Future Care Homewood

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined that the facility staff failed to lock a medication cart. This was evident for 1 (Resident #86) out of 45 residents that were in the survey sample.The findings include:During an environmental tour of the facility on 6/29/26 at 8:37 AM an unlocked medication cart with an open laptop was observed outside room [ROOM NUMBER]. Closer inspection revealed that Resident #86's medications and some personal information were onscreen and visible. This surveyor then stood two feet away from the medication cart to continue the observation.Licensed Practical Nurse (LPN) #5 came out of the room at 8:38 AM, went to the cart and opened the controlled substance logbook. He searched for information regarding whether the resident was administered a particular medication or not. LPN #5 came out of the room again, went to the cart, looked at the computer screen, closed the window on the computer screen, and then locked the cart. Another nurse approached the cart; LPN #5…

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, it was determined that the facility failed to provide or obtain from an outside resource routine dental service to meet the needs of each resident. This was evident for 1 (Resident #19) of 1 resident reviewed for dental services during the recertification survey process.The Findings Included:On 06/24/2026 at 11:20 AM, during Resident #19's interview the resident revealed that he/she would like to see a dentist because his/her dentures were not fitting well. The surveyor observed that the resident had no teeth in his/her mouth.On 06/26/2026 at 9:31 AM, a review of the Resident #19's medical record revealed that oral screenings where conducted on 4 separate occasions (7/18/2025, 10/18/2025, 1/18/2026 and 4/18/2026) and each dental screen revealed that the oral assessment identified the resident's mouth condition as edentulous and dental consult needed; however, there was no documented evidence to support that dental consult was obtained at anytime since the resident's admission in April 2025.On 06/26/2026 at 11:55 AM, in an interview with the…

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

Based on clinical record review, resident interview, and staff interview it was determined that the facility staff failed to ensure a resident's showers were documented accurately. This was evident for 1 (Resident #8) out of 1 reviewed for showers during the recertification/complaint survey.The findings include:During the initial tour of the facility Resident #8 was interviewed on 6/23/26 at 9:09 AM. This surveyor asked if the resident receives two showers each week. The resident replied that they would like to get showers but has not received one. Resident said they only get bed baths because staff would not take them to the showers. A review of the resident's annual minimum data set (MDS) on 6/25/26 at 8:12 AM under Section F the resident replied that it was Very Important for them to choose whether they received a shower or a bath. Further review of the resident's clinical record revealed that under the Documentation Survey Reports for April, May, and June 2026 the resident did not receive a shower but only bed baths. This surveyor interviewed the Fourth Floor Unit Manager (Staff…

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 and staff interview it was determined that the facility staff failed to follow enhanced barrier precautions. This was the result of a random observation during the recertification/complaint survey.The findings include:During a tour of the facility on 6/25/26 at 9:15 AM Staff #11 and Staff #12 were observed entering room [ROOM NUMBER]. The door had a sign alerting anyone entering the room that there were enhanced barrier precautions in place.Enhanced barrier precautions required using hand sanitizer prior to entering the room and prior to exiting the room. The precaution also required using gloves, gown, and mask prior to contact with the resident as well as contact with the resident's linen.The two staff entered without using hand sanitizer prior to entry. The two were observed to have touched the bed several times, they touched the sheets, the air mattress and the air mattress device which maintained the air content. The two left the room after approximately two minutes. While they were…

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 review of facility policy, observations, and interviews, the facility failed to provide a functional, sanitary and comfortable environment for two (2) out of 21 sampled residents (Resident [R] #6 and R#19) when housekeeping staff failed to clean the residents' room and bathroom which had a strong smell of urine; and general housekeeping duties were not completed across three (3) units (Units #4, #5, and #6). Intakes #2608459 and #2599200 are directly related to these findings.The findings include:Review conducted on 5/13/26 at 2:00 PM of the facility's 1.2 Environmental Hygiene Cleaning & Disinfection Program dated July 2020 noted: Cleaning is the physical removal of dirt, body fluids, and other organic matter. Disinfection destroys the number of potential pathogens on a surface.4.1 General Cleaning and Disinfection Procedures for Daily Room and Discharge Cleaning.General Guideline - 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur and when these…

