Holly Hill House

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of a facility-initiated transfer for 1 (#1) out of 4 (#1, #2, #3 and #4) residents sampled. Findings: A review of Resident #1's admission record revealed an initial admission date of 07/17/2025 and a discharged with return anticipated date of 07/27/2025 with diagnoses that included but were not limited to, depression, Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of Resident #1's nurse's notes revealed on 07/27/2025 at 9:30 a.m., Resident #1 transferred out of the facility to the hospital with transportation service via stretcher. A review of the emergency transfer log noting the Ombudsman notifications from July 2025 revealed Resident #1's transfer to the hospital on [DATE] was not identified on the list. On 08/25/2025 at 12:35 p.m., an interview and record review was conducted with S3ADON (Assistant Director of Nursing). S3ADON confirmed Resident #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement a comprehensive person-centered plan of care that identified the resident's need for 1:1 (one on one) supervision to manage behaviors for 2 (#1, #3) out of 4 (#1, #2, #3 and #4) sampled residents.Findings:Resident #1Review of Resident #1's EMR (electronic medical record) revealed the resident was readmitted to the facility on [DATE] with a diagnoses not limited to depression, unspecified Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of Resident #1's EMR, progress notes revealed a progress note dated 07/26/2025 at 4:28 p.m.,. Resident #1 stated I'm going to go in my room and hang myself. At 4:30 p.m., S13LPN (Licensed Practical Nurse) notified S10NP (Nurse Practitioner) who gave an n/o (new order) for 1:1 r/t (related to) suicidal ideation. Resident #1 was placed immediately on 1:1 with S13LPN at nurses' station.Further review of the EMR progress notes revealed no evidence of 1:1…

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

Based on record review and interviews, the facility failed to ensure an RN (Registered Nurse) provided services for at least 8 consecutive hours a day. Findings: Review of the facility's PBJ (Payroll Based Journal) RN Coverage Report for 01/01/2025 to 03/28/2025 revealed no RN hours for 01/01/2025, 01/04/2025, and 01/05/2025. Review of RN clock in hours for 01/01/2025 to 03/28/2025 revealed there were no RN hours for 01/01/2025, 01/04/2025, and 01/05/2025. On 04/14/2025 at 12:30 p.m., an interview was conducted with S1ADM (Administrator). S1ADM acknowledged the PBJ RN Coverage report for 01/01/2025 to 03/28/2025 revealed on 01/01/2025, 01/04/2025, and 01/05/2025 there was not 8 hours of RN coverage on those dates. He stated the RN scheduled to work did not show up for her scheduled shifts. He stated he was unaware at the time it occurred and did not find out about it until after the fact. S1ADM stated they must have 8 hours of RN coverage daily. On 04/15/2025 at 10:00 a.m., an interview and review of RN timesheets was conducted with S10HR (Human Resources). She stated 01/01/2025 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 review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner. The facility failed to maintain documentation of evidence of its ongoing facility QAPI program. This deficient practice has the potential to affect 88 residents residing in the facility. Findings: Review of a facility policy on 04/15/2025 at 3:00 PM titled, QAPI Policy with a revised date of 01/2024, revealed the following in part, the QAPI program takes a systematic, comprehensive and data-driven approach to maintaining and improve safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirements, understand the CMS (Center for Medicare and Medicaid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident's respiratory equipment was labeled, dated ,and stored properly for 4 (Resident #20, #30, #63 and #237) out of 4 (Resident #20, #30, #63 and #237) sampled residents reviewed for respiratory care. Findings: Resident #20 Review of Resident #20's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease and SOB (shortness of breath). Review of Resident #20's current physician's orders that read in part, 03/31/2025 - Oxygen Tubing - Change weekly every night shift every Thursday; 03/31/2025 - Oxygen (O2) - clean O2 concentrator filter with water and allow to air dry weekly every night shift every Thursday; 03/31/2025 - Oxygen - Change nebulizer and nebulizer tubing weekly every night shift every Thursday; 03/31/2025 - OXYGEN 2L (liters) via N/C (nasal cannula) - every shift; 03/31/2025 -…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #58 Review of resident #58's medical record revealed resident was admitted to the facility on [DATE] with diagnoses including morbid obesity, mild cognitive impairment, insomnia, anxiety disorder, major depressive disorder, apraxia, unspecified anemia, and frontal lobe and executive function deficit. Review of resident #58's June 2024 physician's orders revealed: Sertraline HCl oral tablet 100 mg (milligrams), give 1 tablet by mouth one time a day for depression related to major depressive disorder; give with 50 mg daily to equal 150 mg; (start date 06/19/2024) Sertraline HCl oral tablet 50 mg, give 1 tablet by mouth one time a day for depression related to major depressive disorder; give with 100 mg to equal 150 mg daily; (start date 06/19/2024) Trazadone HCl oral tablet 50 mg, give 1 tablet by mouth at bedtime for sleep related to major depressive disorder; insomnia; (start date 06/18/2024) Wellbutrin SR oral tablet extended release 12 hour, give 100 mg by mouth at bedtime for depression related to…

