Future Care Capital Region

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor record review and facility staff interviews it was determined that the facility failed to ensure timing, revision and updates of Resident care plans. This finding was found to be evident in 2 (Resident #1 and #140) out of 10 Residents reviewed for care plan timing and revision.The findings include:In an interview with Resident #1 at 9:29 AM on 1/21/2026 about care plan meeting, he/she stated that he/she has not attended a care plan meeting. Resident #1 was alert and oriented to person, place and time.The surveyor conducted a record review of Resident #1's medical record on 1/22/2026 at 7:56 AM. Review of the medical record revealed that Resident #1 was admitted to the facility on [DATE]. Further review of the medical record revealed that there was no documentation that a care plan meeting was held for Resident #1. In an interview with the Licensed Nursing Home Administrator (LNHA) on 1/22/2026 at 8:00 AM, the surveyor requested any documentation that a care plan meeting occurred for Resident…

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

Based on observations, facility staff interview and record review it was determined that the facility failed to provide proper tube feeding management for a Resident. This finding was found to be evident for 1 (Resident #10) out of 3 Residents reviewed for tube feeding.The findings include:Gastrostomy tube (G-Tube)/feeding tube is a tube surgically placed into the stomach through an opening in the abdomen to provide nutrition, fluids and medication when a person cannot eat or drink safely by mouth.Enteral nutrition/feedings is a medical method of providing nutrition and fluids through the gastrointestinal (GI) tract using a feeding tube. The liquid formula contains essential nutrients like protein, carbohydrates, fats, vitamins, and minerals.On tour of the PCU Unit on 1/20/2026 at 8:50 AM the surveyor observed Resident #10 in bed in no distress. Hanging on a pole next to Resident #10's bed were 2 bags of fluid; one bag was labeled with the enteral feeding, and the other bag had a clear liquid substance contained in the bag. The clear liquid bag did not have a label 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.

Number of residents sampled:Number of residents cited:Based on observation, record review and interviews it was determined the facility staff failed to provide appropriate care and services to a resident with intravenous access devices. This was evident for 1 (Resident #168) out of 2 residents reviewed for fluids and dehydration. A central venous catheter (CVC) is a long, flexible tube that a provider inserts into a vein. It can be found in the neck, chest, arm or groin. The tube leads to your vena cava, a large vein that empties into your heart. A CVC helps a person receive drugs, fluids, or blood, for long-term treatments. A type of CVC is a PICC (peripherally inserted central catheter). CVCs have risks which include infection, blood clots, vein inflammation and (rarely) displacement or vessel damage and need to be cared for appropriately. The findings include: On 1/20/26 at 8:40 AM, the surveyor conducted an interview with Resident #168. During the interview Resident #168 stated that he/she had recently been in the hospital. Next the surveyor observed that Resident #168 had a…

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

Number of residents sampled:Number of residents cited:Based on interview and record review it was determined that the facility failed to administer pain medications consistent with professional standards. This was found evident of 1 (Resident #168) out of 4 Residents reviewed for pain management during the survey. The findings include: On 1/20/26 at 8:47 AM, the surveyor conducted an interview with Resident #168. During the interview Resident #168 stated that he/she learned that he/she had to maintain a schedule with pain medication because if he/she waited too long to take the medication it was hard to bring the pain back down to an acceptable level. On 1/22/26 at 11:19 AM, the surveyor reviewed Resident #168's medical record. The review revealed on 1/10/26 Resident #168 had an order written for Oxycodone 10mg, with instructions, give 1 tablet by mouth every 4 hours as needed for pain of 5-10 on a pain scale. On further review this same order was written again on 1/16/26. Next the surveyor reviewed Resident #168's January 2026 Medication Administration Record (MAR) along with…

