The Orchards at Three Rivers

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain oxygen equipment in a sanitary manner and follow physician's oxygen orders for 1 (Resident #87) of 1 resident reviewed for respiratory care resulting in the potential for excessive oxygen levels and/or an infection.Findings include:Review of Resident #87's admission Record, print date 3/5/26, indicated she was readmitted on [DATE] and had a power of attorney (authorized person to make decisions for another individual) for medical care. The admission record included medical diagnoses of chronic respiratory failure, other disorders of lung, and other forms of dyspnea (shortness of breath). Review of Resident #87's physician order for oxygen, dated 2/23/26, stated, Oxygen @ 2L (at 2 Liters per minute) via NC (nasal cannula/oxygen tubing) .During an observation on 03/03/2026 at 11:17 AM, Resident #87 was in her bed receiving supplemental oxygen from the bedside oxygen concentrator at a flow rate of 2 liters per minute. Resident #87'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to maintain complete and accurate medical records in 2 of 18 residents (Resident #61 & #7) reviewed for accuracy of medical records, resulting in inaccurate code status information within the electronic health record and missing documentation in the treatment record with the potential for advanced directive/code status preferences to not be honored and deterioration in resident status.Findings include:Resident #61 Review of an admission Record revealed Resident #61 was a female, with pertinent diagnoses which included high blood pressure, paraplegia (impairment or loss of motor and sensory function in the lower half of the body), muscle weakness, depression, anxiety, and chronic kidney disease. Noted Resident #61 was her own responsible party. Review of a Minimum Data Set (MDS) assessment for Resident #61, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, indicating she…

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 they educated, offered and administered COVID-19 vaccines or maintained valid declination in the medical record for 1(Resident #87) of 5 residents reviewed for Covid-19 immunizations resulting in the increased likelihood of severe infection and complications/death related to COVID-19. Findings include:Resident #87 Review of an admission Record revealed Resident #87 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pneumonia (an infection that inflames the air sacs in one or both lungs) and pulmonary hypertension (condition characterized by high blood pressure in the lungs' arteries, causing the right side of the heart to work too hard, leading to weakening and potential failure). Review of Resident #87's Immunization Record revealed, SARS-COV-2 (COVID-19)-Dose 2. Date administered: (there was no date indicated). Status: Pending historical . During an interview on 3/04/2026 at 10:22 AM, Infection…

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 best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: In an observation and interview on 12/17/25 at 11:43 AM, within the main kitchen, noted Dietary Services Aide MM standing beside the tray line (with lunch service in progress) with no hair net or hair restraint worn. Dietary Services Aide MM reported the lunch today was fried chicken, mashed potatoes and gravy and carrots, with rice and pork (leftover from 12/16/25) available as alternate menu items. Observed the stated food items were present in trays on the steam table. In an observation and interview on 12/17/25 at 11:53 AM, lunch service was in progress for the main dining room. Noted the leftover pork that had been reheated and placed in a tray on the steam table to serve as an alternative menu item.…

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 2689916.Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and failed to implement effective corrective interventions for known issues involving staffing and meal service, with the potential to impact all residents who reside at the facility, resulting in insufficient staff to meet resident needs and poor food quality.Findings include:Refer to noncompliance cited at F677, F725, and F804.In an interview on 12/16/25 at 12:09 PM, Resident #103 stated in regard to staffing .we have no help in here at all. The aides are great, but they are overworked . Resident #103 reported she experienced long call light wait times, especially on third shift. Resident #103 reported staff will often respond to the call light and turn the light off, saying they will be back later, but .they don't come back . Resident #103 reported call light wait times as long as an hour. Resident #103 reported some days she was unable to get up in her power chair because there were not enough staff 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.

This citation pertains to Intake # 2670974, 2689916, & 2646054.Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, homelike environment in 3 of 5 residents (Resident #102, #103, & #108) reviewed for a safe/clean environment, resulting in refusal of care due to uncomfortable water temperatures and dissatisfaction with the living conditions.Findings include:Resident #102 Review of an admission Record revealed Resident #102 was a male, with pertinent diagnoses which included Parkinson's disease (a progressive brain disorder affecting movement), major depression, legal blindness, need for assistance with personal care, dementia, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 11/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating he was cognitively intact. In an interview on 12/16/25 at 12:50 PM, Resident #102 reported he does not receive his showers as scheduled, partly due to issues with the facility not having…

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 # 2670974 & 2689916.Based on interview, and record review, the facility failed to ensure showers/baths were provided per resident preference and plan of care in in 4 of 7 residents (Resident #101, #102, #103, & #113) reviewed for showers/bathing, resulting in dissatisfaction with the care provided and the potential for discomfort and feelings of impaired self-worth.Findings include:Personal hygiene affects patients' comfort, safety, and well-being. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities such as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation, foster a positive self-image, promote healthy skin, and help prevent infection and disease. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.Resident #101Review 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.

