Jena Nursing and Rehabilitation Center, LLC

Based on observation, interview and record review, the facility failed to provide care and services that met professional standards of quality by failing to ensure medications were accurately documented on the TAR (Treatment Administration Record) for 1 (Resident #4) of 7 sampled residents. The facility had a total census of 73 residents according to the Resident List Report provided by the facility.Findings:Review of the facility's policy and procedure titled Medication Administration with a review date of 03/01/2026 read in part.Guideline: 14. Document as each medication is prepared on the MAR (Medication Administration Record). 18. If medication is not given as ordered, document the reason on the MAR.Review of Resident #4's medical record revealed an admission date of 04/08/2024 with a re-entry date of 09/24/2024 with diagnoses that included in part, Depression, Pressure Ulcer of Sacral Region, Stage 4, Paraplegia, Presence of Urogenital Implants, and Neuromuscular Dysfunction of Bladder.Review of Resident #4's Quarterly MDS with an ARD of 02/17/2026 revealed a BIMs summary 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 interviews and record reviews, the facility failed to notify the Nurse Practitioner (NP) of a resident's change in condition of an elevated heart rate for 1 (Resident #5) of 7 sampled residents. The facility census was 73.Findings: Review of the facility's policy on 03/18/2026 at 1:44 p.m. titled Notification of a Change in a Resident's Status with a history date of 11/2017, revealed in part.Policy: The attending physician extender (NP) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. Procedure: 1. Guideline for notification of physician/responsible party: a. significant change in/or unstable vital signs (Pulse). Review of Resident #5's medical record revealed an admission date of 12/15/2025 with diagnoses that included in part, Acute Respiratory Failure, Depression, Urinary Tract Infection, Pressure Ulcer of Left Buttock, Stage 3, and Infection of the Skin and Subcutaneous Tissue. Review of Resident #5's Quarterly MDS with an ARD of 03/15/2026 revealed a BIMs summary…

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 interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) registry verification was obtained prior to re-hire for 1 (S9 CNA) of 2 (S9 CNA and S10 CNA) personnel records reviewed.Findings: Review of S9 CNA's personnel record revealed, in part, S9 CNA had an initial hire date of 10/22/2012, a termination date of 04/19/2018, and a re-hire date of 10/10/2018. Further review revealed a CNA registry verification with a date of 10/22/2012. There was no documented evidence, and the facility did not present any documented evidence, a CNA registry verification was obtained prior to re-hire for S9 CNA. In an interview on 03/18/2026 at 11:50 a.m., S1Admin confirmed the facility did not have documented evidence a CNA registry verification was obtained prior to re-hire for S9 CNA as required.

Observation on 03/18/2026 at 8:45 a.m. revealed a form for Daily Nursing Staff Posting dated 03/18/2026 was posted on a bulletin board in the middle of the facility. The resident census at start of shift, daily staffing hours required, or the actual hours worked were not posted on the form.Observation on 03/18/2026 at 8:45 a.m. also revealed a form for Daily Nursing Staff Posting dated 03/17/2026 that did not have resident census at start of shift, daily staffing hours required, or the actual hours worked documented on the forms or updated from the previous day.In an interview on 03/18/2026 at 9:20 a.m. with S4 SDC RN to review 03/17/2026 and 03/18/2026 Daily Nursing Staff Posting forms, S4 SDC RN confirmed the facility did not post the resident census, daily nursing hours required, or the actual nursing hours provided.S4 SDC RN confirmed that she had always posted the forms without the required information but should not have.