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 staff interviews, it was determined that the facility failed to provide appropriate pain management for residents. This was evident for 2 resident (Resident #137 and Resident #410) of 3 residents who were reviewed for pain management during the recertification/complaint survey. The findings include: 1) During a complaint investigation on 5/12/2025, at 5:58 PM, it was revealed that in February 2025, a complainant reported Resident #410 was in constant pain from wounds and often received medication late. On 5/13/2025, at 9:50 AM, Registered Nurse (RN #13) explained that nurses documented medication administration time when they physically handed medications to residents. The final documented time was entered after leaving the resident's room and saving the record. RN #13 stated, it should have a couple minutes gap, but not hours gap. Additionally, RN #13 explained that wound nurses communicated wound care schedules to floor nurses, enabling them to administer pain medication prior to treatment. When interviewed on 5/13/2025, at 10:48 AM, the…

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

Based on a review of staff personnel files and staff interview, it was determined that the facility staff failed to ensure nursing staff are retrained on an annual basis. This was evident for 3 (Staff #6, #34, #37) out of the 5 nurses reviewed for skills and competencies. The findings include: A review of the employee files for Staff #6, Staff #34 and Staff #37 revealed trainings for: Abuse and Neglect, Active Shooter Response, Age-Specific Care, Employee Safety Basics, Fire Safety, Infection Control and Prevention Basics, Person-centered Care, Normal Aging Process, and Understanding Dementia were past due. Staff #6's trainings were due by these dates as follows: Abuse and Neglect - 2/28/25, Active Shooter Response - 4/30/25, Age-Specific Care - 2/28/25, Employee Safety Basics - 4/30/25, Fire Safety - 3/31/25, Infection Control and Prevention Basics - 3/31/25, Person-centered Care - 4/30/25, Normal Aging Process - 2/28/25, and Understanding Dementia - 3/31/25. Staff #34's trainings were due by these dates as follows: Abuse and Neglect - 2/28/25, Active Shooter Response - 4/30/25,…

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 staff interviews, it was determined that the facility failed to maintain food trays and dinnerware in good condition and failed to store and serve food in a manner that prevents food borne illness to the residents. This was evident during the initial and subsequent kitchen observations conducted during the recertification/complaint survey. The findings include: On 5/12/25 at 8:10 AM during the initial kitchen observation tour, the surveyor noted multiple dinner trays that were chipped at the edges and sides. The trays were stacked on a rack by the dish washing machine. In an interview with staff #24, a porter responsible for washing the dishes on 5/12/25 at 8:20 AM, he was asked about the chipped trays. He stated that they have lots of chipped trays which they use to serve food to the resident's during meals. He asked the surveyor if the trays should be thrown out and not be used. The surveyor referred him to his supervisors. On 5/13/25 at 09:20 AM on a second visit to the kitchen, the surveyor again observed chipped trays coming off the dish washer line.…

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, it was determined that the facility failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and NOMNC (Notice of Medicare Non-coverage) was provided to the residents who were discharged from Medicare Part A services but had benefit days remaining. This was evident for 2 (Resident #30 and Resident #420) of 3 randomly selected residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification during the recertification/complaint survey. Findings included: Residents with Medicare Part A have certain rights and protections related to financial liability and appeals. The financial liability, appeal rights, and protections are communicated to beneficiaries through notices given by providers to residents who are being discharged from Medicare services but have Medicare benefit days remaining. The SNF ABN should be provided to residents/responsible parties in order to provide information so the resident/responsible party can make a decision to continue to receive services that may not be paid for by…

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

Based on observation, record reviews and interviews, it was determined that the facility failed to develop a person-centered comprehensive care plan for each service and treatment provided. This was evident for 1 (Resident #14) of the 28 sample size resident records reviewed during the survey process. Findings Included: BiPAP (Bilevel Positive Airway Pressure) is a non-invasive respiratory treatment that uses air pressure to assist with breathing, particularly for conditions like sleep apnea, COPD, and other respiratory problems. On 05/12/25 at 11:48 AM, an observation of Resident #14's room revealed that the resident was on oxygen via nasal cannula with oxygen concentrator and the resident also had a Bi PAP machine at bedside. In an interview with Resident #14, he/she reported that he/she requires oxygen at all times and uses the Bipap machine to sleep. The resident expressed concern about discharge planning and the ability to receive the respiratory treatment upon discharge. On 05/19/25 at 10:16 AM, a review of the Resident #14's Treatment Administration Record (TAR) revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a medical record review, observation, and interviews, it was determined that the facility failed to: 1) revise care plans quarterly, 2) the inter-disciplinary team (IDT) failed to attend care plan meetings at the time of the quarterly revision, and 3) revise care plans with a change in the resident's condition. This was evident for 3 (Resident #2, #130, #46 ) of the 75 Residents reviewed during the facility's recertification/complaint survey. The findings include: Care plans are developed for Residents to guide the care they receive in the facility. They describe residents' needs and the interventions to address them; they are required to be developed within 7 days of completion of a resident's comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). and they must be reviewed and revised at least every quarter and/or as changes in the residents' conditions occur. The facility is required to have care plans developed and revised by IDT, including: the…

