New Harmony Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate supervision, monitor behaviors, update the plan of care, and document relevant information to prevent accidents and then following an accident for 2 of 3 residents reviewed for accidents and dementia care. A resident (Resident C) with a history of wandering behaviors was not observed to enter another resident's room (Resident D) which led to a resident-to-resident altercation and a bite wound. (Resident C, Resident D)Findings include:1. During record review on 10/15/25 at 9:30 A.M., Resident C's diagnoses included but were not limited to dementia with behavioral disturbance.Resident C's most recent admission MDS (Minimum Data Set) assessment, dated 10/8/25 indicated the resident had severe cognitive impairment, a behavior of wandered daily during a 7-day review period, and that the wandering did not significantly intrude on the privacy or activities of others.Resident C's physician orders included, but were not limited to,…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received only the medications ordered by a physician and that medications were properly labeled for 1 of 3 residents reviewed for pharmacy services. A resident was self-administering an antacid medication without the medication being properly labeled or ordered by a physician. (Resident D) Finding includes: During an interview and observation on 3/4/25 at 10:30 A.M., Resident D was sitting in a reclining chair in her room. A clear plastic cup was approximately two-thirds full of multi-colored tablets. The cup contained no labels or information that indicated what the contents of the cup were. Resident D indicated that her stomach had been bothering her and that the Tums (motioned towards the cup of tablets)(calcium carbonate medications) had not helped. Resident D was holding a sheet of paper and indicated that a nurse had just brought her the results of a scan completed the previous day. During record review on 3/4/25 at 2:00 P.M., Resident D's diagnoses included but were not limited to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plans were revised quarterly in 12 of 13 residents reviewed for care planning and conferences, 1 of 2 residents reviewed for UTI (Urinary Tract Infections) catheters, and 2 of 3 for siderails. (Resident 7, Resident 9, Resident 11, Resident 12, Resident 13, Resident 17, Resident 18, Resident 19, Resident 12, Resident 23, Resident 37, Resident R) Findings include: 1. On 9/12/24 at 10:35 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were limited to, hypertension and Deep Vein Thrombosis. The current annual MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was cognitively intact. The resident needed supervision with toileting and set up with dressing, eating, and transfer. During the 7 days look back period the resident was on the following types of medications antiplatelets, anticoagulant, antidepressant, diuretic, opioid, and hypoglycemic. Care conferences were offered but declined by the POA…

