Poplar Care Strategies

Based on observation, interview, and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent and treat a facility acquired pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. Skin assessments were not completed and a resident's plan of care was not followed and revised to monitor and assess the resident's right ankle pressure ulcer. (Resident 7)Finding includes:On 1/6/26 at 9:53 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, polyneuropathy, and Stage II (Partial thickness loss of skin, which may present as a blister or shallow open sore) pressure ulcer. The stage of pressure listed was an inaccurate diagnosis. The resident had a Stage III (full-thickness loss of skin occurs, potentially exposing fat tissue. The ulcer may appear as a deep crater) pressure ulcer/injury.The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/30/25, indicated the resident was cognitively intact, dependent on staff assistance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls for 1 of 1 residents reviewed for accidents. Fall interventions were not in place for a resident with multiple falls, a fall assessment was not completed after a fall, and an interdisciplinary note was not completed after a fall. (Resident 23)Findings include:During an observation on 1/05/2026 10:07 AM Resident 23 was observed in the common area with a staff member. She had fall socks on and a fall alarm attached to her wheelchair.On 1/5/26 at 3:21 P.M., Resident 23's clinical record was reviewed. Diagnoses included, but were not limit to, fracture of the right pubis, dementia, abnormalities of gait and mobility, and unsteadiness on feet.The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/18/25, indicated Resident 23 had severe cognitive impairment and was dependent on staff for transfers and toileting.Resident 23's Physician's Orders included, but was 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 observation, interview, and record review, the facility failed to ensure a resident's plan of care for nutrition was followed for 1 of 1 residents reviewed for nutrition. A resident with weight loss was not receiving the diet and supplements ordered, the resident was not being weighed weekly as ordered, and the care plan was not revised. (Resident 7)Finding includes:On 1/6/26 at 9:53 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, polyneuropathy, and pressure ulcer.The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/30/25, indicated the resident was cognitively intact, supervision of staff for eating, dependent on staff assistance for showering, transfers, toileting, 137 pounds (lbs), 64 inches tall, had weight loss (not on prescribed regimen), no swallowing disorder, and not on a therapeutic diet.Current physician's orders included, but were not limited to, the following:Regular diet, regular texture, thin consistency, give double portions of protein with meals, initiated 1/21/25…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the safe, secure, and orderly storage of medications in 1 of 3 medication carts observed and 1 of 2 medication storage rooms observed. (East Hall medication storage room, [NAME] Hall medication cart)Findings include:1. During an observation on 10/9/25 at 11:20 A.M., the Hall 1 medication cart contained the medications Alka-[NAME], melatonin, and Dulcolax. The medications were contained in an original box with Resident D's name handwritten on the box. No labeling containing ordered dosage, route, frequency of administration, or prescriber name were on the medication. During an interview on 10/9/25 at 11:25 A.M., QMA 4 indicated Resident D's family had brought the unlabeled medications into the facility for the resident and that the resident did not have a physician's order to receive the medications. During record review on 10/9/25 at 12:00 P.M., Resident D's physician orders did not include orders for the resident to receive…

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

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during 1 of 2 observations of care. Staff failed to complete hand hygiene after removal (doffing) of used gloves and prior to putting on (donning) new gloves and staff failed to complete hand hygiene immediately after doffing used gloves and prior to opening a resident's desk drawer and handing the resident a hair comb. (Resident B)Findings include:During an observation on 8/28/25 at 10:40 A.M., CNA 4 and CNA 5 were assisting Resident B to use the commode in the resident's bedroom bathroom. Resident B was assisted from a wheelchair to stand in front of the commode. CNA 4 and CNA 5 lowered resident's pants and brief and assisted Resident B to sit on the commode. CNA 4 and CNA 5 then assisted Resident B to stand, and CNA 5 provided perineal care. CNA 5 then encouraged Resident B to keep standing while CNA 5 doffed the gloves used prior and donned new gloves. No hand hygiene was completed between glove changes. CNA 5 then and CNA 4 then assisted Resident B by…

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 adequate care was provided to prevent and treat new pressure wounds for 2 of 3 residents reviewed for pressure wounds. Initial observations of deteriorating skin areas were not documented or communicated, initial wound care was not documented following the development of pressure wounds, and ordered treatments were not completed for pressure wounds. (Resident D, Resident F) Findings include: 1. During an interview on 2/18/25 at 10:30 A.M., QMA 4 indicated that Resident D had multiple wounds. During an observation and interview on 2/18/25 at 3:30 P.M., Resident D was lying in bed with heel protector boots on each foot. Resident D indicated there were wounds on her feet and coccyx. Resident D's record review indicated the resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis, type II diabetes, need for assistance with personal care, obesity, and neurofunctional disorder of bladder. Resident D's most recent admission Minimum Data Set (MDS) assessment, dated 12/20/24, 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.

Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist working at least part-time at that facility. Finding includes: On 10/28/24 9:45 A.M., the Director of Nursing (DON) indicated she was the facility's appointed Infection Preventionist (IP) and full time DON. On 4/5/24 at 10:08 A.M., the DON indicated she it varied from week to week on how many hours were spent for IP duties, but she does not spend as much time on IP duties as she would like to. At that time, she indicated she did not have any documentation of hours worked as an IP. On 11/1/24 at 10:23 A.M., the DON provided a current, undated Infection Preventionist job description that indicated, An Infection Preventionist is an individual responsible for the Infection Prevention and Control Program, developed to control the spread of infections and/or outbreaks .

Based on interview and record review, the facility failed to ensure residents who did not have a gradual dose reduction for psychotropic medications had a clinical contraindication documented for 1 of 5 residents reviewed for unnecessary medications. (Resident 12) Finding includes: On 10/29/24 at 10:38 A.M., Resident 12's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety and depression. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 9/5/24, indicated no cognitive impairment, and use of an antianxiety medication. No gradual dose reduction (GDR) information was listed. Current physician orders included, but were not limited to: Alprazolam 0.5mg (milligram) twice a day, dated 4/8/23. A nurse's note, dated 1/29/24, indicated a GDR recommendation was received to decrease alprazolam 0.5mg to 0.25mg. The GDR request was denied due to attempting this would not be in the best interest for this resident. On 10/30/24 at 1:17 P.M., the Director of Nursing (DON) indicated no other contraindication for GDR was located in Resident 12's clinical…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchens observed. Hairnets did not cover hair, food temperature log was not completed for all meals, measuring devices/scoops were stored inside containers of ice, oats, sugar, thickener, and bread was touched with bare hands. (Kitchen) Findings include: 1. During an observation of the kitchen on 10/28/24 at 9:43 A.M., two dietary staff members had hair outside of their hairnets at their temples and nape of the neck. During an observation of the kitchen on 10/31/24 at 11:05 A.M., two dietary staff members had hair outside of their hairnets at their temples and nape of the neck. 2. On 10/28/24 at 9:53 A.M., the food temperature log was reviewed from October 1 through October 27, 2024 and lacked food temperatures for the following meals: 10/21/24 lunch 10/22/24 dinner 10/23/24 breakfast and lunch 10/24/24 breakfast and dinner 10/25/24 breakfast, lunch, and dinner 10/26/24 breakfast, lunch, and dinner 10/27/24…

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 observation and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents observed for incontinence care. Staff did not use hand hygiene between glove changes during care and did not change gloves after touching multiple items before starting incontinence care. (Resident 13, Resident 27, Resident 15). Findings include: 1. On 10/30/24 at 9:20 A.M., CNA (Certified Nurse Aide) 5 and CNA 7 were observed doing incontinence care for Resident 13. Both CNAs cleaned their hands with sanitizer as they entered Resident 13's room. Both CNAs put on gloves. CNA 7 pulled the curtain around the resident, pushed the bed away from the wall, went behind the bed and pulled the covers down. CNA 5 used the remote to put the head of the bed down and raise the bed. They did not change gloves before starting care. CNA 7 unfastened the brief, pushed it down between her legs and assisted Resident 13 to turn to the right side. CNA 5 removed the brief, took a wipe and cleaned…

