Hutchinson Operator, LLC

The facility identified a census of 42 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 6 and R20's as needed (PRN) psychotropic medication (alters mood or thoughts) had a 14 day stop date, or a specified duration with a physician rationale for extended use. The facility failed to ensure R6's PRN antipsychotic (a psychotropic medication used to treat severe mental disorders) had the required 14 day stop date. Findings included:1. R6's Electronic Medical Record (EMR) listed a Physician's Order for haloperidol (an antipsychotic medication) 0.5 milligrams (mg) tablet, give one tablet by mouth every four hours as needed for agitation/aggression, dated 10/18/25. The order lacked a stop date. R6's EMR documented an order lorazepam (antianxiety a class of medications that calm and relax people) 0.5 mg tablet, give one tablet by mouth every two hours as needed for anxiety/seizure, dated 11/04/25. The order lacked a stop date. An observation on 01/28/26…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 42 residents. The sample included 12 residents with two reviewed for discharge and three for hospitalization. Based on interviews and record review, the facility failed to provide a written bed hold policy including duration for Resident (R)21, and R20. The facility also failed to notify the Office of the Long-term Care Ombudsman (LTCO) of a transfer for R46.Findings included:1.R21's Electronic Medical Record (EMR) recorded a Quarterly Minimum Data Set (MDS), dated [DATE], which documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R21's Nursing Progress Note, dated 01/02/26 at 06:36 AM, which documented R21 was admitted to the hospital with urosepsis (sepsis related to UTI) and a verbal bed hold was given before departure. R21's EMR lacked evidence a written bed hold notice was provided to R21. During an interview on 01/27/26 at 09:11 AM, R21 reported she did not know anything about a bed hold. 2. R20's Quarterly MDS, dated 12/30/25,…

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

The facility identified a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 20's psychotropic (alters mood or thought) medications, and R7's activities of daily living (ADLs) for a dependent resident. Findings included:1. R20's Electronic Medical Record (EMR) revealed diagnoses of major depressive disorder (major mood disorder which causes persistent feelings of sadness) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R20's 09/29/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R20's MDS documented no behaviors and minimal depression. R20's MDS recorded he received an antianxiety, (a class of medications which calm and relax people), an antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality), and an antidepressant (a class of medications used to treat mood…

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 The facility identified a census of 42 residents. The sample included 12 residents with three residents reviewed for urinary catheters (a tube inserted directly into the bladder to drain urine). Based on observation, interview, and record review, the facility failed to ensure adequate catheter related care for Resident (R) 4, R7 and R21 when staff did not ensure each resident's catheter tubing was secured to prevent pulling or dislodgement. The facility additionally failed to ensure each resident was provided with a dignity bag to cover the urine collection bag and failed to ensure the urine collection bags remained sanitary and off the floor. Findings included:1.R4's Electronic Medical Record (EMR) recorded a diagnosis of bladder dysfunction and inflammatory reaction due to an indwelling urethral (tubelike part of the body conveys urine from the bladder to the exterior) catheter.R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 indicating…

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.

The facility identified a census of 42 residents. The sample included 12 residents with five reviewed for immunizations. Based on record review and interview, the facility failed to provide education and obtain consent or informed declination for the pneumococcal (type of bacterial infection) vaccine for Resident (R) 1, R20 and R25. Findings included:- Review of R1's Immunization Record lacked documentation of education provided by the facility, regarding the risk verses benefits of pneumococcal vaccine administered on 10/11/22, since his entry on 08/29/19. Review of R20's Immunization Record lacked documentation of education provided by the facility regarding the risk verses benefits and/or the offer of pneumococcal vaccine since his entry on 09/25/25. Additionally, the documentation lacked indication of historical data of the resident's pneumovax status. Review of R25's Immunization Record lacked documentation of education provided by the facility, regarding the risk verses benefits and/or the offer of pneumococcal vaccine, since his entry on 04/06/23. Additionally, 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.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 42 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 04/09/24 at 08:30 AM, observation revealed dietary staff in the kitchen prepared the breakfast meal. On 04/09/24 at 08:40 AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had three residents with mechanical soft diets and one with a pureed diet who is in the hospital. On 04/11/24 at 02:00 PM, Administrative Staff A verified Dietary Staff BB was not certified. The facility's Food Service Staffing dated 10/2024, documented the community will employ sufficient staff with the appropriate competencies and skills to carry out the function of the food and nutrition services. The qualified Dietician would help oversee clinical nutrition and dietary…

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.

