Ely Manor

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 (Resident #49 and Resident #51) of 2 residents reviewed for abuse resulting in an allegation of physical abuse not being thoroughly investigated and the potential for ongoing resident to resident physical abuse to occur. Findings include: Resident #49 Review of Resident #49's Progress Notes dated 9/11/25 and documented by Physician Assistant (PA) AAA revealed, RN (Registered Nurse) called and notified me resident (Resident #49) was in an altercation with another resident (Resident #51). Resident (Resident #49) was struck in the face with a book by another resident (Resident #51) Resident #51 Review of Resident #51's Incident Report dated 9/11/25 and documented by Registered Nurse (RN) G revealed, The author writing this note heard the resident (Resident #51) raising her voice. This author observed (Resident #51) holding onto another resident (Resident #49) walker and yelling 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 interview and record review, the facility failed to thoroughly investigate an allegation of resident-to-resident abuse and protect residents from further abuse for 2 residents (Resident #49 & #51) of 2 residents reviewed for abuse, resulting in the potential for ongoing abuse due to an incomplete investigation of abuse. Findings include: Resident #49 Review of Resident #49's Progress Notes dated 9/11/25 and documented by Physician Assistant (PA) AAA revealed, RN (Registered Nurse) called and notified me resident (Resident #49) was in an altercation with another resident (Resident #51). Resident (Resident #49) was struck in the face with a book by another resident (Resident #51) Resident #51 Review of Resident #51's Incident Report dated 9/11/25 and documented by Registered Nurse (RN) G revealed, The author writing this note heard the resident (Resident #51) raising her voice. This author observed (Resident #51) holding onto another resident (Resident #49) walker and yelling at other resident (Resident #49). This author removed (Resident #51) from the day room . In 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1(Resident #4) of 1 resident reviewed for Pre-admission Screening and Resident Review (PASARR) was referred for a comprehensive level II PASARR evaluation, resulting in the potential for the resident to not receive the appropriate mental health treatment and services. Findings include:Resident #4Review of an admission Record revealed Resident #4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).Review of a Minimum Data Set (MDS) assessment for Resident #4 with a reference date of 7/31/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 0/15, which indicated the resident was severely cognitively impaired.Review of a PASARR Level I screening form for Resident #4 with a reference date of 7/22/25, section II revealed the resident 1.has a current diagnosis of mental illness,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise a comprehensive, individualized plan of care for 1 of 18 residents (Resident #51) reviewed for care plans, resulting in further occurrences of resident-to-resident physical aggression and the potential for unmet care needs and impaired physical, mental, and psychosocial well-being. Findings include: Resident #51 Review of an admission Record revealed Resident #51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease and major depressive disorder. Review of Resident #51's Care Plan revealed, (Resident #51) has the potential to demonstrate physical and verbal aggression R/T (related to): hitting, kicking, resistive to care, biting, slapping, repetitive movements, yelling, screaming and abusive language r/t dementia, delusional thinking, depression and anxiety. Start date: 1/8/25. Goal: Will not harm self or others through the review date. Date Initiated: 01/08/2025. Interventions:…

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, the facility failed to implement interventions to reduce hazards and risks for 2 residents (Resident #71 and Resident #24) of 6 residents reviewed for accidents, resulting in: 1. Resident #71 maintaining possession of smoking paraphernalia while unsupervised. This deficient practice has the potential to impact all 80 residents of the facility due to the increased risk of a potential fire. 2. Resident #24 being transported in a wheelchair without foot pedals in place, resulting in the potential for an avoidable injury.Findings include:Resident #71Review of an admission Record revealed Resident #71 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression (persistent sad mood that impacts daily life).Review of a Care Plan for Resident # 71 with a reference date of 3/12/25, revealed there was no care plan related to Resident 71's noncompliance with the facility smoking policy, hiding smoking paraphernalia, and smoking in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify the need of a bubbler/humidifier to aid in oxygen therapy for 1 of 1 resident (R69) reviewed for oxygen therapy, resulting in the resident experiencing dryness and sores in her nose resulting in psychosocial and physical distress. Findings include: R69According to R69's Minimum Data Set (MDS) dated [DATE], the resident was independent performing her ADLs (activities of daily living). The resident's BIMS (Brief Interview Mental Status) had not been completed however, in conversations with the resident, she was able to recall long and short-term memories and hold an intellectual conversation. Review of R69's Diagnoses List included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and emphysema.Review of R69's Order Summary, dated 2/21/25, revealed, Oxygen at 2 L/min (deliver liters per minute) via nasal cannula (NC) to maintain saturation greater than 88% every shift for COPD.Review of R69'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents pain medications as ordered in 1 resident (Resident #7) of 6 residents reviewed for medications, resulting in Resident #7 receiving prescribed opioid (pain reliever) medication at a lower dose than the physician had ordered potentially causing Resident #7 to be at risk for breakthrough pain.Findings include:Resident #7(R7)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R7 admitted to the facility on [DATE] with pertinent diagnoses including hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction (stroke), dementia (decline in mental abilities such as memory, thinking and reasoning that is severe enough to interfere with daily life), aphasia (impaired speech and language that can limit ability to communicate) and depression. Brief Interview for Mental Status (BIMS) could not be completed due to R7's cognitive impairment. She was under Hospice care due…

