Hammond-Whiting Care Center

Based on record review and interview, the facility failed to invite and hold care planning conferences for residents and/or their family members. The facility also failed to update care plans related to medications for 3 of 19 residents whose care plans were reviewed. (Residents 6, 11, and 13)Findings include:1. During an interview on 2/5/26 at 10:33 a.m., Resident 6 indicated she has not been invited to a care conference. The record for Resident 6 was reviewed on 2/6/26 at 1:09 p.m. Diagnoses included, but were not limited to, heart failure, heart disease, chronic kidney disease, and depression. The 12/17/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. A Psychosocial Note, dated 3/27/25 at 10:30 a.m., indicated the IDT (interdisciplinary team) met with the resident for a quarterly care plan meeting. There were no other care plan meetings in the clinical record. During an interview on 2/10/26 at 9:20 a.m., the Administrator indicated the facility was without a Social Service Director (SSD) for a couple 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, record review and interview, the facility failed to ensure a resident who needed assistance with ADL's (Activities of Daily Living) received help related to oral care and washing of hair for 1 of 3 residents reviewed for ADL's. (Resident 6)Finding includes: During an interview on 2/5/26 at 10:30 a.m., Resident 6 indicated her hair was not washed every week and staff do not set her up to brush her teeth. At that time, the resident's hair was unkempt. During an interview on 2/9/26 at 9:35 a.m., the resident indicated CNA 1 got her up and dressed, however, she did not set her up to brush her teeth or provide oral care. She also indicated her hair had not been washed recently. The record for Resident 6 was reviewed on 2/6/26 at 1:09 p.m. Diagnoses included, but were not limited to, heart failure, heart disease, chronic kidney disease, and depression. The 12/17/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident needed set up assistance with oral care and partial/moderate assist 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 observation, record review and interview, the facility failed to ensure a skin rash was assessed and monitored for 1 of 2 residents reviewed for non-pressure related skin conditions, and blood pressure medications were administered as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications. (Residents 18 and 37)Findings include: 1. During an interview on 2/5/26 at 12:10 p.m., Resident 18 indicated he had a red area on the left side of his neck that had been there for about two months. He had told nursing staff and nurses at dialysis but still has not had any treatment for it. At that time, there was a red circular area on the side of his neck. He indicated it was starting to itch. On 2/9/26 at 12:45 p.m., RN 1 was asked to perform a skin assessment to the resident's neck area. At that time, she observed the red and raised area to the left side of his neck. During an interview at that time, RN 1 indicated she was unaware of the skin rash and was not provided any information during the end of shift report she had received in the morning. 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 observation, record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to a dialysis fistula and pressure ulcer treatments for 1 of 1 resident reviewed for dialysis and 1 of 2 residents reviewed for pressure ulcers. (Residents 18 and 74)Findings include:1. During an observation on 2/6/26 at 12:10 p.m., Resident 18 was observed sitting in a wheelchair in his room. At that time, his shirt was off and a perma catheter was observed in his upper chest. He indicated, that was being used for his dialysis treatments. He had never had a fistula, as they were going to do that later. The record for Resident 18 was reviewed on 2/9/26 9:30 a.m. Diagnoses included, but were not limited to, heart failure, end stage renal disease, dialysis, heart disease, anemia, and anxiety.A Physician's Order, dated 7/24/25, indicated dialysis resident, assess bruit/thrill (assessments performed on a dialysis fistula) upon return from dialysis every evening shift every…

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 infection control practices were in place and implemented related to staff not donning personal protective equipment (PPE) for a resident in enhanced barrier precautions (EBP), an indwelling Foley catheter bag observed on the floor, and the improper storage of personal care equipment during random infection control observations. (Residents 74 and 76)Findings include:1. During random observations on 2/5/26 at 9:49 a.m., 10:19 a.m., and 12:16 p.m., Resident 74 was observed in bed. At those times, the indwelling Foley catheter bag was observed on the floor. The record for Resident 74 was reviewed on 2/6/26 at 2:20 p.m. Diagnoses included, but were not limited to, paraplegia and neuromuscular dysfunction of the bladder. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) was still in progress. A Physician's Order, dated 1/29/26, indicated Indwelling catheter to straight drainage, size 16 French 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 observation, record review and interview, the facility failed to ensure a resident's right to participate in her care related to not being informed on the medication she received during medication pass for 1 of 7 residents observed for medication administration. (Resident E)Finding includes:During medication administration on 9/15/25 at 9:22 a.m., RN 1 prepared the powdered medication Lokelma (given for high potassium level) in water for Resident E. RN 1 handed the resident the medication and the resident was gagging on the mixture and indicated how bad it tasted and did not want to finish it. RN1 instructed to drink the rest of the medication. RN 1 did not educate or inform Resident E what the medication was or why it was important to drink it all.During medication administration on 9/16/25 at 9:28 a.m., LPN 1 prepared the powdered medication Lokelma for Resident E. LPN 1 handed the medication to the resident and did not inform her what the medicine was for. The resident struggled to drink the medication fully and was starting to cry due to the poor taste. LPN 1 added more…

