Adira Medical Resort

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to immediately notify the resident's representative after an incident with an injury for 1 (#2) of 3 (#1, #2, #3) sampled residents reviewed. Findings: Review of the facility's Condition Change of the Resident policy (no revision date) revealed: Procedure: After all resident falls, possible injuries or changes in physical or mental function: 6. Notify Resident's Responsible Party. Review of Resident #2's medical record revealed an admit date of 02/26/2025 with diagnoses which included, in part: Type 2 diabetes mellitus, unspecified dementia, muscle weakness, difficulty walking, cognitive communication deficit and chronic kidney disease. Review of Resident #2's admission MDS (Minimum Data Sets) assessment dated [DATE] revealed Resident #2 had a BIMS (Brief Interview for Mental Status) score of 11 indicating moderately impaired cognition. Review of the facility's incident log revealed Resident #2 had an incident which involved an injury on 03/16/2025. Review…

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 baseline care plan was developed for 1 (#2) of 3 (#1, #2, #3) sampled residents. The facility failed to ensure a baseline care plan was developed for Resident #2. Findings: Review of Resident #2's medical record revealed an admit date of 02/26/2025 with diagnoses which included, in part: Type 2 diabetes mellitus, unspecified dementia, muscle weakness, difficulty walking, cognitive communication deficit and chronic kidney disease. Review of Resident #2's admission MDS (Minimum Data Sets) assessment dated [DATE] revealed Resident #2 had a BIMS (Brief Interview for Mental Status) score of 11 indicating moderately impaired cognition. Review of Resident #2's medical record failed to reveal a baseline care plan had been completed. During an interview on 04/01/2025 at 1:30 p.m. S3 LPN (Licensed Practical Nurse) confirmed Resident #2 did not have a baseline care plan and should have. During an interview on 04/01/2025 at 2:15 p.m. S1 Administrator…

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

Based on record review and interview, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day 7 days per week. This deficient practice had the potential to affect all 24 residents residing in the facility. Findings: Review of the Nursing/Ancillary Personnel Staffing Pattern Reporting Form for the week days of 03/09/2025 to 03/22/2025 completed by S4 Human Resource Director revealed there were no staffing hours for an RN on 03/21/2025. Review of the facility's Employee Hours Per Day record, provided by S4 Human Resource Director, dated 03/21/2025 revealed no RN hours were clocked on 03/21/2025. During an interview on 04/01/2025 at 2:15 p.m. S1 Administrator reviewed the Personnel Staffing Pattern report from 03/02/2025 to 03/22/2025 and confirmed the facility did not have RN coverage on 03/21/2025.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure an effective system was in place for advanced directives. The facility failed to ensure: 1. Resident's medical records accurately reflected the residents' wishes for emergency basic life support for 8 (#1, #15, #9, #76, #77, #126, #127, #175 ) residents; 2. Failed to document residents and/or resident's representative were given information on Advanced Directives on admission for 12 (#9, #76, #77, #126, #127, #175, #4, #11, #12, #20, #75, #125) residents, of 19 (#9, #77, #11, #75, #12, #76, #125, #126, #1, #127, #4, #20, #15, #175, #2, #8, #22, #24, and #18) residents reviewed for Advanced Directives. Total facility census was 23. Findings: Review of the Facility's Advance Directive Policy dated 07/2024 revealed in part: It is the policy of the Facility to respect the resident's right of self-directed care including the right to issue Advance Directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails and received a written order from the physician for bed rails prior to installation for 7 (#4, #20, #125, #22, #75, #9, #126) of 7 (#4, #20, #125, #22, #75, #9, #126) residents reviewed for accident hazards. Findings: Review of the Facility's Restraint Evaluation & Restraint Reduction Policy dated 07/2024 revealed in part: -Definition: Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Responsibility: All members of the interdisciplinary team (as appropriate to individual resident needs) and monitored by the Director of Nursing. -Procedure: 1. The following devices are considered physical restraints and require evaluation (Category I is considered most…

