Legacy Nursing at St. Christina

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. The facility failed to ensure that kitchen staff were wearing hair restraints including beard restraints to prevent hair from contacting food. The deficient practice had the potential to affect all of the residents who received meals from the kitchen. There were 131 residents who resided in the facility.Findings:Observation on 02/23/2026 at 12:15 p.m. of the facility's kitchen revealed three male kitchen workers with beards not wearing beard restraints while preparing food, serving food, and washing dishes. Interview on 02/23/2026 at 12:17 p.m. with S6 Dietary Manager revealed that beard restraints are easily available to the male workers with beards. She confirmed that the male kitchen workers with beards should have had beard restraints on but did not.

Based on record review and interview, the facility failed to ensure the Quality Assessment and Assurance committee met at least quarterly to identify facility issues and coordinate and evaluate performance improvement projects.A review of the facility's Quality Assurance binder revealed that the last documented Quality Assurance (QA) meeting was held on 10/15/2025 for the 2025 3rd quarter (July-September).In an interview on 02/24/2026 at 4:33 p.m., S2 ADM stated that the QAA committee did have a meeting for the 2025 4th quarter, and the documented meeting minutes were located in the QAPI (Quality Assurance and Performance Improvement Program) binder, which the facility cannot locate. S2 ADM stated he had no documented evidence of the QAA committee meeting for the 2025 4th quarter.

Based on observation and interview, the facility failed to maintain an effective pest control environment by failing to ensure the facility was free from insects. The deficient practice had the potential to affect all 131 residents who resided in the facility.Findings: Review of the facility's undated policy titled, Pest Control Policy and Procedure read in part.Policy: The facility shall maintain an effective pest control program.Procedure: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During an observation of Resident #8's room on 02/23/2026 at 7:51 a.m., 8:50 a.m., and 9:20 a.m. revealed multiple gnats on a basket of soiled clothes and multiple gnats flying around on top of the basket of clothes. In an interview on 02/23/2026 at 2:05 p.m., S8 NS Adm acknowledged multiple gnats were observed in Resident #8's room in the basket and on top of the soiled clothes and should not have been. In an interview on 02/24/2026 at 6:20 p.m., S5 CES confirmed the above findings.

A review of the facility's undated policy titled, Quality of Care Policy and Procedure, read in part. It is the policy of our company that each resident receives the necessary care to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the resident's comprehensive assessment and plan of care.Resident #1Review of Resident #1's medical record revealed an admission date of 10/06/2022, with diagnoses that included, in part. Chronic Obstructive Pulmonary Disease, Type II Diabetes, and Benign Prostatic Hyperplasia with lower urinary tract symptoms, Obstructive and Reflux Uropathy.Review of Resident #1's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/30/2025 revealed Resident #1 had a BIMS score of 14, which indicated intact cognition. Resident #1 required moderate assistance with showering and bathing.Review of Resident #1's electronic health record's facility task titled, Bathing/Shower Scheduled (Three times weekly) Specify days:(Monday, Wednesday, Friday OR Tuesday, Thursday, Saturday) with a…

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

Based on record review and interview, the facility failed to ensure that an allegation of verbal abuse was reported immediately, but no later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 3 sampled residents reviewed for abuse. Review of the facility's undated policy titled, Abuse Reporting and Investigation Policy and Procedure, read in part. 2. An Alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance or sight, regardless of age, ability to comprehend, or disability. Examples: Name-calling, cursing, yelling at a patient in anger.Review of Resident #1's medical record revealed an admission date of 10/06/2022, with diagnoses that included, in part. Chronic Obstructive Pulmonary Disease,…

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

Based on interview and record review the facility failed to ensure an allegation of staff to resident sexual abuse and resident to resident physical abuse was reported to the State Survey Agency immediately, but not later than 2 hours after the staff to resident sexual abuse and resident to resident physical abuse was discovered, for 2 (Resident #1 and Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents. Findings:Review of an undated facility policy titled “Abuse Prevention and Prohibition” revealed in part . “An alleged violation of abuse…will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury - to the mandated state agency per reporting criteria within guidelines of notification of an alleged abuse.” Resident #1 Review of Resident #1's medical record revealed an admission date of 04/08/2025, a discharge date of 09/25/2025, with diagnoses that included in part…Intellectual Disabilities, Schizoaffective Disorder; Anxiety Disorder; Major Depressive…

