Riverside Nursing Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the physician failed to address pharmacy recommendations, the facility failed to implement physician approved pharmacy recommendations, and/or the facility failed to implement physician approved pharmacy recommendations timely for 4 of 5 residents (R2, R3, R12, and R24) reviewed for monthly pharmacy medication regimen reviews. Findings include: R2 A review of R2's Face Sheet, dated 2/11/26, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included a post-traumatic stress disorder (PTSD), depression, and anxiety. A review of R2's Consultation Report, dated 1/22/26, revealed the pharmacist recommended that the physician either discontinue the as needed (prn) alprazolam (a medication for anxiety) or add a stop date not to exceed 14 days from the time it was initiated. The physician signed on 1/27/26 that they accepted the recommendation. A review of R2's Physician Order Report, dated 1/11/26 to 2/11/26, failed to reveal…

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 medications were administered in accordance with physician orders without errors for 2 (R17 and R5) of the 7 residents observed during the medication administration task. This resulted in a facility medication error rate of 10.34% (3 errors out of 29 opportunities).Findings include:Resident #17 (R17 Review of a Face Sheet revealed R17 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 1 Diabetes. Review of R17's Physicians Orders revealed an active order for insulin aspart U-100, before meals at 9:15AM, 12:15PM, and 5:00PM.During a medication administration observation on 02-10-2026 at 8:04 AM, Licensed Practical Nurse (LPN) B was observed preparing to administer insulin Aspart to R17. LPN B attached a new pen needle to the insulin pen, dialed the ordered insulin amount and administered the insulin to R17. LPN B did not dial a priming dose or expel insulin into the needle…

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

Based on observation, interview and record review, the facility failed to ensure there were no expired medications and ensure opened medications were dated in one of one medication cart and in one of one medication storage room. Findings include: During an observation on 2/10/2026 at 7:00 AM, the following were noted in the medication room: (a) an opened Tuberculin Purified Protein Derivative vial (used for skin testing to detect if a person has been infected with Mycobacterium tuberculosis or TB) vial was observed in the refrigerator opened and undated (Per Physician Desk Reference (PDR) recommend vial should be discarded 30 days after opened) and (b) four bottles of Famotidine 20mg (milligram) tablets with 300 tablets in each bottle that expired January 2026. During an observation on 2/10/2026 at 7:15 AM, the following were noted in the medication cart: (a) an opened Albuterol inhaler with 196 puffs remaining with no date indicating the date it was opened (Per PDR recommend inhaler should be discarded 90 days after opened), (b) Gas Relief 125 mg bottle with expiration 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.

