Cardinal Care Strategies

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to ensure residents were free of chemical restraints related to the use of antipsychotic medications without diagnoses for use, identified targeted behaviors for use, documented displayed targeted behaviors, and/or a care plan to address targeted behaviors for 3 of 5 residents reviewed for unnecessary medications. (Residents 5, 6 and 7) Findings include:1. Resident 5's clinical record was reviewed on [DATE] at 2:47 p.m. Diagnoses included Alzheimer's Disease, generalized anxiety, insomnia, and depression. The resident was admitted to the facility on [DATE]. Current physician orders included Risperdal (an antipsychotic medication) 0.5 mg- take one tablet two (2) times daily for agitation. This order originated [DATE] upon admission. A [DATE], admission, Minimum Data Set (MDS) assessment indicated the resident was rarely able to be understood or understand. The staff were interviewed regarding the resident's cognitive status. The resident was…

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

Based on record review and interview, the facility failed to complete a thorough investigation of and maintain record of the investigation of resident-to-resident abuse for 2 of 3 residents reviewed for abuse. (Resident B and Resident 76)Findings include:Review of a facility investigation for a resident-to-resident altercation, on 12/18/25, between Resident B and Resident 76, and provided by the facility on 1/7/26 at 4:31 p.m., indicated it included the following information: A recapitulation of a facility reported incident that occurred on 12/18/25 at 8:20 p.m. with a brief description of the resident-to-resident altercation. Resident B accused roommate (Resident 76) of stealing clothing from his closet. Resident B was yelling for Resident 76 to get out of his closet. Type of Injury: None. Immediate Action Taken: The staff immediately separated the residents. The nurse completed skin assessments and neither of the residents had any issues identified. Resident 76 was moved to another room. The Administrator and DON were notified immediately of the incident. The provider 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 provide residents and/or their representatives with written notice of transfer/discharge and bed hold policy for 3 of 4 residents reviewed for hospitalizations. (Residents 2, 56, and 43) Findings include: 1.Resident 2's record was reviewed on 1/7/26 at 10:11 a.m. Medical diagnoses included generalized anxiety disorder, epilepsy (seizure disorder), substance abuse, and complex regional pain syndrome. A quarterly minimum data set (MDS) completed on 12/2/25 indicated the resident was cognitively intact. A 9/8/25 nurse's note indicated the resident was sent to the emergency room following mental status changes and urinary tract infection (UTI) symptoms. The clinical record lacked indication the resident and/or representative was provided a notice of transfer/discharge form and bed hold policy. A 10/22/25 nurse's note indicated the resident was transferred to the emergency room after being found unresponsive. The clinical record lacked indication the resident and/or representative was provided notice of transfer/discharge form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure timely completion of a required Level 2 Preadmission Screening and Resident Review (PASARR) assessment for 1 of 2 residents reviewed for PASARR. (Resident 8 ) Findings include:Resident 8's clinical record was reviewed on 1/7/26 at 10:16 a.m. She admitted to the facility on [DATE] and remained in the facility. Diagnoses included delusional disorders, generalized anxiety disorder, unspecified psychosis not due to a substance of known physiological condition, unspecified visual disturbances, and unspecified vascular dementia. A 3/13/25, Notice of Level I PASARR Screen Outcome, indicated the referral for a Level 2 onsite for suspected mental health disability. The clinical record lacked documentation of a completed Notice of Level 2 PASSAR Screen Outcome. During an interview, on 1/8/26 at 10:30 a.m., the SSD indicated she started her position with the facility in November. She utilized the Maximus Assessment Pro online system, and the Level 2 for…

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

Based on interview and record review, the facility failed to invite the resident representative to the resident's care plan meeting, offering them the opportunity to engage/contribute to the resident's admission care plan meeting for 1 of 2 residents reviewed for care planning. (Resident 11) Finding includes:During an interview on 1/6/26 at 10:55 a.m., Resident 11 indicated he had not been included in a care plan meeting. He had an appointed guardian and did not know if the guardian was invited to the care plan meeting. Resident 11's clinical record was reviewed on 1/6/26 at 2:44 p.m. Diagnoses included schizophrenia, atrial fibrillation, pulmonary embolism with acute cor pulmonale, Parkinson's Disease with dyskinesia, encephalopathy, and rhabdomyolysis. An 11/19/25, admission Minimum Data Set assessment indicated the resident was cognitively intact. Active diagnoses included schizophrenia, Parkinson's Disease, atrial fibrillation, pulmonary embolism, respiratory failure, and heart failure. Guardianship papers were in place for the resident. The clinical record lacked documentation…

