Providence Living Center

The facility reported a census of 67 residents; the sample included 17 residents sampled with five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to acknowledge the Consultant Pharmacist's monthly medication regimen review (MRR) and failed to ensure the MRR recommendations were filed in the clinical record for Resident (R) 1, R7, R9, R13, and R30. Findings included:1. R1's Electronic Medical Record (EMR) recorded the following Medication Regimen Review (MRR):R1's Pharmacy Consultant Note on 07/21/25 documented MRR completed, irregularities noted, see report. R1's Pharmacy Consultant Note on 10/13/25 documented MRR completed, The Consultant Pharmacist requested a vitamin level, but no results were found until the facility provided lab results dated 12/18/25. R1's Pharmacy Consultant Note on 11/13/25 documented MRR completed, irregularities noted, see report. R1's clinical record lacked the actual recommendations made and lacked evidence the facility and physician acknowledged and responded. 2. R7's EMR recorded the following…

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 67 residents. The sample included 17 residents with five residents reviewed for vaccinations. Based on record review nad interview, the facility failed to ensure the residents were offered and received the pneumococcal vaccine or informed declinations for the vaccine were obtained for Resident (R) 13, R5, R6 and R34. Findings included:R13's Electronic Medical Record (EMR) documented a signed declination for the influenza vaccine on 10/03/25. The EMR lacked evidence of administration of the pneumovax and lacked evidence of an informed declination signed by the resident or her representative. R5's EMR recorded the resident received the influenza vaccine on 10/08/25, but refused the pneumovax. The EMR lacked evidence of an informed declination signed by the resident or his representative. R6's EMR recorded the resident received the influenza vaccine on 10/08/25 but refused the pneumovax. The EMR lacked evidence of an informed declination signed by the resident or her representative. R34's EMR recorded the resident received the influenza vaccine 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 67 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to provide a safely secured handrail in the stairwell corridor leading to the basement. Findings include:- During an observation on 12/15/25 at 12:30 PM, the handrail to the stairwell on the north side of the courtyard was wobbly and not secured. Resident (R) 62 sat at the bottom of the stairway near the secured basement door. During an interview on 12/16/25 at 11:00 AM, Administrative Staff A observed the loose, wobbly handrail in the stairwell corridor leading to the basement and reported he had not been aware of the loose handrail. Administrative Staff A moved the railing, observed the base was out of the hole in the concrete, and reported it would need to be fixed. The facility policy Other Environmental Conditions dated 10/2025 documented the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Equip corridors with firmly secured handrails on each side.

The facility reported a census of 67 residents, the sample included 17 residents. Based on interview and record review, the facility failed to inform Resident (R) 1 and R13 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications. Findings included: - Review of both Electronic Health Record (EHR) and paper records revealed the following:1.R1's EHR under the Orders tab revealed orders for the following:Fluphenazine HCl (an antipsychotic [a class of medications used to treat major mental conditions that cause a break from reality] medication), five milligrams (mg) to be given orally two times daily for schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), dated 11/19/25.Mirtazapine (antidepressant medication used to treat mood disorders), 15 mg to be given orally at bedtime for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dated 11/15/25.Lorazepam (an antianxiety [a class of medications…

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

The facility identified a census of 67 residents. The sample included 17 residents with one resident reviewed for advanced directives. Based on observation, record review, and interviews, the facility failed to accurately identify Resident (R) 30's advanced directives for a Do Not Resuscitate (DNR- expressed desire to not receive cardiopulmonary resuscitative measures in the event of cardiac or respiratory arrest). Findings included:- R30's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of 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). R30's Significant Change Minimum Data Set [MDS] dated 11/10/25 documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R30 received hospice (palliative) care. R30's Care Plan dated 09/19/18 documented she wished to have a DNR. R30's EMR under the MISC tab revealed an outside-of-hospital DNR signed…

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 67 residents. The sample included 17 residents with one resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to offer and provide assistance with nail care for Resident (R) 9, who participated in her hygiene activities but needed staff assistance. Findings included:- R9's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and a need for assistance with personal care. R9's 07/22/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS documented R9 required moderate assistance with bathing, dressing, and personal hygiene. R9's 08/05/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R9 was at risk for falls. The plan of care would be reviewed and revised to ensure proper interventions were in place to prevent falls.…

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 67 residents; the sample included 17 with one resident reviewed for prevent decrease in range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) and mobility. Based on observation, interview, and record review, the facility failed to provide a palm guard to prevent contractures (abnormal fixation of a joint or muscle) to Resident (R) 44. Findings included:- R44's Electronic Medical Record (EMR) revealed diagnoses including acute cerebrovascular insufficiency (CVI- a sudden, temporary lack of blood flow to part or all of the brain, often due to blocked arteries or low blood pressure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) R44's 11/25/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 99, which indicated severely impaired cognition. R44's MDS recorded impairment to both sides of her upper and lower extremities. The MDS recorded R44 required total dependence on staff for all activities of daily living…