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 ensure each resident's drug regimen was free of unnecessary medications for 4 (#9, #11, #76, #175) of 5 (#9, #11, #76, #127 and #175) residents reviewed for unnecessary medications. The facility failed to ensure adequate monitoring of: Resident #9 for edema related to the use of diuretic Bumex. Resident #11 for edema related to the use of the diuretic Furosemide (Lasix). Resident #11 for bleeding related to the use of an anticoagulant Apixaban (Eliquis). Resident #76 for edema related to the use of the diuretic Furosemide. Resident #175 for bleeding related to the use of the anticoagulant Dabigatran Etexillate Mesylate. Findings: #9 Review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included, in part, Parkinson's disease, systolic (congestive) heart failure, essential (primary) hypertension, and chronic kidney disease. Review of Resident #9's 5-day MDS (minimum data set) with ARD…

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 ensure each resident's drug regimen was free of unnecessary medications for 2 (#9, #175) out of 5 (#9, #11, #76, #127, #175) residents reviewed for unnecessary medications. The facility failed to ensure monitoring of side effects and behaviors had been conducted for Resident #9 and Resident #175 who were each receiving a psychotropic. Findings: #9 Review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] and had diagnoses that included, in part, Parkinson's disease, systolic (congestive) heart failure, essential (primary) hypertension, chronic kidney disease, and generalized anxiety disorder. Review of Resident #9's 5-day MDS (minimum data set) with ARD (assessment reference date) of 10/08/2024 revealed Resident #9 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated Resident #9 was cognitively intact. Review of Resident #9's physician orders revealed the following orders: 10/04/2024…

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

Based on record reviews and interviews the facility failed to comply with Federal, State, and Local Laws, and Professional Standards by: 1. Failing to ensure CNA (Certified Nursing Assistant) staff had undergone and passed criminal background checks prior to working in the facility for 2 CNAs (S12, S14) of 5 CNA personnel records reviewed. 2. Failing to ensure the nurse aide registry/adverse action list was searched monthly for 3 CNAs (S12, S13, S14) of 5 CNA personnel records reviewed. Findings: Review of S12 CNA's personnel record revealed S12 CNA was hired on 05/17/2024 with a criminal background check performed on 09/06/2024. Further review of S12 CNA's personnel record failed to reveal monthly nurse aid registry/adverse action list searches. Review of S13 CNA's personnel record revealed S13 CNA was hired on 01/05/2018. Further review of S13 CNA's personnel record failed to reveal monthly nurse aid registry/adverse action list searches. Review of S14 CNA's personnel record revealed S14 CNA was hired on 07/23/2023 with a criminal background check performed on 09/06/2024. Further…

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 ensure a baseline care plan was completed within 48 hours of admission for 2 (#75, #76) of 20 sampled residents. Findings: #75 Review of Resident #75's medical records revealed an admit date of 10/09/2024 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus due to underlying condition with diabetic polyneuropathy, and hyperlipidemia. Review of Resident #75's admission MDS (Minimum Data Set) with an assessment reference date 10/09/2024 in progress (not completed). Review of resident #75's medical record failed to reveal a Baseline Care Plan was completed. During an interview on 10/17/2024 at 1:50 p.m. S4 DOCO (Director of Clinical Operations) reported it is the nurse's responsibility to complete the Baseline Care Plan for the resident on admit. S4 DOCO reported if the Baseline Care Plan is not in the paper chart, it has not been completed and it should have been. #76…

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 oxygen therapy was provided according to the facility's Policy and Procedure for Oxygen therapy for 3 (#12, #15, and #175) of 3 residents reviewed for respiratory care. The facility failed to ensure: Resident #12 had a physician order for oxygen therapy when Resident #12 had been receiving oxygen for several days. Resident #15's CPAP (continuous positive airway pressure) mask and tubing was stored properly when not in use. Resident #175 had a physician order for CPAP and was care planned for the use of CPAP. Resident #175's CPAP mask and tubing was stored properly when not in use. Findings: Review of the facility's Oxygen Therapy Policy and Procedure presented by S4 Director of Clinical Operation (DOCO) (07/2024) revealed, in part: Subject: Oxygen Therapy Policy: Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Responsibility: All licensed Nursing…

