Carroll Health and Rehab LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor lab results for a resident receiving anti-seizure medication for 1 (#12) of 5 (#1, #5, #6, #12, #23) residents reviewed for unnecessary medications.Findings: Review of the record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage without loss of consciousness, initial encounter; other seizures; altered mental status and encephalopathy.On 07/22/2025 at 10:00 a.m., a review of Resident #12's current care plan revealed the facility should obtain lab/diagnostic work as ordered and report results to physician.On 07/22/2025 at 10:15 a.m., a review of Resident #12's active physician orders revealed an order for Valproic Acid oral solution 15 milliliters (ml) by mouth every morning ordered 04/10/2025 and Valproic Acid oral solution 20 ml by mouth every evening for seizures ordered 04/09/2025.…

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

Based on observations and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to properly store the ice scoop utilized in serving ice to residents in a sanitary manner.Findings: On 07/21/2025 at 8:15 a.m., an observation of the facility's kitchen revealed that an ice scoop was being stored inside an ice chest that contained ice for resident use.On 07/21/2025 at 8:22 a.m., an observation with S8Dietary Supervisor confirmed the ice scoop was being stored in the ice chest containing resident ice.On 07/23/2025 at 11:45 a.m., S3Director of Nursing (DON) was informed of dietary staff storing an ice scoop in the ice chest for resident use.

Based on record review and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) committee met at least quarterly with all required members present.Findings: Review of the QAA committee meetings revealed quarterly meetings with required staff present were recorded on 08/08/2024, 11/21/2024, and 04/24/2025. On 07/23/2025 at 4:20 p.m., an interview/observation with S2Corporate Registered Nurse (RN) confirmed records of the quarterly meetings with required staff present were recorded on 08/08/2024, 11/21/2024, and 04/24/2025. On 07/23/2025 at 4:20 p.m., an interview with S3Director of Nursing confirmed four quarterly QAA committee meetings with all required staff present had not been completed in the past year.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment by failing to ensure that Enhanced Barrier Precautions (EBP) were implemented as ordered for 1 (#47) of 3 (#11, #47, #50) residents reviewed for pressure ulcers.Findings:Review of the undated EBP policy revealed, in part:Purpose: Prevent the spread of novel or targeted multi-drug resistant organisms (MDROs)EBP expand the use of personal protective equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.EBP apply to:Wounds and/or indwelling medical devices (i.e., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. On 07/21/2025 at 9:36 a.m. and 07/22/2025 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 reviews and interview, the facility failed to provide in-services, at least 12 hours in a year, sufficient to ensure the continued competence of Certified Nursing Assistants (CNA) for 3 (S12CNA, S14CNA, S15CNA) of 5 (S11CNA, S12CNA, S13CNA, S14CNA, S15CNA) CNAs reviewed for in-service training. Findings:Review of the personnel record for S12CNA revealed a hire date of 07/02/2021. Further review of the personnel file revealed no documented evidence of 12 hours of annual training. Review of the personnel record for S14CNA revealed a hire date of 04/19/2023. Further review of the personnel file revealed no documented evidence of 12 hours of annual training. Review of the personnel record for S15CNA revealed a hire date of 05/30/2012. Further review of the personnel file revealed no documented evidence of 12 hours of annual training. On 07/22/2025 at 4:40 p.m., an interview with S3Director of Nursing (DON) confirmed that the required annual in-service training had not been provided to S12CNA, S14CNA and S15CNA.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to prevent the development and transmission of communicable diseases and infections for 4 (#2, #5, #6, and #7) of 4 residents reviewed for infection control. S7Certified Nursing Assistant (CNA) failed to clean the whirlpool according to manufacturer's guidelines. Residents #2, #5, #6, and #7 received whirlpool baths three times a week while having open wounds to their body. Residents #2, #5, #6 and #7 were currently receiving antibiotics related to wound infections. Findings: Review of the whirlpool manufacturer`s guidelines for cleaning whirlpool revealed the following in part: Clean and disinfect the tub and swivel lift after every bath with cleaner/disinfectant. 1. Raise the swivel lift completely and rotate or swing the chair back into the tub. 2. Close and lock the door. 3. Press the tub fill button and turn the temperature control knob all the way to the left to its warmest level to heat 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 observations, record reviews and interviews, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent cross contamination for 1 (#1) of 1 (#1) residents observed for wound care. The deficient practice was evidenced by the Wound Care Nurse (WCN) contaminating a cream used to treat a resident's burn and by storing a contaminated bottle of Dermal Wound Cleanser (DWC) inside of the wound care cart. Findings: Review of the medical record revealed resident #1 was re-admitted to the facility on [DATE] with diagnoses which included in part, acquired absence of right leg below knee, Type 1 diabetes with diabetic neuropathy, and hypertensive chronic kidney disease. Review of the medical record revealed a physician's order dated 01/11/2025 for Silvadene External Cream 1% (Silver Sulfadiazine) apply to right thigh topically one time a day related to patient's other non-compliance with medication regimen; Burn to right thigh-apply…