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

Based on observation and interview, the facility failed to ensure a sanitary and home-like environment for 5 of 5 halls and 1 of 1 Dining Rooms reviewed for environment. Personal items were not labeled in shared bathrooms, vent fans were caked with dust, toilets were soiled, non-skid strips were peeling up and/or worn, paint was missing, and incontinence pads were stored uncovered in the shower rooms. (A Hall, B Hall, C Hall, E Hall, F Hall, Dining Room) Findings include: 1. On 10/28/24 at 10:35 A.M., the following was observed in Room B6 and shared bathroom (3 residents) with Room B4: the second non-skid strip by bed closest to the window was peeling up and covered in debris, non-skid strip in bathroom in front of toilet was worn, paint around door frame was peeling and missing in spots, caulk around toilet was brown and soiled and peeling, black and brown stains on the inside of the toilet bowl, a brown substance was smeared on the back of the seat, black scuff marks were along the bottom of the wall and paint was scratched off the same wall across from the toilet, vent fan 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 revise resident's plan of care for 3 of 17 resident care plans reviewed. Care plans were not revised to reflect discontinued medications, and alarms were in use without an order or care plan. (Resident 29, Resident 1, Resident 2) Findings include: 1. On 10/28/24 at 11:40 A.M., Resident 29's clinical record was reviewed. admission date was 8/22/24 after a fall from home that resulted in a fracture. Diagnosis included, but were not limited to, dementia, depression, and history of falling. The most recent admission MDS (Minimum Data Set) Assessment, dated 9/11/24, indicated a moderate cognitive impairment and a fall prior to admission. Resident 29 required substantial to maximum assistance with bathing, bed mobility, transferring, and toileting. Discontinued orders included, but were not limited to: Bed/Chair Alarms, two times a day for fall risk, dated 8/23/24 through 9/4/24. A current risk for falls care plan, dated 8/26/24, lacked an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practicefor 3 of 3 residents reviewed for Respiratory Care. The facility failed to obtain a Physician's Order for oxygen, failed to follow Physician Orders for oxygenation, and failed to properly store a nebulizer mouthpiece and oxygen tubing while not in use. (Resident 6, Resident 28, Resident 133) Findings include: 1. During an observation on 10/28/24 at 2:08 P.M., Resident 133 was observed in bed with oxygen on via nasal cannula at 2 LPM (Liters per minute). During an observation on 10/29/24 at 11:58 A.M., Resident 133 was observed in the dining room with oxygen on via nasal cannula at 1.5 LPM. At that time, QMA (Qualified Medication Aide) 3 indicated she needed to verify the Physician's Order, but she thought Resident 133's oxygen should be set at 2 LPM. During an interview on 10/29/24 at 12:01 P.M., QMA 3 verified 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 pharmaceutical services met the needs of each resident for 2 of 4 residents observed for medication administration and 2 of 2 residents who had medication supplies disrupted without permission. Staff obtained medications for residents from other residents supplies. (Resident 22, Resident 233, Resident 27, Resident 24) Findings include: On 10/30/24 at 8:09 A.M., Registered Nurse (RN) 27 was observed to administer medications. While obtaining medications for Resident 22, RN 27 indicated the resident's Miralax could not be located. RN 27 then obtained the Miralax dose from another resident's bottle (Resident 24) to administer to Resident 22. At that time, RN 27 indicated Resident 22's Miralax was on an auto refill and should have been at the facility, but would contact the pharmacy for the medication. On 10/30/24 at 8:22 A.M., RN 27 was observed to obtain medications for Resident 233 and indicated the resident's Colace could not be located. RN 27 then obtained the dose of Colace from another resident's…

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

Based on interview and record review, the facility failed to provide privacy and dignity for 1 of 3 residents reviewed for resident abuse. Staff members recorded video footage in resident's restroom while the resident can be identified in the background on the commode. (Resident B) Finding includes: On 8/9/24 at 10:05 A.M., during a review of facility grievances, a grievance dated 8/1/24, concerning Resident B indicated that an anonymous community member brought a recording of a video that was seen on a social media site to the Business Office Manager (BOM). During record review on 8/9/24 at 10:15 A.M., Resident B's diagnoses included, but were not limited to, dementia, overactive bladder, and anxiety. Resident B's most recent Quarterly Minimum Data Set (MDS) assessment, dated 6/14/24, indicated the resident had moderate cognitive impairment. Resident B's nurse's progress notes included a note, dated 8/1/24 at 5:30 P.M., included that a staff member had notified the Power of Attorney (POA), physician, law enforcement, and state agency about an allegation. During an interview 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 services of an RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 5 of the days reviewed from the PBJ (Payroll Based Journal) Staffing Data Report during Quarter 4 of 2023 (July 1, 2023 through September 30, 2023). Finding includes: On 1/4/24 at 4:45 P.M., the [NAME] report was reviewed and indicated there was not an RN for 8 consecutive hours on the following dates: 7/3/23 8/5/23 8/6/23 8/18/23 8/27/23 9/10/23 9/16/23 9/17/23 9/21/23 9/23/23 9/24/23 9/30/23 On 1/3/24 at 9:15 A.M., the Time Card Report from 7/1/23 through 9/30/23 was provided by the Administrator. Review of the Time Card Report indicated there was no RN coverage for 7/3/23, 8/27/23, 9/10/23, 9/23/23 and 9/24/23. During an interview on 1/8/24 at 2:00 P.M., the Administrator indicated there should be an RN scheduled 8 consecutive hours a day, 7 days a week. On 1/8/24 at 3:48 P.M., a policy for RN Coverage was requested and not received. The Administrator indicated they follow state regulations. 3.1-17(b)(3)

