Greentree of Hubbell Rehabilitation and Health

Based on observation, interview, and record review, the facility failed to ensure residents received diets as prescribed by a physician and in accordance with the plan of care for four Residents (#1, #17, #28 and #34) of five residents reviewed for therapeutic diets. Findings include:Resident #28 (R28)During breakfast meal rounds on 3/2/2026 at 8:05 AM, R28 was noted to have scrambled eggs and sausage with gravy served. R28's meal tray card indicated Diet: 2gm (gram) Na+ (Sodium).During an interview on 3/2/2026 at 8:35 AM, the Certified Food Service Manager (CFM) T was asked about the diet and she stated, We are out of low sodium gravy right now.The medical record for R28 indicated a physician diet order dated 9/4/2025 of No Added Salt (NAS), Low fat. Beneprotein (a protein supplement) BID (twice daily).Resident #17 (R17)During breakfast meal rounds on 3/3/2026 at 8:25 AM, R17 was observed to be eating in the dining room and received a cheese and egg croissant and oatmeal. R17's meal tray card indicated a Diet: 2gm Na+.The medical record for R17 indicated a physician diet order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain consent for psychotropic medications for one Resident (#3) of five residents reviewed for unnecessary medications. Findings include: Resident #3 (R3)Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed admission to the facility on [DATE], with diagnoses including: anxiety disorder, depression, and post traumatic stress disorder [(PTSD) A mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or violent events].Review of R3's Electronic Medical Record (EMR) included active physician orders for the following medications:Chlorpromazine Oral Tablet 50 MG(milligram),Duloxetine Oral Capsule Delayed Release Sprinkle 60 MG- 1 capsule by mouth (psychotropic medication prescribed for depression), and;Mirtazapine Oral Tablet 30 MG Give 1 tablet by mouth at bedtime (psychotropic medication prescribed for depression).The EMR did not reveal any consent signed by the R3 or their responsible party.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 observation, interview, and record review the facility failed to deliver mail/package unopened for one Resident (#20) of one resident reviewed for privacy related to receiving mail.Findings include:Resident #20 (R20)During an interview on 3/1/2026 at 2:28 PM, R20 voiced a concern about not receiving a package on the preceding Friday (2/27/2026). R20 had ordered a product and had been advised by a family member the order had been acknowledged as delivered. R20 stated they did not receive the package and had requested her Certified Nurse Aide (CNA) U look around the building for it. R20 said, I got it Saturday when I asked (CNA U) to look for me. R20 said CNA U found it opened in the conference room. R20 said, It had been opened and left there. I was very mad. I filled out a complaint and reported it to the administrator. The package was in R20's room and was observed to be clearly addressed to R20.During an interview on 3/1/2026 at approximately 2:35 PM, CNA U stated they did find the package on Saturday (2/28/2026) opened and in the conference room and they delivered it to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide information to formulate an advance directive for two Residents (#3 and #49) of twelve residents reviewed for advance directives.Findings include:Resident #3 (R3)Review of R3's Minimum Data Set (MDS) assessment, dated 2/17/26, revealed admission to the facility on [DATE].Review of R3's Electronic Medical Record (EMR) did not reveal the resident/responsible party had received advance directive information or formulated an advance directive.Resident #49 (R49)Review of R49's MDS assessment, dated 11/18/25, revealed admission to the facility on 5/16/25.Review of R49's EMR did not reveal the resident/responsible party had received advance directive information or formulated an advance directive.During an interview on 3/2/26 at 2:45 p.m., Social Services Designee (SSD) V reported the advance directives had not been completed for these residents and were supposed to be done on admission and reviewed quarterly.Review of policy titled Communication 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 interview and record review, the facility failed to provide timely information of a change in coverage and subsequent changes in the amount billed for services for one Resident (#35) of three residents reviewed for receipt of Notice of Medicare Non-coverage. Findings include:Resident #35 (R35)The facility presented a list of residents whose Medicare Part A Service had ended and were eligible to receive a Notice of Medicare Non-coverage (a document to alert of payment changes). Three residents on this list were chosen, and their medical records were requested to ensure proper notification had been delivered two days prior to a change in billing.On 3/3/2026 at 2:37 PM, during this review, it was determined R35 was notified his Medicare coverage for current PT/OT/ST (Physical Therapy/Occupational Therapy/Speech Therapy) services would end on 10/8/2025. This form instructed the resident how to appeal this decision to end coverage and what would happen next. The signature line indicated R35 was notified that coverage of my services will end on the date on this notice, and that I…

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# 2631101 Based on observation, interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property, by a staff member for one Resident (Resident #51) of three residents reviewed for misappropriation of property, resulting in 120 narcotic medication pills missing, increased potential for undetected controlled drug diversion and the potential for uncontrolled pain and discomfort with medication delivery delays from refill too soon notices flagged by the pharmacy provider.Findings include:Review of the Food and Drug Administration current labeling information https://www.fda.gov/drugsatfda read in part: NORCO. Abuse.NORCO contains hydrocodone, a substance with a high potential for abuse similar to other opioids including fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, and tapentadol, can be abused and is subject to misuse, addiction, and criminal diversion .Resident #51 (R51)Review of 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.

