The Villa at Rose City

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that oral care was provided for one resident (Resident #71) of three residents reviewed for Activities of Daily Living (ADL) care. Findings include:Resident #71:On 4/20/26 at 9:50 AM, Resident #71 was observed in their room. The Resident was in bed, positioned on their back. The Resident's hair was unkempt and uncombed. While speaking, Resident #71's teeth were observed to have a significant, visible amount of build up on them. When queried if they are able to brush their teeth themselves, Resident #71 revealed they need help. Resident #71 stated, Not brushed my teeth since been here. With the Resident's permission, a tour of their bathroom and room was completed. One unopened toothbrush was observed in the top drawer of the Resident's dresser.Record review revealed Resident #71 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess, monitor and document wound care for two residents (Resident #12, Resident #75) and improperly used a positioning device for one resident (Resident #5) out of three residents reviewed for quality of care, resulting in old, undated wound dressings and no physician's orders for a positioning device. Findings include. Resident #75: On 4/20/2026, at 1:20 PM. Resident #75 was sitting in their wheelchair in their room. They had on an occlusive dressing on their left elbow/forearm that was dated 4/17. Resident #75 stated, he bumped it when he fell the day before. On 4/20/2026, at 1:28 PM, an observation with Nurse U of Resident #75's left elbow dressing was conducted. Nurse was asked what the date was on the dressing and Nurse U stated, 4/17. Nurse U removed the dressing. There was an approximate 1 centimeter (cm) by 1 centimeter skin abrasion. The wound bed was red and shiny. Nurse Ucleansed the area with normal saline and a 4 x 4 cloth…

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, interviews and record reviews, the facility failed to prevent the development of facility-acquired Deep Tissue Injuries (DTI) for two residents (Resident #6, Resident #29) of 6 residents reviewed for wounds.Findings include: Resident #6:Record review of Resident #6's 2/12/2026 significant change Minimum Data Set (MDS) section M: Skin conditions noted that the resident was at risk of developing pressure ulcers/injuries, but that the resident had no unhealed pressure ulcers/injuries at the time of the assessment. During an observation on 04/20/2026 at 9:46 AM, Resident #6 was sleeping/resting on top of the covers on the bed with regular socks on her feet. There were gray soft boots (Prafo boots) with Velcro straps located in the wheelchair at bedside. The protective boots were not on the resident while in the bed. Resident #6's heels were resting on the mattress. The state surveyor observed slight right ankle/foot swelling. There were no extra pillows noted in room for heel elevation or…

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 sanitary nebulizer storage for one resident (Resident #2) and provide safe oxygen administration for one resident (Resident #77) of two residents reviewed for respiratory medication needs. Findings include. Resident #2: On 04/20/26 at 10:07 AM, Resident #2 was observed in their room in bed. A nebulizer machine was observed on the dresser next to the resident's bed. The nebulizer tubing was observed going into the top dresser drawer. A nebulizer mask was sitting in the drawer. The mask was uncontained and connected with visible fluid present in the medication administration chamber. An interview was completed at this time. When queried if they were receiving nebulizer treatments, Resident #2 confirmed that they were. Record review revealed that Resident #2 was admitted to the facility on [DATE] with diagnoses which included heart disease, Congestive Heart Failure (CHF), diabetes mellitus, Chronic Obstructive Pulmonary Disease…

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 that one (Resident #5) of 5 residents reviewed for medication storage were properly stored.Findings Include: Resident #5: Review of the Face Sheet, nurse's notes dated 2/26 through 4/26, and care plans dated 3/25, revealed Resident #5 was 61 years-old, admitted to the facility on [DATE], alert and able to make own healthcare decisions, and dependent on staff for Activities of Daily Living. The residents diagnosis included, low back pain, muscle wasting, muscle weakness, osteomyelitis, sacral wound, urinary catheter in place, adjustment disorder, major depression and chronic kidney disease. Review of the residents Mood problem care plan dated 11/11/24, revealed staff were to administer mediations as ordered and monitor for side effects. Review of the facility medication Preparation and General Guidelines policy dated May 2022, revealed all resident medications were to given per the 5 Rights of Medication Administration (including…

