Royalton Manor, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all licensed nursing staff remained competent and possessed the technical and communication skill sets necessary to provide nursing and related services to meet the residents' needs in 2 of 2 resident (Resident #207 and Resident #101) resulting in mismanagement of controlled substances, and the potential for all residents residing in the facility to not attain or maintain their highest practicable level of physical, mental, functional and psychosocial well-being. Findings include: Resident #207 During an observation of medication administration on 04/15/25 at 10:20 AM, RN JJ opened the top drawer of the medication cart and grabbed a handful of medications that were wrapped in foil, but not labeled with a resident name. RN JJ reported that she had pulled the medications from Resident #207's supply earlier that morning. RN JJ placed the pills in a cup, then prepared Lantus (insulin) 10 units to administer by injection. RN JJ…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clear and concise controlled substance count and failed to accurately document administration of controlled substances impacting 9 residents (Resident #101, #207, #102, #36, #206, #86, #62, #43, #18) in 2 of 6 medication carts reviewed, resulting in the potential for overdose and/or ineffective management of pain, and the potential for drug diversion of controlled substances. Findings include: In an interview on 04/15/25 at 10:12 AM, Registered Nurse (RN) JJ reported that Resident #101 had not received her Tramadol (controlled medication for pain) with her other morning medications because it was not in the medication cart, and she would have to go pull it from back up. RN JJ reported that she had signed out the Tramadol as not available in the resident's chart. Review of Resident #101's Physician Orders for current date of 4/15/25 revealed: Tramadol (narcotic pain medication) 50 mg upon rising. Review of Resident #101's 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: 1.) ensure adequate hand hygiene with Enhanced Barrier Precautions for 1 (R54) of 12 residents reviewed, 2.) ensure proper transportation of clean linen, 3.) maintain cleanliness of resident-shared equipment, and 4.) maintain an effective water management program to prevent Legionella, resulting in the potential for harborage and cross-contamination of infectious pathogens to a vulnerable population. Findings include: According to R54's Minimum Data Set (MDS) dated [DATE], the resident was cognitively intact with a score of 15/15 on the BIMS (Brief Interview Mental Status). Review of R54's Skin and Wound Evaluation dated 4/2/25, indicated the resident had a stage 2 pressure wound to her sacrum. During an observation and interview on 4/14/25 at 9:58 AM, Resident #54's room had Enhanced Barrier Precautions (EBP) signage on the door with a 3-drawer isolation cart outside of room. On the top of the cart was a bottle of hand sanitizer.…

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 timely and consistent weight monitoring and complete and accurate documentation for 2 residents (Resident #100, Resident #31) of 5 residents reviewed for nutritional status resulting in undetected weight changes and potential for nutritional status decline and unmet nutritional needs. Findings include: Resident #100 (R100) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R100 admitted to the facility on [DATE] with diagnoses including weakness and dysphagia (difficulty swallowing). Brief Interview for Mental Status (BIMS) reflected a score of 99 which indicated it could not be complete due to R100's severe cognitive impairment. On 4/14/2025 at 2:36 PM, R100 was observed to be lying in bed and was unable to respond to questions. An empty can of Jevity 1.5 (nutritional supplement) and a syringe was inside a plastic cup on the bedside table. Review of physician orders revealed Enteral feed (method delivering nutrition…