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for psychotropic medications for one Resident (#20) of five residents reviewed for unnecessary medications.Findings include:Resident #20 (R20)A review of R20's electronic medical record (EMR) revealed an admission date of 5/1/2024 with diagnoses which included depression and anxiety disorder. The medical record included active Physician's Orders dated 3/1/22 including: Cymbalta (psychotropic medication prescribed for anxiety) Oral Capsule Delayed Release Particles 60 MG (milligrams) and busPIRone (psychotropic medication prescribed for depression) HCl (hydrochloride) Oral Capsule 10 MG.The Care Plan for R20 included focus plans for antidepressant medications and antianxiety medications.During an interview on 3/2/2026 at 3:40 PM, the Director of Nursing (DON) was asked if the facility had tried a gradual dose reduction (GDR). The DON stated, We rely on our pharmacist to let us know when GDRs are due.The EMR was reviewed and no evidence of a GDR attempt could be found. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain a PASARR (Preadmission Screening/Annual Resident Review) prior to admission for one Resident #3 (R3) of one resident reviewed for PASARR screening.Findings include:Resident #3 (R3)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE] with active diagnoses that included: Post Traumatic Stress Disorder (PTSD), anxiety disorder, depression, and Non-Alzheimer's dementia.During an interview on 3/2/26 at 3:33 p.m., Registered Nurse (RN) X reported we complete the PASSAR just prior to admission to the facility and then annually.the only one for R3 was completed on 10/2/24 and not one prior to her admission on [DATE]. R3 does need a new or updated PASSAR.Review of policy titled Resident Assessment-Coordination with PASARR Program date reviewed/revised 8/14/25 read in part .This facility coordinates assessments with the preadmission screening and resident review (PASARR) program.all applicants to 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 observation, interview, and record review, the facility failed to store oxygen equipment in a sanitary manner for two Residents (#18 and #37) of three residents reviewed for oxygen equipment and storage.Findings include:Resident #18 (R18) Review of R18's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 4/1/24 with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD) [a progressive long term lung disease that causes obstructed airflow, making it hard to breathe] and anxiety disorder. During an observation on 3/2/26 at 7:38 a.m., R18's oxygen tubing was draped over an oxygen concentrator with the nasal cannula laying on the floor. During an interview on 3/2/26 at 8:23 a.m., Registered Nurse (RN) B reported, R18 on not on continuous oxygen but the oxygen cannula and tubing is supposed to be in a bag when not in use, not just lying on the floor. Resident #37 (R37) A review of R37's medical record revealed a most recent admission date of 1/29/2026 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 interview and record review, the facility failed to identify triggers or implement a comprehensive person-centered care plan for one Resident #3(R3) of one resident reviewed for Post Traumatic Stress DisorderFindings include:Resident #3 (R3)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE] with active diagnoses including post traumatic stress disorder [(PTSD) a mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or violent events], anxiety disorder, depression, and Non-Alzheimer's dementia.Review of Electronic Medical Record (EMR) revealed a psychiatric or mental health consult dated 1/8/26, read I part .Psychiatry Follow up.Post Traumatic Stress Disorder.Nonpharmacologic: maintain trauma informed approach, minimize environmental triggers when possible, use calm redirection/distraction, and comfort measures. Continue close observation for agitation/distressDuring an interview on 3/2/26 at 9:20 a.m., Social…

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

Based on interview and record review, the facility failed to ensure two Certified Nurse Aides (CNA's) [ L and N] of five CNA's reviewed for competencies had the required yearly competency trainings, including demonstration in skills and techniques necessary to care for residents.Findings include:A review of facility staff personnel records revealed CNA L was hired 1/15/24. CNA L's personnel record did not demonstrate dated competency skills since the date of hire.A review of facility staff personnel records revealed CNA N was hired 2/24/23. CNA N's personnel record did not demonstrate dated competency skills since the date of hire.During an interview on 3/3/26 at 8:34 a.m., Business Office Manager (BOM) O reported two of the CNA's do not have competency trainings in their personnel files and the staff is supposed to have annual competency training.Review of policy titled Competency Evaluation date reviewed/revised 1/1/25, read in part It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skill for performing their job.evaluating…

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 eligible residents were administered pneumococcal vaccinations after receiving consent for 2 Residents (#7 & #28) of 5 residents reviewed for immunizations/vaccinations and;Have a process for tracking and securely documenting the pneumococcal vaccination status of residents. Findings include: Resident #7 (R7) Review of an admission Record revealed R7 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 R7 with a reference date of 02/17/2026 revealed a Brief Interview for Mental Status (BIMS) score of 06/15 which indicated R7 was cognitively impaired. Review of R7's Electronic Medical Record (EMR) read in part: General Progress Note 2/25/2026 09:54 Text: (Registered Nurse) RN entered Resident's room to give resident morning medications. Resident was sitting up in bed. RN called out Resident's name. Resident was slow…

