Franklin Restorative Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow provider orders for wound care dressing changes for 1 of 1 resident (R4) reviewed for pressure injury.Findings include:R4's face sheet provided on 4/22/26, included diagnoses of paraplegia (paralysis causing impairment of motor sensory function of lower extremities) and pressure ulcers to right and left buttock.R4's annual Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. No behaviors. Pressure ulcer to sacral region. Independent with most activities of daily living. Mobility per motorized wheelchair.R4's provider orders dated 4/22/26, indicated: sacrum dressing: cleanse coccyx with wound cleanser. Place calcium alginate (absorbent dressing used primarily for managing exudate in wounds) in wound bed. Place barrier cream around peri-wound. Cover with ABD (abdominal pad) and tape down. Two times a day, start 4/22/26.R4's care plan dated 11/23/21, indicated…

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 document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 2 of 5 residents (R8, R28) reviewed for unnecessary medications.Findings include:R28's face sheet received on 4/23/26, included diagnoses of wedge compression fracture of lumbar vertebrae, hypertension, dependence on renal dialysis, hyperlipidemia (high levels of fat in the blood), depression, diabetes, congestive heart failure (heart not able to pump enough blood) and anemia. R28's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated her brief interview for mental status (BIMS) was 99, indicating the cognitive interview was not able to be completed. R28 had clear speech, could understand and be understood. Behaviors included rejection of care and verbal behaviors directed towards others. R28 was dependent upon staff for activities of daily living (ADLs) and didn't walk. R28's orders included 28 medications. R28's care plan identified diagnoses and problem…

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.

I'm not sure if this is correct, I used other surveyors tags as guidiance, and their tag from last year. Let me know if you want me to change anything. Based on interview and document review the facility failed to ensure a registered nurse (RN) was scheduled for at least 8 consecutive hours a day, seven days a week. This had the potential to affect at 35 residents who reside in the facility. Findings include: The Facility's PBJ Staffing report 1705D dated quarter 1 2025 October 1st-Decemeber 31st, indicated the facility had triggered the following staffing concerns: 1. One star staffing rating. 2. Excessively low weekend staffing. 3. No RN hours. Review of the facility's license staff schedule for May 10th, 2025, and May 24th, 2025, confirmed they was no consecutive eight hours of RN coverage in the facility. The Daily Timecards Log dated 5/6/25 -5/10/25, listed punch in and outs times for licensed employees from 5/6/25 -5/10/25, and 5/23/25-5/26/25. These logs confirmed there was no RN coverage on 5/10/25, and 5/24/25. On 5/28/25 at 9:59a.m., the administrator and health unit…

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 record review and interviews, the facility failed to ensure all required data were included on the nurse staffing information posted daily. This had the potential to affect all 35 residents residing in the facility and their visitors who may wish to view the information. Findings include: The Facility's PBJ Staffing report 1705D dated quarter 1 2025 October 1st-December 31st, indicated the facility had triggered the following staffing concerns: 1. One star staffing rating. 2. Excessively low weekend staffing. 3. No RN hours. The staff schedule and posting documentation dated from October 2024 through May 2025, was reviewed and the following dates failed to include any or all of the following requirements for the daily staff posting: 1. Facility name. 2. Current date. 3. Facility Census. 4. Total number and actual hours worked by licensed staff. 5. Total number of licensed staff, and their designation or title. October 2024: 10/5/24, 10/12/24,10/13/24, 10/15/24,10/19/24, 10/20/24, 10/24/24, 10/28/24 December 2024: 12/19/24, 12/31/24 February 2025: 2/6/25, 2/17/25, 2/23/25,…

