Grand Traverse Pavilions

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide applicable bed hold policy information and/or written transfer notifications to two Residents (#154 and #68) of four residents reviewed for transfer and discharge process. Findings include: Resident #154 (R154) The medical record for R154 revealed a census record on 2/24/25 stating R154 was sent out to the hospital. The medical record did not have a record that a written notification of discharge or explanation of the bed hold policy was sent to the resident or the responsible party. On 6/11/25 at approximately 12:00 PM, a request was made to the Director of Nursing (DON) for documentation of any written notification of hospital transfers and bed hold policy notifications for R154 for all hospitalizations over the past six months. At 2:36 PM that same day, an email follow up was sent to the DON for the transfer documents for R154. While a written notification of transfer was presented for a December transfer, the 2/24/25 documents were not…

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 revise care plan interventions for one Resident (R155) of five residents reviewed for behavior care planning. Findings include: Review of R155's Electronic Medical Record (EMR) revealed admission to the facility on 9/16/24 with diagnosis including Alzheimer's Disease. R155 was not responsible for her medical and financial decisions. R155 had a recent resident to resident altercation on 6/6/25. Review of R155's Care Plans read, in part, .Modify environment: (redirect others away from my room. If I allow it, place [Name Brand] stop/gate on my room door when I am not in it. I often remove this, but at times it can reassure me) date initiated: 4/2/25 . On 6/10/25 at approximately 11:50 a.m., R155's room was observed by this Surveyor. R155 was not located in her room, and a stop sign appeared to be placed on a fire exit door adjacent to R155's room. The Director of Nursing provided an incident report for R155 on 6/12/25. There was one incident which was provided which occurred on 6/4/24 at approximately 3:40 p.m.…

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 medication per physician order for one resident (Resident #2) of 35 residents reviewed for quality of care. Findings include: Resident #2 (R2) Review of R2's electronic medical record (EMR) revealed initial admission to the facility on 6/13/16 with diagnoses including anemia, depression, diabetes mellitus, nausea, and hypertension. Review of R2's progress note, dated 3/10/25 at 11:19 PM, read in part, Resident received wrong dose of medication .Resident aware of medication error. Review of facility incident and accident report, dated 3/10/25, read in part, .Incident description .Floor nurse gave resident wrong dose of medication. Resident is ordered 0.5mg (milligrams) of (name brand for lorazepam, a controlled substance commonly used to treat anxiety) and was given 3.0mg .Level of consciousness: Lethargic (drowsy) .Mental status: Resident drowsy due to (name brand for lorazepam) being administered 30 minutes prior . Review of R2's physician…

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 supervise one Resident (#121) of two residents reviewed for Activities of Daily Living during (ADL) care. This deficient practice resulted in a fall with injury. Resident #121 (R121) On 6/10/25 at 12:24 p.m., R121 was observed sitting in the main dining hall waiting for her meal tray. R121 was noted to have a large purple bruise under her left eye and a dark red/purple bruise under her left nostril. An attempted interview was conducted with R121 who was not able to respond appropriately. Review of R121's Progress Notes read, in part, 6/6/25: (R121) is being seen today to follow up on a witnessed fall that occurred this morning at 6:06 a.m. in the member's room while CNA (Certified Nursing Aide) was dressing her for the day. She (CNA) had turned her back for a moment and the resident fell forward from a seated position on her bed and struck the left side of her head on the floor She is lying in her bed at this time and a large hematoma to the left forehead with ecchymosis to the left eye is noted. 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 observation, interview, and record review, the facility failed to ensure the sanitary storage and cleaning of respiratory equipment for two Residents (#430 and #433) of two residents reviewed for respiratory services. Findings include: Resident #430 (R430) Review of R430's electronic medical record (EMR) revealed initial admission to the facility on 5/27/25 with diagnoses including chronic obstructive pulmonary disease (COPD), moderate persistent asthma, and chronic respiratory failure. Review of R430's Minimum Data Set (MDS) assessment, dated 6/2/25, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicative of intact cognition. On 6/10/25 at 11:42 AM, oxygen tubing was observed connected to a concentrator next to R430's bed and coiled up on the floor. No storage bag was noted. R430 verified she required supplemental oxygen at night and did not recall ever having a storage bag for the tubing. Review of R430's EMR revealed a physician's order, initiated 5/30/25, which read: Continuous Oxygen 2 L (liters)/min (minute) via NC [nasal cannula] at night and PRN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify Post Traumatic Stress Disorder (PTSD) triggers and develop individualized care plan interventions to mitigate trauma triggers for one Resident (#79) of one resident reviewed for trauma-informed care. Findings include: Resident #79 (R79) R79 was admitted to the facility 1/9/24 with diagnoses including PTSD. The Electronic Medical Record (EMR) contained a psychiatric follow up report dated 5/15/25 that read, in part: .significant history of psychiatric trauma from an abusive relationship . The report did not include trauma triggers. A nursing admission assessment dated [DATE] contained an initial trauma screening. The portion of the admission assessment; Section AS_15. Screening Trauma Informed Care documented the following questions and responses: 1. Have you faced a traumatic event or experience in the past? The answer was yes. 2. Recently, have you thought about the event(s) or experience when you did not want to? The answer was documented 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 ensure availability of prescribed medications for one Resident (#431) of six residents reviewed for pharmacy services. Findings include: Resident #431 (R431) Review of R431's EMR revealed initial admission to the facility on 6/4/25 with diagnoses including fracture of the left acetabulum (a break in the socket portion of the hip joint), fracture of the left ulna (a break in one of the two bones of the forearm), fracture of the left tibia (a break in the large bone in the lower leg), displaced fracture of the left acromial process (a break in the bony projection of the shoulder blade), and fractures of facial bones. ). Review of R431's Minimum Data Set (MDS) assessment, dated 6/10/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 6/10/25 at 12:20 PM, R431 was observed in his room standing at a platform walker with his left leg immobilized. An interview was conducted with R431 regarding his level of satisfaction with care at the facility. R431 stated he was admitted to…

