Highland Place Rehab and Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations and interviews, the facility failed to ensure residents who were unable to complete their activities of daily living received the necessary services to maintain grooming and hygiene for 4 (#50, #68, #74, #187) out of 4 (#50, #68, #74, #187) residents reviewed for activities of daily living. The facility failed to:1. Ensure Resident #50 received baths, washed hair and toenails were trimmed,2. Ensure Resident #68 received baths, oral care and nail care,3. Ensure Resident #74 received proper peri-care for MASD (moisture-associated skin damage)4. Ensure Resident #187 received baths. Findings: Review of Facility's Activities of Daily Living (ADLs)/Maintain Abilities (undated) revealed: Procedure: 2. The facility will ensure a resident is given the appropriate amount of treatment and services to maintain or improve his or her ability to carry out the activities of daily living. 3. The facility will provide care and services for the following activities of daily living: a. hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents received care and services that are resident centered, in accordance with professional standards of practice for 2 (#74, #110) of 63 sampled residents. The facility failed to: 1.provide a splint for Resident #74 as ordered.2.complete all admission lab test ordered Resident #110.3.revise/update Resident #110's plan of care to reflect a diagnosis of hyperkalemia.4.complete Resident #110's admission lab in a timely manner. Findings: Resident #74 Review of Resident #74’s medical record revealed an initial admit date of 02/24/2017 with a re-admission date of 01/22/2023 with the following diagnoses, in part: Spastic diplegic cerebral palsy, chronic pain syndrome, muscle wasting and atrophy, not elsewhere classified, left and right upper arms, and contracture, unspecified joint. An observation on 07/21/2025 at 12:32 p.m. revealed one hand splint on the bed side table of Resident #74. During an interview on 07/23/25 at 9:16 a.m. S31 COTA…

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 environment remains as free of accident hazards for 1 (#158) reviewed for accidents. The facility did not maintain resident #158's wheelchair in safe operating condition. Findings:Review of the Accident and Incident Prevention, Reporting, and ResponseAdministrative Policies (7/2025) revealed in part:Purpose: To ensure a safe environment for all residents by minimizing accidents hazards, providing adequate supervision and assistive devices, and implementing a proactive and systematic approach to preventing, investigating, and mitigating accidents and incidents in accordance with federal regulations, facility policies, and resident-centered care principles.Policy StatementThe facility is committed to:Maintaining a resident environment that is as fee as possible from accident hazards while meeting individual resident needs.Observation on 07/21/2025 at 11:36 a.m. revealed resident #158's wheelchair was in need of repair. Resident #158's wheelchair locks did not lock, the right wheel was loose and…

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

Based on record reviews and interviews, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 (#62) resident reviewed for nutrition. The facility failed to consult a Registered Dietician for Resident #62 diagnosed with a pressure ulcer.Findings:Review of Facility's Pressure Ulcer Treatment Policy and Procedure dated 06/2025 revealed: Purpose: The purpose of this procedure is to provide guidelines for the treatment of pressure ulcers to facilitate healing and to prevent further deterioration. 3. Consult Dietary as needed/ordered. Review of Resident #62's medical records revealed an admit date of 05/02/2025 with the following diagnoses, including in part: other ulcerative colitis without complications, paraplegia complete, other idiopathic peripheral autonomic neuropathy and pressure ulcer of sacral region, stage 4. Review of Resident #62's medical records failed to reveal Resident #62 receiving supplements for wound healing.Review of Resident #62's weights revealed on 05/02/2025, the resident weighed 181 lbs. (pounds). On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 5 (#2, #35, #109, #128, #188) out of 6 (#2, #35, #109, #128, #186 and #188) residents reviewed for respiratory. The facility failed to store hand held nebulizer equipment in a covered bag and change and date oxygen tubing and humidification bottles weekly.Findings:Procedure Guidelines: Oxygen Administration -3. [NAME] bottle with date and initials upon opening.4. Change prefilled humidifier when water level becomes low.5. Change oxygen cannulas and tubing every 7 days and date. Resident #2Review of Resident #2's face sheet revealed an initial admission date of 02/20/2024 with a re-entry date of 05/07/2024 with the following diagnoses chronic respiratory failure with hypoxia. Review of Resident #2's July 2025 Physician orders revealed dated 07/03/2025: oxygen at 2L (liters) via NC (nasal cannula), every 8 hours 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 interviews and record review the facility failed to provide specialized rehabilitation services for 1 of 1 (#158) sample resident as required by the resident's plan of care. Resident #158 was not provided restorative services. Findings:During an interview on 7/21/2025 at 11:18 a.m. resident #158 reported she had therapy for three days and she had not had any therapy since then. Resident #158 reported she was told by therapy she would be seen by Restorative, and she had not been seen.Review of resident 158's Physical Therapy Restorative Referral dated 05/27/2025 revealed restorative service was to start dated 06/05/2025 for six weeks.During an interview on 07/22/2025 at 1:30 p.m. S17 Restorative CNA (certified nursing assistant) reported they did not provide restorative services for resident #158. S17 Restorative CNA reported there is only two Restorative CNAs for the entire facility. S17 Restorative CNA reported they obtain the referrals for restorative services from physical therapy then they give the referral to their supervisor. S17 Restorative CNA reported their…

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 electronically submit accurate direct care staffing information based on payroll to Centers for Medicare and Medicaid Services (CMS) as required. Findings:Record review of the PBJ (Payroll Based Journal) Report for FY (Fiscal Year) Quarter 2 2025 (January 1 - March 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. Review of staffing pattern forms for weekends of FY 2025 quarter 2 ([DATE]- March 31) revealed the facility provided more hours than required and failed to reveal any days in which the facility did not provide enough hours. During an interview on 07/23/2025 at 4:35 p.m. S1Administrator reported corporate submitted the information for the PBJ and did not submit correct information. During an interview on 07/24/2025 at 8:55 a.m. S2Chief Nursing Officer reported she did not know why the information submitted by corporate to PBJ was not accurate.

