Westgate Hills Rehab & Healthcare Ctr

Based on record review and observation, it was determined that the facility failed to ensure staff maintain professional standards of practice when an active order was signed off. This was evident for 1 (Resident #9) of 3 residents reviewed for pressure ulcers.The findings include:On 05/18/2026 at 12:01 PM, review of Resident #9's medical record revealed a skin and wound progress note dated 5/15/26 at 9:11 AM, that indicated the resident has a sacral wound and a wound on their buttock, both of which were noted to be stage 3 pressure ulcers.At the same time, further review of Resident #9's medical record revealed an active order to turn and reposition the resident every two hours, and as needed. On 05/19/2026 at 8:17 AM, an observation of Resident #9 revealed the resident was in bed lying on their back. On 05/19/2026 at 10:26 AM, an observation of Resident #9 revealed the resident was in bed lying on their back. On 05/19/2026 at 12:36 PM, an observation of Resident #9 revealed the resident was in bed lying on their back. On 05/20/2026 at 7:03 AM, an observation of Resident #9…

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 a resident received treatment and care in accordance with the comprehensive person-centered care plan and professional standards of practice. This was evident for 3 (Resident #11, #16 and #74) out 76 residents reviewed during the annual survey. The findings include: 1) On 5/18/26 at 1:43 PM, the surveyor reviewed Resident #11's medical record. The review revealed an order for Resident #11's right elbow to have wound treatment with betadine solution and to be covered with foam dressing daily starting on 4/17/25. Next the surveyor reviewed the April and May Treatment Administration Records (TAR)s. The surveyor noted several days were left blank and are listed as follows: 4/17/26, 4/23/26, 4/27/26 4/29/26 4/30/26, 5/6/26, 5/8/26, 5/12/26, and 5/13/26. 2) On 5/18/26 at 7:49 AM, the surveyor conducted an interview with Resident #16. During the interview Resident #16 alleged that his/her dressing changes were not always completed. On 5/18/26 at 1:15 PM, the surveyor reviewed Resident #16's…

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

Based on record review and interview, it was determined that the facility failed to flush a gastrostomy tube in accordance with professional standards of practice. This was found to be evident for 1 (#12) out of 1 resident reviewed for gastrostomy tube flushing. The findings include:During a record review on 5/20/2025 at 8:30 AM, the surveyor noted an order written on 2/5/2025 at 18:00 that read, Flush G-Tube Q 6 Hours four times a day for hydration There was no mention of what or how much to flush the gastrostomy tube with.During an interview on 5/20/2025 at 9:30 AM, the Director of Nursing acknowledged the concern and stated, The order is incomplete. It should have specified the amount in the order.

Based on observation, medical record review, review of facility's policy and interview, it was determined that the facility staff failed to ensure residents received respiratory care consistent with professional standards of practice by providing oxygen at flow rate inconsistent with prescribed orders. This was evident for 2 (Resident #46 and #10) of 3 residents reviewed for respiratory care.Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels.The findings include:1) On 5/18/26 at 8:23 AM, the surveyor observed Resident #46's oxygen concentrator (the machine that delivers supplemental oxygen) dialed at 4.5 liters of oxygen per minute (l/min). No humidification bottle was noted. The nasal cannula tubing was directly attached to the concentrator. No label was noted on the tubing. Shortly after this observation, Licensed Practical Nurse (LPN) #4 walked into the room. The surveyor asked LPN #4 what Resident #46's ordered rate of oxygen was and LPN #4 stated he would look up the order to confirm. On return to the room LPN #4…

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

Number of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure annual performance review and regular in-service education were conducted for certified nurse aides (CNA)1. This deficient practice was evident for 2 of 5 CNA1 employee files reviewed during the annual survey.The findings include:On 05/20/2026, a review of CNA1 #9 and CNA1 #12's employee files failed to show documented evidence of an annual performance review and related in service education based on the outcomes of the 2025 performance review.During an interview conducted with Human Recourse (HR) #16 on 05/20/2026 at 11:42 AM, she explained that CNA1's annual performance review are completed yearly based on the employee's hire month. She further stated that unit managers and/or Director of Nursing are notified of upcoming annuals performance reviews that are due. The surveyor informed HR #16 of the missing annual performance reviews and related in service education for CNA1 #9 and CNA1 #12. HR #16 stated she would continue to searching…

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 medication administration observation, medical record review and staff interview, it was determined the facility failed to ensure a medication error rate of less than 5 percent during the medication pass observation. This finding was evident for 5 medication errors out of 26 opportunities which resulted in a medication error rate of 19%. Facility stock supply medications- Are mostly common over the counter medications in multidose containers to be shared amongst residents that are prescribed those medications. Examples would be vitamins and/or supplements. Aspirin Enteric-Coated (EC) or Delayed-Release (DR) is a form of aspirin with a special coating that prevents the tablet from dissolving in the stomach. Instead, it passes into the small intestine, where it is absorbed. This form is designed to prevent stomach irritation, ulcers, and gastrointestinal bleeding. The findings include: On 5/21/26 at 7:39 AM, the surveyor observed Certified Medicine Aide (CMA) #23 prepare medications for Resident #106. During the preparation CMA #23 took one table of the facility's stock…

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

Based on observation and interview, it was determined the facility failed to provide palatable food at an appetizing temperature. This was evident for 1 out of 1 observation of a kitchen tray line and test tray.The findings include:On 05/20/2026 at 11:46 AM, the surveyor observed the kitchen tray line for lunch begin.On 05/20/2026 at 12:33 PM, the test tray plate was prepared.On 05/20/2026 at 12:36 PM, the test tray plate arrived at the unit.On 05/20/2026 at 12:46 PM, the last resident lunch tray was delivered.On 05/20/2026 at 12:47 PM, the surveyor requested Assistant Dietary Director (Staff #19) who was present to take the temperature of the food on the test tray plate. The temperatures were as follows: Tilapia (a type of fish) was 108.5 degrees Fahrenheit, mashed potatoes and gravy were 116.2 degrees Fahrenheit, and sauteed mixed squash was 130.7 degrees Fahrenheit. On 05/20/2026 at 12:50 PM, two surveyors tested the entree and sides, which failed to be a palatable taste and at an appetizing temperature.On 05/20/2026 at 1:28 PM, the surveyor reviewed the concern with the Food…

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 interview it was determined that the facility failed to ensure food was stored in accordance with professional standards of practice for food service safety. This was evident during the initial tour of the kitchen upon entry into the facility. The findings include:On 05/18/2026 at 7:08 AM, an initial observation of the kitchen refrigerator revealed a ziplock bag of approximately 5 pizza slices, 2 peanut butter and jelly sandwiches which indicated use by 5/16/26, and an opened container of tomato juice, all of which were opened, without a label or date.On 05/18/2026 at 7:10 AM, an initial observation of the kitchen freezer revealed whole grain breaded alaska [NAME] square (fish patty), tilapia filet which looked to to freezer burnt, golden breaded veal (a type of meat) and beef patties, and biscuits which were all opened exposed to the freezer air, without a label or date.On 05/18/2026 at 7:13 AM, an initial observation of the kitchen dry storage room revealed 3, 4lb containers of peanut…