This citation pertains to Intake # 2670974, 2689916, 2646054, 2639254, & 2693899.Based on interview, and record review, the facility failed to ensure sufficient staffing to meet resident needs in 4 of 6 residents (Resident #102, #103, #108, & #109) reviewed for sufficient staffing and timely response to resident needs, resulting in long call light wait times, missed showers, and the potential for unmet needs.Findings include:Resident #102Review of an admission Record revealed Resident #102 was a male, with pertinent diagnoses which included Parkinson's disease, major depression, legal blindness, need for assistance with personal care, dementia, and anxiety.Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 11/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating he was cognitively intact.In an interview on 12/16/25 at 12:50 PM, Resident #102 reported he does not receive his showers as scheduled, partly due to issues with the facility not having enough hot water. Resident #102…

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 # 2689916.Based on observation, interview, and record review, the facility failed to follow the menu and serve food items from the menu as scheduled, post the current menu for residents to review, and update the menu with changes when they occurred, in 1 of 8 residents (Resident #103) reviewed for food, with the potential to affect all residents who receive meals from the kitchen, resulting in frustration with the food service process and the potential for decreased intake.Findings include:Resident #103 Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included cerebral palsy (a neurological disorder affecting movement, posture, and coordination), major depression, muscle weakness, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 12/3/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, indicating she was cognitively intact. In an interview on 12/16/25 at 12:09 PM,…

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 # 2670974, 2689916, 2671774, 2667436, 2646054, 2639254, 2599079, 2693899, & 2693872.Based on observation, interview, and record review, the facility failed to provide adequate portions of palatable food, served at an appetizing temperature in 8 of 9 residents (Resident #102, #103, #105, #108, #109, #110, #111, & #113) reviewed for food quality, resulting in dissatisfaction with the meals served, frustration with the food service process, and the potential for decreased meal intake and weight loss.Findings include:In an interview on 12/17/25 at 10:03 AM, Ombudsman FF reported she had received many complaints from residents and family members regarding the quality of the food served at the facility and small portion sizes. Resident #102 Review of an admission Record revealed Resident #102 was a male, with pertinent diagnoses which included Parkinson's disease (a progressive brain disorder affecting movement), major depression, legal blindness, need for assistance with personal care, dementia, and anxiety. Review of a Minimum Data Set (MDS) assessment…

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 #2690782Based on interview, and record review, the facility failed to obtain informed consent for psychotropic medications for 1 (Resident #106) of 3 residents reviewed for notification of change resulting in lack of communication and/or education to the resident/resident representative for initiation and/or dose changes of psychotropic medications.Findings include:In an interview on 12/16/25 at 2:34 PM, Family Member HH reported she was not notified regarding changes to Resident #106's medications. Family Member HH stated .He has been put on medications that I knew nothing about . Family Member HH reported she recently learned that Resident #106 had been prescribed and was taking Seroquel (generic name quetiapine - an antipsychotic medication) and they are currently in the process of discontinuing that medication. Family Member HH reported Resident #106 did not take Seroquel prior to his admission to the facility, and stated .I did not know he was on it . Family Member HH…

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 # 2677000 & 2693899.Based on interview, and record review, the facility failed to ensure ordered medications were administered timely per physician orders in 2 of 8 residents (Resident #107 & #114) reviewed for quality of care, resulting in a delay of care, and the potential for worsened infection, increased seizure activity, and impaired health status.Findings include:Review of the policy/procedure Medication Administration and General Guidelines, dated 11/2022, revealed .Medications are administered in accordance with written orders of the attending physician .Resident #107Review of an admission Record revealed Resident #107 was a male, admitted to the facility on [DATE], with pertinent diagnoses which included peripheral vascular disease (a circulatory problem resulting in reduced blood flow to the limbs), heart failure, left foot ulcer, bacteremia (presence of bacteria in the bloodstream), chronic pain, high blood pressure, left leg atherosclerosis (plaque buildup inside the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2663418Based on interview, and record review, the facility failed to report injuries of unknown origin to the State Agency in a timely manner for 1 (Resident #100) of 5 residents reviewed for abuse and reporting, resulting in the potential for ongoing mistreatment to go unrecognized.Findings include:Resident #100Review of an admission Record revealed Resident #100 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (disease causing progressive decline in cognitive skills), cognitive communication deficit (communication challenge caused by impaired thinking skills), and fracture of nasal bones.Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 10/29/25, revealed Resident #100 was rarely to never understood and a Brief Interview for Mental Status (BIMS) could not be conducted. Section GG revealed Resident #100 was dependent for rolling in bed and transferring from bed 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 intakes #2663418, # 2648487, 2648458, 2645961, and #2671459Based on interview and record review, the facility failed to thoroughly investigate an incident of potential mistreatment for 4 (Resident #100, Resident #102, Resident #104, and Resident #109) of 5 residents reviewed for abuse resulting in the potential for mistreatment to go unrecognized and resolved.Findings include:Resident #100Review of an admission Record revealed Resident #100 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (disease causing progressive decline in cognitive skills), cognitive communication deficit (communication challenge caused by impaired thinking skills), and fracture of nasal bones (9/18/25).Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 10/29/25, revealed Resident #100 was rarely to never understood and a Brief Interview for Mental Status (BIMS) could not be conducted. Section GG revealed Resident…