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

Based on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRR's) were addressed by the attending physician and maintained in the clinical record for two Residents (#45 & #79) of five residents reviewed for MRR. Findings include: Resident #45 (R45) R45 was admitted to the facility 9/8/23. A review of physician's orders in the Electronic Medical Record (EMR) revealed R45 had an order for diclofenac (a pain medication) and quetiapine (an antipsychotic medication for mental health conditions). The EMR of R45 was reviewed for MRR on 6/11/25. No MRR's were found in the EMR, and a request was made to the Director of Nursing (DON) on 6/11/2025 at 5:37 PM to provide the MRR's for R45. MRR's were provided by the DON on 6/12/25 at 8:47 AM. Review of the MRR's revealed the pharmacist made requests and recommendations to R45's physician for dosage clarification of diclofenac on 1/24/25 and 3/19/25. The pharmacist documented in the MRR's for diclofenac on 1/24/25 and 3/19/25 both of which, read in part: . Resident has an order for diclofenac gel twice daily.…

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 adaptive dining equipment for two Residents (#80 and #111) of three residents reviewed for adaptive dining equipment needs. This deficient practice resulted in increased difficulty with food consumption and independent eating. Findings include: Resident #80 (R80)/Resident #111 (R111) On 6/11/25 at approximately 9:00 AM, the breakfast meal was observed. R80 did not receive dycem (a non-slip material placed under the plate) to help secure his plate while eating. R80 did have special built up utensils for ease of gripping and feeding self. The breakfast tray card indicated R80 needed 1 each Nonslip Dycem. On 6/12/25 at 9:34 AM, the breakfast meal was observed. R80 did not receive dycem to help secure his plate while eating but did have special built up utensils to assist in feeding himself. During this same meal, R111 also did not receive non-slip dycem as indicated on his tray card. During an interview on 6/12/25 at approximately 9:35 AM, Certified Nurse Aide (CNA) CC stated R80 has not been using dycem…

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 an eligible resident was provided a pneumococcal vaccine as recommended by the Centers for Disease Control and Prevention (CDC) for 1 Resident (#54) of 5 residents reviewed for immunizations. Findings include: Resident #54 (R54) Review of R54's electronic medical record (EMR) revealed initial admission to the facility on 5/23/25 with diagnoses including fractured left ribs, anemia, coronary artery disease, diabetes mellitus, and hypertension. R54 was admitted to the facility for rehabilitation. Review of R54's vaccination on the Michigan Care Improvement Registry (MICR), revealed the last dose of the pneumococcal was administered on 8/2/21. The status for eligible PCV20/PCV21/PPSV23 vaccination read, Overdue. Review of facility document for R54 titled, admission Consent Checklist, dated 5/16/25, read in part, .#9. Can we provide influenza vaccine, pneumococcal vaccine, tetanus and COVID-19 if due? Yes (marked) . Review of R54's EMR 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure eligible residents were provided a COVID-19 vaccine as recommended by the Centers for Disease Control and Prevention (CDC) for 2 Residents (#54 & #433) of 5 residents reviewed for immunizations. Findings include: Resident #54 (R54) Review of R54's electronic medical record (EMR) revealed initial admission to the facility on 5/16/25 with diagnoses including fractured left ribs, anemia, coronary artery disease, diabetes mellitus, and hypertension. R54 admitted to the facility for rehabilitation. Review of R54's vaccination on the Michigan Care Improvement Registry (MICR), revealed the last dose of the COVID-19 was administered on 12/13/21. The status for eligible COVID-19 vaccination read, Overdue. Review of facility document for R54 titled, admission Consent Checklist, dated 5/16/25, read in part, .#9. Can we provide influenza vaccine, pneumococcal vaccine, tetanus and COVID-19 if due? Yes (marked) . Review of R54's EMR revealed a COVID-19…