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

Based on observation, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. Food storage: A. Refrigerated items: 1. One container of peaches not labeled with the date it had been prepared. 2. Two containers of brown gravy with meat not labeled with the date it had been prepared. 3. One container of white gravy not labeled with the date it had been prepared. 4. One bag of pepper jack cheese not labeled with the date it had been opened. 5. One bag of sausage not labeled with the date it has been opened. B. Freezer items: 1. One bag of fries opened and not labeled with the date it had been opened or placed in a closed bag. 2. One bag of mushrooms opened and not labeled with the date it had been opened or placed in a closed bag. C. Walk-in refrigerator items: 1. Two red bell peppers with texture changes in the refrigerator indicated the items were spoiled. This deficient practice had the potential to affect the 88 residents who consumed food from 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 observation, interviews, and record reviews, the facility failed to maintain dignity for 2 (Resident #27 and #61) out of 29 sampled residents by failing to provide residents with metal utensils and non-disposable drinking cups during dining. Findings: A review of the facility's policy titled, Resident Rights Policy with a last review date of 12/2024, read in part, Each resident in this community has the right and will be afforded he right to a dignified existence, self-determination, and communication with an access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal. Resident #27 A review of Resident #27's Quarterly MDS (Minimum Data Set) dated 11/13/2024 revealed he had a BIMS (Brief Interview for Mental Status) of 12, indicating his cognition was moderately impaired. On 04/13/2025 at 12:09 p.m., an observation was conducted of dining. Resident #27 was observed consuming lunch using plastic utensils and drinking out of a disposable cup.…

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

Based on observations and interviews the facility failed to maintain 3 (#23, #41, and #75) of 3 (#23, #41, and #75) clients rooms and property observed for cleanliness. This had the potential to affect the census of 88 residents that reside in the facility. Findings: On 04/13/25 at 10:32 a.m., an observation in Resident #23 room revealed behind the head of her bed was covered with dust, Her Fan grill was covered with lint and her wheel chair spokes and frame was were covered with dust. At 10:40 a.m., an observation in Resident #41's room revealed the floor under her bed was covered with dust and dirt particles and her wheel chair spokes and frame were covered with dust. At 11:00 a.m., an observation in Resident #75's room revealed the floor under his bed was covered with dust and dirt particles and his wheel chair spokes and frame were covered with dust. On 04/14/25 at 3:00 p.m., an interview and observation of Resident #23, Resident #41 and Resident #75's rooms was conducted with S12 HKM (House Keeping Manager). S12HKM confirmed the floors under the resident's beds were dirty 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 review and interview, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #16) of 1 (Resident #16) residents investigated for PASARR in a final sample of 29 residents. Findings: Review of Resident #16's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, alcohol induced dementia with an onset date of 01/02/2025, schizoaffective disorder, anxiety, restlessness and agitation with an onset date of 12/27/2025. Review of Resident #16's Level I PASARR dated 05/25/2012 revealed part A - Mental illness, Question #1 Does the individual have indications of or a diagnosis of a major mental illness as defined in the D8M-IVR (Advance Directive for Mental Health Treatment), limited to schizophrenia, mood disorder, severe anxiety disorder, personality disorder, other…