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 Based on observation, interview and document review the facility failed to ensure dishwasher temperatures were within the manufactures minimum temperatures to ensure resident dishes were sanitized. In addition, the facility failed to ensure temperatures were monitored in 4 of 4 refrigerators and 2 of 2 freezers reviewed for the kitchen. This had the potential to affect all 35 residents who resided in the facility. Findings include: On 5/18/25 at 1:50 p.m., during the initial walk through of the kitchen the dishwashing machine was being used by a nursing assistant (NA)-A, the machine was labeled a [NAME] Temp star Dishwasher with temperature requirements as follows: wash temperature 150 degrees Fahrenheit (F), and rinse temperature of 180 degrees F. The actual temperatures observed were as follows: 1. 2:02 p.m., wash -165 degrees F, rinse -170 degrees F 2. 2:03 p.m., wash -164 degrees F, rinse -168 degrees F 3. 2:04 p.m., wash -165 degrees F, rinse -170 degrees F 4. 2:05 p.m., wash -154 degrees F, rinse -160…

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 document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively sustained ongoing compliance related to repeat citations from past surveys regarding immunizations. This had the potential to affect all 35 residents residing in the facility. Findings include: Review of the facility CASPER Report dated 4/16/25, indicated the facility was cited F883 for influenza and pneumococcal immunizations on the survey exited 3/28/24. See F883: Based on interview and document review, the facility failed to ensure 3 of 5 residents (R10, R27, R31) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). The facility's Quality Assessment and Assurance (QAA) committee meeting minutes from April 2024 through May 2025 lacked ongoing data related to the above repeat citation. On 5/28/25 at 5:31 p.m., the administrator acknowledged the importance of continued monitoring of prior…

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 document review, the facility failed to obtain informed consent, including risks and benefits, for 4 out of 4 residents (R8, R15, R22, R27) reviewed for use of psychotropic medications. Findings include: R8's quarterly minimum data set (MDS) dated [DATE], indicated R8 was admitted [DATE], was moderately cognitively impaired, and had the following diagnoses: hypertension (HTN) (high blood pressure), hyperlipidemia (HLD) (high level of fat content in the bloodstream), dementia, and depression. R8's order report summary dated 5/20/25, indicated R8 was currently prescribed mirtazapine (antidepressant) with a start date of 4/23/2025, and Olanzapine (antipsychotic) start date 9/5/2024. R8's Order recap report dated 5/21/25, indicated original start dates for the Mirtazapine was 11/3/2023, and olanzapine was 7/2/2024. Additionally, R8 has a discontinued order for lorazepam (benzodiazepine) start date 7/12/2024 end date 9/5/2024 and paroxetine (antidepressant/anti-panic) original start date…

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 document review, the facility failed to implement a system to monitor stored narcotics to prevent diversion. This had the potential to affect all 16 residents prescribed Schedule II-V medications. Findings include: On 5/21/25 at approximately 11:00 a.m., assistant director of nursing/infection preventionist (ADON/IP) confirmed the following: 1. The facility's West Individual Narcotic Record's Index page indicated the last narcotic entered on the Index page was Lyrica entered on page 55. However, the narcotic book had medications documented through page 127. 2. The facility's East Individual Narcotic Record's Index page indicated the last narcotic entered on the Index page was Lyrica entered on page 55. However, the narcotic book had medications documented through page 127. On 5/28/25 at 11:07 a.m., registered nurse (RN)-A and licensed practical nurse (LPN)-C were observed completing a medication cart narcotic count. LPN-C had the narcotic book. RN-A unlocked the narcotic box in the medication cart, pulled out the first card, called out the number…

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 document review, the facility failed to ensure pharmacist consultant recommendations were acted upon for 5 of 5 residents (R8, R15, R22, R24, R27) reviewed for unnecessary medications. Findings include: R8's quarterly minimum data set (MDS) dated [DATE], indicated R8 was admitted [DATE], was moderately cognitively impaired, and had the following diagnoses: hypertension (HTN) (high blood pressure), hyperlipidemia (HLD) (high level of fat content in the bloodstream), dementia, and depression. R8's order report summary dated 5/20/25, indicated R8 was currently prescribed the following medications: 1. Mirtazapine (antidepressant) take 2 tablets by mouth daily, and take 1 tablet 7.5 mg by mouth daily 2. Olanzapine (antipsychotic) 2.5 mg by mouth twice daily (BID) R8's monthly pharmacy reconciliations were reviewed for the last 6 months. Of those, the corresponding months had the following recommendations: 1. April 2025-Pharmacist requested laboratory work up for Olanzapine, as none had been…

