Dexter Health Care

Based on review of the facility's investigation/written statements and interviews, the facility failed ensure that a resident was free from restraint when a Registered Nurse used body contact as a method of physical restraint to limit a resident's voluntary movement for 1 of 1 facility reported incidents reviewed (8/16/25). Finding:The facility's policy, Use of Restraints, revised 3/2025, indicated Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. On 8/26/25, RN1's employee file was reviewed and included a Performance Correction Notice, dated 8/18/25 that indicated RN1 was on leave, pending investigation, because of an incident with an allegation of abuse that was considered restraining a resident that included details that RN1 held a resident's arms/hands down while resident was trying to hit staff. On 8/26/25, the surveyor reviewed the written statements and…

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

Based on facility policy review, the Nursing Facility Reportable Incident Form and investigation review, timecard review, and interviews, the facility failed to protect residents after staff notification of concern of behavior by a Registered Nurse towards a Resident for 1 of 1 facility reported incident reviewed (8/16/25).Finding:The facility's Identifying types of Abuse, revised 3/2025, indicated the following: Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that on 8/16/25, staff reported to the Director of Nursing (DON) 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 Nursing Facility Reportable Incident Form review and interview, the facility failed to notify the State Agency (Division of Licensing and Certification [DLC]) timely for an allegation of abuse for 1 of 1 facility reported incidents reviewed (8/16/25).Finding:On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that on 8/16/25, staff reported to the Director of Nursing (DON) that Resident #1 (R1) was agitated and Registered Nurse #1 (RN1) escalated resident's behavior to the point that R1 bit RN1's hand. Per documentation on this incident form, on 8/18/25, staff came to further report additional information to the events that occurred on 8/16/25 between RN1 and R1 that occurred when R1's behaviors were escalating and R1 was exit seeking, which included RN1 putting R1 in his/her room, closed the door and held the door for several seconds up to one minute. In addition, on 8/16/25 at 11:04 a.m., Certified Nursing Assistant #1 (CNA1) reported to the DON via text…

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, facility investigation with written statements, and interviews, the facility failed to fully develop and implement a care plan for a resident who was agitated and trying to leave the facility for 1 of 1 facility reported incidents reviewed (8/16/25) when staff observed a Registered Nurse yelling at the resident instead of approaching/speaking in a calm manner and for the intervention to distract the resident from eloping, the resident preferences was BLANK. Finding:On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that staff reported that Resident #1 (R1) was exit seeking and escalating.On 8/26/25, R1's care plan was reviewed and included the following:Focus: The resident is an elopement risk/wanderer related to (r/t) safety awareness, dementia with interventions that included distract resident from wandering by offering pleasant diversions, structure activities, food, conversation, television, book. Resident prefers: IS BLANK. This 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 record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information which included documentation of Resident Representative notification of hospital transfer, charge nurse documentation of resident behaviors as directed per Treatment Administration Record (TAR), and documentation to indicate that a resident returned from the hospital for 1 of 1 facility reported incidents reviewed (8/16/25). On 8/26/25, the surveyor reviewed Resident #1's (R1) clinical record after an incident that occurred on 8/16/25 which resulted in R1 being transferred to the hospital for evaluation of increased behaviors. The clinical record lacked evidence of documentation on 8/16/25 of Resident Representative notification or an attempt to notify, notes from Registered Nurse #1 (RN1) who had signed of the treatment sheet that behaviors were monitored, or information regarding when R1 returned to the facility after being transferred from the hospital. On 8/26/25 at 1:35 p.m., during an interview with the Administrator and the Director of…

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

Based on record reviews and interviews, the facility failed to ensure that physician orders for medications and treatments were followed for 6 of 25 sampled residents medications reviewed (Resident #11 [R11]), R14, R15, R27, R30, R144, ). Findings: 1. On 10/30/24, a review of R15's clinical record was completed. Documentation in R15's nurse's notes indicated that on 10/9/24, R15 was sent to the Emergency Department due to respiratory concerns. On 10/11/24, R15 returned from the hospital with an order for Levaquin (an antibiotic) 750 milligrams (mgs) by mouth everyday for 7 days to treat pneumonia. On 10/13/24, a nurse's note indicated R15 returned from the hospital with an order for Levaquin and this facility was notified by pharmacy that they sent a note to R15's physician regarding prior authorization for it's use and that the medication may be contraindicated with R15's other medicines. There has been no update from the physician. The nurse note indicated that R15 had not received the antibiotic. On 10/17/24, a nurse's note indicated that on 10/16/24, R15 was started on Levaquin.…