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

Based on record reviews and an interview, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 (#18) of 1 resident reviewed for dialysis by failing to obtain weekly weights according to the plan of care and communicate and collaborate with the dialysis facility by completing the hemodialysis communication record form. Findings: Review of Dialysis Communication Record (dated 07/2024) policy revealed, in part: Policy: A Dialysis Communication Record Form is completed each time a resident receives outpatient dialysis. This ensures communication between the two facilities. Procedure: 1. The top section of the Dialysis Communication Record Form is completed by the nurse responsible for sending the resident to the dialysis unit/facility. 2. The middle section of the form is completed by personnel responsible for the resident at the dialysis facility and returned to the nursing home with the resident. 3. The bottom of the form is completed by personnel responsible for the resident upon return 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.

Based on record reviews and interview, the facility failed to ensure the use of services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week during FY (Fiscal Year) Quarter 3 2024 (April 1- June 30). Findings: Review of the PBJ (Payroll Based Journal) Staffing Report for FY Quarter 3 2024 (April 1- June 30) revealed the facility triggered for: Failed to have Licensed Nursing Coverage 24 Hours/Day on 05/04/24, 05/05/2024, 05/18/2024, 05/26/2024, 06/02/2024, 06/16/2024, 06/22/2024, 06/23/2024, 06/29/2024, and 06/30/2024. During review of the Facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 10/17/2024 provided for the triggered dates on the PBJ Staffing Report FY Quarter 3 2024 (April 1- June 30) failed to reveal RN services were used on 05/05/2024 and 05/18/2024. During an interview on 10/17/2024 at 2:00 p.m. S1 Administrator reviewed the Facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 10/17/2024 for the triggered dates on the FY Quarter 3 2024 (April 1- June 30) PBJ Staffing Report and acknowledged…

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

Based on record reviews and interview the facility failed to ensure annual performance evaluations were conducted on 2 CNAs [Certified Nursing Assistants (S13 CNA, S14 CNA)] out of 5 CNA personnel records reviewed. Findings: Review of S13 CNA's personnel record revealed S13 CNA was hired on 01/05/2018. Further review of S13 CNA's personnel record failed to reveal documentation of an annual performance evaluation since 01/12/2023. Review of S14 CNA's personnel record revealed S14 CNA was hired on 07/23/2023. Further review of S14 CNA's personnel record failed to reveal documentation of an annual performance evaluation since hire. During an interview on 10/17/2024 at 12:36 p.m. S15 Human Resources reviewed S13 CNA and S14 CNA's records and confirmed there was no documentation of annual performance evaluations.

Based on record review and interviews the facility failed to accurately submit mandatory direct care staffing information to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 3 2024 (April 1- June 30). Findings: Review of the PBJ (Payroll Based Journal) Staffing Report for FY Quarter 3 2024 (April 1- June30) revealed the facility triggered for Failed to have Licensed Nursing Coverage 24 Hours/Day on 05/04/24, 05/05/2024, 05/18/2024, 05/26/2024, 06/02/2024, 06/16/2024, 06/22/2024, 06/23/2024, 06/29/2024, and 06/30/2024. Review of the Facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 10/17/2024 for the triggered dates on the FY Quarter 3 2024 (April 1- June 30) PBJ Staffing Report revealed licensed nursing coverage. During an interview on 10/17/2024 at 2:00 p.m. S1 Administrator reported the facility's corporate office submits the PBJ to CMS from the facility's time clock management system. S1 Administrator indicated agency staffing hours were likely left off of the submission to CMS.

