St. Elizabeth Rehabilitation & Nursing Center

Based on interviews with resident, staff and review of the grievance process it was determined that the facility failed to give adequate responses to grievances presented by a resident/family regarding an allegation of neglect. This was found evident in the review a facility reported incident of neglect that was also a reported grievance from Resident #2 reviewed during the complaint survey.The findings include:A review of the medical record for Resident #2 on 8/28/25 at 8:25 AM revealed admission to the facility in June of 2025 for therapy and antibiotics. On the nightshift of 7/6/25 into 7/7/25 Resident #2 put on their call-light repeatedly asking for help to be changed out of a soiled brief. According to a grievance form completed by Resident # 2's family on 7/9/25, GNA #7 failed to provide any activities of daily living on the night shift for Resident #2. According to the response and resolution on the form the employee was terminated, however, there is nothing noted that there was follow up with the family or the resident. Resident #2 was interviewed on 8/28/25 at 8:42 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.

Based on record review and interviews it was determined the facility staff failed to report incidents within required timeframes. This was evident for 2 (#21 and #2) of 12 residents reviewed for neglect and 2 (#15 and #4) of 6 residents reviewed for abuse during the complaint survey. The findings include:1) On 8/23/24 Resident #21 was lowered to the floor by staff # 13. Resident #21 was assessed and put back to bed. The Resident's daughter came to visit and noticed the resident was slumped to the left side of wheelchair and left ankle was swollen. Resident # 21 had a history of blood clots and asked that resident be checked for blood clots and have his/her left lower ankle be x-rayed. On 8/25/24 Lower left ankle was x-rayed and venous doppler was done. Results were the same as before, mild degeneration changes done on 8/26/24. On 8/26/24 resident could not stand or put pressure on foot. Resident was sent out 911 to hospital on 8/26/24 and noted to have a left hip fracture. It was repaired and the resident was sent back to facility. Responsible party was not notified of the fall 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 record review and interview with facility staff it was determined that the facility staff failed to thoroughly investigate allegations of abuse and neglect. This was evident for 2 (Residents #15 and #4) of 6 residents reviewed for abuse and for 1 (Resident #2) of 12 residents reviewed for neglect during the complaint survey. The findings include:1) On 8/26/25 at 11:31 AM, a review of a facility’s self-reported incident, 347659, alleged that Resident #15 reported an allegation of possible sexual abuse to a family member, who then reported the allegation to the facility staff. The facility’s investigation documented that staff became aware of the incident on 11/16/24 at 3:00 PM. The facility’s follow-up investigation report on 11/21/24 documented that Resident #15 was moderately cognitively impaired and resided on the memory care unit. The self-report further documented that Resident #15 was interviewed by the DON (Director of Nurses) and there were no witnesses to the allegation. The facility’s investigation concluded that the allegation of sexual abuse was not verified,…

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, observation and interview it was determined that the facility failed to complete accurate assessments of a resident related to the Brief interview of mental status (BIMS) assessment completed on the minimum data set (MDS). This was evident for 1 of 5 residents (Resident #2) reviewed during the complaint survey. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each resident receives the care they need. BIMS (mandatory, cognitive screening tool used in long-term care facilities to identify and monitor cognitive changes in residents upon admission and periodically thereafter)Review of the medical record for Resident #2 on 8/28/25 at 8:25 AM revealed that on admission to the facility in 2025, the resident signed the admission contract and was…

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

Based on medical record review and interview with facility staff it was determined that the facility failed to develop a comprehensive resident-centered care plan regarding the resident's pertinent diagnosis. This was evident for 1(Resident #5) of 17 residents reviewed for Quality of Care and for 1 (Resident #2) of 6 residents reviewed for Abuse during the complaint survey.The findings include:A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.A PEG (percutaneous endoscopic gastrostomy) tube is a thin, flexible tube inserted through the skin and into the stomach. It provides a direct route for administering food, fluids, and medications and is used in patients who cannot swallow safely.1) Resident #5’s medical record was reviewed on 8/25/25 at 12:30 PM. The Resident’s diagnoses included but were not limited to: Dysphagia (swallowing disorder) with a history of pneumonitis (inflammation of the lungs) due to inhalation of food and vomit, Pulmonary fibrosis (scar tissue in the lungs…