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

Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice by failing to ensure a residents received a prescribed antibiotic in a timely manner for 1 (#2) of 3 (#1, #2, and #3) sampled residents. Findings:Review of Resident #2's medical record revealed an admit date of 03/10/2025 with diagnoses that included: Other Chronic Osteomyelitis, Left ankle and foot, Cerebral Infarction, Unspecified Hemiplegia and Hemiparesis, Persona; History of Urinary Tract Infection, Unspecified Mood Affective Disorder, Epilepsy, Paranoid Schizophrenia, and Major Depressive Disorder. Review of Resident #2's medical record revealed a progress notes dated 06/23/2025 by the facility Nurse Practitioner read in part. New order noted for urinalysis with culture and sensitivity for dysuria and altered mental status. Review of Resident #2's medical records revealed an unloaded urinalysis dated 06/26/2025 with a hand written note at the bottom that read Cefdinir 300 mg BID. Review of Resident #2's 06/2025 Physician Orders read in…

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

Based on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 (#3) of 3 (#1, #2, and #3) sampled residents. Findings:Review of the Facility's undated policy titled Enteral Feeding Therapy (Tube Feeding) Policy and Procedure read in part.Purpose: to provide liquid nourishment through a tube, inserted into the stomach. Policy: All enteral tube feedings shall have care according to physician orders. Review of Resident #3's medical record revealed and admit date of 09/28/2021 with a readmission date of 07/10/2024 with diagnoses that included: Cerebral Palsy, Aphasia, Mild Protein Calorie Malnutrition, Gastrostomy Status, Dysphagia, Type 2 Diabetes Mellitus, and Bipolar Disorder. Review of Resident #3's admission MDS with an ARD of 07/22/2025 revealed a BIMS of 2, which indicated severely impaired cognition. Review of Resident #3's Care Plan with a review date of 11/02/2025 read in part. I require a PEG tube for adequate nutritional intake related to my dysphagia. Administer my tube feeding 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.

Based on a record review and interview, the facility failed to provide care and services that met professional standards of quality by failing to ensure that a resident's medical record reflected whether Physician's Orders were implemented or refused. The facility failed to document whether wound care was or was not provided for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for skin and pressure ulcers. Review of facility undated policy titled, Skin/Wound Documentation Policy and Procedure, revealed in part. Skin and wounds will be documented upon admission, readmission, weekly, and as needed. The facility shall follow the practitioner's orders for treatment of the pressure ulcer (injury). With each dressing change, or at least weekly, the pressure ulcer (injury) wound shall be assessed and documented. Pressure ulcer (injury) documentation should include, in part.date and time of initial and subsequent treatments. Review of Resident #3's medical record revealed an admit date of 03/10/2025 with the following diagnoses in part. Chronic…

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

Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain personal hygiene for 1 (Resident #3) of 3(Resident #1, Resident #2, Resident #3) residents reviewed for Activities of Daily Living (ADL) care. The facility failed to ensure a Bath/Shower was provided for Resident #3.A review of facility undated policy titled, Quality of Care Policy and Procedure, read in part. It is the policy of our company that each resident receives the necessary care to attain or maintain the highest practicable physical, mental and psychological well-being, in accordance with the resident's comprehensive assessment and plan of care.Review of Resident #3's medical record revealed an admit date of 03/10/2025 with the following diagnoses in part. Chronic Osteomyelitis Left Ankle and Foot, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Dysarthria following Cerebral Infarction, Epilepsy, Peripheral Vascular Disease, Presence 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.

Based on observation and interview the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary and orderly interior. This deficient practice had the potential to affect the 124 resident's that resided at the facility. Findings:Observation on 07/21/2025 at 11:45 a.m. of Resident #2's room (Room B) revealed the floor had hair and a dark brown substance near the bed area. The wall near Resident #2's bed had a moderate amount of a splattered substance that was tan and pink in color. The window blinds in the room had broken pieces and was in disrepair.Observation on 07/21/2025 at 11:49 a.m. of Room A area revealed a large puddle of yellow liquid on the floor. The area smelled of urine. Interview with S4Corporate at time of observation confirmed the floor was unsanitary and was in need of cleaning.Observation on 07/21/2025 at 11:56 a.m. of Hall A, near Room C revealed a ceiling tile with a moderate sized amount of mold. Interview with S10HK at time of observation revealed the ceiling had been leaking, for at least a few weeks, and she had…