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 follow physician's orders for 1 (#46) resident in a sample of 29 residents. The deficient practice had a potential to affect a total census of 88 residents. Findings: Resident #46 admitted to the facility on [DATE] with diagnoses that included in part, but were not limited to metabolic encephalopathy, major depressive disorder, bipolar disorder, and anxiety disorder. A review of Resident #46's Care Plan which included a focus that read, the resident has mood problem disease process dementia, bipolar, depression, anxiety. The focus interventions included in part, give anti-anxiety medications ordered by M.D. (Doctor of Medicine). A review of Resident #46's medical record revealed an active physician's order dated 1/06/2025 that read Buspirone oral tablet 10mg give one tablet in the evening for anxiety disorder. A review of Resident #46's EMAR (Electronic Medication Administration Record) for February 2025 through April 14, 2025 revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure routine drugs and biologicals were available for administration for 1 (#46) resident in a sample of 29 residents. The deficient practice had a potential to affect a total census of 88 residents. Findings: Resident #46 was admitted to the facility on [DATE] with diagnoses that included in part, but were not limited to metabolic encephalopathy, major depressive disorder, bipolar disorder, and anxiety disorder. A review of Resident #46's Care Plan which included a focus that read, the resident has mood problem disease process dementia, bipolar, depression, anxiety. The focus interventions included in part, give anti-anxiety medications ordered by M.D. (Doctor of Medicine). A review of Resident #46's medical record revealed a physician's order dated 12/12/2024 that read, Lorazepam oral tablet 0.5 mg (milligram) give 0.5 mg by mouth three times a day related to anxiety disorder. A review of Resident #46's EMAR (Electronic 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 observation and interview, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional practice by failing to ensure the medication cart was locked when unattended for 1 Medication Cart (Med Cart A) out of 3 (Med Cart A, Med Cart B, Med Cart C) medication carts observed. The deficient practice had the potential to affect a total of 88 residents in the facility. Findings: On 04/15/2025 at 8:27 a.m., an observation was made of Med Cart A that was unattended and unlocked. Further observation revealed there was no nurse located on the hall. On 04/15/2025 at 8:29 a.m., an interview was conducted with S9LPN (Licensed Practical Nurse) upon her return to Med Cart A. She confirmed she had left the medication cart unlocked while unattended. S9LPN confirmed she should have locked the med cart prior to leaving the cart.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews the facility failed to serve 1 (Resident #23) of 1 (Resident #23) resident investigated for food, her recommended diet as required by her diagnosis of gastroenteritis and her assessed dislikes. This had the potential to affect the 88 residents that consumed food out of the kitchen. Findings: Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnosis in part, Gastroparesis, Diarrhea, Severe Morbid obesity, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Bipolar Disorder, Obstructive Sleep Apnea, Gastro Esophageal Reflux Disease. She had a BIMS (Brief Interview for Mental Status) of 15, meaning she was cognitively intact. Record review of Resident #23 care plan dated 06/13/2024 read in part, Goal: my dietary preferences will be honored . Foods I dislike are: .Hamburger Patties. Record review of Resident #23 gastroenterologist progress notes dated 09/06/2024 read in part, She needs to be on a gastroparesis diet . Record…

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

Based on record reviews and interviews, the facility failed to resolve a grievance within 5 working days per facility grievance policy for 1 (#3) out of 1 (#3) resident reviewed for personal property. Findings: Review of the facility's policy titled Resident Grievance Policy and Procedure with no revision date revealed in part; The response will be given to the person initiating the grievance within 5 working days of the findings and along with any corrective action accomplished. Review of Resident #3's electronic medical record revealed an admission date of 01/03/2022 with diagnoses that included acquired absence of left leg above the knee, dementia, and morbid obesity. Review of facility grievances revealed a grievance filed regarding Resident #3 concerning odor and a soiled brief. The grievance was dated 01/07/2025. The resolved date was 01/28/2025. On 02/26/2025 at 4:00 PM, concurrent records review and interview was conducted with SDON (Director of Nursing). S2DON reviewed the grievance dated 01/07/2025 and acknowledged the grievance had not been resolved until 21 days later on…

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

Based on record reviews and interview the facility failed to ensure the allegation of abuse/neglect or injury of known origin were reported immediately, but not later than 2 hours after the allegation is made, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury and reported the results of all investigations, and; report the results of all investigations to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 9 (Resident #1 - Resident #9) out of 9 (Resident #1 - Resident #9) residents reviews for timely reporting of critical incidents. Findings: Resident #1 Review of Resident #1's critical incident report related to neglect with head injury revealed the event occurred on 01/14/2025 at 9:50 PM. The discovered date was 01/15/2025 at 8:00 AM. The entered date was 02/11/2025 at 3:59 PM, with a report due date of 01/22/2025. Further review of Resident #1's critical incident revealed the incident investigation 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 review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#1) out of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) sampled residents. The deficient practice had the potential to effect a total census of 82. Findings: Review of Resident #1's electronic clinical record revealed and admission date of 06/03/2024 with diagnoses that included in part atrial fibrillation, vascular dementia, and anxiety disorder. Review of Resident #1's December 2024 MAR (Medication Administration Record) revealed the resident received Eliquis (an anticoagulant) and Trazodone (an antidepressant). Further review of the December 2024 MAR failed to reveal Resident #1 received any antibiotics. Review of the Resident #1's quarterly MDS (Minimum Data Set) dated 12/17/2024 revealed under Section N-Medications, the resident was not indicated for the use of an anticoagulant or for the use of an antidepressant. Further review of Section N-medications revealed the resident was indicated for antibiotic use. On 02/12/2025 at 9:00 AM, a concurrent…