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 adhere with professional standards of practice in assuring the appropriate aseptic, dating/labeling, and resident-specific treatment plan for infection control practices for IV (intravenous (within a vein)) fluids for 2 residents (R302 and R301) of two residents reviewed for PICC (a peripherally inserted central catheter inserted through a vein in the upper arm and moved to a large blood vessel near the heart) line dressing change, resulting in the potential of contracting an infection. Findings include: R302 According to the Minimum Data Set (MDS) dated [DATE], R302 was cognitively intact with a score of 13/15 on her BIMS (Brief Interview Status). Diagnoses included rotavirus (common cause of severe diarrhea and vomiting). Review of R302's Order Summary -6/9/25 Change transparent dressing PICC as needed for IV maintenance . -6/9/25 change transparent dressing to PICC every day shift every 7 days for IV maintenance -It was noted there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who were eligible for recommended vaccines were offered vaccinations in a timely manner for 2 residents (Resident #101& #206) out of 5 residents reviewed for immunizations resulting in lack of documentation and the potential for developing vaccine preventable disease. Findings include: Resident #101 Review of Resident #101's Immunizations revealed, no record of Influenza or Pneumococcal historical records, education, and or consents offered. In an interview on 04/16/25 at 01:45 PM, Infection Preventionist (IP) KK reported that she had not gotten to Resident #101. IP KK reported that immunizations should have been discussed upon admission on [DATE], but there was no record of it. Resident #206 Review of Resident #206's Immunizations revealed, that the resident received 2 doses of pneumococcal historically as follows: PPSV23 on 06/17/2019, and Prevnar 13 on 11/03/2016. There was no record of Influenza, and no record of education and/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 interview and record review, the facility failed to ensure COVID-19 immunization were offered to 2 (Resident #101 & #206) of 5 residents, reviewed for COVID-19 immunizations, resulting in lack of documentation and the increased likelihood of severe infection and complications/death related to COVID-19. Findings include: Resident #101 Review of Resident #101's Immunizations revealed, no record of Covid-19 vaccine received, education provided, and/or consents on record. In an interview on 04/16/25 at 01:45 PM, Infection Preventionist (IP) KK reported that she had not gotten to Resident #101. IP KK reported that immunizations should have been discussed upon admission on [DATE], but there was no record of it. Resident #206 Review of Resident #206's Immunizations revealed, that the resident received 4 doses of Covid-19 vaccination historically prior to admission. The record did not include any documentation related to further Covid-19 booster education, declinations, or consents. In an interview on 04/16/25…

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 MI00148844. Based on interview and record review, the facility failed to protect the resident's right to dignity and respect in 1 resident (Resident #5) of 4 residents reviewed for dignity, resulting in the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Resident #5 (R5) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R5's initial admission date to the facility was 3/10/2024 with diagnoses including Alzheimer's disease, dementia, depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R5 was cognitively intact (13 to 15 cognitively intact). During an interview on 2/19/2025 at 2:37 PM, Licensed Practical Nurse (LPN) MM stated that back in December 2024 (thought it was around 12/9/2024), she was working the floor and she heard Nursing Home Administrator (NHA) A in R5's room. LPN MM reported that NHA A was being rude and mean to R5 and called her a liar.…

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 #MI00146234 Based on interview and record review the facility failed to adhere to professional standards related to ensuring physician orders were in place, monitoring nephrostomy tubes, and providing timely nephrostomy tube care for 1 (Resident #3) of 8 residents reviewed for professional standards resulting in delayed order placement, monitoring, and care of nephrostomy tubes. Findings include: Resident #3 Review of an admission Record revealed Resident #3 was a male, who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: malignant neoplasm of the posterior wall of the bladder (cancer of the bladder that had spread to other areas of the body), severe sepsis (systemic infection of the blood), and infection and inflammatory reaction due to nephrostomy catheter (infection resulting from nephrostomy catheters (tubes placed through the skin in the back directly into the kidneys to drain urine). Review of Nurse's Note for Resident #3 dated…

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 #MI00146234 Based on interview and record review the facility failed to ensure proper care for nephrostomy catheter (tubes placed through the skin in the back directly into the kidneys to drain urine) in 1 (Resident #3) of 1 resident reviewed for nephrostomy catheter care resulting in the potential for decreased effectiveness, catheter dislodgement, and/or infection. Findings include: Resident #3 Review of an admission Record revealed Resident #3 was a male, who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: malignant neoplasm of the posterior wall of the bladder (cancer of the bladder that had spread to other areas of the body), severe sepsis (systemic infection of the blood), and infection and inflammatory reaction (systemic infection) due to nephrostomy catheter (tube). Review of Nurse's Note for Resident #3 dated 7/26/24 at 17:29 pm, (5:29 pm) revealed Resident#3 arrived about 4pm .alert and oriented to place and time .is able 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 citation pertains to intake MI00145692 Based on interview and record review the facility failed to ensure proper procedure for a facility-initiated discharge for 1 (Resident #106) of 1 resident reviewed for facility-initiated discharge resulting in the untimely and unapproved discharge of the resident from the facility. Findings include: Review of an admission Record revealed Resident #106 had pertinent diagnoses which included: alzheimer's disease with last onset, dementia with mood disturbances, and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 7/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #106 was severely cognitively impaired. Review of Notice of involuntary transfer or discharge and facility-initiated discharge for nursing homes for Resident #106 dated 6/10/2024 revealed facility completed sections to include .date of notice was 6/10/2024 .proposed discharge date was 7/15/2024…

