St Joseph Skilled Nursing and Rehabilitation

Based on observations, interview and record review the facility failed to use infection control standards of practice for 1(#2) of 3 (#1, #2 and #3) sampled residents by not properly storing a resident's Foley catheter bag preventing an increased risk of contamination and infection. Resident #2's Foley catheter bag was improperly stored on the floor. Findings:Review of the facility's Catheter Care, Urinary policy (revised September 2014) presented by S1 DON (Director of Nursing) revealed in part:Purpose: The purpose of this procedure is to prevent catheter-associated UTI (urinary tract infections).Infection Control: Be sure the catheter tubing and drainage bag is kept off the floorObservation on 7/29/2025 at 11:25 a.m. with S2 ADON (Assistant Director of Nursing) revealed resident #2's Foley catheter noted to be lying on the floor. Resident #2 noted to be on enhanced barrier precautions according to the sign on her door.Observation on 07/30/2025 at 10:30 a.m. revealed resident #2's Foley catheter bag positioned on the floor at the side of the bed. Review of resident #2's medical…

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 nurses started a medication that had been ordered by the physician for 1(#2) of 3 (#1, #2 and #3) sampled residents. The facility failed to start the medication Naltrexone for resident #2. Findings: Review of resident #2's record revealed in part, a Psych Evaluation, date of service July 3, 2025. Chief complaint and history of present illness, history of dementia and insomnia.Case Conceptualization: Speech unintelligible. Information obtained from staff. They describe resident #2 as being 'hypersexual' and gave examples on behavior. Resident #2 is not aggressive. Resident #2 has a PEG (percutaneous endoscopic gastrostomy) tube for nutrition. Resident #2 does sleep well. Will make recommendations below and will re-assess in 1 month, sooner if needed. -Recommendations: Start trial of Naltrexone 25 mg (milligram) daily. Rationale: Naltrexone shown to reduce inappropriate behavior.Review of resident #2's July 2025 MAR (medication administration record) failed to reveal the medication Naltrexone had been started as…

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: 1) ensure a resident was permitted return to the facility after hospitalization for 3 (#1, #2, #3) of 3 (#1, #2, #3) residents reviewed for transfer and discharge and; 2) have documentation a resident or resident's responsible party and the Ombudsman being notified in writing of the transfer/discharge and appeals right for 3 (#1, #2, #3) of 3 (#1, #2, #3) residents reviewed for transfer and discharge. Review of the facility's Transfer or Discharge, Facility-Initiated policy dated 2022 revealed the following in-part: Transfer and discharge includes movement of a resident from a certified bed in the facility to a non-certified bed in another part of the facility, or to a non-certified bed outside the facility. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Specifically: a. transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified…

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 have documentation a resident received information on resident rights and the temporary leave-bed hold policy for 1 (#2) of 3 (#1, #2, #3) residents reviewed for resident rights. Findings: Record review revealed resident #2 was admitted to the facility on [DATE]. Further review of the medical records revealed there was no documentation resident #2 or his responsible party received information on resident rights and all regulations governing the resident conduct and responsibilities during his stay. On 04/30/2025 at 12:25 p.m. an interview with S1Administrator revealed he was not able to locate resident #2's admission packet. S1Administrator confirmed they did not have documentation resident #2 or his responsible party received information on resident rights and the temporary leave-bed hold policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to assess a resident for self-administration of medications for 1 (#323) of 1 sampled residents. Findings: Review of the facility's Self -Administration of Medications policy and procedure dated 06/14/2006 revealed: A patient may self-administer medications if the patient is determined safe for the patient and other patients of the facility by the facility's interdisciplinary team. Procedure: An assessment for Self-Administration of Medications must be competed on each Patient requesting to self-administer medications and quarterly thereafter. An assessment for self-administration of Medications is kept with the Patient's medical record under the Assessment tab. If it has been determined the Patient is capable of self-administering his/her medications, a physician order must be obtained, a care plan formulated, and staff in-serviced. The nursing staff must interview the Patient on every shift to verify that all self-administered doses on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #62 Review of the medical record for resident #62 revealed an admission date of 06/14/2024 with diagnoses including encephalopathy, epilepsy, malignant neoplasm, protein calorie malnutrition, and dehydration. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #62's Brief Interview for Mental Status (BIMS) score was 99 which indicated that the resident was unable to complete the interview. Resident #62 was dependent on staff for activities of daily living. Review of the current care plan revealed resident #62 required extensive assistance with eating. Further review of the care plan revealed interventions were to allow the resident adequate time to eat, monitor his food intake at each meal, and to document the meal percentage consumed. Review of the resident #62's Activities of Daily Living (ADL) Verification Worksheet for daily meal intake percentages revealed there was no documented evidence of the breakfast, lunch and dinner meal percentage intakes on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for 7 (#3, #16, #41, #45,#58, #62 and #221) of 11 (#3, #16, #37, #40, #41, #45, #58, #62, 221, #223, and #324) residents reviewed for Activities of Daily Living (ADL) care. The facility failed to ensure 1) residents' fingernails were kept clean and/or trimmed for #16, #41, #58 and #62, and 2) residents #3, #45 and #221 received baths as scheduled. Findings: Resident #62 Review of the medical record for resident #62 revealed an admission date of 06/14/2024 with diagnoses including encephalopathy, hypertension, epilepsy, atrial fibrillation, malignant neoplasm, protein calorie malnutrition, dehydration and chronic pain. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #62's Brief Interview for Mental Status (BIMS) score was 99 which indicated that…