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 fresh fluids at bedside for one resident (Resident #49) of six residents reviewed for bedside fluids. Findings include. Resident #49: On 4/20/2026, at 11:06 AM, Resident #49 was lying on their bed awake. There was one Styrofoam cup noted on their nightstand. The cup appeared to have brown liquid in it and the cup had a date written on it of 4/18. There was an empty coke bottle on their overbed table. Resident #49 provided they got it out of the machine. There were no other fluids at bedside. On 4/20/2026, at 11:55 AM, Certified Nursing Assistant (CNA) S was asked if Resident #49 had been provided a cup of water and CNA S provided that Resident #49 usually only wants chocolate milk. On 4/20/2026, at 11:59 AM, an observation along with CNA S of Resident #49's Styrofoam cup. CNA S was asked what the date and fluid was and CNA S offered, 4/18 and it's chocolate milk. CNA S reassured the resident they would get a new cup of milk for…

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

Based on observation, interview, and record review, the facility failed to ensure that the sanitizer for the wiping cloths, used to sanitize food preparation areas, was at the correct concentration for disinfection. Findings include: During a tour of the dietary department on 3/4/25 at 9:42 AM with Certified Dietary Manager (CDM) A, the red sanitizer bucket was observed with a wiping cloth immersed in solution ready to use. The wiping cloths were used to sanitized dietary counters and food preparation areas. CDM A tested the solution to determine the amount of sanitizer present. The quaternary ammonium sanitizing chemical measured 50 - 100 ppm (parts per million). CDM A stated the proper sanitizer level was 200-400 ppm. During a tour of the dietary department on 3/5/25 at approximately 1:30 PM with CDM A, the red sanitizer bucket was observed with a wiping cloth immersed in solution ready to use. The sanitizer bucket was again tested by CDM A. It did not register any quaternary ammonium sanitizer present as the test strip did not change color. CDM A tried a new test strip dispenser,…

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 that medications and medical supplies were secured, stored and disposed of per professional standards of practice in one of two medication storage rooms, one of two medication carts, and one treatment cart. Findings include: A tour of the C and D hall medication cart was completed with Licensed Practical Nurse (LPN) B on [DATE] at 7:29 AM. A container of undated glucometer testing strips were observed in the top drawer of the medication cart. When queried if the strips should be dated when opened, LPN B verbalized they should and indicated the glucometer controls were completed by night shift staff. On [DATE] at 9:30 AM, the treatment cart positioned near the C hall entrance was observed to be unlocked and unattended by staff. No staff were present at the nurses' station. At 9:33 AM on [DATE], Registered Nurse (RN) H approached the nearby medication cart but did not address the unlocked treatment cart. RN H was then queried…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for management and care of a Peripherally Inserted Central Catheter per standards of practice for one resident (Resident #124) of one resident reviewed. Findings include: On 3/4/25 at 12:30 PM, Resident # 124 was observed in their room in bed. The Resident had a neck immobilizer brace in place. An IV pump and pole were positioned on the right side of the Resident. A 250 milliliter (mL) bag of 0.9% normal saline solution containing 1.75 grams (g) of Vancomycin (antibiotic) with approximately 40 mL of solution remaining in the bag was hung on the pole and fed into the IV pump but not connected to the Resident. When queried, Resident #124 revealed they had spinal fusion surgery which was why they had to wear the neck brace. When queried regarding the IV antibiotic, Resident #124 revealed had an infection. When queried regarding IV access, Resident #124 revealed they had a PICC line 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.

