The Laurels of Galesburg

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a quiet homelike environment in resident areas at night as reported by 5 residents (Resident #15, Resident #54, Resident #33, Resident #79, Resident #20) of 18 residents reviewed for environment and as voiced in the confidential Resident Council Meeting resulting in resident dissatisfaction and frustration from constant noise levels.Findings include:Resident #15(R15) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R15 admitted to the facility on [DATE] with pertinent diagnoses including anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R15 was cognitively intact (13 to 15 cognitively intact). During an interview on 9/8/2025 at 10:50 AM, R15 stated that 3rd shift staff are loud and they don't care if they wake up residents. Resident #54 (R54) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R54 admitted to the facility…

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 maintain a complete and accurate medical record in 7 of 18 residents (Resident #47, #10, #69, #54, #9, #18, & #63) reviewed for comprehensive/accurate medical records, resulting in missing/inaccurate documentation and the potential for a deterioration in resident status. Findings include:Resident #47: Review of an admission Record revealed Resident #47 was a male with pertinent diagnoses which included Alzheimer's disease, dementia, psychotic disorder with hallucinations (mental illness causing a person to lose touch with reality, often perceiving this that aren't there), insomnia, altered mental status, and anxiety. Review of current Care Plan for Resident #47, revised on 6/2/25, revealed the focus, .(Resident #47) has a behavior program related to dementia diagnosis, history of hallucinations and delusions, has poor safety awareness, needs assistance with redirection at times . with the intervention .Assist resident to develop more…

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 maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 9/8/25 at 2:11 PM, Observation of the central supply room found numerous items stored on the floor and underneath the storage racks. These items were personal hygiene products and care items for residents such as gauze and oxygen supplies. On 9/8/25 at 2:21 PM, Observation of the [NAME] Hall spa room found used gloves, a used razor, and a dozen used plastic razor guards, spread on the floor. Further review of the spa room found the underside of the shower bed with excess accumulation of what appeared to be, skin flakes, hair, bowel movement, and dirt debris. When asked about the shower bed Maintenance Director (MD) CCC, shook his head. On 9/8/25 at 2:40 PM, Observation of the Birch Hall spa room found eight washcloths laid out next to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 1). develop a person-centered care plan for 1 resident (Resident #7) and 2). implement person-centered care plan interventions for 1 resident (Resident #63) of 18 residents reviewed for person-centered care plan development and intervention implementation, resulting in Resident #7 not having a care plan related to hospice services in place and Resident #63 having increased risk for skin breakdown due to not wearing prevalon boot (prevalon pressure-relieving heel protector boot designed to minimize pressure, friction, and shear on the feet, heels, and ankles of non-ambulatory (non-walking) patients). Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 1: Resident Assessment Instrument (RAI), revealed .The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that.(1) the assessment accurately reflects 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, interview, and record review the facility failed to ensure an orthosis device (a device designed to prevent or prevent the worsening of contractures (the shortening and hardening of muscles, tendons, or other tissues often leading to restricted joint mobility) was used as ordered in 1 (Resident #63) of 2 residents reviewed for mobility resulting in the potential for the worsening of contracture of Resident #63's left hand.Findings include:Resident #63Review of an admission Record revealed Resident #63 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left side weakness and paralysis following a stroke), contracture (shortening and hardening of muscles, tendons, or other tissues often leading to restricted joint mobility) left hand, and acquired absence of right toes (surgical removal of the toes). Review of a Minimum Data Set (MDS) assessment…

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

Based on interview, and record review, the facility failed to address/implement dietitian recommendations for nutritional supplements in 1 of 7 residents (Resident #10) reviewed for nutrition, resulting in the potential for impaired wound healing. Findings include:Resident #10 Review of an admission Record revealed Resident #10 was a male, with pertinent diagnoses which included a stroke with left sided hemiplegia (paralysis), anxiety, major depression, chronic pain, and a stage 3 sacral pressure ulcer. Review of a current Care Plan Report for Resident #10 revealed the need (Resident #10) is at risk for alteration in nutrition and fluid status r/t (related to) Stage 3 skin pressure area, depression, anxiety . revised 8/17/25, with interventions which included Request Vitamin C, zinc to promote healing initiated 7/24/25. Review of a Nutritional Re-Evaluation assessment for Resident #10, dated 2/25/25, revealed .Resident with varied intake between 50-100% at meals. Resident doesn't always eat meals served and has his own frozen, prepackaged meals/snacks .Stage 3 pressure injury is…

