Springs Of Richmond, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess a resident for safe self-administration of medication for 1 of 3 residents reviewed for medication compliance. (Resident C) Findings include: The clinical record for Resident C was reviewed on [DATE] at 11:40 a.m. Medical diagnosis included infection to the left knee related to internal prosthetic. A nursing admission assessment, dated [DATE], indicated Resident C was alert and oriented to person, place, time, and situation. A nursing progress note, dated [DATE], indicated Resident C's son brought in his home medications for tonight's dosage and his intravenous antibiotic. Resident C and his son .administered dose . and Resident C .took all medications including narcotics from home . Review of the clinical record did not indicate a Self-Administration of Medication assessment was completed or a physician order to reflect such. During an interview on [DATE] at 12:45 p.m., Resident C indicated while he was at the facility, the facility did not…

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 1 of 4 residents reviewed for accurate and timely receipt of medications, received their medications as ordered by their physician. (Resident B) Findings include: In an interview with Resident B on 6-2-25 at 4:04 p.m., she indicated she kept track of the medications received while she was a resident of the facility. She indicated several days before she discharged from the facility, I got to feeling real dizzy in the afternoon, and realized no one had given me my morning meds, which included several BP [blood pressure] pills. She did not indicate she had made the facility aware of this at the time of occurrence. In an interview with the Executive Director (ED) on 6-4-25 at 11:05 a.m., he indicated on the date of Resident B's discharge from the facility, 5-6-25, the facility learned of a medication error in which Registered Nurse (RN) 3 had not administered Resident B's morning medications on 5-1-25. In a second interview on 6-4-25 at 1:02 p.m., with the ED, he reiterated the facility did not learn of this until…

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 reflect the behaviors, including refusal of care and verbal aggression, for 1 of 5 residents reviewed for abuse. (Resident C) Findings include: The clinical record for Resident C was reviewed on 6/3/2025 at 11:40 a.m. Medical diagnosis included infection to the left knee related to internal prosthetic. A nursing admission assessment, dated 5/12/2025, indicated Resident C was alert and oriented to person, place, time, and situation. During an interview on 6/2/2025 at 12:45 p.m., Resident C indicated while he was at the facility, two staff came into his room before he left. One of them, he believes was a nurse, kept trying to change the wound dressing on his leg. He had to tell her twice to leave him alone before he kicked her out of his room. He had his son pick him up and he left against medical advice. During an interview on 6/2/2025 at 10:52 p.m., Licensed Practical Nurse (LPN) 19 indicated she took care of Resident C while he was here. Resident C was a .very frustrated person .and he was agitated . During an…

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

Based on observation, interview, and record review, the facility failed to ensure a resident was deemed appropriate to self-administer a nebulizer (a device that converts liquid medicine to mist to inhale it) medication for 1 of 5 residents reviewed for medication administration. (Resident 207) Findings include: An observation was conducted of medication administration for Resident 207 with Licensed Practical Nurse (LPN) 2 on 2/13/25 at 8:08 a.m. LPN 2 prepared Resident 207's morning medications and after the resident took the medications by mouth, she requested a nebulizer treatment. LPN 2 obtained a vial of a medication and dispensed such into the nebulizer medicine cap connected to the nebulizer machine. LPN 2 secured the medicine cup to the face mask and handed the face mask to Resident 207. Resident 207 proceeded to hold the face mask to administer the nebulizer medication at 8:28 a.m. LPN 2 proceeded to leave Resident 207's room to prepare medications for Resident 209. At 8:45 a.m., LPN 2 returned to the medication cart and the nebulizer machine was still on in Resident 207'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, interview, and record review, the facility failed to provide a homelike environment for 1 of 2 residents reviewed for homelike environment. (Resident 14). Findings include: The clinical record of Resident 14 was reviewed on 2/11/25 at 2:45 p.m. The diagnoses included, but were not limited to, acute respiratory disease, heart failure, and obesity. During an observation on 2/11/25 at 2:34 p.m., Resident 14's corner molding was off the wall exposing where the dry wall connected at the corner. The molding was leaning up against the opposite wall. There were areas where the paint was missing on the wall behind the head of the bed. Observations were conducted of Resident 14's room and the molding was observed to be off of the wall exposing the dry wall on 2/12/25 at 11:12 a.m. and 2/12/25 at 1:45 p.m. During a tour on 2/14/25 at 2:15 p.m., the Executive Director (ED) indicated he was not aware of the molding being off the wall and areas where the paint was missing behind the bed. He stated this had been an issue in the past due to Resident 14 being in a motorized…