Based on interview and record review, the facility failed to follow two physicians' orders to discontinue a medication for one resident (Resident #11) of five residents' records reviewed for unnecessary medications. Findings include: Resident #11 (R11): On 3/05/25 at 2:27 PM, the medication orders for R11 were reviewed. An active and current order for Melatonin Oral Tablet 5 MG (milligrams) Give 1 tablet by mouth every 24 hours as needed for insomnia at bedtime was observed. A review of the Behavioral Health Solutions (BCS) recommendations for the date of service 12/29/2024 included, Based on the data obtained and discussions with patient and staff, this provider concludes: a change in medication will be recommended at this time-dc PRN (discontinue as needed) Melatonin as not used in December. The summary of this report further stated, Plan: Patient with no c/o (complaints of) insomnia. No PRN Melatonin use is noted in December. Recommend dc of Melatonin at this time. Recommend staff continue to monitor sleep. Document episodes of insomnia. The recommendation had been highlighted,…

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 that one resident (#121) of five residents reviewed for unnecessary medications had appropriate indications for use. Findings include: Record review revealed Resident #121 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, malnutrition, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required set-up to partial assistance to complete Activities of Daily Living (ADLs). The MDS further detailed the Resident expressed symptoms of depression during the Resident Mood Interview but displayed no behaviors. Review of Resident #121's Health Care Provider (HCP) orders and Medication Administration Record (MAR) revealed the Resident was receiving Trazadone (antidepressant medication) 50 mg every evening for sleep. Resident #121 did not have a diagnosis of depression, anxiety, and/or insomnia. Review of Resident #121's Electronic…

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

Based on observations, interviews, and record reviews, the facility failed to effectively maintain food service equipment effecting 63 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 03/19/24 at 10:30 A.M., An initial tour of the food service was conducted with Director of Nutritional Services A. The following items were noted: Walk-In Freezer: The walk-in freezer entrance door perimeter was observed with ice damns. The wall surface, adjacent to the entrance door, was also observed with sporadic ice dam pockets. Director of Nutritional Services A indicated she would contact maintenance for necessary repairs as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, 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.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 63 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and reduced air-quality. Findings include: On 03/20/24 at 11:30 A.M., A common area environmental tour was conducted with Maintenance Services Director C and Environmental Services Director D. The following items were noted: Entrance Foyer: Two acoustical ceiling tiles were observed stained from a previous moisture leak. The two sets of facility entrance double-doors were observed missing the weather stripping between the door slab surfaces. The primary set of entrance double-doors were also observed with air gaps between the door slab and door jamb. The air gaps measured approximately 0.25 - 0.75 inches-wide on the right-side door, viewed from the parking lot. The right-side door was additionally observed to not completely close, due to hinge concerns. Maintenance Services Director C indicated he would contact corporate 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 follow policies and procedures for medication labeling and medication storage in 2 of 3 medication carts reviewed, resulting in opened and undated multi-dose medications, and the likelihood for altered medication efficiency. Findings include: Record review of the facility 'Medication Storage in the Facility' policy, dated 4/2018, revealed: When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. (1.) The nurse shall place a date open sticker on the medication and enter the date opened and the new date of expiration (note: the best stickers to affix contain both an open date and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacture recommends another date or regulations/guidelines require different dating. Observation and review on 03/20/24 at 07:06 AM with Licensed Practical Nurse (LPN) K of the [NAME] C Hall medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection, documentation, and analysis resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for spread of microorganisms and illness to all 62 facility residents. Findings include: During the entrance conference on 3/19/24 at 10:09 AM, the facility Administrator disclosed the facility currently had one resident who was Covid-19 positive. An interview and review of facility infection control program and data was completed on 3/21/24 at 12:57 PM with Infection Control Registered Nurse (RN) E and the Director of Nursing (DON). When queried regarding Covid-19 infection within the building, RN E confirmed the facility currently had one positive (Resident #46). When queried regarding the process/procedure related to outbreak…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to operationalize policies and procedure to ensure neglect was reported to the State Agency for one resident (Resident #216) of one resident reviewed, resulting in the lack of reporting of Resident #216 being pulled from the facility wheelchair van with the platform lift down and suffering multiple injuries including a cervical spinal fracture and the likelihood for additional unreported incidents of neglect and lack of thorough investigation. Findings include: Resident #216: On 6/7/23 at approximately 4:30 PM, Certified Nursing Assistant (CAN's) G was transporting three facility residents, including Resident #216, back to the facility from off site appointments in the facility wheelchair van. Upon returning to the facility, CAN's G unloaded two residents in wheelchairs from the van and Staff V assisted by taking the residents back to their respective units of the facility. Upon returning to the van to unload Resident #216 in their wheelchair, CAN's G did…

