Pathstone Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to notify the provider of a choking episode for 1 of 2 residents (R11) reviewed for accidents and skin injury for 2 of 2 residents (R30, R3) reviewed for skin. Findings include: Accidents R11's annual minimum data set (MDS) assessment dated [DATE], indicated moderately impaired cognition, no rejection of care, use of walker and wheelchair, independent with eating, and diagnosis of heart failure and fracture. R11's care plan revised 5/21/25, indicated self-care performance deficit related to weakness associated with fracture and eating assistance for set up and clean up but could eat independently. R11's physician's orders dated 4/9/25, indicated regular diet, regular texture, thin liquid consistency. Facility progress note dated 12/6/25 at 5:15 p.m., indicated R11 choked at dinner table, raised her hand and pointed at throat, staff performed Heimlich maneuver and resident started coughing and worked through episode. Emergency contact made…

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 allegations of missing money were reported timely to the State Agency for 1 of 1 resident (R55) reviewed missing property. In addition, the facility to report choking incident with care plan not being followed for 1 of 2 residents (R5) reviewed for accidents. R55's 5-day Minimum Data Set (MDS) assessment dated [DATE], indicated R55 initial admit date was [DATE], makes self-understood, ability to understand others, adequate hearing, severely impaired vision, moderately impaired cognition, no hallucinations or delusions, no rejection of care, utilized a manual wheelchair, required substantial/maximal assistance with eating, showers, upper body dressing; dependent on toileting, lower body dressing, putting on footwear, and transfers; diagnoses included Non-Alzheimer's Dementia, depression, end stage renal disease with dialysis, muscle weakness, difficulty in walking, and essential tremor. Department of Public Safety Report dated 12/1/25 at 2:11…

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 actions were taken to prevent further misappropriation of funds for 1 of 1 and resident (R55) reviewed for missing property and prevent further neglect due to lack of following the care plan for 1 of 2 residents (R5) reviewed for accidents. Further the facility failed to fully investigate these allegations or take actions to protect other residents. Finding include: R55's 5-day Minimum Data Set (MDS) assessment dated [DATE], indicated R55 initial admit date was [DATE], makes self-understood, ability to understand others, adequate hearing, severely impaired vision, moderately impaired cognition, no hallucinations or delusions, no rejection of care, utilized a manual wheelchair, required substantial/maximal assistance with eating, showers, upper body dressing; dependent on toileting, lower body dressing, putting on footwear, and transfers; diagnoses included Non-Alzheimer's Dementia, depression, end stage renal disease with dialysis, muscle…

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 the resident and/or legal representative received a bed hold notice and written notice of transfer for 2 of 2 residents (R13 and R4), reviewed for hospitalization, who were transferred to the hospital for overnight stays. Findings include:R13's face sheet provided on 12/15/25, included diagnoses of congestive heart failure (when the heart cannot pump effectively), chronic kidney disease (kidneys cannot filter blood well) and urinary retention. R13's face sheet indicated R13 was the responsible party and other individuals were listed as emergency contacts.R13's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was able to understand and be understood. R13 required substantial assistance or was dependent upon staff for most activities of daily living (ADLs). R13 had an indwelling urinary catheter. R13 did not walk. R13's progress note order dated 12/2/25 at 1:15 p.m., indicated nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 1 of 1 resident (R13) reviewed for MDS accuracy and 1 of 1 resident (R55) reviewed for dialysis. Findings include: R13's face sheet provided on 12/15/25, included diagnoses of pressure ulcer of contiguous site of back, buttock and hip, unstageable, and irritant contact dermatitis due to fecal, urinary or dual incontinence. R13's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was understood and could understand. R13 required substantial staff assistance or was dependent on staff for activities of daily living (ADLs) and did not walk. R13 had a urinary catheter and was occasionally incontinent of bowel. R13 was at risk for pressure ulcers and had an unhealed pressure ulcer. R13 had two unstageable pressure injuries presenting as deep tissue injury, not present on admission. R13's pressure ulcer/injury Care Area…

