Waters Of Sullivan Nursing Facility, The

Based on observation, interview, and record review, the facility failed to ensure a resident's representative was notified of a new order for 1 of 4 resident representative interviews (Resident 7). Findings include:On 7/28/25 at 9:35 a.m., Resident 7's room was observed with a contact precautions (a set of infection control practices used in healthcare settings to prevent the spread of germs that can be transmitted by direct or indirect contact with a patient or their environment) isolation sign on the wall next to the door. During an interview, on 7/28/25 at 1:12 p.m., Resident 7's representative indicated they were not aware the resident was on isolation precautions or why they were in place. They were not notified the resident was placed on isolation precautions. Resident 7's record was reviewed on 7/31/25 at 9:14 a.m. Diagnoses on the resident's profile included, but were not limited to, moderate vascular dementia (a disruption in blood flow to the brain leading to damage in brain tissue) with anxiety and urinary tract infection (UTI). A quarterly Minimum Data Set (MDS)…

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

Based on record review and interview, the facility failed to ensure an Advance Beneficiary Notice (ABN) (written notice to inform a Medicare beneficiary when they can expect Medicare to deny payment for services) form as required for 2 of 3 residents reviewed for beneficiary notices (Residents 62 and 19). Findings include:Findings include: 1. Resident 62's record was reviewed on 8/1/25 at 10:55 a.m. A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review, completed by the Business Office Manager (BOM), indicated the resident's Medicare Part A stay started on 3/1/25, and the last Medicare Part A stay covered day was 4/30/25. The facility initiated the discharge from Medicare Part A Services when benefit days were not yet exhausted. A Notice of Medicare Non-Coverage (NOMNC) (a document that Medicare providers must give to beneficiaries when their Medicare-covered services are ending), was signed by the resident on 4/28/25.The record lacked documentation an ABN was provided with the NOMNC. 2. Resident 19's record was reviewed on 8/1/25 at 10:48 a.m. A Skilled…

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 staff immediately reported an abuse allegation to the Administrator for 1 of 1 reportable incidents reviewed (Resident 23). Findings include:On 7/29/25 at 11:30 a.m., a police officer answered a knock at the Administrator's office door and indicated the Administrator was not available because she went to find a resident. At the same time, the Director of Nursing (DON) indicated the police officer was at the facility because a reportable incident had occurred. During an interview, on 7/29/25 at 2:01 p.m., the Administrator indicated Resident 23 reported another resident touched her shoulder inappropriately while making a sexual advance towards her. The Administrator indicated the staff had not reported the incident to her immediately and instead left a note under the Social Services Director's (SSD) door. The resident reported the incident to the evening/night shift Qualified Medication Aide (QMA) who reported it to the evening/night shift nurse. The nurse left a note for the SSD but did not call 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 record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment had been coded correctly for 1 of 19 resident MDS assessments reviewed (Resident 46). Findings include:Resident 46's record was reviewed on 7/31/25 at 2:23 p.m. The profile indicated the resident's diagnoses included, but were not limited to, hypertensive heart disease (a condition where high blood pressure over a long period damages the heart, leading to various heart problems) and congestive heart failure (when the heart does not pump blood efficiently as it should). The census indicated the resident began hospice services on 3/13/25. A care plan indicated the resident wished for hospice services. Interventions included, but were not limited to, hospice services as ordered. A quarterly MDS assessment, dated 6/17/25, indicated the resident received hospice services. The assessment lacked documentation of a terminal prognosis. During an interview, on 7/31/25 at 2:47 p.m., the MDS Coordinator indicated the resident's prognosis had been coded incorrectly. The standard was that 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 residents were invited to attend quarterly care plan meetings for 2 of 3 residents reviewed for care plan meetings (Residents 19 and 8), and failed to ensure code status care plans were consistent with the resident's advanced directive for 1 of 19 residents' care plans reviewed (Resident 7). Findings include: 1. On [DATE] at 1:33 p.m., during an interview, Resident 19 indicated she had not attended a care plan meeting and had not been asked to attend one. On [DATE] at 11:35 a.m., during interview the Social Service Director (SSD) indicated she invited residents to attend care plan meetings and documented the meeting and if the resident attended the meeting. Attendance was included in the meeting documentation. On [DATE] at 10:35 a.m., the medical record of Resident 19 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to, hypertension (high blood pressure) and dementia (the loss 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 record review and interview, the facility failed to ensure urinary tract infections (UTIs) were treated in a timely manner after receiving urinary culture results for 2 of 2 residents reviewed for UTI (Residents 3 and 7). Findings include: 1. Resident 3's record was reviewed on 7/29/25 at 11:27 a.m. An admission Minimum Data Set (MDS) assessment, dated 6/30/25, indicated the resident was cognitively intact. A nursing progress note, dated 7/3/25, indicated the resident's daughter was concerned about how much the resident was sleeping and noted increased confusion. A new physician's order for a urinalysis (UA) culture and sensitivity (C&S) was received. A nursing progress note, dated 7/6/25, indicated a urine sample was obtained from the resident and sent to the hospital for a UA C&S. A UA C&S indicated the report was finalized on 7/8/25. The report indicated a colony count greater than 100,000 proteus mirabilis (bacteria) The C&S did not include ciprofloxacin (antibiotic) as an antibiotic that was tested for efficacy against the bacteria. The C&S indicated the bacteria was…