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 immediately consult the resident's physician when a resident had a change in condition or started a new treatment for 1 (#1) of 3 (#1, #3, and #4) residents reviewed for accidents. The deficient practice was evidenced by the nurse failing to notify the physician in a timely manner after she observed blisters on resident #1's skin. Findings: Review of the medical record revealed resident #1 was re-admitted to the facility on [DATE] with diagnoses which included in part, acquired absence of right leg below knee, Type 1 diabetes with diabetic neuropathy, and hypertensive chronic kidney disease. Review of the significant change in status assessment dated [DATE] revealed resident #10 had a brief interview for mental status score of 15 which indicated the resident was cognitively intact with his daily decision making skills. Further review of the assessment revealed that resident #1 was independent with his ability to eat. Review of the medical record…

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 each resident received adequate supervision to prevent accidents for 1 (#7) of 1 (#7) residents observed smoking in an unsafe manner. The deficient practice was evidenced by resident #7 tossing his lit cigarette butt on the concrete when left unsupervised outside in the smoking area. Findings: Review of the medical record revealed resident #1 was re-admitted to the facility on [DATE] with diagnoses including dementia and nicotine dependence. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed that resident #1 had a Brief Interview for Mental Status score of 05 which indicated the resident had severe cognitive impairment with his daily decision making skills. Review of the care plan revealed that resident #7 was a smoker. Further review revealed the approaches included that resident #7 required supervision while smoking. On 01/28/2025 at approximately 12:18 p.m., an observation revealed resident #7 smoking 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 policies were being followed for 1 (#10) of 7 (#5, #7, #8, #9, #10, #11, and #12) residents reviewed for smoking. The deficient practice was evidenced by the facility not having documented evidence of a Safe Smoking Evaluation completed quarterly for resident #7. Findings: Smoking/Tobacco Usage Waiver Smoking Policy (Undated): Review of the policy revealed it is the policy of the nursing facility to enforce a smoke-free environment within the facility for both residents and staff to ensure the rights, safety, and well-being of all residents and staff. Review of the smoking procedure included, but was not limited to: Residents who smoke will be assessed on admission, quarterly, and when there is a significant change in the resident's ability to handle their smoking products. Findings: Review of the medical record revealed that resident #10 was admitted to the facility on [DATE]. Review of the physician's progress notes dated 12/07/2024 revealed…

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 provide a safe, functional, sanitary, and comfortable environment for residents and staff by having environmental concerns throughout the inside and outside of the building. This deficient practice had the potential to affect 51 residents that resided in the building. Findings: On 11/04/2024 at 8:45 a.m. observation of the kitchen revealed the ceiling contained acoustic suspended tiles. The ceiling tiles were observed to have old water stains, the tiles by the ceiling vents were sagging, and 2 holes in the ceiling approximately 4 inches by 4 inches were observed. On 11/12/2024 at 11:40 a.m., an interview with S5Dietary Manager confirmed the ceiling tiles in the kitchen were stained with water damage, sagging, had 2 holes in the ceiling, and the ceiling needed to be repaired. On 11/4/2024 at 2:30 p.m. observation of the hallway floors throughout the facility revealed the floors had a buildup of dirt and grime and needed to be cleaned. On 11/04/2024 at 4:00 p.m. S1Administrator was notified of the hallway floors throughout…

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 nursing staff were able to demonstrate competencies and skills necessary to care for residents needs for 4 (#1, #2, #3, and #6) of 4 residents. The facility failed to have documentation of wound care, tracheostomy care, and medication administration. Findings: Review of Medication Administration General Guidelines policy and procedure dated 07/2024 revealed the following, in part: Procedure: 9. Only licensed or legally authorized personnel who prepare a medication may administer it. This individual records the administration on the resident's Medication Administration Record (MAR)/electronic MAR or Treatment Administration Record (TAR)/electronic TAR after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/TAR to ascertain that all necessary doses were administered and all administered doses were documented. In no case should the individual who administered the medications…