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

Based on record review and interviews it was determined that the facility failed to document medication administration according to procedures that ensure accurate disposition of medications. This was found evident of 28 of 48 narcotic medications removed for Residents #168 and #16. The findings include: On 1/20/26 at 8:47 AM, the surveyor conducted an interview with Resident #168. During the interview Resident #168 stated that he/she had been taking pain medications related to a recent surgery. On 1/22/26 at 11:19 AM, the surveyor reviewed Resident #168's medical record. The review revealed on 1/10/26 Resident # 168 had an order written for Oxycodone 10mg, with instructions, give 1 tablet by mouth every 4 hours as needed for pain of 5-10 on a pain scale. On further review this same order was written again on 1/16/26. Next the surveyor reviewed Resident #168's January 2026 Medication Administration Record (MAR). The review revealed Resident #168 had 20 documented administrations of oxycodone from 1/11/26-1/21/26. The surveyor requested to review the controlled drug…

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 the clinical record and staff interview, it was determined that the facility staff failed to adequately monitor a resident's drug regimen which allowed an unnecessary duplicate order for a medication. This finding was evident for 1 (Resident #168) of 6 residents reviewed for unnecessary medications during the survey. The findings include: On 1/20/26 at 8:47 AM, the surveyor conducted an interview with Resident #168. During the interview Resident #168 stated that he/she had been taking pain medications related to a recent surgery. On 1/22/26 at 11:19 AM, the surveyor reviewed Resident #168's medical record. The review revealed on 1/10/26 Resident # 168 had an order written for Oxycodone 10mg, with instructions, give 1 tablet by mouth every 4 hours as needed for pain of 5-10 on a pain scale. On further review this same order was written again on 1/16/26. However, the order written on 1/10/26 was not discontinued so Resident #168 had two current orders for same medication. Next the surveyor reviewed Resident #168's January 2026 Medication Administration Record (MAR).…

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 facility staff interviews it was determined that the facility failed to ensure that medications were secured in a locked compartment and not expired. This finding was found to be evident on 2 (PCU and Vital Strong) out of 4 nursing units and review of the PCU medication room during the annual survey.The findings include: On tour of the PCU Unit at 1:35 PM on [DATE] the surveyor and the PCU Nursing Manager observed a medication cart unattended and unlocked with the top drawer of the medication cart opened outside of room [ROOM NUMBER]. The PCU Manager closed the top drawer of the medication cart and locked the medication cart as Registered Nurse (RN) #9 was exiting a Resident room. The PCU Manager stated to RN #9 that the medication cart was observed opened and should have been locked. In an interview with the PCU Manager at 1:40 PM on [DATE] the surveyor asked the PCU Manager what the expectation was for the medication carts to be secured when unattended by nursing staff. The PCU…

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 observation, record review, and interview it was determined that the facility failed to obtain laboratory results in a timely manner. This was found evident in 1 (Resident #154) out of 2 residents reviewed for hydration. A peripheral intravenous (IV) catheter is a short, flexible tube inserted into a small vein for short-term (approximately 3-4 days) use to administer fluids, medications, or blood products. The findings include: On 1/20/26 at 9:31 AM, the surveyor observed Licensed Practical Nurse (LPN) #34 removed Resident #154's IV site. The surveyor asked LPN #34 why Resident #154 had an IV placed and was told that the resident just completed the course of IV fluids that was ordered for hydration. On 1/22/26 at 9:55 AM, the surveyor reviewed Resident #154's medical record. The review revealed a change of condition was written on 1/16/26 by LPN #35. The note stated that laboratory (lab) results were reviewed by the Nurse Practitioner #36 and an order was placed for Resident #154 to receive IV fluids and have a repeat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined that facility staff failed to ensure that food menus were followed and prepared in advance to meet residents' meal choices. This was found to be evident of 2 (Resident #11 and #27) out of 10 Residents reviewed for food during an annual survey. The findings include: On 1/21/26 at 9:21 AM, the surveyor conducted an interview with Resident #11. During the interview the Resident alleged that sometimes he/she does not receive the food items that are listed on the meal ticket menu and sometimes his/her meal is delivered in disposable containers. The surveyor observed that Resident #11's breakfast was in a plastic square takeout container however it appeared that the order ticket menu was accurate with the Resident's meal. On 1/23/26 at 11:58 AM, the surveyor observed Unit Manager (UM) #22 deliver Resident #11's lunch tray and placed the lunch on Resident #11's over-the-bed table. UM #22 stated that she would be back with additional gravy for Resident…