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 that the resident environment remained as free of accident hazards as is possible by not completing an Accident/Incident report when a resident was found sitting on the floor for 1 (#62) of 3 (#51, #62, and #222) residents reviewed for falls. Findings: Review of the facility's Accident/Incidents Policy dated May 2016 revealed: 1 An Accident/Incident Report must be completed immediately upon facility staff becoming aware of the occurrence of an accident/incident (to include medication errors) involving a Patient and, if necessary, the Patient's Care Plan must be updated. Review of the facility's Fall Management Guidelines policy dated November 2022 revealed: 1. Definition Unintentional change in position coming to rest on the ground, floor or onto the next lower surface. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Review of the medical record for resident #62…

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

Based on observations, record review and interviews the facility failed to provide respiratory care consistent with professional standards of practice for 3 (#2, #323, and #325) of 3 (#2, #323, #325) residents sampled for respiratory care. The facility failed to ensure 1) Resident's oxygen concentrator filters were clean for (#2, #323) and 2) The resident's nebulizer equipment and tubing were dated and stored appropriately for (#323, #325). Findings: Resident #2 On 09/30/2024 at 3:16 p.m. observation of resident #2's oxygen concentrator revealed the filter on the back of the machine was dirty. Further observation of the oxygen administration revealed resident #2 received 2 liters per minute (lpm) per nasal cannula. Observation of the oxygen tubing revealed there was no date or initial on the humidification bottle or the oxygen tubing. On 10/01/2024 at 8:57 a.m. observation of the oxygen concentrator revealed the filter remained dirty. On 10/01/2024 at 11:58 a.m. observation of the oxygen concentrator with S2Director of Nursing (DON) confirmed the filter on the back of the machine…

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/or reviewed the risks and benefits of bed rails with the resident or resident's representative and/or obtain an informed consent prior to installation of bed rails for 5 (#9, #16, #31, #40, and #62) of 6 (#9, #16, #31, #40, #51, and #62) residents reviewed for accident hazards. Findings: Review of the facility's policy for Bed Safety and Bed Rails dated August 2022 revealed in part: Policy Statement Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. 7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: a. Accident hazards: (1) The resident could attempt to climb over, around, between, or through the rails. Or over the foot board; and/or (2) 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 and interviews, the facility failed to ensure that each resident was free from unnecessary medication use for 5 (#3, #37, #43, #49, and #51) of 5 (#3, #37, #43, #49, and #51) residents sampled for unnecessary medication review. The physician/prescriber failed to provide a rationale for continuation of psychotropic medications. Findings: Resident #3 Review of resident #3's record revealed an admission date of 06/17/2021 with diagnoses including anxiety disorder, chronic kidney disease, other schizoaffective disorders, pain unspecified, unspecified dementia with behavioral disturbance, major depressive disorder, dysphagia, and long term use of opiate analgesics. Review of resident #3's September 2024 Physician's Orders revealed orders for the following psychotropic medications which require a gradual dose reduction (GDR): Seroquel, Buspirone, Lorazepam, Fluoxetine, and Haloperidol. Review of the Note to Attending Physician/Prescriber for resident #3 dated 05/27/2024 revealed the following:…