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 proper storage of medications for 3 of 3 medication carts, 1 of 1 treatment cart, and 1 of 1 medication storage room observed. Loose pills were observed in the medication cart drawers, medication was not labeled, and medication room refrigerator temperature logs were not completed. (200-M Hall, 400 Hall, 300 Hall, [NAME] Medication Storage Room) Findings include: 1. On 9/9/24 at 9:18 A.M., the 200-M Hall medication cart was reviewed. The following loose pills were observed in the bottom of the drawers: 1 white circle pill with marking TCL 340 1 white circle pill with marking 44 157 2. On 9/9/24 at 9:23 A.M., the 200-M Hall treatment cart was reviewed. The following items were observed opened, without labels, and not in a resident bag: Triple Antibiotic Ointment Ready Prep Therahoney Gel At that time, Licensed Practical Nurse (LPN) 10 indicated that once house stock items were opened, they were stored in individual resident bags. 3. On 9/9/24 at 9:58 A.M., the 400 Hall medication cart was reviewed. 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 food was stored, labeled, and dated properly in accordance with professional standards for food service and ensure chemical sanitization was monitored for 2 of 2 kitchen observations. Findings include: On 9/9/24 at 8:57 A.M., an initial tour of the kitchen was conducted. The following items were observed: In the dry storage area,1 bottle apple cider vinegar labeled open 1/24/24 use by 4/24/24 In the walk in freezer: 1 bag of spanish rice labeled 5/14/24 use by 6/14/24 2 bags of coffee cake; 1 labeled 7/24/24 use by 8/24/24 and 1 with no dates/label 4 plastic containers labeled jalapeno's 8/16 use by 8/20 1 plastic container with foil covering top labeled tomatoes 8/13 to 8/18 1 unlabeled/undated package of raw meat 1 bag labeled pizza sauce 6/29 use 7/29 1 bag labeled biscuits 7/23/24 use 8/23/24 In the walk in fridge: 2 unlabeled/undated pitcher of brown liquid 2 unlabeled/undated pitchers of orange liquid 2 unlabeled/undated pitchers orange juice 1 box of black bananas with no dates 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the documentation was completed and accurate for 5 of 6 residents reviewed for accuaracy of falls documentation. (Resident 9, Resident 12, Resident 19, Resident 7, Resident 11) Findings include: 1.On 9/11/24 at 10:28 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 9/7/24, indicated Resident 9 was not assessed for cognitive impairment because the resident was rarely or never understood, required partial to moderate assistance of staff (staff does less than half) for transfers, and had no falls since the prior assessment. A falls risk assessment, dated 9/13/23, indicated the resident was at high risk for falls. A potential for falls and injuries care plan, dated 6/23/21, included the intervention ensure well lit/clutter free area. Fall 1: On 10/7/23 at 6:15 P.M., Resident 9 had a witnessed fall. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident was on EBP (enhanced barrier precautions) for 1 of 2 residents reviewed for catheters, for 3 of 3 random observations reviewed for hand hygiene during incontinence care and medication administration, and for 2 of 2 random observation for cleaning equipment in between residents (Resident 11, Resident 2, Resident 19, Resident 5, Resident 6 Findings include: 1. On 9/9/24 at 9:30 A.M., there was no Enhanced Barrier Precautions (EBP) Sign observed on a Resident 11's door for indwelling catheter. On 9/10/24 at 10:00 A.M., there was no Enhanced Barrier Sign observed on Resident 11's door for and indwelling catheter. On 9/11 at 12:46 P.M., there was no Enhanced Barrier Sign observed on Resident 11's door for and indwelling catheter. On 9/13/24 at 9:07 A.M., there was no Enhanced Barrier sign observed on Resident 11's door for and indwelling catheter. On 9/10/24 at 10:12 A.M., Resident 11's clinical record was reviewed. Diagnoses…

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 the safety of resident's by not utilizing an emergency call system for 6 of 6 days during survey. (Public Restroom) Finding includes: During random observations throughout the week of survey from dates September 9 to September 16, 2024. The visitor restroom located in the main hallway across from the beauty shop lacked an emergency call system. During an interview on 9/16/24 at 9:55 A.M., the DON (Director of Nursing) indicated that residents from the beauty shop used that restroom and there was no emergency call light system in the visitor restroom. A current nondated policy was provided by the Regional Clinical Support Nurse at 10:00 A.M. The policy Personal Property-Home Like Environment lacked information concerning call lights. 3.1-19(b)