Based on record reviews, observations, and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to effect 176 residents residing at the facility at time of entrance on 07/21/2025 as reported by the Administrator. The facility failed to:1. maintain an up to date monthly tracking and trending for infection prevention and control, 2. ensure resident care equipment, dirty linens and briefs were handled in a sanitary manner. Findings: Observations on 07/22/2025 at 11:50 a.m. during a tour of the laundry completed with S25 Housekeeping and Laundry Supervisor revealed bed sheets, pillowcases are worn thin and discolored (yellowish and tan stains). Further observation of the facility’s blankets revealed to be in very poor condition thin, discolored, felt scratchy. During an interview on 07/23/2025 at 10:30 a.m. S20 DON (Director of Nursing) present the facility's…

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

Based on record review and interview the facility failed to maintain and follow policies and procedures for immunization for 4 (#55, #84, #87, #186) of 5 ( #55, #77, #84, #87 and #186) sampled residents for influenza, pneumococcal disease and COVID-19. The facility failed to educate and offer residents and/or their representative immunizations of pneumonia, influenza and coronavirus disease (COVID-19), and failed to allow them to refuse and/or agree to either of the vaccines.Findings:Pneumonia Vaccine for Residents (Nursing Policy Manual 06/2025) revealed in part:Policy: Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized.Pneumococcal Vaccine/Diseasea. Before offering the pneumococcal immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization.b. The resident or the resident's legal representative has the opportunity to refuse immunization.Influenza Vaccine for Residents (Nursing Policy…

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 of observations and interview the facility failed to have the most recent annual survey results of the facility posted in a place readily accessible to the residents, family members or anyone to review. Findings:During an observation on 07/21/2025 at 11:30 a.m., review of the survey results binder near the front door failed to reveal the annual survey from 2024.During an interview on 07/21/2025 at 12:05 p.m. S1 Administrator acknowledged that the previous years' annual survey results were not in the survey binder and should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to accommodate 1 (#165) out of 1 resident reviewed for personal privacy. The facility failed to ensure Resident #165 had a privacy curtain in a shared room. Findings:Observation on 07/21/2025 at 10:00 a.m. of Resident #165's room revealed was in a shared with a roommate. Further observation revealed Resident #165 did not have privacy curtain. During an interview on 07/21/2025 at 10:00 a.m. Resident #165 and visitor reported Resident #165 did not have a privacy curtain.Review of Resident #165's face sheet revealed an admission date of 01/07/2025 with the following diagnoses bipolar disorder, current episode depressed and altered mental status. Review of Resident #165's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 10 indicating moderately impaired cognition. During an interview on 07/23/2025 at 11:30 a.m. S19 CNA (Certified Nurse Assistant) observed Resident #165's room and confirmed…

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 develop an individualized person centered care plan for 1 (#14) of 2 (#5, #14) residents with measurable goals and appropriate interventions to address the care and treatment for a resident with dementia. Findings: Review of Resident #14's face sheet revealed an initial admission date of 12/15/2023 and a re-entry admission date of 02/10/2025 with diagnosis of dementia. Review of Resident #14's July 2025 Physician Orders revealed an order dated 05/10/2024: Memantine HCl (hydrochloride) oral tablet 5 MG (milligram); Give 1 tablet by mouth two times a day related to dementia and anxiety. Review of Resident #14's Care Plan failed to reveal a focus of dementia with measurable goals and appropriate interventions. During an interview on 07/23/2025 at 3:00 p.m. S3 MDS (Minimum Data Sets) Nurse confirmed Resident #14's care plan did not include a focus of dementia with measurable goals and appropriate interventions.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observation, and interviews the facility failed to maintain electrical equipment in safe operating condition for 1 (#35) of 11 (#35, #50, #56, #68, #88, #91, #110, #128, #158, #179, #189) residents reviewed for environment. The facility failed to ensure that Resident #35's bed control was properly maintained and in safe working order. Findings:Review of Resident #35's medical record revealed, in part, a readmission date of 06/02/2025 with diagnoses including, but not limited to chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Review of Resident #35's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #35's cognition was intact. An observation on 07/21/2025 at 8:14 a.m. revealed Resident #35's bed remote had exposed wires. During an interview on 07/21/2025 3:28 p.m., S28Maintenance confirmed Resident #35's bed control had exposed wires. During an…

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

Based on observation and interviews, the facility failed to ensure resident's personal dietary choices were met for 1 (#2) out of 3 (#1, #2, #3) sampled residents. The facility prepared a lunch meal with Resident #2's dislikes. Findings: During an interview on 04/22/2025 at 8:15 a.m., S2CNA (Certified Nursing Assistant) reported Resident #2 only liked white meat chicken and did not like dark meat. Observation of Resident #2's plated lunch meal tray on 04/22/2025 at 12:45 p.m. with S3Dietary Aid, revealed two baked chicken legs as the meat portion. Further observation revealed Resident #2's meal card preference was listed as wants white meat. During an interview on 04/22/2025 at 12:45 p.m., S3Dietary Aid, acknowledged Resident #2's meal card had a preference listed for white meat and lunch meal was plated with dark meat. During an interview on 04/22/2025 at 12:50 p.m., S4Dietary Manager acknowledged Resident #2's lunch meal had been plated with dark meat. S4Dietary Manager further acknowledged Resident #2's preference for white meat had not been honored and should have been.