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 provide written notice of transfer for 1 (Resident #101) of 2 resident reviewed for hospital transfers, resulting in the potential for the resident and/or the resident's representative to be unaware of the resident's transfer out of the facility, the reason for the resident's transfer out of the facility, and/or the resident's rights. Findings include: Resident #101 Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: repeated falls, altered mental status, and adult failure to thrive. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #101 was severely cognitively impaired. Review of eINTERACT SBAR Summary for Providers for Resident #101 dated 6/22/24 at 12:33 PM., revealed ' . the change in condition .abnormal vital signs .tired, weak, confused or drowsy .recommendations: Send to the ER for further evaluation . In an electronic communication…

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 professional nursing standards of documentation were maintained in 1 (Resident #101) of 12 reviewed for professional nursing standards resulting in the potential for inaccurate assessment, lack of monitoring a condition, and incomplete communication of care needs. Findings include: Resident #101 Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: repeated falls, altered mental status, and adult failure to thrive. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #101 was severely cognitively impaired. Review of eINTERACT SBAR summary for Providers for Resident #101 dated 6/22/2024 at 12:33 PM., revealed .Nursing observations, evaluation, and recommendations are, Resident has had 500 ml viqa (via) hyoerdermaclesis (hypodermoclysis - infusion of fluids into the subcutaneous (under the skin) tissue.) and then an additional 500ml running…

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 MI00145627. Based on interview and record review, the facility failed to ensure a resident received timely treatment for an infection in 1 (Resident #103) of 4 residents reviewed for quality of care, resulting in Resident #103 not receiving antibiotic treatment for a urinary tract infection for 10 days after the infection was confirmed. Findings include: Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included: Paroxysmal Atrial Fibrillation (irregular heartbeat), Heart Failure (a condition in which the heart doesn't pump blood as well as it should), and Chronic Kidney Disease Stage 3 (a disease in which the kidneys don't filter excess waste and fluid from the blood effectively). Review of a Nurses Note for Resident #103 dated 6/29/24 at 7:06 PM revealed, Note Text: Patient has positive urine culture result. Awaiting plan for treatment. [A positive urine culture indicated the resident had a UTI (urinary tract infection)]. Review of a Communication Log to provider (physician, nurse practitioner)…

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 consistently and timely monitor for antibiotic medication efficacy and adverse reaction in 1 (Resident #103) of 1 resident reviewed for medication monitoring, resulting in the potential for unrecognized side effects or ineffective treatment. Findings include: Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included: Paroxysmal Atrial Fibrillation (irregular heartbeat), Heart Failure (a condition in which the heart doesn't pump blood as well as it should), and Chronic Kidney Disease Stage 3 (a disease in which the kidneys don't filter excess waste and fluid from the blood effectively). Review of a Nurses Note for Resident #103 dated 6/29/24 at 7:06 PM revealed, Note Text: Patient has positive urine culture result. Awaiting plan for treatment. (A positive urine culture indicated the resident had a UTI (urinary tract infection)). Review of a Physician Order dated 7/10/24 revealed, a Prescriber Entered order for Resident #103 for Nitrofurantoin Macrocrystal (an antibiotic) Oral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain clear, concise, and accurate medical records in 3 (Resident #101, Resident #106, and Resident #104) of 12 residents reviewed for clear, concise, and accurate medical records resulting in an incomplete record of care needs, and the potential for a diminished medical outcome. Findings include: Resident #101 Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: repeated falls, altered mental status, and adult failure to thrive. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #101 was severely cognitively impaired. Review of eINTERACT SBAR summary for Providers for Resident #101 dated 6/22/2024 at 12:33 PM., revealed .Nursing observations, evaluation, and recommendations are, Resident has had 500 ml viqa (via) hyoerdermaclesis (hypodermoclysis - infusion of fluids into…