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

Based on observation and interviews, the facility failed to store trash and refuse containers covered and in a manner that maintains the area to prevent the harborage or feeding of pests.On 9/8/25 at 1:52 PM, Observation of the outside dumpsters, with Maintenance Director (MD) CCC, found the doors pushed open allowing for pests and precipitation to enter. An interview with MD CCC found that staff have a hard time tossing bags of trash into the dumpster unless the doors are opened. Further review of the dumpster area found excess trash, used gloves, and debris on the inside perimeter of the garbage area.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to track and offer the influenza and pneumococcal vaccines for 3 (Resident #9, #7, and #2) of 5 residents reviewed for immunizations, resulting in the failure to provide documentation of declination of immunizations and residents not being given the opportunity to receive or decline the influenza and/or pneumococcal vaccination. Findings include: According to the Centers for Disease Control and Prevention (CDC) PCV20 Vaccination for Adults 65 Years and Older dated 02/09/23, revealed, .Routine vaccination: Adults 65 years or older who have- Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose . www.cdc.gov/vaccines/hcp/admin/downloads/job-aid- SCDM-PCV20-508.pdf Resident #9:Review of an admission Record revealed Resident #9 was a male with pertinent diagnoses which included paralysis on his right…

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 provide a dignified environment and ensure that staff treated residents with dignity and respect in 4 (Resident #105, #104, #106, and #108) of 7 residents reviewed for dignity, resulting in feelings of frustration and the potential for depression, loss of self-worth, and an overall deterioration of psychological well-being. Findings include: Resident #105 Review of an admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included difficulty in walking. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 11/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #105 was moderately cognitively impaired. Review of an Incident Report dated 1/1/25 revealed, Incident Summary: Resident #105 alleged that (Certified Nursing Assistant (CNA) Q) verbally mistreated her when he attempted to ask for her smoking materials to…

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

This citation pertains to intake #MI00149391 Based on interview and record review the facility failed to ensure an incident of neglect (resident received wrong medication) was reported to the State Agency in 1 (Resident #100) of 1 resident reviewed for reporting, resulting in Resident #100 being transferred to an acute care hospital emergency room for treatment and admission to a medical intensive care unit after receiving the wrong medication. Findings include: Review of an admission Record revealed Resident #100 had pertinent diagnoses which included: Cerebral infarction (Stroke), dysphagia (difficulty swallowing), acute respiratory failure with hypoxia (significantly difficult breathing, hypoxia- decreased oxygen in the body's blood) and pneumonitis. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 1/5/2025 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated Resident #100 was severely cognitively impaired. Review of Nurses Note for Resident #100 dated 1/5/25 at 8:18 PM authored by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care in accordance with professional standards in 2 (Resident #101 and #103) of 3 residents reviewed for quality of care, resulting in 1.) Resident #101 receiving an enteral feeding (method of providing nutrition directly into the gastrointestinal tract through a tube) that did not reflect physician orders for 7 days 2.) not being re-weighed timely after a significant weight change 3.) A delayed assessment and treatment for Resident #103's complaints of pain. Findings include: 1.) Resident #101 Review of admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of Resident #101's Orders revealed, Enteral feed (tube feed) order. Isosource (enteral feeding formula) 1.5. 50cc/hr (rate to run the feed) continuous feeding through G-tube every shift for nutrition. Start date: 2/24/25. Review of Resident #101's Care Plan revealed,…

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 properly label, date, and store medications in 1 out of 2 medication carts reviewed for medication storage and labeling resulting in the potential for decreased efficacy of medications and the exacerbation of medical conditions. Findings include: During an interview on 3/5/25 at 10:44 AM, Registered Nurse (RN) G reported that they had concerns with the nurses at the facility not labeling insulin pens when they opened them. RN G reported that they had brought this concern to the Director of Nursing (DON) B and that DON B had told them the policy was for the nurses to contact pharmacy to determine the date that the pen had been delivered, so there was no need to do further education on labeling insulin with nursing staff. RN G reported that calling the pharmacy to determine the date an insulin pen was delivered wasted a lot of time, and was not an accurate way to determine when the insulin pen had pen had been opened. During an observation and interview on 3/5/25 at 12:07 PM, this writer reviewed the 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 This citation pertains to intake number MI00147366. Based on interview and record review, the facility failed to ensure 3 (Resident #101, Resident #102, and Resident #103) of 3 residents reviewed for dementia care, were treated in a manner that supported their psychosocial wellness, resulting in the residents experiencing avoidable stress responses to care interventions. Findings include: Review of The Unmet Needs Model, [NAME]-[NAME] and [NAME] (1995), revealed that those with dementia develop problem behaviors from an imbalance in the interaction between life-long habits and personality, current physical and mental states and less than optimal environmental conditions. Resident #101 Review of an admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia with agitation, difficulty walking, bipolar disorder (mental health condition that causes extreme mood swings), and generalized anxiety disorder (mental health…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents. Findings include: During a tour of the kitchen, at 9:02 AM on 9/17/24, observation of the two door reach in cooler found a container of sliced turkey dated 9/4 to 9/17, an open (half empty) gallon of milk with no date to indicate discard, an open container of hot dogs dated 9/10 to 9/17, a sheet tray with a dozen thawed Mighty Shakes and 10 Magic Cups with no date to indicate discard for these items. Mighty Shakes state they are good 14 days from thaw and the Magic Cups state under refrigeration Consume within 5 days. During a tour of the Activity refrigeration units, at 10:20 AM on 9/17/24, observation of the kitchen fridge found an open container of thickened lemon water with no date. The item states it is good for 4 days after opening. An interview with Dietary Manager (DM) BB found that nursing staff…