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 dependent resident received assistance with ADLs (activities of daily living) related to bathing for 1of 3 residents reviewed for ADLs. (Resident D)Finding includes:On 9/15/25 at 3:33 p.m., Resident D was observed playing bingo. The resident's hair had a greasy appearance.Resident D's record was reviewed on 9/16/25 at 11:05 a.m. The diagnoses included, but were not limited to, heart failure, kidney disease, anxiety, and diabetes.The admission Minimum Data Set (MDS) assessment, dated 7/23/25, indicated the resident was moderately impaired with daily decision. The resident required partial to moderate assistant with toileting.A Care Plan, dated 7/23/25, indicated the resident required assistance with ADLs (activities of daily living) and needed therapy services. Intervention was to assist the resident with ADLs as needed.Showers Sheets indicated the resident had not received a bath/shower on the following dates:8/19/258/20/258/21/258/22/258/23/258/24/258/25/258/26/258/27/25There were no documented…

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 administer medications as ordered related to antibiotic and antianxiety medication for 1 of 3 residents reviewed for medication administration. (Residents B)Finding includes:Resident B's record was reviewed on 9/15/25 AT 10:15 a.m. The diagnoses included, but were not limited to, paraplegia, osteomyelitis (bone and muscle infection), anxiety, hypertension (high blood pressure), muscle weakness, and ulcerative colitis (inflamed bowel).The admission Minimum Data Set (MDS) assessment, dated 7/14/25, indicated the resident was cognitively intact and received an antibiotic and antianxiety medication.A Physician's Order, dated 7/8/25, indicated to administer alprazolam 1 milligram (MG) my mouth at bedtime for anxiety.A Physician's Order, dated 7/11/25, indicated to administer Vancomycin (antibiotic) 1.25 grams intravenously two times a day for a wound infection related to osteomyelitis.The 7/2025 Medication Administration Record (MAR), indicated the following medications were not signed out as being administered:Vancomycin 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 ensure a wound treatment was completed and heels were floated as ordered for 2 of 3 residents reviewed for pressure-related skin conditions. (Residents B and C) Findings include: 1. On 5/5/25 at 11:59 a.m., Resident B was observed lying in bed on her right side. The resident's heels were resting on the bed, not off-loaded, and she had wounds on her left lateral and medial foot. During an interview at the time, the wound nurse indicated the resident did not have an order for off-loading boots but she would call the doctor today to get an order. She indicated the resident's heels were off-loaded the last time she was in the room. The record for Resident B was reviewed on 5/5/25 at 10:48 a.m. Diagnoses included, but were not limited to, dementia, anorexia, tube feeding support, and lymphedema (swelling in arms or legs). The Quarterly Minimum Data Set (MDS) assessment, dated 2/19/25, indicated the resident was cognitively impaired for daily decision making, dependent for all activities of daily living (ADL's) 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, record review, and interview, the facility failed to maintain clinical records that were complete and accurately documented related to conflicting orders for wound treatments for 1 of 3 residents reviewed for pressure. (Resident D) Finding includes: On 5/5/25 at 11:01 a.m., Resident D was observed during a wound treatment. During the wound treatment, the wound nurse went to apply aquacell alginate to the wound bed. The current physician's order called for xerofoam to be placed on the wound bed. During an interview at the time, the nurse indicated she had confirmed the orders with the physician and the 12/20/24 order for xerofoam was the correct order to use going forward. She would delete the aquacell treatment order to ensure the correct order was used. The record for Resident D was reviewed on 5/5/25 at 10:55 p.m. Diagnoses included, but were not limited to, anemia (low iron), dysphagia (difficulty swallowing), and high blood pressure. The Quarterly Minimum Data Set (MDS) assessment, dated 1/14/25, indicated Resident D was moderately impaired for daily…

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 correct Personal Protective Equipment (PPE) was used by a staff member (Wound Nurse) when providing care during a wound treatment for resident who was in Enhanced Barrier Precautions (EBP) for 1 of 3 residents observed for pressure ulcer care. (Resident C) Finding includes: On 5/5/25 at 10:38 a.m., Resident C was observed in bed with 2 blankets covering her. She was lying on her back and crying she was cold. When the blankets were removed to observe the wound treatment, the resident's feet were lying flat on the bed. The Wound Nurse began the wound treatment, the resident's brief was opened and a new pad was placed underneath the resident. Hand hygiene was performed, and a new set of gloves were donned. The wound nurse did not have a gown on, and she began cutting the collagen dressing packet open. She was stopped and asked if the resident was in Enhanced Barrier Precautions. There was an EBP sign observed on the resident's door. During an interview at the time, the Wound Nurse indicated she had…