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

Based on a complaint incident MD00195763, record review, and interviews with residents and staff, it was determined that the facility failed to ensure that a resident receive their showers on scheduled shower days. This was evident for 1(Resident #96 ) of 5 residents reviewed for activities of daily living during the recertification/complaint survey. The findings include: On 5/14/25 at 8:55 AM, a review of a complaint incident MD00195763 was completed. It stated that Resident #96 was not being bathed and because of the neglect, the patient's hair had to be cut off because it began to lock up. In an interview with Staff #25, a Geriatric Nursing Assistant (GNA), on 5/14/25 at 2:00 PM, he was asked how often residents on the floor are scheduled for showers. He stated that they are scheduled two times a week and that they document this on their task sheet. He showed the surveyor where the shower schedules were posted on the wall and explained how it was broken down as to who gets showered, and which shift was responsible to give the shower to the residents. The surveyor then asked for…

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

Based on medical record review, resident and staff interviews it was determined that the facility staff failed to provide fingernail grooming for a dependent resident. This was evident for 1 (Resident #31) of 2 residents investigated for Activities of Daily Living (ADL) during the survey process. The findings include: On 05/14/25 at 08:27 AM, Resident #31 was observed with very long fingernails. The surveyor asked the Resident if he/she prefers long nails. The Resident stated that she/he had requested to have them cut. Resident also stated that his/her niece use to do his/her nails, but she had not visited in a while. A record review of Resident's care plan on 5/14/25 at 9:32 AM indicated that Resident had self-care deficit related to unsteady gait, balance, uncoordinated movement, ambulatory impairment, and weakness bilaterally. Further review of diagnosis revealed no history of diabetes. An Interview was conducted on 05/14/25 at 08:22 AM with Geriatric Nurse Aide (Staff #15). The surveyor asked GNA #15 what tasks were included in Activities of Daily Living (ADL) for the residents.…

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 a review of the resident medical records and interviews with facility staff, it was determined that the facility failed to: 1) ensure that a resident received prescribed medication for 5 days, 2) ensure that a physician's order for a wound consultation was followed timely and 3) clarify a physician's order. This was evident for 3 (Resident # 389, #416 and #394) of 75 residents reviewed during this recertification/complaint survey. The findings include: Tafamidis is a medication primarily used to treat transthyretin amyloid cardiomyopathy. However Resident #389's hospital record showed that he/she had been used this medication for [name of cancer]. 1) On 5/13/2025, at 12:26 PM, the surveyor investigated complaints for Resident #389. One complainant reported that facility staff did not administer prescribed medication to the resident. A review of Resident #389's Medical Administration Record (MAR) for December 2024, conducted on 5/14/2025 at 7:58 PM, revealed the resident was prescribed Tafamidis 61mg by…

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

Based on observation, record review, and interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received treatment and services as ordered. This was evident for 1 (Resident #130) of 1 resident investigated for position and mobility during the recertification/complaint survey. The findings include: Range of Motion (ROM) refers to moving a patient's joints and muscles to maintain or restore their physical abilities, and also to prevent further muscle degradation. Passive ROM is performed to prevent contractures and promote mobility in patients who are unable to move or reposition themselves on their own. Functional maintenance programs (FMP) in long-term care (LTC) are designed to help residents maintain their functional capabilities beyond the time spent in an active therapy program. Documentation of the services provided ensures medical necessity requirements. This program is particularly beneficial for residents who may be at higher risk for declining without therapy, therefore follow-up is essential to assess the program's…

