Harmony Village of Clinton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR) for an Antipsychotic (Seroquel) for one resident (R32) out of one reviewed for GDRs. Findings include: A review of the medical record revealed that R32 admitted into the facility on [DATE] with the following diagnoses, Vascular Dementia and Adjustment Disorder with Anxiety. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating a severely impaired cognition. R32 also required staff assistance with bed mobility and transfers. Further review of the active physician orders revealed the following, Seroquel (Antipsychotic) 25 mg (milligrams) by mouth one time a day and Seroquel 50 mg by mouth at bedtime. On 6/4/2025 at 9:22 AM, an interview was conducted with the Nursing Home Administrator (NHA) and a request for any documented GDR attempt was requested but not received by the end of survey. A review of a facility policy titled, Gradual…

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 timely follow-up on dental services related to dentures for one resident (R61) of one resident reviewed for dental services. Findings include: On 6/2/25 at 11:02 AM, R61 was observed sitting up in bed and asked about any concerns they've had in the facility, and explained they had a pair of dentures when they first admitted into the facility however, they didn't fit properly. R61 explained they had been seen by the dentist last year (2024) in June, in which the dentures were to be realigned however, that has yet to be completed and, they no longer have the dentures. R61 explained they were told that a follow-up would occur but hasn't received an update. R61 further explained their jaw has been hurting, making it difficult to chew. A review of R61's medical record revealed they were admitted into the facility on 4/17/23 with diagnoses which included Type II Diabetes, Depression and Hypertension. Further review of the medical record revealed the resident was cognitively intact and independent for transfers. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00145809. Based on interview and record review the facility failed to ensure the care plan was updated to reflect the wandering and related fall and bowel and bladder behaviors and document interventions for them. Findings include: A review of an incident report for R901 documented a fall on 06/21/24 and was found at 6:40 AM with a last seen time of 5:30 AM. R901 was sent out to the hospital with a head injury. A physical (rehab) medicine note dated 04/16/24 documented, .evaluated secondary to fall and decline in function . A review of a psychiatric note dated 05/23/24 documented, .Dementia with Behaviors .Last seen by writer 01/31/24, Patient was seen and evaluated and discussed with staff. (R901) is reported to have increased confusion and restlessness .will start risperdal .3/12/24 increased risperdal .noted to wander and can be quite intrusive with peers .per staff the increase in risperdal has not helped .requires constant redirection reported to continue to be impulsive…

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 M100143094. Based on interview and record review, the facility failed to provide adequate, meaningful weekend activities for facility residents including eight anonymous group participants. Findings include: On 04/24/24 at 2:29 PM, eight anonymous group participants indicated the facility no longer had activities department staff working on the weekends and no organized or meaningful activities were being provided or facilitated. The group participants reported being bored and having nothing to do on weekends. Review of the facility Activities calendar for March and April 2024 revealed all Saturdays stated Independent leisure activities can be found in the dining room and all Sundays stated 10 AM Independent activity and 1:30 PM Afternoon Worship. On 04/25/24 at 9:37 AM, the facility Activities Director (AD) reported the facility no longer employed Activities aides. The AD reported they work a full time day shift schedule and therefore there are no dedicated Activities department employees scheduled on weekends. The AD reported they set up items…

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 maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 4/23/24 between 8:45 AM-9:30 AM, during an initial tour of the kitchen, the following items were observed: There was a personal cell phone on the food preparation counter. On 4/23/24 at 11:15 AM, Dietary Manager (DM) P confirmed the cell phone should not have been left on the food preparation counter. According to the 2017 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. The flour bin located inside the dry storage room was observed with the scoop stored inside the bin, with the handle resting in the flour. On 4/23/24 at 11:17 AM, DM P confirmed the scoop should not have been stored inside the flour. According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-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.