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 served and prepared under sanitary conditions related to dried food spillage, scoops in bins, and food that was not labeled for 1 of 1 kitchens observed. (The Main Kitchen) This had the potential to affect all residents receiving food from the kitchen. Finding includes: During the brief kitchen sanitation tour on 9/30/24 at 9:34 a.m. with the Dietary Food Manager (DFM), the following was observed: a. An accumulation of dried food spillage was on the outside and on the lids of the flour, sugar, and rice bins. b. A plastic scoop was observed inside the flour and rice bins positioned directly on the food. c. A bag of thawed chicken was observed in a plastic bin in the walk in refrigerator. The bag was twisted closed and not dated. During an interview at that time, the DFM indicated the bins would be cleaned and the scoops removed and the chicken would be discarded. 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure kitchen areas were maintained in a functional and sanitary manner, related to dirty floor tile, dried food spillage, and an accumulation of dust on pipes for 1 of 1 kitchen areas. (The Main Kitchen) This had the potential to affect all residents who received food from the kitchen. Findings include: 1. During the brief kitchen sanitation tour on 9/30/24 at 9:34 a.m. with the Dietary Food Manger (DFM), the following was observed: a. The floor tile throughout the kitchen had an accumulation of dirt and debris along the base boards. The tile grout was also discolored and dirty. b. There was an accumulation of dried spillage on top of the dishwasher and on the front of the dishwasher. c. The metal pipes located above the dishwasher had an accumulation of dust. During an interview at that time, the DFM indicated the above was in need of cleaning. 2. During the kitchen sanitation tour on 10/3/24 at 11:15 a.m. with the DFM, the following was observed: a. The white wall located beneath the coffee and juice machines had 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, record review, and interview, the facility failed to label and store medication appropriately related to storing unlabeled bulk medication for 1 of 2 medication rooms and 1 of 2 medication carts observed during medication storage observations. (South medication room and North medication cart) Findings include: 1. On 10/1/24 at 4:58 p.m., the north medication cart was observed with QMA 1. The top drawer had 2 bottles of acetaminophen that were not labeled. During an interview at the time, QMA 1 indicated the acetaminophen bottles were house medications. 2. On 10/1/24 at 3:30 p.m., the south medication room was observed with LPN 2. In the top left cabinets there was a box of benadryl and 2 bottles of acetaminophen with no labels. During an interview on 10/1/24 at 3:29 p.m., LPN 2 indicated the benadryl and acetaminophen were in the cabinet because those were in house medications. During an interview on 10/2/24 at 9:35 a.m., the nurse consultant indicated they should not have house medications and those medications have been removed. 3.1-25(j)

Based on observation, record review, and interview, the facility failed to ensure the menu was followed as written related to pureed diets. This had the potential to affect the 7 residents in the facility who received a pureed diet. Finding includes: On 10/3/24 at 11:05 a.m., [NAME] 1 was observed preparing the pureed lunch meal. The residents who received a pureed diet were receiving pureed ham, peas, mashed potatoes and gravy, and bread. At that time, the [NAME] indicated the residents who received a regular diet were being served beef tips with mushrooms over parsley noodles. On 10/3/24 at 1:45 p.m., the menu for the pureed diets was reviewed. The residents who received a pureed diet were also to be served beef tips with mushrooms over parsley noodles. During an interview on 10/3/24 at 3:30 p.m., the Dietary Food Manager indicated the residents should have been served pureed beef tips rather than ham based on the spreadsheet. She indicated the cook usually made the pureed residents their own special meal. 3.1-20(i)(1)