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

Based on observation, record review, and interview, the facility failed to provide necessary services for a resident related to humidification for high-flow rate oxygen for 1 of 2 residents reviewed for oxygen administration. (Resident 56) Findings include:During an obseration and interview, on 1/5/26 at 12:02 p.m., Resident 56 was lying in a specialty bed against the wall. The resident was wearing a nasal cannula for oxygen administration. She indicated she wore oxygen consistently and her oxygen setting was 5 liters per minute. The oxygen concentrator was positioned at bedside and was set for 5 liters per minute. The water humidification container was empty. The inside of the container was covered in a white film. The container was dated 11/25 in black marker. On 1/6/26 at 10:32 a.m., Resident 56 was lying in bed wearing a nasal cannula. The oxygen concentrator was positioned at bedside and was set for 4 liters per minute. The water humidification container was empty. The inside of the container was covered in a white film. The container was dated 11/25 in black marker. On 1/7/26…

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

Based on record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies regarding Drug Labeling/Storage. Finding includes:Review of the Summary Statement of Deficiencies for the facility's last annual recertification and licensure survey, completed on 12/17/24, indicated the facility had deficiencies related to unlabeled medications.During an interview, on 1/9/26 at 4:03 p.m. the ADON indicated the Quality Assessment and Assurance (QAA) committee met each morning and monthly to discuss current facility concerns. The current nursing topics were falls. The ADON indicated the facility had weekly audits in place for medication carts. The current QAPI binder for the facility was reviewed on 1/9/26 at 4:26 p.m. The binder lacked any audits for repeat deficiencies.Repeat concerns regarding medication storage/labeling were cited during the 1/5/26 survey as follows:Based on observation and interview, the facility failed to store medications according to professional…

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

Based on observation, record review, and interview, the facility failed to implement the appropriate infection control precautions related to transmission based precautions per the Centers for Disease Control and Prevention (CDC) guidelines for 1 of 2 residents reviewed for infection control. (Resident 43)Findings include:During an observation, on 1/5/26 at 10:10 a.m., Resident 43's door was closed, and an orange Enhanced Barrier Precautions (EBP) sign was present. There was a yellow organizer hanging from the door with Personal Protective Equipment (PPE) available.During an interview, at the time of the observation, LPN 9 indicated the resident had an infection in his urine and he had a catheter. She wore a gown, gloves, and mask for all care. She thought the resident's infection was Candida Auris (C. Auris) and the isolation sign on the door was not the correct isolation precaution.During an observation and interview, on 1/7/25 at 9:59 a.m., Laundry Aide 20 delivered clean laundry to Resident 43's room. Laundry Aide 20 was wearing a surgical face mask. He knocked on the 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 record review and interview, the facility failed to offer and administer appropriate Pneumococcal vaccinations per the Center for Disease and Control (CDC) guidance for 3 of 5 residents reviewed for infection control. (Residents 56, 61, and 8)Findings include: 1. Resident 56's clinical record was reviewed on 1/7/26 at 11:41 a.m. Diagnoses included COPD (chronic obstructive pulmonary disease), neurofibromatosis (a genetic disorder causing tumors), and epilepsy. A 12/30/25, significant change, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. Review of the resident's vaccinations included the following:The resident had a historical administration of an unspecified pneumococcal vaccination on 12/21/23, prior to admission to the facility.The clinical record lacked a Pneumococcal Vaccine Consent or Declination Form.The clinical record lacked any offerings of the Pneumococcal vaccine. 2. Resident 61's clinical record was reviewed on 1/7/26 at 1:46 p.m. Diagnoses included schizophrenia, type 2 diabetes mellitus, and hypertension.A 10/28/25,…

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 record review and interview, the facility failed to complete an in-depth preadmission assessment in order to develop a resident specific behavior management plan to mitigate risks related to behavior expressions (Resident B, C, E, and F) resulting in injury requiring medical treatment of a bite injury. (Resident B)Findings include:1.Resident B's clinical record was reviewed on 8/22/2025 at 11:22 a.m. Diagnoses included epilepsy, anxiety disorder, Paranoid Schizophrenia, convulsions, hypertension, borderline personality disorder, and total traumatic cataract of the left eye. The resident was admitted from another facility on 6/19/2025. Review of a facility self-reported incident, dated 8/2/2025, indicated on 8/1/2025 at approximately 10:45 p.m. Resident B was in a physical altercation with Resident C, resulting in Resident C being sent to the hospital for treatment. Resident C required four stitches and antibiotic therapy for a bite to the back of the right hand. Resident B was not injured. A care plan…

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

Based on record review and interview, the facility failed to implement their facility abuse prevention program policy when staff members failed to report an incident of staff to resident verbal abuse, which delayed the initiation of the facility investigation and reporting to the appropriate agencies, for 1 of 4 residents reviewed for abuse. (QMA 1, Resident D, and LPN 2) Findings include: Review of a facility self-reportable incident report, dated 4/9/25, indicated on 4/9/25 at approximately 5:30 a.m., QMA 1 was overheard using inappropriate language in a disrespectful manner to Resident D. The incident was reported to the State on 4/9/25 at 10:39 a.m. The clinical record for Resident D was reviewed on 5/27/25 at 11:40 a.m. Diagnoses included schizophrenia, convulsions, morbid severe obesity with alveolar hypoventilation, and hypertension. Review of a facility self-reportable incident report, dated 4/9/25, indicated on 4/9/25 at approximately 5:30 a.m., QMA 1 was overheard using inappropriate language in a disrespectful manner to Resident D. The incident was reported to the State…