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 MI00150655 Based on interview and record review the facility failed to assess bowel function for one Resident (R1) of three residents reviewed for bowel care/complaints of constipation. This deficient practice resulted in the potential for missed signs and symptoms of constipation and resulted in hospitalization. Findings include: Review of the complaint intake revealed the following, .Complainant states the resident came from the hospital after having knee replacement for rehab on [DATE]. Complainant states the resident started complaining about his stomach hurting, it was extended and that he was having trouble going to the bathroom .On [DATE] the complainant states .the resident told them his stomach hurt .staff put a blanket over him and did come back later to check on him. Staff found that he was cold and clammy. The resident was transported to [Hospital Name] .he would pass away, which he did on [DATE]. The death certificate states the resident died from ischemic colitis, septic shock and organ failure .…

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 MI00150291. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse and neglect by facility staff for three Residents (#1, #2, #3) of five residents reviewed for abuse, neglect, and exploitation. Findings include: Resident #1 (R1): Review of R1's electronic medical record (EMR) revealed initial admission to the facility on 1/10/25 with diagnoses including prosthetic joint infection and sepsis with septic shock. Review of R1's most recent Minimum Data Set (MDS) assessment, dated 1/23/25, revealed a Brief Interview for Mental Status (BIMS) score of 7/15, indicative of severe cognitive impairment. Review of MDS Section GG (Functional Abilities and Goals) revealed R1 was dependent for both toileting hygiene and lower body dressing. Resident #2 (R2): Review of R2's EMR revealed initial admission to the facility on 1/31/25 with diagnoses including post-hemorrhagic anemia. Review of R2's MDS assessment, dated 2/6/25,…

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 deficiency pertains to Intake MI00148163. Based on interview and record review, the facility failed to provide advanced written notice prior to a room change for one Resident (#2) of six residents reviewed for room changes. Findings include: Resident #2 (R2) Review of R2's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including Parkinson's Disease and neurocognitive disorder with Lewy bodies (a condition which impacts a person's ability to think, learn, and remember). Review of R2's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicative of severe cognitive impairment. An anonymous complaint submitted to the State Agency (SA) on 11/20/24 read, in part: [R2] was admitted [DATE] as a skilled, short term admit. In the evening, he wandered out of his room twice, he was confused. At the direction of [the Director of Nursing (DON)] he [R2] was moved to the locked Elm unit [secured…

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 MI00149104 and MI00149112. Based on interview and record review, the facility failed to protect the resident's right to be free from mental and verbal abuse by facility staff for one Resident (#1) of four residents reviewed for abuse, resulting in feelings of fear, humiliation, and the potential for psychosocial harm. Findings include: Resident #1 (R1) Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed R1 was admitted to the facility on [DATE] and had a primary diagnosis of liver cell carcinoma. Review of the discharge MDS assessment, dated [DATE] revealed R1 was independent with bed mobility, sit to stand transfers, ambulation to 10 feet, and wheelchair use. Further review of R1's MDS assessments revealed the Resident was discharged to an acute care hospital on [DATE] and did not return. Review of R1's Clinical Admission progress note, dated [DATE], revealed R1 was his own decision-maker and was assessed as Alert & Oriented x 3 . able to understand and 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 This deficiency pertains to Intake MI00148163. Based on interview and record review, the facility failed to develop, implement, and operationalize policies and procedures to ensure the appropriate placement on a secured unit for one Resident (#2) of six residents reviewed for involuntary seclusion. Findings include: Resident #2 (R2) Review of R2's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including Parkinson's Disease and neurocognitive disorder with Lewy bodies (a condition which impacts a person's ability to think, learn, and remember). Review of R2's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicative of severe cognitive impairment. Further review of MDS Section E (Behaviors) revealed R2 did not display any physical or verbal behavioral symptoms directed toward others, did not reject care, and did not exhibit wandering behavior. An anonymous complaint submitted to 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.