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 safe transfer in 1 of 3 residents (Resident #101) reviewed for falls resulting in an unsafe transfer, fall and potential for injury. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R101's initial admission date was 2/20/2024 and had diagnoses of pulmonary embolism (condition where one or more arteries become blocked by a blood clot) and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 9 out of 15 which indicated R101 had moderate cognitive impairment (8-12 moderately impaired). During an interview on 6/4/2024 at 2:54 pm, R101 was sitting in her wheelchair and was confused and unable to answer questions regarding her falls. Review of the R101's Fall Report dated 5/26/2024 at 2130 revealed CNA (Certified Nursing Assistant (CNA II)) called writer into resident's room (R101) stating that she had to ease resident to the floor because resident (R101) was off balance when she was helping…

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. Ensure food product was stored off the floor; 2. Clean food and non-food contact surfaces to sight and touch; 2. Ensure general repair of the kitchen; and 4. Ensure staff practices to prevent service line contamination were followed. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 78 residents who consume food from the kitchen. Findings Include: 1. Food Storage: During an observation/interview on 3/24/24 at 9:26 AM during the initial kitchen/food service tour in the dry storage area, noted 3 stacked cases of canned food product placed directly on the floor. DM VV reported deliveries were received on Tuesdays and Thursdays and that he just hadn't had a chance to put those cases of food away yet. DM VV reported food product should not be stored directly on the floor. 2. Surfaces not clean: During an observation/interview on 3/24/24 at 9:35 AM during the initial kitchen/food service tour in the cooler, noted a storage rack 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 This citation pertains to intake: MI00143316. Based on observations, interview, and record review, the facility failed to maintain the dignity and respond to resident call lights timely in 4 (Resident #79, Resident #77, Resident #11, and Resident #382 ) of 21 residents, resulting in residents experiencing a fear of falling, anxiety about potential bladder incontinence, and concern about receiving a timely response in the event of a medical emergency. Findings include: Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, Promote Dignity and Self-Esteem. A sense of dignity includes a person's positive self-regard .attending to the patient's physical appearance promotes dignity and self-esteem. Cleanliness, absence of body odors, and attractive clothing give patients a sense of worth .allow patients to make decisions such as how and when to administer personal hygiene .and timing of nursing interventions. [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals 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 citation pertains to Intakes: MI00140381 and MI00139615. Based on interview and record review, the facility failed to implement policies and procedures for immediate reporting to the State Agency for 4 (Residents #10, #185, #38, and #68) of 9 residents reviewed for abuse reporting, resulting in the potential for further instances of abuse going undetected, unreported, or without thorough investigation. Findings include: Resident #10 Review of a Minimum Data Set (MDS) assessment for Resident #10, with a reference date of 5/23/23 (current at time of occurrence) revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated Resident #10 was severely cognitively impaired. Review of a FRI (Facility Reported Incident) received via online on 8/15/23 at 11:06 AM revealed, .Summary of the incident: On 8/11/23 at approximately 08:00 am (Certified Nurse Aide (CNA) P) noticed that (Resident #10) had a bruise on her outer right hip. (CNA P) went and reported finding…

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 complete annual performance reviews for 2 Certified Nursing Assistants (CNA's) (CNA's DD and FFFF) of 5 reviewed for regular in-service training, resulting in the potential for unidentified CNA performance concerns, a lack of training related to staff performance review outcomes, and the potential for unmet care needs. Findings include: In an interview on 3/25/24 at 9:15am, Director of Nursing (DON) B reported he had worked at the facility for six months and had filled in as a floor nurse regularly because the facility had difficulty filling unfilled nursing shifts. As a result, DON B reported he had not completed some responsibilities of his role. In an interview on 3/26/24 at 2:15pm, Staff Development Coordinator (SDC) Z reported all new CNA's underwent competency evaluations during their orientation but to her knowledge, no other evaluations had been completed in the past year. SDC Z reported no competency evaluations/trainings had been completed for CNA's that had been hired prior to the previous year. Review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide food in a palatable and appetizing temperature for four residents ( R45, R56, R382, and R40) of 21 residents reviewed for food temperature and palatability, resulting in reported meal dissatisfaction and the potential for decreased food acceptance and nutritional decline. Findings include: R45 According to the Minimum Data Set (MDS) dated [DATE], R45 scored 13/15 (cognitively intact) on his BIMS (Brief Interview Mental Status, did not have impairment in either of his arms, and had diagnoses that included cancer, heart failure, and renal insufficiency. During an observation and interview on 3/24/24 at 11:27 AM, R45 stated, Me and wife share this room and are the last room in the hall. The food is cold by the time it gets too us. This morning, I wanted the sausage so badly and when I took a bite of it I almost threw up because it was cold and that made it taste bad. I have steadily lost weight because of the cold food. Review of R45's Weight…