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 the residents received all care and treatment in accordance with professional standards of practice as evidenced by nurses failing to complete neurological checks on a resident with an unwitnessed fall for 2 (Resident #1 and Resident #3) out of 3 (Resident #1, Resident #2, Resident #3) residents reviewed for accident/hazards. Findings: Review of the facility policy titled, Neurologic Assessment, with an approved date of 12/2024 read in part: 1. Neurological assessments will be completed b. following an unwitnessed fall . 3. Neurological assessments (neuro checks) will be done every 15 minutes for the first hour, then every 30 minutes times 2, every hour times 6, every 4 hours times 4, every 8 hours times 6 for a total of 72 hours. a. if the schedule should be interrupted due to transfer to hospital, the schedule will be resumed upon return from the hospital. Resident #1 Review of the Resident #1's incident report dated 01/14/2025 at 9:50 PM,…

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

Based on interview and record review, the facility failed to ensure the Hospice agency provided services based on the agreement and facility policy to meet professional standards for 1(Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to collaborate with the hospice agency to ensure the hospice nurse's visit notes were up-to-date in the resident's hospice binder. Findings: A review of Resident #1's Hospice binder revealed the last hospice nurse visit notes were on 09/27/2024. On 12/11/2024, a review of Hospice services agreement made and entered into on 07/27/2023 by Hospice agency and the facility indicated . 5.1 Compilation of records. 5.1.1 Preparation. Facility and hospice each shall prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient receiving facility services and hospice services under the agreement in accordance with prudent record-keeping procedures .Each clinical record shall completely, promptly and accurately document all services provided. On 12/11/2024, a review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility's policy and procedure review, the facility failed to ensure S4LPN (Licensed Practical Nurse) notified the physician and/or charge nurse when a resident had a significant change in condition for 1 (#3) resident out of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled residents. Findings: On 10/15/2024, a review of the facility's policy titled, Catheter Care, Urinary with a last reviewed date of 07/2024, read in part, . Input/Output: 1. Observe the resident's urine output for noticeable increased or decreases. If the output decreases significantly . report it to the medical practitioner or charge nurse . Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Retention of Urine, Benign Prostatic Hyperplasia, and Parkinsonism. Review of Resident #3's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 7, indicating his cognition…

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 protect the resident's right to be free from physical abuse for 1 (#2) out of 4 (#2, #4, #6, #7) residents investigated for abuse. The facility failed to protect Resident #2 from physical abuse by Resident #7. The deficient practice had to potential to affect a total census of 78. Findings: On 10/15/2024, a review of the facility's policy titled Abuse and Neglect-Clinical Protocol, with a review date of 01/2024, defined abuse as; resident to resident abuse includes the term 'willful'. The word willful means that the individual's action was deliberate (not inadvertent or accidental). Resident #2 Review of the Clinical Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's disease, Major Depressive Disorder, and Mood Affective Disorder. Review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/22/2024 revealed Resident #2 had a BIMS (Brief Interview of Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that services were provided as outlined in the comprehensive plan of care for 1 (#3) out of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled resident as evidence by failing to: 1. foley catheter urinary output was monitored and recorded every shift, and 2. side effects of anticoagulants were monitored and recorded. Findings: On 10/15/2024, a review of the facility's policy titled, Catheter Care, Urinary with a last reviewed date of 07/2024, read in part, . Input/Output: . 2. Maintain an accurate record of the resident's daily output every shift . Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Retention of Urine, Benign Prostatic Hyperplasia, and Heart Failure. Review of Resident #3's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 7, indicating his cognition was severely impaired. Section N:…

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, observations and record review, the facility failed to ensure there was enough dietary staff to provide residents' meals within 45 minutes of the facility's scheduled meal times for 84 residents who consumed meals from the kitchen. Findings: A review of the facility's policy on 09/05/2024, titled, Dining Service Meal Times, with no reviewed date, read in part, procedure: .3. Dining service times are planned in accordance with resident preferences and staffing available at scheduled meal times. 4. Meals and snacks will be served at the following times: Breakfast 7:30 a.m., Lunch 12:00 p.m., Afternoon snack 2:00 p.m., Supper 5:30 p.m., HS (nightly) snack 6:00 p.m. On 09/03/2024 at 8:35 a.m., an interview was conducted with S9CNA. She reported the meals were not always served at the same time each day and meal service was often late. S9CNA could not say what time the breakfast meal was usually served as the time always varied. On 09/03/2024 at 8:40 a.m., an observation of the facility main dining room was done. There were 3 (#2, #R4, #R5) residents in the dining…