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 interviews and record review, the facility failed to protect a resident's right to be free from verbal abuse by staff for 1 of 3 residents reviewed for abuse. (QMA 1, Resident D) Findings include: The clinical record for Resident D was reviewed on 5/27/25 at 11:40 a.m. Diagnoses included schizophrenia, convulsions, morbid severe obesity with alveolar hypoventilation, and hypertension. Review of a facility self-reportable incident report, dated 4/9/25, indicated on 4/9/25 at approximately 5:30 a.m., QMA 1 was overheard using inappropriate language in a disrespectful manner to Resident D. The incident was reported to the State on 4/9/25 at 10:39 a.m. Review of a written statement by LPN 2, dated 4/9/25, indicated she heard QMA 1 tell Resident D You need to clean your f - - king room. Resident D said What? and was crying. QMA 1 left the room before LPN 2 got to the resident's room. QMA 1 told LPN 2 I'm done. He is a f - - king d - -k. LPN 1 indicated she spent approximately 20-30 minutes with the resident and tried to calm him down. CNA 3 entered the resident's room and stayed…

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 implement their policy regarding abuse investigation when they failed to provide assessment for psychosocial harm for vulnerable, cognitively impaired residents following an allegation of staff to resident verbal abuse. This deficient practice had the potential to effect 3 of 17 residents living in on the unit where the abuse was alleged. Residents E, F, and G) Findings include: Review of a facility self-reportable incident report, dated 4/9/25, indicated on 4/9/25 at approximately 5:30 a.m., QMA 1 was overheard using inappropriate language in a disrespectful manner to Resident D. The incident was reported to the State on 4/9/25 at 10:39 a.m. The facility's investigation of a verbal abuse allegation was reviewed on 5/27/25 at 9:57 a.m. The investigation included, staff re-education, staff interviews, interviews of cognitively intact residents, and skin assessments. The investigation lacked psychosocial assessments/evaluations of vulnerable or non-verbal residents. 1. The clinical record for Resident E was reviewed 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 and interview, the facility failed to provide and maintain dated storage bags for oxygen administration equipment to be stored in a clean manner for 3 of 3 residents observed for oxygen administration. (Residents J, K, & L) Findings include: During an initial observation on 3/20/25 at 10:16 a.m., a wheelchair was observed outside of Resident K's room with the nasal cannula attached to a portable oxygen tank. The cannula was observed draped over the back of the wheelchair, with the cannula laying in the seat of the chair. There was no storage bag present on the wheelchair. Another wheelchair outside Resident L's room was observed with a nasal cannula attached to a portable oxygen tank. The cannula was observed tucked into a pocket on the back of the wheelchair that was part of the seat. There was no storage bag present on the wheelchair. During an interview with Resident J on 3/21/25 at 10:29 a.m., an oxygen concentrator was observed in the resident's room with the tubing and nasal cannula rolled up and anchored under the handle of the device. There was no dated…

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

Based on observation and interview, the facility failed to maintain a clean, orderly shower room for resident use for 1 of 4 shower rooms observed for cleanliness. (100 East hall) Findings include: During an observation of the 100 East hall shower room on 3/20/25 at 10:16 a.m., the following was observed: the floor was soiled and had standing water from the shower to the sink. There were two open soda cans and a plastic bottle of a hydration drink on a shelf. There were plastic wrappers and a bottle of powder in the dirty sink. The toilet bowl had dark rings around the water line. The trash container was uncovered, and a bag of linens was observed on the floor next to the trash container. A sheet was observed draped over the seat of a shower chair and onto the floor. During an observation of the 100 East hall shower room on 3/21/25 at 1:52 p.m., accompanied by the Housekeeping Manager and the Unit Manager, the following was observed: multiple smears of feces on the floor from the shower to the sink, sink visibly dirty, and the toilet bowl had dark rings around the waterline. There…