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 document review, interview, and observation the facility failed to ensure shared resident refrigerator 1 of 1 was kept in sanitary conditions and 2 of 2 (shared resident refrigerator and medication refrigerator) reviewed for temperature control were monitored. Findings include: On 5/19/25 at 11:03 a.m. a shared resident refrigerator was observed to contain multiple open, and undated bottles, and a container of milk. Two bottles of pepsi, a bottle of flavored water, and a container of chocolate milk. All opened and undated in the refrigerator. In the freezer, there was a large box of orange popsicles with had melted. There was a large amount of sticky orange substance on the floor of the freezer which encompassed a Tupperware container containing an unknown item. The container was affixed to the floor of the refrigerator by the orange substance. The certified dietary manager (CDM) confirmed the residents used this refrigerator and freezer. Both were unsanitary and unappealing. The CDM was unsure of the last time the refrigerator had been cleaned. The temperature logs of 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 document review the facility failed to ensure a self-administration of medications assessment was completed, and orders obtained, for all medications kept at bedside for 1 of 1 residents (R24) observed with medications at their bedside. Findings include: R24's quarterly MDS, dated [DATE], indicated R24 was cognitively intact, and diagnoses included diabetes, heart failure, and chronic obstructive pulmonary disease (COPD). On 5/20/25 at 7:39 a.m., licensed practical nurse (LPN)-B was observed setting up R24's morning medications but was unable to locate R24's fluticasone-salmeterol (Advair) inhaler in the medication cart. Trained medication assistant (TMA)-A suggested LPN-B look on R24's bedside table to see if the inhaler had been left in R24's room the previous night. On 5/20/25 at 7:59 a.m., when LPN-B entered R24's room to administer his medications, R24's Advair discus was observed on R24's bedside table and was within R24's reach. When LPN-B asked R24 about the Advair…

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 the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) was provided to 1 of 3 residents (R143) reviewed for beneficiary notification. Findings include: R143's discharge minimum data set (MDS) dated [DATE], indicated R143 was admitted on [DATE] and discharged on 3/27/2025, and their Medicare part A services ended on 2/19/2025. R143's SNFABN-CMS-10055 signed on 2/19/25, informed them services would end on 2/19/2025. However, this notice was given outside of the 48 hours prior to services ending requirement, and was provided the same day as services ending. On 5/19/25 at 2:41 p.m., the office manager (OM) stated they were responsible for completing the Medicare SNFABN-0CMS-10055 forms, and they were expected to provide them to the resident 48 hours prior to the end of services. OM stated they were typically informed by therapies or the MDS nurse when someone's services were ending. OM confirmed R143 was given their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and document review, the facility failed to ensure resident living areas were free from unwanted noise for 3 of 4 residents (R3, R14, R22) reviewed for uncomfortable sound levels. This had the potential to affect residents in surrounding rooms, visitors and facility staff. Findings include: R3's annual Minimum Data Set (MDS), dated [DATE], indicated R3 was cognitively intact, and diagnoses included schizophrenia, anxiety disorder, major depressive disorder, bipolar disorder, and delusional disorders. R14's significant change MDS, dated [DATE], indicated R14 was cognitively intact, and diagnoses included major depressive disorder, mood affective disorder, and diabetes. R22's quarterly MDS, dated [DATE], indicated R22 was cognitively intact, and diagnoses included chronic tension-type headache, major depressive disorder, and anxiety disorder. On 5/20/25 at 7:39 a.m., during a medication administration observation, a continuous, loud, high-pitched, obstructive noise was heard…