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, the facility failed to provide medically related social services to attain and maintain the mental and psychosocial health for 3 (Resident #71, Resident #13 and Resident # 4) of 18 residents reviewed for social services resulting in: 1. lack of evaluation of psychosocial needs for Resident #71, 2. expired resident guardianship paperwork for Resident #13, and 3. lack of care planning for Resident #4's psychiatric diagnosis with mood/behavior concerns and the use of psychotropic medication.Findings include: Resident #71 Review of an admission Record revealed Resident #71 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alcohol abuse, depression (persistent sad mood that impacts daily life) and chronic respiratory failure with hypoxia (a condition in which the lungs cannot adequately provide oxygen to the body, leading to low oxygen levels). Review of a Minimum Data Set (MDS) assessment for Resident #71 with a reference…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely follow up with pharmacy recommendations occurred for 2 residents (Resident #3 and Resident# 51) of 5 residents reviewed for medications resulting in the potential for medication side effects and/or unnecessary medications for residents. Findings include: Resident #3Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety disorder. Review of Resident #3's Medication Regimen Review (MRR) dated 6/11/25 revealed, (Resident #3) is receiving Seroquel (antipsychotic medication). Epidemiological studies suggest an increased risk of hyperglycemia (high blood sugar levels)-related adverse effects during atypical antipsychotic use. These agents have been associated with extreme case of hyperglycemia, ketoacidosis (complication of diabetes where the body cannot produce enough insulin), hyperosmolar coma (serious complication of diabetes 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 observation and interview the facility failed to provide food at a palatable texture for 2 residents (R69 and R73) of 18 residents reviewed for palatable foods and 3 of 14 residents in attendance of a confidential meeting, resulting in the potential for decreased food consumption and the potential for nutritional decline.Findings include:R69 According to R69's Minimum Data Set (MDS) dated [DATE], the resident was independent performing her ADLs (activities of daily living). The resident's BIMS had not been completed however, in conversations with the resident, she was able to recall long and short memories and hold an intellectual conversation. Review of R69's Diagnoses List included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and emphysema. During an interview on 9/22/25 at 10:00 AM, R69 complained of cooked vegetables being too soft. R73 According to the MDS dated [DATE], R73's BIMS score of 15 /15 indicated she was cognitively intact. Her diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate and complete medical records for 1 of 18 residents (Resident #13) reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents. Findings include: Resident #13Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia and cognitive communication deficit. Review of Resident #13's Letter of Co-Guardianship dated [DATE] revealed, In the matter of (Resident #13), a legally incapacitated individual . it is ordered the guardianship is continued without modification. The guardian(s) shall continue to file annual reports. The court shall conduct the next review on [DATE] .In an interview on [DATE] at 8:35 AM, Social Services Director (SSD) FF reported that Social Work was responsible for ensuring that all residents with a legal guardian had current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the facility's antibiotic stewardship program protocols for 1 (Resident #51) of 5 residents reviewed for unnecessary medications resulting in resident #51 receiving multiple doses of an unnecessary antibiotic and the potential for adverse effects, and the development of antibiotic-resistant organisms from unnecessary and inappropriate antibiotic use. Findings include: Resident #51 Review of an admission Record revealed Resident #51 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease and major depressive disorder. Review of Resident #51's Progress Notes dated 8/24/25 revealed, During the evening meal in the dining room, Resident #51 was reported by CNA (Certified Nursing Assistant) (Name redacted) to have initiated physical aggression towards another resident . The provider (name redacted) was notified of the acute change in behavior and orders were received . A urine sample will 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's non-smoking policy for 1 of 1 resident (Resident #71) reviewed for smoking, resulting in the resident possessing smoking paraphernalia while unsupervised in his room.Findings include: Resident #71Review of an admission Record revealed Resident #71 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression (persistent sad mood).Review of a Care Plan for Resident # 71 with a reference date of 3/12/25, revealed there was no care plan related to Resident 71's noncompliance with the facility smoking policy, hiding smoking paraphernalia, and smoking in his room.In an interview on 9/22/25, at 2:01pm, Resident #71 reported he had a lighter and cigarettes in his room until a few days ago when a police officer came and confiscated them. Resident #71 reported staff allowed him to go outside and smoke where the staff smoke and to keep his smoking materials in his possession.In 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # 2568748.Based on interview, and record review, the facility failed to provide showers/baths per resident preference and plan of care in 1 of 3 residents (Resident #102) reviewed for Activities of Daily Living (ADL) care, resulting in dissatisfaction with care, and the potential for skin complications and infection due to impaired hygiene.Findings include:In an interview on 8/19/25 at 4:18 PM, Family Member X reported they initiated a discharge for Resident #102 in May of 2025 due to concerns with poor care. Family Member X reported Resident #102 rarely received a shower/bath while at the facility and stated Resident #102 would get a shower/bath .maybe once per month .Resident #102Review of an admission Record revealed Resident #102 was a female, with pertinent diagnoses which included obstructive lung disease, heart failure, anemia, depression, anxiety, venous insufficiency, diabetes, high blood pressure, and arthritis. Noted the resident discharged from the facility 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.