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

Based on interview and record review, the facility failed to provide evening snacks for 1 of 4 residents reviewed for nutrition (Resident 35) and for 7 of 7 residents in resident group interview with the resident council. Findings include: 1. Resident 35's clinical record was reviewed on 12/12/24 at 3:03 p.m. Current diagnoses included dementia, type II diabetes without complications, and moderate protein calorie malnutrition. A current physician's order, dated 5/10/24, indicated to offer peanut butter and jelly at bedtime for nutrition from supplies located in the pantry to make sandwiches. A Nurse's Note, dated 11/29/24 at 9:01 p.m., indicated the order for peanut butter and jelly at bedtime for a nutritional supplement was not provided. A Nurse's Note, dated 11/30/24 at 9:49 p.m., indicated there was no supply to offer peanut butter and jelly at bedtime for a nutritional supplement. A Nurse's Note, dated 12/1/24 at 7:42 p.m., indicated there was no supply to offer peanut butter and jelly at bedtime for a nutritional supplement. A Nurse's Note, dated 12/15/24 at 9:11 p.m.,…

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

Based on observation, interview and record review, the facility failed to provide dementia services related to intrusive wandering for 1 of 1 residents reviewed for a unit relocation due to wandering. (Resident 33) Finding includes: Resident 33's clinical record was reviewed on 12/12/24 at 3:05 p.m. Current diagnoses included, Alzheimer's disease, restlessness and agitation, and generalized anxiety disorder. The resident had a current care plan problem/need regarding wandering, entering other's room and rifling through belongings with no real objective or motive, initiated 9/11/23. The goal for this need was for the resident to remain safe from wandering. An 11/10/24 at 3:44 a.m., Late Entry, Behavior Note indicated the resident was up all night wandering in and out of other resident rooms. An 11/12/24 at 1:19 a.m.,Behavior Note indicated the resident continued to wander at night with multiple redirections required. The resident also continued to wander into other residents' rooms causing agitation in residents attempting to sleep. Resident 33 was redirected multiple times to their…

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 label medications with resident identifying information in 1 of 3 medication carts (East 100 Unit Cart) and 1 of 2 medication storage rooms (200 Unit Storage Room) reviewed for medication storage. This had the potential to affect 19 residents who received medications from the 100 East Cart and 5 residents whose diabetic medications were stored in the 200 Medication Storage Room. Findings include: 1. During an observation, accompanied by LPN 5 on 12/13/24 at 9:16 a.m. , the 100 East Unit medication cart top right drawer contained 2 medication cups. One of the cups contained two pills with no resident identifiers. The other cup contained 7 pills with no resident identifier. She indicated the medication were pre-set because the resident was not out of bed yet. LPN 5 indicated she was aware who the medications belonged to. Since the medications were not labeled with any resident identifiers, others would not have any way to identify which medications were in the cups, nor who they belonged to. She indicated all medications in…

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 with a dairy allergy was not served food containing dairy for 1 of 1 resident reviewed for food allergies. ( Resident 72) Finding includes: Resident 72's clinical record was reviewed on 12/12/24 at 2:53 p.m. Current diagnoses included psychotic disorder and depression. The resident had a documented intolerance of dairy products, entered in the record on 2/29/24. A 11/26/24, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. The resident had a current, 3/4/24, care plan problem/need regarding a potential alternation of nutrition related to multiple heath conditions and food allergies to egg, dairy, peanuts and seafood. During a meal service observation on 12/16/24 at 11:36 a.m., Dietary Aide 13 placed a container of sherbet on Resident 72's meal plate. Resident 72's meal ticket was observed and listed no dairy products due to allergies. The sherbet container's (which was placed on the resident's meal tray) label was reviewed for listed…

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 physician and nurse practitioner notes were documented and signed at the time of the visit for 6 of 6 residents reviewed for physician's services (Residents B, C, D, E, F, and G). Findings include: 1. Resident B's clinical record was reviewed on 11/14/24 at 1:44 p.m. Current diagnoses included anxiety, depression, and diabetes mellitus. The resident's primary care physician was the facility's Medical Director. Nurse Practitioner (NP) 3 was identified as one of the resident's medical care providers. The resident had a care visit completed by Nurse Practitioner 3 on 7/9/24. A care note was not documented for this visit until 9/16/24 (72 days). 2. Resident C's clinical record was reviewed on 11/13/24 at 10:40 a.m. Current diagnoses included schizoaffective disorder, hypertension, chronic obstructive pulmonary disorder. The resident's primary care physician was the facility's Medical Director. Nurse Practitioner 3 was identified as one of the resident's medical care providers. The resident had a care visit note for 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 ensure physician's visits occurred at the regulatory required frequency and nurse practitioner visits alternated with a physician for required visits for 6 of 6 residents reviewed for physician's services (Residents B, C, D, E, F, and G). Findings include: Confidential interviews were conducted during the survey. During a confidential interview, a facility resident indicated, I do not think I have a doctor. All I see is the nurse practitioner. During a confidential interview, a facility resident indicated ,I see the nurse practitioner. I do not have a doctor. During a confidential interview, a facility resident indicated, When I asked to see the doctor, the doctor said no. During a confidential interview, a facility resident indicated, The nurse practitioner is my doctor. During a confidential interview, a facility resident indicated, I am kind of new. I do not think I have ever seen a doctor. 1. Resident B's clinical record was reviewed on 11/14/24 at…