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 infection prevention standards of practice for 1.) adequately identify positive and exposed Covid-19 residents for 2 of 3 residents (R66 and R18), 2.) appropriate use of personal protective equipment (PPE) for Transmission-Based Precautions residents for 3 of 3 residents (R382, R66, R18) of 21 residents reviewed for infection control, and 3.) cleaning, disinfection, maintaining resident-shared and resident-specific equipment, resulting in the potential for the spread of infection, cross-contamination, and disease transmission to a vulnerable population. Findings include: Review of facility policy Multi-Route Transmission-Based Precautions effective 11/22/22, revealed, .Transmission-Based Precautions .are to be used in addition to standard precautions for residents who may be infected .with certain infectious agents for which additional precautions are needed to prevent infection transmission .For some diseases that have multiple…

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 keep the environment free from the accumulation of debris on resident's bathroom and bed area floors and toilets, resulting in the potential of bacterial harborage, a safe sanitary environment, and a possible decreased satisfaction of living conditions. Findings include: Review of facility policy, Housekeeping Services revised date 2/22/2023, revealed, To promote a sanitary environment . frictional cleaning .thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas .Routine Cleaning of Horizontal Surfaces .in resident care areas, cleaning of non-carpeted floors . will be done daily and more frequently if spillage or visible soiling occurs .Infection Prevention .Housekeeping Services play a large role in maintaining a clean health care environment . Observed on 3/25/24 at 7:45 AM, room [ROOM NUMBER]'s had an accumulation of mixed dried and wet dark brown substances all the way around 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.

Based on interview and record review, the facility failed to implement an effective in-service training program for nurse aides that supported mandatory nurse aide attendance, tracked participation, and ensured continuing competence for 5 Certified Nurse Aides (identified as CNAs I, FFFF, F, HHHH and DD) of 6 CNAs whose in-service training files were reviewed, resulting in the potential for unmet resident care needs. Findings include: Review of The Importance of Continuing Education Credits in Healthcare, www.leaderstat.com, 2024, revealed: According to The Institute For Health Care Improvement, CE (continuing education) is a vehicle for spreading best practices and how to improve patient outcomes. In an interview on 3/26/24 at 2:15pm, Staff Development Coordinator (SDC) Z reported she had worked at the facility for a year but had filled in as a floor nurse regularly, conducted new employee orientation three times a week, had not been able to fulfil some of her job responsibilities, and had not tracked Certified Nursing Assistant (CNA) compliance for the 12 hours of required annual…

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 MI00143316 Based on observation, interview, and record review, the facility failed to ensure accommodations for specific care needs were meant for 1.) call light was accessible to 1 resident (R20) of 21 residents reviewed for accommodations of needs, resulting in the potential of unmeet care needs. Findings include: R20 According to the Minimum Data Set (MDS), dated [DATE], R20 scored 4/15 (severely cognitively impaired) on her BIMS (Brief Interview Mental Status), and diagnoses that included dementia, seizure disorder, and anxiety. Observed on 3/24/24 at 11:52 AM, R20 lying on her right side in bed with a soft-touch call light pinned above her right shoulder out of her sight and reach. Observed on 3/25/24 at 9:30 AM, R20 lying on her back in bed with a soft-touch call light pinned above her right shoulder out of her sight and reach. During an interview on 3/27/24 at 2:20 PM, Infection Control Preventionist (ICP) Z stated, I do Staff Development right now and educate staff that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00140381 Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from staff to resident physical and mental abuse for 1 resident (Resident #185) and resident to resident physical abuse for 1 (Resident #68) of 11 residents, resulting in abuse with the potential for psychosocial harm. Findings include: Review of an admission Record revealed Resident #185 was a female with pertinent diagnoses which included dementia and anxiety. In an interview on 3/25/24 at 4:50 PM, Complainant NNN reported the certified nursing assistant (CNA) VVV was wrestling the remote out of Resident #185's hand. Resident was telling her I just want to hold it, let me hold it while she was attempting to pry it out of her hands. This was observed by a housekeeper who reported it to the unit manager. The unit manager reported the incident to the Administrator who believed it was a misunderstanding and the CNA was not that type of person. 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.

