Nortonville Health Care Center

The census totaled 34 with 14 in the sample. Based on observation, interview, and record review the facility failed to provide evidence they designated one infection preventionist who was qualified by education, training, experience and/or certification that worked at least part time on the facility infection control program and completed specialized training in infection prevention and control. This failure created the likelihood for the transmission of infectious agents, subsequent infection, and caused actual severe infection with significant outcomes. Findings included:- The facility identified Administrative Nurse B as the current Infection Preventionist. The facility failed to provide evidence Administrative Staff B was qualified to fill the role by education, training, experience or certification. Review of the Facility Assessment Tool dated 11/18/25 revealed the facility was licensed for 45 beds, with an average census of 32 residents. The facility identified their common diagnoses related to infectious disease as skin and soft tissue infections, respiratory infections,…

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 census totaled 34 with 14 in the sample. Based on interview, and record review the facility failed to provide evidence they offered influenza (highly contagious viral infection) immunizations to residents for the 2025 influenza season, when the vaccines were made available for the year and/or beginning approximately October 1st, 2025. The facility further failed to provide signed consents/declinations and/or evidence of vaccination administration related to the influenza and/or pneumococcal (type of bacterial infection) vaccine for Residents (R) 2, R6, R7, R11, and R16. Findings included:- Review of all resident Electronic Health Records, under the immunizations tab on 01/12/26 for influenza immunizations lacked evidence residents were offered and/or received influenza immunizations at the facility during the 2025 season. Resident charts either reflected the 2024 dates or noted refusals with no dates. Upon request on 01/14/26 at 10:32 AM, the facility was unable to provide influenza, pneumococcal, and Covid-19 vaccination signed consents or declinations or documentation 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 census totaled 34 with 14 in the sample. Based on interview and record review the facility failed to ensure staff had the appropriate competencies and skill sets related to the facility Quality Assurance and Performance Improvement (QAPI) program to provide nursing and related services to ensure staff were aware of goals and aspects of the program that assured resident safety and attained or maintained the highest practicable physical, mental and psychosocial wellbeing of each resident as determined by resident assessments, plans of care and utilizing the facility assessment. Findings included:- The facility failed to provide evidence of staff competency evaluations from Administrative Staff A as requested on 01/11/26 and again on 01/12/26. During an interview on 01/26/25 with Consultant Staff X at 03:51 PM she stated she did not have any proof the facility performed competency evaluations with certified staff. See F865, F867. and F868 for outcomes related to the facility's lack of QAPI training and follow up competency evaluations to ensure staff were aware of 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 34 with 14 in the sample. Based on interview and record review the facility failed to ensure measure the adequacy of any in-service training provided to staff by the failure to evaluate competencies and skill sets of Certified Nurse Aides (CNAs) to ensure the implementation of interventions necessary to meet resident's needs and as identified in the facility assessment. Findings included:- The facility failed to provide evidence of competency evaluations for CNAs from Administrative Staff A as requested on 01/11/26 and again on 01/12/26. During an interview on 01/26/25 with Consultant Staff X at 03:51 PM she stated she did not have any proof the facility performed competency evaluations with certified staff. Review of the Sufficient Staff Policy dated 05/15/24 revealed the facility would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 14 residents with seven residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to respond to and maintain medication regimen reviews (MRR) conducted by the Consultant Pharmacist (CP) for R1, R32, R3, and R24. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). The admission Minimum Data Set (MDS) dated 03/17/25 documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. R1 had no behaviors. R1 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant…

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 34 residents. Based on observation, interview, and record review the facility failed to store schedule II-V controlled narcotic medications in manner in which only authorized staff had access and failed to ensure the quantity stored was minimal in order to identify potential drug diversion and/or missing doses, to include narcotic medications awaiting destruction. The facility had one locked cabinet inside the medication room, which was used for narcotic medications awaiting destruction. The administrator and facility staff did not know who had the key for the locked narcotic destruction cabinet and required maintenance staff to cut the lock off of the cabinet on [DATE], revealing the cabinet was full of narcotic controlled medications which had not been destroyed since at least February 2025. The facility audit revealed at least 55 narcotic medication prescriptions (of an unknown quantity for each) in which the facility could not account for. Findings included:- An onsite…