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 clean and change the brief of an incontinent resident. This was evident for 1 resident (Resident # 6) out of 5 residents reviewed during the complaint survey.Findings include:On 8/26/25 at 1:58 PM an investigation was done for Resident # 6 who complained about not being changed on a regular basis. According to the medical record, the resident is incontinent of bowl and bladder. The GNA Kardex is a record of what is being done for the resident. The GNA Kardex indicated the resident had not been changed on the following days:On June 2025 documentation states the nursing staff did not change Resident on the following:Day shift 6/2/25, 6/7/25, 6/8/25, 6/9/25, 6/16/25, 6/22/25Evening shift 6/1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 16, 17, and 29Night shift 6/1, 3, 4, 6, 8, 9, 10, 11, 12, 15.July 2025 documentation states the nursing staff did not change Resident on the following:Day shift: 7/4, 14, 25, 28Evening shift: 7/2, 5, 14, 30August 2025…

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

Based on medical record review and staff interviews it was determined the facility staff failed to ensure that Resident #25's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 (Resident # 25) of 4 residents reviewed during the survey process. The findings include:On 8/28/25 9:30 AM review of complaint 347660 alleged that Resident #25's did not receive showers in the month of December 2024.The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.Review of Resident #25's most recent MDS completed on 1/30/25, revealed that s/he is maximal assistance for bathing. The Brief Interview for Mental Status (BIMS) revealed a score of 13 indicating adequate cognitive ability.Further review of Resident #25's shower schedule which is every Wednesday and Saturday, as well as the Geriatric Nursing Assistant…

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, the facility failed to monitor a resident's hydration and nutrition status resulting in the resident's change in condition that led to the resident being transferred to the local hospital to be treated for dehydration. This was evident for 1 (Resident #17) of 3 residents reviewed for neglect during a complaint survey. The findings include:On 8/25/25, the surveyor reviewed complaint 347682/MD00215742 which alleged that facility staff members failed to offer water to Resident #17 leading to the resident being transferred to the local hospital for emergency services. Review of Resident #17's medical record on 8/25/25 at 12:39pm revealed that the resident had a change in condition on 3/6/25. The resident was unable to speak, and his/her eyes were unfocused. Facility nursing staff assessed the resident, treated the resident with supplemental oxygen, and received orders to start an IV with a saline solution. Facility nursing staff were unable to establish the IV and the resident was transferred to the local hospital for treatment. Continued…

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 the facility staff failed to maintain the medical record in the most complete and accurate form for a Resident. This was evident for 1 (Resident #7) of 2 residents selected for review during the survey process.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.On 8/21/ 25 at 10 AM a review of Resident # 7's electronic medical record revealed a physician order for PT to evaluate wheelchair and positioning on 12/2/24.On 8/26/25 at 10 AM an interview with the Director of Physical Therapy (PT) revealed that he could not confirm or deny that the evaluations occurred. The information was not available in the electronic medical record.On 8/28/25 at 1:30PM , in an interview with the Director of Nursing confirmed the facility staff failed to maintain the medical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, it was determined that the facility failed to maintain clean carpets. This was found to be evident in many carpeted areas of the facility. The findings include: On 09/30/24 at 08:38 AM, the surveyor walked into room [ROOM NUMBER] and observed that the floor was sticky, and shoes were sticking to the carpet. During an observation on 10/01/24 at 09:19 AM, the surveyor noted sticky carpet in room [ROOM NUMBER]. During an interview with the Maintenance Director on 10/4/24 at 02:03 PM, the surveyor asked about the sticky carpets and floors. The Maintenance Director replied that the floors get sticky when staff use too much cleaning solution ratio to water. He later provided a Staff Education sign in sheet where employees were educated on proper dilution of chemicals to water for floor cleaning. A record review of the facility web based work orders from Technology Enhanced Learning and Science (TELS) log on 10/10/24 at 08:50 AM, revealed many requests for carpet…

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 review of a facility reported incident and interview with staff, it was determined that the facility failed to report the results of an alleged abuse investigation within five working days to the Office of Health Care Quality. This was evident for 4 (Resident #375, #29, #72, and #223) out of 12 residents investigated for abuse during the annual and complaint survey. The findings include: 1.On 10/9/2024 at 8:58AM, the Surveyor reviewed Resident #375's facility reported incident of alleged abuse which occurred 11/28/2023. Additional review of the facility reported incident revealed that the facility initiated an investigation and submitted a self-report on 11/29/2023 to the Office of Health Care Quality. The final investigation report was completed and submitted to the Office of Health Care Quality on 12/12/2023. On 10/10/2024 at 1:15PM, the Surveyor conducted an interview with the Director of Nursing (DON) #2 and confirmed that the final investigation report was not submitted to the Office of Health Care Quality within five working days of the incident. 2. On 10/03/24 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.