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

Based on a review of the complaint and medical records, and staff interviews, it was determined that facility staff failed to provide/document appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. This was evident for one (Resident #288) of two residents reviewed for urinary catheter care during this recertification/complaint survey. The findings include: An indwelling urinary catheter (often known as a Foley catheter) is inserted similarly to an intermittent catheter but remains in place, secured in the bladder by a water-filled balloon. A complaint review on 5/15/2025, at 5:56 PM, revealed that Resident #288's family member reported concerns in December 2022. The family stated, the resident called crying around 12 PM because his/her Foley bag had not been emptied and had been so full. A review of Resident #288's medical records on 5/19/2025, at 7:05 AM, showed that the facility's attending provider documented in the History and Physical (H&P) on October 12, 2022, that Resident #288 had a Foley catheter draining clear urine.…

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

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication. This failure was evident for one resident (Resident #410) out of two residents reviewed for narcotic medication administration during this recertifiation/complaint survey. The findings include: Oxycodone is a narcotic medication used to treat moderate to severe pain. It carries a high risk for addiction and dependence and can cause respiratory distress and death when taken in high doses or when combined with other substances, especially alcohol or other illicit drugs such as heroin and cocaine. A controlled medication utilization record, known as a count sheet, is a form used to document controlled medication dispensing. It records details for each instance a controlled substance amount is removed from its original containers, including the date, time, dose given, the signature of the nurse administering the medication, the amount…

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, medical record review and interview, it was determined the facility failed to maintain a medication error rate of less than 5%. This was evident for two (2) errors identified out of 26 opportunities for error during medication pass observation. The findings include: On 5/13/2025 at 9:40 AM, during an observation of medication administration, Registered Nurse (RN #12) was observed dispensing 4 meds into 4 medication cups and after crushing the ones that were not in liquid form, she administered them to Resident #79 via a gastrostomy tube [G-tube (a medical device inserted through the abdomen into the stomach to provide nutrition, medications, and fluids when someone cannot swallow or cannot eat enough by mouth)]. Following the medication observation on 5/13/2025 at 2:19 PM, a review of Resident #79's May 2025 Medication Administration Record (MAR) revealed two active orders: Multivitamin & Mineral Oral Liquid (Multiple Vitamins w/ Minerals), Give 15 ml via G-Tube one time a day for supplement with start date 7/13/2023 and scheduled to be given at 10:10 AM; and…

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

Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure resident received dental services. This was evident for 1 (Resident #24) out of the 42 residents that were part of the survey sample. The findings include: A member of the survey team interviewed Resident #24 on 5/12/25 at 9:19 AM. The resident said since I have been here, I have not seen a dentist and I would like to. I told them I would like some teeth at the meeting. A review of Resident #24's clinical record on 5/20/25 revealed the resident had not had a dental consultation since admission. The resident's comprehensive review of 2/26/24 noted the resident had missing teeth which means teeth were present at that time. The Director of Nursing (DON) was interviewed on 5/20/25 at 10:44 AM. This surveyor asked if dental consultations/visits are conducted routinely. He replied that dental screens are done through HealthDrive. If a nurse, GNA [Geriatric Nursing Assistant], and/or nurse practitioner does an oral screening and observes a problem and/or if a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3) A review of Resident #120's clinical record on 5/15/25 revealed staff charted that they provided daily and sometimes twice daily showers for the resident. The first floor Unit Manager (Staff #22) was interviewed on 5/15/25 at 11:58 AM. Asked him if the resident gets showers each week. He replied at least two every week and we try for more. He said the resident sometimes refuses but gets a bed bath once or twice a day. This surveyor showed him the set of shower sheets where it shows two to three showers a day. He said No way. It takes two and sometimes three staff to give a shower and never a tub bath. He said it is an education error. New staff are probably clicking 'yes' because they are in a hurry and probably only seeing the word bath not tub bath. The Regional Clinical Services Manager (Staff #4) was interviewed on 5/19/25 at 8:50 AM. This surveyor showed her the shower sheets and asked if she was aware of our concern. She replied that they were aware, confirmed the resident does not get two showers a…

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

Based on medical record review and interview, it was determined that 1) the facility failed to offer the administration of the pneumococcal vaccine to 1 (Resident #6) out of 5 Residents reviewed for immunizations; and 2) provide education about the risk and benefits to resident who refused the pneumococcal vaccine. This was evident for 1 (Resident #2) out of 5 Residents reviewed for immunizations during the survey. The findings include: Adults aged 65 and older should receive at least one dose of the pneumococcal vaccine. The frequency of additional doses depends on previous vaccination history and individual risk factors. If previously vaccinated, an additional dose is given one to five years after your last vaccination, education must be provided as it relates to the immunizations. On 05/20/25 at 11:07 AM the immunization record reviewed for Resident #6 indicated that the resident received the pneumococcal vaccine on 8/14/17. This was indicated on the final hospital discharge summary. Surveyor could not locate any documentation that the pneumococcal vaccine was given 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.