Review of the facility's policy titled Enhanced Barrier Precautions with a review date of 03/01/2026 revealed in part, Enhanced Barrier Precautions (EBP) is an approach of gown and glove use during high contact resident care activities.Examples of high contact resident care activities.wound care.Review of Resident #2's record revealed in part an admit date of 09/03/2025, a primary diagnosis of Acute Respiratory Failure with Hypoxia, an order dated 09/19/2025 for Enhanced Barrier Precautions, and a Care Plan item dated 09/15/2025 for enhanced barrier precautions.Observation on 03/16/20026 at 2:25 p.m. of Resident #2's wound care by S6 TXRN revealed that S6 TXRN failed to follow EBP protocol. S6 TXRN did not wear a gown and change her gloves between cleaning and applying ointments and powder to the wounds for Resident #2.Review of Resident #3's record revealed in part an admit date of 07/02/2024, a primary diagnosis of Restless Legs Syndrome, an order dated 11/19/2024 for Enhanced Barrier Precautions, and a Care Plan item dated 03/05/2025 for enhanced barrier precautions.Observation…

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 review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (Resident #2 and Resident #3) of 3 sampled residents.Findings: Resident #2 Review of the facility's Incident Report revealed Resident #2 had Unwitnessed Fall Incidents on 11/14/2025 and 11/25/2025. Review of Resident #2's EMR revealed an admission date of 08/04/2025 with diagnoses including Seizures, Personal History of Traumatic Brain Injury, Dementia with Behavioral Disturbance, and Delirium. Review of Resident #2's Medicare 5 day MDS with ARD of 11/29/2025 revealed Resident #2 did not have a fall any time in the last month. Review of Resident #2's Discharge - Return Anticipated MDS with ARD of 11/18/2025 revealed the resident did not have any falls since the prior assessment. Resident #2 was not receiving antipsychotic medication. Review of Resident #2's Quarterly MDS with ARD of 11/11/2025 revealed Resident #2 was not receiving antipsychotic medication. Review of Resident #2's Physician's Orders revealed the following, in part. Rexulti 2mg po Q…

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 review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #1) of 3 sampled residents. Findings: Review of Resident #1's EMR revealed an admission date of 03/19/2024 with diagnoses including Anoxic Brain Damage, Cardiac Arrest due to Other Underlying Condition, and Personal History of Other Venous Thrombosis and Embolism. Review of Resident #1's Quarterly MDS with an ARD of 09/16/2025 revealed a BIMS score of 15, indicating intact cognition. Review of Resident #1's Physician's Orders revealed the following, in part.Apixiban 5mg po BID for History of Deep Vein Thrombosis, dated 10/17/2025. Review of Resident #1's Care Plan revealed Resident #1 was not care planned for anticoagulant therapy. Interview with S7LPN on 12/10/2025 at 10:10 a.m. revealed a resident receiving anticoagulant therapy should have been care planned for anticoagulant therapy. Interview with S11MDS on 12/10/2025 at 1:26 p.m. confirmed Resident #1 should have been care planned for anticoagulant therapy, but was not.

Based on observations, record review, and interviews the facility failed to develop and implement a person-centered care plan for each resident to maintain the resident's highest practicable physical, mental, and psychosical well-being. The facility failed to: 1. Ensure staff placed, connected, and ensured proper functioning of Resident #122's bed alarm, as ordered; 2. Develop a comprehensive person-centered care plan for Resident #19; and Resident #30 There were 29 sampled residents. Findings: Resident #122 Review of Resident #122's medical record revealed an admit date of 05/22/2025 with diagnoses including Quadriplegia, Seizures, Generalized Anxiety Disorder, and Attention to Gastrostomy (PEG tube.) Observation and interview with Resident #122 on 06/02/2025 at 09:40 a.m. found resident's bed against the wall with the fall mat on the open side. Bed observed in low position. Detached bed alarm control box was noted hanging on bed frame. There were no wires observed connected to the bed alarm box. Geri chair noted at bedside reclined with bed alarm mat in seat of chair. Resident…

