a.m., Resident 200 indicated that no one had gone over his baseline care plan with him. On 8/8/23 at 11:30 a.m., the DON (Director of Nursing) provided Resident 200's Baseline Care Plan which indicated that sections 1 through 3 had been completed on 8/8/23. During an interview on 8/09/23 at 2:54 p.m., the MDSC (Minimum Data Set Coordinator) indicated that she tried to do the baseline care plan within the first 48 to 72 hours of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to create a discharge planning care plan for a resident with a goal of returning to the community at discharge for 1 of 3 residents reviewed for discharge, to develop care plans for refusal of bathing and shampooing and a resident high risk for dehydration for 1 of 3 residents reviewed for Activities of Daily Living and 1 of 1 residents reviewed of hydration. (Resident 14 and Resident 27 and Resident 202) Findings include: 1. The clinical record for Resident 27 was reviewed on 8/7/23 at 9:05 a.m. The resident's diagnosis included, but was not limited to, dementia. A dehydration risk assessment for Resident 27 dated 6/12/23 indicated a total score of above 8 represents high risk - prevention protocol should be initiated immediately and documented on the care plan. The resident's assessment indicated a score of 10. The assessment indicated the resident was bed bound, totally dependent, incontinent of urine, had predisposing factors 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 timely update toileting care plans for 1 of 1 resident reviewed for bladder and bowel incontinence (Resident 4). Findings include: The clinical record for Resident 4 was reviewed on 8/7/23 at 11:12 a.m. The Resident's diagnosis included, but were not limited to, generalized muscle weakness and constipation. A care plan, last revised on 12/13/22, indicated that Resident 4 needed extensive to total assist with transfers. The goal was for her to feel safe and secure with using mechanical lift for transfers and for her to feel secure with staff providing major support for transfers with some support. The interventions included, but were not limited to, assess for increase in mobility level and/or decrease in mobility level, initiated 6/10/2019, and to use mechanical lift for transfers, revised on 11/8/22. A care plan, last revised on 12/13/22, indicated Resident 4 needed extensive assistance with toileting, bed mobility, and eating. The goal was for her to be able to feed herself after set up and for her to feel safe 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 discharge need for oxygen therapy was identified and to involve the interdisciplinary team to develop a plan of treatment for discharge for 1 of 3 residents reviewed for discharge (Resident B). Findings include: The clinical record for Resident B was reviewed on 8/8/23 at 9:38 a.m. The Resident's diagnosis included, but were not limited to, COVID-19 infection, hypothyroidism, and chronic respiratory failure. She was admitted to the facility on [DATE] and discharged from the facility on 5/29/23. A care plan, initiated 3/13/23, indicated Resident B planned to remain in the facility for long term placement. She understood the need for long term placement, however, would want to return home if given the option to return to the community. The goal was for her to have 24-hour care and supervision while she was in the facility. The intervention, dated 3/13/23, that Resident B's family and Resident B preferred to discuss a return to community unless…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written discharge plan of care to a resident with a planned discharge for 1 of 3 residents reviewed for discharge (Resident B). Findings include: The clinical record for Resident B was reviewed on 8/8/23 at 9:38 a.m. The Resident's diagnosis included, but were not limited to, COVID-19 infection, hypothyroidism, and chronic respiratory failure. She was admitted to the facility on [DATE] and discharged from the facility on 5/29/23. A Practitioner Progress Note, dated 5/3/23, indicated Resident B was scheduled to discharge to another state on May 29, 2023. A Physician/Practitioner Progress Note, dated 5/23/23 at 1:13 p.m., indicated that Resident B was being seen to discuss discharge plans. Resident B planned to discharge on [DATE]. A 30-day supply of medications would be sent to a local pharmacy, seven days of controlled meds would be sent with the patient upon discharge, and that discharge paperwork was to be given to Resident B upon departure…

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 provide bathing and hair shampooing for 1 of 3 residents reviewed for Activities of Daily Living and to timely order a toileting sling to assist a resident with toileting for 1 of 1 resident reviewed for bladder and bowel incontinence (Resident 4 and Resident 14). 1. The clinical record for Resident 14 was reviewed on 8/7/23 at 12:05 p.m. The resident's diagnosis included, but was not limited to, Alzheimer's Disease. A care plan dated 5/23/23 indicated Resident 14 was cognitively impaired. An Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 14 was cognitively impaired. A care plan dated 9/19/22 indicated Resident 14 has a preference that it was important to her to choose bathing. The intervention for bathing was the resident preferred a tub bath twice a week. The clinical record did not include a developed care plan and interventions in place to address refusals of bathing and shampooing. A July 2023 bath report…

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 administer a resident's medication, as ordered, for 1 of 1 resident reviewed for pain and 1 of 6 residents reviewed for unnecessary medications, and to ensure monitoring and addressing wounds and providing skin treatment to dry skin for 1 of 1 residents reviewed for wounds. (Residents' 24, 31 and B) Findings include: 1. The clinical record for Resident 31 was reviewed on 8/7/23 at 10:45 a.m. Her diagnoses included, but were not limited to, herpes viral vesicular dermatitis. The 5/29/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status score) of 15, indicating she was cognitively intact. The at risk for skin breakdown care plan, revised 9/21/22, indicated an intervention was to administer vitamins and minerals as ordered. The physician's orders indicated to administer one 1000 mg tablet of L-Lysine one time a day, starting 5/24/23. An observation of Resident 31 was made on 8/7/23 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.

