Christian Care Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to follow policies and procedures to accurately assess, monitor and treat/improve pressure ulcers for 2 Residents (R1, and R350) of 4 Residents reviewed for pressure ulcers. Findings included: R350 Review of R350's face sheet dated 3/26/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE], her diagnoses included: acute kidney failure, chronic kidney disease, dysphagia (difficulty swallowing), osteomyelitis (bone infection), and vascular disease. She was her own responsible party. Review of R350's admission skin assessment dated [DATE] and locked on 3/21/25 revealed that R350 had a stage 1 ulcer on her gluteal clef that measured 3.4 x 2 x 0.3. there was no mention of any skin issues on R350 thighs or other areas of her buttock. Review of R350's admission skin assessment dated [DATE] at 16:36 (4:36 PM) and locked on 3/27/25 (during the survey) revealed R350 had a stage 3 pressure ulcer on her coccyx that measured 3.7…

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

Based on observation, interview, and record review, the facility failed to: 1) post daily nurse staffing data in a prominent place readily accessible to residents and visitors and 2) list the facility census and actual hours worked by category of licensed and unlicensed nursing staff (i.e., Registered Nurse, Licensed Practical Nurse, Nursing Assistant) directly responsible for resident care per shift on the historic daily nurse staffing data sheets. Findings include: During an observation on 03/27/25 at 08:35 AM, the daily Faith's Terrace Staffing data sheet was observed on a bulletin board next to nurse's station facing nurse's station. The staffing data was not visible to residents and/or visitors in hallway or walking by the nurse's station. The Faith's Terrace Staffing data sheet was posted next to other staff only schedules/postings (i.e., On Call Manager Schedule for March 2025, On Call Maintenance person, a thank-you card). The Faith's Terrace Staffing data sheet had the facility census, names of nursing staff members scheduled per shift, and schedule nurse staffing hours…

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 inform 1 of 5 residents (R350) reviewed for unnecessary medications of the risks versus benefits and indications for use of a psychotropic medication prior to administering it. Findings include: A review of R350's admission Record, dated 3/27/25, revealed they were a [AGE] year-old resident who admitted to the facility on [DATE] with multiple diagnoses that included dementia and cerebral infarction (a condition where blood flow to the brain is interrupted causing brain tissue damage). In addition, R350's admission Record revealed they were their own responsible party. A review of R350's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/27/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 14 which revealed R350 was cognitively intact. A review of R350's March 2025 Medication Administration Record revealed they were being administered aripiprazole…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to respond timely to resident grievances for 2 Residents (R10 and R40) of 15 residents sampled. Findings include: R10 Review of R10's face sheet dated 3/27/25 revealed, she a [AGE] year-old female that was admitted to the facility on [DATE] and had diagnoses that included: generalized weakness, unsteady on feet, vascular dementia, kidney disease and major depressive disorder. She was not her own responsible party. During an interview with R10 on 3/26/25 at 11:26 AM, R10 complained of problems with wheelchair comfort. R10 was scooted down in her wheelchair sitting on her low back. R10 was not able to reposition herself in her wheelchair. R10 also complained that the meals have decreased in quality and said she used to be able to get more fresh fruits. R10 was asked if she attended resident council and if the residents were able to address concerns in the meeting. R10 said she was the resident council president and reported they do talk about…

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 record the reason for a transfer to the hospital emergency department in the resident's medical record for 1 of 1 resident (R47) reviewed for hospital transfers. Findings include: A review of R47's admission Record, dated 3/27/25, revealed they were a [AGE] year-old resident who admitted to the facility on [DATE]. In addition, R47's admission Record revealed they had multiple diagnoses that included liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. A review of R47's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/4/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed R47 was cognitively intact. A review of R47's Health Status note, dated 1/4/25, revealed, [Name of R47] requested to go to ED (emergency department) for evaluation. Contacted on call nurse, called on call, [name of healthcare…

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 to the resident and/or the resident representative written notice which specified the duration of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility for 1 of 1 resident (R47) reviewed for hospital transfers. Findings include: A review of R47's admission Record, dated 3/27/25, revealed they were a [AGE] year-old resident who admitted to the facility on [DATE]. In addition, R47's admission Record revealed they had multiple diagnoses that included liver cirrhosis, chronic congestive heart failure, chronic kidney disease, and diabetes. A review of R47's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/4/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed R47 was cognitively intact. A review of R47's Health Status note, dated 1/4/25, revealed, [Name of R47]…