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

Based on observations, record review and interviews the facility failed to securely store medications in a resident's room per the policy and procedure when self-administering medication for 1 (#323) of 1 (#323) residents self-administering medications. Findings: Resident #323 Review of the faclity's Self - Administration of Medications policy and procedure dated 06/14/2006 revealed: A patient may self-administer medications if the patient is determined safe for the patient and other patients of the facility by the facility's interdisciplinary team. Procedure: An assessment for Self-Administration of Medications must be competed on each patient requesting to self-administer medications and quarterly thereafter. An assessment for self-administration of medications is kept with the patient's medical record under the Assessment tab. If it has been determined the patient is capable of self-administering his/her medications, a physician order must be obtained, a care plan formulated, and staff in-serviced. The nursing staff must interview the patient on every shift to verify that all…

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, policy review and interviews the facility failed to implement policies and procedures for enhanced barrier precautions (EBP) for 4 (#7, #45, #321, #322,) of 4 (#7, #45, #321, #322) residents reviewed for enhanced barrier precautions. Findings: Review of the facility's Enhanced Barrier Precations (EBP) policy dated March 2024 revealed in part: EBP is an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. Infections or colonization with a Centers for Disease Control and Prevention (CDC) targeted MDRO when Contact Precautions do not apply otherwise; or Chronic wounds (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers) and/or indwelling medical devices (devices fully embedded in the body, ie central lines, hemodialysis catheters, urinary catheters, feeding tubes and trach tubes) even if the resident is not known to be infected or…

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 retain the resident's personal possessions, including clothing, by not having a system in place to record residents' personal belongings. The facility failed to have an inventory record of the resident's personal belongings for 1 (#62) of 2 (#42 and #62) residents reviewed for personal property. Findings: Review of the medical record for resident #62 revealed an admission date of 06/14/2024 with diagnoses including encephalopathy, hypertension, epilepsy, insomnia, acute kidney failure, insomnia, atrial fibrillation, malignant neoplasm, protein calorie malnutrition, dehydration, and chronic pain. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #62's Brief Interview for Mental Status (BIMS) score was 99 which indicated the resident was unable to complete the interview. Resident #62 was dependent on staff for activities of daily living. Review of the record revealed resident #62 did not have an inventory…

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 and interview, the facility failed to ensure the most recent state inspection results since the last annual survey were available for resident or family review. Findings: An observation upon entrance to the facility on [DATE] at 7:35 a.m. revealed the results of the last survey in the facility's survey binder was the last annual survey dated 09/13/2023. Further review of the survey binder revealed the last complaint survey results dated 08/16/2024 were not in the binder. An interview on 09/30/2024 at 7:40 a.m. with S2Director of Nursing (DON) confirmed the facility's survey binder did not have the most recent survey results for the complaint dated 08/16/2024.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (#3) of 3 (#3, #62, and #222) residents reviewed for quality of life. The facility failed to transport resident #3 to her appointment in a timely manner to ensure she was seen by the physician. Findings: A telephone interview on 10/01/2024 at 11:53 a.m. with resident #3's son revealed that resident was taken to an appointment out of town today by the facility, and the appointment had to be rescheduled for 10/25/2024 due to resident #3 arrived late for her appointment. Review of the transportation appointments for 10/01/2024 revealed resident #3 had an appointment with a psychiatrist out of town at 9:00 a.m. Review of the current care plan revealed resident #3 currently takes psychotropic medications as evidenced by depression, anxiety, and insomnia and to obtain a psychiatric consult as needed. An interview on 10/01/2024 at 12:15 p.m. 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 interviews the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to obtain a hemoglobin A1C and lipid panel for 1 (#49) of 5 (#3, #37, #43, #49, #51) residents reviewed for unnecessary medications. Findings: Record review revealed resident #49 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic polyneuropathy, insomnia, anemia, essential hypertension, anxiety disorder, bipolar disorder, depression, arthritis, pain unspecified, unspecified dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. Review of the Consultant Pharmacist Communication to Nursing letter dated 08/29/2024 revealed the following recommendation: I did not find any labs ordered routinely. Please verify we are monitoring labs (lithium, hemoglobin A1C, Complete Blood Count (CBC), Complete Metabolic Profile (CMP) and Lipid levels), if not please follow up with the prescriber 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident admitted to the facility with a surgical wound was provided care and treatment to the wound for 1 (#4) of 5 (#1 - #5) sampled residents reviewed. Findings: Review of the resident #4's medical record revealed an admission date of 12/15/2023 with diagnoses that included gross hematuria, chronic obstructive pulmonary disease, rheumatoid arthritis, cachexia, left hip fracture, hypertension, and anemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated the resident was cognitively aware and able to make daily decisions. Further review revealed he needed assistance with bed mobility, transfers, and toileting. Further review revealed under skin conditions the surgical wound was noted. Review of the nursing admission assessment completed on 12/15/2023 revealed no documentation of the surgical wound to the left hip. Review of the admission…