Based on medical record review and interviews with facility staff, it was determined the facility failed to identify the responsible party (RP) and notify them of changes. This was evident for 3 (Resident #382, #66, and #101) out of 57 residents reviewed for resident rights during the facility's annual and complaint survey. The findings include: 1. On 10/10/24 at 7:14 AM, the surveyor reviewed Resident # 382's medical record. The review revealed that Resident #382 was admitted to the facility in 2021 and had a past medical history that included, but not limited to, congestive heart failure, hypertension, paroxysmal atrial fibrillation, and altered mental status. Further review revealed on 2/23/24 at 9:35 AM, the Unit Manager, Staff #36 wrote a progress note that stated Resident #382 is alert and oriented with some confusion noted. The note further clarifies that Resident #382 remains his/her own health care decision maker at this time. A decisional capacity evaluation was performed by Psychologist Staff #38 on 3/38/24 at 12:22 PM. The evaluation determined that Resident #382 did 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.

Based on medical record review and interviews it was determined that the facility failed to inform in advance of treatment changes. This was found evident for 1 (Resident #382) out of 18 residents reviewed for rights during the complaint portion of the annual survey. The findings include: On 10/10/24 at 7:14 AM, the surveyor reviewed Resident # 382's medical record. The review revealed that Resident #382 was admitted to the facility in 2021 and had a past medical history that included, but not limited to, congestive heart failure, hypertension, paroxysmal atrial fibrillation, and altered mental status. On 2/23/24 at 9:35 AM, the Unit Manager Staff #36 wrote a progress note stated Resident #382 is alert and oriented with some confusion noted. The note further clarifies that Resident #382 remains his/her own health care decision maker at this time. The surveyor next reviews an order written on 3/7/24 for a new medication Semaglutige 0.25mg injection weekly for diabetes control. The surveyor was unable to find documentation in the medical record that Resident #382 was informed that a…

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

Based on observation and interviews with facility staff, it was determined that the facility failed to provide the residents ' care with privacy and dignity when providing medications and administering care. This was found to be evident for 3 (Resident #111,114 and #143) out of 5 residents during medication administration. The findings include: Registered Nurse (RN) #20 was observed during medication administration, on October 3, 2024 at approximately 8:00 AM. It was observed that he did not close the patient door or draw the room divider curtain when he assessed the resident, provided treatments, and administered medication. This was observed while Registered Nurse #20 provided care to residents # 111, 114, and 143. An interview with RN #20 was conducted after the completion of medication administration on October 3, 2024 at approximately 9:20 AM. He stated he usually closes the door during assessments, medication administration, and treatments and was aware that maintaining the residents ' privacy and dignity was facility policy.

Based on record review and interviews with the residents and staff, it was determined that the facility failed to answer call bells timely to attend to the needs of dependent residents. This was evident for 3 (Resident # 81, #106, and #382) out of 6 residents call history reports reviewed during the annual and complaint survey. The findings include: 1. On 9/30/2024 at 1:30PM, the Surveyor conducted an interview with roommates, Resident #81 and Resident #106 in their room. An interview with Resident #81 revealed that the resident had to wait over an hour last week for staff to answer the call bell and address his/her needs. On 9/30/2024 at 1:35PM, the Surveyor conducted an interview with Resident #106. The resident informed the Surveyor that one night last week, he/she used the call bell for assistance with incontinent care and had to sit and wait for hours before his/her needs were addressed. During an interview conducted with Nursing Home Administrator (NHA) #1 on 10/3/2024 at 7:43AM, the Surveyor was informed that when a resident uses the call bell, the call will be transmitted 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 facility investigations, record reviews, interviews, and observations, the facility failed to protect residents from abuse and neglect. This was found to be evident for 2 (Resident #41 and #47) out of 12 residents investigated during for abuse and neglect during the annual and complaint survey. The findings include: During a review of intake #MD00205837 on 10/06/2024 at 1:24 PM, the facility had reported on 5/16/24 that Resident #63 was observed hitting Resident #47 in the face. The facility sent Resident #63 to the hospital for emergency evaluation of behaviors and possible changes to medications. On 10/06/2024 at 1:24 PM, the surveyor reviewed a facility reported incident #MD00205828, dated 5/18/24, that reported Resident #41 was kicked in the face by Resident #63. No injuries were noted, and the residents were immediately separated. During an interview with the Director of Nursing (DON) #2 on 10/07/2024 9:29 AM, the surveyor was told that when Resident #63 first arrived at the facility there had a lot of adjustment problems managing her behavior. Resident #63 has…