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 properly protect the potable water supply from plumbing cross connections. This resulted in the potential for increased illness and possible contamination of the domestic water. Findings include: During a tour of the kitchen, at 10:17 AM on 9/17/24, it was observed that the mop sink in the kitchen janitors' closet was found left on and connected to a pre-dispense chemical system. The mop sink faucet has an internal atmospheric vacuum breaker (AVB) that is not approved for constant back pressure. The current set up puts undue back pressure on the faucets internal AVB (when its left on and connected to a pre-dispense system that has a stop valve downstream). During a tour of the beauty shop, at 1:30 PM on 9/17/24, with Maintenance Director UU, it was found that the spray to the hair washing sink was replaced with a kitchen dish sprayer that controls the pressure with a thumb valve (which creates a stop downstream of the faucets atmospheric vacuum breaker). Currently the spray was laying in the bottom of the sink near the drain.…

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 call lights were available and in reach for 2 (Resident #84 and #75) of 20 residents reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs. Findings include: Resident #84 Review of an admission Record revealed Resident #84 was originally admitted to the facility on [DATE] with pertinent diagnoses which included difficulty in walking, muscle weakness, and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #84, with a reference date of 9/1/24 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #84 was severely cognitively impaired. Review of Resident #84's Care Plan revealed, (Resident #84) is at risk for fall related injury and falls R/T (related to): dementia, chronic back pain, weakness. Date Initiated: 08/26/2024. Interventions: . Keep the resident's environment as safe as possible with: even…

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 accurate do not resuscitate (DNR) order was updated timely for 1 (Resident #17) of 20 residents reviewed for advanced directives (legal documents that allow 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 Resident #17 Review of an admission Record revealed Resident #17 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of Resident #17's Electronic Health Record (EHR) revealed that Resident #17 was noted as a full code (health care term which indicates healthcare workers should perform all life saving measures in the event that the patients heart or lungs stop working). Review of Resident #17's DNR order dated 2/11/24 and signed by Resident #17's guardian revealed, I authorize in the event the ward's (Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide a clean and homelike environment that was free of pests and odors for one resident (Resident #9) of 20 residents reviewed for environment resulting in potential for decreased satisfaction of living conditions. Findings include: Resident #9 (R9) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R9 admitted to the facility on [DATE] with diagnoses of anxiety, depression and paranoid schizophrenia (mental disorder characterized by hallucinations, delusions, disordered thinking and behavior, flat or inappropriate affect). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R9 was cognitively intact (13 to 15 cognitively intact). On 9/17/2024 at 11:25 AM, R9 was sitting in his room in his wheelchair. R9's room smelled like feces and a dried-up red spill was noted along the floor by his bed. R9's hairbrush was observed under his bed with dust on it. On 9/17/2024 at 2:24 PM,…

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 address resident grievance timely in 1 (Resident #61) of 2 resident reviewed for grievances resulting in feelings of frustration and anger related to missing personal items. Findings include: Resident #61 Review of an admission Record revealed Resident #61 had pertinent diagnoses which included: cerebral infarction (stroke) and difficulty in walking. Review of a Minimum Data Set (MDS) assessment for Resident #61, with a reference date of 8/12/2024 revealed a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated Resident #61 was cognitively intact. During an interview on 9/17/24 at 1:25 PM., Resident #61 reported he was missing clothing and he had concerns with his clothes returning from laundry. Resident #61 reported he had been missing clothing for about a month. Resident #61 reported had completed a complaint form over a week ago and had no response from anyone yet. During an interview on 9/18/24 at 1:25 PM., Resident #61 reported he had not had any follow up from the management team regarding his…