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 document review the facility failed to ensure ordered as needed (PRN) antipsychotic medications were limited to a 14-day time period and clinical rational indicated continuation past the 14-day time period. Additionally, the facility failed to ensure a gradual dose reduction (GDR) or appropriate indication for use for medications was documented for 2 of 4 residents (R15, and R27) reviewed for unnecessary medications. Findings include: R15's admission MDS dated [DATE], indicated R15 was admitted on [DATE], was moderately cognitively impaired, and had the following diagnoses: anemia (low iron count in the bloodstream), heart failure (failure of the heart to pump blood efficiently), renal insufficiency (kidneys inability to filter blood efficiently), diabetes, HLD, and anxiety. R15's order summary report dated 5/20/25, indicated R15 was currently prescribed alprazolam (benzodiazepine) 0.5 mg (milligrams)-give two tablets by mouth every 6 hours PRN, with a start date of 2/14/2025. R15'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 record review and interviews the facility failed to update the care plan for 1 of 2 residents (R31) reviewed for pressure ulcer interventions. Findings include: R31's significant change minimum data set (MDS) dated [DATE], indicated R31 was cognitively intact and had the following diagnoses: osteoporosis (deterioration of bone structure), thyroid disorder, malnutrition, and depression. R5's care plan last reviewed 4/21/25, indicated R31 has the potential for nutrition/hydration problems and an intervention listed was Arginaid Oral packet (Nutritional Supplements) give one packet by mouth two times daily to aid with wound healing. R5's physician orders accessed 5/27/25, indicated following order: Arginaid Oral Packet (Nutritional Supplements) give 1 packet by mouth two times daily was stated on 2/14/2024 and discontinued on 8/26/2024. On 5/27/25 at 1:48 p.m., the licensed practical nurse (LPN)-A stated the charge nurse on duty was responsible for updating the care plans when necessary. LPN-A stated there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to accurately implement physician orders for 1 of 1 resident (R5) reviewed for weekly weight monitoring. Findings include: R5's annual minimum data set (MDS) dated [DATE], indicated R5 was cognitively intact, and had the following diagnoses: neurogenic bladder, paraplegia (has lost use of some of their limbs), malnutrition, and depression. R5's physician order list accessed 5/22/25, indicated a physician order which started on 12/27/23 indicated weekly weights and vitals on bath day as an active order. R5's care plan last reviewed 3/14/25, indicated R5 was at risk for potential nutrition/hydration problems, and to monitor weights per MD order and/or facility policy. R5's electronic medical administration record (eMAR) and treatment administration record (TAR) were reviewed from December 2024 through May 2025, and the last documented weight for R5 was on 12/25/24. On 5/27/25 at 1:48 p.m., licensed practical nurse (LPN)-A stated the nurse on duty 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 and interview, the facility failed to maintain separately locked and permanently affixed compartments for storage of controlled medications in the medication room refrigerator reviewed for medication storage. Findings include: On 5/20/25 at 10:00 a.m., a vial of Lorazepam Oral Concentrate USP 2 mg/ml (2 milligrams of medication/per milliliter of liquid) a schedule IV (four) controlled Substance was observed in the door of the refrigerator outside of the double lock box. The lock box was not permanently secured to the refrigerator and had a key in the lock. Licensed practical nurse (LPN)-B stated they were agency staff and confirmed the unaffixed lock box, with key, had been there since they had started working in the facility. LPN-B confirmed the key was always left in the box. LPN-B confirmed the Ativan should have been stored and locked in the lock box. Next, writer and LPN-B went to confirm the Ativan medication count in the narcotic box, which was correct, and the Director of nursing (DON) passed by. At 10:14 a.m., the DON came into the medication room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 3 of 5 residents (R10, R27, R31) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 10/24, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R10's significant change Minimum Data Set (MDS), dated [DATE], indicated R10 was [AGE] years old and diagnoses included dementia, diabetes, rheumatoid…