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, review of facility investigation, and interviews it was determined that the facility failed to suspend a staff member and prevent potential abuse while an abuse investigation was still being conducted. This was found evident of 1 (Resident #385) out of 12 Residents reviewed for abuse. The findings include: On 10/3/24 at 8:03 AM, the surveyor reviewed Resident #385's medical record. The review revealed a note written on 8/6/24 by Unit Manager (UM) #36 that described Resident #385's Responsible Party (RP) wanted to report that he was informed by a family member that his mom/dad alleged they were beaten up by the staff. Next the surveyor reviewed the facility's investigation into the incident. After interviews, review of Resident #385's assessments and statements, the facility was unable to substantiate the allegation. On review of the Geriatric Nursing Assistance (GNA) #37 employee file, there was no indication the GNA #37 was suspended. On 10/8/24 at 1:42 PM, the surveyor interviewed the Director of Nursing (DON). When asked if the alleged GNA #37 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 with staff, it was determined that the facility failed to ensure the local Ombudsman was notified of a facility initiated resident discharge or transfer. This was evident for 1 (Resident #25) out of 3 residents investigated for hospitalizations during the annual survey. The findings include: On 10/2/2024 at 9:43AM, during review of Resident #25's electronic medical record, the Surveyor discovered that the resident had Physician orders to transfer to the emergency room on 6/19/2024 for evaluation and treatment. The resident returned to the facility on 6/26/2024. Long term care Ombudsmen are advocates for nursing home residents. On 10/3/2024 at 12:00PM, a review of the Admission/Discharge To/From Report for discharges from 6/1/2024 to 6/30/2024, provided to the Ombudsman, did not include Resident #25's discharge to the hospital on 6/19/2024. During an interview conducted with the Director of Nursing (DON) #2 on 10/3/2024 at approximately 12:30PM, the Surveyor requested documentation to show that a copy of the notice of transfer or discharge to 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, medical record review, and staff interview it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was found to be evident for 1 (Resident #63) out of 57 residents reviewed during the annual survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. During a MDS record review on 09/12/2024 at 08:34 AM, the surveyor noted that Resident #63's current Annual MDS dated [DATE], Section E 0200 Behavioral Symptoms - Presence and Frequency was answered No. However, Resident #63 was noted in the record as having behaviors in the 7 day look back period. During an interview with the MDS Coordinator #15 on 10/02/24 at12:16 PM, the surveyor asked the process…

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 review of medical records, review of correspondences, and interviews with staff, it was determined that the facility failed to have complete, appropriate documentation in the medical record to ensure the discharge needs of a resident were met. This was found evident of 1 (Resident #390) of 3 Residents reviewed for discharges. The findings include: On 10/9/24 at 7:26 AM, the surveyor reviewed Resident #390 ' s medical record. The review revealed Social worker Staff #18 wrote a progress note on 6/28/24 stating that Resident #390 was anticipating returning home with his/her daughter. If further stated that home health equipment had been assessed and the current needed equipment was delivered to the Resident ' s home. The note concludes by stating that Resident #390 will be receiving home health services from an outside company that will include, home health Physical Therapy (PT), Occupational Therapy (OT), Home Nurse, Social Work and Home Health Aide. The discharge information was written in the Resident ' s interdisciplinary team (IDT) discharge form. Home Health Physical…