Based on observation, record review, and interview, the facility failed to provide a safe and sanitary environment for residents, staff, and the public for 9 random observations on 6 of 6 days. Urine odors in entrance hallway, conference room and [NAME] unit hallways. (Entrance Hallway, Conference Room, [NAME] Unit Hallways) Findings include: 1. On 9/9/24 at 8:50 A.M., the odor of urine was observed in the entrance hallway and the conference room. On 9/10/24 at 8:55 A.M., the odor of urine was observed in the entrance hallway and conference room. On 9/12/24 at 6:55 A.M., the odor of urine was observed in the conference room. On 9/13/24 at 8:20 A.m., the strong smell of urine was observed in the Entrance Hallway and the Conference Room. 2. On 9/10/24 at 12:48 P.M., the odor of urine was observed by the [NAME] Hall Unit Nurses Station. 3. On 9/11/24 at 8:20 A.M., the odor of urine was observed in hallway outside of the conference room. On 9/11/24 at 11:00 A.M., the strong odor of urine with air freshener was observed in the hallway by the conference room 4. On 9/12/24 at 7:04 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that a resident who had medication at bedside had a physician order for the medication to be kept at bedside and self-administer, a completed assessment to self-administer, and a care plan based on 2 of 2 residents reviewed for self-administration of medications. (Resident 14. Resident 36) Findings include: 1. On 9/10/24 at 9:22 A.M., Resident 14 was observed having 1 bottle of eye relief drops and 1 bottle of cooling pain relief medication sitting on the bedside table. On 9/12/24 at 11:23 A.M., Resident was observed having 1 bottle of eye relief drops and 1 bottle of cooling pain relief medication sitting on the bedside table. On 9/16/24 at 10:25 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, and depression The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 14 was cognitively intact. Resident 14 needed partial assistance 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 notify a Resident's representative during change in condition for 1 of 2 Residents with severely impaired cognition reviewed for unnecessary medications. (Resident 37) Finding includes: On 9/10/24 at 8:37 A.M., Resident 37's clinical record was reviewed. Resident 37 was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease, anxiety, major depressive disorder, and visual/auditory hallucinations. The most recent Significant Change MDS (Minimum Data Set) assessment, dated 8/14/24, indicated Resident 37's cognition was below measurable, was completely dependent on staff for eating, bathing, toileting, and transfers, and was receiving antipsychotic, antianxiety, antidepressant, hypnotic, and opioid medications during the seven day lookback period. Physician orders included, but were not limited to: Olanzapine Oral Tablet 10 MG Give 10 mg by mouth two times a day for schizophrenia behavior disorder. Start date 7/12/24…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure proper clinical documentation was sent with a resident during a transfer for 1 of 4 residents reviewed for hospital transfers. (Resident 37) Findings include: On 9/10/24 at 8:37 A.M., Resident 37's clinical record was reviewed. Resident 37 was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease and abnormalities of gait and mobility. The most recent Significant Change MDS (Minimum Data Set) assessment, dated 8/14/24, indicated Resident 37's cognition was below measurable, was completely dependent on staff for eating, bathing, toileting, and transfers, and was receiving antiphychotic, antianxiety, antidepressant, hypnotic, and opioid medications during the seven day lookback period. A nurses progress note, dated 8/1/24 at 8:00 P.M., indicated Resident 37 was transferred from the facility to the emergency department by ambulance. The clinical record lacked documentation sent with Resident 37 during the transfer.…

