Center Point Health Care and Rehab

Based on observations, interviews, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to ensure the resident received tube feedings based on the comprehensive assessment for 1 (#1) of 3 residents reviewed with feeding tubes.Findings: Review of the facility's policy titled, Nutritional Management, and revised 05/2023, revealed the following, in part:Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.Compliance Guidelines:1. A systematic approach is used to optimize each resident's nutritional status:c. Developing and consistently implementing pertinent approaches.4. Care Plan implementation:d. Tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. Review of Resident #1's Clinical Record revealed an admission date of 01/20/2025 and diagnoses, which included Cerebral Infarction, Hemiplegia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition them to post discharge care and the reduction of factors leading to preventable readmissions for 1 (#1) of 2 (#1 and #3) residents reviewed for discharge. The facility failed to ensure: 1. The discharge needs of the resident were identified and resulted in the development of a discharge plan;2. Involve the interdisciplinary team in the ongoing process of developing the discharge plan;3. Document the resident had been asked about their interest in receiving information regarding returning to the community; and 4. Create a discharge summary that included a post-discharge plan indicating where the resident planned to reside, any arrangements that had been made for the resident's follow-up care and any post-discharge medical and non-medical services.Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide the resident or RP (Responsible Party) with written notice, which specifies the duration of the bed-hold policy at the time of transfer to the hospital for 2 (#2 and #3) of 3 (#1, #2, and #3) sampled residents.Review of the facility's Bed Hold and Returns policy, revised on 04/2025, revealed, in part:Policy:It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave.Policy Explanation and Compliance Guidelines:1. The facility will issue (2) written notice of bed hold policy to the resident/or resident representative as follows:1. As part of the admission packet and2. At the time of a transfer to the hospital or a therapeutic leave.The facility will provide the resident and/or the resident representative written information that specifies:a. the duration of the State…

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

Based on observations and interviews, the facility failed to ensure dietary support personnel had the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service. The facility failed to ensure S18DW was competent to effectively and sanitarily perform the functions of the facility's dishwasher. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen. Findings: An observation was made of S18DW performing the dish washing process in the facility's kitchen on 05/05/2025 at 10:10 a.m. S18DW was observed to place 18 meal trays upright with two stacked together with no spacing between them in one washing tray. He was observed to stack 17 insulated food tray bases, one on top of the other, with no spacing between them and sent them through the dishwasher. A drink lid was observed between two insulated food tray bases after the washing process was complete and the food tray bases were holding water. An interview was conducted with S18DW at that time. He 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 Based on observations, interviews, and record reviews, the facility failed to ensure sufficient dietary support personnel were employed to safely and effectively carry out the functions of the food and nutrition service when meals were served late on 05/05/2025 and 05/06/2025. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen. Findings: Review of the facility's policy dated 05/2023 and titled, Dietary Services - Staffing revealed the following, in part: Policy: The facility employs sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Policy Explanation and Compliance Guidelines for Staffing: 6. The facility will provide sufficient support personnel to safely and effectively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to ensure a resident with a newly identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation as required for 2 (#19 and # 92) of 6 (#9, #19, #36, #53, #92 and #138) residents reviewed for PASRR. Findings: Resident #19 Review of Resident #19's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part, Schizoaffective Disorder with an onset date of 10/01/2020. Review of Resident #19's most recent Level I PASRR Screening and Determination form revealed a previous assessment was performed on 07/05/2020. Review was attempted of Resident #19's Level 1 PASRR Screen and Determination submission following the addition of a new relevant mental illness diagnosis on 10/01/2020, with no documentation available for review. An interview was conducted on 05/07/2025 at 2:15 p.m. with S9SW. S9SW confirmed Resident #19's Pre-admission Level I PASRR Screen 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#11 and #111) of 4 (#9, #11, #30, and #111) residents reviewed for ADL's. The facility failed to: 1. trim fingernails for Resident #111; and 2. provide incontinent care in a timely manner for Resident #11. Findings: Review of the facility's policy, Nail Care , with a revision date of 09/2017, revealed the following, in part: Policy: Nail care should be included in a Patient's daily hygiene; the best time is during the Patient's bath. Procedure: -Cut nails immediately after bathing when they are the softest and easiest to cut. -Cut nails straight across with a nail clipper. 1. Resident #111 Review of the clinical record for Resident #111 revealed he was admitted to the facility on [DATE] with diagnoses which included Gastrostomy Status and Traumatic Brain Injury. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents received therapeutic diets as ordered by the physician for 3 of 3 (#7, #39, and #40) residents reviewed with double/large portions with meals. Findings: Review of the facility's policy titled, Therapeutic Diet Orders with a revision date of 11/2024 revealed the following, in part: Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by the physician, and/or assessed by the interdisciplinary team to support the patient's/resident's treatment/plan of care, in accordance with his/her goals and preferences. Policy explanation and compliance guidelines: 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Resident #7 Review of Resident #7's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #7's current…

