Clearstream Rehabilitation and Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2674240Based on observation, interview and record review, the facility failed to protect the residents' right to be free from resident-to-resident physical abuse for 2 (Resident #103 and Resident #104) of 4 residents reviewed for abuse resulting in Resident #104 grabbing Resident #103 by the arm, and Resident #103 slapping Resident #104 in the face.Findings include:Resident #103Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills) and generalized anxiety disorder (mental health condition characterized by persistent feelings of worry and restlessness).Review of a Minimum Data Set (MDS) assessment for Resident #103 with a reference date of 11/29/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 0/15, which indicated the resident was severely cognitively…

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 R61 According to the Minimum Data Set (MDS) dated [DATE], R61 was cognitively intact as evidenced by her BIMS (Brief Interview Mental Status) score of 14/15. During an observation and interview on 3/31/25 at 12:15 PM, R61 was awake in bed with her head-of-bed (HOB) at the window. The windowsill track was littered with dead bugs, dust, and debris. The tile sill was cracked and chipped with a large chunk of it missing. The veneer around the bed head board was pulled away from the wood leaving an area large enough to put a hand through. R61 stated, I keep my house neat, tidy, and clean. I would never have my house like this. I have a handyman that helps me at home to keep things fixed. I'm glad I'm going home tomorrow. During an observation and interview on 4/1/25 at 8:00 AM, the window curtain at R61's HOB had a stain the size of a saucer cup at eye level of the resident. R61 stated, I'll be glad when I go home today. I would have stains like this cleaned up. Based on observation, interview, and record review 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 maintain professional standards of nursing practice and notify the provider of missed medication doses, 2 of 19 residents (Resident #6 and Resident #338) reviewed for professional standards, resulting in missed medications and treatments, and the potential for the worsening of a condition and a delay in treatment. Findings include:Resident #6 Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included atrial fibrillation (irregular rapid heart rate that commonly causes poor blood flow). Review of Resident #6's Medication Administration Orders (MAR) revealed, Symbicort Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) (combination inhaler used to treat asthma and chronic obstructive pulmonary disease) 2 puff inhale orally every morning and at bedtime . During a medication administration observation on 4/1/25 at 8:19 AM, Licensed…

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 facial hair grooming was offered and/or provided and/or clean hair was maintained for 4 (Residents #12, 14, 17, 53) of 6 residents reviewed that were dependent on staff for activities of daily living resulting in unwanted facial hair, debris in hair, appearing unkempt, and the potential for feeling embarrassed or having decreased self-worth. Findings include: Resident #12 Review of Resident #12's most recent brief interview for mental status score, dated 2/19/2025, was scored 5 which indicated Resident #12 had severe cognitive impairment. During an observation and interview on 03/31/25 at 10:57 AM, Resident #12 was seated in her wheelchair in the dining/activity room of the locked memory care unit of the facility, appeared confused, and was unable to answer questions asked by the surveyor. Resident #12 had long white facial hairs over the surface of her chin. The hairs' lengths varied, but many were approximately half an inch in length. During an observation on 03/31/25 at 03:49 PM, Resident #12 was…

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

Based on observation, interview, and record review the facility failed to consistently provide residents with their food and beverage preferences for 12 residents (Residents #17, 53, 65, 2, 64, 85, 12, 14, 76, 22, 24, and 338) out of a facility census of 88 resulting in incorrect items provided, decreased satisfaction, and the potential for frustration, weight loss, and/or dehydration. Findings include: During an observation on 04/01/25 at 08:55 AM, Resident #17's breakfast tray was delivered to the dining room of the locked memory care unit and the meal ticket stated, Beverages Apple Juice, Chocolate Boost (nutritional supplement drink), . She was provided a red beverage (not apple juice) and was given a Vanilla Ensure Plus nutritional supplement drink (this is not a comparative product as it contains 110 calories more than an original Boost drink). Additionally, the alternate product provided was vanilla, when her meal ticket preference indicated the Chocolate flavor should be provided. During an interview on 04/01/25 at 08:59 AM, Registered Nurse FF reported if Resident #17…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were cared for with dignity and respect for 1 (Resident #54) of 2 residents reviewed for dignity, resulting in the potential for feelings of embarrassment, frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being. Findings include: Resident #54 Review of an Minimum Data Set (MDS) assessment revealed Resident #54 was originally admitted to the facility on [DATE] with pertinent diagnoses which included diabetes. Review of an MDS assessment for Resident #54, with a reference date of 2/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #54 was cognitively intact. During an interview on 3/31/25 at 1:48 PM, Resident #54 reported that she was frustrated with how some of the staff interacted with and talked about residents. Resident #54 reported that a few days ago, she had overheard Certified Nursing Assistants (CNA) P and Q in the hallway making…

