Presbyterian Village Of Homer

Based on record reviews and interview, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day, 7 days a week, for 4 days within FY (Fiscal Year) Quarter 1 2025 (October 1- December 31). Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY Quarter 1 2025 (October 1- December 31) revealed there were no RN hours for four or more days within the quarter. Further review revealed no RN hours for the dates of 10/27/2024, 11/30/2024, 12/01/2024, and 12/28/2024. During an interview on 05/28/2025 at 1:00 p.m. S1 Administrator reported he was responsible for completing the PBJ staffing report. S1 Administrator reviewed the PBJ for FY Quarter 1 2025 (October 1-December 31) and reported during that time period the facility only had one full time RN and 4 part time RNs. S1 Administrator confirmed there was not RN coverage for at least 8 consecutive hours a day for 10/27/2024, 11/30/2024, 12/01/2024, and 12/28/2024 and there should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #47 Review of Resident #47's record revealed an admission date of 12/16/2024 with diagnoses including hemiplegia and hemiparesis, muscle wasting, lack of coordination, dysphagia, cognitive communication deficit, aphasia, hyperlipidemia, reflux, depression, polyosteoarthritis, heart disease, and pseudobulbar affect. Review of Resident #47's Quarterly MDS assessment dated [DATE] revealed a Brief Interview of Mental Status score of 3 which indicated severe cognitive impairment for daily decision making. Further review of the MDS revealed Resident #47 was provided substantial/maximal assistance with bed mobility and dependent on staff for toileting. Resident #47 had limitation in range of motion on one side of upper and lower extremities. Review of Resident #47's May 2025 Physician's Orders revealed no documented evidence of an order for the use of bedrails/positioning bars/turn bars. Review of Resident #47's care plan dated 05/08/2025 revealed Resident 47's bed was equipped with turning bars for…

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.

Resident #39 Observations on 05/27/2025 at 9:45 a.m., 05/28/2025 at 10:10 a.m. and at 1:45 p.m. of Resident #39's room revealed the air conditioner unit contained a black substance on the vents and needed to be cleaned. On 05/28/2025 at 3:45 p.m., an observation of Resident #39's room with S2 DON present revealed Resident #39's air conditioner had a black substance on the vents. S2 DON confirmed the air conditioner vents needed to be cleaned. Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#3 and #39) of 2 residents rooms observed. The failed practice was evidenced by 1) Resident #3 and #39's air conditioner vents needed cleaning, and 2) Resident #3's bed control needed cleaning, and 3) Resident #3's room had a bedrail stored under his bed. Findings: Resident # 3 Observations on 05/27/2025 at 10:05 a.m. and 05/28/2025 at 12:10 p.m. of Resident #3's room revealed the air conditioner vent was dirty with a buildup of dust, the bed control was noted on the Resident's night stand and was dirty and had 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.

Based on record review and interview the facility failed to ensure each resident/RP (Responsible Party) was notified in advance of care planning conferences to enable resident/RP participation for 1 (#27) of 28 sampled residents. Findings: Review of facility's undated Care Plan Policy revealed, in part: Application of Policy . 4. Care plan conferences (meetings) are scheduled for each resident at admission and continuing at least quarterly by the MDS Coordinator. The resident and his/her legal guardian/family member is given at least a seven (7) day notice of invitation to attend and participate in the resident's care planning conferences. The conference may be scheduled at an alternate date and time if more convenient for the resident and/or family member. 5. The MDS Coordinator or designee will invite family members and maintain records of the invitation and whether the resident and/or family member participated in the care plan conference. 6. Participation by the resident and/or family member is not limited to attending the scheduled conference but may be done by conversations in…

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 the physician documented a rationale for denying a gradual dose reduction for 1 (#36) of 5 (#17, #24, #35, #36 and #47) Residents reviewed for unnecessary medications. Findings: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Resident #36 had diagnoses including restlessness and agitation, pseudobulbar affect, depression, muscle wasting, Alzheimer's disease, dementia, and bipolar disorder. Review of Resident #36's May 2025 physician orders revealed an order dated 02/26/2025 for Abilify 5 mg (milligrams) every morning and evening. Review of the consultant Pharmacist report revealed a dose reduction letter dated 03/18/2025 recommended a gradual dose reduction for Abilify 5 mg bid (two times a day) for Resident #36. Further review of the report revealed the physician chose not to attempt a gradual dose reduction, and failed to give a written clinical rationale. On 05/28/2025 at 3:50 p.m. interview with S2…

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 interview, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in the kitchen as evidenced by the deep fryer's internal compartment having a heavy grease buildup. Findings: Initial observation of the kitchen on 05/27/2025 at 8:50 a.m. revealed the deep fryer internal compartment had a heavy grease buildup and needed to be cleaned. On 05/27/2025 at 2:27 p.m. S5 DM (Dietary Manager) confirmed the deep fryer's internal compartment had a grease buildup and needed to be cleaned.