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

Based on record review and interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards for accuracy. This was found evident in 1 (Resident #15) out of 55 residents reviewed during the survey. The findings include: On 1/21/26 at 8:22 AM, the surveyor conducted an interview with Resident #15's family member. During the interview the family member stated that Resident #15 had multiple chronic conditions and had been in and out of the hospital recently. On 1/22/26 at 8:13 AM, the surveyor reviewed Resident #15's medical record. The review revealed Resident #15 had a past medical history, that included but not limited to, end stage renal disease, dependence on dialysis, peripheral vascular disease (PVD) and history of colostomy (a surgical procedure that creates an opening in the abdominal and bringing and end of the large intestine to the exterior creating a stoma). Next the surveyor reviewed Resident #15's care plans. The review revealed that a care plan was placed in Resident # 15's care plan on 10/2/25 that…

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

Based on observations and interviews it was determined that 1) the facility failed to maintain practices to help prevent the transmission of infections and 2) failed to follow infection control protocols of the laundry process, maintain laundry dryers in sanitary and hazard free condition, and maintain a copy of the manufacturer's instructions for the washer and dryer. These findings were found to be evident in 2 out of 3 medication administration observations and 1 random observation of shared equipment, and in 3 out of 3 dryers observed during the annual survey. The findings include:1) On 1/28/26 at 8:38 AM, the surveyor observed License Practical Nurse (LPN) # 20 prepare medications for Resident #138. The surveyor observed LPN #20 take Resident #138's multidose lispro (short acting) insulin pen and apply the needle and then administer the medication. The surveyor noted that LPN #20 did not clean the port prior to applying the needle. On 1/28/26 at 9:01 AM, the surveyor conducted an interview with LPN #20 and asked if the pen was supposed to be cleaned before applying the needle.…

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 facility staff interviews it was determined that the facility failed to have a call light device accessible and functioning properly for Residents. This finding was found to be evident in 2 (Resident #96 and #125) out of 19 Residents reviewed for Resident call system.The findings include: During tour of the Resident rooms on the PCU Nursing Unit on 1/20/2026 at 1:15 PM the surveyor observed that Resident #96 was lying in bed, with head of bed (HOB) elevated and in no distress. The call light device was hanging on the bed frame at the HOB. In an interview with the PCU Nursing Unit Manager on 1/20/2026 at 1:30 PM, the surveyor conveyed that Resident #96 did not have an accessible call light device. The PCU Nursing Unit Manager and the surveyor observed Resident #96 in bed with the call light device hanging on the HOB bed frame. The PCU Nursing Unit Manager removed the call light device from the HOB bed frame and positioned the call light device to be accessible for Resident #96. The PCU…

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 ensure that residents were provided reasonable accommodations as evidenced by call lights not readily available for Residents (#6, #46, #62, #97,100, #124). This was found to be evident for 6 out of 6 residents reviewed for accommodation of needs. The findings include: During the initial tour of the PPCU-1 unit on 7/15/2024 at 9:15 AM, the surveyors observed the following residents without a call light in reach. Resident (#6) was in bed and the call light cord was observed hanging on the oxygen gauge on the wall, and Residents (#62 and #100) were in bed and the call light was observed on the floor. In addition, the surveyors observed that Residents (#46, #97 and #124) did not have an available call light. On 7/15/2024 at 11:00 AM the surveyors conducted an interview with the Regional Clinical Services Manager (RCSM) RN #2 on the PPCU-1 unit after the surveyor's initial tour. The surveyors conveyed to the Regional Clinical Services Manager (RCSM) RN #2 that call lights were not available 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 observations, interviews and record reviews it was determined that the facility failed to follow appropriate tube feeding care and services. This was evident in 4 (Resident #24, #62, #83 and #100) out of 4 residents reviewed for tube feeding management. The findings include: Enteral tube/feeding tube/gastrostomy tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called gavage, enteral feeding or tube feeding. A variety of feeding tubes are used in medical practice. The tube is inserted through the abdomen and into the stomach or intestines. Enteral feeding syringes are designed for delivering enteral tube feed, water, and medications via enteral feeding tube and/or to aspirate (suction) a feeding tube. On the initial tour of the PPCU-1 unit on 7/15/2024 at 9:15 AM the surveyors observed Resident #62, #83 and #100 in bed with a 60-cc enteral feeding syringe at the bedside which was not labeled with a date. In addition,…