Based on observation, interview and record review, the facility failed to maintain best practices for storage of foods brought to residents by family and other visitors. Findings include: On 02/09/2026 at 10:32AM, at time of interview Dietary Supervisor (DS) S states they do not have the key to the refrigerator and freezer; and DS S left to the nurse's station to obtain the key to open the doors of refrigerator and freezer. DS S, noted dietary staff is not responsible for dating food or discarding food from the residents' refrigerator. Observed the following items, in the resident's refrigerator, without a date of when food was received and placed in refrigerator: cream-based soup with room number only on container, opened jar of Tostitos cheese dip, oatmeal in kitchen dishware. Record review of the facility's policy, Foods Brought in to Resident Education Material, #5 Cooked food items will be labeled with the resident's name and date of delivery. If the food items need refrigeration/freezing, the items will be placed in a resident designated refrigerator/freezer.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly assess one resident (R9) out of twelve reviewed for self-administration of medications.Findings include:Review of a Face Sheet revealed R9 admitted to the facility on [DATE] with pertinent diagnosis which include type II diabetes mellitus, major depressive disorder, anxiety disorder, and cognitive communication deficit. In an observation on 2/10/2026 at 8:42 AM R9 was observed to have a bottle of Flonase nasal spray (24-hour nasal spray that treats allergy symptoms) at the bedside. Licensed Practical Nurse (LPN) B asked R9 if she had already administered the medication and R9 answered that she was unsure why the Flonase nasal spray was at bedside. LPN B administered the Flonase nasal spray as physician ordered and placed the Flonase into the medication cart.Review of a Physician Order dated 03/05/2025 Flonase Allergy Relief (fluticasone propionate) spray, 50 micrograms one spray each nostril every morning. Further review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a resident with written notice of the facility's bed hold policy upon transfer to the hospital for 1 of 2 residents (R27) reviewed for hospital transfers. Findings include: A review of R27's Face Sheet, dated 2/12/26, revealed R27 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included obstruction of the bile duct and weakness, A review of R27's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/9/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R27 was cognitively intact.A review of an Interdisciplinary Team note, dated 1/24/26 for 1/19/26, revealed R27 had been transferred to the hospital emergency room on 1/18/26 for evaluation and treatment of excessive purulent drainage (thick, milky, or opaque fluid often having a foul odor that signifies an active infection) from R27's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete Preadmission Screening and Resident Review (PASARR) Level 1 Screenings timely for 2 of 2 residents reviewed (R2 and R12). Findings include:R12 Review of a Face Sheet revealed R12 admitted to the facility on [DATE] with pertinent diagnosis which include schizoaffective disorder, bipolar type, and type II diabetes. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R12, with a reference date of 12/22/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 04, out of a total possible score of 15, which indicated R12 had severe cognitive impairment. Further review of the MDS revealed R12 had received an antipsychotic and an antidepressant within the 7-day assessment period. Review of the electronic medical record revealed a PASARR Level 1 Screening dated 09/22/2025 marked hospital exemption discharge which meant that R12 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 implement the facility policy for pressure injury/wound management for 3 of 12 residents (Resident #21, #17, and #6) reviewed for alterations in skin integrity.Findings:Resident #21 (R21)Review of an admission Record revealed R21 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Chronic Diastolic Heart Failure.Review of R21's Order Summary dated 10/2/25 until 1/19/26 revealed, Skin Assessment Weekly.Review of R21's weekly Skin Body Assessment dated 12/18/25 revealed, LLE (left lower extremity) ulcer known finding treatment in place .There were no weekly Skin Body Assessment completed on 12/25/25 or on 1/1/26.Review of R21's Skin Body Assessment dated 1/8/26 revealed, .some excoriation on buttocks bilateral cream applied house stock barrier cream on open areas on buttock noted.Review of R21's Electronic Health Record revealed no documentation that the Director of Nursing, the provider, or 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 maintain complete medical records for 3 of 12 sample residents (R2, R3, and R27). Findings include: R2 A review of R2's Face Sheet, dated 2/11/26, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included a post-traumatic stress disorder (PTSD), depression, and anxiety. A review of R2's electronic medical record (EMR), dated 1/13/26 to 2/9/26, failed to reveal any advanced directive documentation that would indicate if R2 had been offered to formulate an advanced directive and/or complete an advanced directive. A second review of R2's EMR, dated 1/13/26 to 2/9/26, failed to reveal if R2 had a Preadmission Screening and Resident Review (PASARR) Level 1 Screening (a screening that evaluates all applicants for serious mental illness and/or intellectual disability in order to ensure that they receive the appropriate care and services that they require) performed prior to admission. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes 1275500. Based on interview and record review, the facility failed to 1.) ensure care conferences were completed and 2.) ensure residents/their representatives participated in their cares at the facility for 3 residents (R2, R4, and R8) of 4 residents reviewed for care conferences. This deficient practice affects all 33 residents who reside in the facility.Findings include: Resident #2 (R2)Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE]. In an interview on 7/8/25 at 9:03 AM, Family Member (FM) I reported concerns about R2 needing to see the eye doctor for a few months and as of last month R2 needed new glasses. FM I reported he had talked to the Social Worker (SW) B several times in the past few months about getting R2 an appointment with the in-house optician and had yet to hear anything. FM I reported he finally gave up and came to the facility and took R2 himself to the eye doctor with no assistance from the facility. FM I had concerns…