This citation pertains to intakes 1234839, 1234837, 2563197, 2564473, 1234842, and #1234844 Based on interview and record review, the facility failed to identify quality deficiencies and issues that should have been addressed in quality assurance committee, resulting in systems failure of ensuring resident treatments were completed and documented per physician's orders, change of condition was identified and assessed in a timely manner, facility beds were properly assembled and maintained in safe working condition, infection control practices were implemented, activities were provided to meet each resident's needs, and the facility provided an environment that was free from abuse. This deficient practice has the potential to affect all 89 residents. Findings include:Review of a Quality Assurance Performance Improvement Committee policy with a reference date of 3/5/25 revealed Quality Assurance and Performance Improvement (QAPI)- a coordinated application.takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality.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 This citation pertains to intakes #1234837.Based on interview, and record review, the facility failed to ensure residents were treated with dignity and respect in 1 (Resident #100) of 3 resident reviewed for dignity, resulting in a staff member refusing to assist Resident #100 with care needs Findings include:Review of an admission Record revealed Resident #100 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression (persistent sad mood with loss of interests), anxiety disorder (condition characterized by excessive and persistent worry), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breath) and chronic systolic heart failure (condition in which the heart's main pumping chamber can't pump enough blood to meet the body's needs).Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 4/29/25, revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2563197 and 2564437Based on interview and record review, the facility failed to ensure an incident of neglect (unsafe environment) was reported accurately to the State Agency in 1 of 1 resident (R108) reviewed for reporting, resulting in inaccurate information being reported regarding an incident to the State AgencyFindings include:According to the Minimum Data Set (MDS) dated [DATE], R108 scored 9/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status). R108 was occasionally incontinent and had diagnoses that included right artificial knee joint, cognitive communication deficit, and a history of falling. Section J-Fall History on Admission/Entry or Reentry, indicated R108 had two or more falls since admission or prior assessment with no injury. Section GG-Functional Abilities and Goals indicated a wheelchair was used for mobility. Review of R108's Emergency Medical Service (EMS) Run-Sheet dated 7/2/25 revealed, .Dispatch Reason.penetrating…

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, the facility failed to provide individualized activities designed to support the psychosocial well-being of 1 of 3 Residents (Resident #104) reviewed for activities, resulting in a potential for feelings of social isolation, loneliness, anxiety and boredom. Findings include:Review of Revolutionizing the Experience of Home by Bringing Well-Being to Life: The [NAME] Alternative Domains of Well-Being, Copyright 2012, Rev. 2020, revealed The [NAME] Alternative defined one domain of wellness as Connectedness- the state of being connected; alive.engaged, involved. Without meaningful interactions the individual can become disconnected.develop loneliness, helplessness, and boredom.Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: anxiety disorder (persist feelings of worry that interfere with daily life), stroke (damage to the brain from interruption of its blood…