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 that the facility failed to ensure: 1) the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) in place and 2) to identify a resident's surrogate as per the authority granted by the Health Care Decisions Act. This was found to be evident for 2 (Resident #116 and #448) out of 5 residents reviewed for the MOLST as part of the instruction. The findings include: MOLST is a medical order form that relays instructions between health professionals about patient care. The MOLST form certifies orders that were agreed to by a patient or a patient's health care agent as named in the patient's advance directive. MOLST determines resuscitation status and includes other 8 sections of treatment choices, for example, medication administration and nutrition. 1) Interview, on 07/16/24 at 09:22 AM, found that Resident #116 was confused, only knew his name and unable to understand simple questions. The family at the bed side stated that he/she had…

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 medical record review it was determined that the facility failed to provide notification to the Ombudsman of the resident that transferred to the hospital. This was evident in 1 Resident (#24) out of 1 Resident reviewed for hospitalizations. The findings include: On 7/17/2024 at 7:30 AM the surveyor reviewed Resident #24's medical record. The review of the medical record revealed that Resident #24 was transferred to the hospital on 4/25/24 and 5/4/2024. In an interview at 8:15 AM on 7/19/2024 the surveyor requested from the Regional Clinical Services Manager (RCSM) Registered Nurse (RN) #1 the documentation of the Ombudsman notification of Resident #24's transfer to the hospital on 4/25/24 and 5/4/2024. In a follow-up interview with the Regional Clinical Services Manager (RCSM) RN #1 at 8:45 AM on 7/19/2024 the RCSM RN #1 stated to the surveyor that the notification to the Ombudsman had not been completed for Resident #24's transfers to the hospital on 4/25/2024 and 5/4/2024. At 9:20 AM on 7/19/2024 the Nursing Home Administrator (NHA) provided 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 medical record review and staff interview it was determined that the facility failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 2 (#116 and #53) of 3 residents reviewed for hospitalization. The findings include: A Bed Hold is the act of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. It must be provided to all facility residents regardless of payment source. The Bed Hold policy should be disclosed in the admission packet during an initial admission to the facility and it should be disclosed to resident/resident representatives at the time of transfer. 1a) During the interview, on 07/15/24 at 12:23 PM, it was revealed that the family was notified by phone on 06/11/24 regarding the transfer of Resident #116 to the hospital. Record review, on 07/17/24 at 12:19 PM, revealed that a transfer order and a transfer form were in place dated 06/11/24 at 10:05…

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 reviews and interviews, it was determined that the facility staff failed to ensure: 1) that Resident (#131) was administered medication and 2) an outside medical appointment was scheduled for Resident (#435) in a timely manner. This was found to be evident for 2 (Resident #131 and #435) out 2 residents reviewed for Quality of Care. The findings include: 1) During record review for Resident #131 on 07/23/24 at 01:29 PM, it was documented that Resident #131 had been evaluated by a medical provider on 05/26/24 for complaints of nausea without vomiting. The surveyor reviewed the medication administration record, it was revealed that Resident #131 did not receive the medication as ordered. During an interview with the Director of Nursing (DON) on 07/24/24 at 08:20 AM, she was asked to provide records that showed the resident received medication per their complaint. The DON reported she did not know if the medications were given, and that progress notes stated they were awaiting delivery of the medication. A Pyxis MedStation is an automated medication dispensing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interviews it was determined that the facility failed to follow appropriate respiratory care and services. This was evident in 2 (Resident #24 and #62) out of 3 residents reviewed for respiratory care. The findings include: On the initial tour of the PPCU-1 unit on 7/15/2024 at 9:15 AM the surveyor observed an oxygen humidifier bottle dated 7/3 attached to the oxygen gauge on the wall in Resident #24's room. The surveyor observed Resident #24 in bed with oxygen in place to the nostrils at 12:29 PM on 7/16/2024. The Minimum Data Set (MDS) is a tool used by the Centers for Medicare and Medicaid Services (CMS) to standardize assessments and care management for residents of Medicare and Medicaid certified nursing homes. The MDS process evaluates a resident's functional capabilities and clinical needs, including their treatments, therapies, and psychosocial functioning. This information helps nursing home staff identify health problems and improve care management. MDS…