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 notice of transfer was provided during a transfer for 1 of 4 residents reviewed for hospital transfers. (Resident 37) Findings include: On 9/10/24 at 8:37 A.M., Resident 37's clinical record was reviewed. Resident 37 was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease and abnormalities of gait and mobility. The most recent Significant Change MDS (Minimum Data Set) assessment, dated 8/14/24, indicated Resident 37's cognition was below measurable, was completely dependent on staff for eating, bathing, toileting, and transfers, and was receiving antiphychotic, antianxiety, antidepressant, hypnotic, and opioid medications during the seven day lookback period. A nurses progress note, dated 8/1/24 at 8:00 P.M., indicated Resident 37 was transferred from the facility to the emergency department by ambulance. The clinical record lacked documentation provided to Resident 37 or her representative. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a bed hold was provided upon transfer for 1 of 4 residents reviewed for hospital transfers. (Resident 37) Findings include: On 9/10/24 at 8:37 A.M., Resident 37's clinical record was reviewed. Resident 37 was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease and abnormalities of gait and mobility. The most recent Significant Change MDS (Minimum Data Set) assessment, dated 8/14/24, indicated Resident 37's cognition was below measurable, was completely dependent on staff for eating, bathing, toileting, and transfers, and was receiving antiphychotic, antianxiety, antidepressant, hypnotic, and opioid medications during the seven day lookback period. A nurses progress note, dated 8/1/24 at 8:00 P.M., indicated Resident 37 was transferred from the facility to the emergency department by ambulance. The clinical record lacked documentation provided for Resident 37. During an interview on 9/13/24 at 1:07 P.M., the ADON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 2 of 2 residents reviewed for restraints (Resident 11, Resident 19), 1 of 5 residents reviewed for unnecessary medications(Resident 37) and 1 of 6 residents review for falls(Resident 37). (Resident 11, Resident 19, Resident 37) Findings include: 1. On 9/10/24 at 10:12 A.M., Resident's 11 clinical record was reviewed. Diagnoses included, but not limited to, systemic lupus erythematosus, chronic kidney disease stage 3, and neuromuscular dysfunction of bladder. The Current Quarterly MDS (Minimum Data Set) Assessment date 7/23/24 indicated Resident was cognitively intact and was dependent to transfer and toilet. The assessment indicated that the resident had a restraint of bed rails and used daily Current physician orders included, but were not limited to, Bilateral 1/2 siderails every shift related to weakness. For resident to assist with positioning and turning dated 6/12/24. 2. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop care plans for 1 of 3 residents reviewed for UTIs and 1 of 5 residents reviewed for unnecessary medications. A care plan was not developed for residents with new diagnoses and new medication orders. (Resident 12 and Resident 7) Findings include: 1. On 9/11/24 at 11:26 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, urinary tract infection (UTI). The most current Annual Minimum Data Set (MDS) Assessment, dated 6/17/24, indicated Resident 12 had severe cognitive impairment, required setup assistance for toileting, and did not have a UTI. Current physician orders included, but was not limited to: Ciprofloxacin (an antibiotic) 500 milligrams (mg) - Give 1 tablet by mouth every 12 hours for UTI until 09/13/24, dated 9/8/24 A Nursing progress note, dated 9/7/24 at 2:17 P.M., indicated Resident 12 returned from the hospital on that date with antibiotics for a UTI. The clinical record lacked 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure practitioner's diagnostic practices met professional standard of care for 1 of 1 Resident reviewed for a schizophrenia diagnosis over [AGE] years of age after admission. (Resident 37) Finding includes: On 9/10/24 at 8:37 A.M., Resident 37's clinical record was reviewed. Resident 37 was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease, anxiety, major depressive disorder, and visual/auditory hallucinations. On 7/12/24 Resident 37 was given a new diagnosis of schizophrenia. The clinical record lacked any documentation related to that diagnosis, why the diagnosis was given, or any assessment that lead to the diagnosis. The most recent Significant Change MDS (Minimum Data Set) assessment, dated 8/14/24, indicated Resident 37's cognition was below measurable, was completely dependent on staff for eating, bathing, toileting, and transfers, and was receiving antipsychotic, antianxiety, antidepressant, hypnotic, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor progression of pressure ulcers and document assessments for 2 of 2 residents reviewed for wound care. (Resident 23 and Resident 18) Findings include: 1. On 9/11/24 at 10:21 A.M., Resident 23's clinical record was reviewed. Resident 23 was admitted on [DATE]. Diagnoses included, but were not limited to, multiple sclerosis and peripheral vascular disease. The most recent Quarterly MDS assessment, dated 8/20/24, indicated Resident 23 was cognitively intact, was dependent on staff for toileting, showers, and transferring, and had two stage four pressure ulcers. Physician orders included, but were not limited to: Right Ischium: Cleanse area with wound cleanser, pat dry, skin prep peri wound, apply Leptospermum Honey and Calcium Alginate to wound bed, cover with bordered dressing every day shift. Start date 8/28/24 Sacral wound: Cleanse with wound cleanser, pat dry, skin prep peri wound, apply Leptospermum honey and Calcium Alginate to slough areas…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility failed to provide care, services, and supervision to prevent accidents, lacked thorough and complete assessments post fall, and failed to update interventions after falls for 1 of 6 residents reviewed for falls (Resident 37) and 1 of 1 for unsafe wandering. (Resident 201) Resident 37 experienced an unwitnessed fall and sustained a nose fracture. Findings include: 1. On 9/10/24 at 8:37 A.M., Resident 37's clinical record was reviewed. Resident 37 was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease, anxiety, major depressive disorder, and abnormalities of gait and mobility. A physician order for antipsychotic medication monitoring was started on 4/18/23. A care plan, created on 4/19/23 and last revised on 4/19/23, and indicated (Resident) is risk for falls. Interventions: Be sure (Resident's) call light is within reach and encourage the resident to use it for assistance as needed. Ensure that (Resident) is wearing…