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

Based on interview and record review, the facility failed thoroughly investigate the an allegation of physical abuse of a cognitively impaired resident by a staff member for 1 of 5 residents reviewed for abuse. (CNA 1 and Resident F) Findings include: Review of a facility self reportable, dated 8/6/24 at 6:49 p.m., was completed on 9/19/24 at 1:33 p.m. The report indicated on 8/6/24, CNA 1 allegedly abused Resident F. The follow up for the investigation indicated staff who witnessed the incident were interviewed. The facility investigation lacked interviews of other staff members and residents to determine if there had been any other concerns with abuse. Resident F's clinical record was reviewed on 9/20/24 at 12:50 p.m. Diagnoses included Alzheimer's Disease, pulmonary fibrosis, rheumatoid arthritis, stage 3 chronic kidney disease, restless and agitation, muscle weakness and dementia with behavioral disturbances. An annual Minimum Data Set (MDS) assessment, dated 7/25/24, indicated the resident was severely cognitively impaired. An 8/6/24 written statement, by CNA 2 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 residents had privacy while using the facility telephone. (Swan Unit) Findings include: During an interview with Resident E, on 5/17/24 at 12:22 p.m., she indicated she used the phone at the nurses station and everyone could hear what she talked about. During an interview with the Social Service Director, on 5/17/24 at 2:11 p.m., she indicated she didn't know Resident E needed a phone. They didn't have land lines in the residents' rooms. There was an office phone at the nurses station. She knew while being back in the Swan unit, Resident K would squat down in front of the nurses station to talk on the phone. During an interview with QMA 7, on 5/17/24 at 3:01 p.m., she indicated Resident E talked on the phone at the nurses station when no one was around. Resident E could go as far as the cord would allow her to go to talk privately. During an interview with the Administrator, with the DON present, on 5/21/24 at 11:57 a.m., she indicated some of the residents had cell phones. She had spoken to the Social…

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.

A. Based on observation, interview and record review, the facility failed to ensure to physician's orders were initiated and implemented for blood glucose monitoring for a resident receiving insulin for 1 of 3 residents reviewed for hospitalizations. (Resident H) B. Based on observation, interview, and record review, the facility failed to monitor resident's bowel movements for 4 of 5 resident's reviewed for bowel management. (Resident B, Resident E, Resident F and Resident H) Findings include: A. Resident H's clinical record was reviewed on 5/21/24 at 9:42 a.m. Diagnoses included type 2 diabetes mellitus without complications, unspecified dementia, severe, with agitation, unspecified dementia, severe, with other behavioral disturbance, unspecified dementia, severe, with psychotic disturbance, unspecified dementia, severe, with anxiety, long term (current) use of insulin, unspecified dementia, unspecified severity, with other behavioral disturbance, type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye, fracture of orbit, unspecified,…

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

Based on record review and interview, the facility failed to ensure a psychoactive medication was not administered to manage behavioral expressions without an order from medical provider . (Resident B) Findings include: The clinical record for Resident B was reviewed on 4/3/24 at 11:03 a.m. Diagnoses included hypertension, alcohol dependence with alcohol induced persisting dementia, and vascular dementia with agitation. Review of a facility self-reportable dated 3/22/24 indicated, on 3/20/24 LPN 1 administered lorazepam 2 mg (anti-anxiety medication) to Resident B. LPN 1 had failed to follow appropriate procedure when she gave the medication without securing an order for the medication and did not call the pharmacy for confirmation before taking the medication from the emergency medication kit. Review of Resident B's March 2024 Medication Administration Record (MAR) was completed on on 4/3/24 at 11:03 a.m. The MAR indicated a 3/19/24 order for lorazepam 2 mg injection intramuscularly (IM) one time for restlessness and agitation. The medication was signed off as given on 3/20/24 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 identify resident behavioral health needs and failed to develop individualized care plans to address resident behavioral safety for 3 of 3 residents reviewed for resident behavioral health needs (Residents B, C, and D). Findings include: 1. Review of a 3/9/24 facility Self Reported Incident indicated the facility found two needles in Resident D's room when cleaning. The facility suspected drug use. The police were contacted. The resident was sent to the hospital for a drug screen. Resident D's clinical record was reviewed on 3/12/24 at 11:36 a.m. Current diagnoses included anxiety, major depressive disorder and bipolar disorder. A history of substance abuse was not included on the resident's current diagnoses. The clinical record contained scanned in documents of the resident's history prior to admission. Review of documents related to the resident's hospital stay on 10/3/23 included the following: Diagnoses of cocaine dependence, uncomplicated, methamphetamine abuse, episodic, amphetamine-type substance use…