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 This citation pertains to intake # 123442Based on interview and record review, the facility failed to assess and monitor resident nutritional status in 1 of 3 residents (Resident #105) reviewed for notifications, resulting in a 12% weight loss for Resident #105.Findings include:Resident #105Review of an admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: encounter for surgical repair aftercare following surgery on the nervous system, dysphagia (difficulty swallowing) and weakness.Review of a Minimum Data Set (MDS) assessment for Resident #105 with a reference date of 5/3/25, revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #105 was mildly cognitively impaired. Section K revealed Resident weighed 191 pounds at the time of admission and was on a mechanically altered diet. Section L indicated the resident experienced mouth or facial pain, discomfort or difficulty with chewing. Review of a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes #1234844 and #1234842Based on observation, interview and record review the facility failed to ensure facility staff documented resident care in the medical records for 2 residents (Resident #104 and Resident #105) reviewed for records, resulting in the potential for worsening of health conditions in incontinuity of care. Findings include:Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: stroke (damage to the brain from interruption of its blood supply), and pressure injury to heels, sacral region(bottom).Review of a Minimum Data Set (MDS) assessment for Resident #104 with a reference date of 3/1/25 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated Resident #104 was not able to complete the interview. Section GG revealed Resident #104 was dependent for bed mobility and transferring from bed to wheelchair. Section H revealed Resident #104 had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure standards of infection control practices for one (R112) of one resident reviewed for the use PPE (Personal Protection Equipment) for Enhanced Barrier Precautions (EBP), resulting in the potential of cross-contamination and harborage of bacteria to a vulnerable population. Findings include:According to the Minimum Data Set (MDS) dated [DATE], R112 scored 12/15 (cognitively intact) on her BIMS (Brief Interview Mental Status), required substantial/maximal assistance for toileting needs, used a wheelchair for mobility, and surgical aftercare for cardiovascular system. Review of R112's Order Summary revealed:-7/1/25 Enhanced Barrier Precautions while performing high-contact care activities including changing bed linens.-7/2/25 Monitor surgical incision to sternum.-7/3/25 32 staples to midline sternum. Review of R112's Care Plan dated 7/11/25, indicated a potential for complications from surgical wounds. Surgical incision midline chest…

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 record review, the facility failed to maintain dignity and respond to residents' call lights in a timely manner in 2 (Resident #104 and #105) of 5 residents reviewed for dignity, resulting in feelings of frustration and the potential for overall decline in quality of life. Findings include: Resident #104 Review of an admission Record revealed Resident #104 was a male, with pertinent diagnoses which included: depression and type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood). Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 2/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #104 was cognitively intact. In an interview on 3/11/25 at 9:24 AM, Resident #104 reported sometimes it takes forever for his call light to be answered. Resident #104 reported this was especially true when the facility was serving lunch or dinner, and he wanted something. Resident #105 Review of an admission 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 interview and record review, the facility failed to demonstrate evidence of prompt action taken to resolve resident council concerns of lengthy call light wait times in 4 of 6 resident council meetings reviewed for concern resolution, resulting in on-going dissatisfaction with call light response and the potential for feelings of frustration. Findings include: In an interview on 3/12/25 at 9:11 AM, Certified Nurse Aide (CNA) I reported occasionally residents had complained to her about long call light wait times. CNA I reported staff tried to get to the residents as soon as possible but sometimes the residents complained that it took too long. In an interview on 3/12/25 at 9:22 AM, Activities Assistant (AA) H reported residents have complained to her about long call light wait times. Review of Resident Council Minutes dated 10/25/24 revealed, .residents are waiting longer periods of times to have their call light answered . Review of Resident Council Minutes dated 11/29/24 revealed, .residents are having troubles with their call lights being answered . Review of 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.

This citation pertains to intake MI00150558 Based on interview and record review, the facility failed to inform the resident's emergency contact of a fall in a timely manner for 1 (Resident #101) of 3 residents reviewed for falls resulting in a delay in the time the emergency contact was made aware of the fall. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was a male, with pertinent diagnoses which included: aftercare following joint replacement surgery and presence of left artificial knee joint. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 2/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #101 was cognitively intact. Review of Resident #101's Nurses Note dated 2/21/25 at 4:39 AM and authored by Licensed Practical Nurse (LPN) F revealed, Note Text: Resident observed on the floor next laying on right side with back next to recliner and head facing bed. [NAME] was next to him. Resident stated I was getting up to use…

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.