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

This citation pertains to intakes 1275500, 1275498, and 1275497. Based on interview and record review, the facility failed to administer the facility and use its resources effectively and efficiently to ensure resident cares and services met the residents needs to attain or maintain the highest practicable physical, mental and psychosocial well-being. This deficient practice affects all 33 residents who reside at the facility. Findings include: Review of the Administrator/Administration Job Description revealed: GENERAL PURPOSE: Direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern long term care facilities, as well as all company policies to assure that the highest degree of quality care can be provided to the residents at all times. ESSENTIAL JOB FUNCTIONS: A. Administrative and Supervisory Functions, . C. Personnel Functions, . D. Resident's Rights Functions, . E. Continuous Quality Improvement Functions, . OTHER FUNCTIONS: A. Committee Functions, . C. Staff Development Functions, . In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes 1275500, 1275498, and 1275497. Based on observation, interview and record review, the facility failed to ensure the Medical Director's involvement in the collaboration, coordination, and oversight of cares and services for 6 residents (R2, R4, R5, R6, R8, and R9), of 6 residents reviewed for physician involvement. This deficient practice affects all 33 residents who reside at the facility. Ancillary Services for Vision CareResident #2 (R2)Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE].In an interview on 7/8/25 at 9:03 AM, Family Member (FM) I reported concerns about R2 needing to see the eye doctor for a few months and as of last month R2 needed new glasses. FM I reported he had talked to the Social Worker (SW) B several times in the past few months about getting R2 an appointment with the in-house optician and had yet to hear anything. On 6/10/25 he came to the facility and R2's glasses were missing, and she was wearing some random pair…

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 1275499, 1275500, 1275498, and 1275497. Based on interview and record review, the facility failed to operationalize policies and procedures for an effective Quality Assurance and Performance Improvement (QAPI) program by not monitoring, identifying, developing and promptly implementing corrective actions. This deficient practice affects all 33 residents who reside in the facility. Findings include: Review of a policy titled Quality Assurance and Performance Improvement (QAPI) dated 11/2022 (which does not show it is annually reviewed/revised) revealed: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. 3. The QAPI plan will address the following elements:a. Design and scope of the facility's QAPI program and QAA Committee responsibilities and actions.b. Policies 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 This citation pertains to intakes 1275500, 1275498, and 1275497. Based on interview and record review, the facility failed to 1.) follow physician orders to obtain labs and change medication orders for 1 resident (R2) and 2.) ensure physician supervision of wounds for three residents (R5, R6, and R9), of 5 residents reviewed for physician supervision and the effectiveness of treatments. Findings include:Resident #2 (R2)Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE].Review of a Nurse Practitioner Progress note dated [DATE] for R2 revealed: increase lisinopril from 30 mg (milligrams)/d (daily). Will repeat BMP (basic metabolic panel lab) next lab day.Review of a Physician Progress note dated [DATE] for R2 revealed: Lisinopril recently increased from 30mg/d to 40mg/d however not changed in chart. BMP ordered however no results, will re-order.Review of the Medication Administration Record (MAR) for R2 revealed the changed dose of lisinopril 40 mg originally ordered on [DATE]…

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 1275500, 1275498, and 1275497. Based on interview and record review, the facility failed to 1.) implement systematic documentation and accurate reflection of 2 residents (R2, R5 and R6) of 4 residents reviewed for complete and accurate medical records and 2.) ensure wound dressing changes were not falsified for 1 resident (R5) of 4 residents reviewed for treatment administration. Findings include:Resident #2 (R2)Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE].Review of a Physician Progress note dated 7/1/25 for R2 revealed: Lisinopril recently increased from 30mg/d to 40mg/d however not changed in chart. BMP ordered however no results, will re-order.Review of a Nursing Progress note dated 7/6/25 for R2 revealed: T.O. (telephone order) from [Practitioner] to give a one-time dose of hydralazine 25 mg for elevated BP (blood pressure) now.Review of the July MAR for R2 revealed no hydralazine orders and no documentation indicating it 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.