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

Based on observation, interview, and record review, the facility failed to ensure proper storage of respiratory equipment for 2 of 3 reviewed for respiratory care (Residents 51 & 46). Findings include:1. On 7/28/25 at 11:28 a.m., Resident 51's unbagged nebulizer mask was observed on top of a blanket and other linens on the resident's chair next to her bed. The nebulizer machine was sitting on the chair cushion. On 7/28/25 at 1:15 p.m., Resident 51's unbagged nebulizer mask was observed on top of a blanket and other linens on the resident's chair next to her bed. There was also a metal lid next to the nebulizer mask from the resident's lunch tray. On 7/29/25 at 9:30 a.m., Resident 51's unbagged nebulizer mask was observed on top of a blanket and other linens on the resident's chair next to her bed. On 7/30/25 at 10:10 a.m., Resident 51's unbagged nebulizer mask was observed sitting on top of the chair cushion next to her bed. The medication chamber was detached from the mask and was in contact with the floor. During an interview, on 7/30/25 at 10:16 a.m., Resident 51 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's dialysis (medical treatment that helps remove waste products and excess fluid from the blood when a person's kidneys are not functioning properly) access site was accurately assessed for 1 of 1 residents reviewed for dialysis (Resident 42). Findings include:Resident 42's record was reviewed on 7/31/25 at 11:39 a.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, stage four chronic kidney disease (severe kidney disease with significantly reduced kidney function) and dependence on renal dialysis. An admission Minimum Data Set (MDS) assessment, dated 7/10/25, indicated the resident was cognitively intact. A medication administration record (MAR), dated July 2025, included a physician's order, dated 7/7/35, to maintain the resident's dialysis access site. The order indicated check for blood flow by feeling for a pulse or rushing…

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

Based on record review and interview, the facility failed to ensure behavior monitoring was completed for 1 of 5 residents reviewed for unnecessary medications (Resident 22).Findings include:Resident 22's record was reviewed on 7/29/25 at 11:31 a.m. The profile indicated the resident's diagnoses included, but were not limited to, metabolic encephalopathy (a condition where the brain's function is impaired due to a metabolic or chemical imbalance in the body), Parkinson's disease (a progressive neurological disorder that affects movement), and hallucinations unspecified (when someone experiences something with their senses [see, hear, smell, taste, or feel] that isn't actually there). A quarterly Minimum Data Set (MDS) assessment, dated 4/19/25, indicated the resident had severe cognitive deficit, had no documented behaviors, and received hospice services. A care plan was observed that indicated the resident was at risk for hallucinations and delusions (a fixed, false belief that is not based on reality and is held with strong conviction, despite evidence to the contrary).…

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 medication was labeled properly for 1 of 2 medication storage rooms reviewed for medication storage. Findings include:On 7/30/25 at 1:45 p.m., the East wing medication storage room contained an undated and opened multi use vial of Tubersol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution.During an interview, on 7/30/25 at 1:44 p.m., Licensed Practical Nurse (LPN) 14 indicated Tubersol solution was good for 30 days once it had been opened. She would dispose of the vial since it was not labeled with an open date, and she wasn't sure how long it had been in the refrigerator.During an interview, on 7/30/25 at 1:54 p.m., LPN 7 indicated Tubersol solution was good for 30 days once it had been opened and should be dated when opened.On 7/30/25 at 2:17 p.m., the Director of Nursing (DON) provided a document, dated July 2024, titled, Medication Storage in the Facility, and indicated it was the current policy used by the facility. The policy indicated, .Medications…