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 deficient practice pertains to Intake 2728102.Based on interview and record review, the facility failed to monitor and notify a physician of a change of condition for one Resident (#1) of three residents reviewed for quality of care.Findings include:Resident #1 (R1)Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia, dysphagia, and chronic kidney disease.Review of R1's EMR revealed the following entries:A General Progress Note written by Registered Nurse (RN) C on 1/7/26 at 14:10 [2:10 PM] read: RN did a breathing treatment and [R1's] SPO2 [oxygen saturation] was 82%. Resident was trying to eat breakfast and didn't want to continue breathing treatment. Oxygen was applied and resident is tolerating it.A Communication with Physician note written by Licensed Practical Nurse (LPN) B on 1/8/26 at 11:35 AM read, in part: Resident sat (oxygen saturation) drops with oxygen titration after finishing course 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 This deficient practice pertains to Intake 2728102.Based on interview and record review, the facility failed to monitor respiratory symptoms per the guidelines set forth by the Centers for Disease Control and Prevention (CDC) for one Resident (#1) of three residents reviewed for infection control.Findings include:Resident #1 (R1) Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia, dysphagia, and chronic kidney disease. Review of a complaint submitted to the State Agency (SA) on 1/28/26, read, in part: Patient [R1] was transferred to our ER [emergency room] on 1/8[2026] with severe respiratory issues and was confirmed covid positive. The nursing home did not test her when she first showed symptoms. She [R1] was only treated for pna [pneumonia].Review of R1's EMR revealed a Communication with Physician note written on 12/29/25 at 15:34 [3:34 PM] which read, in part: Resident presenting with congested cough…

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# 2561427.Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs in 4 of 5 residents (Resident #1, #3, #4, and #5) reviewed for sufficient staffing, resulting in a 3rd degree burn for Resident #5, missed grooming and hygiene, a lack of supervision of residents at risk for choking, extended call light wait times and with the potential for all residents to be affected.Findings include: Burnout is the condition that occurs when perceived demands outweigh perceived resources ([NAME] et al., 2013a). It is a state of physical and mental exhaustion that often affects health care providers because of the nature of their work environment. Over time, giving of oneself in often intense caring environments sometimes results in emotional exhaustion, leaving a nurse feeling irritable, restless, and unable to focus and engage with patients ([NAME] et al., 2013b) .Compassion fatigue impacts the health and wellness of nurses 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 intake #2561427Based on observation, interview, and record review, the facility failed to maintain resident dignity in three residents (Resident #1, #3 and #4) of five residents review for dignity.Findings include:According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.Personal hygiene affects patients' comfort, safety, and well-being. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities such as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation, foster a positive self-image, promote healthy skin, and help prevent infection and disease .During an initial tour of the facility on 9/12/25 at 3:30 PM., it was observed that multiple residents were unkept and appeared disheveled. Many residents were observed to have food…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 53 residents of the facility. Findings include: On 12/9/24 at approximately 3:25 PM, a snack cart was observed in the hallway near resident room [ROOM NUMBER]. No staff were observed near or around, tending to the cart. The cart had an uncovered Lexan container, sitting on the top shelf with ice cubes and tongs. At approximately 3:40 PM, during an interview, Activity Aide (AA) F confirmed he was passing snacks to residents and the container of ice cubes was used to fill resident drinking water cups. When asked if he had been instructed to ensure the ice cubes were protected from contamination by covering or other means, AA F stated he had not been instructed to cover the ice cubes. The FDA Food Code 2017 states: 3-307.11 Miscellaneous…

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 ensure the environment was safe, sanitary and functional for residents, staff and the public, potentially affecting all 53 residents. Findings include: On 12/9/24 at approximately 3:00 PM, exit door, identified as Exit #4 was observed with a gap between the threshold and the bottom of the door. This gap allowed cold air and potentially insects and other vermin entrance into the building. On 12/10/24 at approximately 10:15 AM, an interview with Maintenance Director (Staff) D was conducted who confirmed the door was in disrepair and needed to be replaced. On 12/9/24 at approximately 3:30 PM a community shower room located near resident room [ROOM NUMBER] was observed with a vertical wall, separating the toilet and shower enclosure. The wall was missing eight 6 x 6 ceramic tiles, exposing sharp edges which could potentially result in lacerations or other injury to residents or staff. On 12/10/24 at approximately 10:30 AM an interview with Staff D confirmed…

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 advance directives related to code status were accurately and timely completed for four Residents (R6, R26, R46, and R50) out of a total sample of 14 residents reviewed for advance directives. This deficient practice resulted in absent or improperly documented resident's code status. Findings include: Resident #6 (R6) Review of R6's Minimum Data Set (MDS) assessment, dated 11/4/24, revealed admission to the facility on 5/1/24 with active diagnoses that included the following: dementia, anxiety, and respiratory failure. R6 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. Review of R6's Electronic Medical Record on 12/10/24 at 11:47 a.m., found no documentation of an Advance Directive. On 12/10/24 at 4:25 p.m., R6's Code Status form was received from Social Services Designee (Staff) G. The document was signed by Staff G, as a witness on 5/2/24, with only one witness signature on the form. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a sanitary, clean, homelike environment for all 53 facility residents. This deficient practice resulted in unpleasant odors, rooms that were aesthetically unpleasing, and resident dissatisfaction with their environment. Findings include: During an observation and interview on 12/9/24 at 3:57 p.m., a strong odor of urine and feces was present surrounding the Hall B nurses' station, on both the resident room hall, and the hall outside of the kitchen and dining room. During an interview at this time, Certified Nurse Aide (CNA) Q was asked about the strong, pungent odor of urine and feces. CNA Q said they were unable to smell anything because of an issue with their sinuses, but indicated perhaps someone resident had recently received a brief change. During an observation on 12/10/24 at 9:46 a.m., the resident shower room on A Hall was emitting a strong odor of urine when the shower room door was opened by CNA Q, and an unidentified…