Based on interview and record review, the facility failed to ensure accurate submission of all direct care staffing data into the Payroll Based Journal (PBJ) system for the reported 4th Quarter period of July 1, 2023 through September 30, 2023. Every day from July 1, 2023 through September 30, 2023 was triggered in error for licensed nursing coverage 24 hours per day due to a reporting error. Finding includes: On 1/3/24 at 8:15 A.M., review of the facility's PBJ information indicated licensed nursing coverage for 24 hours per day was triggered daily in the 4th reporting quarter of July 1, 2023 through September 30, 2023. During an interview on 1/3/24 at 8:40 A.M., the Administrator indicated they had licensed staff in the facility every day, and she had reported to their corporate office that there was an issue with reporting staff, but nothing was done to correct the issue. On 1/4/24 at 4:45 P.M., the Time Card Report for July 1, 2023 through September 30, 2023 was reviewed and indicated there was licensed staffing in the facility daily during that period. On 1/8/24 at 3:52 P.M., a…

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

Based on observation, interview, and record review, the facility failed to ensure MDS (minimum data set) Assessments accurately reflected resident's status for 5 of 13 resident assessments reviewed. (Resident 1, Resident 2, Resident 4, Resident 25, Resident 10) Findings include: 1. On 1/8/24 at 10:00 A.M., Resident 1's clinical record was reviewed. admission date was 11/28/23. Diagnosis included, but were not limited to, bipolar and schizophrenia. The most recent admission MDS Assessment indicated no PASRR (preadmission screening and resident review) Level 2 had been completed. A PASRR Level 2, completed 11/29/23, was observed in Resident 1's clinical record. 2. On 1/4/24 at 11:19 A.M., Resident 2's clinical record was reviewed. The most recent quarterly/state optional MDS Assessment, dated 12/5/23, indicated a current stage 3 pressure ulcer. On 1/5/24 at 11:52 A.M., Resident 2's most recent four weeks of wound assessments for a left heel pressure ulcer were reviewed. All assessments indicated the pressure ulcer was a stage 2. On 1/5/24 at 2:13 P.M., the Director of Nursing (DON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 2 of 2 medication carts observed and 2 of 2 medication storage rooms observed. Loose pills were observed in the medication carts, refrigerator temperature logs were not filled out completely in the medication room, and supplies were expired in the medication rooms. Findings include: On [DATE] at 11:15 A.M., the following was observed on the East/West Hall: The medication cart was observed with the following loose pills in the drawers: 1 oblong white pill with marking E on one side and 01 on the other 1 round peach pill with marking 10 2 white rectangular pills marking of CTN on one side and 5 on the other 1 off white capsule no letters or numbers 1 1/2 oblong white pill with marking ZE/ 37 1 round yellow pill with marking L 1 round white white pill with marking EP 116 1 oblong green pill with marking A 16 1 round dark red pill with marking G 2 1 round white pill with marking 128 C 1 white…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Food containers were not labeled, food was open to air in the refrigerator, and a food item was observed on the freezer floor. (Kitchen) Findings include: On 1/2/24 at 9:20 A.M., the following was observed in the kitchen: Cereal on a shelf in two unlabeled containers A plastic bag of sliced cheese was observed open to air in the refrigerator A brick of margarine was observed open to air in the refrigerator A wrapped beef pot roast was observed sitting on the freezer floor An unlabeled plastic bag with six rolls was sitting on the counter The ceiling above the dishwasher was observed flaking with areas falling of The top of the dishwasher was observed with a lot of debris and dust On 1/8/24 at 9:29 A.M., the following was observed in the kitchen: Cereal on a shelf in two unlabeled containers The ceiling above the dishwasher was observed flaking with areas falling of The top of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely notification to the provider and family representative following a change in condition for 1 of 2 residents reviewed for nutrition, and 1 of 5 residents reviewed for unnecessary medications. The Registered Dietician and provider were not notified following a significant change in weight, and a physician was not notified after an ordered medication was not given. (Resident 22, Resident 37) Findings include: 1. On 1/4/24 at 10:15 A.M., Resident 22's clinical record was reviewed. Diagnosis included, but were not limited to, aortic valve stenosis, chronic venous insufficiency, edema, hypertension, anemia, and chronic heart failure. The most recent quarterly/state optional MDS Assessment, dated 12/20/23, indicated no cognitive impairment, no weight loss or swallowing concerns, a requirement of supervision with setup with transfers, and limited assistance of one with eating. Current physician orders included, but were not limited 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 an ordered therapeutic diet was provided for 1 of 2 residents reviewed for nutrition. (Resident 33) Finding includes: On 1/2/24 at 12:15 P.M., Resident 33 was observed in the dining room where he was served a lunch tray of ground meat, brussel sprouts, mashed potatoes, peach cobbler, and a biscuit. The lunch tray lacked a bowl of gravy. On 1/5/24 at 12:01 P.M., Resident 33 was observed in the dining room where he was served a lunch tray of a fish patty, cole slaw, creamed corn, a slice of bread, and ice cream. The lunch tray lacked a bowl of gravy. On 1/4/24 at 10:09 A.M., Resident 33's clinical record was reviewed. Diagnosis included, but was not limited to, dysphagia. The most recent quarterly/state optional MDS (minimum data set) Assessment, dated 10/13/23, indicated no swallowing or dental concerns, limited assistance of one staff for eating, and cognition status was unable to be assessed. Current physician orders included, but were not limited to, the following: Regular diet, mechanical soft…