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 67 residents. The sample included 17 residents, with one resident reviewed for smoking. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 33 when staff failed to assess R33 for safe smoking ability and determine if safety equipment was required. Findings included:- R33's Electronic Medical Record (EMR) revealed diagnoses of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) R33's 12/20/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R33's MDS documented she had no behaviors and no depression.…

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 67 residents. The sample included 17 residents, with one resident reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to apply, clean, and store a continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) within the standards of practice for Resident (R) 3.Findings included:- R3's Electronic Medical Record (EMR) revealed diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and sleep apnea (a disorder of sleep characterized by periods without respirations). R3's 08/16/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) was not completed as the resident was rarely/never understood, indicating severely impaired cognition. R3's MDS documented R3 used oxygen therapy and a non-invasive mechanical ventilator (CPAP). R3's 08/28/25 Cognitive…

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 67 residents; the sample included 17 residents with one resident reviewed for trauma. Based on observation, interview, and record review the facility failed to implement approaches for trauma informed care to prevent triggers that were identified for Resident (R) 33, who had a history of personal trauma.Findings included:- R33's Electronic Medical Record (EMR) revealed diagnoses of posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) R33's 12/20/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R33's MDS documented no behaviors and no depression. R33's 01/03/25 Psychotropic…

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 67 residents. The sample included 17 residents with two residents reviewed for bed rail safety. Based on interview, observation, and record review, the facility failed to assess Resident (R)1 and R29 for safe use and necessity of the bed rails. The facility further failed to obtain and document that risks of bed rail use were explained and informed consent from the resident and/or representative was obtained. Findings include:- 1. Review of R1's Electronic Health Record (EHR) revealed diagnoses that included morbid obesity (excessive body fat) and schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), R1's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. R1 utilized a wheelchair for locomotion, required substantial/maximal assistance for rolling left to…

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

The facility reported a census of 67 residents. The sample included 17 residents with two residents reviewed for bed rail safety. Based on interview, observation, and record review, the facility failed to inspect the bed rails to ensure correct and secure installation on the beds for Resident (R)1 and R29. Findings include: - Upon request for a record or log of the regular maintenance inspections of the bed rails, the facility provided the Assessment history Nursing: Side Rail Evaluation-V5 with a date range of 12/01/24 through 12/22/25. The document did not list any assessments for R1 or R29 prior to the survey event. The facility was unable to provide any evidence of regular maintenance inspections of the bed rails for R1 or R29 upon request. During an observation on 12/15/25 at 01:37 PM, R1's bed had a quarter-length bed rail attached to both sides of the bed. R1 was able to move the bed rail side-to-side with minimal effort. During an observation on 12/16/25 at 08:20 AM, R29 rested in bed with an eighth-length bed rail attached to one side of the bed frame. During a walk-through…

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 72 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure staff monitored and reported lab results to the provider as they became available in order to treat Resident (R) 1's urinary tract infection (UTI). This placed the resident at risk of ongoing pain with urination, agitation, and confusion related to delayed treatment of a UTI. Findings included:- R1's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-high blood pressure) and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS noted the resident required substantial assistance with oral hygiene, personal hygiene, and dressing. The resident was dependent on staff assistance for toileting…

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 72. The sample included three residents. Based on observation, record review, and interviews, the facility failed to follow physician-ordered parameters regarding medication monitoring for Resident (R) 1. This placed the resident at risk for medication-related complications and adverse effects.Findings included:- R1's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-high blood pressure) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS noted the resident required substantial assistance with oral hygiene, personal hygiene and dressing. The resident was dependent on staff assistance for toileting and bathing.R1's Care Plan initiated on 09/13/21 and revised on 01/30/24 documented the resident had hypertension 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 76 residents. Based on observation, interview, and record review the facility failed to provide the services of a full-time certified dietary manager for the residents who resided in the facility and received their meals from the kitchen, placing the residents at risk for inadequate nutrition. Findings included: - On 02/07/24 at 09:30 AM, observation revealed Dietary Staff BB overseeing staff cleaning up the kitchen after meal service. On 02/07/24 at 09:30 AM, Dietary Staff BB verified she had not completed a certified dietary management course and was currently taking those classes. On 02/13/24 at 10:07 AM, Administrative Staff A verified the facility should employ a certified dietary manager. The facility's Food Service Staffing policy, dated 10/2023, stated a Food Services Manager would oversee the production, storage, and delivery of food. If the dietician is not full-time, the facility would employ a nutritional professional to serve as the dietary manager. The person must meet one of the following qualifications: Certified dietary manager,…