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 staff failed to provide a follow up after a psychiatric consult for (Resident #60). This was evident for 1 out of 1 resident's reviewed for physician services. The findings include: During a review of Resident #60's physician orders conducted on 07/18/24 at 01:26 PM, the surveyor reviewed an order for a psychiatric consult ordered on 01/24/23. Following the order, a psychiatric consult comumnity Health Services completed an evaluation for Resident #60 on 01/26/23. It was documented in the subject area under the PLAN that the patient did not require two antidepressants based on current presentation. During an interview with the Director of Nursing (DON) on 07/25/24 at 01:39 PM, she was asked about the documented psychiatric plan for the resident and was also asked about the follow-up physician or nursing notes based on the psychiatric consult conducted by the community Health Services. During an interview with the DON on 07/26/24 at 10:38 AM, she stated that the resident was found to have depressive…

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, record review and observation, it was determined that the facility failed to ensure medications were administered as prescribed by the medical provider. This was found to be evident for 1 (Resident #337) out of 1 resident's reviewed for medication timeliness. The findings include: A medical provider, also known as a health care provider, is a licensed individual or organization that provides health care services. During an interview on 07/15/24 at 12:35 PM, Resident #337's daughter stated that the night nurse had changed the time on a seizure medication without checking it with the doctor. No documentation was found on the record related to the medication time change. The surveyor requested additional information from the facility. 07/25/24 at 10:25 AM Review of the Clinical Incident Report written on 7/9/24, stated that Registered Nurse (RN) #22 did not administer a medication as ordered and scheduled. Education was provided to RN #22 on medication administration in relation to notifying the Medical Doctor or Nurse Practioner before making any timing changes.…

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

Based on observations and interviews, it was determined that the facility failed to ensure sanitary and safe food handling practices were followed to reduce the risk of foodborne illness. This was found for 2 out of 4 food refrigerator and storage areas observed during the annual survey. The findings include: During the initial tour of the kitchen with the Food Service Director on 07/15/24 at 08:02 AM, the surveyor identified concerns with outdated food. Lemon pie was dated use by 2/14 with no open date or year in the freezer, a container was labeled opened 1/16 with no discard date or year in the dry storage area, and containers of teriyaki sauce and soy sauce were not labeled or dated in the cooking area. The Food Service Director stated that all items should be dated with the received, opened and discard dates including the year and she would educate staff. On 07/17/24 at 11:40 AM, the surveyor requested that Registered Nurse (RN) #11 to unlock the refrigerator door on the Vital Strong 2 (VS2) unit. An unlabeled, undated container of fruit, an undated bag with a resident name 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 medical record review and interviews, it was determined that the facility staff failed to accurately document the Morse Fall Scale assessments for (Resident #60). This was evident for 1 out of 1 resident's reviewed for falls. The findings include: The Morse Fall Scale (MFS) is a tool that estimates a patient's risk of falling in various settings by assigning a score between 0 - 45 and higher points. During a review of Resident #60's medical record on 07/18/24 at 08:42 AM, it was revealed that Resident #60 fell on 09/22, 10/22, 8/23, 2/24, and 3/24. A review of the MFS assessment dated [DATE] did not accurately record the past history of falls as noted above. Therefore the resident fall risk was assessed inaccurately at a fall risk factor for moderate risk for falls. A review of the MFS assessment dated [DATE] did not accurately record the past history of falls as noted above. Therefore, the resident fall risk was assessed inaccurately at a fall risk factor for low risk for falls. During an interview…