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

Based on interview and record review, the facility failed to ensure 6 staff members (Certified Nursing Assistant (CNA) G, CNA TT, CNA Z, CNA G, CNA UU and Registered Nurse (RN) BB ) of 6 staff reviewed for behavioral competency, had the appropriate skills needed to provide care in a manner that supported each resident's psychosocial wellness, resulting in the potential for inappropriate staff to resident interactions, inability of staff to appropriately address residents in psychological distress, unmet care needs, and resident not maintaining or achieving highest practical psycho-social wellbeing. Findings include:In an interview on 11/20/25 at 9:24am, CNA P reported she struggled to successfully care for several residents in the memory care unit of the facility. CNA P reported working in memory care was her least favorite hall because she did not know how to care for the resident's without triggering their stress responses. CNA P stated I say I'm sorry to residents back there more than anywhere else in the building because they get so upset.In an interview on 11/20/25 at 1:58pm,…

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 #2663418Based on interview and record review, the facility failed to operationalize its abuse policy and procedure for 1 resident (Resident #100) of 5 residents reviewed for abuse, resulting in potential abuse not being reported to the Nursing Home Administrator (NHA) immediately.Findings include:Resident #100Review of an admission Record revealed Resident #100 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (disease causing progressive decline in cognitive skills), cognitive communication deficit (communication challenge caused by impaired thinking skills), and fracture of nasal bones.Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 10/29/25, revealed Resident #100 was rarely to never understood and a Brief Interview for Mental Status (BIMS) could not be conducted. Section GG revealed Resident #100 was dependent for rolling in bed and transferring from bed to wheelchair.Review…

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 #2671515Based on interview and record review the facility failed to provide appropriate first aid care for a burn for 1 (Resident #103) of 3 residents reviewed for professional standards, resulting in Resident #103 (who suffered a second-degree burn) receiving inappropriate treatment and a potential for worsening of the injury because of the care provided. Findings include:Resident #103Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: altered mental status (a change in a person's cognitive status), muscle weakness, and cognitive communication deficit (communication challenge caused by impaired thinking skills), and type 2 diabetes mellitus (condition in which the body does not produce enough insulin resulting in high blood sugar levels).Review of a Minimum Data Set (MDS) assessment for Resident #103 with a reference date of 10/1/25, revealed a Brief Interview for Mental Status (BIMS)…

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 #2663418Based on interview and record review the facility failed to promptly recognize and assess 1 resident (Resident #100) of 3 reviewed for quality of care, resulting in Resident #100, who had new symptoms of unknown head trauma, not being properly assessed for 5 days, and a potential for care needs to go unmet. Findings include:Resident #100Review of an admission Record revealed Resident #100 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (disease causing progressive decline in cognitive skills), cognitive communication deficit (communication challenge caused by impaired thinking skills), and fracture of nasal bones (9/18/25).Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 10/29/25, revealed Resident #100 was rarely to never understood and a Brief Interview for Mental Status (BIMS) could not be conducted.Review of a Care Plan for Resident #100 with a reference date of…

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

Based on interview, and record review, the facility failed to complete annual performance reviews for 3 Certified Nursing Assistants (CNAs) (CNA's T, X, and KK) of 3 reviewed for regular performance evaluations, 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 email sent to Nursing Home Administrator (NHA) A on 10/30/25 at 8:12am, annual performance reviews were requested for CNA's T, X and KK.Review of personnel files for CNA's T, X, and KK revealed no annual reviews were present for the past 12 months. Further review of the employee files revealed all CNA's had been employed by the facility for more than 12 months.In an interview on 10/30/25 at 12:51pm, Business Office Manager (BOM) BB reported every nursing assistant should have a performance review done at least every 12 months and the evaluation should be kept in the employee file. BOM BB reviewed the employee files for CNA T, X and KK and confirmed no performance reviews completed…

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 quality assurance and performance improvement (QAPI) program identified and corrected quality deficiencies, resulting in decreased quality of care.Findings include:Review of a Quality Assurance and Performance Improvement(QAPI) policy with a reference date of 6/2025 revealed Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.Policy Explanation and Compliance Guidelines: The QAPI program includes.a written QAPI Plan. The QAA (Quality Assessment and Assurance) Committee shall. consist of a minimum of.The Medical Director/designee.implement appropriate plans of action to correct identified quality deficiencies.regularly review and analyze data.At a minimum, the QAPI program will: address all systems of care and management practices.Considerations include, but are not limited to: Certain classes of…

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

Based on interview and record review the facility failed to ensure the medical director or their designee attended Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly, resulting in the potential for the decline in overall medical care provided and decreased oversight of the implementation of resident care throughout the facility.Findings include:Review of the facility's QAPI committee sign-in sheets revealed neither the medical director nor their designee physically or virtually attended a committee meeting from April-August 2025. In an interview on 10/30/25 at 3:16pm, Nursing Home Administrator (NHA) A reported the facility had a large turnover in within the management team since April 2025 and as a result QAPI had not been running smoothly. NHA A reported the facility also changed Medical Directors in April and the former Medical Director did not attend QAPI as required. NHA A reported the new Medical Director was agreeable to attending but needed to have it scheduled in advance and that initially lead to them not attending the meeting as…