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

Based on record review and interview, the facility failed to ensure medications were obtained and administered in a timely manner after a resident was admitted to the facility for 1 of 3 residents reviewed for pharmaceutical services (Resident D). Findings include: Resident D's record was reviewed on 2/27/25 at 2:24 p.m. A Progress Note, dated 12/16/24, indicated the resident was admitted to the facility at 7:32 p.m. Diagnoses on the resident's profile included, but were not limited to, encounter for other specified surgical aftercare and type two diabetes mellitus without complications. A 5-day Minimum Data Set (MDS) Assessment, dated 12/18/24, indicated the resident was cognitively intact. A Physician's Order, start date 12/16/24, indicated enoxaparin (anticoagulant) injection prefilled syringe, 100 milligrams (mg)/milliliters (ml), inject 1 pre-filled syringe subcutaneously (fatty layer underneath skin) (SQ) twice daily for preventative. A Medication Administration Record (MAR), dated 12/16/24 and 12/17/24, indicated the enoxaparin injection was scheduled to be administered, on…

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

Based on interview, observation, and record review, the facility failed to ensure food was served at a safe and appetizing temperature for 3 of 3 resident's reviewed for dietary services (Residents C, B, and G). Findings include: 1. During an interview, on 2/26/25 at 11:40 a.m., Resident C indicated the food was always cold and not good. He ate all meals in his room. During an observation, on 2/27/25 at 12:13 p.m., the tray cart arrived to east wing with the Dietary Manager. The trays in the cart had plates directly on the tray with no warmer. They were covered with a plastic cover. The cart was metal and unheated. At the same time, the Dietary Manager indicated she planned to check the temperature of the food on the last resident's meal tray. She had not understood an extra tray was necessary. She returned to the kitchen to retrieve an extra tray. During an observation, on 2/27/25 at 12:16 p.m., the Dietary Manager returned to the hall with the test tray and placed it on the cart. During an observation, on 2/27/25 at 12:25 p.m., the staff on the unit finished passing the meal…

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 observations, interviews, and record reviews, the facility failed to discard expired items, failed to maintain completed temperature logs, failed to maintain and monitor sanitizer concentration levels, failed to label and date food items that were received without a manufacturer's expiration date, and failed to store food at a minimum of six inches from the floor for 1 of 2 kitchen observations. Findings include: 1. During an initial kitchen tour with [NAME] 11 on 6/17/24 at 9:48 a.m., observed the walk-in refrigerator temperature logs to lack a.m. and p.m. temperature documentation for 6/16/24. On 6/17/24 at 10:05 a.m., observed the walk-in freezer temperature logs to lack p.m. temperature documentation for 6/14/24, and lacked a.m. and p.m. temperature documentation for 6/15/24 and 6/16/24. [NAME] 11 indicated it was typically the responsibility of the cook to complete the temperature logs and should be completed each shift. On 6/20/24 at 1:23 p.m., the Regional Nurse Consultant provided a document, dated 4/2017, titled, Storage of Refrigerated/Frozen Foods,, and indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 2 of 24 residents reviewed for care plan meetings (Residents 19 and 30). Findings include: 1. During an interview, on 6/17/24 at 2:06 p.m., Resident 19 indicated he did not remember being invited to or attending a care plan meeting recently. He indicated it had been a while since he had one. Resident 19's record was reviewed on 6/19/24 at 9:48 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 5/12/24, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE]. A Care Plan note, dated 3/20/24 at 4:20 p.m. indicated a care plan meeting was conducted on this day for Resident 19. Resident 19's record lacked documentation of additional quarterly care plan meetings being conducted for the last year from June 2023 to June 2024. The resident had one care plan meeting for the entire year. During an interview, on 6/19/24 at 11:07…

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 observations, record reviews, and interviews, the facility failed to ensure that a physician was notified of a resident's change in condition related to edema for 1 of 1 resident's reviewed (Resident 46). Finding includes: On 6/17/24 at 11:04 a.m., Resident 46 was observed sitting up on the right side of his bed, the resident had edema (swelling) to his bilateral feet and ankles. The resident indicated he had noticed some swelling off and on to his feet and ankles and he tried to elevate his legs in bed as much as he could. The resident indicated he was not taking a diuretic (helps reduce fluid buildup in the body) and wasn't sure if the staff had noticed the swelling. On 6/18/24 at 1:30 p.m., Resident 46 was observed sitting up in his wheelchair in his room. Edema was noted to his bilateral feet and ankles. On 6/19/24 at 2:30 p.m., Resident 46 was observed sitting up in his wheelchair in his room and was watching tv. Edema was noted to his bilateral feet and ankles. On 6/20/24 at 1:56 p.m., Resident 46 was sitting in his wheelchair across from the nurse's station. Edema…