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 written notification to the State Long-Term Care (LTC) Ombudsman of facility-initiated transfers/discharges since January 2023, resulting in the potential for all residents to be discharged without an advocate who can inform them of their options and rights. Findings include: On 9/13/2024 at 3:48 PM, an email was received from the State LTC Ombudsman (Ombudsman) TT which stated, . They have not provided the required notice of transfers and discharges since January of 2023 . During an interview on 9/19/24 1:47 PM, Nursing Home Administrator (NHA) A reported that he was not sure what the facility process was for notifying the ombudsman of transfers and discharges, and that he would need to check into this. NHA A reported that he was unaware of this regulation. During a follow up interview on 9/19/24 at 3:08 PM, NHA A reported that the facility used to have a nurse manager that was responsible for sending the discharge and transfer notices to the ombudsman. NHA A reported that the nurse manager that was responsible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the facility bed hold policy upon discharge to an acute care hospital for 2 ( Resident #8 and #17) of 2 residents reviewed for emergency hospital transfer resulting in the potential for unanticipated expense or the loss of desired room placement in the facility. Findings include: Resident #8 Review of an admission Record revealed Resident #8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of Resident #8's Progress Notes dated 9/8/24 revealed, . asked by (Resident #8) to go to hospital . called PA (physician assistant) on call and EMS (emergency medical services) transport . Review of Resident #8's electronic health record (EHR) did not reveal a bed hold document for Resident #8's discharge on [DATE]. Resident #17 Review of an admission Record revealed Resident #17 was originally admitted to the facility on [DATE] with pertinent diagnoses which 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 ensure the Preadmission Screening and Resident Review (PASARR) for a level II OBRA evaluation was completed for 2 (Resident #77 and #27) of 2 residents reviewed for PASARR, resulting in the potential for unmet mental health care needs. Findings include: Resident #77 Review of an admission Record revealed Resident #77 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: schizophrenia, unspecified psychosis, major depressive disorder, generalized anxiety disorder, and insomnia. Review of Resident #77's Physician Orders revealed the following medications: Aripiprazole (antipsychotic medication) for depression, Trazodone (antidepressant) for insomnia, Venlafaxine (antidepressant), Zyprexa (antipsychotic medication) for psychosis, and Clonazepam (antipsychotropic medication) for anxiety. Review of Resident #77's Preadmission Screening and Resident Review (PASARR) revealed, a level 1 screening dated 5/17/24 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, interview and record review the facility failed to develop person centered care plans related to antipsychotic and antidepressant use and implement pressure ulcer interventions for 2 (Resident #44, Resident #36) of 20 residents reviewed for person centered care plans resulting in the potential for unmet care needs of the residents. Findings include: Resident #44 (R44) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R44 admitted to the facility on [DATE] with diagnoses of depression, anxiety, mild cognitive impairment and psychotic disorder (disconnection from reality). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R44 was cognitively intact (13 to 15 cognitively intact). Review of R44's care plan revealed there was not a care plan regarding R44's psychotic disorder or antidepressant diagnoses. During an interview on 9/19/2024 at 9:17 AM, Social Worker (SW) FF stated that she typically completes care plans on residents…

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 follow physician orders for use of oxygen in 1 (Resident #81) of 2 residents reviewed for respiratory care, resulting in inaccurate settings and the potential for respiratory infection. Findings include: Resident #81 Review of an admission Record revealed Resident #81 was originally admitted to the facility on [DATE] with pertinent diagnoses which included adult failure to thrive. Review of Resident #81's Orders revealed, Oxygen 2 l/min (liters per minute) via nasal cannula as needed for SOB (shortness of breath). Start date: 8/23/2024. During an observation on 9/17/24 at 1:25 PM, Resident #81 was sitting in her room wearing oxygen via nasal cannula. It was noted that Resident #81's oxygen was running at 4 liters per minute. During an observation on 9/18/24 at 10:44 AM, Resident #81 was lying in her bed. It was noted that Resident #81's oxygen was running at 4 liters per minute. During an observation and interview on 9/18/24 at 10:50 AM,…