Based on observation, record review, and interview, the facility failed to ensure call lights were placed within reach of the resident for 1 of 1 resident reviewed for accommodation of needs. (Resident B) Finding includes: On 10/2/24 at 9:08 a.m., 11:15 a.m., and 12:05 p.m., Resident B was observed in her room in bed. Her eyes were closed and she was positioned on her right side. At 12:29 p.m. and 1:57 p.m., the resident's eyes were open and she remained in bed. The resident's call light was clipped to the call light cord above the head of the resident's bed and was out of reach at all of the above times. During an interview on 10/2/24 at 12:29 p.m., CNA 3 indicated the resident could tell staff if she needed assistance. On 10/3/24 at 8:58 a.m. and 10:35 a.m., the resident was observed in her room in bed. The call light remained out of the resident's reach and clipped to the call light cord. On 10/4/24 at 9:10 a.m., the resident was observed in her room in bed. Again, the call light remained out of reach. The record for Resident B was reviewed on 10/2/24 at 2:46 p.m. 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 record review and interview, the facility failed to ensure residents' care plans were held and families were invited to attend care plan meetings for 2 of 19 residents whose care plans were reviewed. (Residents 35 and 37) Finding includes: 1. On 10/1/24 at 3:48 p.m., Resident 35 was observed lying in bed. The resident indicated he did not know about his care plan meetings. The staff told him they would call and talk with his daughter regarding his care plan. Resident 35 indicated the staff never called his daughter or held his care plan meeting. Resident 35's record was reviewed on 10/2/24 at 10:07 a.m. Diagnoses included, but were not limited to, retention of urine, insomnia, chronic obstructive pulmonary disease, heart failure, gout, and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 7/9/24, indicated the resident was cognitively intact for daily decision making. During an interview on 10/03/24 at 10:19 a.m the Social Service Director indicated she did not have any documentation showing that she attempted to reach out to the resident or…

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 dependent residents received assistance with activities of daily living (ADL's) related to meal assistance and the removal of facial hair for 2 of 7 residents reviewed for ADL's and for 1 of 2 meal observations. (Residents 28, 29, and 27) Findings include: 1. On 9/30/24 at 12:02 p.m., Resident 28 was seated in her broda chair (a type of wheelchair) in the restorative dining room. She and her tablemate were served their lunch trays at 12:02 p.m. Resident 28's tray was placed in front of her and remained covered. The resident was not assisted with her meal until 12:15 p.m. The record for Resident 28 was reviewed on 10/1/24 at 3:44 p.m. Diagnoses included, but were not limited to, dementia without behavior disturbance, diabetes, and long term use of insulin. The Quarterly Minimum Data Set (MDS) assessment, dated 8/21/24, indicated the resident was cognitively impaired for daily decision making and required supervision or touching assistance with eating. A Care Plan, reviewed on 8/8/24, 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 provide a personalized activity program for a cognitively impaired and dependent resident related to ongoing stimulation and one to one visits for 1 of 1 resident reviewed for activities. (Resident C) Finding includes: On 9/30/24 at 4:18 p.m., Resident C was observed in her room in bed. The resident was awake and attempting to lift her head off of the pillow and her feet off of the mattress. The resident's television was turned off and the privacy curtain was pulled half way between her and her roommate. The resident was confined to her room due to being in isolation. On 10/1/24 at 11:30 a.m. and 4:40 p.m., the resident's television remained off. On 10/2/24 at 2:05 p.m., the resident was again lifting her head and feet off of the mattress and her television was turned off. On 10/3/24 at 9:30 a.m., the resident was fidgeting in bed and her television was turned off. The record for Resident C was reviewed on 10/2/24 at 3:09 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia 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 observation, record review, and interview, the facility failed to ensure insulin was administered as ordered and held per insulin parameters for 2 of 5 residents reviewed for unnecessary medications. (Residents 28 and 219) The facility also failed to ensure areas of bruising were assessed and monitored for 1 of 6 residents reviewed for skin conditions non-pressure related. (Resident 35) Findings include: 1. The record for Resident 28 was reviewed on 10/1/24 at 3:44 p.m. Diagnoses included, but were not limited to, dementia without behavior disturbance, diabetes, and long term use of insulin. The Quarterly Minimum Data Set (MDS) assessment, dated 8/21/24, indicated the resident was cognitively impaired for daily decision making and she had received insulin injections during the assessment reference period. A Care Plan, reviewed on 8/8/24, indicated the resident had Diabetes Mellitus. The goal was for the resident to have no complications related to diabetes through the next review date. A Physician's Order, dated 8/13/24, indicated the resident was to receive Lispro insulin,…

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 the necessary treatment and services were provided to promote healing of pressure ulcers related to the use of pressure reducing devices for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Finding includes: On 10/2/24 at 9:08 a.m., 11:15 a.m., 12:05 p.m., 12:29 p.m., and 1:57 p.m., Resident B was observed in her room in bed. Her pressure reducing heel boots were observed in her wheelchair and her feet were not off loaded (positioning the body so that pressure does not rest on top of the wounded area) while she was in bed. On 10/3/24 at 8:58 a.m., the resident was in her room in bed sleeping. The resident was dressed and she was not covered with any blankets. The resident was observed with gauze dressings to both of her feet that were dated 10/2/24. The resident's feet were resting directly on the mattress and her heel boots were in the chair next to the bed. The record for Resident B was reviewed on 10/2/24 at 2:46 p.m. Diagnoses included, but were not limited to, hemiplegia/hemiparesis…