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 Resident #172 Review of the Facility's policy dated 11/2017 titled Weekly Skin Audit read in part .Policy: A skin audit will be documented on resident weekly. Any identified skin conditions will be documented and treatment initiated. Procedure: 1.Every resident will have a head to toe skin evaluation performed and documented on a weekly basis. Review of Resident #172 medical record revealed an admit date of 02/11/2025 with diagnoses that included: COPD, Congestive Heart Failure, Atherosclerotic Heart Disease, Depression, and Essential HTN. Review of Resident #172 Care plan with a review date of 05/20/2025 read in part . Risk for impaired skin integrity related to impaired mobility with interventions for weekly skin audits. Review of Resident #172 skin assessment dated [DATE] by S10 TX Nurse revealed 3 scabs to forehead area. No bruises noted. Interview on 06/04/2025 at 9:15 a.m. with S1 Admin revealed she was notified by S21 Marketer that during a hospital visit he was notified by hospital staff that Resident…

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 protect the residents' right to be free from physical abuse for 1 (#51) of 4 (#31, #50, #51, and #172) sampled residents investigated for abuse. The facility failed to protect Resident #51 from physical abuse by Resident #272. This failed practice resulted in an actual harm for Resident #51 on 05/20/2025 at 4:09 p.m. when Resident #272 hit Resident #51 multiple times on the head, causing lacerations to Resident #51's left cheek, right cheek, forehead, and chin. Findings: Review of the facility's undated policy entitled Abuse Prevention revealed, in part .the facility is committed to protection residents from abuse. Physical abuse includes hitting. Review of Resident #51's medical record revealed an admission date of 05/06/2024 with diagnoses including, in part .Depression, Anxiety, Mood Disorder, and Other Seizures. Review of Resident #51's Annual MDS with an ARD of 05/06/2025 revealed, in part .a BIMS Score of 11, indicating moderately impaired cognition. Resident #51 did not have a history of physical behaviors…

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

Based on record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, for 1 (#34) of 6 (#16, #21, #28, #34, #49, and #122) residents sampled for Unnecessary Medications. Findings: Review of Resident #34's medical record revealed an admission date of 11/06/2020 with diagnoses including, in part .Schizophrenia. Review of Resident #34's Annual MDS with an ARD of 05/20/2025 revealed, in part .a BIMS Score of 15, indicating intact cognition. Resident #34 used antipsychotic medication, a gradual dose reduction had not been attempted, and the physician had not documented a gradual dose reduction was contraindicated. Review of Resident #34's current orders revealed, in part .Risperdal 1mg tablet by mouth two times a day related to Schizophrenia, ordered on 09/13/2024. Review of Resident #34's Consultant Pharmacist Communication to Physician dated 04/17/2025 revealed the provider had not documented a response to the pharmacist's recommendation of gradual dose reduction for Risperdal 1mg. 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 record review and interview the facility failed to ensure an injury of unknown origin and allegation of abuse was reported immediately to management staff for 2 (#50 and #172) of 30 sampled residents. Findings: Review of the facility's 01/2025 policy titled, Abuse Prevention, read in part The facility is committed to protecting the resident from abuse by anyone .Identification: 1. Identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. 2. The Executive Director and Director of nursing services must be promptly notified of suspected abuse or incidents of abuse. Resident # 172 Review of Resident #172 medical record revealed an admit date of 02/11/2025 with diagnoses that included: COPD, Congestive Heart Failure, Atherosclerotic Heart Disease, Depression, and Essential HTN. Review of Resident #172's Quarterly MDS with an ARD of 02/18/2025 revealed a BIMS score of 03, which indicated severe…

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, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 3 (#34, #51, and #60) of 5 (#16, #34, #44, #51, and #60) residents sampled for review of resident vaccinations. Findings: Resident #34 Review of Resident #34's most recent MDS revealed, in part .COVID-19 vaccination was not up-to-date. Review of Resident #34's Resident Immunization Record revealed COVID-19 vaccinations were administered to Resident #34 on 09/22/2021, 10/22/2021, 04/29/2022, 01/31/2024, and 06/12/2024. Resident #51 Review of Resident #51's most recent MDS revealed, in part .COVID-19 vaccination was not up to date. Review of Resident #51's Resident Immunization Record revealed COVID-19 vaccinations were administered to Resident #51 on 04/08/2021, 06/12/2024, and 11/13/2024. Resident #60 Review of Resident #60's most recent MDS revealed, in part .COVID-19 vaccination was not up to date. Review of Resident #60's Resident Immunization Record revealed COVID-19 vaccinations were administered to Resident #60…