Based on record reviews and interviews the facility failed to ensure 1 (#4) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure: 1. Resident #4's high blood glucose levels were rechecked as ordered after being administered sliding scale insulin for glucose levels greater than 400. 2. Resident #4's blood glucose levels were checked to determine if sliding scale insulin needed to be administered as ordered. 3. Resident #4's MD (medical doctor) was notified when Resident #4's finger stick glucose was greater than 250. 4. Resident #4's Lantus insulin was administered as ordered. Findings: Review of Administration of Medications policy with review date of November 15, 2022 revealed, in part: Policy Statement Standards: Medications shall be administered in a safe and timely manner, and as prescribed. Procedure 3. Medications must be administered in accordance with the orders, including any required timeframe. 5. Licensed Nurse/CMT (certified medical technician) giving…

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 residents received necessary treatment and services, consistent with professional standards of practice to promote healing and prevent the development of new pressure ulcers for 1 (#4) of 4 (#3, #4, #5, and #6) residents reviewed for pressure ulcers. The facility failed to perform wound care as recommended by S2 Wound NP (nurse practitioner) for Resident #4. Findings: Review of Resident #4's record revealed an admit date of 02/14/2025 and a discharge date of 03/14/2025 with diagnoses that included, in part, gluteal cleft pressure injury, type 2 diabetes mellitus with hyperglycemia, encounter for attention to gastrostomy, muscle weakness generalized, and nontraumatic intracerebral hemorrhage unspecified. Review of Resident #4's physician orders revealed the following: -02/18/2025 (end date of 03/12/2025) Gluteal cleft: Clean area with wound cleaner. Apply Venelex to wound bed. Cover with dry cover dressing every day and prn - every day shift for pressure injury and as needed for dressing dislodge/soiled. -03/12/2025…

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, interviews and record reviews the facility failed to ensure the facility's Grievance Policy was followed for 1 (#2) of 7 (#1, #2, #3, #4, #5, #6 and #7) sample residents. The facility failed to resolve a grievance of resident #2's call light not being answered and failed to provide a completed review of the grievance in writing and/or verbal to resident #2 or his RP (responsible party). Findings: Review of the facility's Grievance/Complaint form revealed in part a resident, their representatives, interested family members or advocates may file a grievance or complaint with the facility without fear or threat of reprisal of any kind. Please fill out, date, and sign this report and submit it to any department manager. You will be provided with an oral and/or written report of the facility's findings as soon as possible. Review of resident #2's grievance/complaint form dated 01/31/2025 revealed grievance was filed by resident #2's RP. Resident #2's RP documented in part, the incident occurred on 01/25/2025 and again on 01/31/2025 during the 7-3 and 3-11 shift.…

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 ensure an alleged violation of sexual abuse was reported immediately to the facility's administrator and to the state agency within 2 hours after the allegations were made for 1 (#1) of 7 (#1, #2, #3, #4, #5, #6 and #7) sample residents. Findings: Review of the facility's Abuse Prevention Policy last reviewed date of 11/15/2022 revealed in part: 1. Prevention: The abuse coordinator in the facility is the administrator. Reports of allegations or suspected abuse, neglect .will be reported immediately to Facility Abuse Coordinator, Director of Nursing. 6. Report and Investigate: (e) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made .to the administrator of the facility and to other officials (including to the State Agency .in accordance with state law).…

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 thoroughly investigate an allegation of sexual abuse for 1 (#1) of 7 (#1, #2, #3, #4, #5, #6 and #7) sample residents. Findings: Review of the facility's Abuse Prevention Policy (dated 9/5/16 and reviewed 11/15/22) revealed in part the following: Policy Statement: Standards The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Facility has a zero-tolerance Abuse Standard regarding all proven allegations of verbal, sexual, physical, mental, neglect Action Prevention: The abuse coordinator in the facility is the administrator. 6. Report and Investigate: When suspicion of reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components 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 interviews, the facility failed to ensure medical records were accurately documented for 1 (Resident #2) of 7 (Resident #1, #2, #3, #4, #5, #6, and #7) sampled residents. The facility failed to have documentation of a physician's discharge order. Findings: Review of Resident #2's record revealed an admit date of 12/26/2024 and a discharge date of 12/27/2024. Review of Resident #2's medical record revealed the following diagnoses which included but not limited to: Pain in left wrist, chronic viral hepatitis C, cognitive communication deficit, cannabis use, unspecified. Review of Resident #2's MDS (Minimum Data Set) revealed a BIMS (Brief Interview of Mental Status) of 06 indicated severe impaired cognition. Review of Resident #2's physician orders failed to reveal a discharge order to the hospital on [DATE]. During an interview on 01/20/2025 at 3:20 p.m. S6 ADON (Assistant Director of Nursing) reported she could not locate the discharge order for Resident #2. S6 ADON reported she was…

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

Based on record reviews and interviews the facility failed to ensure residents had access to services outside the facility for 1 resident (#2) out of 3 residents (#2, #3, #4) reviewed for appointments outside the facility. Findings: Review of the facility's Transportation to Appointments Policy dated April 2022 revealed in part: Policy Interpretation and Implementation 1. .Facility will provide transportation to and from appointments for all residents, unless resident prefers to provide their own transportation. 2. Scheduled appointments for doctor's appointments, follow-ups, and referrals while residing in facility will be the responsibility of the Transportation Supervisor or designee. 3. Documentation of refusals, missed appointments, and rescheduling of appointments will be completed by the floor nurse on duty in the chart or medical record; after receiving confirmation from the Transportation Supervisor. 4. The Transportation Supervisor will also ensure all paperwork from appointments are handed to floor nurse and uploaded into medical records after scheduling follow 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure the plan of care had been revised for 1 (#4) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) sampled residents. Findings: Review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] and had diagnoses that included, in part, fracture of shaft of left tibia, fracture of shaft of left fibula, traumatic subarachnoid and subdural hemorrhage, multiple fractures of ribs, left side, fracture of base of skull, fracture of unspecified thoracic vertebra, and fracture of unspecified lumbar vertebra. Review of Resident #4's 07/20/2024 Quarterly MDS (minimum data set) revealed Resident #4 had a BIMS (Brief Interview of Mental Status) score of 15, indicating Resident #4 was cognitively intact. Further review of the 07/20/2024 quarterly MDS revealed Resident #4 did not have any functional limitation in ROM (range of motion) for upper or lower extremity. Review of Resident #4's 07/20/2024 State Optional MDS revealed Resident #4…