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 protect the resident's right to be free from sexual abuse by a resident for 2 (#2 and #3) of 3 (#1, #2, #3) residents reviewed for abuse. The facility failed to protect Resident #2 and Resident #3 from inappropriate sexual advances by Resident #1. Findings: Review of the facility's Abuse Prohibition Protocol dated April 2019 revealed the following, in part: 1. The Patient has the right to be free from abuse, neglect, mistreatment of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treating the Patient's symptoms. 7. e. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault, or any nonconsensual sexual contact of any type with the Patient. Resident #1 A review of Resident #1's medical record revealed an admission date of 11/01/2023 with diagnoses of acute kidney…

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 inform the resident's responsible party of a resident's change in condition for 2 (#5 and #6) of 4 (#4, #5, #6 and #7) records reviewed for resident rights. The facility failed to notify 1) resident #5's responsible party when she expired on [DATE], and 2) resident #6's responsible party when the facility had to reschedule 2 psychiatric appointments. Findings: Review of the facility's Change in Condition Policy and Procedure with a revised date of [DATE] revealed: Policy: To identify and evaluate a change in condition and notify the Physician and Responsible Party when indicated. A significant change in Resident's status is any sign or symptom that is: Acute or sudden onset A marked change (i.e., more severe) in relation to usual signs and symptoms New or worsening symptom Examples include but are not limited to the following: cardiovascular, respiratory, behavioral, fall with major injury, infection, dehydration, altered mental status, pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene by, not having documented evidence that residents received baths as scheduled for 1 (#6) of 3 (#5, #6 and #7) records reviewed for Activities of Daily Living (ADLs). Findings: Review of the medical record for resident #6 revealed an admission date of 06/17/2021 with diagnoses including anemia, acute bronchitis, edema, anxiety, chronic kidney disease, schizoaffective disorder, dementia, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact for daily decision making. Further review of the MDS revealed the resident required extensive assistance with personal hygiene. Review of the care plan revealed a problem regarding ADL functions 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 observation, record review, and interviews, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#6) of 3 (#4, #6 and #7) residents reviewed for limited range of motion. Findings: Review of the medical record for resident #6 revealed an admission date of 06/17/2021 with diagnoses including anemia, acute bronchitis, edema, anxiety, chronic kidney disease, schizoaffective disorder, dementia, and dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact for daily decision making. Further review of the MDS revealed the resident required assistance with activities of daily living. Review of the care plan revealed resident #6 was at risk for skin integrity and for a soft brace to be worn while in the bed.…

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 residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The facility failed to ensure 1) resident #1 was administered medications per physician orders, and 2) the nurses documented the amount of sliding scale insulin administered to resident #2 in a total of 3 residents reviewed for medications. Findings: Resident 1 Review of the medical record for sampled resident #1 revealed an admission date of 11/03/2023 and a discharge date of 11/30/2023. Resident #1 had diagnoses including cellulitis of the umbilicus, transient ischemic attack, Alzheimer's disease, hyperlipidemia, hypertension, acute kidney failure, anemia, diabetes mellitus and epilepsy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition for daily decision making and required assistance with activities of daily living. Review of the physician…