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 updated and accurate advanced directive information was in place for 1 of 19 residents (Resident #338) 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 #338 Review of an admission Record revealed Resident #338 was originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension (high blood pressure). Review of Resident #338's Designation of Patient Advocate Form dated 7/23/24 revealed Resident #338 had designated Family Member (FM) RR as her patient advocate to act in accordance with her end of life decisions .2. Specific Instructions Regarding Life-Sustaining Treatment: I understand I do not have to choose one of the instructions regarding life sustaining…

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 responsible party of a change in resident condition in 1 of 2 residents (R7) reviewed for notification of changes, resulting in the guardian/emergency contact not being made aware of an injury of unknown origin (R7) causing the inability to participate in timely medical decision-making. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R7 was moderately cognitively impaired as evidenced by her BIMS (Brief Interview Mental Status) score of 10/15. Her diagnoses included dementia and Alzheimer's disease with no mention of intermittent urinary catheterization. Review of R7's Progress Note dated 3/15/2025 at 00:30 (AM) revealed, . When doing straight cath at this time noted that her labia (inner and outer folds of vulva at either side of vagina) was bruised bilaterally (both sides) and swollen. Had 1/4-inch laceration above urethra (duct that drains urine from body) . During an interview on 4/2/25 at 12:27 PM, Registered…

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 MI00150533 Based on interview, and record review, the facility failed to prevent the misappropriation of resident narcotic medications in 1 of 1 residents (Resident #64) reviewed for misappropriation of property, resulting in loss of resident's pain medication, and the potential for uncontrolled pain and discomfort. Findings include: Resident #64 Review of an admission Record revealed Resident #64 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness. Review of the facility's Drug Diversion Investigation revealed, On Thursday January 23rd at approximately 4:30 PM (Director of Nursing B) received a phone call from (Facility pharmacy) regarding a narcotic discrepancy regarding (Resident #64) Percocet (narcotic) script (prescription) . The pharmacy stated that they had a discrepancy for 20 unaccounted for Percocet . (DON B) was also unable to locate the shift narcotic count sheet for same said script. There was no line item 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 operationalize its abuse policy and procedure for 1 resident (R7) of 2 residents reviewed for potential sexual abuse, resulting in staff not reporting observations of abuse to the Nursing Home Administrator immediately, potential for further resident to resident observations of abuse to go unreported and uninvestigated. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R7 was moderately cognitively impaired as evidenced by her BIMS (Brief Interview Mental Status) score of 10/15. Her diagnoses included dementia and Alzheimer's disease with no mention of intermittent urinary catheterization. Review of R7's Progress Note dated 3/15/2025 at 00:30 (AM) revealed, . When doing straight cathed (using a device to drain urine from bladder) at this time noted that her labia (inner and outer folds of vulva at either side of vagina) was bruised bilaterally (both sides) and swollen. Had 1/4-inch laceration above urethra (duct that drains urine…