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 residents received diets and preferences as described on diet cards were followed for 5 (#R1, #R2, #R3, #R4, and #R5) of 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) of 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) residents reviewed for nutrition. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 84 residents who received meals from the kitchen. Findings: On 09/03/2024 at 11:07 a.m., an interview was conducted with Resident #R1. She stated she was supposed to get a banana and yogurt every day and had not been getting them for some time. She stated the 2 weeks ago they were only served a small portion of fish and a few fries with nothing else to go with it. She stated they had only got water on meal trays for a couple of weeks. On 09/03/2024 at 12:09 p.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #R6 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue (Tuesday) for monitoring for 4 weeks. There was no documentation any weights were obtained until 09/05/2024. Resident #R7 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation ordered weekly weight were obtained for weeks 2, 3, 4. Resident #R8 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation ordered weekly weights were obtained for week 2. Resident #R9 admitted to the facility on [DATE]. Further review of her admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation ordered weekly weights were obtained for weeks 3 and 4. Resident #R10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure residents maintained acceptable parameters of nutrition for 2 (#3 and #R18) of 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) residents reviewed for nutrition The facility failed to ensure: 1.Resident's #3 was assessed for weight changes and intervene to prevent severe weight loss; and 2.The registered dietician's recommendations were implemented for Resident #R18. Findings: 1. Review of facility's policy on 09/05/2024 titled, Weight Assessment and Intervention, with a reviewed date of 01/2017, revealed in part: 1. The nursing staff will measure resident weights on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly. 2. Weights will be recorded in the individual's medical record. 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where…

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 protect the resident's rights to be free from neglect by failing to ensure the availability of supplies in sufficient number the residents required necessary to provide care to residents as evidenced by: 1. Failing to provide appropriate sized incontinence briefs to 74 incontinent residents; and 2. Failing to provide a sufficient number of clean linens, when the facility was observed not having an adequate amount of clean towels and washcloths available. This had the potential to affect the census of 89. Findings: On 06/10/2024 at 9:30 a.m., an observation was made of S6CNA (Certified Nursing Assistant) assembling 4 incontinence briefs together. S6CNA stated the facility ran out of the size 2XL (extra-large) and 3XL incontinence briefs. S6CNA stated she was assembling the incontinence briefs together because she was told to get creative because the appropriate size briefs were not available. On 06/10/2024 between 1:00 p.m. and 1:25 p.m., an observation of the facility's supply closets for incontinence…

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, observation, and interviews, the facility failed to follow the physician's orders for 1 (#3) resident out of 5 (#1, #2, #3, #4, #5) residents sampled, as evidence by failing to follow orders for obtaining an x-ray timely causing a delay in care for the resident. Findings: Review of Resident #3's Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE]. The resident had diagnoses which included, but were not limited to Fracture of Unspecified part of Neck of Right Femur, subsequent encounter for Closed Fracture with routine healing and Encounter for other Orthopedic Aftercare. Review of Resident #3's physician's orders revealed the following orders for x-rays: An order date of 05/24/2024 at 1:44 p.m. that read, X-ray left femur. An order date of 05/28/2024 at 7:55 a.m. that read, X-ray left leg. An order date of 05/28/2024 at 8:15 a.m. that read, X-ray left hip, femur, knee, tib (tibia), fib (fibula), ankle, foot. An order date of 05/31/2024 at 2:02 p.m. that…