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

Based on interview and record review the facility failed to maintain an effective training program which included training in resident rights, quality assurance, infection control, compliance and ethics, and communication for all existing employees, resulting in the potential for decreased resident safety for all residents who resided in the facility.Findings include:In an interview on 10/30/25 at 12:47pm, Director of Nursing (DON) B reported the facility used a computer-based training platform for staff training for a portion of the year but after the facility opted to stop using the platform/paying for the service, it was no longer able to access record of any training the staff had completed. DON B reported there was no current staff training program in place.In an interview on 10/30/25 at 1:14pm, DON B reported any training the staff completed would be recorded in their employee file.Review of employee files for CNA T, X and KK revealed no training related to the QAPI program, Infection Control, Compliance and Ethics, Communication or Resident Rights in the last 12 months.In an…

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

Based on interview and record review, the facility failed to implement an effective in-service training program for nurse aides that supported mandatory nurse aide attendance, tracked participation, and ensured continuing competence for 3 Certified Nurse Aides (identified as CNAs T, X, and KK) of 3 CNAs whose in-service training files were reviewed, resulting in the potential for unmet resident care needs. Findings include:Review of a Nurse Aide Training Program policy with a reference date of 10/28/25 revealed Policy: The facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides. In an email on 10/29/25 at 3:28pm, documentation of Certified Nursing Assistant (CNA) in-service training for the last 12 months was requested for CNA T, X and KK.In an interview on 10/30/25 at 12:47pm, Director of Nursing (DON) B reported the facility had been without a staff educator and she was trying to cover the responsibilities of that role. DON B reported she was working on developing a staff training…

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 call lights were within reach for 1 of 2 residents (R102) reviewed for accommodation of needs, resulting in the potential for residents to not meet their highest practicable level of well-being.Findings include:According to R102's Minimum Data Set (MDS), dated [DATE], indicated the resident was severely cognitively impaired and required assistance with most activities of daily living (ADLs).Observations:-10/20/25 at 3:15 PM a round soft-touch call light was under the sheet to the left side of R102's bed approximately waist level to the resident.- 10/21/25 at 8:12 AM, R102 eyes closed in bed. Soft touch call light clipped to fitted sheet at head of bed, out of sight and reach of resident.-10/21/25 at 10:05 AM, R102 eyes closed in bed. Soft touch call light clipped to fitted sheet at head of bed, out of sight and reach of resident.-10/21/25 at 3:20 PM, R102 was lying in the fetal position on his left side in bed. Call light positioned…

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 resident centered activities designed to support leisure needs for 1 (Resident #102) of 3 residents reviewed for activities, resulting in the potential for decreased physical, mental, and psychosocial well-being.Findings include:Review of The Needs of Older People with Dementia in Residential Care, [NAME] G. A. Woods B. [NAME] D., & [NAME] M. (2006). Published by in the International Journal of Geriatric Psychiatry, 21, 43-49. doi:10.1002/gps.1421 revealed Determining which activities have high degrees of meaningfulness can aide recreation staff in creating programs more likely to promote health and wellness for persons with dementia.Resident #102Review of an admission Record revealed Resident # 102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia with other behavioral disturbance(a type of brain disorder that causes cognitive decline due to damage to the blood vessels 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number: 2640123Based on observation, interview, and record review the facility failed to develop and implement person centered dementia care interventions to address wandering, disorientation, and frustration for 1 (Resident #102) of 3 residents reviewed for dementia care, resulting in Resident #102 experiencing ongoing wandering, emotional frustration, and stress.Findings include:Review of The Unmet Needs Model, [NAME]-[NAME] and [NAME] (1995), revealed that those with dementia develop problem behaviors from an imbalance in the interaction between life-long habits and personality, current physical and mental states and less than optimal environmental conditions. Resident #102 Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia with other behavioral disturbance (a type of brain disorder that causes cognitive decline due to damage to the blood vessels in the brain). Review…

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 number: 2640123Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record in 1 of 3 residents (Resident #102) reviewed for comprehensive/accurate medical records, resulting in inaccurate documentation and the potential for unmet needs.Findings include:Resident #102Review of an admission Record revealed Resident # 102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia with other behavioral disturbance(a type of brain disorder that causes cognitive decline due to damage to the blood vessels in the brain), adjustment disorder with mixed disturbance of emotions and conduct(maladaptive response to psychological stressor), and other sequalae of cerebral infarction (long term complications of a stroke).Review of a Minimum Data Set (MDS) assessment for Resident #102 with a reference date of 9/17/25, revealed a Brief Interview for Mental Status (BIMS) assessment score…

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 staff was adequately trained and evaluated for competencies specifically related to administration of Peritoneal Dialysis (PD) (a procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) in 5 (Resident #2, Resident #8, Resident #9, Resident #10, and Resident #11) of 5 residents reviewed for PD, resulting in the potential for unsafe administration of PD, unrecognized complications, increased risk for infection and adverse reactions.Findings include:Resident #2Review of an admission Record revealed Resident #2 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: end stage renal disease (chronic condition where the kidney can no longer function to meet the needs of the body to removed excess water, solutes and toxins) and dependence on renal dialysis.Resident #8Review of an admission Record revealed Resident #8 was 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 interview and record review the facility failed to ensure 1). pre and post dialysis treatment assessments were completed; 2). administration of peritoneal dialysis (PD)(a procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) was administered by qualified trained staff; 3). ongoing assessments and/or monitoring were completed during the administration of peritoneal dialysis; 4). ongoing communication between the facility and the dialysis facility (Name Omitted) was documented; and 5). administration of peritoneal dialysis per physician orders occurred for 5 (Resident #2, Resident #8, Resident #9, Resident #10, and Resident #11) of 5 residents reviewed for peritoneal dialysis resulting in the potential for staff being unprepared for a decline in resident condition related to dialysis treatment, unrecognized adverse reactions, and the potential for improper technique/unsafe administration of peritoneal dialysis treatment.Findings…