This citation pertains to intakes MI00149113, MI00149014 and MI00148163. Based on interview and record review, the facility failed to report allegations of abuse to the State Agency (SA) within the appropriate time frame for one Resident (#1) of four residents reviewed for abuse, resulting in the potential for continued abuse. Findings include: Review of a Facility Reported Incident (FRI), submitted 12/13/2024 at 8:55 a.m., revealed the following: Incident Summary: Email received from unknown individual alleging that a staff member yelled at a patient [R1], pointed his finger in his face and told him 'You will not go outside until I say so.' Allegation states the patient [R1] said he was afraid and humiliated . The investigation substantiated the complaint . As a result of the complaint and the facility's investigation, the perpetrator [former Nursing Home Administrator (NHA) A] is no longer employed at the facility . It was noted in review of the investigation documents, no date or time of the alleged incident was provided. During an interview on 1/9/2025 at 9:16 a.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00149014. Based on interview and record review, the facility failed to ensure a thorough investigation of an allegation of verbal abuse for one Resident (#6) of four residents reviewed for abuse, resulting in the potential for unidentified and continued abuse. Findings include: Resident #6 (R6) Review of the Minimum Data Set (MDS) assessment, dated 12/27/2024, revealed R6 was admitted on [DATE] with diagnoses including depression and bipolar disease. Further review of the MDS assessment revealed R6 scored 15 out of 15 on the Brief Interview for Mental Status, indicating the Resident was cognitively intact. During a confidential interview on 1/9/2025 at 8:52 a.m., Staff U reported a concern that an allegation of staff verbal abuse of a resident was never investigated. Staff U described an incident when R6 was called a derogatory name by a member of the housekeeping staff. Staff U stated on May 17, 2024, Staff T called R6 a butt head in a manner that was reported as demeaning.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Intake MI00147235. Based on interview and record review, the facility failed to ensure a resident representative was informed about medication changes for one Resident (#1) of 3 residents reviewed for medication review. Findings include: Resident #1 (R1) Review of R1's electronic medical record (EMR) revealed initial admission to the facility on 1/18/22 with diagnoses including dementia, type two diabetes with hyperglycemia (high blood glucose levels), and cognitive communication deficit. Review of R1's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. Review of Intake MI00147235 read, in part: .On or about July 1, 2024, the facility's doctor [Medical Director (MD) K] discontinued [R1]'s diabetes medication. [R1] had been taking diabetes medication(s) for at least the prior 15-20 years. [Durable Power of Attorney (DPOA) M] of [R1] had durable power of attorney, was…

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

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 164 residents of the facility. Findings include: On 9/16/24 at approximately 11:10 AM, kitchen staff were observed in the kitchen, near the dish washing area removing trays containing soiled dishes, utensils and uneaten food from wheeled Cambro insulated transport carts. These carts were returned to the kitchen with trays removed from residents' eating areas. Once the soiled trays, utensils and uneaten food were removed from the wheeled transport carts, the carts were relocated to an unused dining area west and adjacent to the kitchen. No cleaning of the carts had been conducted following the removal of the soiled trays and uneaten food. At approximately 11:35 AM Food Service Worker (FSW) B was observed filling a small bucket from a disinfectant dispenser in the kitchen and going to the unwashed carts in 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 Quality Assurance & Performance Improvement (QAPI) program that included development, monitoring, and evaluation of adverse events to correct quality deficiencies and maintain sustained compliance. This deficient had the potential to affect all 164 residents in the facility. Findings include: On 9/19/24 at 10:10 AM, an interview was conducted with Registered Nurse (RN)/Staff Educator P who verified she oversaw the QAPI process. When asked if adverse events such as a death in the facility, were reviewed in QAPI. RN/Staff Educator P stated these events were discussed in Interdisciplinary Team (IDT) meetings but not in QAPI. RN/Staff Educator P verified she considered an unexpected death an adverse event but, It's just something we never really discussed [in QAPI]. RN/Staff Educator P was unable to explain how medical errors or adverse resident events were identified, analyzed, corrected, or monitored to ensure desired outcomes throughout the QAPI process. Review of facility policy titled, Quality…