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 census totaled 34 with 14 in the sample. Based on interview, and record review the facility failed to provide evidence they offered Covid-19 (highly contagious respiratory virus) immunizations to residents who resided at the facility. The facility further failed to provide signed consents/declinations and/or evidence of vaccination administration related the Covid-19 vaccine for Residents (R) 2, R6, R7, R11, and R16. Findings included- Upon request on 01/14/26 at 10:32 AM, the facility was unable to provide Covid-19 vaccination signed consents, declinations, or documentation of vaccination administrations for influenza, pneumococcal, and/or Covid-19 vaccinations for R2, R6, R7, R11, and R16. On 01/14/26 at 12:13 PM, Consultant Nurse C stated she was unable to find requested immunization documentation. During an interview with Consultant Nurse C at 05:45 PM on 01/14/26 she reported the facility Director of Nursing or Social Services would complete the immunization consent/declinations. She stated it was the responsibility of Administrative Nursing Staff B to oversee 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 identified a census of 34 residents. The sample included 14 residents, with three residents reviewed for beneficiary notification. Based on record review and interviews, the facility failed to provide Form CMS 10055- Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to Resident (R) 29 and R42. Findings included:- Upon request of the Medicare Liability Notice, CMS 101123- Notice of Medicare Non-Coverage (NOMNC) and SNF ABN for R29, the facility provided a NOMNC, but no ABN for R29. The NOMNC documented R29's physical therapy services ended on 07/29/25 due to R29 meeting their goals. R29 signed the NOMNC on 07/25/25. The facility filled out the SNF Beneficiary Notification Review form and indicated the facility initiated the discharge from Medicare Part A services with the resident having remaining benefit days. The form documented a SNF ABN was not provided as the facility was unaware the form needed to be completed. Upon request of the NOMNC and ABN for R42, the facility provided a NOMNC, but no ABN for R42. The NOMNC documented R42's Med 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 The facility identified a census of 34 residents. The sample included 14 residents with seven residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure the physician documented a rationale with risk versus benefit and nonpharmacological attempts prior to the use of antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) medications for R1, the facility failed to ensure a 14-day stop date for an as needed (PRN) psychotropic (alters mood or thought) medication for R32, and the facility failed to attempt a gradual dose reduction (GDR) or provide a rationale against a GDR for psychotropic medications for R1, R32, and R3. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance and bipolar disorder (a major mental illness…

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 34 residents. The sample included 14 residents. Based on record review and interviews, the facility failed to complete the Care Area Assessment (CAA) analysis of findings, related to a Comprehensive Minimum Data Set (MDS), for Resident (R) 1, R16, and R32, in order to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs. Findings included:- R1's admission MDS dated 03/17/25, triggered CAAs for cognitive loss/dementia, urinary incontinence/indwelling catheter, and psychotropic drug use. The triggered CAAs lacked completion with analysis of findings. R16's admission MDS dated 07/09/25, triggered CAAs for cognitive loss/dementia and activities of daily living (ADL) functional/rehabilitation potential. The triggered CAAs lacked completion with analysis of findings. R32's admission MDS dated 08/24/25, triggered CAAs for cognitive loss/dementia and behavioral symptoms. The triggered CAAs lacked completion with analysis of findings. On 01/20/26 at 01:01 PM,…

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 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to develop and implement a comprehensive, individualized care plan to address Resident (R) 1's dementia diagnosis with behaviors, triggers, and interventions; and failed to develop and implement a comprehensive, individualized care plan to address R16's activities of daily (ADL) status and required assistance with ADLs. Findings included: - R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). The admission Minimum Data Set (MDS) dated 03/17/25 documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. R1 had no behaviors. R1…