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 administer its policies and procedures in a manner that displayed effective and efficient use of resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being for 5 (Resident #2, Resident #8, Resident #9, Resident #10, and Resident #11) of 5 residents reviewed. This deficient practice resulted in 8 staff members administering treatments to Resident #2, Resident #8, Resident #9, Resident #10, and Resident #11, they were neither trained nor qualified to administer.Findings include:Resident #2Review of an admission Record revealed Resident #2 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: end stage renal disease (chronic condition where the kidney can no longer function to meet the needs of the body to removed excess water, solutes and toxins) and dependence on renal dialysis.Resident #8Review of an admission Record revealed Resident #8 was a female…

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). implement gait belt use for safety during ambulation (walking) of one resident (Resident #5) and 2). ensure safe transport of a resident in a wheelchair with footrests in place in 1 (Resident #6) of 3 residents reviewed for safety, resulting in the potential for an accident, and/or an injury to occur during ambulation and transport.Findings include:Resident #5Review of an admission Record revealed Resident #5 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: muscle weakness, need for assistance with personal care, and displaced intertrochanteric fracture of the left femur (a break in the thigh bone in the area where hip stability and mobility occurs).On 7/29/25 at 10:11 am, Physical Therapy Assistant (PTA) LL was observed assisting Resident #5 to walk in the hallway between the therapy room and Resident #5's room. PTA LL was not using a gait belt.In an interview on 7/29/25 at…

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

Based on observation, interview, and record review, the facility failed to properly store narcotic medications in a secure manner resulting in the potential for residents, visitors, and/or staff to access the medication in the facility with a current census of 82 residents. Findings include:On 7/30/2025 at 10:05 am, a plastic medication cup with a name written in black on the side of it, containing a white substance submerged in liquid, was observed sitting on top of the medication cart next to a plastic drinking cup of tan colored liquid in the common area in the secure unit of the facility. At this time there were 7 residents in the room, 1 resident was walking around the room, and 1 CNA was noted to be sitting at a table in the room with her back to the medication cart. No other staff member was present in the room, or near the cart, nor did any staff member have the medication cart or medication within their line of sight.In an interview on 7/30/2025 at 10:10 am, Certified Nursing Assistant (CNA) GG reported that she had nothing to do with medications. When CNA GG was 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 ensure proper infection control protocols and practices as evidenced by: 1). The use of personal protective equipment (PPE) during personal care and transfers for 2 (Resident #2 and Resident #7) of 2 residents requiring enhanced barrier precautions, 2. Sanitize resident shared equipment during uses, resulting in increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility. Findings include:Resident #2Review of an admission Record revealed Resident #2 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: end stage renal disease (chronic condition where the kidney can no longer function to meet the needs of the body to removed excess water, solutes and toxins) and dependence on renal dialysis.During an observation on 7/29/2025 at 2:00 pm, signage was noted displayed outside of Resident #2'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.

This citation pertains to intake MI00151744 Based on observation, interview, and record review the facility failed to ensure the dietary manager had adequate competencies and skill set to carry out the functions of the food and nutrition service resulting in potential for unmet nutrition and hydration needs for all residents who rely on food and hydration from the facility kitchen. Findings include: During an initial tour of the kitchen on 4/2/25 at 9:45 am, Dietary Aide (DA) W and X along with Dietary Cook (DC) Y and AA all reported the food delivery that occurred the day before only included milk, eggs, and a few loaves of bread. DA W reported there was food in the pantry, refrigerator, and freezer that could be served to the residents, but it may not be what was on the menu to be served. DC Y was noted to be visibly upset, crying, and reported today's lunch menu was supposed to be ravioli, and that she had to use the ravioli from the emergency food supply. DC Y reported she had used beef stew from the emergency food supply last week and it had not been replaced yet. DC Y reported…

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 MI00151744 Based on observation, interview, and record review the facility failed to follow menus resulting in the potential for inadequate nutritional value, unequal substituted nutritional value, and unmet nutritional needs. This deficient practice has the potential to affect all residents who consume food from the facility kitchen. Findings include: During an initial tour of the kitchen on 4/2/25 at 9:45 am, Dietary Aide (DA) W and X along with Dietary Cook (DC) Y and AA all reported the food delivery that occurred the day before only included milk, eggs, and bread. DA W reported there was food in the pantry, refrigerator, and freezer that could be served to the residents, but it may not be what was on the menu to be served. DC Y was noted to be visibly upset, crying, and reported there was no sausage and gravy nor biscuits to be served this morning for breakfast. DC Y reported the menu for breakfast tomorrow included French toast and bacon, but there was not enough bread or bacon to fulfill the menu items for all the residents. DC Y reported she…