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 the Center for Disease Control and Prevention, Enhanced Barrier Precaution policy, Wound Care policy, record reviews, observations, and interviews the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections during pressure ulcer dressing changes for 2 of 2 residents requiring pressure ulcer dressing changes (Resident #17 [R17], and Resident #11 [R11]). In addition, the facility failed to follow Enhanced Barrier Precautions (EBPs) pertaining to a Resident with an indwelling urinary catheter for 1 of 1 resident observed for urinary catheter care (R17). Findings: The Centers for Disease Control and prevention Definition and Scope of Enhanced Barrier Precautions: dated 6/23/24 states, Enhanced Barrier Precautions (EBP) involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds 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 interviews, the facility failed to ensure that a resident's choice in the area of bathing was being followed for 1 of 1 sampled resident (Resident #3 [R3]). Finding: On 10/28/24 at 12:30 p.m., during an interview with a surveyor and a resident representative, he/she stated that one of their concerns is that R3 does not always get his/her scheduled showers, and that staff tell them that because R3 was already washed he/she did not need a shower. The resident representative stated that R3 likes his/her showers and only gets one once a week. On 10/30/24, R3's electronic clinical record was reviewed which indicated that R3 was to receive a shower on Saturdays day shift. Review of the electronic clinical records electronic charting System (ECS) (facility was transitioning from one electronic system to another and went live with the new system on October 1, 2024) ECS shows documentation that for the Months of August and September R3 missed 5 showers. For the month of October, the new electronic charting Point Click Care system (PCC) lacks evidence that R3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building, resident equipment in good repair and in a sanitary condition for 2 of 2 environmental tours. On 10/30/24 at 1:35 p.m. through 1:55 p.m., and at 2:45 p.m., environmental tours were conducted with the Administrator. Findings were confirmed at the time of the observations. - room [ROOM NUMBER], the veneer on the dresser drawers was faded and had blotches of missing veneer, chipped wood and scratched. - room [ROOM NUMBER]B, the right upper corner of the dresser drawer was missing, chipped areas and a handle was askew. - Resident #11's wheelchair was observed to be dirty, the left armrest cushion was missing foam pieces, and the left leg/foot rest was taped creating an uncleanable surface. - room [ROOM NUMBER], the second drawer of the three drawer dresser was missing a piece of wood on one corner. - Resident #27's wheelchair was dirty and the left armrest was…

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

Based on record review and interview, the facility failed to implement a care plan intervention for 1 of 1 residents reviewed for nutrition (Resident #27 [R27}). Finding: On 10/30/24, R27's care plan was reviewed and included an intervention added on 7/13/23 under the care area of Nutrition, to weigh the resident every week. On 10/30/24 at 9:32 a.m., a surveyor and Resident Assessment Instrument (RAI) Coordinator reviewed R27's weights documented in the electronic system for the month of October and noted that it lacked evidence of weekly weights from 9/29/24 - 10/5/24 and 10/13/24 - 10/19/24; the surveyor confirmed weights were not documented weekly during this review.

Based on observation and interview, the facility failed to ensure that a physician order was followed for a pressure ulcer dressing change for 1 of 1 observation for Resident #11 [R11]. Finding: On 10/29/24, a surveyor reviewed R11's clinical record and noted that there was documentation of measurements on 10/7/24, 10/8/24, 10/23/24, 10/25/24 and 10/26/24 for R11's right 3rd toe pressure injury. On 10/29/24 at 2:25 p.m., a surveyor observed Licensed Practical Nurse #1 (LPN1) complete a pressure ulcer dressing change for R11. The physician order directed staff to change the dressing to R11's Stage II, right third toe daily. The surveyor observed LPN1 remove the old dressing, cleanse the area, and apply the dressing to R11's second toe of the right foot. Upon exit of the room, the surveyor asked LPN1 to review the physician order and stated to LPN1 that she dressed the second toe. LPN1 went back to the room, removed R11's sock and LPN1, R11, and the surveyor noted the second toe was dressed and not the third. R11 stated, right foot, wrong toe. The surveyor confirmed that 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 record review and interview, the facility failed to ensure the physician reviewed the resident's total program of care, which included signing orders for medications and treatments listed on the Physician Orders (block orders) in a timely manner for 1 of 11 residents reviewed (Residents #6 [R6]). Finding: On 10/28/24, R6's clinical record was reviewed and included block orders (60 day) signed by the physician on 7/11/24. The next block orders), including a 10-day grace period, needed review and the Physician's signature by 9/19/24; the Physician visited on 9/9/24 but failed to sign the block orders. On 10/30/24 at 11:29 a.m., during an interview with the Director of Nursing, a surveyor confirmed that the last block orders were signed were 7/11/24, making them now 41 days late.

