The Guest House Skilled Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interview, the facility failed to accommodate the needs of 3 (#26, #30, #325) of 41 sampled residents. The facility failed to ensure the resident's call lights remained in reach. Findings: Review of the facility's Resident Call Light System Policy revealed the following: Purpose: A call light system (audible or visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and or bathing and toileting facilities. General Guidelines 4. Ensure that the call light is easily reachable by the resident. Resident #26 Review of Resident #26's MDS (Minimum Data Set) assessment dated [DATE] revealed severe cognitive impairment and functional limitations requiring one person assistance for bed mobility, transfer, and toilet use. Observation on 04/07/2025 at 6:15 a.m. revealed Resident #26 was sitting in a chair at 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 residents' grievances voiced during Resident Council Meeting. The facility failed to act promptly upon 1 (#79) of 1(#79) resident's grievances concerning issues of resident care and life in the facility. Findings: Review of the facility's Resident Grievance/Complaints, Recording and Investigating Policy (revised November 2023) revealed in part: Policy Statement: All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance (s). Policy Interpretation and Implementation: 1. Administrator has assigned the responsibility of investigating grievances and complaints to the Grievance Officer. 2. Upon receiving a grievance and complaint report, the Grievance Officer will begin an investigation into the allegations. 3. The department director (s) of any named employee (s) will be notified of the nature of the complaint and that an investigation is underway. 4. 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 complete a significant change assessment for 1 (#75) of 3 (#14, #75, #84) residents reviewed for hospitalization. The facility failed to complete a significant change assessment after Resident #75 was diagnosed with a cerebral vascular infarction resulting in right dominant side hemiplegia. Findings: Review of Resident #75's medical record revealed an initial admit date of 11/20/2024 and a readmission date of 03/04/2025 with a new diagnosis hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Review of Resident #75's Nurse Practitioner's progress note dated 03/10/2025 revealed Resident #75 had been admitted to the hospital from [DATE] to 03/04/2025 and treated for weakness, confusion, and bilateral ptosis. An MRI (magnetic resonance imaging) on 02/26/2025 revealed Resident #75 had experienced a new cerebral vascular accident. Resident #75 was readmitted to the facility on [DATE] with a new diagnosis of a CVA…

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 residents comprehensive care plan for 2 (#116, #225) out of 40 total sampled residents reviewed. The facility failed to: 1. develop Resident #116's plan of care to include diabetes with insulin use, diuretic use and oxygen use, and 2. monitor Resident #225's urinary catheter for urine color and consistency. Findings: Resident #116 Review of Resident #116's medical record revealed in part an admit date of 02/07/2025 with diagnoses that include in part: type 2 diabetes mellitus, chronic respiratory failure with hypoxia and essential (primary) hypertension. Review of Resident #116's physician's orders revealed in part orders dated: 02/07/2025 O2 (oxygen) at 2 Liters via N/C (nasal cannula) PRN (as needed) for SOB (shortness of breath) or Sat (saturation) < (less than) 90% O2 sat Q (every) shift. 04/01/2024 Valsartan-hydrochlorothiazide oral tablet 160-25 mg (milligram) (valsartan-hydrochlorothiazide) give 1 tablet by mouth one time…