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, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to: 1. Perform AM care including face/hair washing and shaving for Resident # 38; and 2. Provide daily bed baths for 2 (Resident #26 and Resident #34) residents. The total Sample Size is 29 residents. Findings: Review of the facility's 10/2009 policy titled A.M. Care read in part . A.M. Care will be given to residents daily. Procedure: 5. Residents to wash, rinse and dry face and hands if able. 11. Provide/assist with shaving (male and female) as needed. Resident #38 Review of Resident #38's Care plan with a review date of 06/11/2025 revealed impaired mobility due to Muscular Dystrophy. Resident #38 requires 2 person assist with bathing, dressing, and grooming. Review of Resident #38's Quarterly MDS with ARD of 03/11/2025 revealed the BIMS was not conducted because Resident #38 is rarely/never understood. Resident #38 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 observation, interview, and record review the facility failed to provide necessary services to maintain optimal skin integrity for 1 (Resident # 26) of 29 sampled residents. Findings: Resident # 26 A review of facility policy titled, Turning and Positioning Program with revision date of 07/2018, revealed in part . Policy: All residents will be turned and positioned as per the plan of care in an organized system . A review of Resident #26's medical record revealed an admission date of 05/17/2023 with diagnoses that included Spinal Stenosis of lumbar region without neurogenic claudication, Alzheimer's with late onset, Epilepsy unspecified with Status Epilepticus, Morbid (severe) Obesity due to excess calories, Obstructive Sleep Apnea, Osteoarthritis, Neuromuscular Dysfunction of bladder, Cognitive Communication Deficit, Atrial Fibrillation, Candidiasis of skin and nail, and other lack of coordination. A review of Resident # 26's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/18/2025 revealed a BIMS score of 13, which indicated intact cognition.…

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 (#25) of 3 (#25, #53, and #122) residents reviewed for tube feeding. Findings: Review of the Facility's 01/2025 policy titled Tube Feeding read in part Residents with a Gastrostomy or Jejunostomy tube will be provided nutrition and hydration via the feeding tube. Procedure: Administer feeding as ordered via continuous pump feeding per physicians orders. Review of Resident #25's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses that included: Acute Respiratory Failure, Hyperlipidemia, Hypothyroidism, and Insomnia. Review of Resident #25's admission MDS with an ARD of 05/14/2025 revealed a BIMS of 13, which indicated intact cognition. Review of Resident #25's Care Plan with a review date of 08/13/2025 read in part: Resident requires tube feeding related to nothing by mouth status. The resident is dependent on tube feeding 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.

Based on record review and interview, the facility failed to complete an annual performance review and provide regular in-service education based on the outcome of the annual performance reviews for 2 (S16 CNA and S17 CNA) of 3 (S13 CNA, S16 CNA, S17 CNA) certified nursing assistants reviewed for sufficient and competent nurse who required it. Findings: Review of S16 CNA's personnel records revealed a date of hire of 11/01/2023. Further review revealed no evidence of an annual performance being completed within the past 12 months. Record review revealed the last annual performance was completed on 06/19/2023. Review of S17 CNA's personnel records revealed a date of hire of 05/24/2024. Further review revealed no evidence of an annual performance review being completed in the past 12 months. In an interview on 06/04/2025 at 2:01 p.m., S1 Administrator acknowledged annual performance reviews had been requested multiple times for the sampled CNAs, but had not been provided. In an interview on 06/04/2025 at 2:15 p.m., S15 HR (Human Resources) stated she provided the requested annual…