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 develop a comprehensive care plan for 1 of 1 resident (R46) reviewed for colostomy care.Findings include: R46's face sheet provided on 12/15/25, included diagnoses of malignant neoplasm (cancer) of rectum, rectosigmoid junction (where the S-shaped sigmoid colon joins the rectum) and anus (the exit point for feces [stool] from the body). R46's annual Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was understood and could usually understand. R46 had an ostomy, specifically a colostomy (an opening in the abdomen connecting the large intestine to the outside of the body), required supervision or was dependent upon staff for activities of daily living (ADLs). R46's Care Area Assessment (CAA) dated 10/27/25, did not identify an ostomy or colostomy. R46's physician orders and TAR (treatment administration record) dated 12/1/25, included change colostomy bag twice a week on Mondays and Fridays. 1) Use stoma cleanser…

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 residents received assistance with meals for 1 of 2 resident (R5) reviewed for nutrition who required staff assistance and/or supervision with meals.Findings include:R5's five-day Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition, no behaviors or rejection of care, use of wheelchair, substantial/maximal assistance for eating and oral hygiene, dependent for shower/bath, dressing, and toileting hygiene, and diagnoses of Alzheimer's disease, depression, and pressure ulcers.R5's care plan revised 10/27/25, indicated self-care performance deficit related to cognitive and physical limitations with intervention of supervision/touch assistance of one helper for eating. Helper to provide verbal cues, touch/steady, and/or contact guard assist intermittently.R5's physician orders dated 10/15/25, indicated regular diet, soft and bite sized texture, thin liquids.Facility chart progress note dated 12/7/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide incontinence care for 1 of 1 resident (R12) reviewed who was dependent upon staff for assistance with activities of daily living (ADL). Findings include: R12's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated: severe cognitive impairment, no rejection of care, dependent on staff for toileting hygiene, shower/bath, lower body dressing, personal hygiene, and transfers, utilized a wheelchair, current toileting program, always incontinent of urine, frequently incontinent of bowel; diagnoses included cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke, anxiety, depression, history of falling.R12's Care Area Assessment (CAA) dated 8/29/25, requires assist x2 staff for toileting tasks, including assistance with transfers, peri cares, and clothing management, as well as the use of an EZ Stand (mechanical lift) for transfers, not aware of the need to toilet, so staff anticipate needs, on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide services to maintain and/or prevent loss of range of motion (ROM) for 1 of 3 residents (R4) reviewed for limited range of motion. In addition, the facility failed to ensure a hand splint was properly applied to ensure palmar protection. Findings include:R4's face sheet provided on 12/15/25, indicated diagnosis of hemiplegia (paralysis affecting one side of the body) following stroke and affecting his left side. R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was usually understood and was usually able to understand. R4 required substantial assistance or was dependent upon staff for help with most activities of daily living (ADLs). R4 did not walk.R4's provider orders dated 12/2/25, indicated the following: 1) PT/OT (physical therapy/occupational therapy evaluation and treatment every shift. 2) Apply resting hand splint when in wheelchair, at HS (bedtime) and in the morning.…

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 document review the facility failed to ensure the infection control program included ongoing surveillance, trending and analysis of resident infections, and failed to ensure enhanced barrier precautions (EBP) were implemented for 1 of 1 residents (R38) reviewed for nephrostomy tube. This had potential to affect all 64 residents who resided in the facility. Finding include: On 2/11/25 at 1:23 p.m., during an interview the assistant director of nursing (ADON)-B who also identified as infection preventionist, stated he tracked and documented infections and antibiotics use on a software program but was having difficulty accessing reports. ADON-B showed a separate spread sheet used for Influenza and Covid-19 outbreaks they recently had in December 2024 and January 2025, which did not include signs and symptoms, treatment, or if transmission based precautions were implemented. On 2/11/25 at 2:45 p.m., the ADON-B was able to print out infection/antibiotic use lists. The form…

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 implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use. Finding include: On 2/11/25 at 1:23 p.m.,during an interview, the assistance director of nursing (ADON)-B, also identified as infection preventionist, stated he tracked and documented infections and antibiotics use on a software program but was not able to print out any reports. On 2/11/25 at 2:45 p.m., ADON-B was able to print out infection/antibiotic use lists. Review of the facility's monthly antibiotic use from 5/1/24 through February 11, 2025, included: resident, unit/room number, infection date, infection, diagnosis, medication, provider, outcome, date infection resolved and bacteria. There was also a space for signs and symptoms and other information located underneath the headings. Review of the data indicated 34 urinary tract infections (UTI) treated with antibiotics out of 37…