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 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to review and revise Resident (R) 32's comprehensive care plan to include fall prevention interventions following multiple falls in the facility. Findings included:- R32 admitted to the facility on [DATE]. R32's Electronic Medical Record (EMR) documented diagnoses of diffuse traumatic brain injury (TBI-an injury to the brain caused by external forces) with loss of consciousness, adult failure to thrive, and other seizure (violent involuntary series of contractions of a group of muscles). R32's admission Minimum Data Set (MDS) dated 08/24/25, documented R32 had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severe cognitive impairment. R1 had no falls since admission. R32's Quarterly MDS dated 11/04/25, documented a BIMS was not conducted due to R32 being rarely/never understood. R32's Cognitive Loss/Dementia (a progressive mental…

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 census totaled 34 with 14 sampled and one reviewed for catheter use and urinary tract infection. Based on observation, interview, and record review the facility failed to ensure Resident (R) 11 who entered the facility with a urinary catheter received the appropriate treatment and services to prevent urinary tract infections and other catheter associated concerns of wounds to both inner thighs without the use of an anchor for the catheter. The resident admitted to the hospital on multiple occasions, received intravenous antibiotics, and returned to the facility with no monitoring or intervention to prevent further infection or wound development. Findings included:- Review of the Centers for Medicare and Medicaid Services Form 802 also known as the Matrix for Providers provided by the facility on 01/11/26 to the survey team lacked evidence any residents required the use of an indwelling catheter. Question 11 instructs the facility to note residents with an indwelling catheter. Review of R11's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 14 residents, with one resident reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, record review, and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and failed to complete assessments after dialysis for Resident (R) 27. Findings included:- R27's electronic medical record (EMR) documented diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and chronic kidney disease stage 4 (CKD - kidneys are moderately or severely damaged and are not properly filtering waste from the blood). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R27 required partial to moderate assistance for sit to stand, chair,…

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 34 residents. The sample included 14 residents. Based on observations, record review, and interviews, the facility failed to provide trauma-informed, individualized care including implementing a resident-specific care plan with identified triggers and interventions related to past trauma for Resident (R) 1. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). The admission Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. R1 had no behaviors. The Quarterly MDS dated [DATE] documented R1 had a BIMS score of nine, which indicated moderate cognitive impairment. R1 had no behaviors.…

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 34 residents. The sample included 14 residents with one reviewed for dementia care. Based on observations, record review, and interviews, the facility failed to provide dementia care and services for Resident (R) 1 when the facility failed to assess, identify, record, respond to, and reassess R1's specific behaviors and triggers to promote an environment, which supported R1's individualized care needs. Findings included:R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). The admission Minimum Data Set (MDS) dated 03/17/25 documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. R1 had no behaviors. R1 preferred reading books, newspapers, 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.

The facility reported a census of 34 residents with 14 residents included in the sample. Based on observation, interview, and record review the facility failed to ensure Resident (R) 7, who had a history of sepsis, received needed dental care and services. R7 refused her dental visit on 10/30/25. The record lacked evidence of staff attempts to get R7 to a dentist after her 10/30/25 refusal, and approximately two months R7 began complaining of tooth pain. The records revealed R7 had an infection to her left lower molar, which caused her pain, affected her eating, and required antibiotics to treat. Findings included: - The Electronic Health Record (EHR) revealed the resident diagnoses included pain and sepsis. Review of the 08/11/25 Annual Minimum Data Set (MDS) revealed R7 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS documented the resident had no rejection of care and was dependent on staff for most of her activities of daily living (ADL). The resident received scheduled pain medication, as needed (PRN) pain…

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 33 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for Resident (R) 1, who was independently mobile, at risk for falls, and had impaired cognition. On 07/28/25 at approximately 06:45 AM, Certified Nurse Aide (CNA) N let R1 out of the facility doors after R1 had requested to go outside. Staff reported they were unable to locate R1 in the facility and began searching for him at approximately 08:20 AM. Consultant HH thought R1 may have tried to return to his apartment at the Assisted Living (AL), across the street, and went to look for him. R1 was found in his electric wheelchair, sitting under a gazebo, in front of his previous apartment building. R1 drove his electric wheelchair several blocks down the road, into the surrounding neighborhood, after he was asked to return to the facility by staff. Staff followed R1 and got him to return to the facility. The facility's documentation recorded R1 was let out of the facility at…