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, record review, and interview the facility failed to provide care and services that meet professional standards of quality, by failing to: 1. Perform weights as ordered for 3 (#3, #4, and #R1) of 6 (#1, #2, #3, #4, #R1, and #R2) residents reviewed for weights; and 2. Input orders for wound care for 1 (#4) of 3 (#2, #3, and #4) residents reviewed for wound care. Findings: 1. Resident #3 Review of the Facility's undated policy titled Weight Evaluation Policy and Procedure read in part .Purpose: To review, monitor, and maintain the resident weight. Procedure: 1. Weights are to be completed and documented in PCC chart for resident. 3. The following residents will be weighed weekly for 4 weeks until stable unless otherwise prescribed by the physician. D. 5% loss or gain in less than 31 days. Review of Resident #3 's medical record revealed an admit date of 03/28/2025 with diagnoses that included in part: Spondylolisthesis, Neuromuscular Dysfunction of Bladder, Pseudoarthrosis after Fusion, Major Depressive Disorder, Hemiplegia, and Personal History of Urinary Tract…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received reasonable accommodation of needs for 2 (#3 and #4) of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to ensure Resident #3 and Resident #4 had an appropriate call light and that it was within reach to call for assistance. Findings: Review of the Facility's undated policy titled Call light, Use of Policy and Procedure read in part . Policy: To respond promptly to residents call for assistance. Procedure: 13. Have the resident demonstrate the use of the call light to be sure he/she understands your instructions. 15. Be sure the call lights are placed on the bed at all times, never on the floor or bedside stand. Resident #3 Review of Resident #3 's medical record revealed an admit date of 03/28/2025 with diagnoses that included in part: Spondylolisthesis, Neuromuscular Dysfunction of Bladder, Pseudoarthrosis after Fusion, Major Depressive Disorder, Hemiplegia, and Personal History of Urinary Tract Infection. Review of Resident #3's Minimum Data Set (MDS) with an ARD 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.

Based on observation, record review and interview, the facility failed to ensure 1 (Resident #3) of 2 ( Resident #3 and Resident #4) sampled residents received the necessary treatment and services to prevent and promote the healing of pressure ulcers by failing to perform hand hygiene during treatment of a pressure ulcer. Findings: Review of Resident #3 's medical record revealed an admit date of 03/28/2025 with diagnoses that included in part: Spondylolisthesis, Neuromuscular Dysfunction of Bladder, Major Depressive Disorder, Hemiplegia, and Personal History of Urinary Tract Infection. Review of Resident #3's Minimum Data Set (MDS) with an ARD of 04/08/2025 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #3 was totally dependent on staff and required physical assistance for all activities of daily living. Review of Resident #3's 06/2025 Physician Orders read in part . Treatment #1- Unstageable Pressure Ulcer to left buttocks. Cleanse with wound cleanser, pat dry, apply medihoney to wound bed, followed by calcium…

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 interview, the facility failed to ensure each resident was free of medication errors for 1 (#4) of 4 residents reviewed. The facility failed to ensure medications were administered to Resident #4 as ordered by the physician. Findings: Review of Resident #4 's medical record revealed an admit date of 04/28/2020 and a re-entry date of 06/05/2025 with diagnoses that included in part: Paroxysmal Atrial Fibrillation; Acute and Chronic Respiratory Failure with Hypoxia; Hypertensive Heart Disease with Heart Failure; Mild Protein-Calorie Malnutrition; Schizoaffective Disorder; Bipolar Type; Major Depressive Disorder; Generalized Anxiety Disorder; and Peripheral Vascular Disease. Review of Resident #4's Minimum Data Set (MDS) with an ARD of 06/08/2025 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Resident #4 was dependent or required substantial/ maximum assistance with activities of daily living. Review…

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

Based on interviews, and record reviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices. The facility failed to ensure: 1. A wound care order was documented for Resident #3 when received by facility; 2. Documentation on the Treatment Administration Report (TAR) was accurate for Resident #3; and 3. Wound care was documented for Resident #3. Findings: Interview with S5 ADON on 02/26/2025 at 11:25 a.m. revealed Resident #3 had a fall with a wound to his right elbow on 02/21/2025. S5 ADON confirmed there should have been an order for wound care for Resident #3, but there was not. Interview with S2 DON on 02/26/2025 at 2:07 p.m., revealed she was not at the facility on 02/21/2025, and was notified by S10 RN via telephone that Resident #3 had fallen and had a wound to his right elbow. S10 RN notified the provider on 02/21/2025 at 11:38 p.m., and was given an order for wound care. S2 DON stated on 02/25/2025 she realized the order for wound care had not been documented or entered. S2 DON stated she performed wound…