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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#74) of 2 (#74, #131) sampled residents reviewed for dignity. This deficient practice was evidenced by staff members calling resident #74 a name other than his legal name. Findings: Record review revealed resident #74 was admitted to the facility on [DATE] with diagnoses that included cervical spinal stenosis, hemiplegia following cerebrovascular accident, muscle weakness, pain, and skin damage. Review of the most recent Minimum Data Set (MDS) data dated 08/10/2023 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated he was cognitively intact. Review of Section G- Mobility in the MDS revealed resident #74 was dependent on staff with at least one person assistance for bed mobility, transferring, locomotion on the unit, locomotion off the unit,…

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 interview, the facility failed to ensure residents were informed of the type of care giver or professional that will be providing services. This deficient practice had the potential to affect 70 residents who resided in the facility as per the facility's Resident Census and Conditions of Residents Form. Findings: Review of the current policy and procedure titled Identification Name Badges revealed all employees were required to wear identification name tags or badges during their work shift. On 09/12/2023 at 09:30 a.m. wound care was observed for Resident #74 by S3 Licensed Practical Nurse (LPN)/Treatment Nurse. As S3 LPN/Treatment Nurse provided wound care, S15 Certified Nursing Assistant (CNA) knocked on the door and entered the room. S15 CNA asked S3LPN if she needed assistance. S3 LPN/Treatment Nurse accepted the offer for help. S15 CNA did not have a name tag on her uniform and she did not introduce herself to anyone in the room. Observation on 09/11/2023 at 8:08 a.m. revealed S10LPN did not have a name tag displayed. Observation on 09/12/2023 at 7:46…

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 conduct a comprehensive assessment which included the resident's dental assessment for 1 (#6) of 1 (#6) residents reviewed for dental care. Findings: Record review for resident #6 revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disorder, type 2 diabetes, and morbid obesity. On 09/12/2023 at 4:25 p.m., resident # 6 was in her room in bed. Resident reported that she would like to have her front teeth removed. An observation revealed she had missing and broken front upper teeth. Review of resident #6's Quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Further review of Section L (Oral/Dental Status) revealed the facility failed to identify that resident #6 had broken natural teeth. On 09/13/2023 at 3:30 p.m., an interview with S7Licensed Practical Nurse/Minimum Data Set Nurse (LPN/MDS…

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 implement a comprehensive person centered plan of care to attain or maintain a resident's highest practicable physical well-being for 2 (#74, #131) of 4 (#60, #70, #74, #131) sampled residents reviewed for pressure ulcers. The facility failed to have evidence that the residents were turned and repositioned every 2 hours and received incontinent care as stated in the careplan for resident #74 and resident #131. Findings: Resident 131 Review of the medical record for sampled resident #131 revealed an admission date of 01/13/2014 with diagnoses that include dementia, acute cystitis with hematuria, coronary artery disease, cerebral vascular accident (CVA) with right side paralysis, blindness, hypertension, chronic obstructive pulmonary disease and coronary artery disease. Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident has a Brief Interview for Mental Status (BIMS) score of 4 which indicates the resident is cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide assistance for residents who were unable to carry out activities of daily living (ADL) by failing to maintain good grooming and personal hygiene for 3 (#13, #36, and #281) of 7 (#13, #36, #45, #67, #74, #131, and #281) residents reviewed for activities of daily living. Findings: Resident #36 Review of the medical record for resident #36 revealed the resident was admitted on [DATE] with diagnoses, in part of osteomyelitis, diabetes, hypertension, and bilaterally below the knee amputation. Review of the admission Minimum Data Set, dated [DATE] revealed the resident had independent cognitive skills for daily decision making. The resident required one person extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and the resident was totally dependent on staff for bathing. Review of the care plan revealed: personal hygiene - resident requires extensive assistance. Further review of the interventions…

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 that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#35) of 1 resident reviewed for nonpressure related wound care and for 1 (#54) of 1 resident reviewed for positioning. The facility failed to provide wound care for resident #35 as ordered by the physician and failed to provide appropriate positioning while feeding resident #54. Findings: Resident #35 Review of the medical record revealed the resident was admitted on [DATE]. The resident had diagnoses, in part: nutritional deficiency, pain, wound on right great toe, cerebral infarction, multiple sclerosis, and epileptic seizures related to external causes. Review of the Quarterly Minimum Data Set, dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on staff for bed mobility, dressing, toilet use…