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 30 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse coverage for eight consecutive hours a day, seven days a week, placing all residents at risk of a lack of assessment and inappropriate care. Findings included: - A review of June 2024 and March 2025 nursing schedules revealed that no registered nurse was on duty on 06/08/24, 06/09/24, and 03/15/25. On 04/14/25 at 03:00 PM, Consulting Staff GG reported she was able to verify Registered Nurse coverage due to the staffing program, which had changed to a different company. Upon request, the facility failed to provide a Registered Nurse Coverage policy.

The facility had a census of 30 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to ensure the required annual performance reviews were completed for five of the five staff members reviewed. This deficient practice placed the residents at risk of receiving impaired care. Findings included: - A review of the facility nurse and nurse aide performance evaluations revealed Licensed Nurse (LN) H, Certified Medication Aide (CMA) RR, Certified Nurse Aide (CNA) N, CNA O, and CNA P, randomly selected employees, who had been employed for over a year, lacked an annual review. On 04/16/25 at 04:40 PM, Administrative Nurse D reported she could not locate or verify that the previously listed employees had not had an annual performance review. Upon request, the facility failed to provide an Employee Annual Performance Review policy.

The facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to have a system to account for controlled medications' receipt and disposition in sufficient detail to enable an accurate reconciliation and conduct a periodic reconciliation to account for controlled medications in order to prevent loss or diversion. Findings included: - On 04/14/25 at 03:25 PM, the door to Administrative Nurse D's office, which had a keypad lock, opened easily without entering a code. No staff were present in the office at the time. On 04/15/25 at 02:55 PM, the door to Administrative Nurse D's office opened easily and no staff were present in the office. The charge nurse was in another office and contacted Administrative Nurse D who came in from outside the building. On 04/15/25 at 03:01 PM, Administrative Nurse D verified the emergency kit for narcotic medications was kept in her office. She stated when the emergency kit was received at the facility one of the three drawers was not closed and therefore unlocked.…

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 30 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to provide the services of a Consultant Pharmacist to review and identify irregularities in the 30 residents' drug regimen during December 2024. This deficient practice placed the 30 residents at risk for adverse consequences related to medication therapy to the extent possible, from a lack of oversight by a licensed pharmacist, and further placed R5 at risk for adverse consequences from medications. Findings included: - R5's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, pain in the knee, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle spasms, repeated falls, 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.

The facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary condition for 30 residents who reside in the facility and received meals from the facility's kitchen, placing them at risk for foodborne illness. Findings included: - On 04/15/25 at 11:30 AM, during the tour of the kitchen, observation revealed: Dietary Staff (DS) CC preparing for the midday meal service. DS CC reported that he cooked eggs at the request of the residents. He stated the residents would request over-easy, sunny-side-up, and scrambled eggs. DS CC stated the facility used pasteurized eggs but was not able to verify that the eggs in the refrigerator were pasteurized. The back door entrance to the kitchen's bottom seal did not reach the ground completely, and outside light was visible. The window above the microwave, where bags of bread were stored, had a layer of brown dust on the window seal. The handwashing sink with an eyewash station bottle had dirt throughout the handles,…

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 30 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to prioritize improvement, develop and implement action plans, conduct at least one Performance Improvement Project (PIP) annually, and regularly review, analyze, and act on data collected. This deficient practice placed the 30 residents of the facility at risk for a lack of quality improvement activities in their facility. Findings included: - Upon request, the facility did not provide documentation of any PIPs done in 2024 and 2025. On 04/16/25 at 05:20 PM, Administrative Staff A verified the facility had not started any Performance Improvement Project (PIP) this year and had no documentation of PIPS in the previous year. She stated the facility had seven administrators in the past two years. The facility's Quality Assurance and Performance Improvement (QAPI) policy, dated 06/24/2022, stated the facility would develop, implement, and maintain an effective, comprehensive, data-driven QAPI program. The QAPI program would include…