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 bowel movements were documented and followed up when a resident went over three days without having a bowel movement for 1 of 1 resident reviewed for constipation. (Resident G) Findings include: The clinical record for Resident G was reviewed on 2/13/25 at 12:31 p.m. The diagnoses included, but were not limited to, constipation. An admission Minimum Data Set (MDS) assessment, dated 12/16/24, indicated Resident G was cognitively intact and always continent of bowel. A bowel and bladder care plan, start date of 12/11/24, indicated Resident G was continent of bowel. The approach was to notify the charge nurse of a change in bowel and bladder patterns as needed and report signs and symptoms of constipation. An interview conducted with Family Member (FM), on 2/12/25 at 11:00 a.m., indicated Resident G went 13 days without a bowel movement after her admission to the facility. The electronic health record, under the Vitals section, noted the following bowel movements documented for Resident G: - No bowel…

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 gastric tube (g-tube) feeding and water flushes were administered as ordered by the physician for 1 of 4 residents reviewed for nutrition. (Resident 299) Findings include: The clinical record for Resident 299 was reviewed on 2/11/25 at 2:45 p.m. The diagnoses included, but were not limited to, encounter for orthopedic aftercare following surgical amputation, severe sepsis with septic shock, and dysphagia. A care plan for tube feeding, initiated on 2/5/25 and revised on 2/11/25, indicated Resident 299 required tube feeding related to dysphagia. The approaches indicated providing a diet as ordered, providing water flushes as ordered, and provide tube feedings as ordered. A review of the physician orders indicated, effective on 02/11/25 09:50 a.m., Resident 299 was to receive Jevity 1.5 (brand of tube feed) at 60 mL/hr (milliliters per hour) and flush with 180 mL of water every four hours. The previous order for the g-tube was for Jevity 2.0 at 50mL/hr with 150 mL every four hours of water flushes 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 date oxygen tubing for 1 of 1 resident reviewed for respiratory care needs. (Resident 253) Findings include: The clinical record for Resident 253 was reviewed on 2/13/25 at 9:14 a.m. Diagnoses included, but were not limited to, acute kidney failure and falls. A physician's order, dated 2/9/25, indicated Resident 253 was to be on continuous oxygen of two to three liters per minute. During an observation on 2/11/25 at 12:42 p.m., Resident 253 had oxygen tubing at the bedside not dated when it was initiated. During an observation on 2/12/25 at 11:38 a.m., Resident 253 had oxygen tubing on that was not dated. During an observation on 2/13/25 at 9:41 a.m., Resident 253 had oxygen tubing on that was not dated. During an interview on 2/13/25 at 12:29 p.m. with the Assistant Director of Health Services (ADHS), she indicated oxygen tubing was dated but it kept rubbing off, so we ordered labels to date and time the oxygen tubing. The ADHS indicated they date and time the tubing, then a couple hours later it would be…