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 requiring respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen use. A resident did not receive oxygen as ordered. (Resident 20) Finding includes: On 1/2/24 at 11:13 A.M., Resident 20 was observed laying in bed with oxygen per nasal cannula set at 3 LPM (liters per minute). On 1/5/24 at 10:56 A.M., Resident 20 was observed laying in bed with oxygen per nasal cannula set at 3 LPM. On 1/5/24 at 3:00 P.M., Resident 20 was observed laying in bed with oxygen per nasal cannula set at 3 LPM. On 1/5/24 at 2:02 P.M., Resident 20's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure and shortness of breath. The most recent Quarterly MDS (minimum data set) Assessment, dated 12/9/23, indicated Resident 20 was cognitively intact and totally dependent on staff for transfers. Current Physician's Orders included, but not limited to, the following: Monitor oxygen saturation BID Oxygen…

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 clinical record was maintained with accurate documentation for 1 of 5 records reviewed for unnecessary medications. (Resident 37) Finding includes: On 1/5/24 at 11:03 A.M., Resident 37's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with mod behavior. The most recent Admission/State Optional MDS (minimum data set) Assessment, dated 12/7/23, indicated Resident 37's cognition was moderately impaired and she needed limited assistance of 1 staff for bed mobility, transfers, and toileting. December 2023 Physician's Orders included, but were not limited to, the following: olanzapine (antipyschotic) 10 mg (milligrams) by mouth at bedtime, ordered 12/3/23 Rexulti (antipyschotic) 1 mg by mouth one time a day for agitation related to dementia. DC (discontinue) olanzapine when Rexulti is started, ordered 12/23/23 The December 2023 MAR (Medication Administration Record) was reviewed and indicated Resident 37 was given both olanzapine and Rexulti by 3 different licensed staff on…

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

Based on observation, interview, and record review the facility failed to follow the written contract with the Hospice provider, failed to ensure a communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for 1 of 1 residents reviewed for hospice care. The clinical record lacked documentation of ongoing communication between facility staff and hospice staff. (Resident 14) Finding includes: On 1/3/24 at 11:03 A.M., Resident 14 was observed sitting in her recliner wearing oxygen per nasal cannula at 3 LPM (liters per minute). On 1/5/24 at 10:04 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure and chronic obstructive pulmonary disease. The most current Quarterly/State Optional MDS (Minimum Data Set) Assessment, dated 12/11/23, indicated Resident 14 was cognitively intact, on hospice, and required supervision with set up for bed mobility, transfers, and toileting.…

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.