This citation pertains to Intake: MI00148829, MI00147804, MI00148226 and MI00148227. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from staff to resident and resident to resident verbal and physical abuse for 4 (Resident #107, #101, #102, and #104) of 11 residents reviewed for abuse, resulting in the potential for physical, emotional and psychosocial harm. Findings include: Resident #107: Review of an admission Record revealed Resident #107 was a female with pertinent diagnoses which included Parkinson's disease, hallucinations, and mild intellectual disabilities. Review of Care Plan for Resident #107, revised on 9/3/24, revealed the focus, .(Resident #107) has impaired communication r/t (related to) as evidenced by my primary language is Spanish. I am fluent in English . with the intervention .Encourage resident to continue stating thoughts even if resident is having difficulty .Observed for non-verbal indicators of attempts to express self, such as, tears, furrowing of the brow, pursing of lips, yelling,…

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.

This citation pertains to Intake: MI00147804 Based on interview and record review, the facility failed to ensure staff fully implemented the abuse policy for reporting an incident of abuse to the abuse coordinator in 2 out of 13 sampled residents (Resident #101, and #102) reviewed for abuse reporting, resulting in the potential for incidents of abuse going undetected, unreported, or without thorough investigation. Findings include: Resident #101: Review of an admission Record revealed Resident #101 was a female with pertinent diagnoses which included Alzheimer's disease, chronic fatigue, diabetes, impulsiveness, chronic pain, psychosis, COPD, and stroke. Resident #102: Review of an admission Record revealed Resident #102 was a female with pertinent diagnoses which included intellectual disabilities, bipolar disorder, anxiety, schizoaffective disorder (combination of symptoms of schizophrenia (serious mental illness that affects how one thinks, thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, decreased participation in daily activities)…

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, the facility failed to implement resident comprehensive care plans for 1 resident of 13 (Resident #101) reviewed for care planning resulting in a lack of service for the resident to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #101: Review of an admission Record revealed Resident #101 was a female with pertinent diagnoses which included Alzheimer's disease, chronic fatigue, diabetes, impulsiveness, chronic pain, psychosis, COPD, and stroke. Review of Care Plan revised on 1/12/25, revealed the focus, .(R101) is at risk for fall related injury and falls R/T (related to): Confusion , Gait/balance problems, History of Falls, Incontinence, Medication, Mobility/uses a device, Unaware of safety needs, (R101) frequently declines assistance from staff for transfers. (R101) is self-determined to maintain her independence and frequently self-transfers/ambulates without calling for assistance and she will…

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 record review the facility failed to ensure facility nursing staff followed physician orders to obtain urine sample in 1 of 13 residents (Resident #101) reviewed for laboratory orders and standard of practice, resulting in the potential for the worsening of a condition and a delay in treatment. Findings include: Resident #101: Review of an admission Record revealed Resident #101 was a female with pertinent diagnoses which included Alzheimer's disease, chronic fatigue, diabetes, impulsiveness, chronic pain, psychosis, COPD, and stroke. Review of Care Plan for Resident #101, revised on 10/21/24, revealed, the focus, .I have a history of urinary tract infection . with the intervention .Obtain labs/diagnostics as ordered. Report abnormal results to the physician . Review of Incident Report dated 11/21/24, revealed, .Incident Description: Observed pt (patient) lying on her right side on the floor in the bathroom .Obtain U/A (urinalysis)with C&S (culture and sensitivity) in indicated r/t (related to) hallucinations of a person in her room . Review of Order dated…

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.

This citation pertains to Intake: MI00146669 Based on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 2 of 8 residents (Resident #100 and #101) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem. Findings include: Resident #100: Review of an admission Record revealed Resident #100 was a female with pertinent diagnoses which included heart failure, diabetes, COPD, fibromyalgia (chronic health condition that causes pain, tenderness throughout the body, fatigue, and trouble sleeping), peripheral venous insufficiency (veins in legs and arms are damaged or blocked, making it difficult for blood to return to the heart, can lead to swelling, pain, cramping). Review of Care Plan revised on 1/6/25, revealed the focus, .Has a functional ability deficit and requires assistance with self care/mobility r/t (related to): fatigue/weakness, impaired balance . with the intervention…