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

Based on observations, interviews, and record reviews, the facility failed to ensure meals were provided at regular meal times comparable to normal mealtimes in the community and consistent with facility scheduled meal times for 2 (Hall A and Hall B) of 3 (Hall A, Hall B, and Hall C) halls observed for dining. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen. Findings: Review of the facility's policy dated 05/2023 and titled, Frequency of Meals revealed the following, in part: Policy: The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals. Policy Explanation and Compliance Guidelines: 1. The facility has scheduled three regular meal times, comparable to normal meal times in the community. Review of the posted meal times outside of the facility's dining room revealed the following: Breakfast - 7:30 a.m. Lunch - 11:30 a.m. Dinner - 4:30 p.m. An observation was made of the first Hall A breakfast meal tray cart being prepared in the facility'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.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. The kitchen floor remained clean; 2. Food was properly sealed in the refrigerator of the facility's kitchen; 3. Food cans and containers remained uncompromised in the dry storage areas of the facility's kitchen; 4. The dishes were cleaned and sanitized in a way that minimized the spread of foodborne illness; and 5. The food service area remained in a sanitary condition during the meal serving process. This deficient practice had the potential to affect the 140 residents who were served food from the kitchen. Findings: On 05/05/2025 at 8:54 a.m., an initial tour was made of the kitchen with S10DM. Observations were made of the following: 1. Food particles and residue were on the floor throughout the kitchen. 2. The refrigerator contained 1 uncovered bowl of pineapple and 1 uncovered container of pudding. 3. The dry storage pantries contained 7 dented cans of mandarin oranges, 2 dented cans 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, the facility failed to ensure patient care equipment was maintained in safe operating condition for 2 (#92 and #97) of 2 (#92 and #97) sampled residents reviewed for call light safety. Findings: Resident #92 Review of the Clinical Record revealed Resident #92 was admitted to the facility on [DATE] with the following diagnoses, in part: Need for Assistance for Personal Care, Cognitive Communication Deficit, and Other Symptoms involving Cognitive Function and Awareness. Review of Resident #92's Quarterly MDS, with an ARD of 12/31/2024, revealed a BIMS of 13 indicating she was cognitively intact. On 05/05/2025 at 11:00 a.m., an observation was made in Resident #92's room of the call light pulled off the wall with the wires exposed. On 05/05/2025 at 2:00 p.m., an interview was conducted with Resident #92, she stated the call light cover had been pulled off the wall for weeks. She stated she told staff about it several times. On 05/06/2025 at 8:45 a.m., an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident with a mental disorder had an accurate Pre-admission Screening for 1 (#138) of 6 (#9, #19, #36, #53, #92, and #138) residents reviewed for PASSAR. Findings: Review of the facility's policy titled Resident Assessment-Coordination with PASSAR Program dated 05/2023, revealed in part, the following: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the state's Medicaid rules for screening. 6. The social services director shall be responsible for keeping track of each resident's PASSAR screening status, and referring to the appropriate authority. Review of Resident #138's Medical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Post-Traumatic Stress Disorder and Schizophrenia. Review of Resident #138's Level 1 Pre-admission Screening completed by a social worker at a local hospital dated 03/12/2025…