This citation pertains to intake MI00137836 Based on observation, interview, and record review the facility failed to develop person centered care plans related to skin integrity and pressure ulcers for 1 resident (Resident #13) of 18 residents sampled for person centered care plans resulting in the the potiental for unmet care needs. Findings include: Review of an admission Record revealed Resident #13 had pertinent diagnoses which included: dementia with other behavioral disturbance, alzheimer's disease with late onset, muscle wasting, and protein calorie malnutrition. Review of Skin and Wound Evaluation for Resident #13 dated for 2/22/24 revealed .pressure wound, unstageable: obscured full-thickness skin and tissue loss . to right elbow .in-house acquired .New . Review of Care plan for Resident #13 revealed no noted care plan for an acutal wound. Review of Braden Scale for Resident #13 dated for 1/13/24 revealed high risk 12.0 . no subsequent Braden Scale assessments noted in Resident #13's record. In an interview on 3/25/24 at 3:07 PM., Registered Nurse/Unit Manager/Wound Nurse…

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 MI00137836. Based on observation, interview, and record review, the facility failed to update and revise the person-centered comprehensive care plan in a timely manner for two residents ( R186 and R9 ) of 21 residents reviewed for care plan revisions, resulting in the potential for physical, mental, and psychosocial unmet care needs. Findings include: R186 According to the Minimum Data Set (MDS) dated [DATE], R186 scored 1/15 on her BIMS (Brief Interview Mental Status) with diagnoses that included coronary artery disease, diabetes, dementia, and Parkinson's disease. Review of R186's Do-Not-Resuscitate Order dated [DATE], indicated the resident and her guardian authorized that in the event R186's heart and breathing should stop, no person shall attempt to resuscitate her. Review of R186's Care Plan, Advanced Directives, date revised [DATE], indicated (R186) wanted CPR/Full Code with the goal of her advanced directives honored through the next review date of [DATE]. To meet 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 ensure residents received care in accordance with professional standards of nursing practice (provide antibiotics and dressing changes as ordered) for 2 of 21 residents (Resident #79 and Resident #77) reviewed for following of physician's orders resulting in the potential for the worsening of a condition and a delay in treatment. Findings include: Resident #79 Review of an admission Record with a reference date of 3/15/24 revealed Resident #79 was admitted to the facility with the following pertinent diagnoses: need for assistance with personal care, difficulty walking, urge incontinence (urine leakage caused by strong desire to void), and muscle weakness. Review of a Minimum Data Set (MDS) assessment with a reference date of 3/21/24 revealed a Brief Inventory for Mental Status (BIMS) score of 14/15 which indicated Resident #79 was cognitively intact. Review of a Care Plan with a reference date of 3/1/24 revealed a focus/goal/interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide sufficient organized group activities, variety of supplies and equipment, and meet activity needs and interests important to 2 (Resident #21, #36) of 7 residents reviewed for activities, resulting in potential for loss of interaction, joy, connectedness and identity in the facility's memory care unit. Findings include: Resident #21: Review of an admission Record revealed Resident #21 was a male with pertinent diagnoses which included Alzheimer's disease, dementia, hearing loss, cataracts - bilateral, low back pain, dyslexia (learning disability where your brain processes written language differently, affects reading and language skills) and [NAME] (inability to read or comprehend their own written language) Review of current Care Plan for Resident #21, revised on 7/10/2018, revealed the focus, .(Resident #21) is very focused on mechanical, electrical, taking things apart. He is very curious by nature and walks about frequently .…