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 oxygen equipment was properly labeled and respiratory services were provided according to the care plan for 2 of 3 residents reviewed for respiratory care. (Resident 15 and Resident 11) Findings include: 1. On 9/9/24 at 10:53 A.M., Resident 15 was observed receiving 3 Liters (L) of oxygen via nasal cannula. There was no date on the oxygen tubing or humidification bottle. An oxygen tubing storage bag was not observed in the resident's room. On 9/10/24 at 10:40 A.M., Resident 15 was not in her room. The oxygen concentrator was turned on to 3L and the nasal cannula tubing was lying across the resident's recliner. There was an oxygen tubing bag attached to the concentrator with no date. There was no date on the oxygen tubing. The date on the humidification bottle was 9/8/24. On 9/10/24 at 10:53 A.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, chronic respiratory failure with hypercapnia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide ongoing assessment of the resident's condition and monitoring for complications of dialysis by completing Pre Dialysis Assessments, Post Dialysis Assessments, and Dialysis Communication Records for 1 of 1 residents reviewed for dialysis management. (Resident 15) Finding includes: On 9/9/24 at 10:51 A.M., Resident 15 indicated she went to dialysis every Tuesday, Thursday, and Saturday, and sometimes received an extra dialysis session during the week. On 9/10/24 at 10:53 A.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease. The most current admission Minimum Data Set (MDS) Assessment, dated 8/25/24, indicated Resident 15 was cognitively intact, required partial to moderate assistance of staff (staff does less than half) for toileting, and received dialysis. A current hemodialysis care plan, dated 8/3/23, indicated Resident 15 received dialysis related to renal failure. Current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility failed to ensure medication side effects were properly monitored and pharmacy recommendations were considered for 1 of 5 Residents reviewed for unnecessary medications. (Resident 37) Finding includes: On 9/10/24 at 8:37 A.M., Resident 37's clinical record was reviewed. Resident 37 was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease, anxiety, major depressive disorder, and visual/auditory hallucinations. The most recent Significant Change MDS (Minimum Data Set) assessment, dated 8/14/24, indicated Resident 37's cognition was below measurable, was completely dependent on staff for eating, bathing, toileting, and transfers, and was receiving antipsychotic, antianxiety, antidepressant, hypnotic, and opioid medications during the seven day lookback period. Physician orders included, but were not limited to: Lorazepam Oral Concentrate 2 MG/ML (milligrams/milliliter) Give 0.25 mL by mouth every 2 hours as needed for…

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

Based on interview and record review, the facility failed to ensure an intravenous (IV) antibiotic was administered in accordance with physician orders for 1 of 1 resident reviewed for IV therapy. This deficient practice resulted in a resident being re-hospitalized to receive intravenous (IV) antibiotics. (Resident R) Finding includes: On 9/12/24 at 1:28 P.M., Resident R's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure, diabetes mellitus, and bacteremia. The most current Annual Minimum Data Set (MDS) Assessment, dated 5/14/24, indicated Resident R was cognitively intact, required setup assistance of staff to eat, and was not receiving IV therapy. The most current Quarterly MDS Assessment, dated 6/30/24, indicated Resident R had severe cognitive impairment, required supervision of staff to eat, and was not receiving IV therapy. Nursing progress notes from 9/1/24 at 2:28 P.M. to 9/3/24 at 12:22 P.M. indicated R was sent to the hospital on 9/1/24 for evaluation and treatment of pneumonia. Resident R returned to the facility on 9/3/24…

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 ensure food was stored and labeled appropriately, and the areas free of food and debris in 2 of 2 kitchen observations. Food containers were found not labeled in the dry storage area, walk-in freezer, walk-in refrigerator, and shelving for spices in food preparation area in the kitchen. Food debris and paper were located in the walk-in freezer, drink refrigerator, refrigerator and dry storage. Findings include: On 2/6/24, during the initial tour of the kitchen at 8:32 A.M. the following were viewed in the walk-in refrigerator: Dry onion skins on the floor Orange Juice jug was not dated Lemonade container not dated 1 gallon of 2% milk gallon jug no open date Cucumbers in a box with no open date At 8:46 A.M. the drink refrigerator included: 1-gallon sized container of with an open date of 1/23/24 1 jar of chopped garlic in water with no open date 2 pre-made bottles of dressing with no preparation or open date 1 bottle of raspberry vinaigrette dressing no open or expiration date 1 bottle of lemon juice that was separated with…