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, observations, and interviews, the facility failed to ensure that each resident receives necessary respiratory care and services in accordance with professional standards of practice and the resident's plan of care for 2 (#54, #116) of 4 (#54, #75, #89, #116) residents reviewed for respiratory care. The facility failed to change the oxygen tubing and humidification bottle, change the nebulizer mask or provide a cover for the oxygen tubing and nebulizer mask when not in use for Resident #54 and Resident #116, Findings: Review of the facility policy for Oxygen Administration revised 02/2025, revealed in part: Preparation: 5. Oxygen cannula and tubing will be changed within 7-10 days or if visibly soiled/ Store in a covered device (i.e. plastic bag, kangaroo pouch) between uses. Infection Control Considerations and Maintenance related to Medication Nebulizers 6. Nebulizer Tubing will be changed within 7-10 days, or if visibly soiled. 7. Store nebulizer equipment in a covered device (i.e. plastic bag, kangaroo pouch) between uses. Resident #54 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 record reviews and interviews, the facility failed to ensure appropriate care and services were provide for 1 (#52) of 1 (#52) resident reviewed for dialysis. The facility failed ensure Resident #52s dialysis shunt was accurately assessed and monitored. Findings: Review of the facilitys policy for End-Stage Renal Disease Care of a resident (revised September 2010) revealed in part: 2. b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. 3. The resident's comprehensive care plan will reflect the resident's needs related to ESRD (end stage renal disease) Dialysis care. Review of Resident #52's medical record revealed an admit date of 02/24/2018 and diagnoses that include in part type 2 diabetes mellitus with other diabetic kidney complications, benign prostatic hyperplasia without lower urinary tract symptoms and dependence on renal dialysis. Review of Resident #52's comprehensive care plan revealed resident #52 was care planned for dialysis with approaches that included, may have dialysis Monday, Wednesday and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to installation and use for 2 (#43, #80) of 2 residents reviewed for accident hazards. Findings: Review of the facility's Proper Use of Side Rails policy dated as revised August 2024 revealed in part: General Guidelines 3. Upon admission, readmission, with routine quarterly or significant change MDS (Minimum Data Set) and PRN (as needed), therapy/designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation, When used for mobility or transfer, the assessment will include a review of the resident's: c. Risk of entrapment from the use of side rails; and 5. The resident's care plan will reflect the use of side rails and updated as necessary. Resident #43 Review of Resident #43's medical record revealed Resident #43 was admitted…

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 were free from unnecessary medications for 3 (#46, #52, #54) out of 8 (#10, #23, #46, #50, #52, #54, #90, #115, #117) residents review for unnecesary medications . The facility failed to monitor Resident #46, Resident #52, and Resident #54 for edema while receiving a diuretic. Findings: Resident #46 Review of Resident #46's medical records revealed an admit date of 03/21/2019 with the following diagnoses, including in part: localized edema and hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Review of Resident #46's Physician's Orders revealed an order dated 04/01/2025 for Furosemide Oral Tablet 20 mg (milligram) give 0.5 tablet by mouth one time a day for edema. Review of Resident #46's March and April 2025 Medication Administration Records and Treatment Administration Records failed to reveal monitoring for edema while receiving a diuretic. During an interview on 04/09/2025 at 2:15 p.m. S8 Unit Manager acknowledged 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 reviews and interviews the facility failed to ensure resident drug regimens were free of unnecessary medications for 1 (#117) of 5 (#10, #23, #90, #115, #117) residents reviewed for unnecessary medications. The facility failed to ensure monitoring of side effects and behaviors had been conducted on Resident #117 who received psychotropic medications. Findings: Review of Resident #117's medical record revealed Resident #117 was admitted on [DATE] with diagnoses that included, in part, malignant neoplasm of rectum and depression. Review of Resident #117's April 2025 Physician Orders revealed the following: An order dated 02/18/2025 for Amitriptyline HCL (hydrochloride) 25 mg (milligram) tablet give 1 tablet by mouth once daily. An order dated 02/19/2025 for Buspirone HCL 10 mg tablet give 1 tablet by mouth 3 times a day. An order dated 04/03/2025 for Lorazepam tablet 0.5 mg give 1 tablet by mouth every 6 hours as needed for anxiety. Review of Resident #117's March and April 2025 Medication…

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

Based on record reviews, observations and interviews, the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. The facility failed to ensure 1 out of 4 medication carts and 1 out of 3 medication rooms contained unexpired medications. Findings: Review of the facility's Storage of Medications policy dated as revised April 2019 revealed in part: Policy Statement - The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 23. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Observation of Medication Room A on 04/09/2025 at 3:25 p.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.

Based on record reviews and interview the facility failed to ensure CNAs (Certified Nursing Assistants) received required abuse prevention and dementia management training for 4 (S4 CNA, S12 CNA, S13 CNA, S14 Contract CNA) of 6 CNA personnel records reviewed. Findings: Review of S4 CNA's personnel record revealed a hire date of 01/31/2025. Further review of S4 CNA's personnel record failed to reveal documentation of abuse prevention and dementia management training. Review of S12 CNA's personnel record revealed a hire date of 10/02/2024. Further review of S12 CNA's personnel record failed to reveal documentation of abuse prevention training. Review of S13 CNA's personnel record revealed a hire date of 11/04/2024. Further review of S13 CNA's personnel record failed to reveal documentation of abuse training. Review of S14 Contract CNA's personnel record revealed S14 Contract CNA had worked 201.33 hours in the facility in the last 3 months. Further review of S14 Contract CNA's personnel record failed to reveal documentation of abuse training. During an interview on 04/10/2025 at 12:30…