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

Based on observations, interviews, and record review, the facility failed to implement a resident's comprehensive person-centered care plan by failing to implement Physician's Orders for 1 (#30) of 30 residents reviewed for comprehensive care plans in the final sample. Findings: Review of Facility's Policy titled Oxygen Administration, revised 06/2023 revealed the following, in part: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice and the comprehensive person-centered care plan. 1. Oxygen is administered under orders of a physician. Review of Resident #30's Clinical Record revealed an admission date of 08/19/2022 and diagnoses, which included Anxiety, Parkinson's Disease, Depression, and Dementia. Review of Resident #30's Current Physician Orders dated 05/05/2025 revealed the following, in part: Start date: 06/01/2024 - O2(Oxygen) @2L per NC (Nasal Cannula) to maintain Sp02 (Oxygen Saturation) >92% every 24 hours as needed. Review of Resident #30's Quarterly MDS revealed, in part, a BIMS summary score of 7, which indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure medications were administered safely and timely by leaving the medications at the bedside for 1(#19) of 31 residents observed in the final sample. Findings: Review of the facility's Policy titled Medication Storage and dated 12/2024 revealed the following, in part: Policy Explanation and General Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments ( i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During medication pass, medications must be under the direct supervision of the person administering medications or locked in the medication storage area/cart. Review of Resident #19's Clinical Record revealed he was admitted to the facility on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (#111) of 5 (#104, #111, #208, #337, #342) residents reviewed for enteral feedings. The facility failed to ensure: 1. The enteral feeding flush bag was appropriately labeled with a date and time; and 2. The enteral feeding pole was kept clean and free of dried formula. Findings: Review of the Manufacturer's Insert for Kangaroo ePump ENPlus Spike with revealed the following: Note: It is recommended that this device be replaced every 24 hours. Review of the facility's policy titled, Tube Feeding, and dated 05/2023 revealed the following: K. Pre-filled closed system containers will be used to provide enteral nutrition utilizing an enteral feeding pump. A new administration set will be used with each new container, and containers will be changed when empty, or every 48 hours according to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1 of 1 (#138) resident reviewed for IV (Intravenous) fluid therapy. The facility failed to monitor and flush according to professional standards. Findings: Review of Resident #138's Medical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #138 acquired a new diagnosis of Pneumonia on 05/02/2025 requiring central line device placement. Review of Resident #138's physician orders, dated May 2025, revealed an order on 05/02/2025 for Cefepime Intravenous Solution 2 grams per 100 milliliters. Use 2 grams intravenously three times a day for pneumonia for 7 Days. Further review revealed no physician orders for an assessment daily, dressing changes, or flushing schedule for Resident #138's maintenance of PICC line. Review of Resident #138's Medication Administration Record (MAR), dated May 2025, revealed no documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident's laboratory tests were completed as ordered by the physician for 1(#9) of 31 residents investigated in the final sample. Findings: Review of Resident #9's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder and Paranoid Schizophrenia. Review of Resident #9's Physician's Orders revealed, in part: Order date 04/24/2025- laboratory blood draw for Depakote level every three months in January, April, July ,October once every 3 months. Review of Resident #9's clinical record revealed the last collected Depakote level was performed on 02/04/2025. An interview was conducted on 05/07/2025 at 1:52 p.m. with S7NP. She confirmed the last collected lab on record for Depakote level for Resident #9 was collected on 02/04/2025. S7NP confirmed Physician Orders should have been followed and a Depakote level should have been drawn for Resident #9 in April 2025, and was not. An…

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

Based on observation and interviews, the facility failed to dispose of garbage properly by failing to ensure: 1. Trash was contained in the facility's kitchen and outdoor dumpster; and 2. Garbage receptacles and dumpsters were covered. Findings: Review of the facility's policy titled Disposal of Garbage and Refuse and dated 05/2023, revealed in part, the following: 1. Garbage shall be disposed of in refuse containers with plastic liners and lids. 7. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. On 05/05/2025 at 8:54 a.m., an observation was made of the kitchen garbage receptacle, which was uncovered with garbage present. Further observation revealed an empty box of fruit punch on the floor with left over residue to the left side of the garbage receptacle. On 05/05/2025 at 10:26 a.m., an observation was made of the outside garbage area with S10DM. The dumpster was open and full with 1 bag of trash partially falling out of the receptacle. There were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#84) of 7 (#9, #11, #49, #56, #84,#109, and #293) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing gastrostomy feeding to a resident who was on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy titled Enhanced Barrier Precautions revised on 04/2025, revealed the following, in part: For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: g. feeding tubes Review of Resident #84's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses that included, in part: Encounter for Attention to Gastrostomy. An observation was made on 05/05/2025 at 11:00 a.m., 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.