Based on record review and interview, the facility failed to conduct Quality Assessment and Assurance (QAA) meeting at least quarterly with required staff present since last annual survey dated 10/04/2023. Findings: Review of QAA binder with S1 Administrator failed to reveal a QAA meeting for the 1st quarter and the Director of Nursing (DON) was not present for the QAA meeting in the 2nd quarter. During an interview on 10/17/2024 at 4:45 p.m. S1 Administrator confirmed the facility did not meet during the 1st quarter and confirmed the DON was not present for the 2nd quarter meeting.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure immunizations were administered to residents who consented to receive the influenza, pneumococcal and/or COVID-19 immunizations during the admission process for 2 (#11, #77) of 2 (#11, #77) residents reviewed for immunizations. Findings: Review of the facility's Influenza, Pneumococcal and COVID-19 Vaccination policy dated 07/2024 revealed in part, the following: Responsibility: The Director of Nursing in conjunction with the Infection Preventionist or RN (Registered Nurse) designee. Procedure: 1. On admission, residents will be offered the influenza, pneumococcal, and COVID-19 vaccines. 3. For those residents accepting, record all influenza, pneumococcal, and COVID-19 vaccines administered on the resident immunization record. 5. Obtain a physician's order for all residents to receive the Influenza, Pneumococcal, and COVID-19 vaccines. Review of Resident #11's Immunization Informed Consent signed on admission on [DATE] revealed Resident #11…

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

Based on record reviews and interview the facility failed to ensure CNAs (Certified Nursing Assistants) received the required training for 1 CNA (S12) out of 5 CNA personnel records reviewed. Findings: Review of S12 CNA's personnel record revealed S12 CNA was hired on 05/17/2024. Further review of S12 CNA's personnel record failed to reveal S12 received required dementia training. During an interview on 10/17/2024 at 12:36 p.m. S15 Human Resources reviewed S12 CNA's personnel record and confirmed there was no documentation of dementia training.

Based on record review, observations and interviews, the facility failed to ensure 2 (#2, #3) out of 3 (#1, #2, #3) sampled resident's received treatment and care in accordance with professional standards of practice and the comprehensive care plan. The facility failed to: 1. Identify Resident #2 and Resident #3 as high risk falls, and 2. Ensure Resident #3 was wearing proper foot wear to prevent falls. Findings: Review of Facility's Falling Star Program (revision date 07/27/2018) revealed: Policy: To decrease the number of resident falls in the facility, the Falling Star program is designed to facilitate recognition of residents who are at high risk for falls. Procedure: .Residents identified for the program will have a star placed outside their room by their nameplate and on the outside of their chart near the name label. A star will be attached to the resident's w/c (wheelchair), gerichair, and all mobility aids (walkers, canes, etc.). A star will be placed above the resident's bed. Resident #2 Review of Resident #2's Medical Records revealed an admit date of 02/08/2024 with 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, the facility failed to notify resident representative of changes in condition for 1 (#2) out of 3 (#1, #2, #3) sampled residents reviewed. The facility failed to notify Resident #2's resident representative of a fall requiring treatment at a hospital. Findings: Review of Resident #2's Medical Record revealed an admit date of 02/08/2024 with the following diagnoses, in part: acute cerebrovascular insufficiency, muscle weakness (generalized), other lack of coordination, cognitive communication deficit and other abnormal glucose. Review of Resident #2's Baseline Care Plan revealed: Falls - resident has had an actual fall - 03/02/2024 resident states he got up on his own and fell - laceration to back of head - sent to emergency room (ER), area closed with Dermabond. Review of Facility's Incident Log revealed an incident for Resident #2 dated 03/02/2024 - resident room - fall - laceration - 911 EMS (emergency medical services) dispatched .has quarter sized laceration to back of head . During an interview on 03/12/2024 at 9:45 a.m. Resident #2's wife reported she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a care plan for 1 (#1) out of 3 (#1, #2, #3) sampled residents reviewed. Findings: Review of Resident #1's Medical Record revealed an admit date [DATE] with the following diagnoses, in part: end stage renal disease, major depressive disorder, chronic systolic (congestive) and diastolic (congestive) heart failure, muscle weakness (generalized), other lack of coordination, difficulty in walking/not elsewhere classified, polyneuropathy/unspecified, long term use of anticoagulants, diabetes mellitus and dependence on renal dialysis. Review of Resident #1's Care Plan with revision date of 02/29/2024 failed to reveal problems and approaches for: risk for falls, congestive heart failure, anticoagulant therapy, major depressive disorder, impaired mobility, self-care deficit, and diabetes mellitus. Review of Resident #1's Physician's Orders revealed the following orders dated 02/28/2024: Eliquis oral tablet 2.5mg (milligrams) give 1 tablet by mouth two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure appropriate care and services had been provided for 1 (#177) of 1 (#177) resident reviewed for Dialysis. The facility failed to ensure Resident #177's dialysis shunt was accurately assessed and monitored. Findings: Review of the EHR (Electronic Health Record) revealed the following, in part, Resident #177 was admitted to the facility on [DATE] with a primary diagnosis of sepsis. Review of Resident #177's Progress Note dated 10/02/2023 revealed Resident #177 had a dialysis shunt site to the left upper arm. Review of Resident #177's September and October 2023 eMAR (Electronic Medication and Administration Record) failed to reveal documentation the dialysis shunt site had been assessed and monitored. Review of the Dialysis Communication Records for Resident #177 failed to reveal an assessment of Resident #177's dialysis shunt site upon returning to the facility on [DATE] and 10/02/2023. During an interview on 10/02/2023 at 4:00 p.m.…