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 transfer and/or discharge information for continuity of care to outside providers for 4 of 5 residents reviewed for hospitalizations and discharge. (Residents 1, 14, 62, and 70) Findings include: 1. Resident 1's clinical record was reviewed on 1/26/24 at 4:24 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD), heart failure, personal history of COVID-19, and schizoaffective disorder. A Nurse's Note, dated 11/28/23 at 3:57 p.m., indicated the resident was transferred to the emergency room. A Nurse's Note, dated 11/29/23 at 12:43 a.m., indicated the resident was admitted to the hospital with COVID-19. A Nurse's Note, dated 12/3/23 at 10:05 a.m., indicated the resident returned to the facility from her hospitalization. The clinical record lacked a notice of transfer/discharge rights. The clinical record lacked indication of communication of the resident's plan of care, including medications and emergency contact information upon transfer for the receiving acute care facility. 2. Resident 14'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 observation, record review, and interview, the facility failed to ensure a self-administration assessment was completed for 1 of 1 residents reviewed for self-administration. (Resident 13) Findings include: During an interview, on 1/24/24 at 11:53 a.m., Resident 13 was observed in his room with a medication cup on his dresser. The cup contained one oblong white pill. Resident 13 indicated he needed to take medication directly before lunch and he had requested this medication and was allowed to take it back to his room with the nurse's knowledge. Resident 13's clinical record was reviewed on 1/26/24 at 2:29 p.m. The resident's diagnosis included gastro-esophageal reflux disease and diabetes mellitus, type 2. A current physician order, dated 1/3/24, indicated lactase enzyme oral tablet, give 1 tablet by mouth before meals for lactose intolerance. Resident 13's clinical record lacked a medication self-administration assessment. During an interview on 1/29/24 at 11:19 a.m., Resident 13 indicated this happened frequently as he knew the nursing staff were busy. Since he needed 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 honor a resident preference or obtain authorization from the resident's guardian to be transferred to the emergency room for further evaluation and treatment for 1 of 3 residents reviewed for choices. (Resident 1) Finding includes: 1. Resident 1's clinical record was reviewed on 1/26/24 at 4:24 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD), heart failure, personal history of COVID-19, and schizoaffective disorder. A physician's order, dated 1/16/24, included furosemide (diuretic) 20 milligrams (mg) one table by mouth in the morning for three days related to congestive heart failure. A quarterly Minimum Data Set (MDS) assessment, dated 12/26/23, indicated the resident had moderate cognitive impairment. The resident required moderate assistance for transfers and used a wheelchair for mobility. A current care plan, dated 5/9/22, indicated the resident had shortness of breath related to COPD. Interventions included observe for signs and symptoms of acute respiratory insufficiency such as: anxiety,…

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

Based on observation, record review, and interview, the facility failed to develop and implement individualized interventions for a cognitvely impaired resident with intrusive wandering behaviors for 1 of 4 residents reviewed for dementia care. (Resident 37) Findings include: During an observation on 1/24/24 at 2:30 p.m., Resident 37 was observed wandering the 200 hallway. The resident entered an occupied conference room and was observed moving items from one area of the room to another. No facility staff was present at this time. During an observation on 1/24/24 at 2:45 p.m., Resident 37 was observed walking into and out of resident rooms on the 200 hall. During an interview on 1/24/24 at 2:45 p.m., LPN 10 indicated Resident 37 wandered around the facility, into other resident's rooms, and sometimes collected things. During an observation on 1/29/24 at 12:08 p.m., Resident 37 was observed walking from the nurse station down the 200 hallway. During an interview, on 1/29/24 at 3:31 p.m., CNA 13 indicated Resident 37 wandered the facility and staff redirected the resident as much 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 observation, interview, and record review, the facility failed to complete gradual dose reductions or provide rationale when not completed for 1 of 5 residents reviewed for unnecessary medications. (Resident 15) Findings include: Resident 15's clinical record was reviewed on 1/26/24 at 11:21 a.m. Current diagnoses included anxiety, delusional disorder, major depressive disorder, and dementia. The resident had a current, 8/4/23, physician's order for buspirone (an anti-anxiety medication) 5 mg, take 1 tablet 3 times daily. The resident had a current, 8/6/23, care plan problem/need regarding being at risk for side effects due to psychotropic medication use. An approach to this problem was to consider a dose reduction when appropriate a least quarterly. An 11/11/23, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired and displayed no maladaptive behaviors during the assessment period. The resident had an, 1/17/24, Behavioral Assessment, which indicated the resident was not displaying any maladaptive behaviors during 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 observation and interview, the facility failed to store drugs and biologicals in a safe and secure manner for 17 of 17 residents' treatments stored in the 100 Hall medication cart. B. Based on observation and interview, the facility failed to ensure insulin pens were labeled and dated when opened for 2 of 5 medication carts reviewed for medication storage. (100 east cart and Swan cart) C. Based on observation and interview, the facility failed to ensure expired immunizations were removed from the medication refrigerator in the medication storage room for 1 of 2 medication storage rooms reviewed. (100 Hall medication room) Findings include: A. During a random observation on [DATE] at 9:10 a.m., the medication treatment cart on the North end of the 100 Unit was unlocked and unattended. During a continuous observation on [DATE] from 9:14 a.m. to 9:58 a.m., the treatment cart remained unlocked. LPN 2 exited a resident's room on the north end of the 100 unit and walked past the unlocked treatment cart.…