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 an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure: 1. Facility staff wore a gown while administering medications to a resident on EBP, Resident #122, through a Gastrostomy (PEG tube); 2. Standard Precautions were utilized during wound care, 3. Unused resident care items were not stored on the floor 4. Resident's used basins were not stored in a shower 5. Resident's used urinal was not stored in a shower, and 6. A Curtain in the shower area was not visibly soiled. Findings: Resident #122 On 6/04/2025 at 10:30 a.m. the facility provided a copy of their Enhanced Barrier Precautions Policy with a History date of 4/24. Review of the policy revealed, Enhanced Barrier Precautions only require use of gown/ gloves when performing high contact resident activities: a. g. Device care or use: central line, urinary catheter, feeding tube,…

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 services were provided to meet professional standards of practice for 5 (#1, #2, #3, #4, & R1) of 13 (#1-#12 & #R1) sampled residents out of a total census of 74 residents. The facility failed to ensure controlled medications were administered as ordered and documented correctly. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy on 02/20/2025 titled, Controlled Medications Administrations which was last reviewed on 08/2016 read in part . When administering controlled medication, the authorized personnel records the administration on the MAR/eMAR and enters all of the following information on the Controlled Drug Record: a. Date and time of administration b. Amount administered c. Signature of the person preparing the dose d. Quantity reconciled Review of the facility's policy on 02/20/2025…

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 record review and interview, the facility failed to ensure pain management was provided to residents by failing to assess for pain medication effectiveness after administration for 5 (#1, #2, #3, #4, and #R1) of 5 sampled residents reviewed for pain. Findings: Review of the facility's policy on 02/20/2025 titled, Medication Administration-General Guidelines reviewed or revised on 01/2015 read in part . When prn medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and if applicable injection site. b. Complaints or symptoms for which the medication was given. c. Results observed from giving the dose and the time results were noted. d. Resident pain evaluation per facility policy, if applicable. e. Signature or initials of person recording administration and signature or initials of person recording effects, if different from person administering. Resident #1 Review of Resident #1's medical record revealed an admit date of 09/27/2023 with diagnoses that included in part…

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 review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #11) of 2 ( Resident #11 and Resident #12) residents reviewed for abuse. The facility failed to ensure Resident #11 was not physically abused by Resident #12. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's undated policy titled Abuse Prevention on 02/18/2025 read in part . The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, friends, visitors, or any other individual. Definitions: a. Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (#1) of 12 (#1-#12) sampled residents reviewed for quality of care. The facility failed to transport Resident #1 to an orthopedic specialist appointment in a timely manner as ordered. Findings: Review of Resident #1's medical record revealed an admit date of 09/27/2023 with diagnoses that included in part .Heart Failure, Type 2 DM, Pain, and Unspecified Dislocation of Left Hip. Review of Resident #1's Quarterly MDS with an ARD of 01/28/2025 revealed the resident had a BIMS score of 8, which indicated moderately impaired cognition. Review of the MDS revealed Resident #1 was dependent with rolling left and right and required substantial to maximal assistance with sitting to lying and toileting hygiene. Resident #1 required setup or clean up assistance with eating. In an interview on 02/17/2025 at 1:30 p.m., Resident #1 stated his left hip keeps coming…

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 review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #4) of 4 (Resident #1, Resident #2, Resident #3 and Resident #4) sampled residents. The facility failed to ensure Resident #4 was not physically abused by Resident #3. Findings: Review of the facility's policy titled Abuse Prevention, with a review date of 10/2022, revealed in part .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, friends, visitors, or any other individual. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident to resident, staff to resident, family to resident, or visitor to…