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

Based on interview and record review the facility failed to ensure services were provided according to the residents plan of care for 2 (#33 and #91) out of a sample of 40 residents. The facility failed to follow the following physician's orders for monthly labs for Resident #33 and failed to ensure wound care was provided for Resident #91 as ordered. Findings: Review of the facility's undated policy titled Lab/Diagnostic Monitoring Log Policy and Procedure on 01/28/2025 read in part Purpose: To ensure all labs and diagnostics are completed and followed up on for all residents as ordered by the physician. Procedure: All nurses are responsible for: 1. Making sure labs/diagnostics are being performed. Resident #33 Review of Resident #33's medical records revealed an admit date of 01/10/2023 with diagnoses that included: Type 2 Diabetes Mellitus, Cerebellar Stroke Syndrome, Unspecified Convulsions, Generalized Anxiety Disorder and Conversion Disorder with seizures or Convulsions. Review of Resident #33's 01/2025 Physician's Order read in part 11/07/2023-Trileptal Oral Tablet 150 MG…

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

Based on observation, interview, and record review the facility failed to maintain a clean, safe, comfortable and homelike environment by failing to ensure the cleanliness and good repair of patient care equipment for 2 (Resident #52 and Resident #39) of 40 total sampled residents. Findings: Review of the facility's undated policy titled Reusable Medical Devices Cleaning Policy and Procedure read in part . Purpose: To keep reusable medical devices clean and prevent transmission of infection. Policy: Reusable medical devices will be cleaned after each resident use to prevent spread of infection. Procedure: 1. All surface areas of the machine will be cleaned with disinfectant wipe according to manufacture recommendations. Equipment and Supplies: 7. Any reusable medical device Resident #52 Observation on 01/26/2025 at 10:30 a.m. revealed Resident #52's wheelchair cushion was soiled with a large amount of brown substance. Observation on 01/27/2025 at 09:41 a.m. revealed Resident #52's wheelchair and black wheelchair cushion was visibly dirty. Observation on 01/28/2025 at 10:23 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to transmit/encode a Discharge MDS (Minimum Data Set) Assessment accurately for 1 (Resident #100) of 1 sampled resident reviewed for resident assessments. The total sample size was 40 residents. Findings: Review of Resident #100's clinical record revealed an admit date of 11/18/2024 with diagnoses that included Bipolar Disorder, current episode mixed, Severe without Psychotic Features, Sepsis, unspecified organism, Type 2 Diabetes Mellitus, Major Depressive Disorder, unspecified Mood (Affective) Disorder, Anxiety Disorder and Essential (Primary) Hypertension. Review of Resident #100's Discharge summary dated [DATE] read in part . Resident #100 requested to transfer to sister facility. Resident #100 only stayed at facility one night and wanted to leave AMA. Resident #100 decided she would prefer to be transferred to another nursing home and her spouse agreed. Resident #100 was transported by staff with her medications and all of her belongings. Signed by…

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, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure physician's orders were implemented as ordered. The facility failed to ensure the correct tube feeding was administered at a continuous rate for 1 (#67) of 1 residents reviewed for tube feeding. Total sample size was 40. Findings: Review of the Facility's undated Policy titled Enteral Nutritional Therapy, (Tube Feeding) Policy and Procedure revealed in part .All enteral tube feedings shall have care according to physician orders. Review of Resident #67's medical record revealed an admission date of 10/14/2022 with a re-entry date of 05/07/2024 with diagnoses that included in part .Cerebral infarction unspecified; Schizoaffective Disorder, Bipolar type; Type 2 Diabetes Mellitus; Dysphagia following Cerebral Infarction; Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side; Paranoid Schizophrenia; Unspecified Dementia. Review of Resident #67's Annual MDS with an ARD of 01/19/2025 revealed a…

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

Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary service to maintain good nutrition for 1 (Resident #52) resident reviewed during dining services in a total of 40 sampled residents. The facility failed to provide assistance during meal time to Resident #52. Findings: Review of the Facility's undated Policy titled Meal- Time Assistance Policy and Procedure revealed in part . Policy: All residents who require assistance with meals will be provided assistance. Purpose: To ensure residents receive adequate nutrition. Procedure: 1. Assistance will be provided to residents as needed. Review of Resident #52's clinical record revealed an admit date of 08/15/2023 with diagnoses which included in part . Huntington's disease, contracture-right hand, drug induced subacute dyskinesia, and deficiency of other vitamins. Review of Resident #52's Quarterly MDS with an ARD of 11/19/2024 revealed a BIMS was not conducted: resident rarely/never understood. Resident had modified…