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 notify the Resident and/or Resident Representative in writing, the reason for transfer of four Residents (R1, R56, R149, R621) of five residents reviewed for facility initiated transfers. Findings include: Resident #56 (R56) During an interview on 9/16/24 at 12:20 PM, R56 stated he had been sent to the hospital during his stay at the facility. The Electronic Medical Record (EMR) for R56 revealed a transfer to the hospital on 6/24/24 with a readmission on [DATE]. No evidence of written notification for the transfer provided to R56 or their representative could be located in the medical record. During an interview on 9/19/24 at 11:17 AM, the Director of Nursing (DON) stated she did not believe a system was in place to send written transfer notifications to the resident and resident representative. She said, It looks like an opportunity for improvement. She further recommended checking with the social worker. During an interview on 9/19/24 at 11:25 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 interview and record review, the facility failed to provide written notification of the facility bed hold policy for two Residents and/or Resident Representatives (#621 and #149) of five residents reviewed for notice of bed hold policy. Findings include: Resident #621 (R621) Review of the R621's Electronic Medical Record (EMR) revealed the following physician communication on 7/11/24 at 4:22 PM: .Send to [acute care hospital] for evaluation . Review of the facility census report confirmed R621 was hospitalized on [DATE]. On 9/19/24 at 11:17 AM, an interview was conducted with the Director of Nursing (DON) who stated she was unaware if a bed hold policy was issued to R621 upon transfer. On 9/19/24 at 11:31 AM, an interview was conducted with Social Worker (Staff D) who verified a R621 was not issued a bed hold policy. Resident #149 (R149) Review of the EMR revealed R149 was hospitalized from [DATE] - 6/30/24. The EMR did not indicate a bed hold policy was issued to R149. On 9/19/24 at 11:31 AM, 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 develop and implement a comprehensive, person-centered care plan for the use of psychotropic medications for one Resident (#136) of five residents reviewed for unnecessary medications, resulting in the potential for unnecessary use of mood-altering drugs and decreased quality of life. Findings include: Resident #136 (R136) Review of R136's Minimum Data Set (MDS) assessment, dated 7/23/2024, revealed admission to the facility on 4/23/2024 with diagnoses including dementia with psychotic disturbance, depression and anxiety disorder. R136 was rated as having severely impaired cognition. Review of R136's electronic medical record (EMR) revealed the following orders: Lorazepam (a controlled substance anti-anxiety medication) Oral Tablet 0.5 MG (milligram). Give 0.5 mg by mouth every 6 hours as needed for anxiety . Review of R136's care plan revealed the following: Focus: The resident uses psychotropic medications [related to] end of life, comfort measures . Date initiated: 4/25/2024. Goal: The resident will be/remain free 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 apply orthopedic braces per physician orders for two Residents (#104 and #155) out of five Residents reviewed for range of motion, positioning, and mobility. This deficient practice resulted in the potential for a reduction in range of motion and/or complications following cervical [neck] surgery. Findings include: Resident #155 (R155) Review of R155's electronic medical record (EMR) revealed initial admission to the facility on 8/13/24 with diagnoses including surgical aftercare following surgery on the nervous system, inflammatory reaction due to internal fixation device of the spine, and quadriplegia (paralysis of all four limbs due to spinal cord damage). Review of R155's Minimum Data Set (MDS), dated [DATE], revealed a score of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicative of intact cognition. Review of a Neurosurgery Progress Note, dated 9/4/24, read, in part: .Cervical collar to be worn at all times .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement appropriate interventions to prevent unsafe wandering and elopement for three Residents (R132, R156, & R221) of three residents reviewed for elopement. This deficient practice resulted in continued unsafe supervision and an elopement from the locked memory care unit. Findings include: R132 Review of R132's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnosis including dementia. R132's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated severe cognitive impairment. R132 was also noted on the 11/3/23 Elopement Evaluation to be at risk for elopement due to wandering. On 9/15/24 at 11:55 a.m., R132 was observed participating in an activity prior to lunch. R132 was observed in a seated position with no walker or wheelchair present near him. R132 ambulated to the lunchroom after the activity had concluded.…

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 oxygen services per standards of practice for one Resident (#83) out of two residents reviewed for respiratory care. This deficient practice resulted in the potential for hypoxia (oxygen deficiency), respiratory complications, and the potential for re-hospitalization. Findings include: Resident #83 (R83) Review of R83's electronic medical record (EMR) revealed admission to the facility on 8/21/24 with diagnoses including pneumonia, shortness of breath, and sleep apnea (a sleep disorder in which breathing repeatedly stops and starts). Review of R83's Minimum Data Set (MDS), dated [DATE], revealed a score of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicative of intact cognition. On 9/16/24 at 2:08 PM, R83 was observed sitting in a recliner in her room with an oxygen concentrator to her left. R83 did not have supplemental oxygen applied. When R83 was asked about her care satisfaction level, R83 stated, I would…

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 Medication Regimen Reviews (MRRs) were addressed by the physician and maintained in the clinical records for two Residents (R61 and R91) of five residents reviewed for MRR. Findings include: Resident #61 (R61) Medication orders for R61 included three different antianxiety medications and an order for melatonin, a medication used for insomnia. The pharmacist MRR on 4/21/24 recommended the physician evaluate R61 to determine if the dosages of the antianxiety medications could be reduced. The report to the physician read, in part: .If you feel that no GDR (Gradual Dose Reduction) should be attempted, please document your reasoning for clinical contraindication at the bottom of this form or in your next progress note . The portion of the report for the physician's written response to the recommendation was blank, unsigned, and undated. Physician visit notes documented a visit on 5/10/24. The physician documentation did not include reasoning for declining the pharmacist's recommendation for GDR. The pharmacist MRR report…

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 documentation of targeted behaviors and use of non-pharmacological interventions prior to administration of as needed anti-anxiety medication for one Resident (#136) of five residents reviewed for unnecessary medications, resulting in the potential for over-medication and decreased quality of life. Findings include: Resident #136 (R136) Review of R136's Minimum Data Set (MDS) assessment, dated 7/23/2024, revealed admission on [DATE] with diagnoses including dementia with psychotic disturbance, depression and anxiety disorder. Further review of the MDS revealed R136 has severely impaired cognition. Review of R136's June 2024 through September 2024 Medication Administration Records (MARs) revealed the following order: Lorazepam (a controlled anti-anxiety medication) Oral Tablet 0.5 MG (milligram). Give 0.5 mg by mouth every 6 hours as needed for anxiety . Further review of the MARs revealed R136 was administered as needed doses of lorazepam 0.5 mg…