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 assess, monitor and provide care for one (R30) of one resident reviewed for dental care. Findings include: Review of a Face Sheet revealed R30 originally admitted to the facility on [DATE] and has pertinent diagnoses of Alzheimer's disease, dementia, and abnormal posture. During an observation on 3/25/25 at approximately 11:00 AM, R30 was observed at a table near the nurses' station clenching her shirt. She was nonverbal had limited movement. In an interview on 3/25/25 at 12:11 PM, R30's husband reported concerns of his wife not being able to get her tooth extracted timely and she is having pain. He reported he can tell she had pain by her behaviors and the clenching of her teeth. Review of a dental consultation dated 1/3/25 for R30 revealed she needed to have diagnostics done and oral surgery to get her tooth extracted while sedated and was given a referral for oral surgery. Review of a Nursing Progress note dated 3/6/25 for R30 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to provide the care of contractures for one (R3) of one resident reviewed for contractures. Findings include: Review of a Face Sheet revealed R3 originally admitted to the facility on [DATE] and has pertinent diagnoses of contractures, spastic hemiplegia (one sided weakness) affecting left nondominant side, and brain injury. Review of the Minimal Data Set (MDS) dated [DATE] revealed R3 is moderately cognitively impaired and has limited range of motion in bilateral upper and lower extremities and is dependent on staff for mobility. During an observation on 3/25/25 at 10:39 AM, R3 was observed in the hallway with contractures in bilateral upper extremities at both wrist and hands. No devices in place on his right or left hands. During an observation and an interview on 3/26/25 at 9:18 AM, R3 was in his room eating breakfast in bed. He reported he did not know where his hand splints were, and staff have not put them on his hand in a while. R3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to prevent a fall for 1 Resident (R17), of 1 Resident reviewed for falls. Finding included: Review of R17's face sheet dated 3/27/25 revealed she was [AGE] years old, admitted to the facility on [DATE] and diagnoses included: unsteady on feet and vascular dementia. She was not her own responsible party. Review of R17's incident and accident report dated 3/16/25 at 16:00 (4:00 PM) revealed R17 had an unwitnessed fall in her room. Predisposing physiological factors included confused, incontinent and impaired memory. The statement section listed staff, see paper statements. No paper statements were provided. The statement at the end of the report revealed, 3/26/25: Root cause: after assessing the situation, it was noted that her anti-rollbacks were not functioning appropriately. The anti-rollbacks were fixed by maintenance. R17 has many fall interventions in place that were all implemented at the time of the fall. There were no 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.

Based on interview and record review, the facility failed to follow policies and procedures to maintain a sensical system of accountability for controlled substances for 1 Resident (R4), of one resident reviewed for narcotic administration. Findings include: Review of a policy titled Controlled Substance Administration & Accountability last revised 12/29/24 revealed: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. f. All controlled substances (Schedule II, III, IV, V) are accounted for in one of the following ways: . ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. g. In all cases the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded…

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

Based on observation and interview, the facility failed to appropriately maintain medication storage for one medication room of two medication rooms. Findings include: During an observation and an interview on 3/27/25 at 8:35 AM, the Love Unit Medication Room had a refrigerator with an opened multidose tuberculin vial that was not dated when it was opened. Licensed Practical Nurse (LPN) T reported she did not know when it was opened and should be dated when it was opened. Inside the refrigerator was also a urine sample for a newly admitted resident. LPN T reported that this refrigerator is to only have medications in it, and this was not to be stored in this room. Review of a policy from the pharmacy titled Medication Storage in the Facility last revised 1/2018 revealed: G. Potentially harmful substances such as urine test reagent tablets, household poisons . are clearly identified and stored in a locked area separately from medications. H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately…

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

Based on observation, interview, and record review the facility failed to: 1. Properly date mark and discard food product; 2. Properly store food product; 3. Ensure cleaning of food and non-food contact surfaces; 4. Air dry pots and pans; and 5. Minimize bare hand contact with ready to eat food. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 49 residents who consume food from the kitchen. Findings Include: 1. During an interview with Certified Dietary Manager (CDM) M, at 9:25 AM on 4/15/24, it was found that potentially hazardous foods made in house are held for three days and commercially prepared products are generally held for seven days. Observation of the walk in cooler at this time found the following: an open package of honey ham with no date, a container of ham roll ups with no date, a container of beef tips and gravy with no date, an open saran wrapped package of turkey with no date, an open package of hot dogs with no date, a container of purred devil eggs dated 3/29 to 4/7, French onion dip…