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 proper infection control techniques were practiced to prevent urinary tract infection for 1 (#225) of 1 (#14, #61, #225) residents observed during urinary catheter care. Findings: Review of facility's Catheter Care, Urinary (revised January 3, 2023) revealed: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections .Infection control - 3. Routine hygiene catheter care with soap and water or equivalent each shift and prn unless otherwise indicated by physician and will be documented in the EMR (electronic medical record) .Steps in the Procedure - 3. Fill the wash basin with warm water. 7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. 13. With non-dominant hand separate the labia of the female resident .Maintain the position of this hand throughout the procedure. 15. For a female resident: Use a washcloth with warm water and soap/equivalent to cleanse the labia. Use one area of the washcloth for each downward,…

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 to accurately submit mandatory direct care staffing information to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 1 2025 (October 1-December 31). Findings: Review of the facility Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 1 2025 (October 1-December 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. Review of the facility's weekend staffing patterns for FY Quarter 1 2025 revealed hours of direct care provided exceeded the hours of care required. During an interview on 04/09/2025 1:20 p.m. S10 Human Resources (HR) reported she started working at the facility in January 2025. S10 HR reported she had not submitted anything directly to CMS. S10 HR reported she only submitted payroll hours to the facility corporate office through their PBJ portal. During an interview on 04/09/2025 at 3:00 p.m. S1 Administrator acknowledged the information submitted to CMS for the PBJ Staffing Data Report for FY Quarter 1 2025 was not accurate. S1…

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 an alleged violation involving neglect was reported to the State Survey and Certification Agency for 1 (#1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents reviewed for elopement. Findings: Review of the facility's Abuse Investigation and Reporting (Revised October 15, 2022) revealed: Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management .Reporting: 4. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . Review of Resident #1's medical records revealed an admit date of 02/27/2024 with the following diagnoses, in part, including: chronic obstructive pulmonary disease/unspecified, heart 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.

Based on record reviews and interviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are thoroughly investigated for 1 (#3) of 6 (#1, #2, #3, #4, #5, #6) sampled residents reviewed for elopement. Findings: Review of the facility's Abuse Investigation and Reporting (Revised October 15, 2022) revealed: Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management .Role of the Investigator: 1. The individual conducting the investigation will, at a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person (s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (medical appropriate);…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure a resident with wounds or history of wounds received necessary treatment and services, consistent with professional standards of practice, to promote healing, to prevent infection, and to prevent wounds for 3 (#1, #2, and #3) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure weekly skin assessments were performed and/or a written wound care plan was implemented. Findings: Review of the facility's Prevention of Pressure Ulcers/Injuries with a revision date of November 2017 revealed in part: Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Risk Assessment: 2. Conduct a comprehensive skin assessment upon admission/readmission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries; b. Areas of impaired circulation due to pressure from positioning or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to provide pharmaceutical services that met resident's needs by failing to accurately dispose of medications for 1 resident (#1) of 3 residents (#1, #2, #3) reviewed for pharmaceutical services. Findings: Review of the facility policy for Discarding and Destroying Medications dated [DATE] revealed in part the following: 2. Non-controlled and Schedule V (non-hazardous controlled substances will be disposed of in an accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. The facility will maintain all unused medications and destroy them routinely, under any circumstance are any of these medications to be released to family members upon death of a resident. Once a prescription is dispensed for a specified resident, it is illegal to use for anybody else and therefore, has to be destroyed. Meds can only be released to the resident they are prescribed for. The following methods for destroying non-controlled…

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 2 (S6, S7) of 44 staff members required to have a professional license were licensed in accordance with applicable State laws before being allowed to perform the duties of a licensed nurse. Findings: Review of the facility's Credentialing of Nursing Service Personnel dated [DATE] revealed in part the following: -Policy Statement Nursing service personnel who personnel who require a license or certification to provide resident care are treatment without direction or supervision within the scope of the individual's license or certification must present verification of such license or certification prior to or upon employment. -Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring…