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 staff interviews, it was determined that the facility staff failed to ensure and maintain hospice documentation was available in the resident's medical records. This deficient practice was evident for 1 (Resident #3) of 2 residents reviewed for hospice services during the annual survey.The findings include:During an interview with Resident #3 on 05/18/2026 at 9:25 AM, when asked whether hospice services were being received, the resident replied, no. However, review of the resident medical records identified the resident as receiving hospice services.On 05/21/2026 at 7:13 AM, a review of the resident's electronic medical records (EHR) failed to show evidence of a hospice plan of care, hospice medications orders, hospice physician orders, a hospice election form, and physician certification of terminal illness. The surveyor informed the Administrator of the missing documents. The Administrator stated she would follow up with the medical records department and provide an update 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 and interviews, it was determined that the facility failed to follow standard precautions and enhanced barrier precautions. This was evident in 1) 1 (CMA #24) out of 1 staff members observed during the infection control task, 2) 1 (#6) out of 1 resident, and 3) 1 out of 2 observations of shared equipment disinfection during medication administration observed during the annual survey.The findings include: 1) On 5/21/26 at 8:39 AM, the surveyor observed Certified Medication Aide (CMA) #24 prepare medications for Resident #108. The surveyor observed CMA #24 bring Resident #108 his/her medication, however Resident #108 stated he/she was not feeling well and did not want to take the medications at that time CMA #24 asked if she could take Resident #108's blood pressure. Resident #108 agreed the blood [NAME] was taken using a portable blood pressure machine. On 5/21/26 at 8:55 AM, the surveyor observed Certified Medication Aide (CMA) #24 prepare medications for Resident #84. The surveyor observed…

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

Based on observation and interview it was determined the facility failed to ensure a resident had access to the call bell. This was evident for 2 (#1, #63, and #44) of 31 residents reviewed for call light access during the initial pool review.The findings include: 1) On 05/18/2026 at 8:35 AM, an observation of Resident #1 failed to reveal that the call bell was anywhere within reach of the resident nor was it visible to the surveyor. On 05/18/2026 at 8:36 AM, an observation of Resident #63 failed to reveal that the call bell was anywhere within reach of the resident nor was it visible to the surveyor. On 05/18/2026 at 8:37 AM, an interview with Licensed Practical Nurse (Staff #15) revealed that resident call bells should be within reach of them. The surveyor requested dual observation of Resident #1 and #63. On 05/18/2026 at 8:38 AM, during the dual observation, Staff #15 was initially unable to find Resident #1's call bell. She later identified it hanging on the wall where the call bell is plugged in. It was out of reach and out of sight of Resident #1. At the same time, Staff #15…

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

Based on record reviews and staff interviews, it was determined that the facility failed to ensure staff received Quality Assurance and Performance Improvement (QAPI) training. This deficient practice was evident with 2 of 5 employee files reviewed during the annual survey.The findings include:On 05/20/2026, a review of Certified Nursing Assistant1 (CNA1) #9 and CNA1 #6's employee files failed to show documented evidence of QAPI training completed in 2025.During an interview with Staff Educator #7 on 05/20/2026 at 11:44 AM, she explained the annual training and competency requirements for nursing assistants including QAPI. She further stated that since her hire date in December 2025, she had developed a training program to ensure compliance with annual training requirements. The surveyor informed the Staff Educator #7 and Human Resources (HR) #16 of the missing 2025 QAPI training for CNA1 #9 and CNA1 #6. Both the Staff Educator #7 and HR #16 stated they would search for the missing training documents and follow up with the surveyor.On 05/21/2026 at 9:39 AM, HR#16 acknowledged 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 record reviews and staff interviews, it was determined that the facility failed to ensure staff received Infection control training. This deficient practice was evident with 1 of 5 employee files reviewed during the annual survey.The findings include:On 05/20/2026, a review of Certified Nursing Assistant1 (CNA1) #12 employee file failed to show documented evidence of infection control training completed in 2025.During an interview with Staff Educator #7 on 05/20/2026 at 11:44 AM, she explained the annual training and competency requirements for nursing aides including infection control. She further stated that since her hire date in December 2025, she had developed a training program to ensure compliance with annual training requirements.The surveyor informed the Staff Educator #7 and Human Resources (HR) #16 of the missing infection control training for CNA1 #12. Both the Staff Educator #7 and HR #16 stated they would search for the missing training documents and follow up with the surveyor.On 05/21/2026 at 9:39 AM, HR#16 acknowledged the facility was unable to provide…

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

Based on record reviews and staff interviews, it was determined that the facility failed to ensure staff received compliance and ethics training. This deficient practice was evident with 3 of 5 employee files reviewed during the annual survey.The findings include:On 05/20/2026, a review of Certified Nursing Assistant1 (CNA1) #9 , CNA1 #6, and CNA1 #12 employee files failed to show documented evidence of Compliance and Ethics training completed in 2025.During an interview with Staff Educator #7 on 05/20/2026 at 11:44 AM, she explained the annual training and competency requirements for nursing assistants including compliance and ethics. She further stated that since her hire date in December 2025, she had developed a training program to ensure compliance with annual training requirements. The surveyor informed the Staff Educator #7 and Human Resources (HR) #16 of the missing 2025 compliance and ethics training for CNA1 #9, CNA1 #6, and CNA1 #12. Both the Staff Educator #7 and HR #16 stated they would search for the missing training documents and follow up with the surveyor.On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and complaint #2655446, it was determined that the facility failed to: 1) accurately document assessment in the resident medical record and 2) ensure that the residents receive treatment and care in accordance with professional standards of practice to prevent future skin impairment. This was evident for 2 (Resident #2, #6) of 8 residents records reviewed during the complaint process.The findings include: During the complaint investigation on 12/30/25 at 8:27 AM, the surveyor reviewed Resident #6's medical records. The review revealed that the resident received Nitroglycerin (a potent vasodilator used to treat and prevent chest pain caused by coronary artery disease) on 10/16/25, 10/28/25, and 10/29/25. However, there was no documentation of symptoms or assessments prior to the administration of Nitroglycerin on 10/16/25. In an interview with the Director of Nursing (DON) on 12/31/25 at 8:23 AM, she stated that any change in condition, including chest pain, should be documented…