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

Based on interview and record review, the facility failed to ensure a resident's right of self-determination was promoted for 1 of 3 residents reviewed for notifications. A resident's scheduled appointment was rescheduled by the facility without notifying or including the resident in the change of plan. (Resident B) Finding includes: During a review of facility grievances on 10/2/23 at 10:45 A.M., a grievance form was filed on 7/2/23 by Resident B with a concern regarding her appointments and a request that included, .Would like for staff to schedule appointments with [Resident B] . During record review on 10/3/23 at Resident B's diagnoses included but were not limited to; Chronic obstructive pulmonary disease (COPD), heart failure, pulmonary hypertension, and peripheral vascular disease. Resident B most recent quarterly Minimum Data Set (MDS) assessment, dated 9/19/23 , included that the resident was cognitively intact. Resident B's physician orders included but were not limited to; Follow up with [MD] Friday October 6th at 2:45 P.M. (order date 6/6/23 and discontinued date…

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

Based on observation, interview, and record review, the facility failed to ensure food was stored and served in accordance with professional standards for food service safety, and food was prepared in a sanitary manner for 2 of 2 observations of the kitchen, and 1 of 1 meal preparations observed. Food was open to air in the freezer, holes were observed in the walls of the kitchen, an expired label was observed on a container of flour, and food was touched with soiled gloves. (Main Kitchen) Findings include: During the initial kitchen observation on 6/5/23 at 8:09 A.M., the following was observed: A box of sliced carrots was open to air in the freezer. A tub of flour under a preparation table had a label on the side that indicated use by 5/20/23. The same was observed on 6/8/23 at 12:18 P.M. A basketball sized hole (approximately 12 inches in diameter) was observed in the wall under the oven, with several layers of drywall missing, and concrete with black spots exposed. The same was observed on 6/8/23 at 12:18 P.M. The paint around the electrical box was chipped. The same was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and sanitary environment was maintained in 1 of 4 resident halls. Cracks and missing tiles were observed in the floor, the floor was sticky, a toilet paper roll was broken off, window blinds were broken, privacy curtains were torn and missing, and the walls were observed with layers of paint and wall missing. (Secured Hall floor, Secured Hall small dining area, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: 1. On 6/6/23 at 9:23 A.M., room [ROOM NUMBER] was observed with a bad odor in the room. The call light pull cord in the bathroom was observed with a brown substance on it, the back of the toilet seat was chipping and rusted brown. A string was missing from the right side of the window blinds. The same was observed on 6/9/23 at 10:27 A.M. 2. On 6/6/23 at 9:27 A.M., room [ROOM NUMBER] was observed…

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 that 1 of 5 residents observed during medication pass had a self administration assessment and order. (Resident 8) Finding includes: On 6/7/23 at 8:03 A.M., QMA (Qualified Medication Aide) 8 was observed leaving Resident 8's medication on the food tray and left the room without watching the resident take the following medications: 1 Loratidine 10 mg (milligrams) 1 Baby Aspirin 81 mg 1 Carvedilol 25 mg 1 Diltiazem HCL ER 240 mg 1 Farxiga tablet 5 mg 1 Furosemide 40 mg 1 Levetiraceta 500 mg 1 Losartan 100 mg 1 Omeprazole 20 mg 1 Preservision capsule 1 Tradjenta 5 mg tablet On 6/8/23 at 9:00 A.M., Resident 8's clinical record was reviewed. Diagnosis included, but was not limited to, hemiplegia and hemiparesis following unspecified cardiovascular disease and heart failure. The current quarterly MDS (Minimum Data Set) assessment, dated 4/18/23, indicated Resident 8 was cognitively intact. Current physicians orders lacked a self administration order. Current care plan lacked self administration interventions.…