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

Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. a thick layer of debris and food residue on the deep fryer cooking oil collection area; 2. expired foods from the kitchen refrigerator, freezer, and dry storage area; and 3. sticky residue with food debris on the cart used to bring food items from one part of the kitchen to another. This deficient practice had the potential to affect the 72 residents who consumed food from the kitchen. Findings: On 04/22/2024 at 8:30 a.m., a tour of the facility's kitchen was conducted with S1DietarySup (Dietary Supervisor), who stated that she was responsible for the day to day management of the kitchen. On 04/22/2024 at 8:35 a.m., an observation of the deep fryer was conducted with S1DietarySup that revealed the cooking oil collection area had a thick layer of debris and a large piece of fried food material. S1DietarySup stated the deep fryer was last used on 04/21/2024 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 review, observations and interviews, the facility was not administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's administration failed to implement the facility's Enhanced Barrier Precautions (EBP) policy for residents with infection or colonization with a multi-drug resistant organisms (MDRO) or for any resident who has a chronic wound and/or indwelling medical device. The deficient practice was observed for 8 (#17, #24, #30, #35, #48, #68, #75, #232) out of 14 residents who met criteria for Enhanced Barrier Precautions. Findings: Cross reference findings to F880. A review of the facility's policy titled Infection Prevention and Control Manual - Enhanced Barrier Precautions written on 08/21/2023 revealed in part . Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDRO) in nursing homes. Enhanced Barrier Precautions involve gown and glove use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #35 During an interview and observation with S6LPN (Licensed Practical Nurse) on 04/23/2024 at 1:02 p.m., she confirmed that Resident #35 had PEG (Percutaneous Endoscopic Gastrostomy) tubes. S6LPN acknowledged that a PEG tube was considered an indwelling medical device inserted into the stomach through a surgical wound in the abdomen and this could make someone with a PEG susceptible to infection. S6LPN was questioned regarding any awareness of Enhanced Barrier Precautions. S6LPN admitted she was not familiar with what it entailed or any of the requirements. S6LPN verified there was no signage on the door or near the entrance to the rooms of Resident #35 or Resident #68, announcing and explaining the need for Enhanced Barrier Precautions. S6LPN confirmed there was no PPE (Personal Protective Equipment) readily available near the entrance to Resident #35 or #68's room. S6LPN also verified there was no red biohazard waste receptacle in Resident #35 or #68's room, for disposal of PPE after use. S6LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' assessment accurately reflected the status of 1 (#61) out of a total of 33 sampled residents, by failing to ensure MDS (Minimum Data Set) assessment was coded correctly for antidepressant use. Findings Review of Resident # 61's Electronic Health Record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Emphysema, Diabetes Mellitus II, and Legal Blindness. Review of Resident # 61's Annual MDS assessment with an ARD (Assessment Reference Date) of 02/14/2024 revealed in Section N - High-Risk Drug Classes Antidepressant was coded 1, indicating the resident was taking an antidepressant. Review of Resident # 61's February 2024 Physician Orders revealed no orders for use of antidepressants. On 04/24/2024 at 10:15 a.m., an interview and review of Resident #61's Electronic Health Record was conducted with S4MDS nurse. She confirmed the resident was not prescribed an antidepressant. She…

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 refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#55) of 4 (#6, #13, #55, #68) residents investigated for PASARR in a final sample of 74 residents. Findings: A review of Resident #55's record revealed an admission date of 01/14/2024. Further review revealed he was diagnosed with Delusional Disorder on 01/19/2024. Further review of Resident #55's record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 11/28/2023. No PASARR Level II was noted in Resident #55's record. On 04/24/2024 at 3:58 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing). S3ADON confirmed Resident #55 received a qualifying diagnosis of Delusional Disorder after his admission date. She confirmed the facility had not resubmitted for a Level II PASARR review and was unaware that this was required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement a comprehensive person-centered care plan that included monitoring for adverse reactions for antibiotic use for 1 (#10) out of 33 sampled residents. Findings: A review of Resident #10's electronic health record revealed she admitted to the facility on [DATE] with diagnoses that included but were not limited to Cerebral Infarction. Other diagnoses included Retention of Urine and Urinary Tract Infection (UTI). A review of Resident #10's physician orders revealed an order dated 04/17/2024 for Bactrim DS Oral Tablet 800-160 milligram (mg) give 1 tablet by mouth two times a day for UTI (Urinary Tract Infection) for 10 days. A further review of Resident #10's physician orders failed to reveal an order to monitor for adverse reactions of antibiotic use. A review of Resident #10's care plan revealed the following in part .The resident is on Antibiotic therapy Bactrim DS po (oral) until 04/27/2024. Interventions included in part .Any antibiotic may…

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 provide quarterly statements of personal funds for 1 (Resident #7) of 1 resident investigated for personal funds. The deficient practice had the potential to affect a census of 80 residents. Findings: Review of Resident #7's electronic health record revealed that she was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Unspecified Diastolic Congestive Heart Failure. Review of Resident #7's MDS (Minimum Data Set) with an ARD (Assessment Review Date) of 01/16/2024 Section C (Cognitive Patterns) revealed she had a BIMS (Brief Interview for Mental Status) of 15, indicating she was cognitively intact. On 4/04/2024 at 3:23 p.m., an interview was conducted with Resident #7. She stated that the facility was in charge of her funds and that she had not been given a statement in over 2 years. She stated that she would like to know what was in her account. 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 observation, interviews, and record reviews, the facility failed to develop a resident centered comprehensive care plan for 3 (#2, #4, #7) out of a finalized sample of 7 residents as evidenced by: 1. Failing to identify and plan for Resident #2's diagnosis of Sexual Dysfunction, 2. Failing to follow physician's orders to increase Resident #4's medication, 3. Failing to identify and plan for Resident #7's BIPAP (Bi-level Positive Airway Pressure) machine, 4. Failing to follow physician's orders to apply creams, change oxygen tubing, and clean oxygen concentrator filter for Resident #7. This deficient practice had the potential to affect a total census of 80 residents. Findings: 1. Resident #2 A record review of Resident #2's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses in part: Vascular Dementia, Aphasia, Mood Disorder, Sexual Dysfunction, and Disorder of Adult Personality and Behavior. A review of Resident #2's care plan revealed the facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to properly store respiratory equipment for 1 resident (#7) out of 1 resident (#7) investigated for respiratory care. Findings: Review of Resident #7's electronic health record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Unspecified Diastolic Congestive Heart Failure. Review of Resident #7's MDS (Minimum Data Set) with an ARD (Assessment Review Date) of 01/16/2024 Section C (Cognitive Patterns) revealed she had a BIMS (Brief Interview for Mental Status) of 15, indicating she was cognitively intact. Further review of this MDS Section O, (Special Treatments, Procedures and Programs) revealed she was coded for Non-Invasive Mechanical Ventilator. Review of Resident #7's physician's orders revealed in part, BiPAP (Bi-level positive airway pressure) on for sleep at bedtime. Levalbuterol HCL (Hydrochloride)…