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 at risk for wounds received necessary treatment and services, consistent with professional standards of practice, to promote healing, to prevent infection, and to prevent wounds for 1 (#5) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, and #9) sampled residents. The facility failed to ensure an accurate assessment was performed and the Medical Doctor (MD)/Nurse Practitioner (NP) was notifed of a current skin condition. Findings: Review of Resident #5's medical record revealed an admit date of 02/24/2021 with a re-entry date of 01/22/2023. Diagnoses, included in part, Spastic Diplegic Cerebral Palsy, Type 2 Diabetes, Neuromuscular Dysfunction of Bladder and Paralytic Syndrome, unspecified. . Review of Resident #5's Quarterly MDS (Minimum Data Set) dated 08/14/2024 revealed in part, Resident #5 had a BIMS (Brief Interview of Mental Status) score of 10, indicating moderately impaired cognition. Further review of Resident #5's MDS revealed Resident #5 was at risk for developing pressure ulcers and/or injuries and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives to meet residents' medical, nursing, mental and psychosocial needs for 2 (#2, #4) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure: 1.) Resident #2's physician orders had been followed, and 2.) Resident #4's care plan had been revised with each of Resident #4's falls Findings: Resident #2 Review of Resident #2's medical records revealed an admit date of 04/15/2024 and discharge date of 07/06/2024 with the following diagnoses, including in part: acute respiratory failure with hypoxia, dysphagia/unspecified, encounter for attention to gastrostomy, and traumatic subdural hemorrhage without loss of consciousness/subsequent encounter. Review of Resident #2's physician's orders revealed an order dated 06/22/2024 for Keflex Oral Capsule 500 mg (milligram). Give 500 mg via (by way of) PEG (Percutaneous Esophageal…

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 interviews, the facility failed to ensure resident's responsible party was notified when there was a change in condition for 1 (#2) out of 4 (#1, #2, #3, #4) sampled residents. The facility failed to notify Resident #2's responsible party of an infection requiring antibiotic treatment. Findings: Review of Facility's Notification of Resident's Change in Condition (November 2019) revealed, in part: Policy Statement: This facility will promptly notify the resident, his or her Attending Physician, and Responsible Party of changes in the patient's medical/mental condition and/or status (for example (e.g.), changes in level of care, billing/payments, resident rights, etc.). Procedure: Quality of Life - notification of changes - 4. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident, family, or responsibility party of any changes in his/her medical care or nursing treatments. 5. The Nurse Supervisor/Charge Nurse will record document the name of the responsible party that was notified 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 record review, observation, and interview the facility failed to ensure residents with an indwelling catheter received appropriate care and services to prevent urinary tract infections to the extent possible for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents. Findings: Review of policy and procedure reviewed/revised on 04/01/2018 titled Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing revealed: Purpose: The purpose of this procedure is to provide guidelines for the prevention of Catheter-Associated Urinary Tract Infections (CAUTIs). Policy Interpretation and Implementation .Steps in the procedure The following CAUTI prevention strategies have been adopted and are to be followed by clinical staff: . 6. Maintain unobstructed urine flow .c. Keep drainage bag below the level of the bladder at all times. Do not place the drainage bag on the floor. Review of Resident #3's medical records revealed an admit date of 04/01/2024 with the following diagnoses, including in part: acute respiratory failure with hypoxia, acute kidney failure unspecified,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure received a written order from the physician for and an informed consent for bed rails prior to installation for 1 (#2) out of 4 (#1, #2, #3, #4) sampled residents. Findings: Review of Facility's Bed Rail Policy (December 5, 2017) revealed, in part: Policy Statement: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use .The facility's priority is to ensure safe and appropriate bed rail use. It is the policy of this facility to prevent entrapment and other safety hazards associated with bed rail use . Procedure: 1. Resident Assessment - e. facility has indicated documentation that the side rail is the least restrictive alternative for the least amount of time, f. the facility will document ongoing need for the use of a bed rail, .h. obtain informed consent, i. obtain physician order for medical symptom assessed for need for bed rail use, j. resident care plan will…

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 required annual abuse and dementia training was completed for 1 direct care staff [S2 CNA (Certified Nursing Assistant)] out of 6 [S2 CNA, S3 CNA, S4 CNA, S5 CNA, S6 LPN (Licensed Practical Nurse), S7 LPN] direct care staff personnel records reviewed. Findings: Review of the facility's Abuse Prevention Policy dated 09/15/2016 revealed in part: 4. Employee Training: All facility staff including contractors and volunteers will be educated on abuse, neglect, and exploitation . Annual education and training should be provided to all existing employees. Review of S2 CNA's personnel record revealed a hire date of 09/25/2018. Further review of S2 CNA's personnel record revealed abuse and dementia training was last completed on 06/01/2023. During an interview on 08/13/2024 at 4:36 p.m. S1 Staff Development reviewed S2 CNA's personnel record and acknowledged there was not documentation of required annual abuse and dementia training.