The facility had a census of 42 residents. Based on observation, record review, and interview the facility failed to store food in a safe and sanitary manner and failed to adequately sanitize dishes for the 42 residents that resided in the facility and received meals from the kitchen. This placed the residents at risk for foodborne illness. Findings Included: - On 04/09/24 at 08:30 AM, observation during the initial kitchen tour revealed the upright refrigerator-freezer contained the following items in the bottom freezer drawer: One bag of approximately 50 pepperoni circles with an open date of 09/15/23 and an expiration date of 03/15/24. One bag of eight Salisbury steak patties with an open date of 03/18/24 and an expiration date of 03/25/24. On 04/09/24 at 09:00 AM, observation revealed Dietary Staff (DS) DD operated the dishwasher and the wash temperature was at 105 degrees Fahrenheit (F) and the rinse temperature was at 110 degrees F. DS DD ran five loads and the temperature remained at 105 - 110 degrees F. The Dishwasher Temperature Logs, dated April 2024, documented morning,…

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 The facility had a census of 42 residents. The sample included 12 residents with four reviewed for falls. Based on observation, interview, and record review the facility failed to ensure an environment free from accident hazards when the accessible hot water at the dining room sink was 131 degrees F (Fahrenheit) and further failed to provide effective interventions to prevent further falls for Resident (R) 13. This placed the residents at risk for injuries related to hot water hazards and falls. Findings included: - On 04/09/24 at 11:37 AM, observation revealed the facility's dining room sink had a hot water temperature of 130 degrees F. On 04/09/24 at 11:40 AM, Maintenance Staff U obtained a water temperature of 131.6 degrees F. He stated he had just turned up the hot water thermostat that morning after finding the dishwasher temperature was not high enough at 115 degrees F. He stated both the dining room sink and the kitchen were on the same water line. At that time, he turned off the hot water valve under 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.

The facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R)1, R32, and R144s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when outdated and failed to discard expired stock medications. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On 04/09/24 at 09:10 AM, observation of the facility's South Hall treatment cart revealed the following: R1's Lantus (long-acting insulin) flex pen was labeled with an open date of 03/09/24 (expired on 04/05/24, 28 days). R32 basaglar (Lantus) flex pen was opened on 03/09/24 (expired on 04/05/24, 28 days). R144's insulin glargine (Lantus) flex pen was opened on 02/02/24 (expired on 3/01/24, 28 days). On 04/09/24 at 09:15 AM, Licensed Nurse (LN) I verified the nurses were supposed to date the flex pens when opened and discard the outdated insulin. On 04/11/24 at 09:30 AM, Administrative Nurse D verified the nurses should label and date the flex pens…

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.

The facility had a census of 42 residents. The sample included 12 residents with five reviewed for immunizations. Based on observation, interview, and record review the facility failed to provide Residents (R) 11, R13, R19, R25, and R143 with the most recent Center for Disease Control and Prevention (CDC) vaccination information statement (VIS) before administering vaccinations. This placed the residents at risk for uninformed decisions related to vaccinations. Findings included: - Five residents ' records reviewed for immunizations revealed the facility ' s vaccination consent forms lacked the most recent Center for Disease Control and Prevention (CDC) vaccination information. The facility used a consent form with information from the 08/15/19 influenza, the 10/30/19 PCV13, and the 10/30/19 PPSV23 CDC guidelines. The five residents were not provided the most recent CDC VIS at the time of their vaccinations. On 04/11/24 at 11:22 AM, Administrative Nurse E verified the residents had not been provided the most recent VIS before vaccinations. The facility ' s Vaccination of Residents…

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 The facility had a census of 42 residents. The sample included 12 residents with three reviewed for pressure ulcers (PU-localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review the facility failed to provide interventions to prevent a pressure injury for Resident (R) 22 who had recurring blisters to the left heel and was at risk for skin breakdown. This placed the resident at risk for pressure injury and delayed healing. Findings included: - R22's Electronic Medical Record (EMR) documented diagnoses of protein-calorie malnutrition, adult failure to thrive, neuropathy (sharp, shocking nerve pain), chronic pancreatitis (progressive inflammatory disorder), and a Stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) of the left heel. The Quarterly Minimum Data Set (MDS), dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 42 residents. The sample included 12 residents with three reviewed for mood and behavior. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R)21. This placed her at risk for impaired quality of life due to untreated and ongoing mental health concerns. Findings included: - R21's Electronic Health Record (EHR) revealed diagnoses of post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. R21's Annual Minimum Data Set (MDS), dated [DATE], recorded the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 42 residents. The sample included 12 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)141. This placed R141 at risk for inappropriate end-of-life care. Findings included: - R141's Electronic Health Record (EHR) revealed diagnoses of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm of the lung or bronchi (the passage that connects your windpipe to your lungs), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 39 residents with five residents reviewed including three reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to ensure Resident (R)2's oxygen was set at the appropriate physician ordered setting. Findings included: - The Medical Diagnosis tab included diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic pulmonary edema (accumulation of extravascular fluid in the lung tissues), and acute and chronic respiratory failure. The admission Minimum Data Set (MDS) dated [DATE] assessed R2 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition and noted she required oxygen. The Quarterly MDS dated 06/28/23 assessed R2 with a BIMS score of 14, indicating intact cognition and noted she required oxygen. The Care Plan dated 03/15/23 revealed R2 had respiratory failure…