Based on observation and interviews, it was determined that the facility failed to ensure that every resident had access to a communication system to call for staff assistance, if needed. This is evident for 3 (Resident #100, #87, #40) of 8 resident's call bell accessibility observed during the recertification/complaint survey. Findings Included: On 05/21/25 at 08:45 AM, a surveyor conducted an audit for call bell accessibility and function, during the audit the following concerns were identified: In an interview with Resident #95, he/she was asked if there was any concerns about the call light system, Resident #95 stated that his/her call bell was in good working condition, but the roommate's (Resident #100) call bell stop working a while ago. Resident #100 was not present for an interview; however, the surveyor attempted to use Resident #100's call bell and it was in-operable. At approximately 9:10 AM, the surveyor inquired with Resident #87 regarding the call light system and upon closer observation, it was noted that Resident #87's call bell was not within reach. Specifically,…

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

Based on a review of staff personnel files and staff interview, it was determined that the facility staff failed to ensure geriatric nursing assistants (GNA) are retrained on an annual basis. This was evident for 1 out of the 1 GNA's reviewed for skills and competencies. The findings include: A review of Staff #36's employee file revealed these required trainings were late and were due by these dates as follows: Abuse and Neglect - 2/28/25, Active Shooter Response - 4/30/25, Age-Specific Care - 2/28/25, Employee Safety Basics - 4/30/25, Fire Safety - 3/31/25, Infection Control and Prevention Basics - 3/31/25, Person-centered Care - 4/30/25, Normal Aging Process - 2/28/25, and Understanding Dementia - 3/31/25. The Regional Clinical Services Manager (Staff #4) was interviewed on 5/21/25 at 8:30 AM. This surveyor asked about the late trainings and if the employee files were simply not updated. She said she would check and stated that if the employee was hired less than a year ago then they might not be due. Staff #4 returned at 9:30 AM on 5/21/25 and confirmed the training list 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 5. Review of Resident #37's medical record on 7/28/22 revealed the Resident was admitted to the facility on [DATE]. The Resident was discharged from the facility to the hospital on 3/31/22. Further review of the Resident's medical record failed to reveal any documentation that a notice regarding the transfer had been provided to the Resident or the Resident's responsible party. Interview with Regional Nurse #1 on 7/29/22 at 7:45 AM confirmed the facility had no evidence Resident #37 and the Resident's responsible party had been given written notification of the transfer to the hospital and the reason for the transfer. Based on medical record review and interview with staff it was determined the facility staff failed to provide written notice for emergency transfers to the residents, and residents' representative. This was found to be evident for 6 out of 7 (#3, #97 #103, #104, #225, and #37) residents reviewed for a facility-initiated transfer during the investigative of the survey. The findings include: 1. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to develop comprehensive care plans for residents (Resident #37, #64, #89, #113). This was evident for 4 out of 66 residents reviewed during an annual survey. The findings include: A care plan is an outline of nursing care showing all the resident's needs and the ways of meeting the needs. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the individual's specific needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care. 1. The facility staff failed to develop a care plan addressing Resident #37's need for oxygen therapy. Observation of Resident #37 on 7/25/22 at 9:34 AM 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.

Based on resident council members meeting and interviews It was determined that the facility failed to provide residents with enough nurse staffing. The finding includes: On 08/02/22 at 1:00 p.m. during resident council meeting with attending resident's #8, #33, #51, #82, and #110 who asked the Activity Director to be present during council meeting. Five members were interviewed when asked the question do you get the help and care you need without waiting a long time and does answer your call lights in a timely manner all five resident council members answered no, we must sit in our wheelchairs or in lay in bed for over a 1 hour in soiled incontinent briefs only for staff who don't change us this happens on weekend and night shifts. The staff comes turn off the call light and tell you I will be right back and don't return to help you until hours later. On 8/03/22 at 9:00 a.m. during interview with Corporate Regional Nurse was made aware of resident council concerns. The Administrator, Director of Nursing and Corporate Regional Nurse was aware of this concern prior and during survey…