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 update and revise the person centered care plan in a timely manner with appropriate interventions for the prevention of falls for 1 resident (#43) from a total sample of 19 residents, with the potential for physical, mental, and psychosocial unmet care needs and harm. Findings include: .One of the biggest safety challenges is preventing falls .3 of every 4 nursing center residents fall each year .Nursing staff must have the knowledge and skills to prevent injury from falls .Previous falls, diminished strength, gait and balance impairments, medications, Alzheimer's disease or dementia, vision impairment and environmental risk factors .Staffing and organization of care. Inadequate staffing may leave residents who are likely to fall without proper supervision . https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html Resident #43: Review of an admission Record revealed Resident #43 was a male 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent, treat, and promote healing of pressure ulcers in 1 of 1 residents (Resident #288) reviewed pressure ulcers, resulting in the potential for delayed healing of pressure ulcers, infection and the development of new ulcers. Findings include: Review of an admission Record revealed Resident #288 was a female with pertinent diagnoses which included pressure ulcer of right buttock stage 3, pressure ulcer of left ankle unstageable, pressure ulcer of left heel stage 3, chronic venous hypertension with ulcer of bilateral lower extremity (sustained high blood pressure in leg veins leading to open sores or wounds that are slow to heal), and pressure ulcer of other site stage 3. Review of Care Plan for Resident #288 with an initiation date of 3/25/25, revealed the focus, .The resident has cellulitis of the (SPECIFY) r/t (related to) Fragile skin .RLE lymphatic generalized vascular ulcer admission…

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 safety precautions and use of assistive devices for 1 (Resident #33) of 4 residents which have the potential to negatively affect the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #33: Review of an admission Record revealed Resident #33 was a male with pertinent diagnoses which included acquired absence of right leg above the knee, multiple sclerosis (immune system eats away at the protective covering of the nerve fibers and interrupts communication between the brain and the rest of the body), blindness left eye, and muscle wasting and atrophy (loss of muscle mass and strength). Review of Care Plan for Resident #33 revealed the focus, .(Resident #33) is at risk for falls r/t (related to) blind in left eye/low vision, medication use . with intervention .Transfer: Resident is able to use slide board . Review of General Progress Notes dated 6/7/2024 at 7:51 PM, revealed, .Writer…

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 emergency physician services were utilized by facility staff for one resident (R7) of 19 reviewed for emergency physician care needs, resulting in not receiving prompt physician emergency services and the increased potential for complications to a serious health condition. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R7 was moderately cognitively impaired as evidenced by her BIMS (Brief Interview Mental Status) score of 10/15. Her diagnoses included morbid obesity, anxiety disorder, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure. Review of R7's Progress Note dated 3/19/25 at 14:45 (2:45 PM) indicated R7 had returned from the hospital at this time. Review of R7's Progress Note dated 3/20/2025 at 4:13 (AM) revealed, Patient still has yet to void since returning from the hospital the evening of 3/19. This writer called patients provider (Physician KK) afterhours…

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 medication error rate of less than five percent in 2 of 11 residents (Resident #338 and #6) reviewed for medication administration, resulting in a medication error rate 12% and the potential for adverse effects. Findings include: Resident #338 Review of an admission Record revealed Resident #338 was originally admitted to the facility on [DATE] with pertinent diagnoses which included hypertension (high blood pressure). Review of Resident #338's MAR revealed, Coreg Oral Tablet 3.125 MG (Carvedilol) (blood pressure medication). Give 1 tablet by mouth two times a day for HTN (hypertension) hold dose if SBP (systolic blood pressure) less than 90 or HR (heart rate) less than 50. Review of Resident #338's MAR revealed, Depakote (antipsychotic medication) ER Oral Tablet Extended Release 24 Hour (Divalproex Sodium) Give 1 tablet by mouth two times a day related to bipolar disorder Review of Resident #338's MAR revealed, Depakote ER…