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 that a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and was present to properly assess, implement, and manage the Infection Prevention and Control Program. Findings include: During an interview on 4/2/25 at 8:52 am, Assistant Director of Nursing/Unit Manager/ Infection Preventionist (ADON/UM/IP) D reported she educates on enhanced barrier precautions, (EBP) but staff was not compliant with wearing personal protective equipment (PPE). ADON/UM/IP D reported she does perform audits on residents who are in EBP, but the audit was for gown and glove supply availability, not use by staff. ADON/UM/IP D reported she was now the unit manager on the rehab unit in addition to being the ADON and IP. ADON/UM/IP D reported she was also pulled to work the floor and cover open shift or parts of shift weekly. ADON/UM/IP D reported she was on call one weekend a month and was usually called into the building to work during her on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop person centered care plans for 1 (Resident #104) of 9 residents reviewed for person centered care plans resulting in an inaccurate reflection of the resident's current care needs and the potential for unmet care needs. Findings include: Resident #104 Review of an admission Record revealed Resident #104 was male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: psychotic disorder with delusions and dementia with behavioral disturbances. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 1/10/2025 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #104 was severely cognitively impaired, (BIMS score 0-7 indicates severe cognitive impairment). During an observation on 3/31/25 at 8:35 am, Resident #104 was in his wheelchair in the hallway, wearing shorts, and the tubing to a foley catheter was noted along the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to revise person centered care plan for 1 (Resident #106) for 9 residents reviewed for person centered care plans resulting in an inaccurate and incomplete description of resident current care needs and the potential for unmet care needs. Findings include: Resident #106 Review of an admission Record revealed Resident #106 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: traumatic subdural hemorrhage with loss of consciousness. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 1/23/2025 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #106 was severely cognitively impaired (BIMS score 0-7 indicates severe cognitive impairment). In an interview on 3/31/25 Nursing Home Administrator (NHA) A reported that Resident #106's diet was recently advanced and Resident #106's feeding tube (G-tube, tube inserted…

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 MI00148764 Based on interview and record review the facility failed to provide activities of daily living (ADL) to dependent residents, specifically showers to 2 (Resident #101 and Resident #102) of 3 residents reviewed for activities of daily living and showers, resulting in showers not being given as scheduled. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: cerebral palsy (a disorder that affects movement and muscle tone) and the need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/7/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #105 was cognitively intact (BIMS score 12-15 indicates no cognitive impairment). In an interview on 3/31/25 at 8:32 am, Resident #101 reported she went a week and a half without…

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 MI00150708, MI00150714, and MI00151319. Based on observation, interview and record review the facility failed to ensure adequate supervision for safety for 3 (Resident #104, Resident #105, and Resident #106) of 3 residents reviewed for supervision resulting in Resident #105 hitting Resident #104, Resident #105 spitting on Resident #104 and Resident #106 eloping (exit without supervision) from the building. Findings include: Resident #104 Review of an admission Record revealed Resident #104 was male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: psychotic disorder with delusions and dementia with behavioral disturbances. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 1/10/2025 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #104 was severely cognitively impaired, (BIMS score 0-7 indicates severe cognitive impairment). Resident #105 Review of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the use of personal protective equipment (PPE) for residents in enhanced barrier precautions (EBP) for 2 (Resident #104 and Resident #106) of 4 residents reviewed for enhanced barrier precautions personal protective equipment use, resulting in the potential for introduction of infection, disease transmission, and cross contamination. Findings include: Resident #104 Review of an admission Record revealed Resident #104 was male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: psychotic disorder with delusions and dementia with behavioral disturbances and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 1/10/2025 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #104 was severely cognitively impaired, (BIMS score 0-7 indicates severe cognitive impairment). During an…

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

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the potential to affect all 73 residents. Findings include: During an observation of the 100 hall soiled utility room, at 1:38 PM on 11/13/24, an interview with Maintenance Director (MD) Z found that the facility was in the process of taking out the hoppers that staff no longer use and have been removing stagnant and dead end lines in the process. When asked if minimal use or unused fixtures are flushed, MD Z stated that flushing happens with housekeeping and myself. During an interview with MD Z regarding the Water Management Plan (WMP), at 2:05 PM on 11/13/24, it was found that the facility used to send water samples to be tested for legionella, but it hasn't happened in a year or two. When asked if they are currently sampling for anything, MD Z stated no. Observation of the Meadowlane Spa room, at 2:37 PM on 11/13/24, found that a black wooden column…