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 follow infection control practices before donning personal protective equipment (PPE). This was evident during an annual survey. The findings include: Personal protective equipment (PPE) is clothing or equipment that protects the wearer from injury or the spread of infection or illness. In healthcare settings, PPE can include items such as: protective clothing, helmets, gloves, face shields, goggles, and respirators. During observation on 07/24/24 at 12:25 PM, the surveyor observed the PPE cart with a sign posted that stated, Reminder, sanitize your hands before taking a gown. The sign was visible to everyone. The surveyor observed Licensed Practical Nurse Staff #28, remove PPE from the cart without performing hand hygiene before removing the PPE. The surveyor also observed two more facility staff remove PPE without performing hand hygiene first. During an interview with Registered Nurse Staff #29 on 07/24/24 at 12:28 PM, she was directed to the PPE cart, then asked what the process was 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 a resident council meeting and observations, it was determined that the facility failed to post signs identifying the location of survey results in areas of the facility that were prominent and accessible to the public. This was evident on all nursing units in the facility. The findings include: On 08/15/19 at 10:28 AM, during a resident council meeting with Residents #9, #53, #27, #40, #44, #50, and #7, when asked if they knew where the State Survey results were kept, none of the seven residents had seen nor knew the location of the State Survey results for the facility. During an interview on 8/15/19 at 1:00 PM, the nursing home administrator stated there was only one copy of the survey results available to residents. The Administrator stated that the results were kept in the facility's lobby. The Administrator and Director of Nursing was aware of this concern prior to and during survey exit.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that documentation of residents' care plan goals were sent with the resident to the receiving facility when the resident was hospitalized . This was evident for 3 (Residents #30, #54, and #43) of 7 residents reviewed for hospitalizations. The findings include: 1) Resident #30's medical record was reviewed on 8/8/19 at 2:42 PM. During the review, it was found that the resident was hospitalized twice in April, 2019; once was resident-initiated and the other was facility-initiated. Documentation that was sent with the resident for the facility-initiated transfer was reviewed and no documentation could be found that stated the resident's care plan goals. For the resident-initiated transfer, the resident was transported privately to the hospital and it was documented that the resident refused to take facility paperwork with him/her. This was confirmed in interview with the resident on 8/8/19 at 2:50 PM. During an interview with the Director of Nursing (DON)…

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

Based on observation, record review, and interview with facility staff, it was determined that the facility failed to 1. ensure that resident care plans were implemented for the elevation of the heels of a resident with pressure ulcers on both heels, and 2. develop and implement comprehensive person-centered care plan that included measurable objective related to a residents diagnosis and respirator needs. This was evident for 2 (Residents #33 and #277) of 51 residents reviewed during the survey. The findings include: 1) Resident #33 was observed in bed on 8/15/19 at 9:39 AM. The resident was found to be on his/her back with the covers drawn up to his/her chin. The resident appeared comfortable, clean, and well groomed. The silhouette of the resident's feet suggested that the resident's heels were in direct contact with the mattress. Resident #33's medical record was reviewed contemporaneously. A care plan topic entitled, Pressure ulcer related to immobility was found with the intervention, Float/suspend heels while in bed. The Pulmonary Care Unit Manager was interviewed at 9:50 AM.…

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

Based on observation, medical record review and resident and staff interview it was determined the facility failed to accurately document fluid intake for Resident #92. This was evident for 1 of 3 residents reviewed for dialysis during the survey. The findings include: On 8/8/19 at 9:16 AM during an interview with Resident #92, he/she was asked if he/she was on a fluid restriction. The resident indicated he/she was but did not know if staff were recording it or not. A cup was noted on the bedside table partially filled with water, but with no measurements printed on the side. Beginning on 8/8/19 at about 1:00 PM, the medical record for Resident #92 was reviewed. During the review it was noted the resident had a physician order for hemodialysis three times a week on Monday, Wednesday and Friday for end stage renal disease (kidney failure). According to https://www.kidney.org/atoz/content/hemodialysis, it states, You need dialysis if your kidneys no longer remove enough wastes and fluid from your blood to keep you healthy .In hemodialysis, a dialysis machine and a special filter…