This citation pertains to intake 1275499 and 1275500. Based on interview and record review, the facility failed to follow policies and procedures and report allegations of neglect for 1 resident (R8) of 2 residents who complained of not receiving afternoon medications during resident council.Findings Include:Review of an Abuse Prevention Program Policy & Procedure last reviewed 1/2025 revealed: Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. Neglect, is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. REPORTING/RESPONSE: All alleged or suspected violations are to be reported immediately to the Administrator or Director of Nursing, which are responsible to notify required officials, including to the State Survey Agency, Adult Protective Services, Local Public Safety, Licensure Boards, Regional Director of Operations or Regional Clinical Directors (representative…

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 1275498, and 1275497. Based on interview and record review, the facility failed to: 1) operationalize policies and procedures, to 2) investigate and address allegations of neglect for two residents (R8 and another unknown resident from resident council) who alleged they did not receive afternoon medications, 3) ensure the alleged staff had current abuse/neglect training, and 4) continue to monitor, correct, and prevent further neglect of dressing changes and wound care not being provided, for three residents (R5, R6, and R9) of 4 residents reviewed for wound care after a Facility Reported Incident (FRI) was reported to the State Agency on 5/10/25. Findings include: Review of an Abuse Prevention Program Policy & Procedure last reviewed 1/2025 revealed: Neglect, is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect/Deprivation of Goods and Services by Staff. Abuse also includes the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 1275500. Based on interview and record review, the facility failed to accommodate and provide vision services for 1 resident (Resident #2) of 3 residents reviewed for ancillary services.Findings include: Resident #2 (R2)Review of a Face Sheet for R2 revealed she originally admitted to the facility on [DATE]. In an interview on 7/8/25 at 9:03 AM, Family Member (FM) I reported concerns about R2 needing to see the eye doctor for a few months and as of last month R2 needed new glasses. FM I reported he had talked to the Social Worker (SW) B several times in the past few months about getting R2 an appointment with the in-house optician and had yet to hear anything. On 6/10/25 he came to the facility and R2's glasses were missing, and she was wearing some random pair of black glasses that were not hers. FM I reported the Social Worker did not know where R2 got those glasses. FM I reported he talked to SW B many times about getting an eye doctor appointment that he finally gave up 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.

This citation pertains to intake 1275498, 1275500, and 1275497. Based on interview and record review, the facility failed to provide agency staff training/orientation to the facility prior to starting their shift for 2 of 2 agency nurses reviewed for training and one agency Certified Nursing Assistant (CNA). This deficient practice has the potential to affect all 33 residents who reside at the facility.Findings include: In an interview on 7/9/25 at approximately 11:00 AM, Agency CNA L was questioned if a certain resident wore hearing aids. CNA L reported she did not get that information during the shift change report but should be able to find it in the care plan. At this time, she accessed the Electronic Medical Records (EMR) and could not find the resident on the computer. CNA L reported she did not get a training or an orientation to the facility prior to starting and that was her first day. CNA L reported she would provide that information after she found out. Review of two agency nurse employee files revealed Licensed Practical Nurses (LPN) F and LPN M did not have any…

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 1275498, 1275500, and 1275497.Based on interview and record review, the facility failed to ensure 2 Certified Nursing Assistants (CNA's) received their annual competencies out of 2 CNAs reviewed for sufficient training and continuing competencies. This deficient practice has the potential to affect all 33 residents who reside at the facility.Findings include: Review of the employee files for Certified Nursing Assistants (CNA) J and CNA K revealed they had not received their in-service training that included their continuing annual competencies. In an interview on 7/11/25 at 10:13 AM, the Nursing Home Administrator (NHA) reported that one of the duties of the Human Resource (HR) staff was to complete the annual skills checks. The facility did not have an HR staff at the time of this survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare 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 that consume food from the kitchen. Findings include: During a tour of the kitchen, starting at 9:45 AM on 12/2/24, observation of the two door True cooler found that the left and right doors each had a section of gasket that was ripped and torn. During an interview with Dietary Manager (DM) D, at 10:01 AM on 12/2/24, it was found that he has only been at the facility for a month. When asked if there was any plumbing issues in the kitchen, DM D stated that the faucet and water line leading to the one compartment sink on the dish line leaks when it's in use. When asked if Maintenance is aware of the issue, DM D stated he's been informed, but he's only been here less than a week. During a tour of the lunch service, at 12:10 PM on 12/2/24, it was observed that the plate…

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 the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting residents in following areas: During an observation on 12/02/24 at 9:21 AM, the following were noted in the living area of bed 14-2: (a) the window blinds had multiple broken slats, (b) the foot board of the bed had fall off and laid on the floor at the end of the bed on top of the machine that controlled the APM (alternating pressure mattress), and (c) at the foot of the bed a strip of molding that secured and protected a cord had been pulled off the wall and laid on the floor. During an observation on 12/02/24 at 9:59 AM, the following was noted in the east hall dining room: (a) a television was on for residents to sit and watch, (b) there was a hoyer lift stored in the room, (c) four wheelchairs were stored in the room, and (d) two vitals…