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 staff interviews, the facility failed to ensure the plan of care had been revised for 1 (#1) of 3 (#1, 2, 3) residents comprehensive care plans reviewed. The facility failed to ensure resident #1's care plan had been revised for admission to Hospice. Findings: Review of resident #1's physician's orders revealed an order dated 03/13/2024 to admit to Hospice. Review of resident #1's comprehensive care plan failed to reveal the plan had been updated to include admission to Hospice or interventions for Hospice and related care and services. During an interview on 05/08/2024 at 4:00 p.m. S2 MDS (minimum Data Set) Coordinator reported resident #1 was admitted to Hospice on 03/13/2024. S2 MDS Coordinator acknowledged resident #1's comprehensive care plan had not been updated to include Hospice.

Based on record review, observation and interview the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 1 (#3) of 2 (#1, #3) sampled residents reviewed for respiratory services. The facility failed to ensure Resident #3's oxygen concentrator filter was cleaned weekly. Findings: Review of Resident #3's medical records revealed an admit date of 11/07/2023 with the following diagnoses, in part: chronic obstructive pulmonary disease/unspecified, hypertensive heart disease without heart failure, chronic pain syndrome, depression/unspecified, edema/unspecified, and anxiety disorder/unspecified. Review of Resident #3's Physician's Orders revealed and order, in part dated 11/07/23 for oxygen: may have oxygen at 2 Liter per nasal cannula. Further review revealed an order dated 11/07/2023 for oxygen: change mask, (oxygen) tubing, water bottle and clean concentrator filter every night shift; every Wednesday and as needed for contamination. Observation on 05/07/2024 at 9:40 a.m. revealed Resident #3…

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, observations and interviews the facility failed to act promptly to concerns presented in the resident council meetings. The deficient practice affected 4 (#58, #61, #70, #79) of 4 (#58, #61, #70, #79) residents interviewed for resident care and life in the facility. The deficient practice had the potential to affect the total census of 124 residents in the facility. Findings: Review of the facility's Resident Grievances/Complaints, Recording and Investigating policy revealed . 5.) The Grievance Officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: a. The date the grievance/complaint was received; b. The name and room number of the resident filing the grievance/complaint; (if available) c. The name and relationship of the person filing the grievance/complaint on behalf of the resident; (if available) d. The date of the alleged incident took place; e. The name of the person(s) investigating the incident; f. The date the resident, or…

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

Based on record reviews and interviews the facility failed to implement a comprehensive person-centered care plan to meet each resident's medical, nursing, and mental/psychosocial needs identified in the comprehensive assessment for 2 (#39, #74) of 34 sampled residents. The facility failed to ensure (1) Eliquis and Metoprolol had been administered per physician order for Resident #39 and (2.) Cefdinir had been administered per physician order for Resident #47. Findings: 1. Review of Resident #39's medical record revealed an admission date of 09/04/2020 and diagnoses the included, in part, Alzheimer's disease unspecified, fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, essential (primary) hypertension, and atherosclerosis of aorta. Review of Resident #39's physician orders revealed: -10/21/2023 Eliquis Oral Tablet 2.5mg (milligrams) (Apixaban) give 1 tablet by mouth two times a day related to fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing. -10/21/2023…

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 observations, record reviews, and interviews the facility failed to ensure ADLs (activities of daily living) were performed for 3 (#22, #92, #104) out of 5 (#22, #61, #92, #104, #121) residents reviewed for ADLs. The facility failed to ensure residents #22, #92 and #104 received nail care. Findings: Resident #22 An observation on 03/11/2024 at 11:04 a.m. revealed Resident #22's fingernails were long, jagged with brown substance under the nail beds. An observation on 03/13/2024 at 9:12 a.m. revealed Resident #22's fingernails were long and jagged with brown substance under the nail beds. Review of Resident #22's Care Plan revealed Resident #22 required assistance with all ADLs with interventions which included assistance needed with shampoo, shower/bath 3 times a week and nails cleaned and checked. During an interview on 03/13/2024 at 2:40 p.m. S2DON (Director of Nursing) observed Resident #22's fingernails and acknowledged they needed to be cleaned and trimmed. Resident #92 An observation on 03/11/2024 at 8:12 a.m. revealed Resident #92 eating breakfast with long…