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 oxygen was at the correct flow rate for 1 of 1 resident reviewed for oxygen. (Resident 21) Finding included: On 9/30/24 at 4:16 p.m., Resident 21's oxygen was on via nasal cannula and the flow rate was set under 3 liters. On 10/01/24 at 11:32 a.m., the resident's oxygen flow rate was observed under 3 liters. 10/02/24 9:06 a.m., and 11:03 a.m., the resident was observed asleep in bed. She was wearing oxygen via nasal cannula. The flow rate was at 2.5 liters. The record for Resident 21 was reviewed on 10/02/24 at 9:44 p.m. The diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body, candidiasis, hyperlipidemia (high cholesterol), anxiety, depression, heart failure, diabetes, and chronic obstructive pulmonary disease (COPD). The Quarterly Minimum Data Set (MDS) assessment, dated 7/2/24, indicated the resident was moderately impaired for daily decision making. The resident had impairment on one side of the lower extremities and used a wheelchair. The resident required…

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

Based on record review and interview, the facility failed to complete a post dialysis assessment for 1 of 1 resident reviewed for dialysis. (Resident 217) Finding includes: The record for Resident 217 was reviewed on 10/03/24 at 3:31 p.m. The diagnoses included, but were not limited to, kidney disease, hemiplegia (paralysis of one side of the body, dependence on renal dialysis, hypertension (high blood pressure), and anemia (low iron). The 5 day Minimum Data Set (MDS) assessment, dated 9/26/24, indicated the resident was severely impaired for daily decision making. The resident had impairment on one side of the lower extremities and used a wheelchair. The resident required dialysis. A Care Plan, dated 9/20/24, indicated the resident received hemodialysis and had an arteriovenous (AV) fistula (a connection made between an artery and a vein for dialysis access). Interventions included, but were not limited to, observe for bleeding at dialysis access site, obtain dry weights from dialysis center, and assess shunt site for bruit and thrill. A Physician's Order, dated 9/20/24, indicated…

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

Based on observation, record review, and interview, the facility failed to provide ongoing psychosocial visits for a resident in indefinite isolation for 1 of 3 residents reviewed for isolation. (Resident 21) Finding included: On 9/30/24 at 4:14 p.m., Resident 21 was observed sitting up in bed. She was tearful and indicated she was going crazy in isolation. She was told she had another month in isolation and she could not take it anymore, she wanted out. The record for Resident 21 was reviewed on 10/02/24 at 9:44 p.m. The diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body, candidiasis, hyperlipidemia (high cholesterol), anxiety, depression, heart failure, diabetes, and chronic obstructive pulmonary disease (COPD). The Quarterly Minimum Data Set (MDS) assessment, dated 7/2/24, indicated the resident was moderately impaired for daily decision making. The resident had impairment on one side of the lower extremities and used a wheelchair. A Care Plan, dated 7/4/24, indicated the resident was at risk for a change in mood behavior due to anxiety.…