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 the residents' environment remained as free of accident hazards as is possible for 1 (#5) of 3 (#1, #5 and #8) residents reviewed for accident hazards. The facility failed to complete an Accident and Incident Report per the facility's policy and the facility failed to perform a thorough investigation after resident #1 was found to have illegal drugs in his possession. Findings: Review of the facility's Accident and Incident Documentation and Investigation Resident Incident policy undated revealed: Policy: Accidents and/or incidents involving resident care will be investigated and documented on the Risk Assessment section of Point Click Care (PCC) system. An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence…

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, policy review, and interviews, the facility failed to implement policies and procedures for enhanced barrier precautions (EBP) for 1 (#2) of 3 (#1, #2, and #6) residents reviewed for enhanced barrier precautions. Findings: Review of the facility's Enhanced Barrier Precautions (EBP) policy dated 04/01/2024 revealed Definition and Scope Enhanced Barrier Precautions are infection control interventions designed to reduce transmission of multidrug-resistant organisms (MDROs). Example of Use EBP 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) Review of resident #2's medical record revealed an admission date of 10/28/2024 with diagnoses including type 2 diabetes mellitus, chronic kidney disease, abdominal pain, severe sepsis, bacterial peritonitis, abscess of vulva, peripheral vascular…

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 a resident with wounds or history of wounds received necessary treatment and services, consistent with professional standards of practice to promote healing, to prevent infection, and to prevent wounds for 3 (#1, #2, and #3) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure weekly skin assessments were performed. Findings: Review of the provider's policy entitled Preventive Skin Care with a revision date of 07/2024 revealed in part: That it is the practice of this facility to provide routine preventive skin care. This policy will serve as a guide to facility staff with regard to clinically acceptable techniques to be applied for skin care prevention. Procedures include: complete a weekly skin evaluation on all residents; evaluate interventions that may be implemented based upon the resident's Risk Evaluation and develop an individualized care plan for preventive skin care based upon evaluation. Review of the provider's policy entitled Weekly Skin Audit dated 07/2024 revealed in-part: a skin…

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 residents' right to be free from verbal and mental abuse for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled residents. Findings: Review of the facility's Abuse Prevention Policy dated 07/2024 revealed in-part: Policy: 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 guardian, surrogates, friends, or any other individual. Definitions: a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the depravation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Abuse may be resident-to-resident, staff-to- resident, family-to-resident, 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 interviews, the provider failed to: 1) ensure an alleged violation involving verbal and mental abuse witnessed by staff was reported immediately to the Administrator and Director of Nursing and 2) ensure all allegations of verbal abuse/mental abuse were reported immediately, but no later than 2 hours after the allegation was made to State Survey Agency in accordance with State Laws for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled residents. Findings: Review of the facility's current Abuse Prevention Policy dated 7/2024 revealed in-part: Policy: 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 guardian, surrogates, friends, or any other individual. Definitions: a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm,…

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 be incompliance with all applicable Federal, State, and Local Laws, regulations, and codes by S1Administrator response time from residence to facility being over one hour. Findings: During an interview on 09/10/2024 at 10:35 a.m., S1Administrator revealed she lived 1.5 hours away from the facility. Review of S1Administrator's employee file revealed her residence listed was at least a 1.5 hour drive to the facility. During an interview on 09/17/2024 at 1:30 p.m., S1Administrator confirmed that her response time from her residence to the facility was over one hour.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure residents received services in the facility with reasonable accommodation of needs for 5 (#15, #17, #18, #26, #29 and #43) of 5 sampled residents and had the potential to affect all 44 residents that reside in the facility. Findings: Resident #17 Record review revealed resident #17's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. On 06/24/2024 at 9:15 a.m., an interview with resident #17 revealed sometimes the facility runs out of wipes when they are providing care. Resident #26 Record review revealed resident #26's MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated no cognitive impairment. On 06/24/2024 at 9:43 a.m., an interview with resident #26 revealed sometimes the facility does not have enough wipes to provide care. Resident #29 Record review revealed resident #29 was admitted on [DATE]. Further review revealed…