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

Based on interview and record review, the facility failed to ensure staff followed a resident's person centered plan of care, by failing to use 2-person physical assistance when transferring a resident from wheelchair to bed for 1 (Resident #55) of 3 (Resident #55, Resident #79, and Resident #251) residents reviewed for accidents. Findings: Review of the facility's undated policy titled Transfer Activities Policy and Procedure on 01/28/2025 revealed in part . Purpose: To transfer the resident from bed to chair or toilet safely. Procedure: 1. Obtain assistance of another individual if necessary, for safe transfer. Review of Resident 55's medical records revealed an admit date of 04/28/2020 with diagnoses that included: Hypertensive Heart disease with Heart Failure, Schizoaffective Disorder, Major Depressive Disorder, and Peripheral Vascular Disease. Review of Resident #55's Quarterly MDS with an ARD of 09/17/2024 revealed a BIMS score of 14, indicative of intact cognition. Resident #55 required 2-person physical assist for bed mobility and transfers. Resident #55 had range of motion…

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

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #67 and Resident #81) of 4 sampled Residents reviewed for respiratory care. The facility failed to ensure equipment was properly labeled and stored. Total sample size was 40. Findings: Resident #81 Review of Resident #81's medical record revealed an admit date of 04/12/2023 with diagnoses that included in part .Chronic Obstructive Pulmonary Disease, Asthma, Respiratory Infection, Pneumonia in Diseases Classified Elsewhere and Dementia. Review of Resident #81's active Physician orders revealed the following order with a start date of 08/23/2024: Administer Oxygen at 2 Liters per minute via nasal cannula as needed for Shortness of Breath. Review of Resident #81's Care Plan with a Target date of 02/04/2025 revealed in part .I have Asthma, Chronic Obstructive Pulmonary Disease or Chronic Lung Disease with interventions that included in part .I need Oxygen when I have a respiratory crisis, administer nebulizer treatments as ordered.…

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

Based on record review and interview the facility failed to ensure there was sufficient nursing staff available at all times to provide nursing and related services to meet the resident's needs and safety in a manner that promotes each residents rights, physical, mental and psychosocial well-being. The facility failed to ensure there was sufficient staff on Saturday 09/28/2024, to provide care and services for residents residing in the facility. The facility census was 96. Findings: Review of the Payroll Based Journal (PBJ) staffing data submission for fiscal year 2024, Quarter 4 revealed in part .one star staffing rating (triggered), and excessively low weekend staffing (triggered). Review of a Staffing Pattern Reporting Form for 07/01/2024 - 09/30/2024 revealed in part . On 09/28/2024, the facility's census was 110 residents. Minimum staffing hours required for that day was 258.5 hours; however, the total number of nursing hours provided on 09/28/2024 was 256.5. Interview on 01/28/2025 at 4:56 p.m. with S2 Interim DON, confirmed the facility did not provide sufficient nursing…

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

Based on interview and record review, the facility failed to ensure an allegation of resident to resident abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. Resident #1 Review of Resident #1's medical record revealed an admission date of 08/16/2024, with diagnoses that included: Cerebral Infarction, Chronic Kidney Disease, Schizoaffective Disorder, Aneurism of Unspecified Site, Personal History of Traumatic Brain Injury, Major Depressive Disorder, and Anxiety Disorder. Review of Resident #1's admission MDS 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.

Based on interview and record review, the facility failed to ensure an allegation of staff to resident physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's policy on 03/14/2024 at 4:20 p.m. titled Abuse Prevention and Prohibition revision 4.0 dated 01/27/2023 read in part . An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury . The facility administrator or designee shall report or cause a report to be made to the mandated state agency per reporting criteria within guidelines of notification of an alleged abuse. Review of Resident #1's Quarterly MDS with an ARD of 01/16/2024 revealed a BIMS score of 13, indicating intact cognition. Interview 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.