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

Based on observation, record review, and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent residents. This was found evident in 1 (Resident #28) out of 3 Residents reviewed for Activity of Daily Living (ADL) cares. The findings include: On 10/3/24 at 8:55 AM, the surveyor observed Resident #28 sitting at the edge of his/her bed and noted the resident was only in a brief for incontinence. At 9:11 AM, the surveyor informed the Geriatric Nursing Assistant (GNA) of the observations. The GNA went to get new briefs and then went into the resident's room. Following the observation the surveyor review Resident #28's medical record. The review revealed that Resident #28 was admitted to the facility in late August 2024. On review of Resident #28's admission functional abilities assessment, Resident #28 was coded as dependent for the ability to bathe self. On 7/7/24 at 7:18 AM, the surveyor asked the Director of Nursing (DON) for shower records for Resident #28. On review of the shower records from 9/8/24-10/7/24…

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 reviews and interviews, it was determined that 1) the facility staff failed to maintain supervision of a resident to minimize the risk for falls. This was evident for 1 (Resident #224) out of 9 residents reviewed for accidents during the annual survey. 2) The facility staff failed to provide treatments according to a Resident ' s plan of care. This was found evident of 1 (Resident #382) out of 4 residents reviewed for pressure ulcers. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 10/09/24 at 9 AM, review of complaint MD00192468 revealed that on 10/19/22, Resident #224 sustained a fall when left unsupervised in the shower room. A review of Resident #224's medical record was done on 10/09/24 at 9:30 AM. The review revealed that the resident was admitted to the facility on [DATE] with diagnoses including dementia, impaired balance, history of falls 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 observations and interviews, it was determined that the facility failed to post updated staffing information daily. This was found evident in 2 of 12 days observed on the survey. The findings include: On 9/30/24 at 8:08 AM, the surveyor observed that the staffing information posted in the front lobby was dated Friday September 27th. On 10/7/24 at 9:20 AM, the surveyor observed the staffing information posted in the front lobby was dated 10/4/24. The surveyor next asked the front desk personnel who was in charge of posting staffing information. The surveyor was directed to the Staffing Coordinator Staff #25. On 10/7/24 at 9:23 AM, the surveyor interviewed Staff #25. During the interview Staff #25 stated that she was in charge of posting the staffing information. The surveyor reported the two observations in which the last two Mondays the staffing information that was posted was from the Friday before. Staff #25 stated she did not work the weekends and that the nursing supervisor was responsible for updating the staffing information on the weekend. The surveyor next conducted…

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 the facility's Controlled Medication Shift Change Log and interview with staff, it was determined that the facility failed to ensure that an account of all controlled drugs was completed. This was found to be evident for 6 out of 14 logs reviewed during medication administration observation. The findings include: According to the National Institute of Health (NIH) a controlled substance are drugs or medications that possess the potential for being misused and are considered to be substances that have a substantially high risk of resulting in substance use disorder. A Controlled Medication Shift Change Log is a form that is used to document that an account for all controlled medications was completed for each shift change. The count of the controlled medications is completed by 2 licensed nurses. During an observation of the [NAME] medication cart conducted on 10/04/2024 at 11:25 AM, the Surveyors and Licensed Practical Nurse (LPN) #11 reviewed 14 Controlled Medication Shift Change Logs. 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 observations and staff interviews it was determined that the facility failed to: 1) maintain a safe and effective system for securing medication and treatment supplies and 2) properly store and dispose of medications. This was found to be evident for 1) 3 out of 10 medication carts and 2) 2 of 2 medication storage rooms observed during the annual survey. The findings include: 1a. During a tour of the 2nd floor nursing unit conducted on [DATE] at 5:55 AM, this Surveyor observed a medication cart labeled 210-218 unlocked. The Surveyor was able to open each medication drawer that had labeled medications packets with the resident's name and room number, insulin pens, in-house liquid medications, eye drops and inhalers. Insulin is a naturally occurring hormone your pancreas makes that's essential for allowing your body to use sugar (glucose) for energy. If your pancreas doesn't make enough insulin or your body doesn't use insulin properly, it leads to high blood sugar levels (hyperglycemia). This results in…