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

Based on interview and record review the facility failed to ensure a RN (registered nurse) worked 8 consecutive hours on 4/13/2024, 4/27/2024, 5/25/2024, and 5/26/2024, resulting in the potential for unmet care needs for all residents who resided in the building on those dates. Findings include: Review of PBJ Report indicated staffing concerns, no RN coverage for 8 consecutive hours during quarter 3/year 2024. With staffing notes to include no RN hours on 4/7/24, 4/13/24, 4/27/24, 5/25/24, and 5/26/24. Review of Sign in Sheets work schedules provided by the facility dated 4/13/2024, 4/27/2024, 5/25/2024, and 5/26/2024, no registered nurse was scheduled nor did a registered nurse sign in on those dates. In an interview on 9/18/2024 at 2:09 PM., General and Administration (GA) GG reported she did know there needed to be a RN for 8 consecutive hours every day including weekends. GA GG reported she did not schedule a RN on 4/13/24, 4/27/24, 5/25/24, and 5/26/24. GA GG reported there was no RN coverage on those dates. GA GG reported in April she had approximately 3 RN to work on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure 1 (Resident #77) of 3 residents reviewed for behavioral health, received behavioral health care services resulting in the potential for residents to experience a decline in their psychosocial well-being. Findings include: Resident #77 Review of an admission Record revealed Resident #77 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: schizophrenia, unspecified psychosis, major depressive disorder, generalized anxiety disorder, and insomnia. Review of Resident #77's Physician Orders revealed the following medications: Aripiprazole (antipsychotic medication) for depression, Trazodone (antidepressant) for insomnia, Venlafaxine (antidepressant), Zyprexa (antipsychotic medication) for psychosis, and Clonazepam (antipsychotropic medication) for anxiety. Review of Resident #77's Care Plan revealed, no care plan developed for any of Resident #77's mental illness diagnoses, and/or the medications that she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to discontinue psychotropic medications prescribed as needed (PRN), after 14 days and/or document rationale to extend prn psychotropic medication use in 1 (Resident #75) of 6 residents reviewed for unnecessary medications, resulting in the potential for adverse side effects and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: Resident #75 Review of an admission Record revealed Resident #75 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of a Minimum Data Set (MDS) assessment for Resident #75, with a reference date of 8/1/24 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #75 was severely cognitively impaired. Review of Resident #75's Physician Orders revealed, Lorazepam (psychotropic medication used as a sedative) Tablet 0.5 MG Give 2 tablet by mouth every 4 hours as needed…

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 complete documentation in treatment administration records for 1 (Resident #36) of 20 residents reviewed for complete documentation in treatment administration records. Findings include: Resident #36 Review of an admission Record revealed Resident #36 had pertinent diagnoses which included: dementia, pressure ulcer (bed sore- wound that occurs on the skin surface due to prolonged pressure) of the sacrum and the right and left heels. Review of a Minimum Data Set (MDS) assessment for Resident #36, with a reference date of 9/3/2024 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #36 was severely cognitively impaired. On 9/17/24 at 11:42 AM., Resident #36's feet were observed wrapped with gauze. No date was noted in the dressings. Review of Physician Order Summary revealed . rt (right) heel cleanse with normal saline, pat dry, apply collagen matrix, cover with 4 x 4 and wrap with kerlix (gauze) change m-w-f (Monday, Wednesday, Friday) ordered 8/16/2024 . left heel wound cleanse…

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 1.) proper hand hygiene was used during administration of enteral feeding in 1 (Resident #102) of 1 reviewed for enteral feeding; 2.) proper use of personal protective equipment (PPE) by staff for residents in enhanced barrier precautions during showers in facility community shower rooms and 3.) sanitize resident shared equipment between resident use resulting in the potential for the spread of infection, cross contamination and disease transmission for residents residing in the facility. Findings include: Resident #102 Review of an admission Record revealed Resident #102 had pertinent diagnoses which included: Barrett's esophagus (a thickening of the esophagus near the stomach connection causing narrowing), gastrostomy (a tube inserted directly into the stomach through the skin to provide nourishment), and gastro-esophageal reflux disease (condition when stomach acid flow into the esophagus causing irritation). Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date 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.

This citation pertains to intake #MI00144537 and #MI00144432 Based on interview and record review the facility failed to ensure a complete and accurate assessment was completed and documented for 3 ( Resident #101, Resident #110, and Resident #100) of 3 residents reviewed for complete and accurate assessment, resulting in the potential for a lack of monitoring, unnoticed adverse reactions, unnoticed injury, and the potential for a negative impact to the resident's psychosocial well-being. Findings include: Resident #101 Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: Hemiplegia and Hemiparesis (one sided paralysis) following cerebral infarction (stroke) affecting the left dominate side, and cognitive communication deficient. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 7/1/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #101 was cognitively intact. In an interview on 8/27/24 at 3:32 PM., Resident #101 reported that he was given an insulin…