Based on observation, interview, and record review, the facility failed to implement residents' fall interventions for 1 of 1 resident reviewed for accidents and 1 of 6 residents reviewed for unnecessary medication. (Resident 21 and Resident 37) 1. The clinical record for Resident 37 was reviewed on 8/7/23 at 3:00 p.m. Her diagnoses included, but were not limited to, vascular dementia. She resided on the memory care unit of the facility until 6/29/23, when she moved to the upstairs unit of the facility. The 5/26/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 5, indicating she was severely cognitively impaired. The fall risk care plan, revised 8/10/21, indicated an intervention was for her to be a 2 person assist with transfers, starting 5/11/23, and to wrap her call light in bright colored tape so it can be seen easily, starting 8/10/21. An observation of Resident 37's call light in her room was made on 8/10/23 at 10:50 a.m. Her call light was hanging on the wall above her bed. It did not have brightly colored…

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 clarify oxygen services for 1 of 5 residents reviewed for unnecessary medications. (Resident 3) Findings include: The clinical record for Resident 3 was reviewed on 8/7/23 at 11:03 a.m. The resident's diagnosis included, but was not limited to, chronic obstructive pulmonary disease. A care plan dated 2/17/21 indicated Resident 3 requires oxygen. The interventions put in place indicated the staff was to administer oxygen as ordered. A physician order dated 1/20/23 indicated Resident 3 was to wear 2 liters of oxygen continuously. The staff may remove oxygen during showers and at the hair salon. An observation was made on 8/6/23 at 12:12 p.m. Resident 3 was observed sitting in her wheelchair in the common area. She was not wearing oxygen. An observation was made of Resident 3 on 8/10/23 at 1:30 p.m. Resident 3 was observed in her room sitting in her wheelchair. She was not wearing oxygen. An observation was made of Resident 3 with the Regional Nurse Consultant (RNC) on 8/12/23 at 2:02 p.m. Resident 3 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 observation, interview, and record review, the facility failed to ensure psychoactive and narcotic medications were administered as ordered; review and implement a resident's individualized mental health safety plan post inpatient psychiatric stay; and adequately monitor and address a resident's ongoing behaviors resulting in increased behaviors, increased anxiety, and interference of peers' daily routine and environment for 1 of 3 residents reviewed for abuse. (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 8/7/23 at 2:17 p.m. The resident's diagnoses included, but were not limited to, opioid dependence with intoxication, major depressive disorder, bipolar disorder, psychoactive substance abuse, personality disorder, and stroke. The resident was admitted to the facility on [DATE]. An Admissions MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 45 was cognitively impaired. Individualized Mental Health Safety Plan created at Psychiatric Hospital dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent for 1 of 5 residents observed during medication pass. There were 25 opportunities with 2 errors resulting in an 8 % medications error rate. The errors involved 1 resident (Resident 45) in the sample of 5. Findings include: The clinical record for Resident 45 was reviewed on 8/7/23 at 2:17 p.m. The resident's diagnoses included, but were not limited to, opioid dependence with intoxication, major depressive disorder, bipolar disorder, personality disorder, and stroke. The resident was admitted to the facility on [DATE]. An Admissions MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 45 was cognitively impaired. A physician's order, dated 6/12/23, indicated Resident 45 was to receive Buprenorphine sublingual tablet 2 mg to be given three times a day. A physician's order, dated 6/9/23, indicated to give memantine hydrochloride (medication for memory) 10mg daily. The order…

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 store controlled medication under double lock in 1 of 2 medication rooms. Findings include: On 8/11/23 at 10:44 a.m., the 200-hall medication room was observed with QMA 4. The refrigerator in the medication room contained an unlocked metal lock box for the storage of refrigerated controlled substances. The metal lock box contained liquid lorazepam for 3 residents of the second floor. QMA 4 indicated that the box should have been locked while being stored in the refrigerator. During an interview on 8/11/23 at 11:51 a.m., the DON (Director of Nursing Services) indicated the lorazepam should have been stored in a locked container in the refrigerator. On 8/11/23 at 11:51 a.m., the DON provided the Medication Storage in The Facility policy, dated February 2017, which read .All drugs classified as Schedule II of the Controlled Substances Act will be stored under double locks . 3.1-25(n)

Based on interview and record review, the facility failed to implement a corrective plan of action that included monitoring, tracking, evaluating effectiveness for an identified concern area, abuse. This affected 3 of 5 residents reviewed for abuse. This had a potential to effect 48 of 48 residents resided in the facility. Findings include: An interview was conducted with the Executive Director (ED) on 8/7/23 at 10:00 a.m. The ED indicated the Quality Assurance and Performance Improvement (QAPI) committee met monthly regularly. One deficiency that was identified during this recertification and complaint survey on 8/6/23 through 8/11/23, was cited at harm level - F600 - G. Abuse: 1 resident was verbally abused by a staff person while providing incontinent care. 2 residents were verbally and mentally abused by a staff person that refused to honor residents' preference to return to their room and lay down. A fourth resident was sexually abused by her roommate that inappropriately touched her while she was sleeping. There was no evidence the facility had developed or implemented 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.