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 effective pain management was provided for a resident who voiced concerns of pain for 1 of 3 residents reviewed for pain medication. (Resident 251) Findings include: The clinical record for Resident 251 was reviewed on 2/13/25 at 10:11 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, chronic back pain, and chronic vertebral fractures due to osteoporosis. A physician's order, with a start date of 2/10/25 and an end date of 2/13/25, indicated to monitor pain, three times a day, for seventy-two hours. A pain medication order, dated 2/10/25, indicated morphine concentrate solution could be given every four hours as needed for pain or shortness of breath. Resident 251's medication administration record (MAR) was reviewed on 2/13/25 at 12:15 p.m. The MAR indicated resident 251 rated her pain a 5 out of 10 on the pain scale. Per the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 published by the Centers for Medicaid and Medicare Services, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an antibiotic was administered according to physician orders, a resident received their medication, as ordered, during their respite stay at the facility, and ensure administration of a sedative/hypnotic medication as ordered by the physician for 1 of 1 resident reviewed for hospitalization, 1 of 1 resident reviewed for antibiotic use, and 1 of 3 closed records reviewed. (Resident G, Resident C, and Resident 40) Findings include: 1. The clinical record for Resident G was reviewed on 2/13/25 at 1:24 p.m. The diagnoses included, but were not limited to, sepsis and urinary tract infection (UTI). A care plan, dated 12/11/24, indicated Resident G was at risk for bladder incontinence related to a UTI. The approach included, but was not limited to, monitor for signs and symptoms of a UTI and administer medications as ordered. A physician order, dated 12/20/24, was noted for cefdinir (antibiotic) 300 milligrams (mg) twice a day for seven days related 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 ensure a clinical rationale was provided for a decline of a gradual dose reduction of an antidepressant and antianxiety medication for 2 of 5 residents reviewed for unnecessary medications. (Resident 26 and Resident 30) Findings include: 1. The clinical record for Resident 30 was reviewed on 02/13/25 at 9:50 a.m. The diagnoses included, but were not limited to, other generalized epilepsy and epileptic syndromes (seizure disorder), major depressive disorder, agoraphobia with panic disorder (anxiety disorder characterized by fear of places or situations), and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 12/30/24, indicated Resident 30 showed no abnormal behaviors, and showed no abnormal depression or anxiety symptoms. A physician's order, dated 02/29/24, indicated clonazepam (a narcotic antianxiety medication) 1 mg (milligrams) three times a day scheduled, for agoraphobia with panic disorder. A physician's order, dated 11/10/24, indicated Order Set Target Behavior- sweating, SOB [shortness of…

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 maintain infection control practices by not donning personal protective equipment (PPE) while providing activities of daily living (ADL) care for 1 of 1 randomly observed resident. (Resident 299). Findings include: The clinical record for Resident 299 was reviewed on 2/13/25 at 9:15 a.m. The diagnoses included, but were not limited to, encounter for orthopedic aftercare following surgical amputation, severe sepsis with septic shock, and dysphagia. A care plan for tube feeding, initiated on 2/5/25 and revised on 2/11/25, indicated Resident 299 required tube feeding related to dysphagia. The approaches indicated providing a diet as ordered, providing water flushes as ordered, and provide tube feedings as ordered. An observation was conducted of Resident 299's room on 2/11/25 at 11:30 a.m. On the outside of Resident 299's door was a sign stating Resident 299 was in Enhanced Barrier Precautions (EBP). The sign stated everyone must clean their hands before entering and when leaving the room. Providers and staff…

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 1 of 3 residents reviewed for pressure ulcers had routine and timely wound assessments, including measurements, conducted on a weekly, or more often as needed, basis and documentation conducted to reflect these assessments. (Resident B) Findings include: The clinical record of Resident B was reviewed on 8/8/24 at 11:16 a.m. Resident B's diagnoses included, but were not limited to, a displaced fracture of the right femur, hypertensive stage three (3) chronic kidney disease, and age-related osteoporosis. An admission Minimum Data Set (MDS) assessment, dated 5/14/24, indicated Resident B admitted into the facility with an unstageable pressure ulcer (wound in which a full-thickness tissue is lost, with the extent of the wound being obscured by slough or eschar tissue) during the first week of May 2024. It also indicated Resident B was cognitively intact. The admission nursing assessment, dated 5/8/24, indicated Resident B had a skin impairment, with details identified on an associated document entitled, Wound Event. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to routinely document meal intakes for 3 of 3 residents reviewed for nutritional concerns. (Residents B, C and D) Findings include: 1. The clinical record of Resident B was reviewed on 6-25-24 at 11:25 a.m. Her diagnoses included, but were not limited to, non-ST elevation MI (heart attack), Covid-19 at admission, hypertensive chronic kidney disease (stage 3), diabetes, esophageal obstruction, cerebral ischemia, hyperlipidemia, depression, obesity and generalized muscle weakness. Her admission Minimal Data Set assessment, dated 5-15-24, indicated she was cognitively intact, required substantial assistance with bed mobility (turning and repositioning), bathing, toileting, was dependent for transfers, was non-ambulatory and required supervision assistance, after initial meal set up, with eating. It indicated she had concerns regarding her appetite. In an interview, on 6-25-24 at 1:14 p.m., with a family member, she indicated Resident B had difficulty chewing…