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 notify the Guardian of changes for one (R30) of one resident reviewed for notification of changes. Findings include: R30 Review of a Face Sheet for R30 revealed she admitted to the facility on [DATE] with pertinent diagnoses of fracture, Down syndrome, and adult failure to thrive. Review of the Electronic Medical Record (EMR) for R30 revealed on 10/19/24 she weighed 88.8 pounds, 11/5/24 - 83.8 pounds, 11/8/24 - 82.6 pounds, and on 11/12/24 - 81.4 pounds. No other weights were documented to 12/3/24 as of this survey. This indicates an 8.33% weight loss in less than 30 days. Review of the EMR Food Intake for R30 between 11/4/24 and 12/3/24 revealed she received the following: 12 breakfasts, 9 lunches, and 14 dinners. Several days of the month she received no meals at all. No documentation indicating the Guardian was informed. Review of a Dietary Progress Note for R30 dated 11/8/24 revealed: Wt (weight) review: current wt 83.8#, signif wt (significant…

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 keep comfortable temperatures and a homelike environment for 5 (R10, R3, R13, R29, R4) of 5 residents reviewed for comfortable temperatures and homelike environment. Findings include R10 During an observation and an interview on 12/2/24 at 10:04 AM, R10 was observed in bed bundled up in a blanket and shaking. She said she was shivering because it is cold. The hallway thermostat was not proving a temperature, and the Director of Nursing (DON) verified there was no reading. The Maintenance Director was outside shoveling snow at this time. In an interview on 12/2/24 at 10:25 AM the Maintenance Director (MD) N reported he just started working at the facility. He verified with his thermometer the temperature in room [ROOM NUMBER] was reading between 65.5 degrees F (Fahrenheit) and 68 degrees F. There is a thermostat in the room that is set at 68 degrees. He reported the facility has a boiler system and the hallways have heating/air-conditioning units called…

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 account for controlled substances according to professional standards for three of four residents reviewed. (Resident #28, Resident #29, and Resident #32) Findings: Resident #28 (R28) Review of a Face Sheet revealed R28 was a [AGE] year old female, last admitted back to the facility on [DATE] following a three day stay at the hospital, with pertinent diagnoses of Alzheimer's and history of falling. Review of a Physician Order Summary revealed R28 was ordered Hydrocodone-Actetaminophen (Norco- a controlled substance and opioid pain medication) 5-325 milligrams (mg) one tab twice daily. Review of an Electronic Medication Administration Record (Emar) dated February 2025 for R28 showed nursing documentation that the resident received two doses of Norco 5-325 mg on 02/01/25. Review of a Controlled Substance Proof Of Use form for R28 reflected that the resident only received one dose of Norco 5-325 mg on 02/01/25, as evidenced by only one tablet being signed…

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 food at a palatable temperature to 3 of 16 residents and all residents who consume food resulting in the potential for decreased food consumption and potential nutritional decline. During a tour of lunch service, at 12:08 PM on 12/2/24, an interview with Dietary Manager (DM) D found that the plate warmer has not been working that good since he started a month ago. At this time the plates were found to be 88F. DM D stated that he's only been here a month and has had the plate warmer looked at a couple times. When asked if there was a way to turn it up, DM D stated it only has an on and off switch. Outside of thermal covers, the facility does not use any other equipment to ensure hot food to residents. During an interview with DM D at 12:13 PM on 12/2/24, found that he likes to see 180F from hot food on the steam table in order to keep it hot for residents. When asked to see the temperature sheet for today's lunch, in order to check…