Based on interviews and record reviews, the facility failed to: 1. Develop a facility assessment which addressed staff training for skills and non-pharmacological interventions and the process to evaluate competency of skill sets necessary to provide the level and type of care necessary to meet the mental and psychosocial health needs of their resident population diagnosed with Schizophrenia Disorder, Post Traumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD); and 2. Provide staff training for non-pharmacological interventions and ensure competency in the skill sets necessary to meet the mental and psychosocial health needs of their resident population diagnosed with Schizophrenia, PTSD and SUD for 4 of 4 (S4LPN, S5LPN, S6RN, and S7MSW) Personnel Files reviewed. This deficient practice had the potential to affect a current census of 147 residents. Findings: Review of the Facility Assessment, dated 03/15/2024, revealed, in part, the following: Part 1: Our Resident Profile 1.3 Diseases/Conditions, Physical and Cognitive Disabilities Accepted by Facility Psychiatric/Mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the accuracy of Minimum Data Set (MDS) Assessments for 1 (#2) of 7 (#1-#7) residents reviewed in the sample. The facility failed to ensure: 1. Resident #2 was coded for diagnoses of Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD); and 2. Resident #2 was coded for his most recent Gradual Dose Reduction (GDR) date and the provider's response. This deficient practice had the potential to affect a current census of 147 residents. Findings: Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #2's Psychiatry Progress Note, dated 01/31/2025, revealed, in part, the following: Active Diagnoses: Schizoaffective Disorder and PTSD. Review of Resident #2's GDR, performed on 01/09/2025, revealed, in part, the following: Medications Reviewed: Seroquel 400mg 1 by mouth every night. Vistaril 25mg by mouth three times daily. Physician Response to Review: Currently on minimal effective…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop a trauma-informed, comprehensive person-centered care plan, which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 (#2) of 7 (#1-#7) residents reviewed in the sample. The facility failed to develop a care plan for Resident #1's diagnoses of Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD). This deficient practice had the potential to affect a current census of 147 residents. Findings: Review of the facility's Care Plan Revisions Upon Status Change policy, effective 05/2023, revealed, in part, the following: Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: f. Care Plans will be modified as need by the MDS Coordinator or other designated staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for therapeutic diets. The facility failed to ensure Resident #2's diet order was updated in the electronic medical record. The deficient practice had the potential to affect the 134 residents residing in the facility receiving physician ordered nutrition. Findings: Review of the facility's policy titled, Therapeutic Diet Orders with a revision date of 11/2024, revealed the following, in part: Policy Explanation and Compliance Guidelines: 4. The therapeutic diet order shall be documented in the medical record . Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Unspecified Cerebral Infarction and Pneumonitis Due To Inhalation of Food and Vomit. Review of Resident #2's current electronic Physician Orders revealed the following, in part: Diet:…

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

Based on observations, interviews and record review, the facility failed to post nurse staffing data on a daily basis which included the total resident census number, and total number and actual hours worked for licensed and unlicensed nursing staff. This deficient practice had the potential to affect any of the 142 residents currently residing in the facility. Findings: Review of the facility's policy dated June 2024 and titled Nurse Staffing Posting Information revealed in part, the following: Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASARR) Level II by failing to: 1. Refer all Level II residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II resident review after expiration of 6 month temporary effective period for 1 (#5) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASARR; and 2. Incorporate a PASARR Level II determination and recommendations into a resident's care plan for 1 (#37) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASRR. Findings: 1. Review of Resident #5's Clinical Record revealed she was admitted to facility on [DATE] with diagnoses, which included in part Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Other Bipolar Disorders, and Depression. Review of Resident #5's quarterly MDS with ARD of [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status by failing to implement interventions after weight loss for 1 (#45) of 5 (#17, #19, #45, #52, and #132) residents reviewed for nutrition. Findings: Review of Resident #45's clinical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses, which included Osteomyelitis, Stage 3 Pressure Ulcer Of Sacral Region, Stage 4 Pressure Ulcer Of Right Ankle, Stage 3 Pressure Ulcer Of Other Site, Stage 4 Pressure Ulcer Of Other Site, Stage 3 Pressure Ulcer Of Right Ankle, Stage 2 Pressure Ulcer Of Sacral Region, Type 2 Diabetes Mellitus Without Complications, and Dysphagia. Review of Resident #45's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/2024, revealed the provider assessed the resident as having a BIMS of 12, which indicated the resident was moderately cognitively impaired. Review of Resident #45's current care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure: 1. Physician ordered narcotic pain medication was available for administration for 1 (#132) of 5 (#5, #12, #45, #78, and #132) residents reviewed for pain management; and 2. As needed narcotic pain medication was documented as administered on the MAR for 1 (#132) of 5 (#5, #12, #45, #78, and #132) residents reviewed for pain management. Findings: 1. Review of the facility's Medication Reordering policy with an approval date of May 2023 revealed the following, in part: Policy: it is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. Policy Explanation and Compliance Guidelines: 1. The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. 3. Each time a nurse is…