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 document review, the facility failed to ensure 1 of 5 residents (R26) reviewed for immunizations were offered and/or provided the COVID-19 vaccine to help reduce the risk of associated infection(s). Findings include: R26's annual Minimum Data Set (MDS), indicated R26 diagnoses included mild cognitive impairment, transient ischemic attack (TIA) and cerebral infarction (stroke), and aortic valve stenosis. R26's immunization report, dated 5/21/25, indicated R26 had not received any COVID-19 vaccinations. R26's immunization consent form indicated R26 was offered and signed consent to receive the COVID-19 vaccine on 4/26/24. However, R26's record lacked evidence the facility provided the requested COVID-19 vaccine. On 5/28/25 at 3:54 p.m., director of nursing (DON) verified R26's clinical record lacked evidence the facility provided the COVID-19 vaccine to R26. DON stated the COVID-19 vaccine was important to prevent the spread of infection and staff were expected to review and offer immunizations upon admission and quarterly at care conferences. The facility'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 document review, the facility failed to ensure physician orders were followed for pressure ulcer (PU) wound care for 3 of 3 resident (R1, R4, and R5) reviewed for wound care. Findings include: Stage II pressure ulcer: partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage III pressure ulcer: full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Stage IV pressure ulcer: full-thickness skin and tissue loss…

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 hand hygiene was performed during wound care for 2 of 3 residents (R4 and R5) reviewed for wound care. Findings include: R4's significant change Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact and needed extensive assistance with bed mobility and personal hygiene. R4's provider orders dated 4/17/25, indicated R4 had a dressing order to cleanse R4's laceration on her left lower buttock with wound cleanser, apply skin barrier prep around edges, and apply a bordered silicone dressing every 2 days. R5's significant change MDS dated [DATE], indicated R5 was cognitively intact and needed extensive assistance with bed mobility and personal hygiene. R5's provider orders dated 2/18/25, indicated R5 had a dressing order to cleanse R5's left elbow with wound cleanser and cover with foam adhesive bandage daily. During an observation on 4/30/25 at 10:47 a.m., the infection preventionist (IP)-A entered R4's room…

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.

The facility's request for a waiver was accepted and approved by the State Agency following the survey dated 12/22/22. The tag was re-issued however NO plan of correction is required. This will remain in effect until such time as the registered nurse (RN) coverage can be filled and the facility achieves compliance. F727: CFR 483.35 (b)(1), RN coverage 8 consecutive hours a day, 7 days a week. Findings include: Review of 10/1/2023 through 3/15/24 nursing schedule identified 8 days of no registered nurse (RN) had been scheduled on Saturdays or Sundays. Interview on 3/28/24 at 5:00 p.m., with the administrator identified they were aware of the lack of coverage, they are working to stagger hours and have utilized an RN from a sister facility (in-network facility) in an attempt to meet the requirement. Review of the current advertisements in various sources per their waiver plan for available positions identified the facility was actively attempting to hire full time RN for coverage to meet the requirement.

Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 1) 2024 (October 1 - December 31) to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified the following dates triggered for review 10/07/23, 10/8/23, 11/18/23, 12/16/23, 12/17/23 for failure to have licensed nurse coverage 24 hours per day. Review of staffing schedules and staff timecards identified the facility had 1 or more licensed nursing staff present on the above identified dates and therefore data submitted through PBJ to CMS was inaccurate. Interview on 3/28/24, at 5:00 p.m., with administrator identified they have a person offsite that enters the PBJ data, and she would have to reach out to him for more information. No other information was provided by the end of the survey. A policy was requested and 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.

Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 34 residents. Findings include: Review of the monthly QAPI meeting minutes from June 2023 through March 2024 identified department heads were bringing data forth to QAPI on various topics such as infection control, falls, grievance reports, other committee meeting minutes, and incident reports etc., however, there was no documented benchmarks for goals the facility was trying to achieve, nor analysis of data brought forth, identified actions the facility was going to take to achieve their goals, and monitoring to determine if goals were met or QAPI needed to continue monitoring to ensure compliance. Interview on 3/28/24 at 3:10 p.m., with the administrator identified the facility had changed their format for QAPI meetings about a year ago. She revealed that the committee did…

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

Based on interview and document review, the facility failed to have evidence of 1 of 1 Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 34 residents. Findings include: Interview on 3/28/24 at 2:57 p.m., with director of nursing identified the facility did not have a formal PIP however, each department would do their own thing. Interview on 3/28/24 at 4:10 p.m., with trained medication aide (TMA)-A identified she had training on the computer of what QAPI was but other than that she knew nothing about QAPI. She revealed that the facility did not tell the staff what the committee was working on. Interview on 3/28/24 at 4:15 p.m., with the administrator who confirmed the facility did not have a formal PIP they were working on. There was no policy related to QAPI or a PIP provided by the end of the survey.