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 consistently provide bedtime snacks to four of four residents (Resident #17, Resident #5, Resident #12, and Resident #133) reviewed. Findings: Resident #17 (R17) Review of a Face Sheet revealed R17 was a [AGE] year old male with pertinent diagnoses of diabetes mellitus, weight loss, and weakness. During an interview on 12/02/24 at 11:50 AM, R17 reported that he does not get offered a bedtime snack consistently. Review of a bedtime snack log for R17 reflected from 11/02/24 to 12/02/24, the resident was offered a bedtime snack on four evenings. Resident #5 (R5) Review of a Face Sheet revealed R5 was a [AGE] year old female with a pertinent diagnosis of insulin dependent diabetes. During an interview on 12/04/24 at 9:40 AM, R5 indicated that sometimes she was offered a snack at bedtime. Review of a bedtime snack log for R5 reflected that from 11/04/24 to 12/04/24, the resident was offered a bedtime snack on eight evenings. Review of a Care Plan for R5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a call light was within reach for one resident ( Resident #133) out of four residents reviewed. Findings: Resident #133 (R133) Review of a Face Sheet revealed R133 was an [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of recent amputation of left leg below the knee, diabetes mellitus, and dementia. During an observation on 12/02/24 at 9:21 AM, R133's call light touch pad sat on the over bed table in the upper right hand corner. The over bed table was partially across the bed below R133's waist. When interviewed, R133 stated that the call light touch pad was in that location when he woke up this morning and has been there since. When asked to try and reach and activate the touch pad call light, R133 could not. During an observation on 12/02/24 at 10:04 AM, staff were seen leaving R133's room. The call light remained out of reach of R133 in the upper right hand corner of the over bed table. During…

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 follow policies and procedures to resolve a grievance for missing items for one (R183) of one resident reviewed for missing items. Findings include: Review of a policy titled Grievances/Concerns last reviewed 1/2024 revealed: Purpose: To support each resident's right to voice grievances and to ensure that a policy is in place to process grievance. Providing prompt actions to resolve grievances/concerns and to keep the resident apprised of progress towards resolution. Please note: Should a grievance/concern be a missing item, please complete the missing item report, track and trend accordingly. In an interview on 12/3/24 at 8:14 AM, R183 reported she has lots of clothes missing and was told by staff that her clothes will come up (appear) but never does. She claims she is missing her winter boots, a pair of pants, some shirts and a gown. R183 reported she told the Administrator who told her needed receipts, but she does not have any receipts because they are things she has already worn. Review of Resident Council Minutes…

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 develop and implement a comprehensive, person-centered care plan for one (R30) of one resident reviewed for care plans and interventions. Findings include: R30 Review of a Face Sheet for R30 revealed she admitted to the facility on [DATE] with pertinent diagnoses of fracture, Down syndrome, adult failure to thrive, anxiety, depression, dorsalgia (pain in the muscles, nerves, bones, joint or other structures associated with the spinal column) and spondylosis (cervical osteoarthritis). Review of the Care Plan for R30 revealed no focus for anxiety and depression, dorsalgia or spondylosis. Review of the admission Minimum Data Set (MDS) dated [DATE] for R30 revealed she is moderately cognitively impaired. She likes doing things with groups of people. She is dependent on staff for toileting, transfers, bathing, dressing, and mobility. She is incontinent of bowel and bladder. Review of the Care Plans for R30 revealed there is no activity care plan, 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 observation, interview and record review, the facility failed to provide foot care for 1 (R13) of two residents reviewed for foot care. Findings include: Review of a Face Sheet for R13 revealed admitted to the facility on [DATE] with pertinent diagnoses of chronic diastolic (congestive) heart failure, diabetes, and chronic obstructive pulmonary disease. During an observation and an interview on 12/2/24 at 10:18 AM, R13 was in his room sitting up in his wheelchair with no shoes on, toes observed contracted and his toenails are very long. He reported he is supposed to see a podiatrist but has not seen one yet. He did not like his toenails being that long. The big toenails were obviously extended beyond the baseline of his nailbed. In an interview on 12/3/24 at 3:27 PM, Social Worker (SW) H reported R13 is on the list to see podiatry as of yesterday. They had a consent for R13 to see podiatry in May of 2023 and was unsure when he was last seen by podiatry. SW H then clarified R13 was last seen in February…