Based on interview and record review, the facility failed to ensure the Activities Director met the required professional qualifications. Findings include: On 04/25/24 at 9:37 AM, the facility Activities Director (AD) was interviewed and reported they had been in the AD position for approximately one month. The AD reported they are a Physical Therapy Assistant (PTA) and they had been working in the facilities therapy department prior to accepting the AD position. The AD reported they planned to take college classes to pursue Therapeutic Recreation-related credentialing but they were not currently participating in this training/education. On 04/25/24 at 1:06 PM, the AD reported they transitioned directly from the therapy dept. to the AD position and they did not have recent/previous experience in an Activities department. On 04/25/24 at 1:30 PM, the facility Administrator (NHA) acknowledged the current AD did not meet the required professional qualifications. The NHA reported the facility had provided the AD with the resources to pursue their credentialing for the position 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 ensure an Advanced Directive was in place timely for one (R73) of four residents reviewed for Advance Directives (AD-legal documents that allows a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility or other healthcare providers. Findings Include: Review of electronic health record (EHR) on [DATE] at 1:23 p.m. revealed R73 did not have a code status in the banner or a signed advance directive form. Review of an admission Record revealed, R73 originally admitted to the facility on [DATE], and readmitted on [DATE] with pertinent diagnosis which included End Stage Renal Disease and Type 2 Diabetes. Review of a Minimum Data Set (MDS) assessment dated of [DATE] revealed R73 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15 and required dialysis. On [DATE] at 8:48 a.m., an Advance…

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 initiate a care plan for a newly identified facility acquired pressure ulcer for one resident (R441) of four residents reviewed for pressure ulcers. Findings include: On 4/23/24 at 9:26 AM, R441 was observed in bed lying on their backside, face grimacing and indicating that they were in pain. On 4/23/24 at 11:37am and 2:23pm, R441 was observed in the same position as they had been earlier that morning. A review of R441's medical record revealed that they were admitted into the facility on 3/5/24 with diagnoses that included Paroxysmal Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Depression. Further review of the medical record revealed that the resident was severely cognitively impaired and required total dependence for Activities of Daily Living. Further review of the wound doctor's Visit report for 4/12/24 revealed the following, Wound #1 Sacral is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not healed.Sequela wound encounter measurements are 2.2cm (centimeters)…

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 one resident (R441) of four residents reviewed were repositioned timely and appropriately resulting in an acquired pressure ulcers (damage to skin and underlying tissue over bony areas). Findings include: On 4/23/24 at 9:26 AM, R441 was observed lying on their back. R441 heels were on bed surface with a small foam boot around her right ankle and another small foam boot lying under the left calf. A review of the facility's electronic medical record (EMR) revealed that R441 was admitted on [DATE]. Diagnoses include Atrial Fibrillation, Myocardial Infarction (heart attack), Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Chronic Kidney Disease, Morbid Obesity (severe), Dysphagia, Low Back Pain, and Dementia. R441's Minimum Data Set (MDS) revealed severe cognitive impairment. On 4/23/24 at 11:37 AM and 2:30 PM, R441 was observed lying on their back with heels on surface of bed. No heel protection in place On 4/24/24 at 9:04 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide and document weight loss interventions for one resident (R5) of two residents reviewed for nutrition resulting in weight loss. Findings include: On 4/23/24 at 10:44 AM, R5 was observed lying in bed in a fetal position. R5's appearance was very thin and emaciated (muscle and fat loss) with skeletal appearance and visible bones beneath skin surface, sunken cheeks, and very thin arms and legs. R5's water pitcher was observed with thickened liquid and a straw on his overbed table. A review of the facilities electronic medical record (EMR) revealed that R5 was admitted on [DATE]. R5's diagnoses included Metabolic Encephalopathy, Adult Failure to Thrive, Urinary Tract Infection, Diabetes Mellitus, Intracerebral Hemorrhage, Protein-Calorie Malnutrition, Hypertension, and Dysphagia. A review of the Minimum Data Set (MDS) revealed a severe cognitive impairment. 4/24/24 at 12:16 PM, R5 was observed in bed, with head of bed elevated to 45…