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 30 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to have a Quality Assessment and Assurance (QAA) committee of the required membership which met at least quarterly and received reports from the Infection Control Preventionist (ICP). This deficient practice placed the 30 residents of the facility at risk for impaired care and services that met accepted standards of quality, identification of problems, and opportunities for improvement. Findings included: - The facility had QAA committee sign-in sheets for March 13, 2025, and April 10, 2025, but no others. The sign-in sheets lacked attendance for the medical director or their representative, the administrator (or governance leadership), or the consultant pharmacist. On 04/16/25 at 05:20 PM, Administrative Staff A verified the facility lacked documentation of the QAA committee meeting for 2024. She stated she had just texted a former employee to find out where the 2024 QAA committee sign-in sheets were. She stated she could not find any 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 had a census of 30 residents. Based on record review and interview the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella). This placed the residents in the facility at risk for infectious disease. Findings included: - On 04/15/25 at 11:30 AM, Maintenance Staff U stated he attended training a couple of months ago to learn about Legionella prevention but had not developed a surveillance system yet. On 04/16/25 at 05:35 PM, Administrative Staff A verified the facility lacked a surveillance system for Legionella prevention. The facility's Legionella Surveillance policy, dated 06/26/24, stated potable (drinkable) water systems shall be routinely cleaned and disinfected.

The facility had a census of 30 residents. Based on record review and interview, the facility failed to ensure the staff member designated as the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This deficient practice placed the residents at risk for lack of identification and treatment of infections. Findings included: - Upon request, the facility did not provide documentation of a current certified Infection Preventionist employed in the facility. On 04/14/25 at 01:30 PM, Administrative Nurse D verified the facility had no current certified IP. She stated she had only been employed here for four weeks and was unsure if the facility had an infection tracking system prior to that. The facility's Infection Prevention and Control Program policy, dated 10/01/2022, stated the infection Preventionist was responsible for oversight of the infection prevention and control program. The infection Preventionist would serve as the leader in surveillance…

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 30 residents. Based on observation, record review, and interview, the facility failed to maintain an in-service training program for nurse aides that was appropriate and effective, as determined by nurse aide performance reviews and facility assessment, as specific to the needs of the resident population. This deficient practice placed the residents at risk of inappropriate care and services. Findings included: - Upon review of the facility's Certified Nurse Aide (CNA) who had been employed for more than a year, random selection revealed CNA O, CNA P, and CNA N, lacked the required 12-hour in-service training. On 04/16/25 at 04:40 PM, Administrative Nurse D reported she was not able to verify the CNA 12-hour in-service required for CNAs. Upon request, the facility failed to provide a CNA-required 12-hour in-service.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 30 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to provide Resident (R) 7 a Bed Hold notice when he was hospitalized . This deficient practice placed R7 at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R7's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), hypertension (elevated blood pressure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), epilepsy (brain disorder characterized by repeated seizures), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the 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.

The facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to remove expired medications from potential use. This deficient practice placed residents at risk of receiving expired or ineffective medication. Findings included: - On 04/14/25 at 03:25 PM, observation in the facility's medication room revealed the following expired stock medications: Three bottles of multivitamins with iron with a manufacturer's expiration date of 02/2025. One bottle of zinc tablets with a manufacturer's expiration date of 11/2024, and five bottles of zinc with a manufacturer's expiration date of 03/2025. Three bottles of Milk of Magnesia, 16 ounces, with a manufacturer's expiration date of 04/2024. A box of 14-milligram nicotine patches with a manufacturer's expiration date of 02/2025. On 04/14/25 at 03:25 PM, Licensed Nurse (LN) G verified the above medications were expired and should have been removed from possible use. Upon request, the facility failed to provide a policy for medication storage or expired…

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 30 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for the 30 residents who reside in the facility and receive their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition. Findings included: On 04/14/25 at 08:09 AM, observation revealed the kitchen staff finishing up the morning meal and preparing for the midday meal. Dietary Staff BB stated she was the manager and was not a Certified Dietary Manager. Dietary Staff BB stated she had not enrolled in a certification course at this time. Dietary Staff BB reported that the Registered Dietitian came monthly and was available by phone for consultation. Upon request, the facility failed to provide a Certified Dietary Manager Policy.