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, the facility failed to provide consistent, meaningful, person-centered activities for 2 of 2 residents (Resident #102, #104) reviewed for activities provided by the facility, resulting in the potential for loss of interaction, joy, self-esteem, growth, sense of wellbeing, autonomy, connectedness, identity, creativity, independence, pleasure, and comfort. Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a female with pertinent diagnoses which included intellectual disabilities, bipolar disorder, anxiety, schizoaffective disorder (combination of symptoms of schizophrenia (serious mental illness that affects how one thinks, thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, decreased participation in daily activities) and mood disorder), and restlessness and agitation. Review of Care Plan for Resident #102 dated 4/12/24, revealed the focus, .I have a psychosocial well-being problem,…

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.

This citation pertains to Intake: MI00148896 Based on observation, interview and record review, the facility failed to provide adequate supervision, implement care plan interventions, and assistive devices for proper transfer for 1 (Resident #108) of 4 residents, resulting in a fall which had the potential to cause injury and negatively affect the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #108 (R108): Review of an admission Record revealed Resident #108 was a female with pertinent diagnoses which included unsteadiness on feet, weakness, and low back pain. Review of current Care Plan for Resident #108, revised on 11/12/24, revealed the focus, .(R108) has a functional ability deficit and requires assistance with self-care/mobility R/T (related to): weakness, impaired mobility, non-ambulatory since back surgery in March 2024, DM (diabetes mellitus), morbid obesity . with the intervention .Substantial/maximal assist with sit to stand two persons . Review of Incident Report dated 12/2/24 at 09:30 AM, revealed, .Called into…

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, the facility failed to provide an environment that promoted the autonomy in 2 of 20 residents (Resident #334 and Resident #333) reviewed for homelike environment, resulting in emotional distress, loss of independence, and feelings of frustration. Findings include: Review of Older People's Perceived Autonomy in Residential Care: An Integrative Review, Vol. 28 (3), 414-434, published by Nursing Ethics, 2021, revealed: .Older people's perceived autonomy promoted health and quality of life in residential care. However, their autonomy was associated with a number of protective and restrictive individual and environmental factors, which influenced whether autonomy was achieved . limited autonomy led to feelings of confinement and frustration and increased the overall mortality rate .Older people felt that their autonomy in residential care was associated with .the living environment provided by the residential care home. Resident #334 Review of an admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for 2 (Resident #34 and Resident #332) of 20 sampled residents reviewed for care plans, resulting in inconsistent application of pressure relieving device (heel protectors) for Resident #34 and an incomplete reflection of care needs for both Resident #34 and Resident #332. Findings include: Resident #34 Review of an admission Record revealed Resident #34 was a female, with pertinent diagnoses which included: Alzheimer's disease (a form of dementia). In an observation/interview on 7/9/24 at 10:41 AM, noted Resident #34 was seated in her room in her broda chair (a high back wheelchair that is used for positioning). Resident #34 was wearing cushioned boots (heel protectors) on both feet. Agency Nurse (AN) TT reported Resident #34 was on hospice and they had just been in and dressed her left heel wound. A review of Resident #34's current Care Plan was conducted on 7/9/24 at 2:29…

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, the facility failed to revise a comprehensive care plan after a change in resident condition in 1 of 20 residents (Resident #75) reviewed for comprehensive care plans, resulting in an inaccurate reflection of the resident's status, and the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Review of the policy/procedure Care Planning, dated 2/2022, revealed .The comprehensive care plan is developed from the RAI (Resident Assessment Instrument) scheduled and is reviewed and revised by the IDT (Interdisciplinary Team) as necessary . Review of an admission Record revealed Resident #75 was a female, with pertinent diagnoses which included stroke with left sided weakness, muscle weakness, and dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment for Resident #75, with a reference date of 3/9/24, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which…

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, the facility failed to implement interventions to prevent worsening of contractures (hardening of the muscles, tendons, and other tissues) for 1 of 2 residents (Resident #67) reviewed for range of motion resulting in the potential for worsening of right and left hand contractures. Findings include: Resident #67 Review of an admission Record revealed Resident #67 was originally admitted to the facility on [DATE] with pertinent diagnoses which included right and left hand contractures. Review of Resident #67's current Care Plan revealed no focus or interventions related to the resident's right and left hand contractures. Review of Resident #67's Orders did not reveal any active physician orders in place for resident's right and left hand contractures. Review of Resident #67's Occupational Therapy Discharge Summary dated 3/7/24 revealed, .Discharge recommendations: use of bilateral handrolls (handroll with straps on L (left), without straps on R (right)), PROM…