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 comprehensively assess an indwelling urinary catheter upon admission for one resident (Resident #322) of one resident sampled for indwelling catheters. Findings include: Resident #322: On 03/19/24 at 11:00 AM record review revealed that resident #322 is [AGE] years old and admitted on [DATE] with diagnoses of unspecified open wound, right lower leg, atrial fibrillation, type two diabetes, hyperlipidemia and morbid obesity due to excess calories. On 03/19/24 at 02:24 PM, resident #322 stated they had an indwelling catheter at their request and they had it on the day of admission to the facility from the hospital. On 03/20/24 at 10:30 AM, record review revealed no care plan or order for the indwelling catheter. No diagnosis was present in the health record for the catheter as well. On 03/20/24 at 03:40 PM, record review of the 5 day MDS, dated [DATE], section H noted that the resident does not have an indwelling catheter. On 03/20/24 at 03:40…

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 that accurate resident information was completed on the Resident Roster Matrix (802) for two residents (Resident #46, Resident #322), resulting in the inaccurate assessment of the residents with a likelihood for unmet care needs. Findings include: Record review of the facility 'Registered Nurse (RN) MDS/Care Plan Coordinator' job description (undated) revealed the MDS/Care plan coordinator is to coordinate the development and implementation of all resident plans of care in accordance with state & federal regulations and facility policies . Upon entrance conference on 3/19/2024 the team leader was notified of Covid-positive resident with the facility. Observation on 3/19/2024 of the surveyor's self-tour of the D-wing unit revealed that there were transmission-based precaution caddies out in the hallway in front of various room. Record review on 3/19/2024 at 10:33 AM the team leader received a copy of the Resident Roster Matrix (802)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop a baseline care plan for one resident (Resident #322) of one resident sampled for baseline indwelling catheter care plans. Findings include: Resident #322: On 03/19/24 at 11:00 AM record review revealed that resident #322 is [AGE] years old and admitted on [DATE] with diagnoses of unspecified open wound, right lower leg, atrial fibrillation, type two diabetes, hyperlipidemia and morbid obesity due to excess calories. On 03/19/24 at 02:24 PM, resident #322 stated they had an indwelling catheter at their request and they had it on the day of admission to the facility from the hospital. On 03/20/24 at 10:30 AM, record review revealed no care plan or order for the indwelling catheter. No diagnosis was present in the health record for the catheter as well. On 03/21/24 at 09:55 AM the Director of Nursing (DON) was interviewed about indwelling catheters and asked if a resident should have an order and a care plan for an indwelling…