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 implement transmission based precautions (TBP) for a resident with COVID-19 prior to a hospitalization and upon return to the facility through recovery of illness for 1 of 6 residents reviewed for infection control and prevention. (Resident 1) Finding includes: 1. Resident 1's clinical record was reviewed on 1/26/24 at 4:24 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD), heart failure, and personal history of COVID-19. A quarterly Minimum Data Set (MDS) assessment, dated 12/26/23, indicated the resident had moderate cognitive impairment. The resident required moderate assistance for toileting, transfers, and used a wheelchair for mobility. A care plan, dated 5/9/22, indicated the resident had shortness of breath related to COPD. Interventions include, observe for signs and symptoms of acute respiratory insufficiency such as: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, and/or somnolence (5/9/22). 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 prevent the theft of resident's property by a staff member (QMA 14) for 1 of 5 residents reviewed for abuse. (Resident C) Findings include: Resident C's clinical record was reviewed on 1/2/24 at 11:10 a.m. Diagnoses included major depressive disorder, single episode, severe with psychotic features, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, aphasia following unspecified cerebrovascular disease and generalized anxiety disorder. A quarterly Minimum Data Set (MDS), dated [DATE], indicated she was cognitively intact. During an interview with Resident C, on 1/2/24 at 2:32 p.m., she indicated she didn't realize she had dropped her wallet from a hook that was attached to the side of her motorized wheelchair. The wallet was returned to her, but the money was missing. The money was returned to her a week later. She did not want to disclose how much money was in the wallet. During an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report the misappropriation/theft of resident's property by a staff member (QMA 14) to the State Agency and law enforcement in the required time frame for 1 of 5 residents reviewed for abuse. (Resident C) Findings include: Resident C's clinical record was reviewed on 1/2/24 at 11:10 a.m. Diagnoses included major depressive disorder, single episode, severe with psychotic features, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, aphasia following unspecified cerebrovascular disease and generalized anxiety disorder. A quarterly Minimum Data Set (MDS), dated [DATE], indicated she was cognitively intact. During an interview with Resident C, on 1/2/24 at 2:32 p.m., she indicated she didn't realize she had dropped her wallet from a hook that was attached to the side of her motorized wheelchair. The wallet was returned to her, but the money was missing. The money was returned to her a week later. She…

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 thoroughly investigate the misappropriation of resident's property by a staff member (QMA 14) for 1 of 5 residents reviewed for abuse. (Resident C) Findings include: Resident C's clinical record was reviewed on 1/2/24 at 11:10 a.m. Diagnoses included major depressive disorder, single episode, severe with psychotic features, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, aphasia following unspecified cerebrovascular disease and generalized anxiety disorder. A quarterly Minimum Data Set (MDS), dated [DATE], indicated she was cognitively intact. The clinical record lacked documentation of the misappropriation/theft of Resident C's money. During an interview with Resident C, on 1/2/24 at 2:32 p.m., she indicated she didn't realize she had dropped her wallet from a hook that was attached to the side of her motorized wheelchair. The wallet was returned to her, but the money was missing. The money 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 accurately report the RN coverage hours for 12 of 21 days triggered on a Payroll Based Journal Report for Fiscal Year 2023 Quarter 3. Findings include: A Payroll Based Journal (PBJ) report, compiled on 12/4/23, indicated no RN hours were reported for 21 days and included 4/3/23, 4/5/23, 4/6/23, 4/10/23, 4/11/23, 4/15/23, 4/19/23, 4/20/23, 4/29/23, 5/3/23, 5/6/23, 5/7/23, 5/9/23, 5/10/23, 5/13/23, 5/21/23, 5/27/23, 5/28/23, 6/18/23, 6/25/23, and 6/29/23. During an interview with the Corporate Human Resources (HR) Officer and with the Facility HR employee present, on 12/6/23 at 10:12 am., Corporate HR Officer indicated the nurse managers, the Minimum Data Set (MDS) Coordinator and the DON were typically salaried employees. They should be clocking in on the time clock and then the Facility's HR employee would change the code to make sure the hours were captured and then she would report them to CMS. The Facility HR employee indicated she was not always aware when administrative staff worked to make sure the coding was changed…