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 monitor edema for 1(#104) of 5(#3, #14, #79, #104, #122) residents reviewed for unnecessary medications. The facility failed to provide adequate monitoring for Resident #104's edema related to the use of a diuretic (Lasix) ordered by the physician. Findings: Review of Resident #104's current physician orders revealed an order dated 11/01/2023 for Lasix 40 milligram give 1 tablet by mouth one time a day related to congestive heart failure. Review of Resident #104's Care Plan revealed fluid volume deficit/excess-assess and record edema when indicated. Review of Resident #104's January, February and March 2024 MAR (Medication Administration Record) failed to reveal edema was being monitored while on a diuretic. During an interview on 03/14/2024 at 9:47 a.m. S2 DON (Director of Nursing) reviewed Resident #104's January, February and March 2024 MAR's and confirmed Resident #104 was not being monitored for edema and should have been.

Based on record review and interview the facility failed to ensure an abuse allegation was reported to administration staff in a timely manner per facility policy for 1 (Resident #64) of 1 resident reviewed for abuse. Findings: Review of the facility's Abuse and Neglect-Clinical Protocol (Revised October 15, 2022) revealed the following, in part: Policy Statement- The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident. Definitions: Sexual abuse is defined as non-consensual sexual contact of any type with a resident .For an alleged violation of sexual abuse the facility will: a. Immediately implement safeguards to prevent further potential abuse; b. Immediately report the allegation to appropriate authorities; c. Conduct a thorough investigation of the allegation; and d. Thoroughly document and report 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, observations, and interviews the facility failed to ensure the resident was treated with respect and dignity for 2 (#1, #5) of 9 sampled residents. The facility failed to: 1. Provide privacy for Resident #1 while being disrobed for ADL (activities of daily living) care. 2. Provide a privacy cover for Resident #5's catheter bag. Findings: Review of facility's Quality of Life - Dignity policy with the revision date of October 2, 2022 revealed in part: Policy Statement: Each Resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation: 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity, means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 11.…

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' Physician orders were followed for 2 (#1, #5) out of 9 sampled residents. The facility failed to: 1. Ensure continuous enteral feeding was administered for Resident #1. 2. Ensure medication was administered and vital signs were monitored for Resident #5. Findings: Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses, which included in part: aphasia, gastrostomy status, and unspecified dementia. Review of quarterly MDS (Minimum Data Set) dated 05/24/2023 revealed Resident #1 had a BIMS (Brief Interview for Mental Status) of 04 out of 15, indicating severely impaired cognition. Review of Resident #1's current Physician orders revealed in part: 10/08/2022 Isosource 1.5 at 45 ml (milliliter)/hr. (per hour) continuous via efp (enteral feeding pump). Provides 1620 Kcal (kilocalories)/day and 73.4 gm (grams) protein. Observation on 08/14/2023 at 9:30 a.m. revealed Resident #1 was not in her room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observation and interviews, the facility failed to ensure a resident fed by enteral means received the appropriate treatment and services to prevent complications by allowing non-clinical staff to disconnect and reconnect feeding tubes for 1 (#1) of 9 sampled residents. The deficient practice had the potential to affect 7 residents who receive enteral feedings according to the Resident Census and Conditions Report. Findings: Review of the facility's Enteral Feedings - Safety Precautions with the Revision date of November 2018 revealed in part: Preparation: 1. All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. Preventing misconnection errors: 2. Instruct all non-clinical staff, residents and visitors not to reconnect any tubing or lines, but instead to notify a nurse if tubing becomes disconnected. Resident #1 was admitted to the facility on [DATE] with diagnoses, which…

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 provide a safe, sanitary, and comfortable environment by failing to ensure: 1. The shower rooms and equipment on hallways E, G and I had been cleaned. 2. Showers C and D had been cleaned. 3. Soiled shower chair on hallway E had been cleaned. There were 132 residents residing in the facility according to Residents Census and Conditions report provided by the facility. Findings: Review of facility's Shower/Tub Bath policy with a revision date of October 2010 revealed in part: Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. General Guidelines: Steps in the Procedure: 9. be sure the tub or shower is clean. (Note: If the tub or shower is not clean, clean it with approved disinfectant solution. Review of the facility's Cleaning and Disinfection of Resident - Care Items and Equipment policy with the revision date of October 2018 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.