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 timely dental services were provided for three Residents (R49, R61, and R56) of three residents reviewed for dental services. Findings include: Resident #49 (R49) During an interview on 9/16/24 at 3:14 p.m., R49 said, I broke my tooth last month. R49 opened her mouth and pointed to the left upper part of the front of her mouth revealing what appeared to be a tooth fragment in the gum line. R49 said she did not know when she would be able to see the dentist. R49 admitted to a history of issues with dentition and said she has went to dental appointments with a dentist in the community but was waiting to see the dentist in the facility. A progress note in the medical record dated 8/16/24 documented, in part: .Resident had a tooth fall out today .Son has denied consent for inhouse services. Resident is still her own person and would like to consent for those services . A form Consent for Services that included dental services was signed by R49's son on 7/31/24 with a checkmark next to the box that read I wish to use 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 observation, interview and record review the facility failed to follow to evaluate and treat one resident (R119) of two residents reviewed for therapy services. This deficient practice caused R119 to be uncomfortable each day when she sat in her wheelchair. Findings include: On 9/16/24 at 12:52 PM, R119 was observed seated in a high back wheelchair with her legs elevated and fully extended. R119's feet were observed pushed up against the foot cradle. R119 stated, This chair is too long. It is uncomfortable. The Electronic Medical Record (EMR) was reviewed. On 8/7/2024 at 13:32 (1:32 PM) a progress note was written titled: Therapy Communication to Nursing and read, Note Text: Recommend OT (occupational therapy) eval and tx (treatment orders) to address positioning. The EMR also contained a physician order written on 8/8/24 which read, OT to evaluate and treat if indicated. During an interview on 09/18/24 at 4:50 PM, Physical Therapist (PT) N stated there should be an OT screen and evaluation, but PT N looked in the EMR for R119 and did not find these OT documents. PT N…

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 collaboration and communication between the facility and hospice provider for one Resident (R137) of one resident reviewed for hospice services. This deficient practice resulted in gaps in communication for coordination of care. Findings include: Review of R137's Electronic Medical Record (EMR) revealed admission to the facility on 1/11/24 with diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and dysphagia. Review of R137's 6/26/24 Minimum Data Set (MDS) assessment revealed he was unable to complete the Brief Interview for Mental Status (BIMS) and had severely impaired cognition. R137 was admitted to the facility on hospice services and had a Designated Power of Attorney (DPOA) for medical and financial decisions. On 9/16/24 at 1:40 p.m. an interview was conducted with R137's DPOA, who stated there is a lack of communication between R137's hospice services and the facility. The DPOA stated, I know that they are…

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) maintain sanitary equipment, 2) date mark potentially hazardous food, 3) and monitor cooler temperatures, resulting in the potential for contamination of equipment and potential for conditions for foodborne illness, affecting all 138 residents who consume food from the kitchen. Findings include: On 9/11/23 at 12:10 PM, during an inspection of the kitchen, the dual check valve with an atmospheric port (a backflow prevention device commonly used in plumbing to prevent backflow of contaminated liquid into the domestic water supply), provided for the waste disposal submerged inlet, was observed to not have an air gap provided for the atmospheric port. According to the manufacturer's installation directions, it notes, It is important to install a discharge line downward from the vent to a floor drain, sump, or other safe place of disposal that will not result in property damage. A physical air gap must be maintained between the discharge…

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 promoted and enhanced resident dignity in 12 (Resident #80, #431, #44, #12, #36, #125, #84, #98, #16, #20, #97, and #72) of 13 residents reviewed for dignity related to dining experience, call light wait times, and staff assistance of resident needs, resulting in the likelihood of feelings of humiliation, embarrassment, and loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life. Findings include: Resident #80: Review of an admission Record revealed Resident #80 was a female with pertinent diagnoses which included dementia, muscle weakness, anxiety, unsteadiness on feet, kidney disease, cognitive communication deficit, and abnormal weight loss. Review of a Minimum Data Set (MDS) assessment for Resident #80, with a reference date of 10/27/22 revealed a Staff Assessment for Mental Status indicated Resident #80 was severely cognitively impaired. Review of current…

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 resident's accommodation of needs were met for 5 (Resident #81, # 68, #381,#34 and #96) out of 6 residents reviewed for accommodation of needs resulting in resident's inability to call for staff assistance with the potential for unmet care needs and a resident not receiving incontinence care products. Findings include: Resident #81 Review of an admission Record revealed Resident #81, was originally admitted to the facility on [DATE] with pertinent diagnoses which included disorientation and repeated falls. Review of a Minimum Data Set (MDS) assessment for Resident #81, with a reference date of 8/14/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #81 was cognitively intact. Review of Resident #81's Care Card revealed, .Toileting: Please check to ensure I am maintaining my hygiene. Provide Assist prn (as needed) . During an interview and observation on 9/11/23 at 3:29 PM, Resident #81…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was consistently provided with personal hygiene related to facial hair and overall cleanliness with daily ADL care for 5 of 5 residents (Resident #7, #381, #72, #33 and #67) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem. Findings include: Resident #33: Review of an admission Record revealed Resident #33 was a female with pertinent diagnoses which included dementia, depression, low back pain, anxiety, candidiasis (yeast infection), dysphagia (,(damage to the brain responsible for production and comprehension of speech), psychosis, pain, anemia, underweight, lumbrosacral neuritis (inflammation of the nerves along the spinal canal), and dermatitis (skin inflammation). Review of a Minimum Data Set (MDS) assessment for Resident #33, with a reference date of 7/11/23 revealed a Staff…