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 during the survey it was determined that the facility staff failed to post staffing information at the entrance to the facility. This was evident from the start of the survey until 8/5/22. The evidence is: During tours of the facility and observation when the surveyors entered and left the facility it was noted that there was no posting of the current nurse staffing information at the entrance for visitors and residents to see. Regional Nurse #1 was interviewed on 8/5/22 at 1:50 PM and informed of the findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to ensure that medication regimens were free from unnecessary medications (Residents #103, #315, #31 and #110). This is evident for 4 of 66 residents selected for review during the survey process. The findings include: 1. The facility staff failed to hold a medication when the heart rate and systolic blood pressure was (top number) below the set parameter. Medical record review on 8/5/22 at 8 AM for Resident #103 revealed on 7/1/11 the physician ordered: Amlodipine besylate tablet 5 mg give one tablet via Peg tube one time a day for hypertension hold for SBP less than 110 mmhg or heart rate less than 55bpm. Amlodipine is in a class of medications called calcium channel blockers. It lowers blood pressure by relaxing the blood vessels, so the heart does not have to pump as hard. A review of the Medication Administration Record revealed on 7/2 at 9 AM the facility staff documented the resident's SBP as 104 and on 7/19 at 9 AM…

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 and staff interviews it was determined that the facility staff failed to ensure that food was served and handled in sanitary manner during lunch meal service and failed to ensure that food was stored in accordance with professional standards for food service safety. This practice has a potential of effecting all residents in facility. Finding includes: On 7/29/22 at 12:00 p.m. during observation of lunch meal service in main dining room. Surveyor observed staff member #8 was plating up hot resident lunch plates from hot meal cart without wearing required hair net to cover braid hair while handling food. During the same date and time this same staff member #8 was observed bare hand touching and handling hamburger buns serving in this meal observation. On 7/29/22 at 12:25 p.m. conducted interview with staff member #8 replied I forgot to put on a hair net. I was in a hurry to serve lunch. Staff member asked surveyor if he/she was required to plastic gloves while touching food. On 7/29/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for residents (Resident #31, #89, #110 and #226). This was evident for 4 of 66 residents reviewed during the annual survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Review of Resident #89's medical record on 7/29/22 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include depression. Review of the Resident's physician orders revealed the Resident was ordered Mirtazapine 30 mg one time a day for appetite stimulant. Review of the Resident's psychiatric progress note on 3/30/22 revealed the Resident was receiving Mirtazapine 30 mg for depression. Interview with…

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

Based on resident interview, family interview, staff interview, and clinical record review it was determined that the facility nursing staff failed to ensure residents received at least two showers each week (#26, #31, and #102). This was evident for 3 out of the 66 residents reviewed as part of the survey process. The findings are: 1. Resident #26 was interviewed on 7/27/22 at 9:18 AM. The resident stated that he/she was never offered a shower since admission and has only received bed baths. A review of the shower documentation for July and August in the clinical record revealed that the resident has only received a shower on 7/20 and 7/29. That works out to 2 out of 10 opportunities for showers. Regional Nurse #1 was interviewed on 7/27/27/22 at 9:18 AM. She was informed of the findings and confirmed that the resident received two showers since July. 2. Resident #31 was interviewed on 7/25/22 at 12:48 AM. The resident stated that he/she has not received a shower for awhile and bed baths are provided twice a week in the room. A review of the shower documentation in the clinical…