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: 1. 1. Food products held in the refrigerator for re-use were properly dated for date placed in the refrigerator and date to be used by. 2. The bin covers for the flour and sugar containers were closed. 3. Refrigerator and freezer temperatures were documented on facility forms routinely. 4. Manual ware washing logs were documented on facility forms routinely. These deficient practices have the potential to adversely affect 64 of the 65 residents who receive foods from the dietary department. Findings include: 1. During a tour of the walk-in cooler (refrigerator) with the Dietary Manager on 5-14-24 at 1:55 p.m., she indicated any leftovers are to be discarded after 3 days. The following observations were made: -container of chicken, with preparation date of 5-10-24, with no discard date was present. -container of chicken pot pie mixture with label of preparation on 5-1-24 and to discard 5-3-24 was present. -cheese sauce with label of…

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 promptly respond to call light requests for assistance for 2 of 3 residents reviewed for timely response to call lights. (Resident B and M) Findings include: A. The clinical record of Resident B was reviewed on 5-15-24 at 10:29 a.m. Her diagnoses included, but were not limited to, falls, metabolic encephalopathy, recent urinary tract infection and Alzheimer's disease. Her most recent Minimum Data Set assessment, dated 12-15-23, indicated she was severely cognitively impaired, required substantial assistance with meals and was dependent for assistance with bathing, hygiene, toileting and the use of a wheelchair for mobility. In an interview with a family member on 5-16-24 at 9:10 a.m., the family member indicated during a visit with Resident B, she observed Resident B was in need of toileting assistance and clean up. One day, I turned on [name of Resident B]'s call light for help. A nurse was across the hall and said someone would be with me shortly. Still, no one came for over 30 minutes. Someone finally came in 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 develop and implement a care plan for bathing preferences for 1 of 1 residents reviewed for bathing preferences. (Resident H) Findings include: The clinical record of Resident H was reviewed on 5-17-24 at 10:07 a.m. It indicated her diagnoses included, but were not limited to atherosclerotic heart disease, cerebral ischemic, age-related physical debility, adult failure to thrive and unspecified dementia. Her most recent Minimum Data Set (MDS) assessment, dated 4-15-24, indicated she was moderately cognitively intact, had unclear speech, sometimes she understood what was said and sometimes could be understood, was nonambulatory and required a wheelchair for mobility and was dependent for hygiene care and services. It indicated she was frequently incontinent of bowel and bladder. In an observation and interview with Resident H on 5-16-24 at 3:45 p.m., she was unable to recall how long she had been at the facility. She indicated she receives showers, but was unsure of the frequency of this and an occasional partial bed bath…

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 dependent resident received bathing and hygiene care and services on a routine basis, for 1 of 5 residents reviewed for activities of daily living (ADL), specific to hygiene care and services. (Resident H) Findings include: The clinical record of Resident H was reviewed on 5-17-24 at 10:07 a.m. It indicated her diagnoses included, but were not limited to atherosclerotic heart disease, cerebral ischemic, age-related physical debility, adult failure to thrive and unspecified dementia. Her most recent Minimum Data Set (MDS) assessment, dated 4-15-24, indicated she was moderately cognitively intact, had unclear speech, sometimes she understood what was said and sometimes could be understood, was nonambulatory and required a wheelchair for mobility and was dependent for hygiene care and services. It indicated she was frequently incontinent of bowel and bladder. In an observation and interview with Resident H on 5-16-24 at 3:45 p.m., she was unable to recall how long she had been at the facility. She indicated 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.