Based on record reviews, observations and interviews, the facility failed to accommodate the needs of 2 (#39 and #67) of 5 (#21, #39, #51, #67, and #120) residents investigated for environment. The facility failed to ensure residents' call lights remained within reach. Findings: Review of Facility's Call Light, Answering procedure dated April 2022 revealed in part: Purpose The purpose of this procedure is to respond to the resident's requests and needs. Key Procedural Points . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Resident #39 During an interview on 06/03/2024 at 9:45 a.m., Resident #39 reported she did not have a call light. Observation on 06/03/2024 at 9:45 a.m. failed to reveal Resident #39's call light within reach. Further observation revealed Resident #39's call light cord was connected to wall plug and the call light was on the ground between the wall and piece of furniture. Observation on 06/04/2024 at 10:30 a.m. revealed Resident #39's call light cord was connected to teh wall plug wall and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to consider the views of the resident council group and act promptly to concerns related to laundry presented in the resident council meetings. The deficient practice had the potential to affect a total of 189 residents according to Long-Term Care Facility Application for Medicare and Medicaid dated 06/03/2024. Findings: Review of the resident council meeting notes from January 2024 through May 2024 revealed the following grievances related to laundry/ missing clothes: 01/22/2024: Resident #62: missing her black blanket, activities gave her another one. Review of Resident #62's MDS dated [DATE] revealed a BIMS of 6 out of 15 indicating severely impaired cognition. Resident #69: states his laundry is slow coming back sometimes a week. Review of Resident #69's MDS dated [DATE] revealed a BIMS of 15 out of 15 indicating cognitively intact. Resident #13: states he is missing a gray shirt. Review of Resident #13's MDS dated [DATE] revealed a BIMS of 15 out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure a plan of care was developed and implemented for 2 (#25, 98) of 2 residents reviewed for UTI (urinary tract infection). The facility failed to: 1. Develop a plan of care for 2 (#25, 98) residents diagnosed with urinary tract infection. 2. Administer medication as ordered for resident # 98. Findings: 1. Resident #25, Review of resident #25's electronic health record revealed an admission date of 02/07/2023 and a diagnosis of but not limited to chronic congestive heart failure, primary hypertension, type 2 diabetes and Urinary Tract Infection. Review of resident #25's MDS (minimum data set) revealed resident #25 had a BIMS (Brief Interview Mental Status) score of 12 indicating moderately impaired cognition. Review of resident #25's lab results dated 05/29/2024 revealed resident #25 had cloudy yellow urine with a blood urea nitrogen level of 22 and a creatinine level of .56, a presumed UTI pending urine culture. Review of resident #25's Physician's…

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

Based on record reviews and interviews the facility failed to ensure the resident's plan of care was revised to meet the resident's needs for 1 resident (#159) out of 4 residents (#159, #7, #121, #161) investigated for weight loss. Findings: Review of Resident #159's record revealed an admit date of 02/02/2024 with a readmission date of 03/18/2024. Further review of Resident #159's record revealed Resident #159 was NPO (nothing by mouth) and was fed via enteral feedings through a PEG (percutaneous endoscopic gastrostomy) tube. Review of Resident #159's weight log revealed on 02/02/2024, the resident weighed 112.6 lbs. (pounds). Further review of Resident #159's weight log revealed the following weights: -on 02/23/2024 Resident #159 weighed 107.0 lbs. -on 03/25/2024 Resident #159 weighed 106.1 lbs. -on 04/02/2024 Resident #159 weighed 101.3 lbs. -on 04/10/2024 Resident #159 weighed 99.4 lbs. -on 05/08/2024 Resident #159 weighed 97.6 lbs. which indicated a -13.32 % (percent) loss from 02/02/2024. Review of Resident #159's record failed to reveal Resident #159's care plan was revised…

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, observations, and interviews the facility failed to ensure a resident who was unable to complete their activities of daily living received the necessary services to maintain grooming and hygiene for 6 (#25, #57, #98, #120, #141, #174) of 10 residents (#16, #25, #33, #57,#65, #98, #120, #141, #174) reviewed for Activities of Daily Living. The facility failed to ensure: 1. residents #25, #57, #98, and #141's fingernails were clean and trimmed. 2. resident #120's toenails were clean and trimmed. 3. resident #174 received scheduled bath/shower. Findings: Review of the facility's Nail Care (Finger and Toe) Policy dated 11/15/2024 revealed the following: The purpose is to clean the nail bed, prevent infection and comfort the resident. Practice Guidelines Key points 1. Nails can be partially cleaned during bathing. 2. Nursing Assistants do not trim the nails of diabetic residents 3. Nail care includes daily cleaning and regular trimming 4. Stop and report any evidence of ingrown toes nails,…

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 reviews, the facility failed to ensure 1 (#139) resident out of 1 reviewed for edema received treatment and care in accordance with professional standards of practice by failing to follow physician orders for applying ted hose, monitoring for edema with use of diuretics (Lasix), and revision to care plan of edema with use of diuretics (Lasix). Findings: During an interview on 06/03/2024 at 11:45 A.M. Resident #139 reported he had a medical history of blood clots and cellulitis, and reported he was not sure if his edema was from the cellulitis since he has completed treatment of antibiotics and legs are still swollen or from history of blood clots. Resident #139 went on to report he should be wearing ted hose. Observation on 06/03/2024 at 11:45 A.M. revealed Resident #139 had edema to bilateral lower extremities and failed to reveal Resident #139 had ted hose applied to lower extremities. Observation on 6/5/2024 at 2:20 P.M. revealed Resident #139 had edema to bilateral lower extremities and failed to reveal Resident #139 had ted hose…

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 1 resident (#164) out of 3 residents (#164, #6, #94) investigated with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection. The facility failed to obtain and implement wound care treatment orders on Resident #164 upon readmissionn to the facility. Findings: Review of Resident #164's record revealed Resident #164 was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #164's diagnoses included in part anoxic brain damage, cardiac arrest-cause unspecified, acute and chronic respiratory failure with hypoxia, sepsis-unspecified organism, chronic osteomyelitis with draining sinus-left radius and ulna, osteomyelitis-unspecified, bacterial infection-unspecified, bacteremia, carrier of methicillin resistant staphylococcus aureus, and severe hypoxic ischemic encephalopathy. Review of Resident #164's record revealed an incomplete 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.