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 71 residents. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hour data for all direct care personnel as required. This placed the residents at risk for impaired care due to unidentified staffing issues. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 1 indicated data was suppressed though the facility did not meet the reasons for suppressed data other than inaccurate data or failure to report. On 02/08/24 at 01:58 PM, Administrative Staff A verified the lack of PBJ reporting due to a change of staff responsible for the reporting. Administrative Staff A stated that the facility changed its system so reporting would meet submission criteria. The facility's Payroll-Based Journal policy, dated 09/2023, documented the community will submit payroll data in a uniform format to CMS, including staffing…

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 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with effective person-centered interventions for two residents. Resident (R) 65 to include interventions related to bolus feeding by gastrostomy tube (G-tube: a tube for introducing high-calorie fluids into the stomach and R72 who had posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) with no person-centered interventions to address the PTSD. This deficient practice placed the residents at risk for impaired care due to uncommunicated care needs. Findings included: - R65 's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), dysphagia (swallowing difficulty),…

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 76 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to assess gastric (stomach) contents before administering bolus feeding by gastrostomy tube (G-tube: a tube for introducing high-calorie fluids into the stomach) for Resident (R) 65. This deficient practice placed R65 at risk for aspiration (inhaling liquid or food into the lungs) and inadequate nutrition. Findings included: - R65's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), dysphagia (swallowing difficulty), and muscle wasting from calorie loss due to dysphagia and movement disorder. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R65 had intact cognition. The MDS documented R65 was dependent on staff for all activities of daily living including nutrition. The MDS documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 72 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization related to a diagnosis of post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the resident at risk for unmet mental health care needs. Findings included: - R76's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), opioid (medication used to treat pain) dependence, PTSD, and other stimulant abuse. The admission Minimum Data Set (MDS), dated [DATE], documented R72 had intact cognition, hallucinations (sensing things while awake that appear to be real,…

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 76 residents. The sample included 18 residents with one reviewed for Hospice services (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). Based on observation, interview, and record review the facility failed to ensure Resident (R)52 received hospice services as agreed in the hospice plan of care. This placed R52 at risk for inappropriate end-of-life care. Findings included: - R52 's Electronic Medical Record documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), anxiety disorder, and high blood pressure. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS documented R52 required staff assistance with all activities of daily living and received hospice…

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 72 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 72 residents who resided in the facility and received their food from the facility kitchen, when the facility failed to ensure clean and sanitary food prep areas, and failed to sanitize a thermometer prior to checking temperatures of different food items. This placed the 72 residents at risk for foodborne illness. Findings included: - On 08/08/22 at 11:30 AM, observation in the kitchen revealed the following: The floor fan had gray fuzzy particles on the blades and the outer screen. A ceiling vent located between the oven and the prep area counter had gray fuzzy particles. A ceiling vent located by the entrance door to the kitchen had a piece of gray duct tape approximately 2-3 inches long and 2 inches wide hanging with gray fuzzy particles. On 08/08/22 at 11:30 AM, Dietary Staff (DS) BB verified the above issues in the kitchen. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 72 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's consultant pharmacist failed to notify the Director of Nursing (DON), medical director, or physician of recommendations for a 14 day stop date or physician's rationale for extended use on as needed (PRN) psychotropic medications (medications used to treat mental illness, moods, behaviors) for two sampled residents, Resident (R) 1, R42, and a 14 day stop date for a PRN antipsychotic medication (class of medications used to treat psychosis and other significant mental conditions) for R45. This placed the residents at risk for unnecessary psychotropic medications and adverse side effects. Findings included: - The Physician Order Sheet, dated 08/01/22, recorded R1 had diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, fragmentation of thought and impaired communication), borderline…

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 72 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure a 14 day stop date or physician's rationale for extended use for PRN (as needed) psychotropic medication (medications that affect a person's mental state) for two sampled residents, Residents (R) 1, and R42, and a 14 day stop date for a PRN antipsychotic medication (class of medications used to treat psychosis and other significant mental conditions) for R45. This placed the residents at risk for unnecessary psychotropic medications and adverse medication side effects. Findings included: - The Physician Order Sheet, dated 08/01/22, recorded R1 had diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, fragmentation of thought and impaired communication), borderline personality disorder (disorder characterized by disturbed and unstable interpersonal relationships along with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 72 residents. The sample included 18 residents with five reviewed for accidents/falls. Based on observation, record review, and interview, the facility failed to provide occupational therapy (OT) and physical therapy (PT) services as ordered by the physician to prevent falls for one sampled resident, Resident (R) 38. This placed the resident at risk for continued falls with injuries. Findings included: - The Physician Order Sheet, dated 08/02/22, recorded R38 had diagnoses of psychosis (any major mental disorder characterized by a gross impairment in reality testing), schizophrenia (psychotic disorder characterized by a gross distortion of reality, fragmentation of thought and impaired communication), depression (mental health disorder characterized by persistent depressed mood, causing impairment of daily life), delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue), anxiety (mental health disorder characterized by worry and fear…

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.