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 nurse's authorization was obtained prior to the administration of as needed (PRN) medication by a Qualified Medication Aide for 2 of 3 QMAs observed during a medication pass. (QMA 4 and QMA 12) Findings include: During an observation of a medication pass, on 12/5/23 at 1:41 p.m., Resident F indicated to QMA 4 he had pain in his groin area and rated his pain 7 out of a 10. QMA 4 indicated she was going to see what she could give him. He had a current order for hydrocodone - acetaminophen (narcotic pain reliever) 5-325 mg every six hours for pain. She prepared the medication and administered it to Resident F. She then told the nurse that Resident F had pain in his groin, he had rated 7 out of a 10 and she had administered him a pain pill. QMA 4 indicated she would normally ask the nurse prior to giving PRN medication. During an observation of a medication pass, on 12/5/23 at 1:50 p.m., Resident G indicated to QMA 12 he had diarrhea and requested two green pills. QMA 12 indicated he had PRN Lomotil…

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 RN services were provided for at least 8 consecutive hours, 7 days a week. Findings include: The RN coverage time sheets from 11/1/23 to 12/4/23 were provided by the Administrator, on 12/6/23 at 11:32 a.m. and indicated there were not 8 hours of RN coverage on 11/5/23, 11/11/23, 11/12/23, 11/22/23, 11/25/23, 11/26/23, 12/2/23, 12/3/23 and 12/4/23. During an interview with the Corporate Human Resources (HR) Officer and with the Facility HR employee present, on 12/6/23 at 10:12 am., Corporate HR Officer indicated the nurse managers, the Minimum Data Set (MDS) Coordinator and the DON were typically salaried employees. They should be clocking in on the time clock and then the Facility's HR employee would change the code to make sure the hours were captured and then she would report them to CMS. The Facility HR employee indicated she was not always aware when administrative staff worked to make sure the coding was changed in the time clock. During an interview with the Administrator, on 12/6/23 at 11:32 a.m., she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's physician was notified for a resident who was sent to the hospital for 1 of 3 residents reviewed for hospital transfers (Resident C) and failed to notify residents' emergency contacts when the resident was sent to the hospital for 2 of 3 residents reviewed for emergency contact notification (Resident C and Resident B). Findings include: 1. Resident C's clinical record was reviewed on 10/20/23 at 11:20 a.m. Diagnoses included essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, presence of cardiac pacemaker, diabetes mellitus due to underlying condition with diabetic autonomic (poly) neuropathy and unspecified systolic (congestive) heart failure. A quarterly Minimum Data Set (MDS) assessment, dated 8/2/23, indicated he was cognitively intact. He was discharged to the hospital on [DATE]. His resident profile indicated a family member as the emergency contact. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report accurate information regarding allegations of abuse for 1 of 3 allegations of abuse reviewed (Resident B and Resident E). Findings include: Review of a facility reported incident, submitted by the Administrator, dated 8/7/23 at 9:01 p.m. involving Resident E and Resident B indicated the following: Resident E was watching TV when Resident B asked her to turn it down several times without success. They lived across the hall from each other. Resident B became verbally frustrated with Resident E. There were no injuries. The physician, DON and the Administrator were immediately notified. Psychosocial support was provided immediately and continuously. An investigation was initiated and completed. Psychosocial support continued for both residents. Resident B became agitated with Resident E because he kept asking her to turn the volume down to her TV. Resident E had a hard time hearing. A nurse walked down and was able to diffuse the situation. The…

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

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse for 1 of 3 allegations of abuse reviewed (CNA 16 and Resident F). Findings include: During an interview with Resident F, on 9/5/23 at 10:55 a.m., he indicated as he was going into the lounge bathroom to spit some nicotine out of his mouth, CNA 16 grabbed a hold of his left arm and told him he had a bathroom in his own room. CNA 16 then punched him in the arm. Resident F's clinical record was reviewed on 9/6/23 at 11:32 a.m. Diagnoses included schizophrenia, depression, attention and concentration deficit and mild cognitive impairment of uncertain or unknown etiology. A quarterly MDS (Minimum Data Set) assessment, dated 5/20/23, indicated he was moderately cognitively impaired. He had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), he had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public,…

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

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls for residents' who were at a high risk for falls (Resident D and Resident K) for 2 of 3 residents reviewed for falls. Findings include: 1. On 9/5/23 at 4:55 a.m., Resident D was in a recliner in the common area with her legs elevated, wearing non-slip socks. She had a light purple bruising to the left side of her forehead. Resident D's clinical record was reviewed on 9/5/23 at 9:04 a.m. Diagnoses included Alzheimer's disease, epilepsy, unspecified, not intractable, without status epilepticus, unspecified psychosis not due to a substance or known physiological condition, dementia in other diseases classified elsewhere, moderate, with psychotic disturbance, age-related osteoporosis without current pathological fracture, muscle weakness (generalized), and other abnormalities of gait and mobility. Her medications included metoprolol tartrate (blood pressure) 25 mg (milligram) daily, divalproex sodium (seizures) 250 mg twice daily, and escitalopram oxalate (anxiety) 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.