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 safe, clean, comfortable and homelike environment. The deficient practice affected 9 (#8, #11, #15, #17, #23, #26, #27, #29 & #49) of 9 sampled residents and had the potential to affect all 44 residents that resided in the facility. Findings: On 06/24/2024 at 9:15 a.m., 06/25/2024 at 9:28 a.m., and 06/26/2024 at 8:46 a.m., observations of resident #17's bathroom revealed a black substance in the toilet. On 06/24/2024 at 9:37 a.m., 06/25/2024 at 9:30 a.m., and 06/26/2024 at 8:50 a.m., observations of resident #23's bathroom revealed a black substance in the toilet and a foul odor noted. On 06/24/2024 at 9:43 a.m., 06/25/2024 at 9:32 a.m., and 06/26/24 at 8:55 a.m., observations of resident #26's bathroom revealed a black substance in the toilet. On 06/24/2024 at 10:30 a.m., an observation of resident #29's room revealed there was a urine odor noted. Further observation on 06/25/2024 at 12:35 p.m. revealed resident #29's door had spills and splatters on it and dirt and grime was on the closet drawers and around…

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 implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to the stage agency and one or more law enforcement entities for 1 (#34) of 1 (#34) residents reviewed for misappropriation of resident property. Findings: Review of the facilities Abuse Prevention Policy and Procedure (policy was not dated) revealed in-part: Misappropriation of Resident Property: The deliberate misplacement, exploitations, or wrongful temporary or permanent use of a resident's personal belongings or money without the resident's consent. 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. In addition, the facility will follow Section 1150B of the Social Security Act's time limits 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure all alleged violations of misappropriation of resident property are thoroughly investigated in a timely manner for 1 (#34) of 1 (#34) resident reviewed for personal property. Findings: Review of the facilities undated Abuse Prevention Policy and Procedure revealed in-part: Policy: 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, sponsors, friends, visitors, or any other individual. Definitions: Misappropriation of Resident Property: The deliberate misplacement, exploitations, or wrongful temporary or permanent use of a resident's personal belongings or money without the resident's consent. Investigation: The facility will initiate at the time of any finding of potential abuse or neglect an investigation 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 observations, record reviews, 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 for 3 (#6, #17 #23) of 4 (#6, #11, #17, #23) sampled residents for Activities of Daily Living as evidenced by, 1) failing to ensure resident's clothing was clean and free of food debris and 2) failing to ensure resident's fingernails and toenails were trimmed and clean. Findings: Resident #6 Review of the record for resident #6 revealed a date of admission of 07/23/2015 with following diagnoses: chronic obstructive pulmonary disease, type 2 diabetes, cerebral disease, and dysphagia. Review of the quarterly Minimum Data Set, dated [DATE] revealed resident #6 had a brief interview for mental status score of 2. A score of 00-07 indicated that resident #6 was severely impaired with daily decision making skills. Review of functional abilities and goals for eating revealed setup or clean-up…

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 that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 5 (S20Certified Nursing Assistant (CNA), S21CNA, S22CNA, S23CNA, and S24CNA) personnel records reviewed. Findings: Review of the personnel record for S20CNA revealed a hire date of 03/26/2024. Further review of the personnel record revealed no documented evidence of skills checks or competency evaluations for S20CNA. Review of the personnel record for S21CNA revealed a hire date of 07/02/2021. Further review of the personnel record revealed no documented evidence of skills checks or competency evaluations for S21CNA. Review of the personnel record for S22CNA revealed a hire date of 07/28/2023. Further review of the personnel record revealed no documented evidence of skills checks or competency evaluations for S22CNA. Review of the personnel record for S23CNA revealed a hire date of 10/05/2023. Further 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.

Based on observation of the medication pass, review of physician orders and interview, the facility failed to ensure that it is free from a medication error rate of 5% or greater by having 4 errors out of 33 opportunities for a medication error rate of 12.12%. (Residents #41, #13) Findings: Resident 41 Observation of the medication pass for resident #41 on 06/25/2024 at 8:27 a.m. revealed that S15Licensed Practical Nurse (LPN) administered 6 oral medications and 1 eye medication. Review of the June 2024 physician orders for resident #41 revealed the high blood pressure medication Losartan 25 milligrams (mg) administer 1 tablet every day by mouth at 9:00 a.m. Observation of the medication pass revealed Losartan 25 mg was not observed to be administered to resident #41. Interview with S10Registered Nurse (RN) on 06/26/2024 at 11:00 a.m. confirmed that the medication Losartan 25mg, 1 tablet every day should have been administered to resident #41. Observation of the medication pass for resident #41 on 06/25/2024 at 8:27 a.m. revealed that the eye medication, Carboxymethyl Cellulose…