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 ased on observation, interview, and record review, the facility failed to implement and maintain an effective Infection Control Program to include comprehensive surveillance of facility infections and education and implementation of infection control measures for one facility Resident (R9). Findings: Review of the facility policy titled Infection Prevention and Control Program last reviewed 1/23/24 reflected. Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 1. The designated Infection Preventionist(s) is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement and maintain a process to ensure pharmacy monthly medication reviews and recommendations were reviewed and acted upon by the attending physician for five facility Residents (R2, R24, R30, R42, and R9) resulting in pharmacy recommendations not being reviewed and the potential for unnecessary medication to be administered. Resident #2 (R2) Review of the medical record reflected R2 was admitted to the facility 12/4/23 with diagnosis that included Fractures with Multiple Other Trauma and Depression. Review of the EMR for R2 reflected Pharmacy Notes (Pharmacy Review) entered 12/20/23 and 1/24/24. Both entries reflected Consultant Pharmacist Monthly Review . Recommendation(s): Non-Significant Recommendation to Physician. The EMR did not reveal how these Recommendation(s) were conveyed to the Physician and related documentation was not located in other areas of the EMR. Resident #24 (R24) Review of the medical record reflected R24 was admitted 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.

Based on interview and record review, the facility failed to ensure certified nursing assistants completed the required 12 hours a year of in-service training, resulting in the potential for inadequate and substandard quality of care for residents living at the facility. Findings include: Review of Employee Online Inservice Training competencies report, current 4/16/2024, revealed out of 30 Certified Nursing Assistants (CNA) listed on the report, 27 had not completed any of the assigned training's including body mechanics/ergonomics, fire safety prevention guidelines, HIPAA privacy/confidentiality, infection control & awareness, influenza awareness & prevention, pressure ulcers risk control, resident/client rights guidelines, sexual harassment awareness, violence in healthcare workplace, abuse, bloodborne pathogens, emergency and disaster procedures, end of life care, grievance filing guidelines, safety and incident reporting, care for dementia/alzheimers, CNA proficiency skills review, nutrition and hydration, kitchen sanitation, foodborne illness prevention, restraint free/fall…

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 Advanced Directives were documented and communicated sufficiently to reflect the code status of 1 resident (Resident #19), out of 13 residents reviewed for Advanced Directives, resulting in the potential failure to carry out a resident's medical treatment decisions. Findings: Resident #19 (R19) Review of an admission Record reflected R19 originally admitted to the facility on [DATE], and readmitted to the facility after a hospitalization on [DATE] with diagnoses that included vascular dementia. Review of a facility Medical Treatment Decisions of Resident form signed by Resident #19's responsible party, witnesses and the Medical Director (MD) N on [DATE] reflected I have been informed in writing, in language I understand, of my rights and all rules and regulations to make decisions concerning medical care, including the right to accept or refuse treatment and the right to formulate and to issue Advanced Directives to be followed if I become…

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 notification of planned discontinuation of coverage for Medicare Part A services for 2 residents (Resident #1 and #40) of 3 residents reviewed for this requirement, resulting in the loss of the right to appeal the determination and the potential for unforeseen obligation and hardship. Findings: Review of a SNF (Skilled Nursing Facility) Beneficiary Notification Review form completed by the facility reflected Resident #1 received Medicare Part A Skilled Services from 2/8/2024 through 3/27/2024. According to the form, the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The areas on the form indicating that notice of the planned discontinuation (Form CMS-10055 and Form CMS-10123) was provided or other circumstances impacted the notification (resident discharged from the facility and did not receive non-covered services; resident initiated discharge) were not completed. Review of a SNF (Skilled Nursing Facility) Beneficiary Notification Review form completed by 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 revise the Plan of Care for one Resident (R10) with displays of behaviors affecting others. Findings: Review of the medical record reflected R10 was admitted to the facility 8/27/23 with diagnoses that included a History of Stroke, Hemiplegia (weakness or paralysis on one side of the body), and Dementia. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated that R10 was moderately cognitively impaired. Review of section B of this MDS reflected R10 understands and is understood. On 4/15/24 at 12:15 PM an observation was conducted of the noon meal service at the Faith Hall dining area. Eleven residents were present with most seated either in chairs or wheelchairs at a long rectangular table. R10 sat in a wheelchair at the head of this rectangular table with R12 in a wheelchair on the side corner of the table to his right. R10 was talking to staff and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards of quality were followed for 1 resident (Resident #38) of 13 residents reviewed for professional standards of quality, resulting in the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #38 admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disease and heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #38, with a reference date of 2/9/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #38 was cognitively intact. Review of Resident #38's Physician's Orders revealed an order for a Lidocaine External Patch started 1/7/2024 and stopped 4/16/2024 with directions to apply to Resident #38's right upper back. In an interview on 4/17/2024…