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

Based on observation, record review, and interview, the facility failed to ensure a resident was supervised while administering her medications for 1 of 1 residents reviewed for accidents (Resident 104). Findings include: During the initial pool observation, on 6/17/24 at 11:21 a.m., Resident 104 was observed administering her own medication from her medication cup. The resident's nurse was not present in the room at the time of the observation. At the same time, the resident indicated the nurses often would just leave her medication cup with her medications, in her room for her to take. During a random observation, on 6/18/24 at 8:59 a.m., the resident was observed with an empty medication cup sitting in front of her on her overbed table. At the same time, the resident indicated the nurse had brought her medications to her, again this morning, and had not stayed in the room while she was taking them. She could not remember ever being evaluated for taking her medication without supervision. Resident 104's record was reviewed on 6/19/24 at 11:05 a.m. The profile indicated 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, record review, and interview, the facility failed to ensure respiratory equipment was stored in a plastic bag, and failed to ensure a physician order for continuous positive airway pressure (CPAP) settings was obtained for 1 of 1 resident reviewed for respiratory (Resident 22). Findings include: During initial interviews on 6/18/24 at 10:08 a.m., observed Resident 22's continuous positive airway pressure (CPAP) machine (wearable respiratory device that uses mild air pressure to keep breathing airways open while you sleep) with a partially filled humidification chamber on the bedside table. The tubing and mask were unbagged and undated. Resident 22 indicated she required assistance from staff to put it on and take off, and the equipment had not been bagged since she moved in. During random observation on 6/19/24 at 11:54 a.m., Resident 22's CPAP mask and tubing were observed to be unbagged and undated. During random observation on 6/20/24 at 10:28 a.m., Resident 22's CPAP mask and tubing were observed to be unbagged and undated. On 6/20/24 09:36 a.m., Resident…

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

Based on record review and interview, the facility failed to ensure physician documentation to justify a declination of a pharmacy recommendation for 1 of 5 residents reviewed for unnecessary medications (Resident 8). Findings include: Resident 8's record was reviewed on 6/18/24 at 2:28 p.m. The profile indicated the resident's diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder (when the nerves and muscles don't work together very well. which results in the bladder may not fill or empty correctly). A pharmacy recommendation, dated 6/11/23, indicated to consider discontinuing the resident's Vesicare (a medication (med) indicated to treat an overactive bladder with urinary incontinence, urgency, and frequency). The physician disagreed with the recommendation and documented Continue med. The form lacked documentation of any further justification. During an interview, on 6/19/24 at 10:33 a.m., the Regional Nurse Consultant indicated she was unable to find any physician documentation to justify the declination for discontinuing the resident's Vesicare.…

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

Based on record review and interview, the facility failed to ensure physician ordered lab tests had been completed for 1 of 5 residents reviewed for unnecessary medications (Resident 42). Findings include: Resident 42's record was reviewed on 6/18/24 at 3:11 p.m. The profile indicated the resident's diagnoses included, but were not limited to, congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), atrial fibrillation (AFIB-caused by extremely fast and irregular heartbeats), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hypertension (high blood pressure), hyperlipidemia (when the body has too many lipids [fats] in your blood), and gastro-esophageal reflux disease (GERD- a chronic gastrointestinal disorder characterized by the regurgitation of gastric contents into the esophagus). A pharmacy recommendation, dated 12/6/23, indicated to recommend lab testing related to medications ordered, included, but were not limited to: a. A Digoxin (a medication used…

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

Based on observation, record review, and interview the facility failed to maintain infection prevention measures during meal service administration for 2 of 2 meal service observations, failed to maintain infection prevention measures for 2 of 2 residents observed during medication administration (Residents 16 and 49), and failed to ensure staff washed hands for at least 20 seconds for 3 of 3 random observations of staff hand hygiene. Findings include: 1. On 6/17/24 at 12:30 p.m., the noon meal dining service was observed in the main dining room. Observed Certified Nurse Aide (CNA) 7 passing ice to the residents. The CNA touched her ear and hair and continued passing ice to a resident. The CNA then placed the ice scoop into the ice bucket. The CNA failed to sanitize her hands after touching her ear and hair. On 6/17/24 at 12:43 p.m., CNA 7 adjusted oxygen tubing for Resident 7 then continued to assist another resident with meal service. The CNA failed to sanitize hands prior to assisting another resident with meal service. On 6/20/24 at 1:31 p.m., during an interview CNA 7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the representative of the Office of the State Long-Term Care Ombudsman was notified of the hospital transfer and/or discharge for 1 of 3 residents reviewed for hospitalization (Residents 39). Finding includes: During an interview, on 5/9/23 at 10:26 a.m., Resident 39 indicated she had been transferred to the hospital a couple of months ago for an UTI (urinary tract infection, a common infection which happened when bacteria, often from the skin or rectum, entered the urethra, and infected the urinary tract). Resident 39's record was reviewed on 5/11/23 at 1:52 p.m. Diagnosis included, but was not limited, urinary tract infection (UTI). An annual Minimum Data Set (MDS) assessment, dated 3/16/23, indicated the resident was cognitively intact and required limited assistance of one person for toilet use. Census information indicated the resident was hospitalized from [DATE] to 3/3/23. A nursing progress note, dated 3/1/23, indicated Resident 39 was…