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 records and interviews, it was determined that the facility failed to assess or document residents' behaviors regarding mental illness. This was evident for one resident (Resident #7) out of eight residents reviewed during this complaint survey. The findings include: On 12/30/25 at 1:50 PM, the surveyor conducted a phone interview with the complainant for case #2659413. During the interview, the complainant reported that they were not informed of Resident #7's worsening agitation, wandering, and/or behaviors, such as entering other residents' rooms and touching their belongings. The complainant stated that when the resident was ready to be readmitted to the facility, management resisted, claiming that Resident #7 had worsening behavioral issues that resulted in the facility increasing its budget to address the problems.The surveyor reviewed Resident #7's medical records on 12/30/25 at 2:15 PM. The review revealed that the resident had resided at this facility since October 2025 with a diagnosis of dementia with behavioral disturbance. Additionally, the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of complaints, observations and interviews, it was determined that the facility failed to have a fully functioning call bell system. This was evidenced by the lack of an audible call bell system on the second floor and had the potential of affecting all residents.The findings include:Tracheostomy is a surgical procedure that creates an opening in the trachea (windpipe) and inserts a tube to help a person breatheOn 10/07/2025 at 9:30 AM A review of complaint #328740 was conducted. The review revealed an allegation that stated call bells were not answered in a timely manner.On 10/07/2025 at 9:47 AM The surveyor observed that the call bell light was on outside room [ROOM NUMBER], which was located next to the nurses' station. No audible sound was heard in the hallways or at the nurse's station. Resident #216's door had a contact precaution sign on. At 9:58 AM, the Surveyor was gowning to enter the resident's room when Staff #11 told the surveyor that S/He had just changed the resident and 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 reviews and interviews, it was determined that facility staff failed to ensure a resident was free from verbal abuse. This deficient practice was evident for one (#215) resident reviewed for abuse during the complaint survey.The findings include: On 10/08/25, a review of the Facility Reported Incident (FRI) # 2629130 revealed that on 09/26/25 at 1:30 PM, Resident #215 informed Social Service (SS) Director #2 that Geriatric Nursing Assistant (GNA)#17 was verbally aggressive towards them on 09/25/25 during the 3PM-11PM Shift. On 10/08/25, the surveyor requested the employee file for GNA #17. A review of employee file reviewed documentation of an interview conducted on 09/26/25 by the Administrator regarding the incident involving Resident #215 on 09/25/25. During the interview, the GNA stated she was tired of being labeled as the aggressive person. When the Administrator asked if anything occurred with her and Resident #215 on 09/25/25, the GNA confirmed that there had been an incident and stated that the resident had called her inappropriate names. The GNA informed…

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, it was determined that the facility failed to report an injury of unknown origin to the State Agency (SA) within the required time frame of discovering the incident, as required by regulation. This was evident for 1 out of 6 facility reported incidents during the complaint survey.The findings include:On 10/08/2025 at 8:20 AM, the surveyor reviewed the facility's investigation packet for intake #2605804, which revealed the facility reported an injury of unknown origin for Resident #203 on 09/02/2025.On 10/08/2025 8:23 AM, further review of the initial self-report sent to the State Agency (SA) revealed that the facility became aware of Resident #203's injury of unknown origin on 09/02/2025 at 7:20 AM and reported it to the state Agency (SA) on 09/02/2025 at 11:02 AM. The elapsed time between identification of the injury and the facility's report to the SA was approximately 3 hours and 42 minutes, exceeding the required two-hour reporting timeframe.On 10/08/2025 at 12:48 PM, during an interview with the Nursing Home Administrator (NHA), when asked…

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

Based on record reviews and interviews, it was determined that facility staff failed to conduct a thorough investigation of alleged violations for residents. This deficient practice was evident for two (#205, #215) of sixteen residents reviewed for investigation of alleged violations during the complaint survey.The findings include:1.) On 10/07/25 at 8:07 AM, a review of the Facility Reported Incident (FRI) #2594457 revealed that the Administrator and Director of Nursing (DON) received an email on 08/14/25 from a complainant regarding care, nutrition, hydration, and hygiene concerns for Resident #205. Further review of the investigation file revealed that the email from the complainant was missing from the file. The surveyor requested to review the email sent to the Administrator and DON. On 10/07/25, the DON provided the surveyor with an email from the complainant. A review of the email revealed that the complainant expressed specific concerns that were not included in the initial FRI. The complaint involved issues related to the residents' medications, oxygen, food, water,…

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

Based on interviews and record reviews it was determined that facility staff failed to provide care to a resident who was dependent on staff for personal hygiene and incontinence care. This deficient practice was evident for 1 (#201) resident reviewed for ADL care during the complaint survey. The findings include:On 10/07/25 at 10:30 AM, a review of the Facility Reported Incident (FRI) # 2590945 revealed that the complainant alleged that Resident #201 and other residents were often left wet and soiled. During a phone interview with the complainant on 10/08/25 at 12:45 PM, they further explained that Resident #201 was observed unbathed and soiled with urine and bowel movement on their gown on 07/04/25 and 07/25/25.During an interview with Geriatric Nursing Assistant (GNA) #4 on 10/07/25 at 10:45 AM, the surveyor asked about the process for documenting resident's baths, showers, and personal hygiene. The GNA explained that GNA's are responsible for documenting on the computer whether the resident received a shower. She further stated that GNAs must also record the resident's shower or…

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

Based on record review and staff interviews, it was determined that the facility failed to prevent an avoidable pressure injury. This was evident for 1 (Resident #208) out of 2 residents reviewed for pressure injuries. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. The findings include. On 10/6/2025 at 9:39 AM, a review of Complaint #2616868 was completed. The complainant alleged that the facility was not treating and preventing pressure injuries for Resident #208. On 10/6/2025 at 9:54 AM, a review of Resident #208's records was conducted. In the Skin and Wound evaluation on 9/12/2025, Staff #6 documented, Right knee brace removed to assess entire skin when both wound [Nurse Practitioner] and writer noticed an…

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

Based on record review, interviews and observations, it was determined that the facility failed to ensure fall prevention interventions were in place to prevent future falls. This was evident for 1 (Resident #213) of 2 residents reviewed for falls during a complaint survey.The findings include: On 10/06/2025 at 8:03 AM A review of the complaint #328732 sent to the state agency was conducted. The complainant reported that the facility was not implementing interventions to prevent future falls for Resident #213.On 10/06/2025 at 9:47 AM An interview with the complainant was conducted. The complainant reported that Resident #213 had several falls in March 2025 and that not all fall prevention interventions were put in place.On 10/06/2025 at 10:21 AM Further review of the record indicated that the resident had several falls in March 2025. The Resident had a fall on 3/6/25, 3/7/25, 3/19/25 and 3/24/2025.Further review of the records indicated that the resident had been identified as a high risk for falls. The interventions documented on the care plan included frequent rounding on 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 record review and staff interviews, it was determined that the facility failed to maintain accurate resident records. This was evident for 1 (Resident #202) out of 18 residents reviewed during the complaint survey. The findings include: On 10/7/2025 at 9:09 AM, A review of Complaint #2561490 was conducted. The complainant alleged that Resident #202 was not being cleaned after incontinent episodes. On 10/7/2025 at 9:52 AM, A review of Resident #202's medical record was conducted. A review of the Documentation Survey Report for the month of June indicated that the resident had bladder and bowel incontinent episodes on 6/8/2025, 6/25/2025, and 6/27/2025 during the night shift but the Geriatric Nursing Assistant (GNA) documentation noted Not Applicable (NA) for the Toileting Hygiene task during the night shift. On 10/07/2025 at 10:47 AM, an interview with the Director of Nursing was conducted. When asked what the expectation was for GNA documentation in regard to toileting hygiene? The GNA's should document if care was provided and document any refusals. The GNA documentation…