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

Based on record review and interview, the facility failed to ensure gradual dose reductions (GDR's) of psychotropic medications were implemented for 2 of 5 residents reviewed for unnecessary medications. (Residents B and C) Findings include: 1. The record for Resident B was reviewed on 10/2/24 at 2:46 p.m. Diagnoses included, but were not limited to, hemiplegia/hemiparesis (muscle weakness/muscle paralysis) following a stroke, dementia without behavior disturbance, Alzheimer's disease, and major depressive disorder. The 9/27/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired for daily decision making and she had received antipsychotic medications during the assessment reference period. A GDR was attempted on 9/13/24. A Physician's Order, dated 7/10/24 and listed as current on the October 2024 Physician's Order Summary (POS), indicated the resident was to receive Seroquel (an antipsychotic medication) 25 milligrams (mg) at bedtime for restlessness. A GDR Psychiatric Progress Note, dated 9/13/24, indicated the resident's Seroquel was to 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, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to improper use of personal protective equipment (PPE) prior to entering and leaving an isolation room, staff not knowing why a resident was in isolation, and not completing an antiseptic bath as ordered for 1 of 9 residents reviewed for infection control. (Resident 21) Finding includes: On 10/1/24 at 3:34 p.m., the signage on the outside of the resident's door indicated the resident was in contact, enhanced barrier, and droplet precautions. During an interview on 10/1/24 at 3:40 p.m., LPN 3 indicated she was unsure why the resident was in droplet precautions and would have to look it up. On 10/2/24 at 12:43 p.m., family members entered the resident's room and were wearing gloves, gown, mask, face shield, and shoe covers. They indicated they were instructed by staff what PPE to wear before entering the room. On 10/2/24 at 12:47 p.m., QMA 1 was observed donning PPE which included, a mask, gown, gloves, and shoes covers. 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, record review, and interview, the facility failed to ensure areas of skin discoloration and scabbing were assessed and monitored for 2 of 3 residents reviewed for skin conditions non-pressure related. (Residents D and E) Findings include: 1. On 6/5/24 at 11:07 a.m., Resident D was observed with a reddish/purple discoloration to the top of their right hand. On 6/6/24 at 10:25 a.m., Resident D was observed sitting in a wheelchair in front of the nurses' station. The discoloration remained to the top of the right hand. The record for Resident D was reviewed on 6/6/24 at 9:00 a.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a history of falling. The Medicare 5 day Minimum Data Set (MDS) assessment, dated 4/30/24, indicated the resident was cognitively impaired. A Care Plan, dated 3/16/24, indicated the resident was on anticoagulant (blood thinning) therapy. Interventions included, but were not limited to, observe for and report as needed (PRN) adverse reactions 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, record review, and interview, the facility failed to ensure preventative fall measures were in place for a resident who was at risk for falls for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes: On 6/5/24 at 11:01 a.m., Resident B was observed in their room in bed. The head of the bed was elevated and the resident was sleeping. The bed was not in a low position. On 6/6/24 at 8:58 a.m., 9:48 a.m., and 10:18 a.m., the resident was observed in bed sleeping. The bed was not in a low position. The record for Resident B was reviewed on 6/5/24 at 2:10 p.m. Diagnoses included, but were not limited to, hemiplegia (paralysis) and hemiparesis (muscle weakness) following a stroke, seizures, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment, dated 3/14/24, indicated the resident had moderate cognitive impairment and was dependent on staff for bed mobility and transfers. A Care Plan, reviewed on 3/7/24, indicated the resident was at risk for falls due to having had an actual fall. The resident would purposefully put their legs over…

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 areas of bruising, scratches, sutures, and glued lacerations were assessed and monitored for 3 of 4 residents reviewed for skin conditions non-pressure related. The facility also failed to ensure neurological checks were completed as well as fall follow-up documentation for 2 of 3 residents reviewed for falls. (Residents 2, 19, 23, B, and C) Findings include: 1. On 11/27/23 at 10:53 a.m., Resident 2 was observed with scattered areas of reddish/purple discoloration to her bilateral forearms. On 11/28/23 at 10:45 a.m., the scattered areas of discoloration remained to the resident's bilateral forearms. On 11/29/23 at 9:38 a.m., the resident was observed in her room in bed. A new area of dark purple bruising was observed on the top of the resident's left hand and wrist area. The record for Resident 2 was reviewed on 11/29/23 at 10:42 a.m. Diagnoses included, but were not limited to, Alzheimer's late onset, dementia with agitation,…

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 ensure the residents' environment was clean and in good repair related to marred walls, marred door frames, discolored floors, rusted and missing toilet bolts, dirty and broken floor baseboards, missing pieces from an air conditioner, and wash basins not contained in a multi resident room on 2 of 2 units. (The North and South Units) Findings include: During the Environmental Tour with the Environmental Director on 12/1/23 at 10:18 a.m., the following was observed: 1. South Hall a. room [ROOM NUMBER] - The door frame was observed to be marred and there was adhered dirt behind the base of the door. One resident resided in the room and two residents shared the bathroom. b. room [ROOM NUMBER] - The bathroom walls were observed to be marred and the toilet bolts were missing and rusted. There were two residents who resided in the room and four residents who shared the bathroom. c. room [ROOM NUMBER] - The bathroom walls was observed to be marred, the baseboard…