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

Based on observations, interviews, and record review, the facility failed to ensure meals were served at regular times comparable to normal times in the community for 1 (Hall B) of 3 (Hall A, Hall B, and Hall C) halls observed for dining. Findings: Review of the facility's policy last approved May 2023 and titled, Frequency of Meals revealed the following, in part: Policy: The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals. Policy explanation and compliance guidelines: 1. The facility has scheduled three regular meal times, comparable to normal meal times in the community, per day . Review of the facility's listed meal times revealed 200 Hall should be served lunch at 12:30 p.m. An interview was conducted with Resident #132 on 06/24/2024 at 10:11 a.m. He resided toward the end of Hall B. He stated meals are often served late. He stated sometimes he received lunch at 2:00 p.m. An observation was made of Resident #132 on 06/24/2024 at 12:35 p.m. He did not have his lunch tray yet. An observation was made of…

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

Based on observations, record review, and interviews, the facility failed to store, prepare, and distribute foods under sanitary conditions. This had the potential to effect 141 residents who were served from the kitchen. Findings: Review of the policy titled Staff Attire with a revision date of 09/2017 revealed the following, in part: Procedures: 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Review of the policy titled Food Storage: Cold Foods with a revision date of 04/2018 revealed the following, in part: Policy Statement All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the policy titled Food Storage: Dry Goods with a revision date of 09/2017 revealed the following, in part: Policy Statement All dry goods will be appropriately stored…