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

Based on observations and interviews it was determined that the facility staff failed to properly store food in accordance with professional standards for food service and safety. This was found evident in 1 of 3 kitchen observations and 1 out of 2 unit storage refrigerators during the survey. This has the potential to affect all residents. The findings include: On 3/24/25 at 8:15 AM, the surveyor made an initial tour of the kitchen. The observation of the kitchen refrigerator revealed two containers that were labeled cottage cheese. The first one was labeled with a received on date of 1/14/25 and a sell by date of 1/15/25. The second container had a received on date of 12/13/24 and a sell by date of 1/15/25 date. Also noted was a small block of lunch meat. There was no label that identified the product however, the item had a label that stated, opened on 3/7/25 and use by 3/19/25. Next to the lunch meat there was a package of hot dogs. The package was not secured closed and allowed the product to be open to air. On 3/24/25 at 8:28 AM, the surveyor observed the freezer. During the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews, it was determined the facility failed to provide written notice with the reason for transfer of a resident. This was found evident for 1 (Resident #78) out of 3 residents reviewed for hospitalization during the survey. The findings include: On 3/25/25 at 11:30 AM, the surveyor conducted an interview with Resident #78. During the interview Resident #78 stated that he/she had gone to the hospital several times earlier this year. On 3/26/25 at 11:28 AM, the surveyor reviewed Resident #78's medical record. The review revealed a progress note written on 2/13/25 that stated, Resident #78 returned from an appointment, and it was recommended that the resident be admitted to the hospital. The note further stated that they were waiting for the hospital to schedule. On further review the surveyor was unable to find documentation that the written notice of reason for transfer was given and explained to the resident for the hospital transfer on 2/15/2025. On 3/31/25 at 8:34 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and interviews it was determined the facility failed to provide the resident and/or Representative with a written notice of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 1 (Resident #78) of 3 residents reviewed for hospitalization. The findings include: On 3/25/25 at 11:30 AM, the surveyor conducted an interview with Resident #78. During the interview Resident #78 stated that he/she had gone to the hospital several times earlier this year. On 3/26/25 at 11:28 AM, the surveyor reviewed Resident #78's medical record. The review revealed a progress note written on 2/13/25 that stated, the Resident returned from an appointment, and it was recommended that the resident be admitted to the hospital. The note further stated that the facility was waiting for the hospital to schedule. On further review the surveyor was unable to find documentation that the resident or their representative was given a bed hold notice for the 2/15/2025…

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 record review, and interviews, it was determined that the facility failed to accurately document assessments in a Resident's medical record. This was found evident of 2 (Resident #31 & #113) of 38 residents reviewed during the survey. The findings include: 1a) On 3/26/25 at 10:21 AM, the surveyor reviewed Resident # 31's record. The review revealed that a Minimum Data Set (MDS) assessment was completed on 2/19/25 and in section M, skin, it was documented Resident # 31 had one stage 3 pressure ulcer. On 3/28/25 at 1:52 PM, the surveyor reviewed a note written by Wound Nurse (WN) #18 on 2/12/25. The note stated that Resident #31 was readmitted to the facility and on assessment was noted to have a right buttocks sacral wound at a stage 3 and a left hip wound noted at a stage 2. On 3/28/25 at 2:04 PM, the surveyor interviewed Minimum Data Set, Staff # 17. During the interview the surveyor showed Staff #17 the documentation from WN #8 that documented two pressure wounds and asked why only one stage 3 wound was documented on the 2/19/25 MDS assessment. Staff #17 stated 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 interview and record review, it was determined that the facility failed to inform residents of a summary of the resident's initial Baseline Care Plan (BCP) within 48 hours of the admission nor to provide a copy of initial instructions for effective and person-centered care. This was found to be evident for 1 (Resident #217) out of 3 residents for new admissions reviewed. The findings include: The Baseline Care Plan (BCP) must be developed and implemented within 48 hours of admission and needs to include the necessary healthcare information to properly care for the resident immediately upon admission to reduce the likelihood of a negative outcome shortly after admission and to provide immediate residents' needs. Interview, on 03/25/25 at 10:36 AM, Resident #217 stated that there was no initial care information shared which he/she was concerned about the diet and swallowing plan of care. Record Review, on 03/26/25 at 12:01 PM, revealed that this resident was hospitalized this March 2025 for acute subdural…

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 develop a comprehensive person-centered care plan. This was found evident of 2 (Resident #101 & #99) out of 16 residents reviewed for falls. The findings include: A.) On 3/26/25 at 7:33 AM, the surveyor reviewed Resident # 101's medical record. The review revealed that Resident #101 had incomplete, non resident centered care plans initiated. The surveyor noted that 5 care plans were written but did not specify why Resident # 101 needed the care plan. These care plans were written as follows: 1. I have oral/dental health problems r/t (related to), initiated on 9/26/24. 2. I use anti-psychotic medication r/t (related to), initiated on 3/7/24. 3. I use anti-depressant medication r/t (related to), initiated on 3/16/25. 4. At risk for respiratory complications r/t (related to), initiated on 3/17/25. 5. Resident has an automatic implanted cardiac defibrillator (AICD) r/t (related to), initiated on 3/17/25. On 3/27/25 at 1:09 PM, the surveyor conducted an interview with the Director of Nursing (DON). During…

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 it was determined that the facility failed to conduct care plan meetings after each resident assessment and failed to invite a resident to participate in their care plan meeting. This was found evident in 2 (Residents #50 & #217) out of 4 Residents reviewed for care planning. The findings include: On 3/24/25 at 11:20 AM, the surveyor conducted an interview with Resident #50. During the interview Resident #50 stated that he/she had not been invited to participate in a care plan meeting in quite some time. On 3/24/25 at 12:27 PM, the surveyor conducted an interview with the Director of Social Services (SW) #6. During the interview the surveyor asked SW #6 if Resident #50 was invited to participate in care plan meetings. SW #6 stated that she usually reaches out the Resident #50's guardian for care plan meetings. The surveyor asked if there was any rationale that the resident was not invited as well as the guardian. SW #6 stated she would review the records and follow-up. Next the surveyor reviewed Resident #50's Minimum Data Set (MDS) assessment…

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 that the facility failed to provide meaningful on-going personalized activities for the residents who were confined in their rooms. This was evident for 1 (Resident #104) out of 5 residents reviewed for personalized activities. The findings include: Observation, on 03/24/25 at 11:18 AM, 03/25/25 at 09:06 AM and 03/26/25 at 2:36 PM (over 30 minutes for each observation) found that Resident#104 was lying flat in bed, kept staring at the walls and kept falling asleep. No activity staff were in the room or nearby. Record Review, on 03/24/25 at 1:12 PM, found that Resident #104 was admitted to this facility on 12/11/24, with diagnoses of a new cerebral infarction due to thrombosis resulting in a new tracheostomy and feeding tube, past medical history: diabetes mellitus and depression. Interview, on 03/27/25 at 11:06 AM, Activity Director Staff # 20 revealed that for the population like Resident #104's who cannot participate in group/social activities that activity staff visited in their rooms often. Record…

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

Based on interviews and record review, it was determined that the facility failed to provide services to maintain a resident's vision. This was evident for 1 (Resident #66) out of 11 residents reviewed for vision during the annual recertification survey. The findings include: On 3/24/25 at 11:48 AM, Resident #66 was interviewed. They stated that their vision had decreased since their admission to the facility. On 3/28/25 at 10:28 AM, a review of Resident #66's medical records was conducted. The review revealed a progress note dated 2/20/25 with instructions for the resident to follow up with an eye specialist on 3/20/25 at 8:35 AM. Further review of the record failed to show that Resident #66 went for their follow-up eye appointment. On 3/31/25 at 2:03 PM, an interview with the Administrator was conducted. The Administrator acknowledged that there was no documentation that Resident #66 went for their follow-up eye appointment scheduled for 3/20/25. On 3/31/25 at 2:49 PM, an interview with the Director of Nursing (DON) was conducted. They reported that Medical Records was responsible…