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 administer a tube feeding in accordance with the physician's orders for one resident (R81) of one resident reviewed for tube feeding, resulting in the potential for weight loss and dehydration. Findings include: In an observation on 4/23/24 at 9:13 a.m., R81 had a tube feeding pump in room with no feeding running. Review of an admission Record revealed, R81 originally admitted to the facility on [DATE], and readmitted on [DATE] with pertinent diagnosis which included severe protein-calorie malnutrition and dysphagia (difficulty swallowing). Review of a Minimum Data Set (MDS) assessment dated of 1/9/24 revealed R81 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 00 out of 15 (indicating severely impaired cognition) and required a feeding tube. Review of Physician orders revealed R81 had an order for Jevity 1.5 (tube feeding formula) one time a day to be up at 5pm until dose complete. Review of a Medication…

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 obtain Physicians orders for dialysis treatment and to monitor the dialysis site (catheter) for one (R73) of one resident reviewed for dialysis services, resulting in the potential for undetected complications associated with receiving dialysis, including bleeding, infection, and site failure. Findings include: In an interview on 4/24/24 at 9:14 a.m., Licensed Practical Nurse (LPN) M reported R73 has dialysis on Monday, Wednesday, and Fridays. Review of an admission Record revealed, R73 originally admitted to the facility on [DATE], and readmitted on [DATE] with pertinent diagnosis which included End Stage Renal Disease and Type 2 Diabetes. Review of a Minimum Data Set (MDS) assessment dated of 3/1/24 revealed R73 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15 and required dialysis. Review of Physician orders revealed R73 did not have an order for dialysis or to monitor the dialysis site.…

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 monitor the temperatures of one of one medication refrigerator that stored drugs and biologicals. Findings include: On 4/25/24 at 9:50 AM, the Station One medication refrigerator was viewed with Licensed Practical Nurse (LPN F). The temperature log for April 2024 had no documentation for the AM shift, and three days missing on the PM shift: 4/23, 4/24, and 4/25. The temperature log for March 2024 was missing multiple days without refrigerator temperature documentation that included no temperatures taken on the AM shift, and no documentation on 3/29, 3/30, and 3/31. The temperature log for February was missing the following temperature documentation for the AM shift: 2/1, 2/2, 2/4, 2/6, 2/8, 2/16, and 2/21-2/29, and no PM temperature documentation for 2/1, 2/2, 2/3, 2/5, 2/9, 2/16, 2/19 and 2/24. The temperature log for January was missing the following temperatures during the AM shift: 1/3, 1/4, 1/5, 1/8, 1/9, 1/11, 1/13, 1/15-1/17, 1/22, 1/23, 1/25. 1/27, 1/31, and no PM temperature documentation on: 1/13,…

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 MI00141330. Based on interview and record review, the facility failed to follow care plan interventions to prevent a fall for one resident (R701) of two residents reviewed for falls. Findings include: On 3/6/24 at 10:27 AM, a review of R701's electronic medical record (EMR) revealed the following progress note, 10/28/23 14:37 (2:37 PM): CNA (Certified Nursing Assistant) notified writer resident was on floor laying on their stomach, resident fell out of bed during a check and change, resident stated 'I didn't hit my head during the fall.' On 3/6/24 at 10:30 AM, a Post-fall/Fall Risk Assessment involving R701 was reviewed and revealed the following, Briefly .described what occurred: CNA notified writer resident was on floor lying on their stomach, resident fell out of bed during a check and change, resident stated, 'I didn't hit my head during the fall.' Date and Time of incident: 10/28/23 12:00. Was the resident injured? No injuries observed. On 3/6/24 at 10:40 AM, R701's 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 MI00137037 and MI00137858. Based on observation, interview, and record review, the facility failed to document skin treatments per order or complete weekly skin checks, affecting two residents (R908 and R910) of three reviewed, resulting in the potential for unmet care needs, skin breakdown, or ongoing skin issues. Findings include: R908 A review of R908's record revealed the resident was admitted into the facility on 3/3/23 with medical diagnoses of Sepsis due to Methicillin Susceptible Staphylococcus Aureus (MSSA), Idiopathic Chronic Gout with Tophi, Hepatic Failure, Infarction Of Spleen, Dysphagia, Repeated Falls, Respiratory Failure, Urine Retention, Morbid Obesity, Muscle Weakness, and Cognitive Communication Deficit. Further review revealed that R908 was dependent on or required extensive staff assistance for bathing, bed mobility, and transfers. R908 was noted to enter into the facility on 3/3/23 with skin impairments, however, the earliest treatment orders initiated were…