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 staff had the appropriate competencies and skills to carry out the functions of the food and nutrition services. This deficient practice has the potential to result in unsafe practices occurring in the kitchen and dietary services and could affect all 53 residents. Findings include: On 12/9/24 at approximately 4:20 PM, the three compartment sink was observed being used to wash, rinse and sanitize food contact surfaces. An interview with Kitchen Manager (KM) A was conducted at this time. KM A acknowledged she did not know the proper testing procedure to ensure the proper concentration of sanitizing chemical was present to sanitize food contact surfaces. On 12/10/24 at approximately 9:30 AM, [NAME] C was observed conducted dish washing activities at the three compartment sink. When asked to demonstrate the testing procedure to ensure proper concentration of sanitizing chemicals in the sink, [NAME] C was unable to demonstrate the procedure properly. When asked if KM A had provided any training related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide food in a manner that was a palatable (preferable) in temperature and/or form for 10 Residents (#2, #5, #6, #9, #14, #23, #26, #27, #38, & #46) of 14 sample residents in the facility reviewed for food. This deficient practice resulted in frustration with meals and the potential for weight loss and diminished nutrition. Findings include: Resident #2 (R2), Resident #5 (R5), Resident #14 (R14), Resident #26 (R26), Resident #27 (R27), Resident #38 (R38), Resident #46 (R46) During a group interview on 12/10/24 at 1:30 p.m., seven R2, R5, R14, R26, R27, R38 and R46 all agreed the food was not palatable due to cold temperatures of food. R26 stated, the food is cold, and we have told them about the food and nothing has changed. R2 stated, the other day we had pizza, and it was cold. R46 stated, the food here sucks, the noodles we had today were undercooked and cold .the food is very bland. R5 stated, the food is cold and there is no flavor…

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 deficiency pertains to Intake #MI00147055. Based on interview and record review, the facility failed to obtain consent for psychotropic medications prior to initiating them for one Resident (#8) of five residents reviewed for psychoactive medications. Findings include: Resident #8 (R8) Review of R8's electronic medical record (EMR) revealed initial admission to the facility on 8/24/23 with diagnoses including Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression. Review of R8's most recent Minimum Data Set (MDS) assessment, dated 11/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicative of severe cognitive impairment. On 12/10/24 at 2:35 PM, a telephone interview was conducted with Complainant/Guardian L who stated the facility was not communicating with him regarding treatment decisions despite having guardianship. Review of R8's EMR revealed the following pharmacy orders: 1. Quetiapine fumarate Oral Tablet [an antipsychotic medication] 50 MG (milligrams), give 1 tablet by mouth two times a day related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Intake #MI00147055. Based on interview and record review, the facility failed to ensure care conferences were scheduled on a quarterly basis and the responsible party was notified for one Resident (#8) of 14 residents reviewed for resident rights. This deficient practice resulted in the failure to include the responsible party in the development of a person-centered plan of care. Findings include: Resident #8 (R8) Review of R8's electronic medical record (EMR) revealed initial admission to the facility on 8/24/23 with diagnoses including Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression. Review of R8's most recent Minimum Data Set (MDS) assessment, dated 11/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicative of severe cognitive impairment. On 12/10/24 at 2:35 PM, a telephone interview was conducted with Complainant/Guardian L who stated he was not being afforded the opportunity to participate in regular care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform a resident assessment for one Resident (#36) of one resident reviewed for self-administration of medication resulting in a resident self-administering medication without appropriate assessments. Findings include: Resident #36 (R36) A review of R36's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 2/24/22, with diagnoses that included: peripheral vascular disease (PVD) or peripheral arterial disease (PAD). R36 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. Review of facility document titled, Medication Self Administration Screening dated 7/23/24, read in part . Complete this assessment prior to resident initiation of self-administration of medication and with any medication order changes, change in function/condition that might affect the resident's ability to safely self-administer medications. Ongoing assessment should occur at a minimum of quarterly .…

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

Based on observation, interview, and record review, the facility failed to provide incontinence briefs in an appropriate style and size to meet the needs and preferences of two Residents (#23 & #26) out of 14 sample residents. This deficient practice resulted in resident discomfort and dissatisfaction. Findings include: Resident #23 (R23) During an interview and observation on 12/10/24 at 9:07 a.m., R23 voiced dissatisfaction with wearing incontinence briefs that did not fit. R23 said the brief size had gone from a XXL (2 Extra Large) to a Large size which did not fit. R23 stated, They are supposed to go around your belly. It (incontinence brief) goes underneath my belly and lower back - it covers the crotch. I have been complaining . to Certified Nurse Aide (CNA)/Scheduler Q for at least a week. R23 lifted the gown they were wearing to show their incontinence brief was not positioned around the waist, with coverage only of R23's pubic area. Observation of the brief package in R23's closet, found only size Large incontinence briefs in the closet. Resident #26 (R26) 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.