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 1 medication carts resulting in the potential for decreased efficacy of medications and the exacerbation of medical conditions. Findings include: During an observation of the B hall medication cart with Registered Nurse (RN) FF on 4/1/25 at 12:48 PM, one opened insulin lispro (Humalog) pen was noted in the top shelf of the cart. The pen was labeled with the resident's name, but the date the medication was opened was missing. RN FF confirmed that nurses were suppose to label the insulin pens when they open them, and this was missed. In the stock meds (medications used for multiple residents) area of the cart there was one opened bottle of Mucus ER (Medication to help thin mucus) which did not have an open date, and one opened bottle of Cetirizine 10 mg (Allergy medication) that also did not include an opened date. RN FF reported that nurses were suppose to label the medications when they were opened, and this was missed. During an interview on 4/2/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to effectively implement infection control measures that included: 1.) effective implementation of Enhanced Barrier Precautions (EBP) for 2 residents (R7 and R338) 19 residents reviewed for infection control, resulting in the potential for cross contamination of infection to a vulnerable population. Findings include: R7 According to R7's medical records, an Order Summary dated 3/23/25, indicated R7 Maintain foley catheter with 18 Fr 10 cc balloon (size) for urinary retention (diagnosis). Further review of R7's Order Summary on 3/31/25, did not indicate the resident was placed on EBP. Review of R7's Care Plan did not indicate a resident-specific treatment plan for Enhanced Barrier Precautions. Review of R7's Progress Note dated 3/22/2025 at 22:45 (10:45 PM) revealed, .Foley catheter 16FR (french) 10cc balloon inserted. Observed on 3/31/25 at 11:52 AM, R7 lying in bed with a urinary catheter bag attached to her bed. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00146924. Based on interview and record review, the facility failed to ensure proper post-fall care and assessment for 1 (Resident #106) of 3 residents reviewed for falls, resulting in the potential for serious injury. Findings include: Review of the facility's Fall-Care and Treatment policy with a reference date of 7/11/18 revealed Policy: It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care. Procedure: 1. Resident will not be moved until a nurse evaluates the resident's condition. Review of Post-Fall Assessments, published by the American Association of Post-Acute Care Nursing, August 2021, revealed Before a resident can be moved, the nurse must assess them for an injury to the spinal column, obvious fractures, significant bleeding . Review of an admission Record revealed Resident #106, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction…

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 immediately notify the resident's physician of a change in condition in 1 of 4 residents (Resident #103) reviewed for physician notification, resulting in lack of assessment and physician involvement following two unwitnessed falls, with known head trauma. Findings include: Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses which included dementia. Review of Resident #103's Nurse's Note dated 4/13/24 at 11:15 PM written by Registered Nurse (RN) N revealed, Resident kneeling at side of bed with forehead touching the floor .Resident does not know what happened. VSS (vital signs stable) and denies pain. Resident placed in wheelchair and brought to common area to observe. Hospice notified, (Director of Nursing (DON) B) notified and Guardian notified. At 11:45 PM while charting above note, this nurse heard sound behind and turned to find same resident on the floor. Raised bump at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00144035 and MI00144038. Based on observation, interview, and record review the facility failed to protect the resident's right to be free from resident to resident physical abuse in 2 of 4 residents (Resident #105 and #104) reviewed for abuse, resulting in Resident #104 being physically abuse by Resident #105 twice in an 8 day period. Findings include: Review of a Facility Reported Incident dated 4/1/24 at 1:30 PM revealed, .Multiple staff witnessed (Resident #105) have her hands on (Resident #104's) shoulders. (Resident #105) was walking past (Resident #104) and stopped behind her, then placed her hands on (Resident #104's) shoulders .Investigation: .When asked why (Resident #105) touched (Resident #104) she stated, because she wanted (Resident #104) to know that people were watching her. (Resident #105) stated that she came behind (Resident #104) and placed her hands on (Resident #104's) shoulders and gave a little squeeze .When asked why (Resident #105) did this,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to recognize and report an injury of unknown origin for 1 resident (Resident #103) of 4 residents, reviewed for reporting, resulting in the lack of reporting and the potential for a delay in the investigation. Findings include: Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses which included dementia. Review of Resident #103's Hospice Phone Communication Records dated 4/15/24 revealed, .facility stating patient woke up this morning complaining of right hip pain and they want to get an x-ray. I asked if they had some pain medication to treat the pain and she does so she will give the pain medication. I asked if she has fallen or injured her hip in any way and the CG (caregiver) is not aware of any injury. So at this time we will not order an X-ray but treat the pain and will let RNCM (registered nurse case manager) know of the request. Review of Resident #103's Progress Note…