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

Based on record reviews and interview the facility failed to ensure State Registry verifications were completed prior to hire for 1 [S6 CNA (Certified Nursing Assistant)] of 5 CNA personnel files reviewed. Findings: Review of S6 CNA's personnel file revealed a hire date of 01/16/2023 and first day of work 01/16/2023. Further review of S6 CNA's personnel file revealed the Criminal Background and Sex Offender Registry checks were completed on 01/23/2023. During an interview on 10/04/2023 at 3:00 p.m. S3 Human Resources confirmed the State Registry verifications had not been completed prior to hire for S6 CNA and should have been.

Based on record reviews and interview, the facility failed to complete an annual performance review of every nurse aide at least once every 12 months for 4 [S4 CNA (Certified Nursing Assistant) S5 CNA, S7 CNA, and S8 CNA)] of 5 CNA personnel files reviewed. Findings: Review of the personnel records revealed the following: 1. S4 CNA-date of hire was on 03/19/2015. Further review failed to reveal the annual performance review had been completed in March 2023. 3. S5 CNA-date of hire 05/10/2022. Further review failed to reveal the annual performance review had been completed in May 2023. 2. S7 CNA-date of hire 05/26/2021. Further review failed to reveal the annual performance review had been completed in May 2023. 4. S8 CNA-date of hire 05/07/2020. Further review failed to reveal the annual performance review had been completed in May 2023. During an interview on 10/04/2023 at 3:00 p.m. S3 Human Resources confirmed the annual performance evaluations had not been completed every 12 months for S4 CNA, S5 CNA, S7 CNA, and S8 CNA and should have been.

Based on record review and interview, the facility failed to obtain orders on admission for Oxygen, Foley catheter and Trilogy Machine use, care and treatment for 1 (#24) of 2 (#24, #25) closed records reviewed. Findings: Review of resident #24's closed record revealed an admit date of 08/04/2023 with discharge/transfer on 08/12/2023 and diagnoses that include in part acute and chronic respiratory failure with hypercapnia, chronic atrial fibrillation, urinary tract infection, dependence on supplemental oxygen, essential hypertension, and asthma. Review of resident #24's progress notes from 08/04/2023 to 08/12/2023 revealed in part resident #24 was admitted to the facility with Oxygen in use at 2 liters per minute via nasal cannula, Foley catherer in place and a Trilogy machine for use at bedtime. Review of resident #24's physician orders failed to reveal orders for Oxygen, Foley catheter and Trilogy machine use, care and treatment. Review of resident #24's current care plan failed to reveal interventions related to Oxygen, Foley catheter and Trilogy machine use, care and treatment.…

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.