The facility had a census of 30 residents. The sample included 12 residents, with five reviewed for immunizations, including pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to assess Resident (R) 4 and R14 for eligibility to receive further pneumococcal vaccination. The facility failed to offer, or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications. Findings included: - Review of R4 and R14 clinical medical records lacked evidence the facility, resident, or the resident's representative received or signed a consent to receive or informed declinations for the pneumococcal vaccine PCV20. The immunizations noted no pneumococcal vaccination was given historically, had been offered, or declined. On 04/15/25 at…

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 30 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to notify Resident (R) 6's guardian of the discharge and transfer of R6 to another facility until after his discharge from the facility. This placed the resident at risk for further decline and impaired health and well-being. Findings included: - R6's Electronic Medical Record documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), history of traumatic brain injury, aphagia (loss of the ability to swallow), dysphagia (swallowing difficulty), and convulsions (involuntary series of contractions of a group of muscles). R6's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The MDS documented R6 required supervision for eating and was dependent on staff for all other activities of daily living. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers or discharge for Resident (R) 7. This deficient practice had the risk of miscommunication between the facility and resident or their representative and possible missed opportunities for healthcare services for R7 and placed R7 at risk for impaired rights. Findings included: - R7's Electronic Medical Record (EMR) documented diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), hypertension (elevated blood pressure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), epilepsy (brain disorder characterized by repeated seizures), congestive heart failure (CHF - a condition with low heart output…

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 30 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to identify and implement interventions to prevent falls for Resident (R) 5. This placed the resident at risk for ongoing falls and injuries. Findings included: - R5's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, pain in the knee, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle spasms, repeated falls, and intervertebral disc degeneration (the breakdown of bones in the back-spine). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had moderately impaired cognition, and required supervision or touch assistance with activities of daily living, transfers,…

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 30 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 10, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion) and aggressive behavior toward others, with supervision, treatment, and services to attain or maintain highest practicable physical, mental, and psychosocial well-being. This placed R10 at risk for unmet behavioral and psychosocial well-being needs. Finding included: - R10's Electronic Medical Record (EMR) documented diagnoses of dementia with anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Quarterly Minimum Data Set (MDS) dated [DATE] documented R10 had moderately impaired cognition, inattention, disorganized thinking, and an altered level of consciousness, which fluctuated…

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 30 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 8 remained free from a significant medication error when staff failed to administer R8 seven physician-ordered medications for three days in a row. This deficient practice placed R1 at risk for unalleviated pain, decreased ability to participate in rehabilitation, inability to sleep, and psychosocial impairment. Findings included: - R8's Electronic Medical Record (EMR) documented diagnoses of cellulitis (skin infection caused by bacteria) of left lower leg, anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), hypertension (HTN - elevated blood pressure), acute embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream), thrombosis (clot that developed within a blood vessel) of deep…

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 32 residents. The sample included two residents reviewed for pharmacy services. Based on observation, record review, and interviews, the facility failed to ensure the availability of physician-ordered medications for Resident (R) 1 and R2. This deficient practice had the risk for physical complications and less than desired/therapeutic effects of prescribed medications for R1 and R2. Findings included: - R1 admitted to the facility on [DATE] and discharged on 01/10/25. R1's Electronic Medical Record (EMR) documented diagnoses of acute kidney injury (AKI - a sudden decline in kidney function that occurs within a short period), atrial fibrillation (a fib - rapid, irregular heartbeat), and hyperlipidemia (condition of elevated blood lipid levels). The admission Minimum Data Set (MDS) dated 10/15/24 documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 received diuretic (medication to promote the formation and excretion 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 identified a census of 23 residents and 30 active resident trust fund accounts. The sample included nine residents. Based on record review and interview, the facility failed to distribute quarterly statements to all residents that held trust fund accounts in the facility. This placed the residents at risk for uninformed decisions regarding their trust fund and misappropriation. Findings included: - Review of the Trial Balance as of 08/21/24 revealed 30 total accounts with a balance of $63,621.38. The Trial Balance documented R5 had a current trust fund balance of $3705.47. On 08/26/24 at 02:04 PM, R5's representative and responsible financial party stated she has never received a quarterly statement regarding R5's trust account. She stated she has made inquiries into any remaining balances from R5's trust account since R5 discharged in March 2024 but she has not received any answers or account balances. On 08/26/24 at 02:40 PM Administrative Staff C confirmed that she has never sent out any quarterly statements for any of the trust accounts at the facility. She stated…