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 complete and accurate documentation of post fall assessments for 1 of 12 residents (Resident #103) reviewed for complete and accurate medical documentation, resulting in the potential for insufficient follow up and lack of necessary interventions. Findings include: Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses which included dementia. Review of Resident #103's Nurse's Note dated 4/13/24 at 11:15 PM revealed, Resident kneeling at side of bed with forehead touching the floor .Resident does not know what happened. VSS (vital signs stable) and denies pain. Resident placed in wheelchair and brought to common area to observe. Hospice notified, DON notified and Guardian notified. At 11:45 PM while charting above note, this nurse heard sound behind and turned to find same resident on the floor. Raised bump at right temple with purple center. No open abrasion. Placed 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.

Based on interview and record review, the facility failed to employ either a full time Registered Dietitian or Certified Dietary Manager to provide oversight of kitchen and clinical nutritional services. This deficient practice has the increased potential to result in food service sanitation failures, food borne illness, or inadequate assessment of high-risk residents. Findings include: During an interview with Dietary Director (DD) W, at 8:58 AM on 3/25/24, it was found that she took over the position two to three years ago. When asked if she was a Certified Dietary Manager, DD W stated that she enrolled in the course in February of this year, but has had a hard time finding the time to take the classes outside of work, as she has been filling in spots where they have open positions or staff call ins. When asked how often there is a dietitian onsite, DD W stated that the dietitian comes here regularly, but she has a couple other buildings she goes to as well. Record review at this time confirmed that there was no Certified Dietary Manager records for DD W.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Clean food and non-food contact surfaces to sight and touch; 2. Ensure proper cooling of potentially hazardous foods; 3. Ensure proper working order of the dish machine; 4. Provide accurate sanitizer test strips; 5. Maintain equipment in good repair; 6. Ensure general cleaning of the kitchen; 7. Properly wash hands and protect food from contamination; and 8. Properly date mark and discard food product. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 83 residents who consume food from the kitchen. Findings Include: 1. During a tour of the kitchen, at 9:14 AM on 3/25/24, observation of the top gaskets on unit #4 and unit #2 were observed with an accumulation of debris. During a tour of the kitchen, at 9:28 AM on 3/25/24, it was observed that the clean utensil drawer, containing mechanical scoops, was found with an accumulation of food debris and crumbs 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement an effective infection control surveillance plan, ensure cleaning of shared equipment between residents, maintain resident equipment in clean condition, store resident care supplies in a manner to prevent the spread of infection, and prevent cross-connections for plumbing fixtures, with the potential to affect all 83 residents who reside at the facility, resulting in the potential for the spread of infection without timely identification and response, disease exposure, cross-contamination, and the development and spread of infection to a vulnerable population. Findings include: Review of the policy/procedure Infection Prevention and Control Program Overview, dated 7/11/18, revealed .The goals of the infection prevention and control program are to: A. Decrease the risk of infections and communicable diseases to residents, employees, volunteers and visitors. B. Monitor for occurrence of infection and communicable diseases and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration and post-fall assessments in 6 of 11 residents (Resident #135, #56, #77, #24, #78, & #65) reviewed for medication administration, and 1 of 3 residents (Resident #47) reviewed for falls, resulting in medications left unattended at the bedside, medications being pre-set for administration with the potential for medication errors and adverse effects, ordered medications not being delivered and administered, and neurological checks not being completed after an unwitnessed fall. Findings include: Review of the policy/procedure Medication Access and Storage, dated 7/11/18, revealed .It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Only licensed…