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 maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. This deficient practice has the potential to affect all 73 residents. Findings include: During a tour of the kitchen, at 11:00 AM on 11/13/24, it was observed that the three compartment sink and the one compartment sink on the preparation table, were both found to be directly connected to the wastewater drain with no air gap present. When asked what they use the one compartment sink for, Certified Dietary Manager R stated its mainly just used for discarding ice and dumping out water from can goods. When asked where they thaw product, CDM R stated that they just have to use the cooler and plan it out, it would be helpful if we had a preparation sink we could use. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of 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 interview and record review, the facility failed to provide annual required abuse prevention education for all employees. This has the potential to affect all 73 residents residing in the facility at the time of the survey. Findings include: Review of Preventing The Abuse of Residents with Dementia or Alzheimer's Disease In The Long-Term Care Setting: A Systematic Review, Published by The National library of Medicine, 2019, revealed . there is an increasing rate of abuse in the long-term care setting, specifically for those individuals with either dementia or Alzheimer's. Common causes and risk factors leading to this abuse include poor training . In an interview on 11/15/24 at 12:41 PM, Assistant Director of Nursing (ADON) E reported she was not aware she was responsible for training employee education and just found out about a month ago. ADON E reported she does not have access to the (Vendor) electronic training program to track education completion. In an interview on 11/15/24 at 1:09 PM, Director of Nursing (DON) B reported the facility had (Vendor) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F. This resulted in an increased risk of injury among residents in the following areas. Findings include: During a tour of the Riverside Spa, with Maintenance Director Z, at 1:45 PM on 11/13/24, it was found that the hot water from the hand sink reached 123F when using a Thermoworks rapid read digital thermometer. When asked what he normally gets for hot water temperatures, MD Z stated 116F-118F. Observation of the boiler room, at 1:54 PM on 11/13/24, found that the boiler was set at 140F and domestic hot water flows through a thermostatic mixing valve which is showing an outgoing temperature of 125F to the floor. When asked if there were any other hot water systems in the building, MD Z stated no, and that the kitchen and laundry get hot water direct from this source as well, but before its mixed down. When asked when he usually takes hot water temperatures, MD Z stated…

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 1.) provide proper documentation of notice of transfers to 2 (Residents #72, and #40) of 3 residents who were transferred from the facility and 2.) provide resident transfer notifications to the local ombudsman. Findings include: Resident #72 Review of an admission Record revealed Resident #72 had pertinent diagnoses which included: Traumatic hemorrhage of the cerebrum (bleeding in the brain) and non-displaced fracture of the seventh cervical vertebra (a break in the cervical spine in the neck). Review of Notice of Involuntary Transfer or Discharge and Facility-Initiated Discharge for Nursing Homes' provided by Director of Nursing (DON) B for Resident #72 on 11/14/2024 was noted to be dated 7/8/24, with a proposed date of transfer as 7/10/24, reason for transfer was resident no longer needed services provided by the facility. Resident #72 signature was noted on form. In an interview on 11/14/24 at 12:49 PM., Social Work Director (SWD) FF reported she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #35 Review of an admission Record revealed Resident #35 had pertinent diagnoses which included: Alzheimer's disease, dementia, and contracture (condition that causes a joint to become very stiff and prevents normal movement) of the right hand. Review of Physician Orders for Resident #35 revealed monitor skin integrity to RUE (right upper extremity) (R Hand) related to splint use, started on 6/12/2023. Review of Care Plan for Resident #35 revealed soft hand splint to right hand apply every morning and remove at HS (bedtime). During an observation on 11/14/24 at 3:43 PM., Resident #35 was lying in bed and did not have a soft splint on her right arm. Review of Physician Order for Resident #35 revealed remove splint Q (every) HS at bedtime for contracture management note to be discontinued on 9/9/2024. During an observation on 11/15/24 at 8:15 AM., Resident #35 was sitting in her wheelchair, no noted soft hand splint on her right hand. In an interview on 11/15/2024 at 11:00 AM., Certified Nursing Assistant…

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

Based on observation, interview, and record review the facility failed to maintain nebulizer equipment for 1 (Resident #2) of 1 resident reviewed for respiratory care resulting in the potential for inconsistent equipment exchange, irregular cleaning, and respiratory infection. Findings include: Review of an admission Record revealed Resident #2 had pertinent diagnoses which included: chronic obstructive pulmonary disease, COPD (a lung and airway disease that restricts breathing). Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 10/31/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #2 was cognitively intact. During observations on 11/13/24 at 11:48 AM, 11/14/24 at 10:11 AM and 3:15 PM, 11/15/24 at 8:13 AM and 9:59 AM, a nebulizer machine (a machine that turns liquid medication into a fine mist that a person can inhale through a face mask) with tubing with one end connected to the machine and the other end connected to nebulizer kit with a mask attached was noted to be laying directly on the top of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure COVID-19 consents or declinations were obtained for 2 residents (Resident #44, Resident #37) of 5 reviewed for immunizations resulting in residents/family members being unaware of the vaccination and the risks/benefits of having it completed. Findings include: Resident #44 (R44) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R44 admitted to the facility on [DATE] with diagnoses including dementia (condition that is characterized by memory loss and judgement) and cognitive communication deficit. Brief Interview for Mental Status (BIMS) reflected a score of 6 which indicated R44 was severely cognitively impaired (00 to 07 is severe cognitive impairment). Review of R44's immunization record revealed her last COVID-19 vaccine was the Pfizer Booster which was given to her on 10/9/2023 per historical data. Review of R44's medical record did not reveal any indication that her dual POAs were contacted regarding consent…