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 safely secure and store an oxygen tank for one (R183) of one resident reviewed for oxygen tank storage. Findings; R183 During an observation and an interview on 12/2/24 at 9:51 AM, R183 was not in her room, and her coat and a bag of belongings sat in a chair. A portable oxygen tank also sat in the chair laying across the arms of the chair. The Director of Nursing (DON) walked by at this time and the placement of the portable oxygen tank was pointed out to her. The DON reported that it should not stored in that manner. Review of an Oxygen Storage policy last reviewed 1/2024 revealed: -[Oxygen] Cylinders must be secured in racks or by chains.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor weights, provide appropriate nutrition, meals and supplements as ordered, and provide assistance with meals for two (R30 and R29) of 2 residents reviewed for nutrition. Findings include: R30 Review of a Face Sheet for R30 revealed she admitted to the facility on [DATE] with pertinent diagnoses of fracture, Down syndrome, and adult failure to thrive. Review of an Initial Nutritional Assessment for R30 dated 10/21/24 revealed: Average po (oral) intake is ranging 51-75% of documented meals since admission and noted to require 1:1 assistance with po intake. Score of 4 on mini nutrition screen indicating malnutrition, request fortified foods and mighty shake (220 kcal (kilocalories), 6 grams pro, ea) BID (twice a day). admission weight on 10/19/24 of 88.8 lbs (pounds), . estimated nutritional needs of 1290-1505 kcal (30-35 kcal/kg r/t (related to) malnutrition) and 43-52 grams protein (1-1.2 gm pro/kg). Continue to monitor weights with…

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

Based on observation, interview, and record review, the facility failed to store and label medications with currently accepted professional standards for 1 of 1 medication carts reviewed. Findings: During an observation on 12/03/24 at 8:00 AM, the medication cart contained 18 loose pills of various shapes and colors. Each of the pills represented a medication that was prescribed by a physician to a resident. The assistant director of nursing (ADON) indicated that the loose pills should not be there. During the same observation a Basaglar insulin kwik pen prescribed to the resident in bed 12-2, did not have a date written on it indicating when the pen was first opened and used. Review of the facility policy Storage and Expiration dating of Medications (5) Once any medication is opened, facility should follow manufacturer guidelines with respect to expiration dates for opened medications Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to: 1) label medications in the medication cart and the medication room and 2) secure a medication cart when unattended, potentially affecting all facility residents, resulting in the potential for residents to receive another resident's medications, the potential for cross-contamination from the sharing of resident medications, the potential for residents to receive expired/ less effective medications, the potential for expired Tuberculin Protein Derivative being administered, the potential for inaccurate tuberculin test results from possible oxidation and degradation of the solution, and the potential for unauthorized access to the medication cart and misappropriation of resident medications. Findings include: During an observation on [DATE] at 7:55 AM, Registered Nurse (RN) D was preparing medications for a resident. After RN D prepared the medications, she walked down the hallway to the resident's room to administer the medications. However, RN D left…

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: 1. Maintain the seals on the cooler unit and keep it clean; 2. Provide adequate/sufficient cold holding equipment in order to ensure proper thawing, cooling and storage of potentially hazardous and non-potentially hazardous foods; 3. Ensure proper working order of a dish machine; 4. Ensure chemicals are being properly stored; 5. Bulk storage containers are properly labeled; 6. Ensure equipment is maintained and functions in properly. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that can affect 25 residents who consume food and beverages from the kitchen. 1. During a tour of the kitchen, on 1/8/24 at 10:25 AM, the True 2 door cooler unit (only commercial cooler) was observed to have torn door seals. Food residues and debris were found on the sides, bottom, and shelving of the cooler unit and was not being properly cleaned/maintained. According to the 2017 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment (A) EQUIPMENT shall be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide 1 of 3 Residents (R84) reviewed for notice of Medicare Non-Coverage with advanced notice of the ending of Medicare coverage, resulting in the potential for R84 to have unexpected medical expenses and financial hardship. Findings included: Review of R84's face sheet, no date revealed he was a [AGE] year-old male admitted to the facility on [DATE] and he had diagnoses that included Dementia, low back pain, visual loss, neuromuscular dysfunction of bladder and overflow incontinence. He was his own responsible party. Review of R84's Notice of Medicare Non-Coverage notification revealed his Skilled Nursing Services would end on 9/26/23. The signature line was blank. There was a handwritten note dated 9/26/23 that indicated a voice mail message was left for someone else (not R84). During an interview with the Nursing Home Administrator (NHA) on 1/9/24 at 8:55 AM, the NHA said she was the one responsible for notifying residents of their change in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00140469. Based on interview and record review, the facility failed to allow a resident to return to the facility after being sent to the hospital for psychiatric issues for one resident, Resident #79 (R79), of three reviewed for facility-initiated transfers, resulting in R79 being displaced and denied psychiatric help due to having to be held in the Emergency Department (ED) for 2-3 weeks because he did not have a home to return to. Findings: Resident #79 (R79) Review of an admission Record revealed R79 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Metabolic encephalopathy-acute, seizures, Bacteremia, Anemia, Borderline personality disorder, Mild intellectual disabilities, Mild cognitive impairment of uncertain or unknown etiology, Depression, Insomnia, Schizoaffective disorder, bipolar type, and Antisocial personality disorder. Review of a Minimum Data Set (MDS) assessment for R79, with a reference date of 9/28/23…