Based on interview and record review the facility failed to complete a grievance for Resident 30 that verbalized concerns with his care and failed to have a process for residents and/or families to file a grievances anonymously for 1 of 3 residents reviewed for grievance process (Resident 30). Finding include: During an interview with Resident 30 and his family member on 11/27/23 at 2:16 p.m., indicated they did not feel the facility had adequate staffing. The resident had to wait up to 40 minutes to go to the bathroom. The resident had become incontinent of urine due to waiting. The resident had frequently called the Executive Director and the Scheduler on their person phones to report waiting and they would have staff come in and assist him. During an interview with Resident 30 and his family member on 11/28/23 at 1:22 p.m., indicated he was not always provided with fresh water unless he request it. When queried if the resident/and or family had filed a grievance about inadequate staffing and not being provided water, the resident and his wife indicated they had not been offered…

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 nail care for a dependent resident for 1 of 3 residents reviewed for Activities Of Daily Living (ADL) (Resident 3). Finding include: During an observation on 11/28/23 10:17 a.m., Resident 3's fingernails on both hands were long and jagged with chipped fingernail polish. During an observation on 11/29/23 at 10:22 a.m., Resident 3's fingernails on both hands were long and jagged with chipped fingernail polish. During an observation on 11/29/23 at 2:23 p.m., Resident 3's fingernails on both hands were long and jagged with chipped fingernail polish. During an observation on 11/30/23 at 12:45 p.m., Resident 3's fingernails on both hands were long, jagged with chipped fingernail polish. During an observation on 12/1/23 at 11:33 a.m., Resident 3 nails were long, jagged with chipped fingernail polish. During an interview with the Director Of Health Services (DHS) on 12/1/23 at 11:40 a.m., indicated if Resident 3 was a diabetic the nurses were responsible to provide nail care if the resident was not a diabetes…

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

Based on observation, interview and record review the facility failed to store a nebulizer mask in a sanitary manner for good infection control practices for 1 of 3 residents reviewed for respiratory care (Resident 17). Finding include: During an observation on 11/28/23 at 1:43 p.m., Resident 17's nebulizer machine and mask were laying on the resident's bed, there was no storage bag visible in the resident's room for the nebulizer mask. During an observation on 11/29/23 at 11:18 a.m., Resident 17's nebulizer mask was laying on bedside table, there was no storage bag visible in the resident's room for the nebulizer mask. During an interview with the Director Of Health Services (DHS) on 12/1/23 at 11:36 a.m., indicated Resident 17's nebulizer mask should be in a bag have been stored in a bag for infection control purposes. Review of the record of Resident 17 on 12/1/23 at 1:50 p.m., indicated the resident's diagnoses included, but were not limited to, pneumonia, arteriosclerotic heart disease, cardiomyopathy, chronic obstructive pulmonary disease with acute exacerbation, chronic heart…

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 outdoor activities on a regular basis per the resident's preference for 1 of 1 resident reviewed for dementia care (Resident 8). Finding include: During an observation on 11/29/23 at 10:20 a.m., Resident 8 was sitting in the dining room with another resident. Resident 8 was wheeling himself around the dining room without purpose. During an observation on 11/29/23 at 11:18 a.m., Resident 8 was wandering in other resident's room in his wheelchair. During an interview with LPN 1 on 11/29/23 at 11:10 a.m., indicated Resident 8 started having behaviors of wanting to go outside in the Spring and Summer of 2023. The resident would see other residents sitting outside on the porch and he wanted to go outside too. During an interview with CNA 2 on 11/29/23 at 11:21 a.m., indicated yes the resident had behaviors of going outside unsupervised. The resident started having these behaviors in the Summer of 2023. The resident liked to be outside with the other residents. During an interview with the Activity assistant…

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 an elopement assessment for a resident who had behaviors of going outside the facility without supervision for 1 of 1 resident reviewed for elopement (Resident 8). Finding include: During an observation and interview on 11/29/23 at 10:25 a.m., LPN 1 took Resident 8 by the door in the dining room and the wander guard alarmed, the nurse indicated the wander guard was underneath the wheelchair per families request out of the resident's sight. LPN 1 indicated the resident often tried to leave the facility was why he had a wander guard. During an interview with LPN 1 on 11/29/23 at 11:10 a.m., indicated yes she had known of times the resident had gotten out of the facility that is why he has a wander guard on now because he was unsafe to be outside without staff. The resident started this behavior in the late spring 2023 and the summer 2023. The resident would see other residents outside and would want to go. During an interview with LPN 1 on 11/29/23 at 1:50 p.m., indicated on 7/22/23 another resident's…

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