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 in 2 of 5 residents (Resident #59 & #45) reviewed for sufficient staffing, with the potential for all residents to be affected, resulting in missed showers/baths, a lack of supervision of residents at risk for falls and elopement, and long call light wait times. For additional information see citations F677 and F689. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 1589-1592). Elsevier Health Sciences. Kindle Edition.Time management, therapeutic communication, patient education, and compassionate implementation of bedside skills are just a few of the essential skills you need. It is important for your patients to leave the health care setting with a positive image of nursing and a feeling that they received quality care. Your patients should never feel rushed. They need to feel 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 ensure residents were free from physical restraints for staff convenience in 1 (Resident #60) of 3 residents reviewed for restraint use, resulting in potential for injury, and/or psychological harm. Findings include: Resident #60 Review of an admission Record revealed Resident #60 was originally admitted to the facility on [DATE] with pertinent diagnoses which included alzheimer's disease with late onset. Review of a Minimum Data Set (MDS) assessment for Resident #60, with a reference date of 2/8/24, revealed a Staff Assessment for Mental Status indicated that Resident #60 had short and long term memory problems, and her cognitive skills for daily decision making were severely impaired. Review of Resident #60's Orders revealed, Geri- chair (specialized recliner chair that is designed to assist with limited mobility) tray table for increased positioning. Start date: 9/7/23. During an observation on 3/24/24 at 11:56 AM, Resident #60 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 policies and procedures for reporting an allegation for potential abuse for 1 (Resident #64) of 18 residents reviewed for reporting, resulting in the potential for continued unidentified, unreported neglect to occur. Findings include: Review of an admission Record revealed Resident #64 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of a Minimum Data Set (MDS) assessment for Resident #64, with a reference date of 1/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #64 was severely cognitively impaired. During an interview on 3/25/24 at 11:59 AM, Certified Nursing Assistant (CNA) G reported that she had been made aware of an allegation that a staff member had used a gait belt to restrain Resident #64 in his wheelchair. CNA G reported that she believed the incident had been reported to management at the facility, because she recalled 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on obsevation, interview and record review, the facility failed to conduct a thorough investigation into an alleged staff to resident abuse (restraint with gait belt to a wheelchair) for 1 (Resident #64) of 18 residents reviewed for abuse/neglect, resulting in an incomplete and thorough investigation and the potential for abuse to continue. Findings include: Review of an admission Record revealed Resident #64 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of a Minimum Data Set (MDS) assessment for Resident #64, with a reference date of 1/17/24, revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #64 was severely cognitively impaired. During an observation on 3/24/24 at 10:06 AM, Resident #64 was sitting in the main living room area on the unit in his wheelchair. Resident #64 was restless and attempted to stand up out of his wheelchair multiple times. It was noted that Resident #64 did not have a gait belt on.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement person centered comprehensive care plans for 1 (Resident #33) of 18 residents reviewed for care plans, resulting in missed assessments and monitoring for potential side effects related to use of psychotropic medications. Findings include: Review of an admission Record revealed Resident #33 was originally admitted to the facility on [DATE] with pertinent diagnoses which included anxiety and major depression disorder. Review of Resident #33's Orders revealed, QUEtiapine Fumarate Oral Tablet 300 MG (Antipsychotic medication). Give 1 tablet by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition. Start date: 2/29/24. Review of Resident #33's Orders on 3/24/24 did not reveal orders in place for monitoring of psychotropic medication side effects or antipsychotic behavior tracking. Review of Resident #33's Care Plan on 3/24/24 did not reveal a psychotropic medication use care plan.…

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 routine showers to dependent residents for 2 or 4 residents (Resident #45 and #59) reviewed for activities of daily living, resulting in residents feeling dirty and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #45 Review of an admission Record revealed Resident #45 admitted to the facility on [DATE] with pertinent diagnoses which included urinary incontinence, muscle weakness, and alzheimers disease. Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 12/14/2023 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated Resident #45 was severely cognitively impaired. Further review of the same MDS assessment revealed Resident #45 required substantial assistance with bathing. In an interview on 3/26/2024 at 9:47 AM, Regional Nurse Consultant VV…

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 appropriately maintain, store and label respiratory treatment supplies for 3 residents (Resident #8, #76 & #13) reviewed for respiratory care, resulting in the potential for respiratory infections and the exacerbation of respiratory conditions cross-contamination of respiratory equipment, and growth of infectious microorganisms. 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: chronic obstructive pulmonary disease (COPD). Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 1/25/24 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #8 was cognitively impaired. In an observation on 3/24/24 at 1:25 PM., Resident #8 was noted in her room sitting up on the side of her bed. Resident #8's nebulizer machine (delivers medications for respiratory…

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.