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 provide treatment to prevent further decreased range of motion for a resident. This was found evident of 1 (Resident #27) out of 5 residents reviewed for mobility. The findings include: On 3/24/25 at 9:47 AM, the surveyor observed Resident #27 laying on his/her left side with both knees pulled up to the chest. On further observation Resident #27's fingers were contracted on both hands. On 3/28/25 at 7:26 AM, the surveyor reviewed Resident #27's medical record. The review revealed that Resident #27 had an order written on 11/26/24 for bilateral knee extension braces for 6 hours daily as tolerated, to decrease the risk of further knee flexion contracture. Additionally, an order written on 7/30/24 was written for Resident #27 to wear resting hand splints on right and left hands after hand hygiene was performed and for no longer than 2 hours at a time. Next the surveyor reviewed Resident #27's electronic medical record. Nowhere in the record was it recorded that the splints were applied as…

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

Based on observations, interviews with staff, and record review, it was determined that the facility failed to implement an intervention, determined to be necessary, for a resident who was identified as a fall risk. This was evident of 1 (Resident #101) of 5 Residents reviewed for accidents during the annual survey. The findings include: On 3/25/25 at 8:43 AM, the surveyor conducted a telephone interview with Resident #101's spouse. During the interview the spouse stated that Resident #101 had fallen out of bed several times. Resident #101's spouse further stated at one point his/her spouse had a special mattress to help keep him/her in bed. However, after a room change Resident #101 no longer had that mattress. On 3/26/25 at 7:33 AM, the surveyor reviewed Resident #101's medical record. The review revealed that on 3/12/25 Resident #101 moved to his/her current room. On further review the surveyor noted that Resident #101 had an actual fall care plan that stated Resident #101 was at risk for falls related to involuntary movement of both lower extremities and Resident #101 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 interviews it was determined that the facility failed to have the medical provider thoroughly review and accurately prescribe medications after a resident's readmission. This was found evident of 1 (Resident #68) out of 2 residents reviewed for pain. The findings include: On 3/25/25 at 11:16 AM, the surveyor conducted an interview with Resident #68. During the interview the resident stated that he/she had been in and out of the hospital and had a lot of neuropathical pain. On 3/28/25 at 7:38 AM, the surveyor reviewed Resident #68's Medication Administration Records (MARs). The review revealed that Resident #68 had an order for gabapentin to be given at bedtime for neuropathic pain and to start on 12/30/24 however, the medications was discontinued on 1/28/25. On further review it was noted that Resident #68's was readmitted to the facility from a hospital stay on 1/28/25. This was the same day the gabapentin was discontinued. Next the surveyor reviewed the hospital discharge paperwork. The discharge recommendations lists Resident #68's diagnoses and 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 and interviews, it was determined that the facility failed to provide medication as ordered. This was evident for 1 (Resident #74) out of 5 residents reviewed for change in condition during the annual recertification survey. The findings include: SBAR (Situation, Background, Assessment, and Recommendation) is a structured communication tool used to facilitate clear and concise information sharing, especially in healthcare, to improve communication and patient safety. Furosemide is a diuretic medication also known as a water pill. It is used to treat fluid retention caused by congestive heart failure. On 3/25/25 at 11:58 AM, a review of Resident #74's medical records was conducted. The review revealed an SBAR note for Shortness of breath dated 3/18/25. The provider's recommendation to nursing staff was to administer 40mg of furosemide in addition to the prescribed medication. Further review of the resident's medication administration record failed to show that Resident #74 received an additional 40 mg of furosemide. On 3/31/25 at 10:01 AM, the surveyor…

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 process in place that ensured a resident's medication irregularity reports were reviewed by the primary care physician and the actions taken based on the recommendations were being documented. This was found evident of 1 (Resident #50) of 5 residents reviewed for medication regimen review The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the Inter Disciplinary Team (IDT), including the resident, their family, and/or resident representative. On 3/26/25 at 9:43 AM, the surveyor reviewed Resident #50's medical record. The review revealed that on 8/30/24,…

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.

Based on interview, and medical record review, it was determined that the facility failed to have a documented condition that indicated the use of psychotropic medications for a resident . This was found evident in 1 (Resident #101) out of 5 Residents reviewed for unnecessary medications. The findings include: Psychotropic Medication: Any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotic; Anti-depressant; Anti-anxiety; and Hypnotic On 3/26/25 at 7:33 AM, the surveyor reviewed Resident #101's care plans. A care plan for anit-psychotic medication stated, I use anit-psychotic medication related to . and nothing to follow. On further review Resident #101 had a care plan that stated, I use anti-depressant medication related to . again nothing to follow. On 3/26/25 at 8:07 AM, the surveyor reviewed Resident 101's medication list along with the rationale for administration. Lexapro was ordered on 1/2/25 to be given one time a day for anxiety. Clonazepam was ordered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with staff, it was determined that the facility failed to store medication in a locked compartment. This was found evident on 1 random observation on the second floor. The findings include: On 3/27/25 at 10:43 AM, the surveyor observed an unlocked medication cart in the hallway between room [ROOM NUMBER] and 207. On 3/27/25 at 10:46 AM, the surveyor walked to the cart and was able to open the top drawer and observed multiple medications and supplies. On further inspection the 7 other drawers with medications are also able to be opened. While at the medication cart, the surveyor observed Staff #23 walked by and the surveyor asked Staff #23 who was responsible for the medication cart. Staff #23 stated Nurse #8 was responsible and that she would find her. On 3/27/25 at 10:47 AM, the surveyor interviewed Nurse #8. During the interview Nurse #8 confirmed that she was responsible for the medication cart and that it should not be left open. Nurse #8 further stated that she was…

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

Based on observation and interviews, it was determined that the facility failed to maintain the outdoor garbage storage area in a manner to prevent the harboring pests. The findings include: On 3/24/25 at 8:54 AM, the surveyor made an observation of the outside dumpster that was utilized by the kitchen staff. The dumpster was located just outside the kitchen receiving doors. Noted along the back side of the dumpster was approximately 6 inches high of thick accumulated plastic bags, leaves, pine needles and plastic cups. This accumulation was located between the dumpster and the concrete wall behind the dumpster. On 3/24/25 at 8:56 AM, the surveyor conducted an interview with the Director of Maintenance Staff #5. During the interview Staff #5 stated that the accumulation should not be there and that he would have that area cleared.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to ensure that the residents' clean clothes were stored in a manner that minimized the potential spread of infection. This was evident during the infection control investigation task of the recertification survey. The findings include: On [DATE] at 1:44 PM, an observation of the facility's laundry room was conducted. There were 6 green bags observed in the dirty laundry room. On [DATE] at 1:45 PM, an interview with the Environmental Director (Staff #14) was conducted. When asked if the clothes in the bags were clean, they reported that the clothes were clean and belonged to residents who were either hospitalized or had expired. On [DATE] at 8:49 AM, the Director of Nursing (DON) was notified of the potential risk of accidental contamination in the laundry room.