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

Based on interview and record review, the facility failed to ensure a resident did not experience bowel incontinence and/or complications from constipation for 1 resident (Resident #34), out of 13 residents reviewed, resulting in diarrhea and subsequent constipation when the facility did not implement appropriate bowel monitoring and protocols. Findings: Resident #34 (R34) Review of an admission Record reflected R34 admitted to the facility with diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for routine healing, dementia, depression, high blood pressure, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and unsteadiness on feet. During an interview on 4/12/2024 at 9:44 a.m., R34's Power of Attorney (POA) Q reported that R34 had half a colon and did not use laxatives prior to admitting to the facility. POA Q said that the facility was administering laxative daily for over a week at the facility which resulted in R34 having severe diarrhea. POA Q informed the facility that R34 did not take laxative but used Imodium…

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 attempt gradual dose reductions of psychotropic medications and ensure PRN (as needed) psychotropic medications were limited to 14 days for 2 residents (Resident #30 and #42) of 5 residents reviewed for unnecessary medications, resulting in the administration of unnecessary medications and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #30 Review of an admission Record revealed Resident #30 admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease, anxiety, and depression. Review of Resident #30's Pharmacy Notes revealed monthly pharmacist reviews with non-significant recommendations to the physician on 11/17/2023 and 2/14/2024. Physician follow up documentation to recommendations could not be found in the electronic medical record. Review of Resident #30's active Physician Orders on 4/17/2024 at 2:10 PM revealed Resident…

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

Based on interview and record review, the facility failed to implement antibiotic use protocols and a system to monitor antibiotic use for 1 resident (Resident #34) out of 5 residents reviewed for high-risk medications, resulting in the potential for antibiotic resistance, adverse reactions and/or complications from inappropriate antibiotic use. Findings: Resident #34 (R34) Review of an admission Record reflected R34 admitted to the facility with diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for routine healing, dementia, depression, high blood pressure, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and unsteadiness on feet. Review of a hospital After Visit Summary dated 3/15/24 indicated R34 was seen in the hospital emergency department for Multiple complaints from family, fall. R34 was diagnosed with Acute cystitis without hematuria (bladder infection without blood in the urine). Tests run at the hospital included a Urinalysis with reflex microscopic (a test to detect abnormalities in the urine). The summary…

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 treat 2 of 4 residents with dignity (R1 and R4), resulting in R1 soiling herself and R4 spilling his urinals on himself because of a staff member's refusal to provide assistance when requested. Findings include: A review of R1's admission Record, dated 1/17/24, revealed R1 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R1's admission Record revealed multiple diagnoses that included cerebral infarction (stroke), generalized muscle weakness, dizziness, anxiety, depression, lack of coordination, incontinence, and a history of falls. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 11/3/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed R1 was cognitively intact. In addition, R1's MDS revealed R1 had one-sided impairment of the upper and lower body (arms and legs), was dependent 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 M100140268 Based on interview and record review, the facility failed to implement policies and procedures to ensure pre employment screenings were complete, employee trainings done, ensure 2 Certified Nursing Assistants (CNAs) were evaluated for skills competencies, and 2 CNAs in Training (CNAT) were evaluated for skills competencies and licensed within the allotted time frame after the completion of formal nurse aide training, in a total sample of 5 staff reviewed, resulting in the potential for unqualified personnel with incomplete background checks providing care to a vulnerable population that could be a potential for abuse and/or neglect. Findings include: Review of a policy titled Abuse, Neglect and Exploitation last revised [DATE] revealed: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation 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.