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 prepare and distribute food in accordance with professional standards for food service safety by failing to ensure food was defrosted properly. This deficient practice had the potential to affect 44 residents who received meals served from the kitchen. Findings: Review of the facility Policy for Safely Thawing Food (no date noted) revealed in part: How to Thaw Food Safely: 3). Thawing in cold water - fill a bowl with cold water and leave the tap water running over the food as it thaws. This does require a lot of water, but it will keep the surface temperature of your food from growing bacteria too rapidly. If you can, keep your food in its original container or in a plastic bag to protect your kitchen sink and counter from germs. On 6/25/2024 at 6:50 a.m. during a follow-up visit to the kitchen, an observation revealed a large amount of chicken breasts submerged in water in the kitchen sink and there was no running cold water noted. Further observation revealed the chicken breasts were not placed in a container in the…

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

Based on review of the Quality Assessment and Assurance (QAA) record and interview, the facility failed to have documented evidence of having a QAA meeting at least quarterly for the year 2024. Findings: Review of the QAA binder revealed no documented evidence of the facility having a QAA meeting for the first quarter of 2024 to address facility issues. On 06/26/2024 at 5:50 p.m., an interview with S1Administrator confirmed there was no documented evidence of a QAA meeting for the first quarter of 2024.

Based on observation, policy review and interviews the facility failed to implement policies and procedures for enhanced barrier precautions for 5 (#24, #25, #26, #45, #255) of 5 (#24, #25, #26, #45, #255) residents reviewed for enhanced barrier precautions. Findings: Review of the provider's undated Enhanced Barrier Precautions Policy revealed the following in-part: Policy: Enhanced Barrier Precautions are indicated for residents with infections or colonization with a Center for Disease Control (CDC) and Prevention -targeted Multi Drug-Resistant Organisms (MDRO) when contact precautions do not apply or for residents with wounds and/or indwelling medical devices without secretions/excretions that are unable to be covered/contained & are not known to be infected/colonized with any MDRO during high-contact resident care activities as these residents are at an increased risk of being infected. Definition: 1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of MDROs in nursing homes. Enhanced Barrier Precautions involve gown and glove…

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 review of the facility's Infection Control Records, the facility failed to designate an individual/individuals as the Infection Preventionist, who is responsible for the facility's infection prevention and control program. Findings: Review of the facility's Infection Control Records revealed there was no documented evidence that the facility had designated a staff member as the Infection Control Preventionist. On 06/25/2024 at 1:10 p.m., an interview with S1Administrator confirmed they do not currently have a staff member designated as the Infection Preventionist for the facility.

Based on observations, record review, and interviews, the facility failed to maintain an effective pest control program to ensure residents had a pest free environment. The deficient practice affected 11 (#9, #11, #15, #18, #24, #27, #29, #33, #43, #47, and #49) of 11 sampled residents and had the potential to affect all 44 residents that resided in the facility. Findings: Review of the Pest Control Policy dated May 2008 revealed the following, in part: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Observation of the hall where residents #11, #27, #29, and #49 reside on 06/24/2024 at 11:00 a.m. with S1Administrator revealed flies in the hallway. Interview with S1Administrator at this time revealed the facility has a problem with flies. Observations on 06/25/2024 at 8:25 a.m. and 06/26/2024 at 1:40 p.m. of the hall where residents #11, #27, #29, and #49 reside revealed flies in the hallway. Observation on 06/24/2024 at 10:30 a.m. of resident #29's room revealed a urine smell in the room and multiple flies…