Based on record reviews and interview, the facility failed to ensure: 1. Resident #85 received at least quarterly Registered Dietician assessments according to policy. 2. Monthly weights were documented in EHR (electronic health record) to ensure Resident #135 maintained a desired weight. There were a total of 9 (#7, #21, #34, #52, #79, #85, #135, #159, #161) residents reviewed for nutrition. Findings: 1. Review of facility's Role of the Dietician policy dated April 2022 revealed in part, 1. Review all new admissions on each visit. (minimum of Monthly) 2. Review all tube feedings at least quarterly unless there is weight loss/gain, or pressure ulcer. 9. Review residents on dialysis quarterly and as needed. Observation on 06/03/2024 at 9:00 a.m. revealed Resident #85 receiving Glucerna via feeding pump. Review of Resident #85's medical record revealed diagnoses that include in part hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, encounter for attention to gastrostomy, and Type 2 diabetes mellitus. Review of Resident #85's record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations and interview the facility failed to provide appropriate treatment and services for 2 (#85 and #161) of 3 (#21, #85, and #161) residents reviewed for tube feeding. The facility failed to ensure the tube feeding container was appropriately labeled. Findings: Review of Facility's undated procedure with subject of Enteral Tube Feeding via Pump, revealed in part: Intent: It is the policy of the facility to provide enteral feeding as ordered by the physician via pump to ensure adequate nutrition for residents that are unable to maintain their nutrition orally. Procedure . 3. Label the enteral feeding bag/bottle, to include the tubing, with the following information: a. Resident's name and room # b. Type of formula (if using bags) c. Date and time formula is being hung d. Rate of administration Resident #85 Review of resident #85's medical record revealed an admit date of 06/13/2019 and a readmit date of 06/30/2021 with diagnoses that included in part hemiplegia and hemiparesis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards of practice for 4 (#79, #120, #136, #139) out of 5 (#79, #120, #136, #139, #164) residents reviewed for respiratory care. The facility failed to ensure: 1. The oxygen concentrator and filter were clean and the nasal cannula was dated for Resident #79. 2. The respiratory supplies (oxygen mask and tubing for Resident ##139 and nebulizer mask and tubing for Resident #120, #136, and #139 were changed weekly, labeled with date and initials upon opening and stored in plastic bag between uses. Findings: Review of facility's Respiratory Therapy equipment policy dated April 2022 revealed in part: This procedure may involve potential/direct exposure to blood, body fluids, infectious disease, air containments, and hazardous chemicals. Purpose The purpose of this procedure is to provide guidelines to help prevent nosocomial infections associated…

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 there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 3 of 27 weekend days during FY (Fiscal Year) Quarter 1 2024. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY Quarter 1 2024 (October 1 - December 31) revealed excessively low weekend staffing was triggered. Review of the facility's Staffing Pattern forms for weekends from FY Quarter 1 2024 revealed the facility: Provided 275.75 hours on 10/01/2023 and were required to provide 254.85 hours. Provided 375.38 hours on 10/21/2023 and were required to provide 378.35 hours. Provided 366.9 hours on 12/16/2023 and were required to provide 376 hours. During an interview on 06/06/2024 at 5:35 p.m. S13 Interim Administrator/Regional MDS (Minimum Data Set) confirmed the facility did not provide the minimum required hours on 10/01/2023, 10/21/2023, 12/16/2023…

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 adequately monitor for 2 (# 27, #106) residents reviewed for unnecessary medications out of a total 6 (#27, #67, #72, #78, #106, #175) residents reviewed. The facility failed to adequately monitor residents #27 and #106 for edema while on a diuretic, and resident #27 for bleeding and bruising while on an anticoagulant. Findings: Resident #27 Review of Resident #27's current Physician orders revealed in part: 6/4/2024 Monitor for abnormal bleeding or bruising every shift if + (positive) notify medical doctor or Nurse Practioner. 12/1/2023 Lasix Oral Tablet 20 MG (milligram) (Furosemide) Give one tablet by mouth one time a day related to Peripheral Vascular Disease, Check for Edema. 10/27/2023 Eliquis Oral Tablet 2.5 MG (Apixaban) Give one tablet by mouth two times a day related to Peripheral Vascular Disease Review of Resident #27's medical record failed to reveal monitoring for edema, bleeding and bruising. During an interview on 06/06/2024 at 4:45 p.m. S9 LPN (Licensed Practical Nurse) reviewed Resident #27's medical…

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

Based on record review and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly. The failed practice had the potential to affect the 189 residents residing in the facility as documented by the facility's Long-Term Care Facility Application for Medicare and Medicaid form [CMS (Centers for Medicare and Medicaid Services)-671] dated 06/03/2024. Findings: Review of the QAA meeting information provided by the facility failed to reveal evidence of quarterly QAA meetings since the last annual survey on 06/08/2023. During an interview on 06/06/2024 at 5:30 p.m. S1 Administrator and S12 Regional Director of Clinical Operations acknowledged they could not provide documentation of quarterly QAA meetings since the last annual survey on 06/08/2023.

Based on observations, interviews, and record review the facility failed to: 1. Ensure staff practices were consistent with current infection control principles and practices to prevent cross contamination by failing to ensure staff used appropriate PPE (Personal Protective Equipment) during resident care for 1 resident (#112) who was on contact isolation. 2. Ensure an infection prevention and control program was maintained by failing to provide written evidence of implemented infection control policies and procedures for surveillance of tracking and trending of infections in the facility. This deificient practice had the potential to effect the total census was 189 according to the Long-Term Care Facility Application for Medicare and Medicaid Form dated 06/03/2024. Findings: 1. Review of the facility's contact isolation policy dated April 2022 revealed in part: In addition to standard precautions, contact precautions must be implemented for resident's known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect…

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 ensure hallway hand rails were securely affixed to the walls. The facility failed to ensure hand rails were secure on 1 (Hall W) of 4 hallways in the building. This had to potential to affect 31 residents residing on Hall W. Findings: Review of the facility's Physical Environment Policy and Procedure dated 01/01/2023 revealed: It is the policy of the facility to provide care and services related to physical environment in accordance to State and Federal Regulation: The policy will include the Corridors have firmly secured handrails. Observation on 06/04/2024 at 12:50 p.m. revealed on Hall W near the exit door, the hand rail did not have an end cap on it leaving a sharp edge exposed with a crack in the hand rail. During an interview on 06/04/2024 at 2:00 p.m. S4 CNA reported the hand rail on Hall W near the exit door had been broken for a couple of months. Observation on 06/04/2024 at 2:03 p.m. with S3 Maintenance Supervisor revealed on Hall W near the exit door, the hand rail did not have an end cap on it leaving a sharp…