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 provision of training for behavioral health care and services for 128 staff reviewed for behavioral health care and dementia training. This deficient practice had the potential to result in unmet behavioral health care needs and services for residents. Findings include: In an interview on 11/15/24 at 12:41 PM, Assistant Director of Nursing (ADON) E reported she was not aware she was responsible for training employee education and just found out about a month ago. ADON E reported she does not have access to the (Vendor) electronic training program to track education completion. In an interview on 11/15/24 at 1:09 PM, Director of Nursing (DON) B reported the facility had (Vendor) electronic training program prior but the facility was not able to assign trainings to staff as the training program was owned by the facility's previous owners and the new owners did or could not continue with a contract for the electronic training program. DON B reported the facility began conducting educations via in person education…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately report an elopement and submit an investigation report to the State Agency within 5 days, for one resident (Resident #100) of three residents reviewed for abuse, from a total sample of 4 Residents, resulting in an elopement being unidentified or properly investigated, and the potential for continued elopements to go unreported and thoroughly investigated. Findings include: Review of the facility's Elopement and Wandering Residents policy with a reference date of 1/24 revealed: Definition: Elopement occurs when a resident leaves the premises without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Section 5 titled Procedure for Locating Missing Resident item g. stated: Appropriate reporting requirements to the State Survey agency shall be conducted. Resident #100 Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a person centered care plan for one resident (Resident #100) of three residents reviewed for elopement, resulting in the resident exiting the building unsupervised, and a potential for the resident to experience more than minimal harm. Findings include: Resident #100 Review of the facility's Elopements and Wandering Residents policy, with a reference date of 1/2024, revealed Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Definition: Elopement occurs when a resident leaves the premises without authorization .or necessary supervision . Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 2: Assessments for the Resident Assessment Instrument…

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 that was free from accident hazards for two residents (Resident #100 and Resident #104) of four residents reviewed for accidents. This deficient practiced resulted in an elopement for Resident #100 and the potential for more than minimal harm, and Resident #104 enduring a head laceration when he fell from mechanical lift that had not been properly maintained. Findings include: Resident #100 Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia, cognitive communication deficit, muscle weakness, and other specified disorders of bone density and structure (condition causing a decrease bone mineral density and bone mass). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 3/2/9/24 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident…

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

Based on observation, interview, and record review, the facility failed to adequately assist a resident with Activities of Daily Living (ADL) care for 1 (Resident #35) 3 residents reviewed for ADL care, resulting in Resident #35 having unshaven facial hair and the potential for feelings of embarrassment and self-consciousness. Findings include: Resident #35 Review of an admission Record revealed Resident #35 was a female, with pertinent diagnoses which included: Alzheimer's Disease (a type of dementia), muscle weakness, anxiety disorder, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for Resident #35, with a reference date of 8/29/23 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #35 was moderately cognitively impaired. Further review of said MDS revealed Resident #35 required limited, one-person physical assistance for personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands).…

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 supervise 1 (Resident #42) of 5 residents reviewed for accidents/hazards resulting in Resident #42 consuming a non-food item during her meal and the potential for choking. Findings include: Resident #42 Review of an admission Record revealed Resident #42 was a female, with pertinent diagnoses which included: Alzheimer's disease (a type of dementia), unspecified dementia unspecified severity with other behavioral disturbance, major depressive disorder, adult failure to thrive, repeated falls, dysphagia (swallowing difficulty), anxiety disorder, and psychotic disorder with delusions due to known physiological condition. Review of a Minimum Data Set (MDS) assessment for Resident #42, with a reference date of 9/8/23 revealed a Staff Assessment for Mental Status for Resident #42 as having short and long-term memory problems and that her Cognitive Skills for Daily Decision Making were Severely impaired. Further review of said MDS revealed Resident #42 required supervision and one-person physical assistance 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.

Based on observation, interview, and record review the facility failed to ensure that supplemental oxygen was continuously supplied to 1 resident (Resident #31) of 1 reviewed for continuous oxygen use resulting in fear and anxiety, shortness of breath, and hypoxia (low oxygen levels in the blood) which can lead to confusion, disorientation, decreased consciousness, and death. Findings include: Review of an admission Record revealed Resident #31 had pertinent diagnoses which included respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Review of a Minimum Data Set (MDS) assessment for Resident #31, with a reference date of 9/9/23 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #31 was moderately cognitively impaired. During an observation on 10/2/23 at 9:50 AM, Resident #31 was sitting in her wheelchair in the dining room at a table with other residents, conversing and appeared short of breath with speaking. During an observation on 10/2/23 at 10:10 AM, Resident #31 was sitting in her wheelchair in the dining…

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.) perform proper hand hygiene during catheter care in 1 resident (Resident #38) of 1 reviewed for catheter care and 2.) ensure sanitary conditions for privacy curtains in resident's rooms, resulting in the potential for the introduction of infection, cross-contamination, and disease transmission. Findings include: Review of an admission Record revealed Resident #38 had pertinent diagnoses which included obstructive and reflux uropathy (disorder of the urinary system) unspecified and a history of a catheter associated urinary tract infection (CAUTI). Review of a Minimum Data Set (MDS) assessment for Resident #38, with a reference date of 7/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #38 was severely cognitively impaired. Review of Physician Orders for Resident #38 revealed, indwelling urinary (Foley) catheter care: cleanse with soap and water every shift . Review of Care Plan 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.