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

Based on observation, interview, and record review the facility failed to ensure a resident with a PEG tube maintained acceptable parameters of nutritional and hydration status consistent with the resident's comprehensive assessment for 1 (#2) of 8 (#2, #R1, #R2, #R3, #R4, #R5, #R6, and #R7) sampled residents who received nutrition and hydration via PEG tube. The total sample size was 12. Findings: Review of the facility's policy titled: Tube Feeding dated 07/2018 read in part . Residents with a Nasogastric, Gastrostomy, or Jejunostomy tube will be provided nutrition and hydration via the feeding tube. 2. Check Physicians orders and/or treatment record for amount and type of feeding. 7. Label the feeding bag with the resident's name, formula ordered and date. For gravity (intermittent) and continuous pump feedings, each time a feeding is administered into the bag, the amount of formula hung and the time it was hung must be noted on the feeding bag. 8. Administer the feeding as ordered via continuous pump feeding. F. Set the rate as ordered and begin the infusion. Review of Resident…

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 a clean, comfortable, and homelike environment. The facility failed to ensure: 1. The floor in Rooms a, b, and c were clean, sanitary and free of dust, trash and dead insects. 2. The ceiling tiles Rooms a and b were not loose with exposed insulation, and did not have brown stained and holes ceiling tiles were securely in place without exposed insulation and were clean without brown stains. 3. The over bed wall mounted lights were operational in Room b over both beds a and b; and 4. The window pane in Room a was cleaned and allowed resident to see the outside view. Findings: Rooms a Observations of Room a on 04/02/2024 at 12:20 p.m. and 04/03/2024 at 8:35 a.m., revealed a large amount of dust, trash, and dead insects in the corner of the room between the bed and the window. The window pane was noted to have a large amount of mildew, green and brown substance along with a film on the inside of the pane. The outside view was not clearly visible. The ceiling tiles in the room were loose with exposed insulation 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 interviews and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (Resident #43) of 5 (Resident #10, Resident #43, Resident #45, Resident #56 and Resident #57) residents reviewed for unnecessary medication and 1 (Resident #268) of 1 resident reviewed for tube feeding. The facility failed to: 1. Ensure labs were obtained as ordered by the physician for Resident #43. 2. Notify the physician of a dietician's recommendation to meet the nutritional needs of Resident #268. Findings: Resident #43 Review of Resident #43's medical record revealed an admit date of 09/10/2021 with diagnoses that included: Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes Mellitus, Essential Hypertension, Viral Hepatitis C, and Paroxysmal Atrial Fibrillation. Review of Resident #43's 04/2024 Physician Order's read in part . Draw CMC, CMP, HGAIC, IRON, MAG Q3 months in December, March, June and September. (Start Date 12/07/2021) Review of Resident…

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, interview, and record review the facility failed to ensure that residents who were unable to carry out ADL's (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to ensure Residents #1 and Resident #4 were free from facial hair and failed to provide nail care to dependent residents for Residents #11, Resident #17, Resident #21, Resident #38, Resident #48 and Resident #62 in a total sample of 10 residents reviewed for ADL care. Findings: Resident #1 Review of Facility's policy titled Shaving- Male and Female read in part Resident will be free of facial hair- both male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the care plan. Review of Resident #1 medical record revealed an admit date of 09/18/2023 with diagnoses that included: Cerebral Infarction, Hemiplegia following Cerebral infarction affecting left nondominant side, Unspecified Dementia, Bipolar Disorder, Post Traumatic Stress disorder, Schizophrenia, and Anoxic Brain…

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, interview, and record review the facility failed to maintain dignity for 1 (Resident #17) of 1 resident reviewed for dignity by failing to ensure a female resident was free of facial hair. Findings: Review of the Facility's policy titled Shaving- Male and Female read in part Resident will be free of facial hair- both male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the care plan. Review of Resident #17's medical record revealed an admit date of 01/16/2020 with diagnoses that included: Unspecified Dementia, Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, Anxiety Disorder, and Dysphagia. Review of Resident #17's Care plan with review date of 05/28/2024 read in part . Resident requires total assistance with all activities of daily living. Allow for independence as tolerated by resident such as brushing hair and teeth, washing face and assistance with bed mobility. Observation on 04/02/2024 at 11:29 a.m. revealed Resident #17 had ¼ inch facial hair to her chin. Interview on 04/02/2024 at…