Based on daily schedules review and interview, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 2 of 7 weekend shifts reviewed for RN coverage. Findings: On 10/31/24 at 10:00 a.m., a surveyor reviewed the daily staffing schedules with the Administrator and Operations Consultant with the following confirmed: 1. On 10/13/24, there was no evidence of a RN in the building working 8 consecutive hours. 2. On 10/20/24, there was no evidence of a RN in the building working 8 consecutive hours.

Based on record review and interview, the facility failed to ensure there was a physician ordered renewal for an as needed (PRN) psychotropic medication before entering into the new electronic charting system (PCC)'s current physician orders and entered this order without a stop date, making it available for administration for 1 of 5 residents reviewed for unnecessary medications (Resident #9 [R9]). Finding: On 10/31/24 at 8:40 a.m., R9's clinical record was reviewed with the Director of Nursing (DON). The surveyor noted that the physician orders in the old electronic charting system (ECS), included Lorazepam (anti-anxiety) that was to be administered as needed at bedtime thru 9/23/24. The DON was unable to find a new physician order to renew this medication in R9's clinical record. This Lorazepam PRN medication order was entered into the new electronic charting system (PCC) with a start date of 10/1/24 (the date PCC went into effect) without a physician order for the renewal and entered the medication order with no end date, making this medication available to be used greater than…

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

Based on observations and interviews, the facility failed to label supplements with a thaw date and failed to remove expired food for 2 of 4 days of survey (10/28/24 and 10/29/24). In addition, the facility failed to ensure the kitchen was maintained in a clean manner for the exhaust fan located in the dishwashing room on the clean dish side for 3 of 4 days of survey (10/28/24 to 10/30/24). Findings: 1. On 10/28/24 at 11:30 a.m., during the initial walk through of the kitchen, a surveyor observed in the walk-in refrigerator, on a shelf was a box with 9 thawed health shakes supplements that were not labeled with a thaw date. Storage and handling instructions on the carton after thawing keep refrigerated, use within 14 days after thawing. On 10/28/24 at 11:45 a.m. the surveyor confirmed with the Dietary Manager that the health shakes did not have a thaw date on them or on the box. 2. On 10/28/24 at 11:30 a.m., on a shelf on the left side of the walk-in refrigerator there was a tray that held 6 individual serving cups labeled as coleslaw with a label to use by 10/28/24. On 10/29/24 at…

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

Based on record reviews and interviews, the facility failed to ensure a clinical record contained complete and accurate information for 3 of 7 residents reviewed (Resident #11 [R11], R27, and R9). Findings: 1. On 10/30/24, R11's clinical record was reviewed and included an order, dated 3/3/24, for Protonix, 40 milligrams (mg) twice a day. On 10/30/24 at 3:30 p.m., during an interview with the Director of Nursing (DON), a surveyor confirmed that during transfer of physician orders from the old electronic charting system (ECS) into the new electronic charting system (PCC) to begin on 10/1/24, this or was entered, in error, to be administered one time a day instead of twice a day. 2. On 10/30/24, R27's clinical record was reviewed and included a physician order, dated 12/6/22, for Trazodone 50 milligrams (mg) to be administered once a day; the clinical record lacked evidence of an order to discontinue this medication. On 10/30/24 at 2:14 p.m., during an interview with the DON, a surveyor confirmed that during transfer of physician orders from ECS to PCC to begin on 10/1/24, this…

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

Based on record reviews and interviews, the facility failed to ensure a Physician ordered lab was completed and/or completed timely for a urine test for 2 of 2 residents reviewed with urinary symptoms (Resident #3 (R3) and R44). Findings: 1. On 11/6/23, R3's clinical record was reviewed and included the following physician orders: - On 10/3/23, an order was written by the provider for a Urine Fungal lab test. - On 10/17/23, a telephone order was written that directed staff to obtain a urine sample for Urinary Tract Infection (UTI)/also second sample for Fungus. - On 10/31/23, an order was written by the provider for a urinalysis (UA) if possible which was entered on R3's treatment sheet to be completed on 11/2/23. The surveyor was unable to find a urine result for the 10/3/23 and 10/17/23 urinal fungal/fungus test and unable to find the results of the 10/31/23 physician order for the UA. On 11/6/23 at 11:10 a.m., during an interview with a surveyor, the Nurse Manager (NM) stated that the 10/31/23 urine order that was to be completed on 11/2/23 was not obtained and was not sent to…