This deficiency pertains to Intake #MI00147055. Based on interview and record review, the facility failed to obtain authorization prior to the withdrawal of personal funds for one Resident (#8) of 14 residents reviewed for resident rights. Findings include: Resident #8 (R8) Review of R8's electronic medical record (EMR) revealed initial admission to the facility on 8/24/23, with diagnoses including Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression. Review of R8's most recent Minimum Data Set (MDS) assessment, dated 11/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicative of severe cognitive impairment. On 12/10/24 at 2:35 PM, a telephone interview was conducted with Complainant/Guardian L who stated the facility withdrew five hundred dollars from R8's trust fund and applied the sum to the facility bill without authorization. Complainant/Guardian L stated, The money was in that account for her [R8] to get haircuts, go shopping, buy snacks .stuff like that. It wasn't supposed to go towards a bill. On 12/10/24 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.

This deficiency pertains to Intake #MI00147055. Based on interview and record review, the facility failed to provide quarterly resident trust fund financial statements for one Resident (#8) of 14 residents reviewed for resident rights. Findings include: Resident #8 (R8) Review of R8's electronic medical record (EMR) revealed initial admission to the facility on 8/24/23 with diagnoses including Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression. Review of R8's most recent Minimum Data Set (MDS) assessment, dated 11/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicative of severe cognitive impairment. On 12/10/24 at 2:35 PM, a telephone interview was conducted with Complainant/Guardian L who stated, The facility had not sent a quarterly resident trust fund statement despite several requests. On 12/11/24 at 10:07 AM, an interview was conducted with BOM N regarding the typical process for sending out quarterly statements. BOM N stated, The facility recently started using their own EMR system to manage resident fund…

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.

Resident #204 (R204) On 12/12/24 at 12:43 p.m., a Notice of Medicare Non-Coverage (NOMNC) form for R204 was reviewed which revealed the effective date of coverage for R20 skilled services ended on 11/5/24. The formed was signed on 11/4/24. This deficiency pertains to Intake #MI00147055. Based on interview and record review, the facility failed to provide a 48-hour notice of termination of Medicare benefits for three Residents (#8, #204, and #205) of 4 residents reviewed for beneficiary notifications. This deficient practice resulted in the inability for residents to appeal their non-coverage decision in a timely fashion. Findings include: Resident #8 (R8) Review of R8's electronic medical record (EMR) revealed initial admission to the facility on 8/24/23 with diagnoses including Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression. Review of R8's most recent Minimum Data Set (MDS) assessment, dated 11/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicative of severe cognitive impairment. On 12/10/24 at 2:35 PM, 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 notify the resident and/or resident representative in writing with the reason for a transfer out of the facility for one Resident (#49) of four residents reviewed for transfer and/or discharge. Findings include: Resident #49 (R49) Review of R49's electronic medical record (EMR) revealed initial admission to the facility on 7/18/24 with diagnoses including right ankle fracture, congestive heart failure, and chronic obstructive pulmonary disease (COPD). Review of R49's most recent Minimum Data Set (MDS) assessment, dated 10/24/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 12/11/24 at 10:12 AM, an interview was conducted with R49 who stated she had been hospitalized three times since initial admission to the facility. R49 did not recall signing a transfer notification document prior to any hospitalization. Review of the facility census verified R49 was sent to an acute care hospital three times since admission from 7/25/24 - 8/5/24, 8/10/24 - 9/6/24, and 9/21/24 -…

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 update or revise care plans after multiple falls for one Residents (#50) of fourteen residents reviewed for care planning. This deficient practice resulted in the potential for further falls, and the potential for injury. Findings include: Resident #50 (R50) Review of R50's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 8/6/24, with active diagnoses that included: dementia, diabetes, hypertension, and anemia. Further review of the MDS assessment revealed R50 rarely or is never understood and rarely or never makes decisions. Review of facility incident reports revealed R50 had one fall in August on 8/28/24, two falls in October on 10/10/24 and 10/18/24, and two falls in November on 11/18/24 and 11/19/24. The care plan for R50 was not revised after any of the falls. Review of R50's care plan revealed baseline care plan initiated on 8/7/24, revised on 9/12/24 after R50 fell on 9/11/24, and revision on 11/11/24 after…

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 infection control per standards of practice and failed to implement interventions for the prevention and treatment of pressure injuries for three Residents (R11, R26, and R54) out of three Residents reviewed for pressure injuries. This deficient practice resulted in the development of facility acquired pressure injuries, and the potential for delayed wound healing. Findings include: Resident #11 (R11) During a pressure injury wound observation on 12/10/24 at 3:16 p.m., R11's chronic ,Stage III wound treatment was completed by Licensed Practical Nurse (LPN) J. LPN J, donned in a gown and gloves, retrieved her personal cell phone from inside her scrubs, underneath the donned isolation gown. The cell phone was used to call a nurse for an item necessary for the dressing change. LPN J donned clean gloves, and then made a second call on the personal cell phone , using her clean gloves. LPN J requested a little cup (small, plastic medication cup) for their wound solution. LPN J used the same, now dirty…