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 resident receives care, consistent with professional standards of practice to prevent the development of pressure ulcers by failing to have evidence that the residents were turned and repositioned every 2 hours, and received incontinent care for 2 (#74, #131) of 4 (#60, #70, #74, #131) residents at risk for developing pressure ulcers. Findings: Resident 131 Review of the medical record for sampled resident #131 revealed an admission date of 01/13/2014 with diagnoses that include dementia, acute cystitis with hematuria, coronary artery disease, cerebral vascular accident (CVA) with right side paralysis, blindness, hypertension, chronic obstructive pulmonary disease and coronary artery disease. Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident has a Brief Interview for Mental Status (BIMS) score of 4 which indicates the resident is cognitively impaired and unable to make daily decisions. Further review revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that pain management was provided to a resident who requires such services, consistent with professional standards of practice and resident's preference by failing to administer pain medication for 1 (#281) of 2 (#17, #281) residents reviewed for pain management. Findings: On 09/11/2023 at 8:39 a.m. an interview with Resident #281 revealed both hands were numb and he had knots all over his back that are very painful. Resident #281 revealed he has pain all the time. He reported he only gets some Tylenol and Aspirin. Resident #281 reported he received hospice services at home and thought he was supposed to receive hospice services at the facility. He reported he was getting Morphine at home. Resident #281 reported he had a terminal illness and he didn`t understand why he had to be in pain if he was not going to survives. On 09/12/2023 at 9:20 a.m. an interview with Resident #281 revealed he got some pain medicine last night and early this morning…

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, record reviews, and interviews, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for a resident's needs by: 1.) nurses failing to respond to a resident's call light in a timely manner for 1 (#131) of 1 (#131) resident's call lights observed, and 2.) having a Licensed Practical Nurse change the Peripherally Inserted Central Catheter (PICC) line dressings instead of a Registered Nurse for 1 (#60) of 1 (#60) resident that had a PICC line. Findings: Resident #131 Record review for sampled resident #131 revealed an admission date of 01/13/2014 with diagnoses that include dementia, coronary artery disease, cerebrovascular accident with right side paralysis, blindness, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was cognitively impaired and was unable to make daily…

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 ensure State Registry verifications were obtained prior to hire for 4 (S5Certified Nursing Assistant (CNA), S11CNA, S12CNA, S14CNA) and also failed to ensure they were obtained monthly for 5 (S5CNA, S6CNA, S11CNA, S12CNA, S14CNA) of 5 (S5CNA, S6CNA, S11CNA, S12CNA, S14CNA) personnel records reviewed. Findings: Review of the personnel file for S5Certified Nursing Assistant (CNA) revealed a hire date of 07/20/2023. Further review of the personnel file revealed no documented evidence of a CNA state registry verification that was obtained upon hire or monthly thereafter. Review of the personnel file for S6CNA Supervisor revealed a hire date of 05/07/2007. Further review of the personnel file revealed no documented evidence that a CNA state registry verification was obtained monthly. Review of the personnel file for S11CNA revealed a hire date of 03/02/2022. Further review of the personnel file revealed no documented evidence of a CNA state registry verification that was obtained upon hire or monthly thereafter. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs for 3 (#62, #70, and #74) of 6 (#6, #7, #22 #62, #70, and #74) sampled resident reviewed for unnecessary medications. The facility failed to follow parameters for the administration of a blood pressure medication for resident #62 and failed to monitor resident #70 and #74 for edema while receiving a diuretic. Findings: Resident #62 Review of the record revealed resident #62 revealed the resident was admitted on [DATE] with diagnoses including Human Immunodeficiency Virus, atherosclerotic heart disease of native coronary artery without angina pectoris, heart failure, and hypertension. Review of the September 2023 physician's orders revealed an order dated 08/12/2023 for Lisinopril 5 milligrams (mg) 1 tablet by mouth (PO) daily. Review of the August 2023 and September 2023 Medication Administration Records (MAR) revealed parameters for administering blood pressure medication…

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.