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

Based on observations and interviews, the facility failed to ensure that a resident requiring feeding assistance was done in a dignified manner for 1 of 2 residents observed requiring feeding assistance (Resident #18 [R18]). Finding: On 11/6/23 between 12:41 p.m. through 12:50 p.m. two surveyors observed Certified Nursing Assistant (CNA) 1 walk over to R18's table, stand next to R18, picked up a spoon, and fed R18 two spoonful's of dessert. CNA1 immediately walked away from the table. A few moments later CNA1 asked CNA2 if she would feed R18 more dessert. Two surveyors observed CNA2 walk over to R18, stand beside him/her, picked up a spoon, and fed R18 a spoonful of dessert. CNA2 immediately walked away from the table. A few moments later CNA1 walked over to R18's table again, stood next to F18, picked up a spoon, and fed R18 another spoonful of dessert. CNA1 immediately walked away from the table. In an interview on 11/6/23 at 12:50 p.m., a surveyor confirmed the above finding with CNA1, and CNA2.

Based on record review and interviews, the facility failed to ensure that transportation assistance was available and provided for a scheduled eye appointment for 1 of 2 Residents reviewed for eye appointments (Resident #31 [R31]). Finding: On 11/7/23 at 12:14 p.m. in an interview with a surveyor, the nurse scheduler stated that R31 was supposed to have an appointment with an Eye Doctor for a Cataract surgery consult on 10/17/23. The nurse scheduler stated she was told that she could not have the van that day. She stated their facility uses transportation from two other facilities and on 10/17/23 she was told that she could not use the transportation, another facility needed it. R31's appointment had to be canceled for 10/17/23, and the nurse scheduler stated that the next available eye appointment for R31 was not until 11/17/23, one month later. This finding was confirmed with the nurse scheduler at this time.

Based on record review and interview, the facility failed to ensure weekly pressure ulcer documentation was completed for 1 of 2 residents reviewed for pressure ulcers (Resident #6 [R6]. Finding: On 11/6/23, R6's clinical record was reviewed and indicated that R6 had an unstageable pressure ulcer to the left foot bunion area. The surveyor was unable to find weekly monitoring documented in the clinical record. On 11/8/23 at 11:25 a.m. during an interview with a surveyor, the Director of Nursing (DON) stated that the facility used their electronic charting system (ECS) as their pressure wound protocol for weekly monitoring and directed staff to document their assessment weekly (in the resident's treatment record). The surveyor requested information from the DON regarding the weekly assessments for R6. At 11:36 a.m., during an interview with a surveyor, the DON stated that that the pressure wound was first noted on 8/6/23 and measurements and a description of the wound was included in a nursing note. The daily and weekly assessments orders were entered into R6's treatment orders but…

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

Based on facility policy review, record review, and interview, the facility failed to monitor and document the effectiveness of PRN (as needed) pain medications for 1 of 1 sampled residents reviewed for pain control (Resident # [R} 3). Finding: The facility's policy, Pain Medications, Administering, facility last reviewed in 2/2022, indicated the purpose of this procedure was to provide guidelines for assessing resident's level of pain prior to administering analgesic pain medication. This included to conduct a pain assessment which could consist of gathering both subjective and objective data by using a pain intensity scale or FACES pain rating scale prior to administering the pain medication as ordered. Document the following in the clinical record: - Residents of the pain assessment, medication, dose, route of administration and the results of the medication. On 11/8/23, R3's clinical record was reviewed and indicated the following PRN medications were administered between 10/3/23 thru 10/13/23: On 10/5/23 at 1:36 a.m., the clinical record indicated that R3 received Acetaminophen…

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

Based on record review and interview, the facility failed to ensure that the Medical Provider wrote an electronic prescription and provided it to the pharmacy timely for a narcotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident # [R] 3). This failure resulted in R3 having to wait 7 days in order to receive the medication. Finding: R3's clinical record was reviewed on 11/6/23. It included written physician orders, dated 10/3/23, for Oxycodone for pain as needed (PRN)/three times a day. On 10/4/23, a telephone order was written for clarification for the Oxycodone order to be PRN three times a day. On 10/6/23, a fax was sent to the Medical Provider by the facility asking if the Oxycodone could be scheduled versus as needed. This fax also indicated that an E-script (electronic prescription) was needed please! On 10/9/23, the facility sent another fax to the Medical Provider indicating that R3's family member was concerned that he/she has not been able to have the Oxycodone yet. The writer of this fax called the pharmacy and was told the pharmacy was still…