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 investigate an accident for one Resident (#46) of four residents reviewed for accidents/hazards which resulted in the potential for further burns, pain, and disfigurement. Findings include: Resident #46 (R46) Review of R46's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: diabetes mellitus, anxiety disorder, depression, and hypertension. R46 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. During an observation on 12/10/24 at 8:32 a.m., R46 had a scab on his right middle finger. This Surveyor queried R46 regarding the scab on his middle finger. R46 stated, I burned myself when I was smoking .I smoked the cigarettes down to the filter and the staff didn't notice what I was doing .I was told that if I do it again, they will take my smoking privilege away from me. Review of R46's Electronic Medical Record (EMR)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #33 (R33) Review of R33's EMR revealed initial admission to the facility on 6/12/23, with diagnoses including anxiety disorder, Parkinson's disease, dementia with mood disturbance, dementia with anxiety, metabolic encephalopathy, vascular dementia, bipolar disorder, depression, and adjustment disorder. Review of R33's most recent MDS assessment, dated 10/28/24, revealed a BIMS was not able to be completed due to severely impaired cognition. Review of R33's Physician Order Recap, retrieved 12/10/24 at 4:04 p.m., revealed the following pharmacy orders for psychoactive medications without justification for continued use without 14-day PRN (as needed) stop dates: 1. Lorazepam (Ativan) Oral Tablet 0.5 mg (Lorazepam). Give 1 tablet by mouth every 4 hours as needed for agitation. Date Initiated: 4/4/23. No End Date. 2. Lorazepam Oral Tablet 0.5 mg. Give 1 tablet by mouth every 4 hours as needed for anxiety until 5/7/2024 23:59 (11:59 p.m.). Give one 0.5 mg tablet every 4 hours as needed for anxiety. 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.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5 percent for one Resident (#27) of four residents reviewed for medication administration. This deficient practice resulted in two medication errors observed, out of 26 opportunities for error and a medication error rate of 7.69 percent, and had the potential for inaccurate dosing and administration of insulin. Findings include: Resident #27 (R27) Observation of medication administration performed by Registered Nurse (RN) I for R27, found the following medication errors: On 12/12/24 at 8:35 a.m., RN I failed to disinfect the humalog [short acting insulin] qwikpen [brand name pen injection device]) hub prior to placement of the insulin needle onto the pen. The pen was primed with two units of insulin, by placing the pen downward over the medication cart garbage can. When asked if the insulin pen hub and been disinfected prior to application of the insulin needle, RN I acknowledged they had not cleaned the hub. RN I re-started the process preparing the humalog insulin…

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

This citation pertains to intake MI00143791. Based on interview and record review, the facility failed to perform pre-employment and pre-admission screenings for tuberculosis (a contagious infection affecting the lungs) based on current professional guidelines. This deficient practice resulted in the potential for exposure and transmission of tuberculosis to susceptible residents residing in the facility. Findings include: On 4/17/2024 at 9:53 a.m., the staff tuberculosis (TB) screening document binder was reviewed with Office Manager (Staff) E. Upon review of a selection of staff beginning work in January 2024 through April 2024, it was noted no TB screening information was found for the sampled employees. Staff E reported the head of each department was responsible for ensuring appropriate TB screening for newly hired staff. Once completed, the screenings documented were provided to Staff E for filing in the binder. Staff E confirmed she did not have TB screenings for the following staff members who began working inside the facility in April 2024: Dietary Aide (Staff) N, first day…

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 MI00142942. Based on observation, interview and record review the facility failed to ensure a call light was within reach for one visually impaired resident (R16) of three residents reviewed for call light use. This deficient practice resulted in the potential for fear and feelings of helplessness, frustration and anxiety. Findings include: R16 was admitted to the facility on [DATE] and had diagnoses including legal blindness, dementia, anxiety and depression. Review of R16's most recent MDS (Minimum Data Set) assessment, dated 1/23/2024, revealed R16 used a manual wheelchair and was dependent on staff for wheelchair mobility and required substantial/maximal assistance with transfers. Further review of the MDS assessment revealed R16 had highly impaired vision and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. An observation on 4/15/2024 at 2:25 p.m. revealed R16 sitting in a wheelchair in her room, facing the wall near the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00142825 and MI00143791. Based on observation, interview and record review the facility failed to ensure privacy and dignified treatment during the provision of care for two residents (R12 and R15) of three residents reviewed for dignity. Findings include: R12 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, stroke, peripheral vascular disease, anxiety and depression. Review of R12's most recent MDS (Minimum Data Set) assessment, dated 1/09/2024, revealed R12 was dependent on staff for upper and lower body dressing, personal and toileting hygiene, repositioning, and mobility. Further review of the MDS assessment revealed R12 was assessed as always incontinent of bladder and bowel and had severe cognitive impairment. An observation on 4/16/2024 at 11:21 a.m. revealed Certified Nurse Aide (CNA) H and the Nursing Home Administrator (NHA) providing incontinence care to R12. Upon completion of care, CNA H left the room and immediately returned…