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 develop respite care plans for one resident (Resident #65,), resulting in the likelihood for the resident's psychosocial and care needs to be unmet. Findings include: Record review of the facility 'Registered Nurse (RN) MDS/Care Plan Coordinator' job description (undated) revealed the MDS/Care plan coordinator is to coordinate the development and implementation of all resident plans of care in accordance with state & federal regulations and facility policies . Duties/Responsibilities: Calculate triggers and develop resident assessment protocol for initiation of care plans . Resident #65: Record review of Resident #65's closed medical record revealed a Minimum Data Set (MDS) with admission date of 12/18/2023 for hospice/respite care. Record review of the MDS discharge form dated 12/23/2024. Record review of Resident #65's care plans pages 1-17, revealed that there was no hospice/respite care plan noted. In an interview on 03/21/24 at 10:13 AM with the Director of Nursing (DON) revealed that Resident #65 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update or revise care plans with appropriate interventions for two residents (Resident #28, Resident #40), resulting in the likelihood for resident care needs being missed, prolonged illness or injury, recurrent falls and falls with major injury. Findings include: Record review of the facility 'Registered Nurse (RN) MDS/Care Plan Coordinator' job description (undated) revealed the MDS/Care plan coordinator is to coordinate the development and implementation of all resident plans of care in accordance with state & federal regulations and facility policies . Duties/Responsibilities: Calculate triggers and develop resident assessment protocol for initiation of care plans . Resident #28: Observation of Resident #28 during the initial tour of the west unit of the facility revealed Resident #28 to be seated up in a wheelchair with a blue disposable brief on and the resident was attempting to also put on a white elastic pull-up style brief. The Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have the resident's responsible party sign Against Medical Advice (AMA) discharge paperwork for one resident (Resident #63), resulting in a cognitively-impaired resident discharging from the facility. Findings include: Record review of the facility 'admission Packet' undated revealed Section D: Transfer or Discharge, (2.) In the event that the resident and/or resident representative request discharge of the resident against the advice of the attending physician, resident and/or resident representative (in his/her representative capacity) hereby expressly release the facility, its offices, employees, and agents from any and all liability . Resident #63: Record review of Resident #63's hospital Discharge summary dated [DATE] revealed that the resident sustained a fall at home resulting in left maxillary and left orbital facial fractures, left arm fracture of the radius and ulna. The discharge summary noted the resident to experience delusions,…

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 accurate assessment and implement a Restorative Nursing program for one resident (Resident #7) of two residents reviewed, resulting in a lack of accurate assessment and documentation of Range of Motion (ROM), a lack of implementation of Restorative Nursing services for a resident with a known contracture, further decline in ROM, and the likelihood for functional decline and avoidable pain. Findings include: Resident #7: On 3/19/24 at 11:31 AM, Resident #7 was observed sitting in their wheelchair in their room. An interview was completed at this time. When queried how much assistance they require for transferring and bathing, Resident #7 revealed they were unable to stand. When asked the reason, Resident #7 indicated they were unable to really move their legs and stated they also had a lot of pain from an infection in their spine. When queried if they were receiving therapy and/or Restorative Nursing Services for Range of Motion…

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 assess and maintain an indwelling urinary catheter for one resident (Resident #322) and prevent facility-acquired urinary tract infections for two residents (Resident#28, Resident #51, resulting in an indwelling catheter being left in place with no justifiable diagnosis. Findings include: Record review of the 'Nursing 2023 Urinary Tract Infections in Long-term Care, Improving the outcomes through evidence-based practice' Nursing 2023, Volume 53, Number 10, revealed Urinary tract infections (UTI's) are the most common infections in long-term care (LTC) facilities, yet clinical judgement rather than evidence is most often used in evaluation and treatment. Resident #28: Observation of Resident #28 during the initial tour of the west unit of the facility revealed Resident #28 to be seated up in a wheelchair with a blue disposable brief on and the resident was attempting to also put on a white elastic pull-up style brief. The Resident stated that he has to pee all the time. Observation of Resident #28 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 interview and record review, the facility failed to implement and operationalize policies and procedures to ensure informed consent for non-psychotropic medications used to treat mood and behavior disorders for one resident (Resident #10) of one resident reviewed for Depakote (anticonvulsant medication frequently used as a mood stabilizer), resulting in lack of consent for use and the potential for unnecessary and undesired medication use. Findings include: Resident #10: Record review revealed Resident #10 was originally admitted to the facility on [DATE] with diagnoses which included left sided hemiplegia and hemiparesis (one-sided paralysis) following cerebral infarction (stroke), paranoid schizophrenia, and mood disorders. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, displayed no behaviors, and was dependent upon staff to complete all Activities of Daily Living (ADL's) with the exception of eating. Review of Resident #10's…

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