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 provide in-service training for nurse aides to ensure competency for 5 (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA) of 5 personnel records reviewed. The facility failed to ensure: 1.) S20CNA, S21CNA, S22CNA, and S23CNA received training in resident abuse, 2) S20CNA, S23CNA, and S24CNA received training in dementia management and 3) S21CNA and S24CNA who were employed greater than one year received 12 hours of inservice training yearly. Findings: Review of the personnel record for S20CNA revealed a hire date of 03/26/2024. Further review of the record revealed no documented evidence of dementia management training and resident abuse prevention training. Review of the personnel record for S21CNA revealed a hire date of 07/06/2021. Further review of the record revealed no documented evidence of 12 hours per year of in-service training to include resident abuse prevention training. Review of the personnel record for S22CNA revealed a hire date of 07/28/2023. Further review of the record revealed no documented evidence 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 reviews and interview, the facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment within 14 days after the resident was discharged from the facility for 3 (#10, #31 and #40) of 3 residents reviewed for assessments. Findings: Review of the medical record for resident #10 revealed the resident was admitted to the facility on [DATE] and discharged on 03/24/2024. Review of the medical record for resident #31 revealed the resident was readmitted to the facility on [DATE] and discharged on 03/01/2024. Review of the medical record for resident #40 revealed the resident was admitted to the facility on [DATE] and discharged on 01/13/2024. On 06/25/2024 at 2:45 p.m., interview with S5Minimum Data Set (MDS) Coordinator confirmed the discharge MDS assessments were not performed and transmitted in a timely manner for residents #10, #31 and #40.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure residents who received respiratory care are provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 2 (#20 & #34) of 2 residents reviewed for respiratory care. The facility failed to ensure: 1.) resident #20 was administered oxygen via nasal cannula per the physician orders and 2.) resident #34's nebulizer mask and tubing was stored in a plastic bag when not in use. Findings: Review of the record for resident #20 revealed an admit date of 11/27/2023 with the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD) Exacerbation and vascular dementia. Review of the June 2024 Medication Administration Record (MAR) for resident #20 revealed an order for continuous oxygen (O2) therapy at the following rate: oxygen at 2 liters/minute continuous by nasal cannula. Review of the undated policy for oxygen therapy revealed in part that oxygen is administered 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 record reviews and interview, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) initially upon hire and monthly thereafter for 5 (S20CNA, S21CNA, S22CNA, S23CNA and S24CNA), and the facility also failed to ensure the CNA registry was verified upon hire for 1 (S20CNA) for 5 (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA) personnel files reviewed. Findings: Review of S20CNA's personnel file revealed a hire date of 03/26/2024. Further review of S20CNA's personnel file revealed there was no documented evidence of a State Adverse Actions check for S20CNA upon hire or monthly thereafter. There was no documented evidence of the CNA registry check obtained upon hire for S20CNA. Review of S21CNA's personnel file revealed a hire date of 07/02/2021. Further review of S21CNA's personnel file revealed there was no documented evidence of a State Adverse Actions check for S21CNA upon hire or monthly thereafter. Review of S22CNA's personnel file revealed a hire date of 07/28/2023. Further review of S22CNA's personnel…

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 reviews and interviews, the facility failed to ensure that a resident maintains acceptable parameters of nutritional status for 1 (#31) of 1 (#31) resident reviewed for nutrition. The facility failed to notify the Registered Dietician regarding a resident's significant weight loss. Findings: Review of resident #31's medical record revealed diagnoses including Parkinson's disease, severe dementia with behavioral disturbance, major depressive disorder, and delusional disorder. Review of resident #31's Quarterly Minimum Data Set, dated [DATE] Quarterly Minimum Data Set revealed a Brief Interview for Mental Status score of 0, which indicated severe cognitive impairment. Further review revealed she was totally dependent on staff for all activities of daily living with 1-2 person assistance. She was also totally dependent on staff with 1 person assistance for eating. Review of resident #31's Malnutrition Risk assessment dated [DATE] revealed she was assessed to be at a high risk 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 record reviews and interviews the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 2 (#14 and #17) of 6 (#10, 14, 17, 21, 22 and 31) residents reviewed for unnecessary medications. The facility failed to obtain lab work for residents #14 and #17 as ordered by the physician. Findings: Resident #17 Review of the medical record for resident #17 revealed an admission date of 03/02/2020 with diagnoses including acute osteomyelitis, diabetes mellitus, arthritis, venous insufficiency, hypokalemia, heart disease, edema, magnesium deficiency, obesity, hyperlipidemia, and anxiety. Review of the physician orders dated 09/14/2021 revealed an order to obtain a Complete Blood Count (CBC) and chem 14 every 6 months in May and November. Review of the nurses notes dated 05/16/2023 revealed the nurse attempted to draw labs times two attempts and unable. The Nurse Practitioner was notified and an order was obtained to draw the labs on 05/18/2023. Review of the lab results or nurses noted revealed no documented evidence of the CBC or chem 14…

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 review of the Quality Assessment and Assurance (QAA) record and interview the facility failed to have documented evidence of having QAA meeting as least quarterly for the year 2023. Findings: Review of the QAA binder revealed no documented evidence of the facility having a QAA meeting for the first quarter of 2023 to address facility issues. On 07/26/2023 at 11:45 a.m., interview with S3Corporate Nurse revealed the facility did not have documented evidence of QAA meetings done quarterly.