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 MI00142941. Based on observation, interview and record review, the facility failed to ensure resident rooms were maintained in a safe, clean, and homelike manner for two Residents (R13 and R19) of three residents reviewed. This deficient practice resulted in the potential for feelings of worthlessness, embarrassment and loss of dignity. Findings include: R13 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, stroke, peripheral vascular disease, anxiety and depression. A review of R13's most recent MDS (Minimum Data Set) assessment, dated 1/9/2024, revealed R13 had severe cognitive impairment. A review of R13's care plan revealed the following, in part: Focus: I have a self-care performance deficit r/t (related to) dementia, Parkinson's. Date Initiated: 12/23/2023 . Interventions/Tasks: My mattress is on the floor and I will crawl off my mattress across the floor independently . R19 was admitted to the facility on [DATE] and had diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00142941 and MI00143791. Based on observation, interview and record review the facility failed to ensure safe transfers for two Residents (R13 and R18) of three residents reviewed for safety during transfers. This deficient practice resulted in the potential for falls and injury. Findings include: R13 was admitted to the facility on [DATE] and had diagnoses including dementia, Parkinson's disease, muscle weakness and abnormalities of gait/mobility. Review of R13's Minimum Data Set (MDS) assessment, dated 2/15/2024, revealed R13 required substantial/maximal assistance to transfer from sitting to standing and had two or more falls since admission. Further review of the MDS assessment revealed R13 had severe cognitive impairment. An observation on 4/15/2024 at 1:45 p.m., revealed R13 being assisted to the toilet in the shower room on B-Hall by Certified Nurse Aide (CNA) G and CNA D. R13 was observed to be fully seated at approximately 80 degrees in a high-back wheelchair…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to properly clean and sanitize dishes and utensils. B. Failing to ensure food preparation surfaces in the dietary department were properly sanitized. C. Failing to ensure that food items were dated, discarded on or before the expiration date, and kept free from contamination due to debris or due to thawing and refreezing. D. Failing to ensure employees practiced effective sanitation practices for food safety. This deficient practice had the potential to result in food borne illness among any or all 47 residents in the facility. Findings include: During a dietary department tour on 12/17/23 at 10:50 AM with Dietary Staff U, the sanitizing bucket used to clean working surfaces was observed with a cleaning cloth floating in the solution. Staff U tested the solution in the bucket and the quat test strip registered 0 parts per million (ppm) of sanitizer. Staff U stated There is something…

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 a medication administration error rate less than 5%, for 13 of 32 medication administrations. This deficient practice resulted in a medication error rate of 40.63%, with the potential for medical complications related to resident medication treatments for various conditions. Findings include: On 12/18/23 at 8:15 AM, a medication administration was observed with the Director of Nursing (DON)/Registered Nurse (RN). The following was observed: The DON was observed preparing morning medication pass and included insulin for Resident #20 (R20). The DON was observed injection the insulin detemir 42 units in R20's right arm by dialing down the insulin pen from 35 units to 0 units. The DON held the injection site for two seconds and removed the pen quickly. On 12/18/23 at 8:25 AM, an interview was conducted with the DON. The DON was asked about the administration of R20's insulin detemir pen and if it was per the manufactures instructions to only hold for two seconds and dial the insulin pen down from 35…

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 medication storage room free of expired medications, properly dispose of controlled substances, and securely store medications, for one of one medication rooms and two of two medication carts reviewed for medication storage. This deficient practice resulted in the potential for administration of medications with reduced intended effect and the potential for drug diversion. Findings include: On 12/18/23 at 10:00 AM, an inspection was conducted on the B-Hall medication cart. In the second drawer beneath the medication cards an observation was made of one loose fluoxetine 20 mg (milligram) pill, one small piece of a white pill unable to be identified, and one brexpiprazole 2 mg. One loose aspirin 81 mg pill, and an insulin pen with an opened date of 10/25/23 (which expired on 11/21/23) were located in the top drawer. In the bottom drawer in a clear medication cup there was a used fentanyl patch (behind a single locked medication…

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

Based on observation, interview, and record review, the facility failed to ensure sufficient competent dietary staff were employed to safely and effectively carry out the functions of the food and nutrition service. This deficient practice was evidenced by dietary staff who were untrained in maintaining and ensuring a sanitary dietary environment, potentially affecting all 47 residents in the form of a food borne illness outbreak. Findings include: During a tour of the kitchen on 12/18/23 at approximately 7:55 AM, the dietary personnel were observed serving breakfast on the tray line. The cook (Staff D) was not wearing any head covering or hair restraint while serving the resident's meals. The cook was asked why he did not have a hair restraint on, and he replied, I was not told (to wear a hairnet) and I don't even know where they are. During an interview on 12/18/23 at approximately 12:45 PM, Business Office Manager Staff P stated, Staff D had been hired two weeks prior on 12/04/23. Staff D's hiring paperwork was presented and the form titled Facility Orientation Checklist in his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one resident (Resident #38) of one resident reviewed for self-administration of medication was clinically assessed, care planned, and had physician orders for the self-administration of medication. This deficient practice resulted in a lack of an assessment for safe medication administration, inaccurate documentation of medication administration, and the potential for medication mismanagement. Findings include: Resident #38 (R38) Review of R38's EMR revealed an initial admission to the facility on 2/24/22 with diagnoses including peripheral vascular disease (a slow, progressive circulation disorder), glaucoma (an eye disease) and history of falling. R38's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. During an interview on 12/17/23 at 1:47 PM, R38 stated she gives herself her own eye drops. She pointed to her bedside…

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 appropriately care plan and implement interventions for two (Resident #38 and #47) of 12 residents reviewed for comprehensive care planning. This deficient practice resulted in the potential for unmet nutritional needs and unsafe self-administration of medications. Findings include: Resident #47 (R47) Review of R47's electronic medical record (EMR) revealed initial admission to the facility on 6/2/23 with diagnoses including chronic kidney disease, diabetes mellitus, and depression. R47's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. Review of R47's weight history revealed R47 weighed 218.8 lbs. (pounds) on 6/5/23 and weighed 192.4 lbs. on 12/4/23, for a total weight loss of 26.4 lbs. This resulted in a 12.1% weight loss in an approximate 6-month period. On 12/19/23 at 12:38PM, a phone interview was conducted with R47's Durable…