Based on review of facility reported incidents with documentation and interview, it was determined the facility failed to report 1) allegation of misappropriation of property, 2) an injury of unknown source and 3) allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 6 (#31, #42, #47, #34, #48, #50) of 50 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 1/7/25 at 11:30 AM facility reported incident MD00192632 was reviewed and revealed an allegation that on 5/22/23 at approximately 3:00 AM Resident #31 requested to speak with a nursing supervisor to report a geriatric nursing assistant (GNA) threatened the resident, yelled and pounded her first against in the palm of her hand. Review of the email confirmation sheet revealed documentation that the allegation was first reported to OHCQ on 5/22/23 at 9:27 AM. On 1/7/25 at 1:30 PM an interview was conducted with the Nursing Home Administrator (NHA). It was pointed out to the NHA that the nursing supervisor…

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 staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#36, #37, #42, #34) of 63 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 1/8/25 at 8:46 AM a review of Resident #36's medical record revealed progress notes that documented on 2/22/24 at 3:00 AM, Resident #36 was found by the aide on the floor mat next to the resident's bed. Review of the MDS with an assessment reference date (ARD) of 3/6/24, Section J falls,…

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 documentation review and interview it was determined the facility staff failed to promptly notify the physician of a resident's change in condition. This was evident for 1 (#61) of 63 residents reviewed during a complaint survey. The findings include: On 1/9/25 at 11:39 AM a review of Resident #61's medical record revealed Resident #61 was admitted in August 2023 from an acute care hospital for rehabilitation due to debility. Review of complaint MD00196479 alleged that Resident #61 stated to family that he/she had been having chest pains since 10:00 AM on 9/2/23 and that staff had disregarded the resident's complaints. The family arrived at the facility at 4:40 PM and informed staff to call 911, and if they didn't the family would call them. Review of nursing notes dated 9/2/23 at 17:56 (5:56 PM) documented, chest pain. The note also documented, Nitrostat 0.4mg tablet offered, resident refused. Several attempts made and educated on the importance of the medication in the presence of responsible party, [he/she] still refused. Responsible party requested that [he/she] be…

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 facility reported incidents with documentation review and interview, it was determined the facility failed to thoroughly investigate allegation of abuse for residents (Resident #1 and #21). This was evident for 2 of 50 facility reported incidents reviewed during a complaint survey. The findings include: 1. On 1/14/25 review of facility reported incident MD00183017 revealed Resident #21's family member accused other residents of abusing the Resident. Review of Resident #21's medical record on 1/14/25 revealed the Resident was seen by Staff #56 (PsyD/Doctorate of Psychology) on 8/20/22. At that time Staff #56 documented: Resident (#21) stated other residents informed Resident (#21's) family member that a resident was being disrespectful and verbally abusive to patient. The Resident's family member reportedly confronted the Resident. Resident (#21) stated the Resident turned his/her *ss up to me. I'm not doing good. He/she bent down and pulled his/her pants down in the doorway. On 1/15/25 the Surveyor asked the Administrator for the investigation related 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.

Based on observation, medical record review, and interviews, it was determined that the facility staff failed follow the care plan, and failed to evaluate and revise a resident's care plan to reflect accurate and current interventions. This was evident for 1 (50) of 50 resident reviewed for facility reported incidents during a complaint survey. The findings include: Minimum Data Set- The 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 A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 1/13/25, a review of facility reported incident, MD00210186, documented that on 9/25/24, at approximately 7:00 AM, Resident #50 approached the nurse's station and was observed to have a laceration and swelling above his/her right eye, which was an injury of unknown source. The facility's investigation concluded that the resident, who was cognitively…

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 complaint, medical record review and interview, it was determined that the facility staff failed to provide needed activities of daily living for a resident dependent on assistance with care (Resident #22). This was evident for 1 of 31 residents reviewed for complaints during a complaint survey. The findings include: On 1/9/25 review of complaint MD00184963 revealed an allegation that Resident #22 complained the Resident only received 2 showers in a 6 week period. Review of Resident #22 medical record on 1/9/25 revealed the Resident was admitted to the facility in August 2022 and discharged in October 2022 with a diagnosis to include need for assistance with personal care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned…

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 complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health (Resident #27 and #1). This was evident for 2 of 31 residents reviewed for complaints during a complaint survey. The findings include: 1. The facility staff failed to properly perform neuro checks after a fall for Resident #27. A neuro check after a fall refers to a neurological assessment performed by a healthcare professional to evaluate potential brain injuries by checking a person's level of consciousness, orientation, pupil response, muscle strength, sensation, and coordination. Review of Resident #27's medical record on 1/10/25 revealed a nurse's note on 1/20/23 that stated, the Resident was observed lying on the floor on his/her right side beside a wheelchair in which he/she was seated, was attempting to transfer himself/herself to bed. Slight hematoma to forehead. Completed a comprehensive multisystem assessment. No other injuries. Neuro checks initiated and normal so far.…

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 interview it was determined the facility failed to provide timely treatment/services to prevent/heal pressures ulcers. This was evident for 1 (#31) of 31 residents reviewed for complaints during a complaint survey. The findings include: 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). On 1/16/25 at 7:27 AM a review was conducted of Resident #31's medical record which revealed Resident #31 was admitted to the facility in May…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to assess and evaluate the nutrition needs of residents in a timely manner. (Resident #20). This was evident for 1 of 3 residents reviewed for weight loss during a complaint survey. The findings include. Review of Resident #20's medical record on 1/9/25 revealed the Resident was admitted to the facility on [DATE] and facility staff documented the Resident weight as 285.1 pounds. Review of the nutritional assessment revealed it was completed on 11/1/21, 3 days after admission. The nutritional assessment stated goals were to maintain nutritional status with no signs or symptoms of dehydration and malnutrition. Consume at least 50% of meals and supplements daily. Wound healing. Review of the Resident's documented weights revealed the Resident was not reweighed until 11/16/21 and documented weight of 278.7 pounds, for a weight loss of 6.4 pounds. The next weight documented was 252.4 pounds on 12/2/21, for a weight loss of 32.7 pounds since…

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 that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication. This was evident for 1 (#54) of 31 residents reviewed for complaints. The findings include: Seborrheic dermatitis is a common skin condition that can cause dandruff On 1/8/25 a review of complaint MD00212696 alleged that Resident #54's had an infection on his/her head from a condition on the resident's scalp and the facility needed to be investigated for neglect. Review of Resident #54's medical record revealed on 12/13/24 at 5:16 PM, in a progress note, the nurse wrote that on 12/6/24, Resident #54 had his/her hair washed and a haircut, that no injury was sustained from the haircut, and the resident continued on Ketoconazole (antifungal) Shampoo 2 times a week for Seborrheic dermatitis, and the resident had a Dermatology Appointment scheduled on 12/23/24. On 12/23/24, in a Dermatology Report of Consultation, the physician documented the resident had Seborrheic Dermatitis (dandruff), and prescribed…

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 staff failed to follow up with a consultant physician (Resident #22). This was evident for 1 of 63 residents reviewed during a complaint survey. The findings include: Review of Resident #22's medical record on 1/9/25 revealed the Resident was admitted to the facility in August 2022 with diagnosis to include retention of urine. Further review of the Resident's medical record revealed on 8/16/24 the Resident went to a Urology consultation. Review of the Report of Consultation revealed the physician documented, Patient's ambulatory status very poor and wheelchair does not clear the doorway due to his/her bariatric size. Will reschedule at ambulatory surgery center for local cystoscopy and foley change. Further review of the Resident's medical record revealed the Resident was discharged home from the facility on 10/3/22 without a follow up appointment scheduled with Urology. Interview with the Director of Nursing on 1/14/25 at 12:05 PM confirmed the facility staff failed to ensure the Resident had a follow up appointment…

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 interview, it was determined that the facility staff failed to keep complete and accurate medical records. This was evident for 2 (#1 and #50) of 50 residents reviewed for facility reported incidents during a complaint survey. The findings include: 1. A wanderguard is a system that uses bracelets and sensors to monitor and prevent residents from wandering off or exiting a safe area. On 1/13/25, a review of facility reported incident, MD00210186, documented that on 9/25/24, at approximately 7:00 AM, Resident #50 approached the nurse's station and was observed to have a laceration and swelling above his/her right eye, which was an injury of unknown source. The facility's investigation concluded that the resident, who was cognitively impaired, and independently ambulatory with poor safety awareness, had an unwitnessed fall. Following review of the facility's self-report, a review of Resident #50's medical record was conducted. In the medical record, the resident's most recent quarterly assessment with an assessment reference date of 12/4/24…

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.