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 promptly notify the resident's family of medication changes for 2 of 2 residents reviewed for notification of change. (Residents 23 and B) Findings include: 1. During a phone interview with Resident 23's responsible party on 11/27/23 at 1:18 p.m., she indicated she was not always made aware of her brother's medication changes. The record for Resident 23 was reviewed on 11/29/23 at 9:59 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, lung, liver and bladder cancer, epilepsy, high blood pressure, and major depressive disorder. The admission Minimum Data Set (MDS) assessment, dated 9/11/23, indicated the resident was not cognitively intact and needed extensive assistance with 1 person physical assist for bed mobility and transfers. In the last 7 days, the resident received an anti-anxiety medication 6 times. A Nurses' Note, dated 11/10/23 at 1:25 a.m., indicated the resident was observed having a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL's) related to shaving and bathing for 2 of 6 residents reviewed for ADL's. (Residents B and C) Findings include: 1. During an interview with Resident B's spouse on 11/28/23 at 9:38 a.m., they indicated they did not think the resident was receiving a shower at least 2 times a week. The record for Resident B was reviewed on 11/28/23 at 1:25 p.m. Diagnoses included, but were not limited to, metabolic encephalopathy, protein calorie malnutrition, stroke, Atrial Fibrillation (A Fib - irregular heart rhythm), pacemaker, anemia, high blood pressure, and alcohol dependence. The 10/23/23 Medicare 5 day Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact. The resident needed some help and partial assistance from another person to complete bathing, dressing, using the toilet, and walking. The Care Plan, revised on 9/22/23, 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 record review and interview, the facility failed to ensure residents had access to receive services for impaired vision for 2 of 3 residents reviewed for vision and hearing. (Residents 31 and 18) Findings include: 1. On 11/27/23 at 3:49 p.m., Resident 31 was observed in her room watching television. The resident indicated she wore glasses and she needed new glasses. At that time, the resident also indicated she had asked multiple times to be placed on the list to see an eye doctor. The record for Resident 31 was reviewed on 11/28/23 at 1:59 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, anemia, atrial fibrillation (abnormal heart rhythm), heart failure, hypertension (high blood pressure), diabetes, dementia, hemiplegia, anxiety, and depression. The 9/1/23 Annual Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and had no vision impairment or corrective lens. A Physician's Order, dated…

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

Based on observation, record review, and interview, the facility failed to ensure pressure reducing measures were in use for a resident with a deep tissue injury (DTI) for 1 of 1 resident reviewed for pressure ulcers. (Resident 2) Finding includes: On 11/28/23 at 3:38 p.m., Resident 2 was observed in her room in bed. No heel protectors were in use at that time. On 11/29/23 at 9:38 a.m. and 11:28 a.m., the resident was observed in her room in bed. The resident had no sock on her right foot and her foot was resting on a pillow. The resident's left foot was resting on the mattress. The record for Resident 2 was reviewed on 11/29/23 at 10:42 a.m. Diagnoses included, but were not limited to, Alzheimer's late onset, dementia with agitation, Atrial Fibrillation (A Fib - irregular heart rhythm), and hemiplegia/hemiparesis (muscle weakness/paralysis) following a stroke. The Significant Change Minimum Data Set (MDS) assessment, dated 10/31/23, indicated the resident was cognitively impaired for daily decision making. The resident also had one deep tissue injury (purple or maroon localized…

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 tube feeding was infusing at the correct time. The facility also failed to ensure tube feeding placement was checked and a water flush was completed prior to administering gastrostomy tube (an opening into the stomach from the abdominal wall for the introduction of food) medications for 2 of 2 residents reviewed for tube feeding. (Residents 19 and 33) Findings include: 1. On 11/27/23 at 12:03 p.m., Resident 19 was observed in the dining room eating lunch. Her tube feeding was not infusing at that time. On 11/28/23 at 10:17 a.m., 1:38 p.m., and 3:19 p.m., the resident was observed in her wheelchair throughout the facility. Her tube feeding was not infusing nor connected to the gastrostomy tube. On 11/29/23 at 10:39 a.m., the resident was being pushed down the hallway by a staff member, her tube feeding was not connected. At 11:28 a.m., she was seated on the side of her bed. Again, the tube feeding was not connected. A tube feeding pump was observed next to the resident's bed. At 12:15 p.m., 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 oxygen was at the correct flow rate for 1 of 2 residents reviewed for oxygen. (Resident 2) Finding includes: On 11/28/23 at 1:42 p.m., Resident 2 was seated in the hall way across from the nurses' station. The resident was wearing oxygen by the way of a nasal cannula. The portable oxygen tank was set at 2 liters. At 3:38 p.m., the resident was in her room in bed sleeping. She was holding the nasal cannula in her hands. On 11/29/23 at 9:38 a.m. and 11:28 a.m., the resident was in her room in bed sleeping. The resident's nasal cannula was not in place and the oxygen concentrator was set at 2 liters. At 12:10 p.m., the oxygen was in use and the concentrator was set at 2 liters. On 11/30/23 at 10:38 a.m., the resident was observed in her room in bed. The resident's oxygen was in use and the oxygen concentrator was set at 2 liters. The record for Resident 2 was reviewed on 11/29/23 at 10:42 a.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), Alzheimer's late…

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

Based on record review and interview, the facility failed to complete a post dialysis assessment for 1 of 1 resident reviewed for dialysis. (Resident 25) Finding includes: Resident 25's record was reviewed on 11/28/23 at 2:39 p.m. Diagnoses included, but were not limited to, heart failure, hypertension (high blood pressure), end stage renal disease (renal failure), diabetes, malnutrition, and dependent on renal dialysis. The 11/3/23 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. A Care Plan, dated 11/13/23, indicated the resident received hemodialysis related to renal failure and had an arteriovenous (AV) fistula (dialysis access site). Interventions included, but were not limited to, observe for bleeding at dialysis access site, obtain dry weights from dialysis center, assess shunt site for bruit and thrill, and encourage the resident to go for scheduled dialysis appointments on Monday, Wednesday, and Friday each week. A Physician's Order, dated 9/12/23, indicated the resident was a dialysis patient and received…