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 recapitulation of stay was completed for one Resident (R13) out of one closed record reviewed for discharge documentation. This deficient practice resulted in lack of key departmental pieces of the recapitulation of the Resident's stay and the potential for unmet care needs after discharge. Findings include: The medical record was reviewed for R13 and revealed an admission on [DATE] for orthopedic aftercare (physical therapy) following a displaced fracture of the upper arm/shoulder and other diagnoses including end stage renal disease and insulin dependent diabetes. R13 was discharged home on [DATE]. The discharge plan and recapitulation of stay documentation revealed the clinical (nursing) section, the activity department section, and the social services department section were blank. During an interview on 12/19/23 at 10:19 AM, the Nursing Home Administrator (NHA) stated she was aware R13 had an incomplete discharge summary as she had…

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 that 3 of 4 sampled residents (R8, R30, and R34) were free from unnecessary medications resulting in doses of antipsychotic medications without justification. Findings include: Resident #8(R8) On 12/19/23 at 11:00 a.m., review of R8's electronic medical record (EMR) admission medical diagnoses stated in part: depression, unspecified, adult failure to thrive, other specified anxiety disorders. A review of the December 2023 medication administration record (MAR) was reviewed to have orders of Haloperidol Oral tablet 0.5 mg(milligram), give 1 tablet by mouth every 6 hours as needed for agitation or nausea, order dated 11/13/23. Lorazepam oral tablet 0.5mg give 1 tablet by mouth every 4 hours as needed for anxiety, order dated 11/12/23. On 12/19/23 at 11:30 a.m., review of the pharmacy medication review binder regarding R8's psychotropic medications revealed a recommendation on 11/22/23 to discontinue, add stop date to prn (as needed) or no change to the medications Haloperidol 0.5 mg tablet and Lorazepam…

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 prevent a serious medication error for one Resident (#20) of five residents reviewed for medication administration. This deficient practice resulted in the potential for serious diabetic related complications. Findings include: On 12/18/23 at 8:15 AM, a medication administration was observed with the Director of Nursing (DON)/Registered Nurse (RN). The following was observed: The DON was observed preparing morning medication pass and included insulin for Resident #20 (R20). The DON was observed injection the insulin detemir 35 units in R20's right arm by dialing down the insulin pen from 35 units to 0 units. The DON held the injection site for two seconds and removed the pen quickly. At no time was the plunger mechanism depressed to administer the insulin. The DON did not follow-up with the physician regarding this medication error prior to the survey exit. On 12/18/23 at 8:25 AM, an interview was conducted with the DON. The DON was asked about the administration of R20's insulin detemir pen and if it was per…

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

Based on interview and record review, the facility failed to maintain a complete infection control program to help prevent the development and transmission of communication diseases and infections. This deficient practice resulted in the potential for the spread of communicable and infectious diseases within all 46 vulnerable residents within the facility. Findings include: During observations on 10/31/23 at 11:53 a.m. and 12:12 p.m., and 11/1/23 at 2:06 p.m. R1 and R12, respectively, were observed coughing with audible chest congestion. During an interview on 11/1/23 at 2:09 p.m., Registered Nurse (RN) I was asked which residents had been tested for COVID-19 based on symptoms they exhibited, such as coughing and congestion. RN I stated, I don't think any of them (were tested for COVID-19). On 11/1/23 at 2:13 p.m., the Director of Nursing (DON) was asked to provide the October 2023 infection control (IC) line listing of residents with diagnoses or symptoms of infections or communicable diseases. The DON said she was unable to print the computerized infection control line listing…

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

Based on observation, interview, and record review, the facility failed to provide respectful and dignified care to three Residents (R3, R7, and R11) of 13 sample residents reviewed for resident rights. This deficient practice resulted in resident dissatisfaction with care, increased anxiety, frustration, and humiliation. Findings include: This deficiency pertains to Intakes: MI00137715 and MI00138855. During an interview on 11/2/23 at 2:12 p.m., when asked if any residents had complaints regarding disrespectful or undignified care being provided by Registered Nurse (RN) W, Certified Nurse Aide (CNA) V stated, Just about everybody. The residents complain that [RN W] is waking them up for nonsense in the middle of the night. CNA V provided the names of R3, R7, and R11 as residents who frequently voiced concerns about her treatment of them. Review of all of the identified Residents (R3, R7, and R11) found they were their own responsible party and were considered cognitively intact and able to make their own decisions. R3 During an interview on 11/2/23, R3 stated, I have had to tell…

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 dining assistance for one dependent Resident (R1) of four residents reviewed for provision of activities of daily living (ADL's). This deficient practice resulted in feelings of frustration, anxiety, and dissatisfaction with not being provided required level of meal and fluid intake assistance. Findings include: This deficiency pertains to Intakes MI00138821, MI00138855 and MI00140045. During an interview on 11/1/23 at 1:15 p.m., Complainant B said R1 had telephoned them on 9/16/23 and reported facility staff had not assisted R1 with eating. When asked if R1 was reliable with the information provided, Complainant B stated, He is reliable to me as a witness . he said that he cannot feed himself anymore. Review of R1's Minimum Data Set (MDS) assessment, dated 9/19/23, revealed they were admitted to the facility on [DATE] with active diagnoses that include heart failure, atrial fibrillation, anxiety disorder, and amyotrophic lateral…

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.