Based on observations and interviews with facility staff it was determined the facility failed to ensure that a resident call light was accessible to him/her. This was found to be evident for 1 resident (Resident # 15) that was observed during the facility's annual survey. Findings include: An observation was made on 2/24/20 at 11:20 AM of Resident #15 who was sitting in a Geri-chair in his/her bedroom near the window. The resident call light was observed wrapped around the bed rail on the opposite side of the bed. The nurse, Staff #21 was asked to come into the resident room as she was walking past the room at the time of the observation. Resident #15's call light was shown to the nurse and she proceeded to remove it from the bedrail and placed it closer to the resident. The nurse stated that she was unsure why the call light was placed on the opposite side of the resident. The nurse approached the surveyor with Geriatric Nursing Assistant (GNA) #4 on the same date at 11:40 AM and the GNA explained that the resident wanted to be near the window. The nurse informed the GNA to ensure…

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 of facility staff it was determined the facility failed to ensure that residents reside in a clean, comfortable and homelike environment. This was in found to be evident during an initial tour of the facility during the facility's annual survey and has the potential to affect all the residents residing in the facility. Findings include: An initial tour was conducted on the Worthington Unit on 2/23/20 at 6:30 AM. The bathroom located in the shower suite had a toilet that was missing a handle. Additionally, the wall located to the left of the toilet had a large spackled area in need of paint. Along the hallway across from the shower suite there was trash and debris noted on the floor. There were fruit flies noted flying around on each of the units and present in the conference room. A fly trap was located on the shelf in the conference room with multiple dead flies in the bottom. An interview was conducted with the Maintenance Director on 2/28/20 at 2:34 PM and he was made aware of all the concerns and stated that the facility will be correcting…

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 records review and interview with resident and staff it was determined that the facility failed to report allegations of abuse to the appropriate state agency. This was evident for 1 of 3 residents (Resident #56) reviewed for abuse during the survey. The Findings include: Resident #56 was interviewed on 2/25/2020, during the interview the resident verbalized that she had issues and concerns with another resident. The surveyor asked the resident if he/she discussed it with the facility and the resident stated I took care of it. On 2/27/2020 resident #56's medical records were reviewed and revealed a note written by a treating physician in which the resident revealed to her that he/she had it out with the roommate and the resident further revealed that the roommate was talking about him/her and the resident threw a cup at the roommate. Further review of the notes failed to reveal any documentation indicating that the facility was made aware of a resident to resident altercation. During an interview with the 2nd floor unit manager LPN #21 on 2/27/2020 at 11:58 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 medical record review and staff interviews, it was determined that the facility staff failed to initiate a care plan to address a resident with contractures of the right and left knee. This was evident for 1 of 43 residents (Resident #42) reviewed during the survey. The findings include: A care plan is used to identify care area concerns that are specific to the resident and are used to improve and maintain a resident's status. A care plan includes a measurable objective and a time frame to evaluate its effectiveness. Review of Resident #42's medical record on 2/26/20 at 11 AM, revealed that the resident was admitted to the facility with diagnoses that include; contractures of the right and left knee. Further review of medial record revealed no care plan was in place to address the contractures. During interview with the Director of Nursing on 2/26/20 at 1 PM she confirmed the facility staff failed to develop and implement a care plan to manage the contractures. After surveyor intervention a care plan was initiated for the contractures.

Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the residents' status as evidenced by failure to: 1) assess the resident's fall status and and 2a) accurately record medication usage for Anticoagulant therapy and 2b) accurately record medication usage for antipsychotic gradual dose reduction. This was found to be evident for 2 out of 29 residents (Resident #47 and #56) reviewed during the investigation stage of the 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. The MDS provides a comprehensive assessment of the resident's functional capabilities and helps nursing home staff identify health problems. It is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. MDS assessments need to be accurate to ensure each resident receives accurate care and care…

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 that the facility staff failed to initiate a care plan to address resident's contractures. This was evident for 1 of 8 residents (Resident #42) in the survey sample. The findings include: A care plan is used to identify care area concerns that are specific to the resident and are used to improve and maintain a resident's status. A care plan includes a measurable objective and a time frame to evaluate its effectiveness. Review of Resident #42's medical record on 2/26/20 at 11 AM revealed that the resident, was admitted to the facility in December of 2019, with diagnoses that included contractures of the right and left knee. Further review of medial record revealed no baseline care plan was in place to address the contractures upon admission. During interview with the Director of Nursing on 2/26/20 at 1 PM she confirmed the facility staff failed to develop and implement a care plan to manage the contractures upon admission. After surveyor intervention a care plan was initiated for the contractures.

Based on administrative review and interviews with the resident and facility staff it was determined the facility failed to follow the resident care plan and report when a resident was resistive to care. This was found to be evident for 1 of 3 residents (Resident #77) reviewed for allegations of abuse during the survey. Findings include: Facility Report MD00150512 was reviewed on 2/24/20 for allegations of abuse. An interview was conducted with Resident #77 on 2/24/20 at 9:59 AM and s/he was asked the question, has anyone ever abused you? The resident stated, there was an incident a few weeks ago with a Geriatric Nursing Assistant (GNA) who works here that hit me with a box of tissues. The resident stated that the GNA has not worked with him/her again. Review of the facility's investigation on 2/25/20 revealed that on 1/18/20 Resident #77 alleged that a GNA #11 hit the resident with a box of tissues while providing care. In a statement that was provided by GNA #11 she stated that the resident hit her while she was providing care. The GNA stated that she allowed the resident to calm…

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, record review and staff interview it was determined that facility staff failed to administer the correct dosage of medication to a resident. This was found to be true for 1 of 2 residents (Resident # 67) observed for medication administration during the survey. Findings include: Review of the Electronic Medication Administration Record (eMAR) for Resident #67 at on 02/26/20 at 8:08 AM revealed an order to give Valproic Acid Capsule 750 milligrams (mg) by mouth two times a day for a diagnosis of seizures. On 02/26/20, an observation was conducted of Certified Medication Aid (CMA) #4 as she performed administration of medication for residents on the [NAME] Unit. At 8:15 AM, surveyor observed that CMA #4 detached a single dose blister pack of the Resident's Valproic Acid from a multi-blister packet stored in the medication cart. She emptied 1 capsule into a cup, presented the emptied packet to surveyor and replaced the multi-blister packet into the medication cart. A review of the single-dose…