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 the confidentiality of a residents medical condition unless medically necessary in 1 of 3 residents (Resident #100), resulting in the perception that staff would not care for her due to her medical diagnosis and lack of actual care. Findings include: Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of human immunodeficiency virus (HIV) disease. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 12/26/23 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #100 was mildly cognitively impaired. In an interview on 1/18/24 at 11:00 AM., Confidential Informant (CI) Q reported Resident #100 was admitted to the facility around November 2023. CI Q reported (Resident #100) was admitted after having a stroke. CI Q reported when visiting (Resident #100) it was noted that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an injury of unknown origin in 1 of 5 residents (Resident #101) reviewed for reporting, resulting in unreported injury-fractured leg for Resident #101, and the potential for injuries to go unrecognized and reported to the State Agency (SA). Findings include: Review of an admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: end stage renal/kidney disease, renal/kidney osteodystrophy (complication of chronic kidney disease that may weakens your bones). Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 1/4/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #101 was cognitively intact. Review of Resident #101's Emergency Department Note revealed Encounter Date: 12/27/2023 Chief Complaint Patient (Resident #101) presents with Leg Pain Emergency Medical Support (EMS-ambulance): Coming from…

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 residents with their preferred practice/choices to maintain hygiene, activities and the assistance to go outside daily for 4 of 5 residents (Resident #30, #53, #75 & #281) reviewed for self-determination, resulting in feelings of frustration, feeling dirty and the potential for the residents to not meet their highest practicable well-being. Findings include: Resident #30 Review of an admission Record revealed Resident #30, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of stroke. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 7/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #30 was cognitively intact. In an interview on 7/26/23 at 1:15 PM., Resident #30 reported he had gone to the hospital for stroke like symptoms a few months ago. Resident #30 reported after he came back to the facility,…

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 4 of 18 residents (Residents #3, #48, #63, and #66) reviewed for care development/implementation, lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being and decline in uncommunicated care needs. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual V1.17, Chapter 4, revealed, .the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 4:…

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

Based on observations, interview and record review, the facility failed to employ an Activity Director with the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact the residents who choose to participate in structured activities and/or are dependent for their leisure needs. Findings include: In an interview with Activities Director (AD) BB on 7/26/23 at 8:37 am, it was revealed she began working at the facility in January 2023. AD BB reported she had 1.5 years of experience working in activities at another skilled nursing facility, did not have a degree in either Recreational Therapy for Occupational Therapy or a certification as an activity professional. AD BB reported the facility had discussed the need for her to receive additional training for her role, but no further action had been taken. AD BB reported struggling to increase attendance in group activities and providing individualized activity interventions. AD BB expressed difficulty hosting…

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 sufficient staff to meet resident needs for 4 (Resident #36, Resident #28, Resident #30, and Resident # 53) residents and the potential of of unmet care needs for all residents residing in the facility. Findings include: Resident #36 Review of an admission Record revealed Resident #36, was originally admitted to the facility on [DATE] with pertinent diagnoses which included Quadriplegia (Paralysis of all four limbs). Review of a Minimum Data Set (MDS) assessment for Resident #36, with a reference date of 5/22/23 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #36 was moderately cognitively impaired. During an interview on 7/24/23 at 11:59 AM, Resident #36 Reported that staff took a long time to answer call lights, which made Resident #36 frustrated. Resident #36 reported that they (Resident #36) could tell that the staff were overwhelmed and unable to manage their work load. Resident #36…

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 proper infection control practices for proper hand hygiene during a wound dressing change for 1 resident (Resident #30) of 4 review for pressure ulcers, and ensure proper infection control measures were implemented for cleaning and disinfecting resident and resident shared equipment, resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population. Findings include: Resident #30 Resident #30 Review of an admission Record revealed Resident #30, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of stroke. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 7/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #30 was cognitively intact. In an observation/interview on 7/26/23 at 8:47 AM., Resident #30 was lying in his bed waiting for…

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

Based on interview and record review, the facility failed to ensure the provision of resident rights training requirements for 26 out of 134 employees reviewed for resident rights training resulting in the potential of facility staff violating the rights of all residents at the facility. Findings include: During an interview on 7/26/23 at 11:08 AM, Staff Development Coordinator (SDC) E reported that the facility used Relias (an online service for facility staff to complete required training) to complete required training for facility staff. SDC E reported that she was responsible for ensuring that staff completed their required training, and was aware aware that several staff members had overdue training. SDC E reported that was because required training had not been monitored for most of the year as the facility had several changes in management and the oversight of ensuring staff were completing their training had been missed. Review of Incomplete Relias Report revealed that 26 employees had overdue resident rights training.