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

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pests and insects. This deficient practice had the potential to affect 142 residents who currently reside in the facility. Findings: On 06/24/2024 at 8:31 a.m., an observation was made of a live roach the size of an almond outside of the bathroom in Room K. On 06/24/2024 at 8:31 a.m., an observation was made of a live roach the size of an almond outside Resident #78's bathroom. An interview was conducted with Resident #78 at that time. He stated he sees roaches often. On 06/24/2024 at 8:42 a.m., an observation was made of a small live roach noted on the wall just outside of Room F. On 06/24/2024 at 8:43 a.m., an observation was made of Resident #3's bathroom. There was one large brown, live roach approximately 3 inches in length. An interview was conducted with Resident #3 at that time. Resident #3 stated he saw live roaches often in his room and bathroom. He stated he sprayed and the pest control company sprayed, but he had not done…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to accommodate a resident's needs for tube feeding management for 1 (#19) of 3 (#1, #19, and #72) residents reviewed for tube feeding. Findings: Review of Resident #19's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction, Muscle Wasting and Atrophy, Dysphagia, and Gastrostomy Status. Review of Resident #19's Annual MDS with an ARD of 04/12/2024 revealed, in part, a BIMS of 11, which indicated moderate cognitive impairment. Review of Resident #19's current Care Plan revealed the following, in part: Problem: I am at risk for adequate nutrition; I have a PEG tube; I have a diagnosis of Dysphagia; and I am NPO. Interventions: Provide feedings per MD order. Problem: I am NPO; I require tube feeding; I am at risk for aspiration related to my diagnosis of Dysphagia.; and I am disconnected from my tube feeding as ordered due to I like to propel myself around facility at times.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Discharge MDS assessment was completed and transmitted timely for 1 (#105) of 2 (#100 and #105) residents reviewed for Resident Assessment. Findings: Review of the facility's policy dated May 2023 and titled MDS 3.0 Completion revealed, in part the following: Policy: Policy Explanation and Compliance Guidelines: 2. Types of OBRA Assessments. f. Discharge Assessment - completed using the discharge date as the ARD. Must be completed within 14 days of the discharge date /ARD. 7. Transmission Requirements: a. All assessments must shall be transmitted to the designated CMS system (QIES ASAP) within 14 days of completion. Review of Resident #105's clinical record revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 02/23/2024. Further review revealed the resident did not have an electronically transmitted discharge MDS assessment. An interview was conducted on 06/27/2024 at 12:20 p.m. with S21MDS. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure: 1. A record of the Level 1 Pre-admission Screening and Resident Review (PASRR) form was maintained in the resident's record for 1 (#37) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASRR; and 2. A resident with a mental disorder had an accurate Pre-admission Screening for 1 (#46) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASRR. Findings: 1. Review of Resident #37's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Other Sequelae of Cerebral Infarction, Unspecified Mood Affective Disorder, and Recurrent Severe Major Depressive Disorder with Psychotic Symptoms. Review of Resident #37's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/2024, revealed the provider assessed the resident as having a Brief Interview of Mental Status (BIMS) of 11, indicating the resident was moderately cognitively impaired. Review of Section I - Active Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure documentation of weekly nurses' notes were filed as documented on the TAR for 1 (#46) of 32 residents investigated in the final sample. Findings: Review of Resident #30's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus, Essential Primary Hypertension, Rheumatoid Arthritis, Supraventricular Tachycardia, Vascular Dementia, Metabolic Encephalopathy, Cognitive Communication Deficit, and Bilateral Hearing Loss. Review of Resident #30's Physician's Orders revealed the following: 04/27/2023 Weekly Nurses note should be performed every Friday on 2:00-10:00 p.m. shift Review of Resident #30's TAR for May and June 2024 revealed the following: Task: Weekly Nursing Note Further review revealed the task had a checkmark, which indicated the task was completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 (#19) of 3 (#1, #19, and #72) residents reviewed for tube feeding. Findings: Review of Resident #19's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction, Muscle Wasting and Atrophy, Dysphagia, and Gastrostomy Status. Review of Resident #19's Annual MDS with an ARD of 04/12/2024 revealed, in part, a BIMS of 11, which indicated moderate cognitive impairment. Further review revealed Resident #19 did not exhibit rejection of care. Review of Resident #19's current Care Plan revealed the following, in part: Problem: I am at risk for adequate nutrition; I have a PEG tube; I have a diagnosis of Dysphagia; and I am NPO. Interventions: Provide feedings per MD order. Problem: I am NPO; I require tube feeding; I am at risk for aspiration related to my diagnosis of Dysphagia; and I am disconnected from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic medications by failing to ensure there was an acceptable diagnosis for antidepressant and anti-anxiety medications for 1 (#72) of 5 (#10, #46, #72, #117 and #132) residents reviewed for unnecessary medications. Findings: Review of the facility's policy titled Use of Psychotropic Drugs with a revision date of 10/2020 revealed the following, in part: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record . 1. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Review of Resident #72's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction and Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure medications were in locked compartments permitting only authorized personnel to have access for 1 (#28) of 34 residents observed during initial screening of residents upon facility entrance. Findings: Review of the facility's policy titled Medication Administration Storage dated 04/2022 revealed the following: Policy Explanation and Compliance Guidelines: 1.General Guidelines: a.All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) . b.During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage areas/cart. Review of Resident #28's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received a therapeutic diet as ordered by the physician for 1 (#132) of 3 (#102, #131, #132) residents reviewed for food. Findings: Review of the facility's policy last approved May 2023 and titled, Therapeutic Diet Orders revealed the following, in part: Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Review of Resident #132's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Muscle Wasting and Atrophy, Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#30) of 36 residents reviewed in the initial screening for advanced directives. Findings: Review of the facility's policy with a last approved date of 05/2023 titled Residents' Rights Regarding Treatment and Advance Directives revealed the following: Policy: It is the policy of this facility to support and facilitate a resident's right to . formulate an advance directive. Policy Explanation and Compliance Guidelines: 3. Should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Review of Resident #30's clinical record revealed she was admitted to the facility on [DATE]. Review of the quarterly MDS with an ARD of [DATE] revealed Resident #30 had a BIMS of 1, which indicated she had severe cognitive impairment. Review of Resident #30's Advanced Directive in her physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to coordinate hospice care services to ensure a system was in place to update hospice binder with current orders, certification period and care plans for 1 (#30) of 4 (#28, #72, #30 and #78) residents reviewed for hospice care. Findings: Review of the Hospices Services Agreement with an effective date of 10/01/2020 between the facility and local hospice company revealed the following: Article III Facility Services Section 3.5 Facility shall: d) The Facility's designated interdisciplinary team member is responsible for the following: 4) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient; (C) Physician certification and recertification of the terminal illness specific to each patient; (F) Hospice medication information specific to each patient; and (G) Hospice physician and attending physician (if any) orders specific to each patient. Review of the facility's policy last approved 05/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure S13TN and S16CNA wore proper Personal Protective Equipment while providing care for 1 (#72) of 3 (#1, #19, and #72) sampled residents reviewed for peg tube care. Findings: Review of the facility's policy titled Enhanced Barrier Precautions with a revision date of 03/2024 revealed the following, in part: Policy: It is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. 3. Implementation of Enhanced Barrier Precautions: b.…

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.