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 notification of change for 1 of 6 residents reviewed for unnecessary medications. A resident's representative was not notified prior to anti-anxiety or narcotic pain medication as requested by the representative. (Resident 48) Finding includes: Interview on 6/5/23 at 1:31 P.M., Resident 48's daughter (power of attorney) indicated she had spoken with the Director of Nursing (DON), as well as Resident 48's hospice team related to a new prescription of Ativan (an anti-anxiety medication) and Morphine (a narcotic pain medication). She indicated she had requested she be called prior to administration of these medications, as they were prescribed on an as needed basis, and she wanted to speak with staff about implementing other interventions prior to giving the medications. On 6/6/23 at 1:16 P.M., Resident 48's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and COPD (chronic obstructive pulmonary disease). The most recent quarterly MDS (minimum data set) Assessment, dated 5/22/23,…

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

Based on observation, interview, and record review, the facility failed to ensure residents received supervision and consistent implementation of interventions to prevent falls for 2 of 5 residents reviewed for accidents. Fall interventions were observed out of place, and care plans were not updated following falls. (Resident 40, Resident 48) Findings include: 1. On 6/6/23 at 1:42 P.M., Resident 40's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and depression. The most recent quarterly MDS (minimal data set) Assessment, dated 3/29/23, indicated a severe cognitive impairment, no behaviors, and was on hospice. Resident 40 required limited assistance of one staff for bed mobility, transfers, and eating, supervision of one staff for toileting, and was totally dependent on one staff for bathing. Resident 40 had two or more falls since the prior assessment with no injury. A current risk for falls care plan, dated 5/18/22, included, but was not limited to, the following interventions: apply non skid strips to floor in front of the recliner, 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 interview and record review, the facility failed to ensure attempt for management of pain was provided for 1 of 1 residents reviewed (Resident 28). Finding includes: During an interview on 6/8/23 at 10:57 A.M., Resident 28 indicated they were experiencing pain following a recent surgery on 5/11/23, had told staff on multiple occasions they were experiencing pain, and had not received any treatment for the pain in weeks. During an interview on 6/8/23 at 1:45 P.M., the DON (Director of Nursing) indicated that Resident 28 had a positive drug screen on 5/23/23, and the facility physician had discontinued all narcotics, but Resident 28 should still be receiving alternative pain management treatment. On 6/8/23 at 1:55 P.M., Resident 28's clinical records were reviewed. Diagnoses included, but were not limited to, chronic pain, fracture of right humerus, and encounter for orthopedic aftercare. The most recent admission MDS (Minimum Data Set) Assessment, dated 3/20/23, indicated resident was cognitively intact, required extensive assist of 2 staff for bed mobility, transfer, 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 observation, interview, and record review, the facility failed to ensure appropriate social services were provided to meet the resident's needs for 1 of 4 residents reviewed for vision and dental services. (Resident 48) Finding includes: On 6/5/22 at 10:03 A.M., Resident 48 was observed sitting in the dining room. He was not wearing eyeglasses or dentures. Interview on 6/5/23 at 1:18 P.M., Resident 48's daughter indicated Resident 48 was currently eating without his dentures, as they had been in the nurses cart since 9/2022. She indicated speech therapy was supposed to work with him wearing the dentures, but to her knowledge had not done so yet. She further indicated his glasses were missing and staff was aware, but had not assisted to replace them. On 6/6/23 at 1:16 P.M., Resident 48's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent quarterly MDS (minimum data set) Assessment, dated 5/22/23, indicated Resident 48 was severely cognitively impaired and was on hospice. Resident 48 had adequate vision with no corrective…