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

Based on observation, record review, and interview the facility failed to revise a care plan for 1 of 12 residents reviewed for care plans (Resident 26). Finding includes: On 5/10/23 at 2:20 p.m., Resident 26 was observed to be asleep in her bed, no floor mat was observed on the floor by her bed. On 5/22/23 at 9:02 a.m., Resident 26 was not observed to be in her room, no floor mat was observed on the floor by her bed and was not seen anywhere in her room. Resident 26's record was reviewed on 5/10/23 at 10:28 a.m. The profile indicated the resident's diagnoses included, but were not limited to, heart failure (a condition in which the heats doesn't pump as well as it should), type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hemiplegia and hemiparesis (these are similar in that they describe weakness on one side of your body), and hypertension (elevated blood pressure). A quarterly Minimum Data Set (MDS) assessment, dated 4/7/23, indicated the resident had severe cognitive deficit and required a 2 person assist with bed mobility,…

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 suprapubic urinary catheter (a type of indwelling catheter inserted directly into the bladder) drainage bag was prevented from contact with the floor for 1of 2 residents reviewed for urinary catheter/urinary tract infection (Resident 8). Findings include: During a random observation, on 5/8/23 at 2:50 p.m., Resident 8 was sitting in his wheelchair in his room. His urinary catheter drainage bag was placed in a dignity bag (a solid color bag used to cover a clear urinary drainage bag) and the bag was observed to be in contact with the floor. The urinary catheter bag had not been secured by the hook onto the resident wheelchair and had been just set inside the dignity bag. During a random observation, on 5/9/23 at 11:23 a.m., the resident was sitting in his wheelchair in his room. His urinary catheter drainage bag was placed in a dignity bag and the bag was observed to be in contact with the floor. The urinary catheter bag had not been secured by the hook onto the resident wheelchair and had been just…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's supplemental oxygen concentrator machine was turned on, the oxygen tubing connected to the machine and resident was dated, and the portable supplemental oxygen tubing was not outdated for 1 of 1 resident reviewed for respiratory care (Resident 21). Finding includes: During an observation, on 5/8/23 at 2:09 p.m., Resident 21 was observed lying in bed with undated oxygen tubing running from the oxygen concentrator machine underneath a mat on the floor with a bedside table on top of the mat to the resident via nasal canula on the resident, with the oxygen concentrator machine not turned on. The oxygen tubing connected to the portable oxygen concentrator machine on the resident's wheelchair oxygen tank was dated 4/6/23. On 5/8/23 at 3:30 p.m., Resident 21 was observed lying in bed with undated oxygen tubing running from the oxygen concentrator machine underneath a mat on the floor with a bedside table on top of the mat to the resident via nasal canula on the resident with the oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor side effects/behaviors and failed to develop a care plan for the use of anti-psychotic medication (medication primarily used to manage psychosis) for 1 of 5 residents reviewed for unnecessary medications (Resident 14). Finding includes: Resident 14's record was reviewed on 5/11/23 at 11:43 a.m. The profile indicated the resident's diagnoses included, but were no limited to, type I diabetes mellitus (a chronic condition in which the pancreas [organ with two main functions that helps in digestion and an endocrine function that regulates blood sugar] produces little or no insulin), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), recurrent depressive disorders (a mental health disorder characterized by persistently depressed [NAME] or loss of interest in activities causing significant impairment of daily life), and treatment resistant depression (depressive…

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

Based on record review and interview, the facility failed to ensure the pharmacy recommendation was addressed by a physician and the facility failed to ensure the physician's responses to pharmacy recommendations were implemented for 2 of 5 residents reviewed for unnecessary psychotropic medications (Residents 21 and 6). Findings include: 1. Resident 21's record was reviewed on 5/10/23 at 10:30 a.m. The profile indicated the resident's diagnoses included, but was not limited to, depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). A quarterly Minimum Data Set (MDS) Assessment (part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 2/16/23, indicated the resident had a severe cognitive impairment and received an antidepressant medication on a routine basis for depression. A care plan, initiated on 1/10/21 and revised on 11/3/21, indicated Resident 21 had the diagnosis of depression with the potential for signs and symptoms of persistent…

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.