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 appropriate supra-pubic catheter care for 1of 2 residents (R40) reviewed for catheter care, resulting in the potential of an urinary tract infection. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R40 had diagnoses that included neurogenic bladder that required an indwelling catheter. Review of R40's Order Summary, revised date 3/24/24, revealed Suprapubic catheter 18 FR to dependent drainage related to neurogenic bladder. Review of R40's Care Plan, dated 8/22/23, focus At Risk for Urinary Tract Infection and catheter-related trauma: history of UTI with MSSA, has supra-pubic 18 FR catheter related to neurogenic bladder with history of urethral inflammation from catheter and kidney cyst. The goal was R40 not to show signs or symptoms of urinary infect. Interventions to meet this goal included provide catheter care per policy. During an observation and interview on 3/24/24 at 12:00 PM, R40 was sitting 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 identify post traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 1 (Resident #68) of 21 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma. Findings include: Review of an admission Record revealed Resident #68 was admitted with pertinent diagnoses which included Alzheimer's disease, dementia, and history of adult physical and sexual abuse. Review of current Care Plan for Resident #68, revised on 5/30/23, revealed the focus, .(Resident #68) has experienced sexual abuse in her past . with the interventions .Encourage resident/guest to be involved in activities and be engaged with others as possible and desired .Establish and maintain a trusting relationship .Maintain a calm non-threatening relationship by listening to the resident/guest .Move slowly 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 ensure the attending physician reviewed and responded to the registered pharmacist's monthly medication regimen review recommendations for 1 (Resident #20) of 5 residents reviewed for medication regimen review, resulting in the registered pharmacist's recommendations not being addressed and the potential for negative medication side effects as a result of unaddressed recommendations. Findings include: Review of an admission Record revealed Resident #20 was a female, with pertinent diagnoses which included: unspecified dementia, unspecified severity, with other behavioral disturbance; psychotic disorder with delusions due to known physiological condition; residual schizophrenia; major depressive disorder; and generalized anxiety disorder. Review of a Physician's Order for Resident #20 revealed, SEROquel Oral Tablet 25 MG (milligrams) (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for (sic) give with 50 mg seroquel for a total of 75 mg, twice daily hospice order The order had a start date of 4/6/23 and 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 observation, interview, and record, the facility failed to ensure proper labeling and storage of medications in 2 of 2 medication rooms (medication room located on central and south unit) reviewed for medication labeling and storage, resulting in the potential for residents to receive expired medications with altered potency and decreased efficacy. Finding include: During an observation on 3/25/24 at 12:51 PM., in a cabinet of stored stock medications, in the south medication room revealed 4 boxes of stock medication, acetaminophen suppositories 650 mg, 12 suppositories in each box, with an expiration date of 12/2023 and in another cabinet of stored stock medications 1 box with single dose packages of bio-freeze muscle relief ointment (total packaging 100 doses) open with doses missing, with an expiration date of 10/2022. In an interview on 3/25/24 at 12:55 PM., Registered Nurse (RN) NN reported that she was unsure who was to remove expired stock medications from the medication room. RN NN reported medications stored together on the counter in the medication room were in…

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

Based on observation, interview and record review, the facility failed to assess and provide foods that met the residents needs in 1 of 21 residents (Resident #12) reviewed for meals, resulting in the resident having weight loss and inability to maintain the ability to eat independently. Findings include: Review of an admission Record with a reference date of 4/27/19 revealed Resident #12 was admitted to the facility with the following pertinent diagnoses: alzheimer's disease (condition causing progressive cognitive deficits), adult failure to thrive, and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment with a reference date of 1/15/24 revealed Resident #12 was rarely/never understood and could not complete a Brief Inventory for Mental Status (BIMS) assessment. Section C of the MDS revealed Resident #12 had short and long-term memory deficits. Section GG of the MDS revealed Resident #12 was dependent (helper does all the effort) to use suitable utensils to bring food or liquid to the mouth. Review of a Care Plan with a reference date of 5/4/19 revealed 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 observation, interview, and record review the facility failed to: 1. Adequately clean the main ice machine; 2. Ensure proper working order of the dish machine; 3. Properly store an item requiring refrigeration; and 4. Ensure potentially hazardous foods properly cool. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 65 residents who consume food from the kitchen. Findings Include: 1. During a tour of the kitchen, at 10:05 AM on 4/3/23, it was observed that an increased amount of black debris accumulation was observed on the plastic lip of the ice machine. When asked who cleans the ice machine, DM GG stated that maintenance takes care of the ice machine. During a tour of the kitchen, at 10:25 AM on 4/3/23, it was observed that the top of the convection oven showed an increased amount of crumb and debris accumulation. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain resident dignity by responding to calls for assistance and/or providing necessary grooming in 4 of 4 residents (Resident #53, #5, #41, and #50) reviewed for dignity, resulting in the potential for decreased feelings of self-worth. Findings include: Resident #53 Review of an admission Record revealed Resident #53 admitted to the facility on [DATE] with pertinent diagnoses which included Chron's Disease, constipation, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #53, with a reference date of 2/24/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #53 was cognitively intact. Review of a current activities of daily living Care Plan intervention for Resident #53, with a revision date of 10/11/2021, directed staff to use extensive assistance of one staff with incontinence care. In an interview on 4/3/2023 at 11:58 AM,…