Based on record review and interview, the facility failed to develop and/or implement written policies and procedures to protect residents from abuse, neglect, exploitation and misappropriation of their property. The facility failed to obtain documentation of Agency/Contract Staff's criminal background checks, Adverse Actions checks, and/or CNA (Certified Nursing Assistant) Registry checks prior to allowing 17 of 17 unlicensed Agency/Contract Staff reviewed (S6 CNA, S7 CNA, S8 CNA, S9 CNA, S10 CNA, S11 CNA, S12 CNA, S13 CNA, S14 CNA, S15 CNA, S16 CNA, S17 CNA, S18 CNA, S19 CNA, S20 CNA, S21 CNA, and S22 CNA) to work with residents in the facility. This practice had the potential to affect all residents in the facility. Findings: Review of the facility's undated Freedom from Abuse, Neglect, & Exploitation policy revealed in part: The facility must not employ or otherwise engage individuals who: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. b. Have had a finding entered into the State nurse aide registry…

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 conduct a comprehensive assessment which included the resident's safe smoking assessment for 1 (#27) of 1 (#27) resident reviewed for smoking. Findings: Review of the Facility Smoking Policy (no date noted) revealed in part: Smoking Procedure: 4. Residents who smoke will be assessed upon admission, quarterly, and whenever there is a significant change in their ability to safely handle their smoking products. Review of resident #27's medical record revealed she had the following diagnoses in part: cerebral infarction with hemiplegia, unspecified affecting right dominant side, hereditary and idiopathic neuropathy, and memory deficit following cerebral infarction. Review of resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 00 which indicated resident was unable to be tested. Further review revealed resident #27 required extensive to total assistance for 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.

Based on record review, observation, and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) used Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions during transfers for 2 (#44, #46) of 2 (#44, #46) residents reviewed for Enhanced Barrier Precautions. Findings: On 06/04/2024 at 4:16 p.m. review of the undated Enhanced Barrier Precautions (EBP) Policy and Procedures (no date noted) in part revealed: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced barrier precautions include gown and glove use during high-contact resident care activities for resident known to be colonized or infected with MDROs as well as those at increased risk of MDRO acquisitions (e.g. residents with wounds or indwelling medical devices). Enhanced Barrier Precautions are an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of Staph Aureus and MDROs. Overview: 1. MDRO…

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, observations, and interviews, the facility failed to protect the residents' right to be free from verbal abuse by staff. The facility failed to ensure residents were free from verbal abuse by staff for 4 (#1 #2, #3, #4) of 4 (#1 #2, #3, #4) sampled residents. Findings: Review of facility policy and procedure Reporting of Abuse or Suspected Abuse (no policy date) revealed in part: Residents have the right to be free from verbal, sexual, physical and mental abuse .Definition of Abuse .Verbal Abuse is the use of oral, written and gestured language that willfully includes disparaging and derogatory terms to residents . Review of the facility's Self-Reported Incident Report initiated 09/08/2023 revealed in part: Victim: Residents #1, #2, #3, and #4 Accused: S2 CNA (Certified Nursing Assistant) Allegation: Verbal Abuse-substantiated S5 Social Service Director spoke with Resident #1 on 09/08/2023 and Resident #1 stated she could not remember what S2 CNA said, but S2 CNA was really, really ugly and Resident #1 reported S2 CNA told her, I hate you. Resident #1 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.

Based on record review and interview the facility failed to ensure an alleged violation of verbal abuse was reported immediately, but not later than 2 hours to the State Survey Agency for 4 (#1, #2, #3, #4) of 4 (#1, #2, #3, #4) residents reviewed for an abuse allegation. Findings: Resident #1 Review of Resident #1's clinical record revealed an admit date of 11/17/2022 and diagnoses including, but not limited to: Lymphedema, Atrial Fibrillation, and Status Post Bowel Resection. Review of Resident #1's quarterly MDS (Minimum Data Set) assessment with an Assessment Reference Date of 08/31/2023 revealed the resident had a BIMS (Brief Interview of Mental Status) score of 15 out of 15, indicating the Resident #1 was cognitively intact. Resident #2 Review of Resident #2's clinical record revealed an admit date of 08/15/2022 and diagnoses including, but not limited to: Congestive heart failure, Delusional Behaviors, Anxiety Disorder, and Bipolar Disorder. Review of Resident #2's quarterly MDS assessment with an Assessment Reference Date of 07/13/2023 revealed the resident had a BIMS score…

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 ensure a resident received adequate supervision and assistance with devices to prevent accidents by failing to use proper assistance with transfers for 1 Resident (#10) of 2 Residents (#10 and #32) reviewed for accident hazards. Findings: Review of Resident #10's clinical record revealed a diagnosis of morbid obesity and rheumatoid arthritis. Review of Resident #10's clinical record revealed on 07/05/2023 resident's height was 61 inches and weight was 252 pounds. Review of Resident #10's Comprehensive Care Plan revealed resident requires total assistance with two persons for transfers. Review of Resident #10's MDS (Minimum Data Set) dated 04/11/2023 revealed resident had upper and lower extremity impairement on both sides and requied total dependence and two person physical assistance with transfers. Review of Resident #10's clincial record revealed a nurse's note dated 04/11/2023 indicating resident required two person lift assistance with transfers to and from bed to wheelchair. An observation on 07/10/2023 at 9:20 a.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.