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 MI00136203. Based on observation, interview, and record review the facility's staff failed to report a fall for one sampled resident (R906), resulting in a delay in treatment for a fractured right hip. Findings included: A review of the intake revealed, Incident Summary Resident (R906) was unable to move [R906] right leg. Physician was notified and a stat xray was ordered. Radiology report identified an intertrochanteric fracture of the proximal right femur with varus deformity. Physician notified of the results and ordered the resident to be sent to the hospital for further evaluation. Investigation of injury of unknown origin immediately initiated. On 9/19/23 at 12:33 PM R906 was observed in bed and was asked if they had a fall. R906 stated, Yes a while ago. R906 was not able to provide details of the fall. R906's bed was observed with the left side against the wall and the right side opened to the room with a floor mat next to the bed. On 9/20/23 at 11:58 AM, R906 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00135079. Based on interview and record review, the facility failed to accurately document medication refusals for one resident (R903) of three reviewed, resulting in an inaccurate representation of the resident's status and a lack of documented rationale for subtherapeutic serum drug levels. Findings include: A review of R903's record revealed the resident was admitted into the facility on [DATE] and discharged to the hospital on 3/6/23. The resident never returned to the facility. R903's medical diagnoses included Epilepsy, Hemiplegia/Hemiparesis (weakness on one side of the body) following Cerebral Infarction (Stroke), Bipolar Disorder, Multiple Sclerosis, Obesity, Dysphagia, and Liver Disease. A review of R903's medication orders included the following anti-seizure medications: -Valproic Acid Solution 250 MG (milligrams)/5ML (milliliters) (Valproate Sodium) Give 10 ml by mouth every 6 hours for Seizure disorder -Start Date- 11/07/2022 -D/C (discontinue) Date- 03/08/2023.…

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 employ a qualified social worker on a full-time basis for one resident (R85) of six residents reviewed for social service needs to meet the psychosocial, mental, and behavioral health care needs of the residents, resulting in the potential to affect all residents that require the services of a social worker. Findings include: On 2/8/2023 at 10:30 AM, a confidential group meeting was held with six confidential residents. During the confidential group two residents stated that they have never seen a social worker. Confidential group members stated that they have asked to see the social worker on many occasions, and no one ever comes. The group collectively stated that they do not have regular care conferences and don't receive help with things such as discharge planning and obtaining outside resources. On 2/8/2023 at 1:15 PM, an interview was conducted with Social Worker (SW) B regarding their role in the facility. SW B stated that they work part-time 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review, the facility failed to offer/provide HS (hour of sleep) snacks to five (R78, R41, R32, R98 and R96) of 23 sampled residents resulting in resident dissatisfaction with snack provision. Findings include: Review of the facility record for R78 revealed an admission date of 2/22/22 with diagnoses that included cardiomyopathy and congestive heart failure. Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R78 required set up to maximum self care assistance and a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognitive function. On 2/06/23 at 11:14 AM, R78 reported that they do not get offered or provided with bedtime snacks and stated, The only time I get a snack at night is if my roommate brings me one back from the nurses' station. On 2/07/23 at 10:03 AM, R78 reported that a snack was not offered or provided by staff the previous night. Review of the facility record for R41 revealed an admission date of 10/15/20 with diagnoses…

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 care conferences were completed and/or documented for four residents (R48, R56, R69, and R81) out of six reviewed for care conferences, resulting in residents and resident representatives not informed or included in their plan of care. Findings Include: R48 On 2/8/2023 at 10:30 AM, an interview was conducted with R48 regarding their care conferences being held in the facility. R48 stated that they did not who their social worker was and that they had never had a care conference since admitting in the facility. A review of the medical record revealed that R48 admitted into the facility on 5/26/2022 with the following diagnoses, Muscles Weakness and Hypertension. A review of the most recent Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3/15 indicating impaired cognition. R48 also required extensive one person assistance with bed mobility and transfers. A review of the progress notes revealed no…