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 23 residents and 30 active resident trust fund accounts. The sample included nine residents. Based on record review and interview, the facility failed to ensure the conveyance of personal funds within 30 days of discharge and/or death for Resident (R) 5, R6, R7, R8 and R9. This placed the residents at risk for impaired rights and misappropriation. Findings included: - Review of the Trial Balance as of [DATE] revealed 30 total accounts with a balance of $63,621.38. The Trial Balance documented R5 had a current trust fund balance of $3705.47. R5's Electronic Medical record (EMR) recorded R5 discharged from the facility on [DATE]. The Trial Balance documented R6 had a current trust fund balance of $8342.61. R6's EMR recorded she died in the facility on [DATE]. The Trial Balance documented R7 had a current trust fund balance of $20.46. R7's EMR recorded he died in the facility on [DATE]. The Trial Balance documented R8 had a current trust fund balance of $21.02. R8's EMR recorded…

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 23 residents and 30 active resident trusts accounts, held by the facility. The sample included nine residents. Based on observation. Interviews, and record review, the facility failed to hold, safeguard, and manage Resident (R)4's trust fund as required when the facility failed to obtain appropriate authorization to disperse or use monies from R4's trust fund. This placed R4 at risk for impaired rights and potential misappropriation. Findings included: - R4's Quarterly Minimum Data Set (MDS) dated [DATE] documented R4 had severely impaired cognition. Review of R4's trust transactions as listed on the Resident Statement Landscape revealed a personal need items debit of $124.61 dated 07/15/24 and a personal need item debit of $300.00 dated 07/18/24. A Withdrawal Receipt with a receipt number W000215 for record number 00006 dated 07/12/24 listed an amount of $124.61 for personal needs items. The receipt included a handwritten note that indicated the resident was unable to sign…

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 35 residents. The sample included three residents sampled for abuse. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1, R2, and R3 were free from mental abuse and intimidation. This deficient practice had the risk for further abuse, a decline in psychosocial well-being, and unwarranted physical complications for the affected residents. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), generalized muscle weakness, and need for assistance with personal cares. The Annual Minimum Data Set (MDS) dated 06/30/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R1 required extensive assistance with staff for bed mobility, dressing, and toileting; extensive assistance with two staff for transfers and personal…

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 33 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training and possessed the required certification in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 07/27/23 at 09:00 AM, Administrative Nurse E stated she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. Administrative Nurse E stated she had completed the training modules but had not yet taken the test or received the certification. The Facility Assessment Tool policy, dated 03/23/23 documented the Infection prevention and control program would establish and infection control prevention and control program (IPCP) that would include, at a minimum, the following elements (1) a system for preventing , identifying, reporting, investigating,…