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 obtain routine medication as ordered by the physician to meet the needs of 1 (#3) out of 3 (#1, #2, #3) sampled residents. Findings: Resident #3 was admitted to the facility on [DATE] at 6:30 p.m. with diagnoses that included in part, Encephalopathy, Type 2 Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Nonalcoholic Steatohepatitis, Low Back Pain, and Fibromyalgia. On 03/25/2024, a review of Resident #3's admitting Physician Orders revealed the following orders: 03/01/2024 Atorvastatin 40 milligrams (mg) -Give by mouth one time a day 03/01/2024 Carboxymethylcellulose sodium ophthalmic Gel 1% - Instill 1 drop in both eyes every 4 hours as needed for pain 03/02/2024 Furosemide 20 mg -Give 20 mg one time a day 03/02/2024 Insulin Glargine -Inject 28 units subcutaneously two times a day 03/02/2024 Insulin Lispro -Inject 5 units subcutaneously three times a day 03/01/2024 Lactulose - Give 40 milliliters (ml) by mouth three times a day…

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 residents are free significant medication errors for 1 (#3) out of 3 (#1, #2, #3) sampled residents. Findings: Resident #3 was admitted to the facility on [DATE] at 6:30 p.m. with diagnoses that included in part, Encephalopathy, Type 2 Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Nonalcoholic Steatohepatitis, Low Back Pain, and Fibromyalgia. On 03/25/2024, a review of Resident #3's admitting Physician Orders revealed the following orders: 03/01/2024 Atorvastatin 40 milligrams (mg) -Give by mouth one time a day 03/01/2024 Carboxymethylcellulose sodium ophthalmic Gel 1% - Instill 1 drop in both eyes every 4 hours as needed for pain 03/02/2024 Furosemide 20 mg -Give 20 mg one time a day 03/02/2024 Insulin Glargine -Inject 28 units subcutaneously two times a day 03/02/2024 Insulin Lispro -Inject 5 units subcutaneously three times a day 03/01/2024 Lactulose - Give 40 milliliters (ml) by mouth three times a day 03/02/2024…

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 notify the State Long Term Care Ombudsman of facility-initiated transfers for 1 (Resident #1) out of 3 (#1, #2, #3) sampled residents. The deficient practice has the potential to affect a census of 61. Findings: On 01/30/2024, a request was made for the facility's policy for Ombudsman notifications of hospital transfers. No policy was provided by the time of exit. Review of Resident #1's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part; Interstitial Pulmonary Disease, Unspecified Dementia, and Parkinsonism. Review of Resident #1's nurses' notes revealed on 12/31/2023 at 14:42 (2:24 p.m.), the resident was sent to the hospital and returned on 12/31/2023 at 19:56 (7:56 p.m.). Review of the Emergency Transfer Log for December 2023 revealed no documented evidence that Resident #1's transfer to the hospital on [DATE] was not identified on the log. On 01/29/2024 at 3:45 p.m., an interview 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 interviews, and record reviews, the facility failed to implement a residents' plan of care by failing to provide documented evidence that monitoring of behaviors and adverse reactions was conducted for 2 (#1 and #3) out of 3 (#1, #2, #3) residents who received an antipsychotic and/or antidepressant medications. Findings: Resident #1 Review of Resident #1's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part; Interstitial Pulmonary Disease, Unspecified Dementia, and Parkinsonism. Review of Resident #1's physician's orders dated 01/01/2024 - 01/31/2024 revealed an order for Seroquel (an antipsychotic medication) 25mg (milligram) by mouth two times a day. Review of Resident #1's care plan revealed, in part, to include the following: The resident is at risk for adverse reactions r/t (related to) antipsychotic medication .Monitor for possible signs and symptoms of adverse drug reactions. Further review of the care plan revealed, in part, 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 interview, the facility failed to ensure quality of care in accordance with professional standards of practice for 1 (#1) of 3 (#1, #2, #3) sampled residents for unwitnessed falls. This was evidenced when 72 hours of neuro-checks were not complete after an unwitnessed fall and hit their head. Findings: A review of the facility's policy titled, Neurological Assessment read in part: 1. Neurological assessments will be completed .b. following an unwitnessed fall c. Following a fall or other accident/injury involving head trauma. 3. Neurological assessments (neuro checks) will be done every 15 minutes for the first hour, then every 30 minutes x2, every hour x6, every 4 hours x4, every 8 hours x6 for a total of 72 hours. A. if the schedule should be interrupted due to transfer to hospital, the schedule will be resumed upon return from the hospital. Review of Resident #1's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the provider failed to ensure nursing personnel and/or other direct care personnel followed physician's orders for 3 (#1, #2, and #3) of 3 sampled residents. The facility census was 64. Findings Resident #1 Review of resident #1's medical records revealed she was admitted to the facility on [DATE] with diagnoses including Psychotic Disturbance, Mood Disturbance, Anxiety Disorder, Essential Hypertension, Hyperlipidemia, Essential Tremor, Major Depressive Disorder, Dysphagia, Drug Induced Subacute Dyskinesia, Non-Rheumatic Aortic Valve Stenosis, Personal History of TIA (Transient Ischemic Attack) and Cerebral Infarction without Residual Deficits, and Presence of a Cardiac Pacemaker. Review of current physician's orders for Resident #1 indicated a start date of 08/13/2023 for Resident #1 was to have barrier cream applied to her sacral/coccyx area every shift. Review of Resident #1's December 2023 TAR (Treatment Administration Record) indicated that barrier cream was not…