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 collaborate with dialysis for the medical care of 1 Resident (R9) of 1 Resident reviewed for Dialysis care, resulting in the potential for medical needs to be missed. Findings include: R9 Review of R9's face sheet, no date revealed she was a [AGE] year-old female admitted to the facility on stage renal disease, Acute kidney failure, congestive heart failure, diabetes type II, morbid obesity and gout. During an interview with the Director of Nursing (DON) on 1/10/24 at 11:13 AM, the DON was asked how the facility communicates medical concerns with R9's Dialysis staff. The DON said they complete a communication form on dialysis treatment days and place it in a book that goes to dialysis with R9. The DON said staff are to check R9's book on return form dialysis. If the form is not returned, staff are expected to call dialysis for a report and document the conversation in R9's progress notes. The DON reviewed R9's dialysis book and she was not able locate…

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 monthly pharmacy medication regimen review was performed and/or the pharmacy recommendation was acted upon in a timely manner after the physician approved the recommendation for 2 of 5 residents reviewed (R9 and R15), resulting in the pharmacy not performing a monthly medication regimen review for R9, the pharmacy recommendation not being implemented after the physician approved it in a timely manner for R15, the potential for the physician not being made aware of potentially serious concerns with a resident's medication regimen, and the potential for serious adverse effects from a delay in implementing a physician approved pharmacy recommendation. Findings include: R15 A review of R15's Face Sheet, dated 1/9/24, revealed R15 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R15's Face Sheet revealed multiple diagnoses that included repeated falls, stage 3 chronic kidney disease (a disease and stage in which 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 provide collaborative care for 1 hospice Resident (R24) of 1 Resident reviewed for hospice care, resulting in the potential for unmet needs. Findings included: Review of R24's face sheet no dated revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Multiple sclerosis, bipolar disorder, heart failure, chronic pain, and acute respiratory failure with hypoxia. R24 was her own responsible party. R24 was observed in bed on 1/8/24 at 10:47 AM. R24 said she was in hospice care. R24 was asked what days hospice provides care. R24 said they do not have any specific days. R24 denied ever being asked when she wanted care or being provided a schedule for hospice staff visits. During an interview with R24's hospice Registered Nurse (RN) C at the nurse's station, on 1/10/24 at 9:07 AM, RN C was asked about hospice staff scheduling R24's care. RN C she does not schedule R24's care because she is in 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.

Based on interview and record review, the facility failed to have the required Quarterly Quality Assessment and Assurance Committee meeting that included key personnel (Medical Director, Director of Nursing, and at least one of who must be: Nursing Home Administrator, a board member or other individual in leadership role and the Infection Preventionist) for 1 of the 4 quarters in 2023, resulting in the potential for quality improvement concerns to be missed. Findings included: During the Quality Assessment and Assurance (QAA) review with the Nursing Home Administrator (NHA) on 1/19/24 at 2:21 PM the NHA said she started at the facility in August of 2023. The NHA said the Quality Assessment and Assurance (QAA) Committee meets monthly. The NHA reviewed the QAA book, and each month had a tab with a signature page for everyone that attended the meetings for that month. Signature pages for January through May of 2023 did not reveal that all key personnel (Medical Director, Director of Nursing, and at least one of who must be: Nursing Home Administrator, a board member or other individual…

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.