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 residents received routine dental services for 1 of 4 residents reviewed for dental services. (Resident 31) Finding includes: On 11/27/23 at 3:50 p.m., Resident 31 was observed sitting up in bed watching television. At that time, the resident indicated she had asked to see the dentist and was told she was put on the list months ago by social services. The record for Resident 31 was reviewed on 11/28/23 at 1:59 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, anemia, atrial fibrillation (abnormal heart rhythm), heart failure, hypertension (high blood pressure), diabetes, dementia, hemiplegia, anxiety, and depression. The 9/1/23 Annual Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 2/2/23, indicated the resident may have Dental, Podiatry, Audiology, and Optometry care as needed. There was no documentation 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 resident care equipment was in safe operating condition, related to glucometers (blood sugar testing machine) not calibrated for 1 of 2 units where 8 residents received glucometer testing. (North Unit) (Residents L, M, N, P, Q, R, S, and T) Finding includes: The Glucometer Calibration/Control Binder for the North Unit was reviewed on 8/8/23 at 3 p.m. There were eight residents who received glucometer testing listed in the binder. Resident L was admitted into the facility on 7/21/23. Resident M was admitted into the facility on 5/23/23. Resident N was admitted into the facility on 8/4/23. Resident P was admitted into the facility on 4/10/23. Resident Q was admitted into the facility on 3/15/23. Resident R was admitted into the facility on 3/19/23. Resident S was admitted into the facility on 7/14/23. Resident T was admitted into the facility on 6/23/23. There was no calibration/control checks on the glucometers in the month of July. The first documentation of the calibration/control testing was completed on 8/8/23.…

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, record review, and interview, the facility failed to ensure residents were treated with dignity, related to not assisting residents who required assistance with meal intake in a timely manner, for 2 of 8 residents during 1 of 1 meals observed. (Residents C and D) Finding includes: During an observation of the lunch meal on 8/8/23 from 11:40 a.m. through 12:33 p.m. the following was observed: The meals were served to the Resident C and D at 11:40 a.m. At 11:45 a.m., Resident C had her eyes closed and an uncovered tray of food was sitting in front of her. Resident D's meal was uncovered and sitting in front of her, she fed herself one bite of chocolate pudding. At 11:56 a.m., CNA 2 woke Resident C and asked her if she was going to eat. At that time, she was holding a spoon in her hand, though not feeding herself. Resident D has not taken any further bites of her meal. At 11:58 a.m., Resident C continued to hold her spoon and was not feeding herself and Resident D continued to not feed herself. There were five staff members in the dining room and two of the 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 record review and interview, the facility failed to ensure residents and/or their Responsible Party were notified in writing of an intrafacility transfer, the reason for the transfer, and the approval of the transfer/room transferring to, for 3 of 3 residents reviewed for discharge/transfer. (Residents B, E, and F) Findings include: 1. Resident B's record was reviewed on 8/8/23 at 11:12 a.m. The diagnoses included, but were not limited to, end stage renal disease with dialysis, stroke, and vascular dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 7/26/23, indicated an intact cognitive status. There were intrafacility transfers on 7/24/23, 7/31/23, and 8/1/23. A Social Service Progress Note, dated 7/24/23 at 3 p.m., indicated the resident's daughter was notified of the room change. The daughter informed Social Service the resident had never had a roommate and might have a problem with the roommate. There was no documentation of why the resident was moved or if the resident and/or family waived the right to be moved. There was also no documentation why 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 resident's record was complete and accurate, related to a resident's behavior which resulted in an intrafacility transfer, for 2 of 9 resident records reviewed. (Residents B and G) Finding includes: Resident B's record was reviewed on 8/8/23 at 11:12 a.m. The diagnoses included, but were not limited to, end stage renal disease with dialysis, stroke, and vascular dementia. An intrafacility transfer to another room occurred on 7/31/23. There was no documentation for the reason of the room transfer. During an interview on 8/8/23 at 2:20 p.m., the Social Service Director indicated on 7/31/23, the resident was transferred to another room by the nurse during the night. She was informed the transfer occurred due to his roommate (Resident G) had come over to his side of the room and had been standing over him when he was in bed. Resident G's record was reviewed on 8/9/23 at 9:58 a.m. The diagnoses included, but were not limited to, Alzheimer's disease. The Nurse's Progress Note, dated 7/31/23 at 2:10 p.m. indicated he had…

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.