Based on interview and record review, the facility failed to have evidence that an allegation of staff to resident physical abuse was thoroughly investigated for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents. Findings: Review of the facility's policy on 03/14/2024 at 4:20 p.m. titled Abuse Prevention and Prohibition revision 4.0 dated 01/27/2023 read in part . Investigation: Administrator or designee will complete a thorough investigation. Interview employees who were working in resident's room during the time in question. Signed statements should be obtained from these employees. Interview the resident if they are cognitively able to answer questions. If the resident is not interviewable, interview the roommate. Resident family and friends may be questioned. A licensed professional nurse will examine the resident for signs of injury and notify the resident's physician of any injuries noted. Maintain a file in the administrator or designee office. This file must be kept private and confidential. Review of the facility's investigation documentation…

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 act promptly on grievances concerning issues of resident care and life in the facility reported by residents during a monthly Resident Council meeting for 1 (10/30/2023) of 3 (08/28/2023, 09/26/2023, and 10/30/2023) meetings reviewed. Findings: Review of the facility's policy titled Grievance Policy and Procedure read in part . Purpose: 1. To ensure each resident has the right to voice grievances with respect to treatment or care, that is, or fails to be furnished without discrimination or reprisal for voicing grievances. 2. To ensure each resident grievance will be followed up by prompt efforts to resolve grievance that the resident may have, including those with respect to the behavior of other residents. Policy: All grievances will be investigated thoroughly, and appropriate corrective action taken. Procedure: 1. The facility Administrator or designee will act as the Grievance Official. 6. Resident council or other resident meeting minutes are to be given to administration after completion of meeting. Review of Resident…

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

Based on observation, record review, and interview, the facility failed to ensure services were provided to meet professional standards of practice for 3 (Resident #70, Resident #80, and Resident #90) of 37 sampled residents. The facility failed to ensure: 1. A resident's peg tube was checked for placement and residual prior to beginning a feeding as ordered for Resident #70, 2. Physician's orders for peg tube feedings were followed for Resident #80, and 3. Physician's orders for documenting percentages of Mighty Shake and House Supplement were followed for Resident #90. Findings: Review of the facility's policy titled Enteral Nutritional Therapy, (Tube Feeding) Policy and Procedure revealed in part . Procedure: 1. Place resident in semi-Fowler's position, unless contraindicated. 2. Remove plug from end of feeding tube, check position of tube, and attach barrel of syringe to end of tubing. 3. Check position of tube by: a. Listening for breath sounds at end of tube or place end of tube in a glass of water below water level to be sure no bubbles appear from Nasogastric tube. b.…

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

Based on record review and interview, the facility failed to ensure the facility had 8 consecutive hours per day of Registered Nurse (RN) coverage for 4 of 91 days reviewed for RN hours. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year Quarter 3 2023 (April 1-June 30) revealed no RN hours on 04/16/2023, 04/23/2023, 04/29/2023, and 04/30/2023. In an interview on 11/15/2023 at 3:46 p.m., S1 Administrator stated she could not confirm there was no RN coverage on the days reported in April 2023 because she was not employed by the facility at that time and was unable to obtain the information from the previous owner of the facility. S1 Administrator acknowledged the four days were reported by the old company as not having RN coverage. In an interview on 11/16/2023 at 8:10 a.m., S2 DON acknowledged she did work at the facility in April 2023 and confirmed there was no RN coverage on 04/16/2023, 04/23/2023, 04/29/2023, and 04/30/2023.

Based on record review and interview, the facility failed to complete an annual performance review of every nurse aide at least once every 12 months for 5 (S5 CNA, S6 CNA, S7 CNA, S8 CNA, and S9 CNA) of 5 CNA personnel records reviewed. Findings: Review of personnel records revealed the following: 1. S5 CNA-date of hire was on 08/31/2018. Further review failed to reveal evidence that an annual performance review had been completed in the past 12 months. 2. S6 CNA- date of hire was on 08/21/2015. Further review failed to reveal evidence that an annual performance review had been completed in the past 12 months. 3. S7 CNA-date of hire was on 10/02/2019. Further review failed to reveal evidence that an annual performance review had been completed in the past 12 months. 4. S8 CNA-date of hire was on 09/14/2017. Further review failed to reveal evidence that an annual performance review had been completed in the past 12 months. 5. S9 CNA-date of hire was on 08/01/2017. Further review failed to reveal evidence that an annual performance review had been completed in the past 12 months. In…