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 The facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to provide all residents with a safe, functional, and comfortable environment by failure to repair, clean, or maintain several environmental areas to include carpets (which ran down all resident hallways) and baseboards throughout the facility, as well as the walls in two resident rooms. This failure had the ability to affect all residents, staff, and visitors in the facility. The facility further failed to replace a cover over light bulbs, leaving them open above a residents head. Findings Included: - Observation during the initial tour on 08/11/22 at 08:51 AM revealed two resident rooms on the south hall had holes noted in the walls. The carpet from the entry tiled floor on either side, down both north and south halls, lacked transition strips and the carpet was fraying. The baseboards on both north and south halls were peeling back away from the wall, some sticking out and could catch 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.

The facility reported a census of 42 residents. The facility had one main kitchen serving one dining room. Based on observation, interview, and record review the facility failed to employ a certified dietary manager or a certified dietary food service manager. This failure affected all residents who receive meals at the facility. Findings Included: - Interview on 08/08/22 at 08:59 AM Dietary Manager N revealed she started at the facility in March 2022 and had begun classes for Certified Dietary Manager (CDM) in August 2022, but verified she was not a CDM. On 08/12/22 at 08:21 AM Administrative Nurse B confirmed they should have a CDM and thought they did but had confirmed they did not. On 08/12/22 at 11:56 AM Administrative Staff A confirmed they should employ a CDM. A review of the facility's policy, Food Service Staffing dated November 2021documented the community will employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The facility failed to employ a CDM, which affected all residents who ate in 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.

The facility reported a census of 42 residents. The facility had one main kitchen where food was stored and prepared serving one dining room. Based on observation, interview, and record review the facility failed to properly store food in the main kitchen refrigerators and freezers due to the lack of temperature monitoring; failed to store clean dishes in upright positions; and failed to store opened food products per their policy and in accordance with professional standards for food service safety. Findings included: - During the brief initial tour of the kitchen on 08/08/22 at 08:40 AM the following items were discovered: 1. The small freezer located in the kitchen had thick built-up ice on the inside, two baggies of a red substance stuck in the door of the freezer, and one large bag of fries open with no date and not resealed. 2. The refrigerator with a freezer under it in the kitchen had a bag of 17 hamburger patties open with no date and not resealed. 3. The dry storage had one five-pound bag of instant grits open, not resealed, and no date noted, and seven containers 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.

The facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to administer the facility effectively by the failure to have resident care supplies in stock for staff to care of the residents, and failed to keep the building in good, sanitary, clean repair. Findings included: - On 08/08/22 at 07:30 AM a tour of the facility revealed the main hall with large dirty stains on the carpet extending down all hallways. No hand sanitization stations noted in any hall. No wipe containers or boxes of gloves seen in resident rooms. On 08/08/22 at 09:49 AM Resident (R) 37 stated they were out of wipes and size three or size four briefs. R37 stated the staff were using size two for her and leaving them unfastened. On 08/08/22 at 02:18 PM R5 stated he had been without a strap for his tubing from his urostomy for some time now. R5 stated he had asked for one, but the staff told him they were back ordered. On 08/09/22 at 11:42 AM R22 reported they don't have any pants here or wipes so I have started buying my own so I will have some. 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.

The facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to ensure a sanitary environment by the failure to know wet times of the disinfectant used to clean the facility, lack of access to ABHR in the facility, lack of hand hygiene with cares, catheter tubing on the floor, and dirty/stained carpet observed throughout the facility. This had the potential to affect all residents residing in the facility. Findings included: - On 08/08/22 at 07:30 AM a tour of the facility revealed the main hall with large dirty stains on the carpet extending down all hallways. No hand sanitization stations noted in any hall. No wipe containers or boxes of gloves seen in resident rooms. All rooms did have sinks to wash hands. A housekeeper could be seen down a hall as she cleaned rooms. On 08/12/22 at 10:00 AM Housekeeping Staff V reported when she cleaned a contaminated room she gowned, gloved, and wore goggles and she already had a mask in place. She entered the room and wiped all the high touch surfaces using a cleaner called Peroxy Clean.…

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 The facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to provide a safe, functional, and comfortable environment by failure to repair, clean, or maintain several environmental areas accessible to all staff and visitors, to include carpets (which ran down all resident hallways) and baseboards throughout the facility. Findings Included: - Observation during the initial tour on 08/11/22 at 08:51 AM revealed the carpet from the entry tiled floor on either side, down both north and south halls, lacked transition strips and the carpet was fraying. The carpet was the walkway to all resident rooms. The baseboards on both north and south halls were peeling back away from the wall, some sticking out and could catch a visitor's pants or ankles causing injury. The carpet, which ran down both hallways had numerous stains, too many to count, and dark spots that almost covered the entirety of the carpet. Surveyors noted some stickiness while walking through 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.