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 properly manage the funds of a resident (Resident #109). This was evident for 1 out of 3 residents reviewed during an annual survey. The findings include: During interview with Resident #109 on 7/26/22 at 11:51 AM the Resident stated the facility has failed to pay his/her AARP (The American Association of Retired Persons) insurance coverage from his/her pension funds. The Resident stated he/she had the AARP insurance prior to coming to the facility and the facility agreed to pay using his/her funds when he/she was admitted to the facility. Resident also stated had that time he/she has received 2 late notices from AARP. Review of the Resident's medical record revealed the Resident was admitted to the facility on [DATE]. On 7/26/22 the facility provided the surveyor a copy of the Resident's RFMS (Resident Fund Management Service) Resident statement that showed payments monthly for insurance premiums in the amount of $441.00. The Resident provided 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 review of facility documents and staff interview it was determined the facility failed to timely report an allegation of abuse to the State Survey Agency which is the Office of Health Care Quality (OHCQ). This was evident for 2 (#218 and #317) of 12 residents reviewed for abuse. The findings include: On 7/29/22 at 9:15 a.m. closed medical record review was conducted of the facility reported incident MD00168244 related to an allegation of verbal abuse involving resident #218 on 6/2/21. The facility documentation indicated the alleged incident was reported to the state agency on 6/4/21 which was two days after the alleged incident. Law enforcement agency documented reporting to facility on 6/4/21 arrival 9:24 p.m. The facility failed to report the abuse incident immediately not later than 2 hours of the event that caused the allegation. On 7/29/22 at 1:00 p.m. conduct staff interview with Corporate Regional Nurse verified these allegations had not been reported to the Office of Healthcare Quality in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to provide wound treatments as ordered by the physician for residents (Resident #37 and #315). This was evident for 2 out of 7 residents reviewed for skin conditions during the annual survey. The findings include: 1. The facility staff failed to provide wound care for Resident #37. Review of Resident #37's medical record on 7/29/22 revealed the Resident was admitted to the facility on [DATE] and had a physician order on 6/15/22 for wound care on left second finger daily. Further review of the Resident's medical record revealed the wound to be an arterial ulcer related to vascular insufficiency. Arterial wounds, also known as arterial ulcers, are painful injuries in your skin caused by poor circulation. During interview with Resident #37 on 8/3/22 at 11:28 AM, the Resident stated the facility staff are not changing his/her wound dressings daily. Review of Resident #37's Treatment Administration Records (TAR) on 8/3/22 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers for a resident (Resident #37). This is evident for 1 of 7 residents reviewed for pressure ulcers during an annual survey. A pressure ulcer also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). The findings include: Review of Resident #37's medical record on 7/29/22 revealed the…

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

Based on medical record review, observation, and interviews with facility staff it was determined the facility staff failed to provide evidence of adequate care to residents with indwelling urinary catheters (Residents #103). This was evident for 1 of 5 residents reviewed for indwelling urinary catheters during the annual survey. The Findings: A review of Resident #103's clinical record revealed that the resident's primary physician wrote an order on 6/30/2022, Patient has Foley catheter 16Fr; Balloon size 10ml, for stage 4 sacral ulcer. Provide catheter care every shift. On 07/26/22 at 10:22 AM an observation of resident #103's revealed the foley catheter tubing resting by the resident's left hip. At that time the Unit Manger was made aware of the findings and confirm that the resident did not have a foley catheter leg strap. On 8/5/22 at 1 pm interview with Regional Nurse revealed that catheter care does not include leg straps and a physician order will be obtained.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure a resident's physician was notified about weight loss (#102), failed to recognize a resident's weight loss, reweigh and provide a dietary consult in a timely manner (#5), and failed to obtain ordered weights (#61). This was evident for 3 residents out of the 66 sampled as part of the survey. The evidence is: 1. A review of Resident #102's clinical record revealed that the resident has had a 22% weight loss since admission a year ago. There was no mention in the clinical record of the physician being contacted regarding this weight loss. A review of the resident's clinical record revealed that on 8/2/21 the dietician wrote a note Resident readmitted after short stay hospital . Received IVF [Intravenous fluids] and IVABT [IV antibiotics] during hospital course. Wt [weight] 7/29 168.3#. Magic cup (nutritional supplement) was ordered to continue, and dietician added Med Pass 120 ml…

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, medical record review and interview, it was determined the facility staff failed to provide oxygen therapy consistent with professional standards of practice for a resident (Resident #37). This was evident for 1 out of 3 residents reviewed for oxygen therapy during an annual survey. The findings include: Observation of Resident #37 on 7/25/22 at 9:34 AM revealed the Resident was wearing humidified oxygen at 2 liters nasal cannula. Review of Resident #37's medical record on 7/29/22 revealed the Resident was admitted to the facility on [DATE] and did not have a physician order for oxygen. Further review of the Resident's medical record revealed the facility staff began documenting the Resident was wearing oxygen on 8/27/21. During interview with Resident #37 on 8/3/22 at 11:28 AM, the Resident stated he/she couldn't remember the exact date he/she began wearing oxygen but stated it has been a long time. Observation of the Resident's humidified oxygen revealed it was dated 7/28/22. Review of…

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