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

Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 119 residents who resided in the facility. Findings: Observation on 11/13/2023 at 9:00 a.m. of the facility dumpster area accompanied by S23 DM revealed there were three dumpsters. Two of the three dumpsters were observed to be overflowing with garbage bags with lids unable to be completely closed. One dumpster was observed to have bags of trash stacked on top of the partially closed lid. The above findings were confirmed with S23 DM at the time of observation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #101) of 1 residents sampled for dignity. The facility failed to ensure Resident #101 was dressed in appropriate footwear. Findings: Review of the clinical record revealed Resident #101 was admitted to the facility on [DATE] with diagnosis that included: Hypertensive Heart Disease, Moderate Protein-Calorie Malnutrition, Anxiety Disorder, Hyperlipidemia, Obstructive and Reflux Uropathy, Chronic Pain Syndrome, and Major Depressive Disorder. Review of Resident #101's MDS Assessment with an ARD of 10/06/2023 revealed a BIMS score of 10, indicating moderate cognitive impairment. The MDS revealed Resident #101 required supervision for bed mobility, transfers, and toileting. Review of the Resident #101's care plan with a target date of 01/24/2024 revealed in part…

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

Based on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (Resident #45 and Resident #66) residents by failing to ensure the floor was in good repair for Room A; and by failing to ensure a residents clothes were stored properly off the floor. Total sample size was 37. Findings: Resident #45 Review of Resident #45's medical record revealed an admit date of 02/07/2019 with diagnoses which included: Schizoaffective Disorder, Anxiety Disorder, Major Depressive Disorder and Vascular Dementia Severe with other Behavioral Disturbance. Review of Resident #45's Annual MDS with an ARD of 01/19/2023 revealed a BIMS score of 99 (indicating resident was unable to complete the interview). The MDS revealed Resident #45 was always incontinent of bowel and bladder. Observation on 11/13/2023 at 9:23 a.m. revealed Resident #45 who resided in room A lying on the bed. At the foot of Resident #45's bed were several missing floor tiles. Observation on 11/14/2023 at 9:17 a.m. of Room A revealed several missing floor tiles at the foot 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.

Based on interview and record review the facility failed to ensure their grievance policy and procedure was followed by failing to ensure prompt investigation of an allegation and to provide a written resolution of a resident's complaint/grievance for 1 (Resident #29) resident of 37 sampled residents. Findings: Facility's Grievance Policy read in part . Purpose: To ensure each resident grievance will be followed up by prompt efforts to resolve grievances that the resident may have, including those with respect to the behavior of other residents. Policy: All grievances will be investigated thoroughly, and appropriate corrective action take. Review of Resident #29's Quarterly MDS with an ARD of 07/08/2023 revealed resident had a BIMS score of 15 (indicating intact cognition). Resident #29's MDS revealed he is able to be understood and understand others. Resident #29 had clear speech and used distinct intelligible words. Review of a facility form titled Grievance/Complaint Report dated 09/28/2023 at 12:15 p.m. by S12 SSD read in part .Resident #29 stated that another Resident (Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a reportable incident was reported to the State Agency for 1 (#18) of 3 (#18, #108, #313) residents reviewed for incidents and accidents. The facility failed to report an incidence of resident to resident abuse. Findings: Review of the facility policy titled Abuse Prevention and Prohibition revealed in part . Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Resident abuse may include: 1. resident to resident abuse Physical Abuse may include an aggressive act, including…

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

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered plan of care consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #55) of 37 sampled residents. The facility failed to include in Resident #55's care plan the need for staff assistance with ADLs. Findings: Review of Resident #55's medical record revealed an admit date of 02/13/2023 with diagnoses which included: Schizoaffective Disorder, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Osteoarthritis, Neuropathy, and Glaucoma. Review of Resident #55's Quarterly MDS with an ARD of 09/13/2023 revealed a BIMS score of 14, indicating intact cognition. The MDS revealed Resident #55 required extensive 2+ person physical assistance with bed mobility, transfer, and toilet use; limited one person physical assistance with dressing and personal hygiene; and one person physical help in…

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

Based on interview and record review, the facility failed to revise a comprehensive person-centered care plan for 1 (Resident #78) of 37 sampled residents, by failing to reflect Resident #78 required increased supervision due to wandering behavior. Findings: Review of Resident #78's medical record revealed an admission date of 11/10/2022 with diagnoses that included in part .Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant side; Traumatic Subdural Hemorrhage; Major Depressive Disorder Recurrent-Severe with Psychotic symptoms; Generalized Anxiety Disorder; Schizoaffective Disorder Bipolar Type, and Post Traumatic Seizures. Review of Resident #78's Quarterly MDS with an ARD of 05/31/2023 revealed a BIMS score of 99 (indicating unable to complete interview) The MDS revealed Resident #78 had verbal behavioral symptoms directed toward other (threatening others, screaming at others, cursing at others). The MDS revealed Resident #78 was coded as requiring 2 person assistance for bed mobility, transfers, and toilet use and 1 person assistance for eating,…