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, interview with residents, and interview with facility staff, it was determined that the facility failed to ensure that resident meals arrived at an appropriate temperature and near the scheduled time of meal delivery. This was evident for 1 of 2 observations of lunchtime tray delivery. The findings include: Resident #91 was interviewed on 8/7/19 at 12:46 PM. During the interview, the resident stated that there was often a significant delay between when the tray cart arrived and when staff brought trays to resident rooms. The resident illustrated this by saying that on the day prior, 8/6/19, the resident witnessed the food cart arrive to the unit at 1:10 PM but that s/he didn't receive his/her lunch tray until 1:40 PM. The resident stated these times were typical based on his/her experience. The resident further stated that entree items often arrive cold and ice cream arrives melted. The resident gave the opinion that not enough staff were available to assist in delivering trays and that the ones who did deliver the trays were slow about it. Resident #53 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, medical record review and resident and staff interviews, it was determined that the facility 1) failed to ensure Resident #92 received lunch prior to the routinely scheduled pick-up time for dialysis, failed to ensure the resident was transferred to a geriatric chair (Geri Chair) in order to be ready for dialysis on time, and failed to ensure that dialysis staff picked up the resident on time; and 2) failed to ensure residents' meal selections and dietary preferences were honored during meal service. This was evident for 1 (Resident #92) of 3 residents reviewed for dialysis during the survey and 1 (Resident #26) of 51 residents reviewed during the survey. The findings include: 1) Resident #92's medical record was reviewed on 8/8/19 at about 1:00 PM. During the review it was noted the resident had a physician order for hemodialysis three times a week on Monday, Wednesday and Friday for end stage renal disease (kidney failure). It was also noted that the resident had Diabetes Mellitus type 2. According to https://www.diabetes.org/diabetes/type-2, Type 2 means…

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 medication cart observations and staff interviews it was determined the facility staff failed to ensure medical records were kept in a confidential manner. This was evident in 3 out of 9 medication carts. The findings include: During an observation that took place on 8/7/19 at 8:49 AM of the [NAME] and Vent units, the surveyor observed the nursing shift-to-shift report laying on top of an unattended medication cart. This document is used by the facility's nursing staff for assigned nursing tasks that need to be preformed during the nurse's shift. This shift-to shift-report that the surveyor viewed contained residents' names, room numbers, vital signs, pain medications, labs, code status, bowel movement status with nursing medication and treatment comments visible for the public to view for the residents in rooms 210 - 218. This document was on top of medication cart-1. On 8/7/19 at 9:00 AM on the Vent unit, the surveyor observed another shift-to-shift report on top of the unattended medication cart-3…

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

Based on medical record review and staff interview it was determined facility staff erroneously coded the discharge destination on a Minimum Data Set (MDS) report for Resident #125. This was evident for 1 (Resident #125) of 3 closed records reviewed for discharge during the survey and for 1 (Resident #277) of 51 residents reviewed in the annual survey. The findings include: The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions (also referred to as MDS Items). Each triggered care area must then be assessed in order to determine if care planning is needed; and if so to drive an effective plan that will ensure the assessed needs of each resident are met when care is delivered 1) On 8/14/19 beginning…

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, interview with residents, and interview with facility staff, it was determined that the facility failed to ensure that residents were given the opportunity to select meals from a menu in advance of the meal being serviced and that residents received the items that they selected from the menu. This was evident for 1 (Resident #30) of 2 residents reviewed for food. The findings include: Resident #30's medical record was reviewed on 8/8/19 at 2:47 PM. During the review, it was found that the resident was legally blind and that the resident experienced weight loss from weighing 164 lbs on 4/9/19 to weighing 148 lbs on 6/16/19. Resident #30 was interviewed on 8/9/19 at 12:17 PM. During the interview, the resident stated that s/he was able to feed him/herself with only minor assistance from facility staff in setting up the tray. However, the resident stated that s/he would often receive food that s/he did not like. Resident #30 stated that the facility used to provide menus in advance and would come ask the resident at the beginning of the week which entrees s/he…

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