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

Based on record review and interview, the facility failed to act promptly on grievances concerning issues of resident care and life in the facility reported by residents during a monthly Resident Council meeting for 1 (02/13/2024) of 3 (01/09/2024, 02/13/2024, and 03/14/2024) meetings reviewed. Findings: Review of the facility's undated policy titled Resident Council on 04/02/2024 at 3:05 p.m. read in part . The Social Services Director or designee will facilitate the organization and maintenance of a facility Resident Council. Review of the facility's undated policy titled Grievance/Missing Property on 04/02/2024 at 3:05 p.m. read in part .Purpose: To provide an opportunity for residents, resident representatives, and/or family to present concerns or grievances to the proper authorities at the facility and to receive responses to the issue(s) raised. Review of the facility's Resident Council Department Response Form read in part . Date of council meeting: 02/13/2024. Date this form was distributed to Department Head: 02/14/2024. Date response due back to Resident Council…

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 review the facility failed to ensure services were provided according to the resident's Comprehensive Plan of Care for 1 (Resident #268) of 1 (Resident #268) residents sampled for tube feeding. The facility failed to ensure Resident #268's nutritional needs were met. Findings: Review of the clinical record revealed Resident #268 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure, Anoxic Brain Damage, Rhabdomyolysis, Metabolic Encephalopathy, Tracheostomy status, and Hypertension. Review of Resident #268's Comprehensive Plan of Care with target date 06/22/2024 revealed in part .Requires PEG tube for adequate nutritional intake. Goals include .nutritional needs will be met thru enteral feedings. Approaches include .Dietician to evaluate current nutritional status. Observation on 04/02/24 at 11:03 a.m. revealed Resident #268 awake in bed, nonverbal. Tube feeding infusing per dual pump of Jevity 1.5 at 50ml per hour with 50ml H20 flushes every…

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 ensure that the nurse staffing information was posted daily. Findings: Observation on 04/02/2024 at 9:30 a.m. revealed the daily nurse staffing information posted was dated 03/29/2024. Interview on 04/02/2024 at 11:56 a.m. with S2 DON confirmed the daily nurse staffing information posted was dated 03/29/2024. S2 DON confirmed the nurse staffing information posted should have been updated daily, and was not.

Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 3 (#11, #17, and #48) of 3 Residents who were ordered and served pureed diets. Findings: Review of the facility's approved 2024 Lunch Menu revealed the facility was on Week: 4, Day: Tuesday: Roasted Turkey, Mashed Potatoes, Turnip Greens, Bread Roll, Dessert- Sugar cookie, and a Beverage. Review of the facility's approved recipe for Pureed Roast Turkey read in part . Ingredients: 3 oz. Roast Turkey, [NAME] Sliced Bread, Water, and Chicken Base. Instructions: Combine chicken base and water to make chicken broth. Place prepared turkey and bread in a washed and sanitized food processor. Gradually add liquid and blend until smooth. Note: Follow any facility policy/procedures, such as the puree volume method procedure, to ensure a correct portion is served. Review of the facility's approved recipe for Pureed Turnip Greens read in part . Ingredients: Turnip greens, Margarine, and [NAME] Sliced Bread. Instructions: Place prepared…

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, interview and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of an infectious communicable disease. The facility failed to ensure all staff adhered to Enhanced Barrier Precautions for 1 (Resident #6) of 6 (Resident #6, Resident #56, Resident #59, Resident #218, Resident #268, and Resident #269) residents reviewed for infection control. Findings: Review of the facility policy titled: Enhanced Barrier Precautions, revealed in part .Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). Enhanced Barrier Precautions only require use of gown/gloves when performing high contact resident activities: dressing, bathing/showering, transferring, AM/PM care, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding…