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

Based on observation and interview, the facility failed to provide food in a palatable and appetizing temperature for 4 residents (Resident #80, #74, #36, and #84) of 4 reviewed for food palatability resulting in dissatisfaction with meal service with the potential for decreased food acceptance and nutritional decline. Findings include: Review of Meal Times document provided on 9/12/23, revealed, .Breakfast: Dogwood - 9:00 - 9:15 AM .Lunch: Dogwood - 1:00 PM - 1:15 PM . During an observation on 09/12/23 at 09:17 AM, this writer observed the breakfast meal cart in the hallway. Residents #36, #62, #94, #44, #86, #431, #125, and #12 were seated in the center of the unit. Residents #94 and #62 were observed to have their breakfasts in front of them. Resident #12 received his breakfast at 09:37 AM. Residents #36, #44, #431, and #125 had not received their breakfasts yet. Resident #44 was seated next to R#94, Resident #36 was seated next to Resident #62, and Resident #431 was seated next to R#86. In an interview on 09/12/23 at 09:24 AM, CNA ZZ reported the residents had not all had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY In an observation on 9/11/23 at 1:16 PM., noted 2 sit to stand lifts (lift that assist residents to stand and transfer) parked on the 400 unit near room [ROOM NUMBER]. The bases (where residents plant their feet) of the lifts were noted to be soiled with dust, debris and food crumbs. There were no sanitizing wipes near or attached to the lifts. In an observation on 9/11/23 at 3:09 PM., noted 2 sit to stands parked on the 400 unit near room [ROOM NUMBER]. The bases of the lifts were noted to be soiled with dust, debris and food crumbs. A dark brown dried smeared substance was noted on the knee area of one of the lifts. There were no sanitizing wipes near or attached to the lifts. In an observation 09/12/23 at 3:00 PM., noted 2 sit to stands parked on the 400 unit near room [ROOM NUMBER]. The bases (where residents plant their feet) of the lifts were noted to be soiled with dust, debris and food crumbs. A dark brown dried smeared substance was noted on the knee area. There were no sanitizing wipes near or attached…

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, observation, and record review the facility failed to perform a resident assessment and obtain a physician order for the self administration of medication for 1 of 1 resident (Resident #81), reviewed for self administration of medication, resulting in the potential for the mismanagement of medication and adverse side effects. Findings include: Review of an admission Record revealed Resident #81, was originally admitted to the facility on [DATE] with pertinent diagnoses which included disorientation and repeated falls. Review of a Minimum Data Set (MDS) assessment for Resident #81, with a reference date of 8/14/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #81 was cognitively intact. During an interview and observation on 9/11/23 at 3:29 PM, Resident #81 reported that she suffered from chronic dry eyes, and would frequently use eye drops. Resident #81 had a bottle of Systane eye drops on her tray table. Resident #81 reported that she was not…

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 follow their policy and immediately report to the State Agency an allegation of staff to resident abuse for 1 residents (Resident #95) of 6 residents residents reviewed for abuse, resulting in the potential for allegations of abuse to go unreported, undetected and the potential for further abuse to continue and go unrecognized. Findings include: Review of an admission Record revealed Resident #95, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic kidney disease. Review of a Minimum Data Set (MDS) assessment for Resident #95, with a reference date of 8/24/23 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #95 was mildly cognitively impaired. Review of Resident #95 Electronic Medical Record (EMR) revealed: On 6/25/2023 at 18:29 (EDT) CNA came up to med cart and informed this nurse that resident (Resident #95) had accused CNA of punching him (Resident #95). CNA…

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 follow their policy and procedure and thoroughly investigate and protect residents after an allegation of staff to resident physical abuse was made by Resident #95, resulting in the alleged perpetrator not being immediately removed from direct resident care, and an allegation of physical abuse not being investigated, and the potential for future mistreatment and/or abuse to go undetected and investigated to protect a vulnerable population. Findings include: Resident #95 Review of an admission Record revealed Resident #95, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic kidney disease. Review of a Minimum Data Set (MDS) assessment for Resident #95, with a reference date of 8/24/23 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #95 was mildly cognitively impaired. Review of Resident #95 Electronic Medical Record (EMR) revealed: On 6/25/2023 at 18:29 (EDT) CNA…

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 implement resident comprehensive care plans for 3 of 3 residents (Resident #12, #86, and #33) reviewed for care planning, resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #33: Review of an admission Record revealed Resident #33 was a female with pertinent diagnoses which included dementia, depression, low back pain, anxiety, candidiasis (yeast infection), dysphagia (,(damage to the brain responsible for production and comprehension of speech), psychosis, pain, anemia, underweight, lumbrosacral neuritis (inflammation of the nerves along the spinal canal), and dermatitis (skin inflammation). Review of a Minimum Data Set (MDS) assessment for Resident #33, with a reference date of 7/11/23 revealed a Staff Assessment for Mental Status was completed indicating Resident #33 was severely cognitively impaired. Review of current Care Plan for Resident #33, currently active focus, .I have an alteration in my…