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 dietitian failed to do timely assessments on residents with multiple comorbidities requiring monitoring. This was evident during the review of 2 of 4 residents (Resident #86 and Resident #29) reviewed for documented weight loss. The findings include: 1. Review of the medical record for Resident #86 on 2/26/20 at 9:21 AM revealed diagnoses including history of stroke with resultant hemiplegia and hemiparesis. The medical record also documented and noted the resident had a significant weight loss. The assessment completed by the dietitian on 8/9/19 documented that the resident would continue weekly weights. A review of the weights completed after that assessment revealed weighing occurring inconsistently from 3 days to 2 weeks until 10/2/19 when the weights continued monthly. A weight variation of 11 lbs. in 2 weeks was documented on 9/2/19 to 9/16/19, 177 lbs. to 166 lbs., a 6% weight loss which is considered significant. There was no documentation in the resident's chart that the dietitian…

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 resident medical records and interview with facility staff, it was determined that the facility failed to ensure that a resident with as-needed pain medication regimens received pain medication according to physician prescribed orders and care plans. This was evident for 1 of 2 residents (Resident #47) reviewed for pain management. The findings include: A numeric pain scale is a common tool to evaluate a resident's perception of his or her own pain. The resident is asked to rate pain from 0 (no pain) to 10 (worst pain of your life). Resident #47's medical record was reviewed on 02/28/20 02:14 PM and revealed that the resident was prescribed as-needed Tylenol 325 milligrams, 2 tablets by mouth every 6 hours as needed for pain. Review of the resident's care plan revealed a care plan for chronic pain related to generalized weakness with the interventions to anticipate the need for pain relief and respond to any complaints of pain and evaluate the effectiveness of pain interventions. Further review of Resident #47's medication administration record (MAR) for September…

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, facility competency training records and staff interview it was determined that the facility failed to ensure all licensed nursing staff had the specific competencies and skill sets necessary to care for residents with a suprapubic catheter. This was evident for 1 of 2 residents (Resident #83) reviewed for suprapubic catheter care during the survey. The findings include: A suprapubic catheter is a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the stomach, a few inches below the navel (belly button). Medical record review on 2/27/20 revealed Resident #83 was admitted to the facility with diagnoses that included: history of paraplegia, above the knee amputation, use of a suprapubic catheter, and urinary tract infection. During an interview on 02/28/20 at 10:26 AM with the Assistant Director of Nursing (ADON)/Staff Educator, she stated that only licensed nurses took care of residents with suprapubic catheters, and that their competency training was done annually and as needed. On…

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

Based on observations and interviews with facility staff it was determined the facility failed to have the assignment board that posts the staff assignments reflective of the actual staff working. This was found to be evident for 1 of 2 hallways that were observed during the initial tour of the facility. Findings include: On 2/23/20 at 6:20 AM an observation was made of the Worthington Unit and the assignment board was dated 2/22/20. The assignment board had 4 Geriatric Nursing Assistants (GNA's) listed as working and 2 nurses. The surveyor approached a GNA #4 and asked to see her badge . The surveyor approached a nurse Staff #3 and asked to see her badge. The assignment board did not reflect either staff as currently working. An interview was conducted with Staff #3 on 2/23/20 at 6:25 AM and she was asked to explain why the assignment board was not reflective of the staff that was present in the building and she stated that the assignment board was of staff who worked on Saturday evening 2/22/20 on the 3-11 PM shift. Staff #3 was asked who is responsible for updating the assignment…

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 and interview with staff it was determined that the facility failed to: 1.) ensure pharmacist recommendations resulting from identified irregularities during the monthly pharmacy review were addressed and acted on by the physician. This was found to be evident for 1 out of the 5 residents (Resident #47) sampled for medication regimen review and 2.) failed to have time frames for the different steps in the process for the monthly drug regimen review. This was found to be evident during the unnecessary medication review during the investigative stage of the survey and has the potential to affect all the residents. The findings include: 1. On 02/27/20 11:17 AM, Resident #47's medical records were reviewed and revealed that the resident was admitted to the facility for long term care in June 2019. Review of the admitting orders revealed the following: Lorazepam 0.5 milligram (mg) take 1 tablet by mouth two times a day for anxiety and Seroquel 25 mg take 1 tablet a day for dementia. Review of the monthly pharmacy medication review revealed that on July,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined the facility failed to: 1.) ensure that medications were kept secure as evidenced by the observation of an insulin syringes on top of a medication cart located in a hallway and 2.) keep a medication cart locked when unattended. This was found to be evident for 1 of 4 medication carts observed on the second floor and 1 of 4 medication carts observed on the first floor during the initial tour of the facility. Findings include: 1. An observation was made of medication cart #1 on 2/23/2020 at 6:20 AM and on top of the medication cart was a syringe with long-acting insulin. Additional observation of medication cart #1 revealed that it was unlocked and unattended. During an interview with LPN #1 on 2/23/2020 at 6:30 AM he acknowledged that the cart was left with a syringe on top and unlocked. He further revealed that he had to go into a resident's room to check on the resident, and clarified that he could have put the insulin away and locked the cart before…

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 pertinent facility documents and interview with facility staff, it was determined that the facility failed to develop a facility assessment that included information related to staffing needs and has has the potential to impact all residents. The findings include: Review of the facility assessment on 2/28/2020 at 11:38 AM while reviewing sufficient staffing, it was determined that the facility failed to identify the numerical staffing needs of the facility based on the facility assessment in order to ensure a sufficient number of qualified staff are available to meet each resident's needs. Interview with the Administrator on 2/28/2020 at 1:34 PM revealed that the facility assessment provided to the survey team was completed by corporate staff and he agreed that it did not include the individual numbers of staff needed to ensure enough for resident care. He further stated that, that was what he was used to doing in other facility assessments, but that was not how it is completed by this company. This concern was reviewed during exit again with the Administrator and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, facility documentation review and staff interview it was determined the facility failed to maintain accurate documents related to: 1) the Medical Orders for Life-Sustaining Treatment (MOLST) for Resident #42; 2.) documentation that an initial assessment was completed by the dietitian when the Resident #38 was admitted and 3.) a personal belongings inventory record for Resident #468. This was evident for 3 of 43 residents reviewed during the annual survey. The findings include: Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based on a resident's wishes about medical treatments 1. Review of Resident #42's medical record on [DATE] at 9:47 AM revealed a MOLST form dated [DATE] and signed by the resident's primary physician indicating the resident had a DNR (Do Not Resuscitate) order. Continued review of the medical record revealed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility's staff failed to maintain a clean, safe and sanitary environment for residents. This finding was evident for 2 of 2 medication storage rooms, and 1 of 4 medication carts located on the first floor of the facility. This deficient practice has the potential to affect all residents in the facility. The findings include: An observation was conducted on the Avalon unit on 2/23/20 at 6:07 am. Surveyors noted the night shift's Nurse Supervisor (staff # 2) at the nursing station on the telephone. Further observation on the unit revealed a female resident ambulating down the hallway. The resident passed an unattended medication cart (cart #1) stationed outside room [ROOM NUMBER]. At 6:14 am, surveyors noted that the medication cart remained unattended. Continued observations of cart #1 revealed an undated, opened cup of apple sauce, opened cartons of juice and milk, and a mug filled with liquid. The cart was unlocked and its drawers easily…

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.