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

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (Resident #19, Resident #77, and Resident #90) of 5 (Resident #19, Resident #31, Resident #55, Resident #77, and Resident #90) residents investigated for activities of daily living out of a total sample of 37 residents. Findings: Review of the facility's policy titled Nail Care Policy and Procedure read in part . Policy: 1. To prevent infection. 2. To prevent irritation. 3. To prevent break in skin integrity. 4. To promote peripheral circulation. 5. To promote cleanliness. 6. To relieve pain. Procedure: 1. Care of fingernails and toenails is part of the bath. 2. Be certain the nails are clean. Resident #19 Review of Resident #19's medical record revealed an admit date of 01/01/2011 with diagnoses which included in part . Schizoaffective Disorder Depressive Type, Type 2 Diabetes Mellitus, Aphasia, Vascular Severe with other Behavioral Disturbance and Pain…

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, interview, and record review the facility failed to ensure that a resident received adequate supervision to prevent accidents and incidents for 1 (#363) of 3 (#18, #108, and #363) sampled residents for incidents and accidents. The facility failed to ensure Resident #363 received increased supervision after inflicting injury upon Resident #18. Findings: Review of the facility policy titled Abuse Prevention and Prohibition revealed in part . Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Resident abuse may include: 1.…

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

Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. The facility failed to ensure that expired/outdated items were not available for resident consumption. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen. Findings: Initial tour of the kitchen on 11/13/2023 at 8:30 a.m. accompanied by S23 DM revealed the following items on cooler shelves for use: 1 opened case of 118 mL thickened orange juice containers with a use by date of 10/24/2023, 1 opened 48 count case of 4 oz. yogurt cups with a use by date of 11/07/2023, and 1 opened case of sugar free gelatin cups with a use by date of 11/01/2023. The above findings were confirmed with S23 DM at the time of observation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident's responsible party (RP) was notified of an unplanned discharge and a significant change in physical, mental, or psychosocial status for 2 (#1, #2) of 3 (#1, #2, #3) residents reviewed for notification of change. The facility failed to: 1. Notify Resident #1's RP of his unplanned discharge from the facility. 2. Notify Resident #2's RP of a significant change in her condition that required a transfer to the hospital. Findings: Review of the facility's policy titled, Change of Condition policy and procedure revealed in part: Purpose: to ensure that person's involved in the residents care are made of aware of any changes to the resident. Policy: Physicians, responsible family members or legal representatives shall be notified as soon as possible, or within 24 hours, of any changes in the resident's condition. Procedure: 1. The Charge nurse shall be responsible for notifying the attending physician and the resident's RP members or legal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered plan of care for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to have Hydrocodone-Acetaminophen (a narcotic analgesic) 10-325 mg available to administer PRN when Resident #4 required it for pain. Findings: Review of the facility's policy titled Medication Administration Policy and Procedure revealed in part . Policy The facility shall provide medications as ordered by the physician. 35. Each dose of medication administered shall be properly recorded in the resident's medical record. Review of Resident #4's Medical Record revealed an admit date of 11/02/2022 with diagnoses that included: Other Secondary Parkinsonism; Other Lack of Coordination; Other Abnormalities of Gait and Mobility; Chronic Pain…

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

Based on interview and record review, the facility failed to ensure medications were available to be administered as ordered for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to have Hydrocodone-Acetaminophen (a narcotic analgesic) 10-325 mg available to administer PRN when Resident #4 required it for pain. Findings: Review of the facility's policy titled Medication Administration Policy and Procedure revealed in part . Policy The facility shall provide medications as ordered by the physician. Review of a facility document titled Orders, Monitoring Guidelines revealed in part . Areas to Monitor Daily 4. Clinical Dashboard a. Number of Active and On Hold Medication Schedules for Each Resident i. Review the current medication count of all active and on hold pharmacy category orders for each resident. ii. This information can assist with billing and pharmacy reviews. Review of Resident #4's Medical Record revealed an admit date of 11/02/2022, with diagnoses that included: Other Secondary Parkinsonism;…

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.