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 revise an individualized care plan to reflect current therapy recommendations for 1 (Resident #297) of 25 residents reviewed for care plan revision, resulting in the potential for staff to provide care that was not consistent with the needs of the resident. Findings include: Review of a current activities of daily living Care Plan intervention for Resident #297 on 9/12/2023 at 8:57 AM revealed staff were directed to use one person assistance with a Sara Steady for all transfers. Review of Resident #297's latest Therapy Communication to the interdisciplinary team, dated 9/1/2023, revealed therapy recommended staff use one person assistance with a front wheeled walker to transfer Resident #297. In an interview on 9/12/2023 at 2:45 PM, Assistant Director of Nursing (ADON) SS reported Resident #297's care card was updated on 9/3/2023 to reflect the Therapy Communication from 9/1/2023 but not the care plan. ADON SS reported Resident #297's care plan still directed staff to use the Sara Steady for transfers instead of directing…

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 thoroughly assess and monitory a resident after a fall in 1 (Resident #297) of 5 residents reviewed for accidents and injuries, resulting in the potential for unnoticed and untreated head injury. Findings include: Review of a Face Sheet revealed Resident #297 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, cognitive communication deficit (difficulty communicating), and fall with hip fracture. Review of a Minimum Data Set (MDS) assessment for Resident #297, with a reference date of 9/5/2023 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated Resident #297 was severely cognitively impaired. Further review of same MDS assessment revealed Resident #297 had been taking anticoagulant medication. Review of Resident #297's Physician Orders revealed an order for the anticoagulant medication Lovenox, ordered 8/16/2023 to continue until 9/8/2023. Review 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 monitor and ensure the resident safety 1 of 5 residents (Resident #96) reviewed for accidents and hazards, resulting in the potential for falls and injury. Findings include: According to the MDS dated [DATE], R96 scored 7/15 (cognitively impaired) on her BIMS, required limited assistance for transfers, walking in her room, and toileting. Her diagnoses included a recently fractured back from a fall. Review of R96's Care Plan reported she had an alteration in her ability to perform her ADLs independently and be independent with mobility related to age-related physical debility, history of falls, osteoporosis, impaired balance, times of incontinence and vertigo. She was at risk for injury from falls. Effective 2/15/2022 - Present. Her goal was to be clean, odor free, well groomed, and comfortably dressed with encouragement to participate as able. Interventions to meet this goal included assist me to the bathroom per protocol. Keep my call…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a leg strap (a device that goes around a leg to comfortably secure a urinary drainage bag in place) was in place for 1 resident (R98) in 1 resident reviewed for urinary catheter care, resulting in pain and injury. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R98 scored 3/15 (severely cognitively impaired) on her BIMS (Brief Interview Mental Status), and required extensive assistance of one person for transfers. She was incontinent of bowel/bladder and had an indwelling catheter. Her diagnoses included neurogenic bladder (unable to control bladder), urinary tract infection (UTI), multiple sclerosis (MS), and anxiety. During an observation and interview on 9/13/2023 at 9:09 AM, Certified Nursing Assistant (CNA) DD was performing bowel movement incontinence care for R98. R98 had a urinary foley catheter. Observed with the CNA, R98 did not have a device to secure her foley catheter tubing to her leg. CNA DD…

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 pain management interventions were implemented for 1 of 24 resident, (Resident #72) reviewed for pain, resulting in Resident #72's complaint of pain and inadequate pain management. Findings include: Review of a Face Sheet for Resident #72 dated 1/22/19, revealed the resident was admitted to the facility with the following pertinent diagnoses: Hemiplegia following a Cerebral Infarct (paralysis on one side following a stroke), Generalized Anxiety Disorder, and Major Depressive Disorder, Chronic Pain Syndrome, and Idiopathic Neuropathy (nerve damage of unknown origin). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 scored 14/15 on a Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Section J of the MDS revealed Resident #72 received scheduled pain medication as well as non-medication interventions to assist with pain management. During the MDS Pain 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 Based on interview and record review, the facility failed to maintain complete and accurate medical records for 2 residents (Resident #95, #381) of 2 residents reviewed for medical records, resulting in the potential for facility staff and providers not having all of the pertinent information to care for residents and track the history of abuse allegations. Findings include: Resident #95 Review of an admission Record revealed Resident #95, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic kidney disease. Review of a Minimum Data Set (MDS) assessment for Resident #95, with a reference date of 8/24/23 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #95 was mildly cognitively impaired. Review of Resident #95 Electronic Medical Record (EMR) revealed: On 6/25/2023 at 18:29 (EDT) CNA came up to med cart and informed this nurse that resident (Resident #95) had accused CNA of punching him (Resident #95). CNA stated that 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.