Based on interview and record review, the facility failed to ensure the provision of abuse, neglect, and misappropriation training requirements for 6 out of 134 employees reviewed for abuse, neglect, and exploitation training resulting in the potential for all resident at the facility to experience abuse, neglect, and misappropriation. Findings include: During an interview on 7/26/23 at 11:08 AM, Staff Development Coordinator (SDC) E reported that the facility used Relias (an online service for facility staff to complete required training) to complete required training for facility staff. SDC E reported that she was responsible for ensuring that staff completed their required training, and was aware that several staff members had overdue training. SDC E reported that was because required training had not been monitored for most of the year as the facility had several changes in management and the oversight of ensuring staff were completing their training had been missed. Review of Incomplete Relias Report revealed that 6 employees had overdue abuse, neglect, and misappropriation…

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 provision of Quality Assurance and Performance Improvement (QAPI) training requirements for 10 of 134 employees reviewed for QAPI training resulting in the potential for staff to lack knowledge of the elements and goals of the facility's QAPI program, and their role and potential input, with the potential to affect all residents at the facility. Findings include: During an interview on 7/26/23 at 11:08 AM, Staff Development Coordinator (SDC) E reported that the facility used Relias (an online service for facility staff to complete required training) to complete required training for facility staff. SDC E reported that she was responsible for ensuring that staff completed their required training, and was aware aware that several staff members had overdue training. SDC E reported that was because required training had not been monitored for most of the year as the facility had several changes in management and the oversight of ensuring staff were completing their training had been missed. Review of Incomplete…

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

Based on observation and interview, the facility failed to ensure the provision of infection control training for 5 of 134 employees reviewed for infection control training resulting in the potential for potential for the spread of diseases and infectious processes to all residents at the facility. Findings include: During an interview on 7/26/23 at 11:08 AM, Staff Development Coordinator (SDC) E reported that the facility used Relias (an online service for facility staff to complete required training) to complete required training for facility staff. SDC E reported that she was responsible for ensuring that staff completed their required training, and was aware aware that several staff members had overdue training. SDC E reported that was because required training had not been monitored for most of the year as the facility had several changes in management and the oversight of ensuring staff were completing their training had been missed. Review of Incomplete Relias Report revealed that 5 employees had overdue infection control training.

Based on observation and interview, the facility failed to ensure the provision of compliance and ethics training for 7 of 134 employees reviewed for compliance and ethics training resulting in the potential for unethical and unprofessional staff conduct which could affect all residents at the facility. Findings include: During an interview on 7/26/23 at 11:08 AM, Staff Development Coordinator (SDC) E reported that the facility used Relias (an online service for facility staff to complete required training) to complete required training for facility staff. SDC E reported that she was responsible for ensuring that staff completed their required training, and was aware aware that several staff members had overdue training. SDC E reported that was because required training had not been monitored for most of the year as the facility had several changes in management and the oversight of ensuring staff were completing their training had been missed. Review of Incomplete Relias Report revealed that 7 employees had overdue ethics and compliance training.

Based on observation, interview, and record review the facility failed to provide activities of daily living (ADL) care to promote dignity in 1 of 18 residents (Resident #63) reviewed for dignity resulting in the potential for a reasonable person to experience feelings of embarrassment and/or shame. Findings include: Review of an admission Record revealed Resident #63, a female, with pertinent diagnoses which included dementia. Review of a Minimum Data Set (MDS) assessment for Resident #63, with a reference date of 5/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #63 had severe cognitive impairment. During an observation on 7/24/23 at 12:10 PM, in the main dining room of the special care unit, Resident #63 was present at the table in the dining room without food while two other residents at the table were eating. Resident #63's was noted to have white hairs on her chin and her hair appeared greasy and uncombed with a dry matted area to the back right side of her head. Record review of the Task - Shower/Bath Monday Thursday 2nd shift…

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 report to the abuse coordinator and thoroughly investigate a resident to resident altercation per facility policy in 2 of 4 sampled residents (Resident #59) reviewed for abuse investigation, resulting in in the potential for additional resident to resident altercations with injury and potential psychosocial harm. Findings include: Review of an admission Record revealed Resident #59 was a female with pertinent diagnoses which included dementia, abnormalities of gait and mobility, restlessness, muscle weakness, age related debility, Alzhemier's disease, COPD, and stroke. Review of Nurses Notes dated 5/15/2023 at 9:00 PM, revealed, .At 2020, (Resident #59) was sitting with a group of other residents in a chair across from the nurses station. Her head was down- resting on her fist- and her eyes were closed. This RN was down the hall in front of bed 102 when (Resident #59) yelled stop. This RN looked over and saw a male resident leaning over (Resident #59) in the chair with his hands on the arms of the chair beside (Resident…