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 provide documentation of notice of bed hold policy upon transfer to the hospital for one sampled resident (R90) of one resident reviewed for transfers, resulting in the potential for residents and/or resident representatives not being aware of the facility bed hold policy. Findings include: On 2/6/23 at 9:03 AM, R90 was asked about their stay in the facility, and explained that they would prefer to transfer back to the room they resided in prior to their transfer to the hospital in December 2022. R90 explained that they were admitted into the hospital for approximately one week and upon return, was placed in their current room. R90 was asked if they received a bed hold notice upon transfer to the hospital, and they indicated that they did not. A review of R90's medical record revealed that they were initially admitted into the facility on 1/23/22 with diagnoses that included Lymphedema, Sleep Apnea, Hypertension and Hoarding Disorder. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to update a Preadmission Screening and Resident Review (PASARR screening) for two sampled residents (R63, R85, and R38) out of seven residents reviewed for PASARR screenings, resulting in the potential for unmet mental health and psychiatric care needs. Findings Include: R63 A review of R63's PASARR Level I screening dated 12/31/2020 was completed and revealed that Section II, numbers 1 and 2 on the form were checked Yes with the diagnosis of Mental Illness checked and included a diagnosis of Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, Schizoaffective Disorder. R63 was also taking antipsychotics at the time. On 2/7/23 at 3:30 PM, R63's PASSAR Level I screening for 2021 and 2022 was requested from the facility, and not received by the end of the survey. R85 A review of R85's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Vascular Dementia, Delirium, Adjustment Disorder with Mixed…

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 skin care interventions per the plan of care for one sampled resident (R8) out of two residents reviewed for care plan interventions resulting in, the potential for skin integrity concerns. Findings include: On 2/06/23 at 10:09 AM, R8 was observed in bed and asked about the stay at the facility and stated, They are not rubbing me down with lotion. R8's legs and feet were observed with very dry and flaky skin on their legs and feet. Large skin debris were observed laying on the sheet of the bed. On 2/07/23 at 10:51 AM, R8 was observed in bed with their legs and feet in the same condition. On 2/08/23 at 10:28 AM, R8 was asked if staff had put any lotion on their legs and feet today and stated, No. They move so fast. At that time R8's legs were appeared dry and flaky. There were large skin debris were observed laying on the sheet of the bed some brown and white in color. On 2/08/23 at 10:35 AM, the Unit Manager, Licensed Practical…

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 care plans to reflect current status and needs for three sampled residents (R10, R85, R34) of four residents reviewed for care plan accuracy resulting in, the potential for unmet care needs. Findings include: R10 A review of R10's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Dysphagia, Chronic Kidney Disease, and Diabetes. Further review revealed a Quarterly Minimum Data Set assessment dated [DATE] which revealed a Brief Interview for Mental Status score of 7/15 indicating a severely impaired cognition, and required supervision to extensive assistance for Activities of Daily Living. Further review of the medical record revealed an active care plan addressing the following, .I [R10]smoke cigarettes. Date Initiated: [DATE] .Revision on: [DATE] .Interventions: I require no supervision while smoking. Date Initiated: [DATE] . Instruct me about the facility policy on smoking:…

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 accurately document the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, resulting in the potential for inadequate coordination of care and negative clinical outcomes, affecting all 48 residents currently residing in the facility. Findings include: A review of the facility's provided documentation of 18 months of staff posting revealed the following days marked with 0 or blank for RN scheduled eight hours during a 24 hour period: November 2022 11/01 11/02 11/06 11/08 11/11 11/13 11/14 11/18 11/22 11/26 11/27 11/28 December 2022 12/2 12/11 12/12 12/16 12/17 12/20 12/21 12/25 12/26 12/31 January 2023 1/3 1/9 1/17 1/22 1/23 1/28 1/31 February 2023 2/5 2/6 2/28 On 2/08/23 at 3:14 PM, the Nursing Home Administrator (NHA) was asked about the days that were missing RN coverage and explained she needed to go find out, because agency staff may have not been counted for those days. On 2/8/23 at 3:45 PM, the NHA replied via email noted, We are looking at the RN coverage for those specified days.…