Based on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility specific Quality Assurance Performance Improvement (QAPI) Program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. Findings include: Interview on 3/28/24 at 4:00 p.m., with dietary aide identified she had never had any type of training on QAPI however, maybe other staff did she was unsure. She was not sure how to bring a concern to the QAPI committee and she was unaware if the facility was working on any problems. Interview on 3/28/24 at 4:10 p.m., with trained medication aide (TMA)-A identified she had training on the computer of what QAPI was but other than that she knew nothing about QAPI. She revealed that the facility did not tell the staff what the committee was working on. Interview on 3/28/24 at 4:15 p.m., with the administrator identified the facility 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 interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA)) when 1 of 1 resident (R15) with new on-set of mental illness. Findings include: R15's 6/6/23, nursing progress note identified R15 required law enforcement along with emergency medical services (EMS) to transport him to the local hospital emergency department for behavioral issues. He was later transported from the hospital to a mental health inpatient facility. R15's current physician's orders identified a diagnosis of Post Traumatic Stress Disorder (PTSD) and Paranoid Personality Disorder. R15's 8/20/23 quarterly MDS identified R15 re-entered the facility on 6/28/23, and had a new diagnoses of PTSD and Paranoid Personality Disorder. R15's 6/21/23 Pre-admission Screening (PAS) (following his behavioral health inpatient stay), indicated R15 had no diagnosis of mental illness, had no symptoms of mental illness that significantly interfered with functioning in life activities, or caused the person significant distress within the past 6 months, and had 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 document review, the facility failed to offer and/or administer the most recent Centers for Disease Control (CDC) pneumococcal vaccine for 2 of 5 residents (R22 and R32) reviewed for immunizations. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 1) Adults 19-[AGE] years old with specified immunocompromising conditions, a) the PCV-20 at least 1 year after prior PCV-13, b) the PPSV-23 (dose 1) at least 8 weeks after prior PCV-13 and PPSV-23 (dose 2) at least 5 years after first dose of PPSV-23. Staff were to review the pneumococcal vaccine recommendations again when the resident turns [AGE] years old. 2) Adults [AGE] years of age or older, a) If NO history 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 document review the facility failed to report an allegation of injury of unknown origin with serious bodily injury timely to the State Agency (SA) for 1 of 1 resident (R1) reviewed who had injury of unknown origin. Findings include: A facility Reported Incident (FRI) submitted to the State Agency (SA) on 9/14/23 3:52 p.m., alleged physical abuse and injury of unknown origin when R1 complained of pain with standing, was unable to stand on his own, and had outward rotation of the left foot. R1 was transferred to the hospital for further evaluation. The report identified on 8/27/23 at 8:30 a.m. staff had become aware of the injury. R1's quarterly minimum data set (MDS) dated [DATE], indicated R1 was severely cognitively impaired and was independent with ambulating, transferring, and bed mobility. During an interview on 9/21/23 at 12:10 p.m., the director of nursing (DON) stated she was notified by the phone of R1's injury and transfer to the emergency department (ED) on 8/27/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (R2) reviewed for abuse. Findings include: A facility reported incident (FRI) to State Agency (SA) dated 8/5/23 at 8:20 p.m., indicated a staff member heard a commotion down the east hallway and found R1 punching R2. R1 punched R2 three times before staff was able to get to the residents. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact. R2's diagnoses included paraplegia (paralysis of the legs) and chronic pain. The MDS further indicated R2 used a wheelchair. On 8/6/23 at 2:00 a.m., a progress note indicated staff heard a commotion coming from the east wing. When staff looked down the hallway they could see R1 punching/hitting R2 in the face and shoulder. Staff saw R1 hit R2 three times before getting R1 to stop. Trained medication aide (TMA)-A came over and removed R2, and another staff member took R1 to his room. R2 did not sustain any visible…

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.