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 interview and record review the facility failed to make a prompt effort to resolve grievances filed by a resident, and the resident's representative, for 1 (#7) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled Residents. Findings: The Facility's Policy Titled Grievance/Missing Property read in part . Procedure: 1. Respective Department Head, Executive Director and/or Grievance Official will follow-up on issues noted. Review of Resident #7's medical record revealed an admit date of 07/26/2017, with diagnoses that included: Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease, Morbid severe Obesity with Alveolar Hypoventilation, Chronic Systolic Heart Failure, Sleep Apnea Unspecified, Cardiomegaly, and Unspecified Asthma Uncomplicated. Review of Resident #7's Quarterly MDS with an ARD 11/10/2023, revealed Resident #7 had a BIMS score of 1? (indicating intact cognition); required partial/moderate assistance for dressing and personal hygiene; independent with eating; and dependent 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.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #7) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled Residents. The facility failed to ensure respiratory equipment was properly changed, labeled and contained. Findings: Review of the Facility's Policy Titled Oxygen Therapy read in part . Procedure: 9. Date tube when changed (weekly). Review of Resident #7's medical record revealed an admit date of 07/26/2017, with diagnoses that included: Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease, Morbid severe Obesity with Alveolar Hypoventilation, Chronic Systolic Heart Failure, Sleep Apnea Unspecified, Cardiomegaly, Unspecified Asthma Uncomplicated. Review of Resident #7's Physician orders dated 02/2024 revealed in part . oxygen per concentrator, and to keep oxygen saturation equal to or greater than 90%. Bi-pap wear at night and during the day while napping. Review of Resident #7's care plan…

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 interview and record review, the facility failed to ensure an allegation of staff to resident verbal abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of the facility's policy titled Abuse Prevention revealed in part . Investigation: The Executive Director, or designee, shall report any allegations of abuse, neglect, or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 1150B of the Social Security Act to the Department of Health as required. Protection: l. Any allegation of abuses, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident. 2. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a reasonable suspicion or crime (immediately but no later than 2 hours if abuse or serious…

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 interview and record review, the facility failed to have evidence that allegations of abuse were thoroughly investigated for 3 allegations of abuse involving 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of the facility's policy titled Abuse Prevention revealed in part . Protection: 2. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families and/or representative, and as required by state guidelines. Resident #1 Review of the facility's Supervisor Investigation Summary Form for Resident #1 revealed in part . Date of event: 10/12/2023 Investigation: On the morning of 10/12/2023, S1 Administrator received 2 text messages from Resident #1's responsible party. S1 Administrator immediately went to Resident #1's room to assure she was safe. Resident #1 verbalized to S1 Administrator that last night S2 CNA spoke louder than…

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, interview, and record review, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to ensure Resident #5 had a bed alarm applied to prevent falls after sustaining a fall with major injury. Findings: Review of Resident #5's clinical record revealed an admit date of 07/11/2023 with diagnoses that included: Acute Respiratory Failure, Aphasia, Dysphagia, Unspecified Convulsions, Non-traumatic Intracranial Hemorrhage, Other symptoms and signs with cognitive functions following Cerebral Infarctions, and Insomnia. Review of Resident #5's MDS with an ARD of 11/01/2023 revealed a BIMS was not conducted as Resident #5 was rarely/never understood and Resident #5 had severely impaired skills for daily decision making. Review of the MDS revealed Resident #5 was dependent with sit to lying, lying to sitting on the side of the bed, sit to stand, and chair/bed to chair transfer. 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.

Based on interview and record review the Facility failed to ensure each Resident had the right to be free from abuse by other Residents. The Facility failed to protect 1 Resident (#4) of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled Residents from being physically abused by another Resident. Findings: Review of the facility's Abuse Prevention Policy read in part .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff or other residents . Protection: (3) It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect or mistreatment. Resident #4 Review of Resident #4's medical record revealed an admit date of 04/07/2023 with diagnoses which included: Hemiplegia Left Non-Dominant Side, Mental Disorder Not other specified, HIV, Acute Bronchitis, Chronic Viral Hepatitis C, Idiopathic Neuropathy and Chronic Obstructive Pulmonary Disease. Review of Resident #4'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.