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 that seven Certified Nurse Aides (CNA's F, G, H, I, J, K, and L) whose in-service training files were reviewed, had the required 12 hours annual in-service training within the required time period, resulting in the potential for unmet educational needs and unmet resident care needs. Findings include: On 2/7/23 at 11:01 AM, the Administrator was requested to provide the annual 12-hour in-service education for CNA's F hire date 4/8/1994, G hire date 4/15/2021, H hire date 10/31/1996, I hire date 11/03/2021, J hire date 12/27/2016, K 1/17/1991, L hire date and hire date 3/12/2019. The facility provided in-services for the above CNAs that did not document the duration of each in-service. The documents were titled Pre/Post Test. On 2/08/23 at 11:18 AM, the Administrator was asked for documentation that reflected the durations and dates of the in-services completed by the selected CNAs. The Administrator stated, I will have someone come down and help with that information. On 2/08/23 at 11:30 AM, the Director of Nursing…

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 the attending physician reviewed and acknowledged recommendations and irregularities identified by the consultant pharmacist during medication regimen reviews for one (R32) of five residents reviewed for Medication Regimen Review (MRR). Findings include: R32 Review of the clinical record revealed R32 was initially admitted into the facility on and readmitted on [DATE] readmitted on [DATE] with diagnosis of Delirium due to known Physiological condition, Psychotic Disorder, Major Depressive Disorder, Anxiety Disorder, and Post-Traumatic Stress Disorder. Further review of R32's medical record noted, progress noted, 11/10/22 Psych Services Progress note. AIMS, Med review . ASSESSMENT & PLAN Major depressive disorder, recurrent, moderate . Plan: Patient was seen and evaluated and discussed with staff. [R32] presents as calm, cooperative, and pleasant with underlying confusion noted. [R32]appears less somatically preoccupied and anxious 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to obtain psychotropic medication consent and ensure the appropriate use of and rationale for the use of a PRN (as needed) anti-anxiety medication beyond 14 days for one sampled resident (R85) of five residents reviewed for unnecessary medications resulting in, unnecessary medication use with the increased potential for adverse side effects. Findings include: A review of R85's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Vascular Dementia, Delirium, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Traumatic Subdural Hemorrhage. Further review of the medical record revealed that R85 was severely cognitively impaired, and required extensive assistance for Activities of Daily Living. Further review of the medical record revealed the following physician order, Order Summary: Ativan Tablet 1 MG (Lorazepam). Give 1 mg (milligram) by mouth every 4 hours as needed for agitation. The order…

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 ensure foods were served in a palatable manner for two residents (R96, and R98) in a census of 113 residents reviewed for food and nutrition, resulting in dissatisfaction with the meal service. Findings include: On 02/06/23 at 10:02 AM and 3:10 PM, R98 and R96 were interviewed. They commented they were always the last unit to be served. R98 and R96 agreed this could be due to the facility being short staffed. On 02/06/23 at 11:40 AM, the lunch tray cart was observed delivered to the 300 hall. The meals were served in white foam clamshell take out style containers. On 02/06/23 at 12:21 PM, the food trays were delivered on the 100 hall. The meal items were served in white foam clamshell containers. R16 reported they felt they received potato, rice or pasta every day. On 02/06/23 at 1:21 PM, R103 was asked about the food and reported, It's like dog food, I order out spending $200.00 dollars a month on food. On 02/06/23 at 1:30 PM, R41 reported the food was often served cold and not appetizing to look at. On…

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

Based on observation, interview and record review the facility failed to ensure routine food preferences were honored for four residents (R96, R98, and R105) in a census of 113 reviewed for care concerns, resulting in disatisfaction with the meal service. Findings include: On 02/06/23 at 10:02 AM and 3:10 PM, R98 and R96 were interviewed. The residents reported that their meal tickets indicated double portions but did not always get them. R96 commented they had received egg salad with just a single (ice cream scoop size) scoop of the egg salad with the bread and that was it. R98 agreed. They further commented they were always the last unit to be served and have been told the food items had run out or staff could not get them seconds at that time. R98 reported that had asked for peanut butter crackers for nightime snack because they are diabetic but does not always get them. A review of the meal tickets for R96 and R98 documented, Double Portions, Everything in capital letters for each meal. On 02/07/23 at 9:13 AM, R105 reported they had received two orange juice cups and a water 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.