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 ensure the MDS (Minimum Data Set) assessment accurately reflected the resident's status for 1 (#178) of 2 (#178, #34) residents investigated for hospitalization. Findings: Review of Resident #178's record revealed a discharge date of 03/12/2024. Review of Resident #178's progress note dated 03/12/2024 revealed resident #178 was discharged to another long term care facility. Review of Resident #178's discharge MDS assessment dated [DATE] revealed Resident #178 was discharged to a short term general hospital. During an interview on 06/05/2024 at S10 RN (Registered Nurse)/MDS Director reviewed Resident #178's record and acknowledged Resident #178 was discharged to another long term care facility. S10 RN/MDS Director further acknowledged Resident #178's discharge MDS assessment dated [DATE] indicated Resident #178 was discharged to the hospital and should have indicated Resident #178 was discharged to another long term care facility.

Based on record review and interview the facility failed to ensure a medical doctor or representative was notified after a resident had a fall in the facility for 2 (#1, #2) of 2 (#1, #2) residents reviewed for falls. Findings: Resident #1 Record review of the facility's incident report dated 03/08/2024 failed to reveal a medical doctor or representative was notified of Resident #1's fall on 03/08/2024. During an interview on 03/26/2024 at 12:30 p.m., S1 Administrator verified she could not find any documentation the NP (Nurse Practitioner) or MD (Medical Doctor) were notified of Resident #1's fall on 03/08/2024 and should have been notified. Resident #2 Record review of the facility's incident report dated 03/09/2024 failed to reveal a medical doctor or representative was notified of Resident #2's fall on 03/09/2024. During an interview on 03/26/2024 at 11:55 p.m., S1 Administrator verified she could not find any documentation the NP or MD were notified of Resident #2's fall on 03/09/2024 and should have been notified. During a telephone interview on 03/26/24 at 12:10 p.m., S2 LPN…

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 a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #9) of 13 (Residents #1, #2, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) sampled residents. Findings: Review of Resident #9's Physician orders for March 2024 revealed the following order: Sacrum: Apply house barrier, every shift, every day, until resolved. Every shift for pressure injury. Created date was 02/07/2024. Review of Resident #9's comprehensive care plan revealed a plan with a focus of, Impaired skin integrity: Pressure injury noted to sacrum. Interventions: Notify Nurse Practitioner and/or Medical Doctor of decline noted to area being treated, skin checks to per company protocol, and treatment to area as ordered. Review of Resident #9's TAR (treatment administration record) for February 2024 revealed the following: 7:00 a.m. to 3:00 p.m. shift - Treatment not completed on February…

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 were a sufficient number of personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 1 of 26 days reviewed during the month of February 2024. Findings: Review of the Facility's Staffing Pattern forms for February 4, 2024 to February 29, 2024 revealed the facility provided 384.57 hours on 02/24/2024 and were required to provide 397.15 hours. During an interview on 03/06/2024 at 4:05 p.m. S1 Assistant Administrator confirmed the facility did not provide the minimum required hours on 02/24/2024.

Based on record reviews and interview, the facility failed to develop a comprehensive care plan for 2 (#1, #2) out of 4 (#1, #2, #3, #4) sampled residents reviewed. Findings: Review of Resident #1's Medical Records revealed an admit date of 10/13/2023 from with the following diagnoses, in part: hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting right dominant side, dysphagia following non-traumatic intracerebral hemorrhage, aphasia following non-traumatic intracerebral hemorrhage, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, encounter for attention to tracheostomy, encounter for attention to gastrostomy, essential hypertension, abnormalities of breathing, and acute upper respiratory infection Review of Resident #1's Physician Orders revealed: 10/13/2023: Trach: trach care every shift and as needed, suction every shift and as needed NPO (Nothing by mouth) diet Tube: peg tube .RN (Registered Nurse) to replace as needed for occlusion and dislodgement, check placement tube by aspiration 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 interviews, the facility failed to ensure resident received care and necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#1) out of 4 (#1, #2, #3, #4) sampled residents. The facility failed to follow up on Resident #1 identified skin issue and complete weekly skin checks for Resident #1. Findings: Review of MDS (Minimum Data Sets) revealed Resident #1 was admitted to facility on 10/13/2023 from a short-term general health hospital. Review of Resident #1's Medical Diagnoses on admit 10/13/2023 revealed a diagnoses but not limited to hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting right dominant side, and aphasia following non-traumatic intracerebral hemorrhage. Review of S4 LPN's (Licensed Practical Nurse): Skin Evaluation dated 10/13/2023 at 7:57 p.m. revealed a skin issue: small open area to coccyx-purulent exudate, dressing…

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 the plan of care was developed and/or implemented for 6 (#32, #40, #73, #109, #125 and #130) of 6 residents reviewed. 1. The facility failed to ensure labs were obtained for resident #32 as ordered by the physician 2. The facility failed to ensure splint devices were used according to resident's plan of care for residents #40, #73, #109, #125 and #130. Findings: Resident #32 Review of the facility's Laboratory, Radiology and other Diagnostic Services Policy (reviewed in 11/2022) revealed in part: The facility will provide laboratory and diagnostic services to meet the needs of the residents in a timely manner. If facility does not provide laboratory services on-site; it shall have an agreement to obtain these services from a laboratory or radiology provider or supplier that is approved to provide these services under Medicare. It is the practice of this facility to provide laboratory or diagnostic services upon an order from a physician, physician assistant, nurse practitioner or clinical nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations and interviews the facility failed to ensure residents who were unable to complete their (ADLs) activities of daily living received the necessary services to maintain proper hygiene and grooming for 4 (#91, #5, #43, #79) of 7 (#32, #67, #5, #43, #91, #79, #111) residents reviewed for ADL. The facility failed to ensure Resident #91 received nails care and weekly skin assessments #5, #43, #79 received nail care #79 face was shaved Findings: Resident #91 Review of facility policy for Activity of Daily Living with a date of November 2022 revealed: Policy statement in part revealed Each resident shall receive, and this facility will provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident comprehensive assessment and care plan. Scope: Residents will be given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living,…