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 This citation pertains to intake# MI00145167 Based on interview and record review, the facility failed to ensure that residents received adequate treatment and care for pain management for 1 of 2 residents (Resident #380) reviewed for pain, resulting in increased pain with the potential to affect activities of daily living (ADL). Findings include: Resident #380 Review of an admission Record revealed Resident #380 was originally admitted to the facility on [DATE] with pertinent diagnoses which included fracture of right femur. Review of Resident #380's Hospital Discharge Instructions dated 6/11/24 revealed, . Discharge medications .Tramadol 50 mg oral tablet 1 tab, PRN (as needed) every 6 hours Review of Resident #380's Orders revealed traMADol HCl (pain medication) Oral Tablet 50 MG. Give 1 tablet by mouth every 6 hours as needed for pain. Start Date: 6/11/2024 at 6:30 PM. During an interview on 7/09/24 at 11:38 AM, Family Member (FM) II reported that Resident #380 did not receive her pain medication (tramadol)…

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, the facility failed to ensure a mechanically altered diet was provided as ordered to meet individual needs in 1 of 13 residents (Resident #75) reviewed for dining and dietary orders, resulting in the potential for aspiration, choking, and harm. Findings include: Review of an admission Record revealed Resident #75 was a female, with pertinent diagnoses which included stroke with left sided weakness, muscle weakness, and dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment for Resident #75, with a reference date of 3/9/24, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated she was cognitively intact. In an observation on 7/9/24 at 10:15 AM, Resident #75 was in her room sitting in her wheelchair with a blanket over her shoulders. Observed an orange sign on the wall above Resident #75's bed which stated .Must be up in dining room for chewable foods with line-of-sight 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 observation and interview the facility failed to maintain general cleanliness and repair of the dry storage room as well as provide proper storage for items in central supply. Findings Include: During a tour of the facility, at 10:00 AM on 7/9/24, it was observed that the floor drain in the dry storage room was being used for draining the ice machine and walk in cooler condensers. The floor in this area was found with black lines between the floor tiles and visible water coming up from the gaps in the tiles when walked on. During a tour of the central supply storage room, with Environmental Services H, at 3:04 PM on 7/9/24, it was observed that some storage shelving being used was made from raw wood with no covering to make it smooth and easily cleanable. Further observation found clean and sanitary items stored on the floor and on the raw wood surface. These items were: Catheter care equipment, ice bags, hair brushes, bottles of saline, re-usable urinals, and personal protective equipment. When asked about the storage, Environmental Services H stated they needed to rework…

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 the facility failed to provide care to meet the resident needs in 1 of 8 sampled residents (Resident #106) reviewed for accomodation of need, resulting in discomfort in activites of daily living care for Resident #106. Findings include: Review of an admission Record revealed Resident #106, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: paraplegia. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 1/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #106 was cognitively intact. In an interview on 1/31/24 at 4:15 PM., Resident #106 reported he has a long standing chronic pressure ulcer on his buttock. Resident #106 reported he also has shearing on his upper thighs, in which nurses and CNA's apply wound dressing changes and cleaning up after he has a bowel movement. Resident #106 the washcloths the staff use to clean him up are very…