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

Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) evaluation for a level two OBRA evaluation was completed for one resident (Resident #75) of 18 residents reviewed for PASARR, resulting in the potential for the resident to not receive appropriate mental health treatment and services. Findings include Review of an admission Record for Resident #75 dated 5/18/23 revealed the resident was admitted from an acute care psychiatric hospital with the following pertinent diagnoses: Dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with other behavioral disturbance, Psychotic Disturbance and Major Depressive Disorder. Review of a Minimum Data Set (MDS) assessment for Resident #75 dated 5/25/23 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #75 had a moderate cognitive impairment. Section D, Mood of the MDS indicated Resident #75 experienced feeling hopeless, down, or depressed during 7-11 of the 14 days during the assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide services that meet professional standards of practice related to physician orders for 1 of 18 residents (Resident #12) reviewed for professional standards and quality of care, resulting in a delay for laboratory testing and a potential for delay in treatment for a bacterial infection. Findings include: Review of an admission Record revealed Resident #12 was admitted to the facility on [DATE] with pertinent diagnoses that included: Encephalopathy (disease in which the functioning of the brain is affected by some agent or condition (such as viral infection or toxins in the blood), Dementia (condition characterized by progressive or persistent loss of intellectual functioning), and Diabetes Mellutis (chronic disease resulting in difficulty regulating blood sugar levels). Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 7/4/23, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total…

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 a resident was consistently provided with showers/bathing for 1 of 4 residents (Resident #3) 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: Review of an admission Record revealed Resident #3 was a female with pertinent diagnoses which included dementia with behavioral disturbance, anxiety, pain, PTSD, dysphagia (damage to the brain responsible for production and comprehension of speech), Parkinson's disease, falls, and insomnia. Review of current Care Plan for Resident #3, revised on 9/12/22, revealed the focus, .(Resident #3) has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility r/t (related to) dementia. She also has DM (diabetes), Parkinson's, tremor, history of CA (cerebrovascular accident), vertigo, and OP (osteoporosis) .decreased…

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 post dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) assessment and monitoring were completed for 1 (Resident #57) of 1 resident reviewed for dialysis care, resulting in the potential of being unprepared for a decline in resident condition, due to adverse effects of dialysis. Findings include: Resident #57 Review of an admission Record revealed Resident #57, was originally admitted to the facility on [DATE] with pertinent diagnoses which included end stage renal (kidney) disease and dependence on renal dialysis. Review of a Minimum Data Set (MDS) assessment for Resident #57, with a reference date of 5/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #57 was cognitively intact. During an interview with Resident #57 on 7/25/23 at 12:32 PM, Resident #57 reported that it was common for their (Resident #57) 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 Based on observation, interview, and record review the facility failed to identify post-traumatic stress disorder (PTSD), triggers, and develop individualized care plan interventions to mitigate triggers for 2 (Residents #3 and #11) of 18 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma. Findings include: Resident #3: Review of an admission Record revealed Resident #3 was a female with pertinent diagnoses which included dementia with behavioral disturbance, anxiety, pain, PTSD, dysphagia (damage to the brain responsible for production and comprehension of speech), Parkinson's disease, falls, and insomnia. Review of Resident #3's care plan did not contain a focus which addressed her PTSD (Post Traumatic Stress Disorder) diagnosis and interventions which addressed potential triggers. In an interview on 07/26/23 01:32 PM, Unit Manager (UM) D reported during the clinical meeting and 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 Resident #66 Review of an admission Record revealed Resident #66 a female, with pertinent diagnoses which included dementia. Review of a Minimum Data Set (MDS) assessment for Resident #66, with a reference date of 6/26/23 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #66 had severe cognitive impairment. A review of Resident #66's Diagnosis list on 7/25/23 revealed a diagnosis of .Unspecified dementia, unspecified severity, with other behavioral disturbance . A review of Resident #66's Care Plan on 7/25/23 revealed no current individual and/or specific care plan in place related to a diagnosis of dementia or any behavioral disturbances. A review of Resident #66's Medication Administration Record revealed a current physician order with start date of 6/26/23 Risperdal oral tablet 1 mg (Risperidone) give 1 tablet by mouth a bedtime for dementia, and Risperdal oral tablet 0.5 mg (Risperidone) give 1 tablet my mouth one time a day for hallucinations, anxiety . (Risperdal is…

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.