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 medications were administered appropriately for 1 of 6 residents reviewed for unnecessary medication use. An antianxiety medication and narcotic pain medication were administered without rationale. (Resident 48) Finding includes: Interview on 6/5/23 at 1:31 P.M., Resident 48's daughter (power of attorney) indicated she had spoken with the Director of Nursing (DON), as well as Resident 48's hospice team related to a new prescription of Ativan (an anti-anxiety medication) and Morphine (a narcotic pain medication). She indicated she wanted to speak with staff about implementing other interventions prior to giving the medications. She indicated about a month ago, a staff member had given Ativan and Morphine both without notifying her first. A nurse that was there at that time indicated to her that the staff that administered the medication had indicated I gave him enough meds to knock over a horse. He'd better find a couch soon. On 6/6/23 at 1:16 P.M., Resident 48's clinical record was reviewed. Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 2 of 6 residents reviewed for unnecessary medications. Residents had PRN (as needed) anti-anxiety medications that were ordered for greater than 14 days without a rationale included in their clinical record (Resident 21, Resident 48). Findings include: 1. On 6/7/23 at 8:40 A.M., Resident 21's clinical record was reviewed. Resident 21 was admitted on [DATE]. Diagnosis included, but was not limited to, major depressive disorder. The most recent annual MDS (Minimum Data Set) Assessment, dated 3/2/23, indicated Resident 21 was cognitively intact and an anti-anxiety medication was administered for 7 of 7 days during the look back period. Current physician orders included, but were not limited to, the following: Xanax Oral Tablet 0.5 MG (Alprazolam) 0.5 mg by mouth at bedtime for restlessness/tearfulness/anxiousness, dated 4/19/23. Xanax Oral Tablet 0.5 MG (Alprazolam) by mouth every 24 hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide proper storage of medications in 3 of 4 medication carts and 3 of 3 wound/treatment carts. Loose pills were found in the bottom of the medication cart drawers in 2 of 4 medication carts (Cardinal Hall and East Hall). There were improperly labeled bulk medications and over the counter medications in 3 of 3 wound/treatment carts (Wound/ treatment cart for East/Cardinal Hall, [NAME] Treatment Cart I/M Hall, Big Cart Wound Cart). Findings include: 1. On 6/7/23 at 6:12 A.M., the medication cart in the M Hall was observed to have the following unlabeled medications and bulk medications in a drawer: Nicotine gum. Active liquid protein [Patient Name], date present, but no MD (Medical Doctor) listed. 2. On 6/07/23 at 6:47 A.M., the medication cart on the Cardinal Hall was observed to have the following loose pills laying in 2 drawers: 1 green pill. 1 red with #(number) 242 pill. 1 1/2 oblong pill with # l1nvr. 1 small white pill with L #1. 1 large yellow…

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 meals were prepared to meet resident's needs according to the plan of care for 1 of 2 residents reviewed for dental care. A resident was not provided a diet as ordered. (Resident 48) Finding includes: On 6/6/23 at 1:16 P.M., Resident 48's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent quarterly MDS (minimum data set) Assessment, dated 5/22/23, indicated a severe cognitive impairment. Resident 48 required limited assist of one staff with eating, had no swallowing disorders, and required a mechanical soft diet. Current physician orders included, but were not limited to, the following: Regular diet, mechanical soft texture, regular/thin consistency, double portions with gravies on ground meats, dated 10/21/22. House shake mixed with ice cream at meals. Dietary to mix and provide on tray at meals, dated 3/13/23. A current nutrition care plan, dated 8/31/22, included, but was not limited to, the following interventions: provide house shake mixed with ice…

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 that the appropriate antibiotics were prescribed in 1 of 6 residents reviewed for unnecessary medications. The resident was prescribed antibiotics on 3 occurrences that were resistant (ineffective) to the organism found in the culture and sensitivity (C&S). (Resident 21) Findings include: On 6/7/23 at 8:40 A.M., Resident 21's clinical record was reviewed. Resident 21 was admitted on [DATE]. Resident 21's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, systemic lupus erythematosus, and retention of urine. The most recent annual MDS (Minimum Data Set) Assessment, dated 3/2/23, indicated the resident was cognitively intact, had an indwelling catheter, was always incontinent of bowel, and an antibiotic medication was administered for 5 of 7 days during the look back period. Previous orders included, but were not limited to: Ceftriaxone Sodium Solution…

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