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 This citation pertains to intakes: #MI00139716, MI00139718, MI00139719, MI00140206 & MI141271. Based on observation, interview, and record review the facility failed to ensure adequate supervision to prevent resident to resident physical altercations for 3 Residents (Resident #102, #103, and Resident #104) of 6 residents reviewed for abuse resulting in Resident #102 striking both Resident #103 & Resident #104 on more than one occasion and the potential for further resident to resident altercations to continue for vulnerable residents residing in the facility. Findings include: Resident #102 Review of an admission Record revealed Resident #102, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer disease. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 12/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 03/15 which indicated Resident #102 was cognitively impaired. Resident #103 Review of an admission 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 observation, interview, and record review, the facility failed to provide appetizing and temperature appropriate food products to 4 residents (Resident #23, #28, #63, and #7) of 4 residents reviewed for food palatability, resulting in dissatisfaction with meals, the potential for decreased food acceptance and nutritional decline. Findings include: Resident #23 Review of a Minimum Data Set (MDS) assessment for Resident #23, with a reference date of 6/14/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #23 was cognitively intact. In an interview on 8/22/2023 at 9:47AM, Resident #23 stated the food here is horrible. Resident #23 reported the broccoli is overcooked like mush, the rice is dry, and the spaghetti sauce is watery. Resident #23 stated, the food just isn't prepared good. In an interview on 8/23/2023 at 8:46 AM, Resident #23 reported his main issue with the food is the bland flavor and the rice is overcooked. Resident #28 Review of a Minimum Data Set (MDS) assessment for Resident #28,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents are treated with dignity and respect for 1 of 2 residents (Resident #386) reviewed for dignity, resulting in episodes of incontinence, causing embarrassment and potential for a decline in self-worth. Findings include: Resident #386 Review of an admission Record revealed Resident #386 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: UTI (urinary tract infection), weakness and Parkinson's disease (a chronic degenerative disorder that affects movement). A Minimum Data Set (MDS) assessment for Resident #386 was not available due to new admission to the facility. Review of Resident #386's Kardex (direct care guide) revealed, .Toileting- one assist . In an interview on 08/21/23 at 11:55 AM, Resident #386 reported being very new to the facility and concerned that she has to wait a long time for her call light to be answered. Resident #386 reported that the wait time was worse during the night 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 observation, interview, and record review the facility failed to obtain physician orders for use of a continuous positive airway pressure (CPAP) machine for 1 of 1 resident (Resident #52) reviewed for respiratory care resulting in the potential for improper use, inaccurate settings, irregular cleaning, and respiratory infection. Findings include: Review of an admission Record revealed Resident #52 had pertinent diagnoses which included acute and chronic respiratory failure, chronic obstructive pulmonary disease, and obstructive sleep apnea. Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 8/11/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #52 was cognitively intact. During an observation and interview on 8/21/23 at 12:10 PM, Resident #52 was observed awake and wearing a nasal pillow (head strap and plastic tubing with soft prongs for nostrils that connects to a continuous positive airway pressure (CPAP) machine) with a CPAP machine on the nightstand next to the bed turned on 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 interview and record review, the facility failed to identify emotional triggers for 1 of 1 resident (Resident #56) reviewed for trauma informed care, resulting in the potential for re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma, and the lack of care plan interventions in place. Findings include: Review of a admission Record dated 7/11/22, revealed Resident #56 was admitted to the facility with the following pertinent diagnoses: Post Traumatic Stress Disorder (a disorder in which a person has difficulty recovering after experiencing a terrifying event), Difficulty Walking, Bipolar Disorder (disorder characterized by episodes of mood swings ranging from depressive lows to manic highs), Suicidal Ideations (thinking about or planning suicide), Major Depressive Disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE], section D (Mood) revealed Resident #56 experienced feeling down, depressed, hopeless 2-6 days during the 14-day assessment period.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records regarding advanced directives in 2 (Resident #28 and #84) of 5 residents reviewed for advanced directives, resulting in incomplete medical records and the potential for inappropriate care being provided in the event of an emergency. Findings include: Resident #28 Review of Resident #28's electronic medical record on [DATE] at 9:10 AM revealed Do Not Resuscitate (DNR) documentation but no DNR physician order. In an interview on [DATE] at 11:36 AM, Registered Nurse (RN) X reviewed Resident #28's electronic medical record and reported Resident #28 had signed DNR papers but she could not find a corresponding DNR physician order. RN X reported she expects to see a physician order and an alert in the electronic medical record if a resident is DNR. RN X reported the unit managers typically update the physician order when DNR paperwork is signed. In an interview on [DATE] at 11:42 AM, Licensed Practical Nurse…

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 record review, the facility failed to provide requested immunizations to 1 of 5 residents (Resident #48) reviewed for immunizations, resulting in the potential for acquiring, transmitting, or experiencing complications from communicable diseases. Findings include: Review of an admission Record revealed Resident #48 had pertinent diagnoses which included schizophrenia, psychotic disorder with delusions, and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of 5/25/23 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #48 was moderately cognitively impaired. Review of the Electronic Medical Record (EMR) on 8/22/23 revealed that Resident #48 had a Durable Power of Attorney (DPOA) and was no longer able to give consent. Review of an EMR Immunization Record on 8/22/23 for Resident #48 revealed the pneumococcal vaccine had a status of consent refused with no date indicated. During an interview on 8/23/23 at 8:53 AM, Unit Manager (UM) CC was unable to provide a signed consent 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.