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

Based on observation and interview, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 1 medication supply room (medication supply storage room behind nursing station), and 1 of 2 medication carts (medication cart A). Findings: On 11/8/23 between approximately 2:15 p.m. and 2:40 p.m., during a medication supply review with the Certified Nursing Aid-Medications (CNA-M), two surveyors observed the following: In the medication supply room behind the nursing station: - One vial of Humulin R (liquid vial of insulin) 10 ml (milliliter), located in a refrigerator, labeled cubex stock that was available for use with an expiration date of September 2023 - One vial of Humulin 70/30 (liquid vial of insulin) 10 ml, located in a refrigerator, labeled cubex stock that was available for use with an expiration date of September 2023 -One bottle of Fish Oil (a dietary supplement) 1200 mg (milligrams) 100 soft gel bottle that was available for use with an expiration date of April 2023 -One bottle of Ibuprofen (a nonsteroid anti-inflammatory…

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

Based on record review and interview, the facility failed to ensure that a physician order for an x-ray was completed timely for 1 of 1 resident (Resident #13 [R13]). Finding: On 11/8/23, R13's clinical record was reviewed. Documentation in the physician orders indicated that on 8/1/23, the physician ordered an x-ray of R13's left wrist and thumb related to potential fracture, increased pain and decreased mobility. The x-ray was scheduled on 8/2/23 for Mobile Lab to come to the facility and take the x-ray per order. Documentation in the radiology report, dated 8/6/23 (4 days after the order), indicated no fracture or dislocation. A review of R13's daily pain monitoring indicated there was no increase in his/her pain level while waiting for an x-ray and documentation on R13's Medication Administration Record indicated no as needed pain medication were administered. On 11/8/23 at 8:05 a.m., in an interview with the surveyor, the Director of Nursing confirmed that the Mobile x-ray company did not take the x-ray timely and as scheduled because the x-ray company told her they were down…

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

Based on observations, and interview the facility failed to ensure that proper hand sanitizing and proper food handling during lunch service was followed for 1 of 2 lunch service observations in the dining room (11/6/23). Findings: On 11/6/23 between 12:41 p.m. through 12:50 p.m., two surveyors observed Certified Nursing Assistant (CNA) 1 contaminate her hands while clearing tables after lunch service. She picked up and handled used trays of food, dirty plates, bowls, and utensils, and placed them on a meal cart. CNA1 did not wash or sanitize her hands after contaminating them. CNA1 immediately walked over to R18 and was observed feeding him/her a spoonful of dessert with her contaminated hands. Two surveyors observed that CNA1 did not wash or sanitize her hands after touching dirty plates, bowls, and utensils. A surveyor discussed this finding at the time of observation with CNA1.

Based on interviews, review of the facility incident report, and investigation, the facility failed to ensure the entrance door locked/alarmed when a resident that wore an ankle secure care transmitter and had been identified as an elopement risk was able to leave the building unnoticed for 1 of 1 facility reported incidents reviewed (10/2/23). A nearby neighbor who lived 0.2 miles away called the facility to let staff know that Resident #1 was at their residence. Finding: Review of the facility's incident report sent to the State Agency, dated 10/2/23, indicated that [Resident #1] was wearing a secure care bracelet but was able to exit the facility unwitnessed. A near by neighbor called the facility to alert them that they had a resident at their property. On 10/5/23, the facility completed their investigation and sent it to the State Agency. This investigation indicated that after reviewing the facility cameras, it was found Resident #1 exited the front door at 5:34 p.m. The neighbor called the facility at 5:50 p.m.; staff immediately went to get Resident #1 from the neighbors…

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 facility reported incident form, record review, the facility 'Lifting Machine' policy and procedure, and interviews, the facility failed to ensure a resident did not slide out of a Hoyer sling during a transfer for 1 of 3 residents requiring Hoyer transfer (Resident #1). Finding: On 8/30/23, a Nursing Facility Reportable Incident form, dated 8/20/23, and the 5-day Follow-Up form, dated 8/25/23, were reviewed. The forms indicated that on 8/20/23, Certified Nurse Assistant #1 (CNA1) and Certified Nurse Assistant #2 (CNA2) were using a Hoyer lift to transfer Resident #1 (R1) from his/her wheelchair to the bed. CNA1 failed to use the appropriate size sling and failed to properly apply the Hoyer lift sling resulting in R1 sliding out of the sling to the floor. R1 landed on the Hoyer lift legs causing a 9 centimeter (cm) long by 1.7 cm wide abrasion on his/her back. R1 was sent to the hospital for evaluation and returned to facility with no injuries other than the abrasion. On 8/30/23, R1's clinical record was reviewed. A discharge report from the hospital indicated…

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.