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 1) resident-shared equipment was properly cleaned/sanitized 2) commonly used/touched items were cleaned/sanitized 3) bathroom in the facility were maintained in sanitary conditions resulting in the potential for cross-contamination and bacterial harborage, and the spread of infection to a vulnerable population. Findings include: Review of a facility Policy with a revision date of 9/9/2022 titled Environmental Cleaning and Disinfection . Routine cleaning and disinfection of frequently touched or visibly soiled surfaces in common areas, guest/resident rooms and at the time of discharge .Note: privacy curtains should be changed when visibly dirty and should be laundered or disinfected with an EPA-registered disinfectant per curtain and disinfectant manufacturer's instructions .Routine cleaning and disinfection of guest/resident care equipment including equipment shared among guests/ residents (e.g., blood pressure cuffs,…

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 confidential resident health information was protected and private for 3 of 6 residents (Residents #12, #26, and #32) reviewed for privacy and federally regulated HIPAA (Healthcare Insurance Portability and Accountability Act), resulting in the potential for unauthorized disclosure of protected health information. Findings include: Resident #32 In an observation on 4/04/23 at 7:50 AM., during medication administration for Resident #32, Licensed Practical Nurse (LPN) I was observed leaving the medication cart after setting up Resident #32's medications and entering Resident #32's room. LPN I walked away from the medication cart, leaving the laptop computer screen which displayed personal medical information for Resident #32 viewable. LPN I did not lock the computer screen. The unlocked screen displayed medication orders and medical diagnoses for Resident #32. LPN I quickly exited Resident #32's room and walked to the opposite end 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 observation, interview, and record review, the facility failed to provide an environment free from neglect for 1 resident (Resident #62) of 6 residents reviewed for abuse/neglect resulting in staff neglecting to serve Resident #62 her entire breakfast meal, causing stomach pain, feelings of hunger, frustration and the potential for increased hunger pains, weight loss, and loss of necessary nutrients. Findings include: Review of an admission Record revealed Resident #62, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia. Review of a Minimum Data Set (MDS) assessment for Resident #62, with a reference date of 3/14/2023 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #62 was cognitively impaired. Further review of Resident #62's MDS revealed for eating Resident #62 needed supervision and set up assistance with meals. During an interview on 4/05/23 at 12:43 PM., Resident # 62 stated: I did not get my breakfast 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.

Based on observation, interview and record review, the facility failed to provide adequate supervision and effective interventions for 1 Resident (Resident # 24) of 4 reviewed for accidents, resulting in a potential for serious injury. Findings include: A review of an admission Record revealed Resident #24 was admitted with pertinent diagnoses that included: Alzheimer's Dementia (progressive disease resulting in progress cognitive decline), delusions (false belief or judgement about external reality). A review of a Minimum Data Set Assessment (MDS) for Resident #24, dated 2/22/23 revealed a Brief Inventory of Mental Status (BIMS) assessment score of 99 which indicated Resident #24 was not able to complete the assessment due to cognitive impairment. Section F of the MDS revealed Resident # 24 was ambulatory without a device and required supervision when ambulating. Section GG of the MDS revealed Resident #24 could ambulate 150 feet. A review of a nursing progress note dated 3/13/23 revealed Resident #24 was found fidgeting with an electrical outlet, with a metal utensil, while…

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 adequate staff on the memory care unit to meet resident needs for 1 residents (Resident #62) reviewed for staffing resulting in Resident #62 missing an entire breakfast meal, and resident care and needs not being consistently met and the potential for negative outcomes. Findings include: Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed: 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 the quality of care provided to patients…

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.