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, interviews and observations, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for 4 (Residents #31, #22, #66, #132) of 4 sampled residents (Residents #31, #43, #79, #142) who received nutrition via a PEG (percutaneous endoscopic gastrostomy) tube. There were 25 residents in the facility with orders for feeding via gastrostomy tube. The facility failed to: 1. Assure tolerance to feedings with gastric residual checks prior to restarting resident's daily feedings for residents #22, #66, and #132. 2. Ensure the water flush and feeding bags were labeled properly for residents #22, #66, and #132. 3. Ensure the tubing was covered to prevent contamination for resident #31. Findings: Review of facility's policy Gastrostomy, checking placement of Gastrostomy feeding tube policy dated 12/07/2017 revealed in part: To prevent aspiration and assure tolerance of feedings. -3. Place stethoscope over abdomen. Inject 30ml (milliliters) of air into the stomach; listen for a swish of air. -4. Slowly aspirate stomach…

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 a resident who required dialysis received services consistent with professional standards of practice for 1 (#46) of 1 (#46) resident reviewed for dialysis by failing to communicate and collaborate with the dialysis facility as evidenced by completing dialysis pre/post evaluation form. Findings: Review of Electronic Scanning of Medical Records Policy (reviewed 03/04/2020) revealed: Policy statement revealed in part .Medical records will be maintained to reflect documentation of care and services for each resident. All documents must be uploaded into PCC (point click care) within 24 hours. Although the majority of the scanning is done by the Medical Records department, other departments listed below are responsible for scanning these documents into PCC. Nursing: dialysis return documentation Review of Resident #46's Medical Diagnoses revealed the following, but not limited to end stage renal disease and dependence on renal dialysis. Review of Resident #46's June 2023 Physician Orders revealed the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident assessments were transmitted within the required timeframe for 1 (#127) of 1 (#127) residents reviewed for assessments. Findings: Review of Resident #127's medical record revealed in part, Resident was admitted to facility on 01/06/2023 and left the facility AMA (Against Medical Advice) on 01/23/2023. Review of Resident #127's MDS (Minimum Data Set) assessments revealed the last transmitted MDS was an admission assessment dated [DATE]. Further review of Resident #127's MDS assessments failed to reveal a discharge MDS had been transmitted. During an interview on 06/06/2023 at 2:10 p.m. S12 MDS Nurse and S26 MDS Nurse reported a discharge MDS had not been transmitted for Resident #127 and should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure MDS (Minimum Data Set) assessments were accurate for 1 (#141) out of 2 (#131, #141) residents reviewed for hospitalization. The facility failed to enter an accurate discharge status for Resident #141. Findings: Review of resident #141's electronic medical record revealed an admission date of 3/9/2023 and a discharge date of 4/1/2023. Review of resident #141's MDS dated [DATE] revealed a (planned) discharge with a return not anticipated to an acute hospital. Review of resident #141's progress note dated 3/31/2023 at 12:11 p.m. revealed resident is being discharged on 4/1/2023 home with wife. Review of resident #141's Discharge Summary by S28 Nurse Practitioner dated 3/31/2023 revealed chief complaint: discharge to home on 4/1/2023. During an interview on 6/7/2023 at 9:25 a.m. S29 MDS nurse confirmed Resident #141 was discharged home on 4/1/2023. S29 MDS confirmed Resident #141's MDS was coded inaccurately.

Based on record review, observation and interview the facility failed to ensure a resident who was incontinent of the bladder received appropriate treatment to prevent urinary tract infections for 1 (#7) of 1 (#7) residents reviewed. The facility failed to position resident #7's catheter bag above the floor. Findings: Review of the facility's Urinary Catheter Care, Anchoring and Changing Policy revealed the following: Standard of Practice #16: Secure Foley catheter drainage bag below level of bladder and above the floor. Review of the facility's Catheter Insertion Policy revealed the following: Standard of Practice #23: .Keep drainage system off the floor. Review of resident #7's electronic medical record revealed an admit date of 12/10/2019 with diagnoses of but not limited to toxic encephalopathy, history of sepsis and urinary tract infection, type 2 diabetes, quadriplegia, essential hypertension and convulsions. Observation on 06/07/2023 at 8:30 a.m. with S13 LPN (licensed practical nurse) revealed resident #7's catheter bag lying on the floor with cloudy yellow urine noted…

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 Action Website checks were completed at time of hire and then monthly for 5 [S15 CNA (Certified Nursing Assistant), S16 CNA, S17 CNA, S18 CNA, S19 CNA] of 5 employees whose personnel files were reviewed. Findings: Review of S15 Contract CNA's personnel file revealed the first day of work in the facility was 05/27/2023. Further review of S15 Contract CNA's personnel file failed to reveal the State Adverse Action website check performed prior to first day worked in the facility. Review of S16 CNA's personnel file revealed a hire date of 02/23/2022. Further review of S16 CNA's personnel file revealed no State Adverse Actions checks were completed. Review of S17 CNA's personnel file revealed a hire date of 06/21/2022. Further review of S17 CNA's personnel file revealed no State Adverse Actions checks were completed. Review of S18 CNA's personnel file revealed a hire date of 04/15/2020. Further review of S18 CNA's personnel file revealed no Stage Adverse Actions checks were completed. Review of S19…

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 nurse aides received required in-service training for 1 [S15 CNA (Certified Nursing Assistant)] of 5 employees whose personnel files were reviewed. Findings: Review of S15 Contract CNA's personnel file revealed the first day of work in the facility was 05/27/2023. Further review of S15 Contract CNA's personnel file failed to reveal S15 had received required dementia training. During an interview on 06/07/2023 at 3:15 p.m. S2 DON confirmed S15 Contract CNA had not completed the required dementia training.