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 33 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to develop a care plan to ensure staff were aware of skin issues and treatments for Resident (R)13, and failed to develop a care plan fo the use of R15, R24, and R20's bed rails. This placed the residents at risk for complications related to uncommunicated and/or unmet care needs. Findings included: - R13's Electronic Medical Record documented diagnoses of hypertension (high blood pressure), colon cancer, cerebrovascular accident (stroke), and right below the knee amputation (BKA). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating cognitive impairment. The MDS documented R13 required staff supervision for eating and extensive staff assistance for bed mobility, transfers, dressing, toileting, and hygiene. The MDS documented R13 had range of motion impairment in one lower extremity, used 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 had a census of 33 residents. The sample included 15 residents, with six reviewed for side rails. Based on observation, record review, and interview, the facility failed to ensure a safe environment, free from accident hazards, when the facility failed to ensure the opening of the side rails used for Resident (R)11, R24, R8 and R15's were within the acceptable safety limits. This placed the affected residents at risk for injuries related to preventable accidents. Findings included: - On 07/24/23 at 02:35 PM, observation revealed R11 sat in wheelchair in the room. Continued observation revealed an upside down U shaped side rail on the right side of the bed. The upside down U shaped side rail on the upper right side of the bed had an opening which measured approximately 13 inches by 19 inches. On 07/24/23 at 02:33 PM, observation revealed R24 sat in a wheelchair in the room. Continued observation revealed an upside down U shaped side rail on the right side of the bed. The upside down U shaped side rail on the upper right side of the bed had an opening which measured…

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 33 residents. The sample included 15 residents, with six reviewed for side rails. Based on observation, record review, and interview, the facility failed to ensure the actual side rail placed into use was assessed for safety for Resident (R)11, R24, R8 and R15's side rails. This placed the affected residents at risk for entrapment or injury. Findings included: - R11's diagnoses included cerebral vascular accident (CVA-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia ( paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin.) R11's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R11 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 15 residents. Based on observation, record review, and interview, facility staff failed to discard outdated vials of influenza (flu) vaccine in the medication room and failed to ensure Resident (R)31's expired insulin (hormone that lowers the level of glucose in the blood) was disposed of. This placed residents at risk for receiving an expired/ineffective dose of the vaccine and R31 at risk to receive expired/ineffective insulin. Findings included: - On [DATE] at 08:44 AM, observation in the facility's medication room revealed 31 vials of influenza (flu) vaccine with expiration date [DATE]. On [DATE] at 09:47 AM, observation of the nurse's medication cart revealed R31's vial of Lispro (fast acting) insulin dated as opened [DATE] and expired [DATE]. On [DATE] at 10:03 AM, Administrative Nurse D verified the above findings. The facility's policy for Medication Storage, dated [DATE], stated all medication rooms were routinely inspected by the consultant…

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 33 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to ensure a functional and sanitary environment for residents and staff in the facilty kitchen. Findings included: - On 07/24/23 at 09:30 AM, observation in the kitchen revealed the following: A hole in the wall above the three-compartment sink, where the exhaust fan had been removed, approximately 15-18 inch (in) in diameter to outside wall with louvres (a set of angled slats or flat strips fixed or hung at regular intervals in a door, shutter, or screen to allow air or light to pass through) closed, but small gaps of up to one-half by 12 inches. The ceiling by the vent hood had a stained ceiling tile, approximately two by four-foot. One of six ceiling fluorescent light fixtures had a broken cover and one was missing its cover. On 07/25/23 at 1:04 PM, Maintenance Staff (MS) U and Administrative Staff A verified the above findings and agreed the opening where the exhaust fan had been removed should have been sealed against pests. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 33 residents. The sample included 15 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to provide dignity and quality of life for Resident (R)137, by having an uncovered urinary collection bag visible to guests and other residents, placing the resident at risk for embarrassment and an undignified living environment. Findings included: - R137's Electronic Medical Record (EMR) recorded diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid,) hypertension (elevated blood pressure,) chronic kidney disease and palliative care (therapy designed to relieve or reduce intensity of uncomfortable symptoms.) R137's admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact), and an indwelling urinary catheter (a tube in the bladder to drain urine). R137's Care Plan dated 07/22/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census 33 residents. The sample included 15 residents with one reviewed for speech therapy rehabilitation, Resident (R)31. Based on record review, observation, and interviews, the facility failed to provide R31 the frequency of the physician ordered speech therapy sessions. This placed the resident at risk for decline. Findings included: - R31's diagnoses include hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (CVA- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) of right dominant side, need for assistance with personal care, muscle weakness, and reduced mobility. R31's admission Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, required extensive assistance of two staff for bed mobility and toileting, was totally dependent on staff for personal hygiene and dressing.…

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.