The facility census totaled 42 residents, with 12 sampled, including one for indwelling urinary catheters (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review the facility failed to promote dignity when staff failed to provide a dignity bag for the indwelling urinary catheter drainage bag for Resident (R) 31. Findings included: - R31's pertinent diagnoses from the Electronic Health Record (EHR) documented no appropriate diagnosis for the use of an indwelling urinary catheter. The 12/01/21 admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 11, indicating moderately impaired cognition. R31 had an indwelling urinary catheter. The 07/03/22 Quarterly MDS documented a BIMS of 13, indicating intact cognition. R31 had an indwelling urinary catheter. The 12/01/21 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R31 had an indwelling urinary catheter in place and required staff assistance with managing his catheter. The 06/09/22 Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 42 residents with 12 in the sample. Based on interview and record review the facility failed to ensure the staff reported all allegations of neglect. On 07/04/22 Transportation Staff Q reported a fall while transporting Resident (R)34 to an appointment and required emergency room evaluation. Licensed Nurse (LN) D made a nurse's note but did not report the fall to administrative staff. Findings included: - R34's signed Physician Orders dated 08/01/22 revealed the following diagnoses: end stage renal failure (a terminal disease because of irreversible damage to vital tissues or organs), anemia in chronic kidney disease (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), and muscle weakness. The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating…

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.

The facility reported a census of 42 residents with 12 sampled including one for Activities of Daily Living (ADL). Based on observation, interview, and record review the facility failed to provide ADL assistance to include bathing services to maintain good grooming for Resident (R) 41, who required limited assistance of two staff with bathing. Findings Included: - The 08/09/22 Electronic Health Record (EHR) documented R41 had the following diagnoses: Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and dementia (progressive mental disorder characterized by failing memory, confusion). The 07/28/22 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 99, indicating he could not finish the assessment. Per staff R41 had long and short-term memory problems and had moderately impaired cognition. R41 required limited assistance of two staff with bathing. The 07/28/21 ADL Function/Rehabilitation Care Area Assessment (CAA)…

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 The facility reported a census of 42 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to provide a safe environment free of falls when Transportation Staff Q did not secure all straps on Resident (R)34's three wheeled scooter prior to driving. During transportation to an appointment, R34's three wheeled scooter tipped over, causing R34's head to hit the side of the van hurting her ear and she required hospital assessment in response. This failure placed R34 at risk of serious harm and injury. The facility also failed to ensure a safe enviroment for R18 by the failure to ensure the bed locks worked appropriately to prevent him from falling from the bed. Findings included: - R34's signed Physician Orders dated 08/01/22 revealed the following diagnoses: end stage renal failure (a terminal disease because of irreversible damage to vital tissues or organs), anemia in chronic kidney disease (condition without enough healthy red blood cells to carry…

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.

The facility reported a census of 42 residents with 12 sampled including one for an indwelling urinary catheter. Based on observation, interview, and record review the facility failed to obtain a physician's appropriate diagnosis for the use of an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) for Resident (R) 31. Findings included: - Review of (R)31's diagnoses from the Electronic Health Record (EHR) lacked documentation of an appropriate diagnosis for the use of an indwelling urinary catheter. The 12/01/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R31 had an indwelling catheter. The 12/01/21 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented the resident had an indwelling urinary catheter with contributing factors of incontinence and wounds. The Care Plan dated 06/09/22 revealed staff assisted R31 with catheter care every shift and more often as needed. The Electronic Health Record (EHR) documented as of 07/20/22 R31…

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.

The facility census totaled 42 residents, with 12 sampled, including five for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate follow up of the consultant pharmacist recommendations regarding as needed (PRN) Haldol (antipsychotic medication) for Resident (R) 32, and R2's behavior monitoring regarding antidepressant medications. These failures placed the residents at risk for adverse effects related to medication use. Findings Included: - R32's Physician's Orders in the Electronic Health Record (EHR) dated 08/09/22 documented diagnosis of schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and hallucinations (sensing things while awake that appear to be real, but the mind created). The 06/22/22 Annual Minimum Data Set…

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.

- R32's Physician's Orders in the Electronic Health Record (EHR) dated 08/09/22 documented diagnosis of schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and hallucinations (sensing things while awake that appear to be real, but the mind created). The 06/22/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment documented the use of an antipsychotic medication daily for R32. The 05/02/22 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15. The assessment documented the use of an antipsychotic medication daily for R32. The Physicians Orders documented an order dated 06/28/21 for Haldol (antipsychotic medication) five milligrams(mg)/milliliter…

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.