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 assess 1 (#1) out of 1 (#1) residents for self-administration of medication by the Interdisciplinary Team (IDT) to determine that this practice is clinically appropriate in a sample of 3 (#1, #2, #3) residents. Findings: A review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] with diagnoses that included in part: Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory failure with Hypoxia, Hypertensive Heart Disease, Heart Failure, Dependence on Supplemental Oxygen, Tobacco use, and Peripheral Vascular Disease (PVD). A review of Resident #1's Minimum Data Set (MDS) Annual assessment with an Assessment Reference Date (ARD) of 07/27/2023 revealed that he had a Brief Interview for mental status (BIMS) score of 15 which indicated resident was cognitively intact. A review of Resident #1's care plan included: Resident #1 wishes to self- administer nebulizer treatments. Interventions included 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 policy review, record review and interviews, the facility failed to ensure nursing staff provided Basic Life Support (BLS), including notifying Emergency Medical Services (EMS) of a resident that was unresponsive with full code status according to the policy and procedure for 1 (#1) of 3 (#1, #2, #3) sampled residents. Findings: A review of the policy titled Emergency Procedure - Cardiopulmonary Resuscitation revealed the following in part: 7) The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). Staff will call 911 when CPR is initiated. Begin CPR if the adult victim is unresponsive and not breathing normally without assessing the victim's pulse. Following initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing. Provide ventilations with a compression-ventilation ratio of 30:2. A review of Resident #1's electronic medical record revealed that he…

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 policy review, record review, and interviews, the facility's staff failed to assess and monitor a resident who had a significant change of respiratory status for 1(#1) of 3 (#1, #2, #3) residents sampled. Findings: A review of the policy titled Significant Condition Change and Notification included the following in part: To ensure that the resident's family and medical practitioner are notified of resident changes that included sudden onset of shortness of breath, significant change in/or unstable vital signs. The medical practitioner will be contacted immediately for any emergencies. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. Charting will include an assessment of the resident's current status as it relates to the change in condition. Charting will be done each shift for 72 hours for residents with a change of condition. A review of Resident #1's electronic medical record revealed that he was admitted to…

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

Based on record review and interview, the facility failed to maintain documented evidence of an effective training program for all new and existing staff. This deficient practice was identified for 2 (S4RN (Registered Nurse), S5CNA (Certified Nursing Assistant)) of 5 (S4RN, S5CNA, S6CNA, S7RN) personnel records review for training requirements. Findings: Review of S4RN's personnel record revealed a hire date of 09/16/2021. Further review of S4RN's personnel record revealed no documented evidence S4RN received training related to the following topics: communication, infection prevention and behavioral health. Review of S5CNA's personnel record revealed a hire date of 12/07/2021. Further review of S5CNA's personnel record revealed no documented evidence S5CNA received training related to the following topics: communication, infection prevention and control and behavioral health. During an interview with S6HR on 09/21/2023 at 1:00 p.m., she reported she had provided all the personnel files for requested staff and their training documentation. She state ifd the training documentation…

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