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

Based on record review and interviews, it was determined that the facility failed to have a system in place that assured accurate entry was completed to enable the ability for laboratory specimens to be processed by an outside company. This was found evident in 5 out of 8 laboratory samples reviewed for Resident #28. The findings include: On 10/3/24 at 2:30 PM, the surveyor reviewed Resident #28's laboratory results. On 9/3/24 Resident #28 was ordered to have blood samples for a Comprehensive Metabolic Panel (CMP), Lipid Panel, Complete Blood Count (CBC) with differential, and a stool sample for Clostridioides difficile (C-diff). On review of the results a note was written by an outside laboratory company that stated, blood samples rejected/canceled due to wrong date of birth (DOB) on the specimen tubes. Confirmed the DOB with the Nurse but the date was not changed. It further stated the wrong DOB was on the specimen cup with the stool sample by the nurse and was also rejected/canceled. Next the surveyor reviewed the blood lab result for a CBC with diff for 9/23/24. The comment 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 observation and staff interviews, it was determined that the facility failed to properly store food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility's kitchen. The findings include: On 10/01/2024 at 9:45 AM the Surveyors and the Certified Dietary Manager (CDM) #8 conducted an initial tour of the kitchen. The Surveyors and the CDM #8 observed the following: in the walk-in freezer there was 1 frozen pork loin that was partially unwrapped that appeared to have freezer burn and was undated and a partial package of Polish Pork sausage that was in an opened plastic bag and was undated. In the walk in refrigerator there were 9 packages of bologna that had an expiration date of 9/29/2024 and no internal thermometer. In the dry storage room there were 3 boxes of bananas with the fruit wrapped in plastic and condensation inside the bags and on the bananas, and 9 boxes of Baker's Source [NAME] Cake Mix that did not have an expiration date. An interview was conducted…

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 staff interviews it was determined that the facility failed to ensure the staff sanitized medical equipment between residents. This was found to be evident for 4 out of 5 residents (Residents #111, #424, #426, and #114) observed for infection control. The findings include: During an observation of the medication administration conducted on 10/03/2024 at approximately 10:15 AM, the surveyor observed Registered Nurse (RN) #20, remove the upper arm blood pressure cuff from the monitor and thoroughly clean it with a disinfectant wipe. He obtained Resident #111's blood pressure and returned the cuff to the monitor without sanitizing the cuff or the monitor. RN# 20 was observed on 10/03/2024 at approximately 10:30 AM, obtaining blood pressure for Resident #424. He did not sanitize the blood pressure cuff and monitor before or after he obtained #424's blood pressure. RN #20 then proceeded to the next Resident #114's room on 10/03/2024 at approximately 10:45 AM where he obtained their blood pressure. The blood pressure cuff and monitor were not sanitized before or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with staff and medical record reviews the facility failed to send out written notices to the responsible party for Resident numbers 123, 5, and 81 when discharged to the hospital . This was evident for 3 out of 3 residents transfered to the hospital. The findings include: 1. On 8/2/19 Resident # 123 got up in the middle of the night to use the bathroom. The resident stated after using the bathroom she /he attempted to wash his/her hands and lost his/ her balance and fell to the floor. Resident #123 experienced pain on the right side od body. She/he was sent to the hospital and diagnosed with a fracture of the right hip and underwent surgery. The resident was sent back to the nursing home on 8/4/19. According to nursing notes, Resident #123 does not ask for help when she /he wants to get up, and has an unsteady gait. On 9/27/19-10/18/19 Resident #123 was sent to the hospital with complaints of dizziness and weakness on the right side. The resident diagnosed with a stroke. The resident'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 observations, medical record review and resident and staff interview it was determined the facility failed to ensure that fingernails were kept trimmed for Resident #2. This was evident for 1 of 3 residents reviewed for Activities of Daily Living (ADLs) during the survey. The findings include: On 10/28/19 at 2:17 PM Resident #2 was noted to have a contracted right hand with long fingernails. When asked if she liked her nails long, she stated, No. On 10/31/19 beginning at 11:30 AM the Care Plan for Resident #2 was reviewed. Included in the Care Plan was a Focus area stating, The resident has an ADL self-care performance deficit . According to https://www.elderlawanswers.com/activities-of-daily-living-measure-the-need-for-long-term-care-assistance-15395: .The long-term care community measures personal needs by looking at whether an individual requires help with six basic activities that most people do every day without assistance, called activities of daily living (ADLs). This includes the ability to perform personal hygiene tasks such as trimming the fingernails. According…

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.