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 a care plan included cultural aspects for 1 of 2 residents (R20) reviewed for food. Findings include: R20's facesheet printed on 2/11/25, included diagnoses of chronic kidney disease, heart failure and diabetes. R20's admission Minimum Data Set (MDS) assessment dated [DATE], indicated he was moderately impaired cognition, clear speech, was understood and could understand. R20 had no problems eating and required partial assistance with most activities of daily living. R20's physician orders dated 1/6/25, included a low sodium diet; 1/11/25, oral supplement, and 1/16/25, daily weights. R20's care plan dated 1/10/25, indicated R20 had a potential nutritional problem related to risk for malnutrition and need for a therapeutic diet. The care plan did not include cultural aspects at all, including food and/or meal preferences for R20. R20's [NAME] (a brief overview summarizing a residents care plan and used by NA's (nursing assistants) did 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 observation and interview, the facility failed to ensure 3 of 7 (R16, R54, R226) resident ceiling vents in the 3400 wing were clean when they had a black substance present on the vents. This deficient practice had the potential to affect all residents, staff, and visitors on the 3400 wings. Findings include: R16's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R16 was admitted on [DATE]. R54's quarterly MDS dated [DATE], indicated R54 was admitted [DATE]. R226'S entry MDS 1/30/25, indicated R226 was admitted [DATE]. On 2/10/25 at 2:14 p.m., R226 stated the vent on his ceiling was dirty, and stated he didn't know if it was just dirt or mold. R226's ceiling vent was observed and the vent slates were covered with black substance. On 2/11/25 at 7:52 a.m., R226's ceiling vent was observed with the maintenance director (MD)-A and MD-A stated the vent had dust and dirt buildup and the vents need to be taken down and cleaned. MD-A added it was likely due to moisture causing the dirt to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review the facility failed to ensure the infection control program included ongoing surveillance, trending and analysis of resident infections, staff doffed (removed) personal protective equipment (PPE) incorrectly for 1 of 1 resident (R16), failed to ensure PPE was stored in a manner to prevent transmission of bacteria when PPE was observed stored directly on the floor for 18 of 18 residents (R12, R52, R218, R3, R20, R36, R41, R10, R27, R15, R16, R6, R8, R17, R57, R46, R21, and R219) placed on enhanced barrier precautions (EBP) and the staff placed a meal tray on the floor for 1 of 1 resident (R27). This had the potential to affect all 56 residents who resided in the facility. Finding include: Enhanced Barrier Precautions Facility document titled Enhanced Barrier Precautions printed 4/10/24, indicated the following residents had Enhanced Barrier Precautions (EBP) R12, R52, R218, R3, R20, R36, R41, R10, R27, R15, R16, R6, R8, R17, R57, R46, R21, and R219. During an…

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

Based on interview and document review, the facility failed to implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any of the 56 residents who had infections requiring antibiotic use. Findings include: During interview on 4/10/24, 1:13 p.m., with the director of nursing (DON) and assistant director of nursing (ADON), who was the infection prevention nurse. The DON stated the nurses completed monitoring of symptoms if resident had a possible infection and report that information to the providers. The provider identified potential infections and order testing and review the cultures. The DON further stated the nursing staff also were responsible to review lab and culture results to ensure resident is taking proper antibiotic. The ADON stated he was the infection prevention nurse and was responsible for the infection control program, including antibiotic stewardship. The ADON confirmed education completion of infection control/prevention and antibiotic…

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 an allegation of misappropriation of property was reported to the state agency (SA) within 24 hours, in accordance with established policies and procedures, for 1 of 1 resident (R1) reviewed for allegation of money theft. Findings include: R1's facesheet printed on 4/11/24, included diagnoses of macular degeneration (an eye disease that causes vision loss) and cognitive communication deficit. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, had adequate vision and hearing, clear speech, was understood and able to understand. R1 was independent with most activities of daily living. R1's care plan initiated on 8/18/23, indicated R1 had a behavior problem of paranoia related to dementia and would have fewer episodes of paranoia. During an interview on 4/8/24 at 1:20 p.m., R1 stated he had cash stolen from his room a couple weeks ago, approximately $70 in a pouch. R1 stated the facility was aware 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 resident status was accurately identified in the Minimum Data Set (MDS) assessment for 2 of 2 resident (R52, R21) reviewed for hospice and pressure ulcers. Findings include: R52's Face Sheet indicated admission date was 2/7/24, and diagnoses of malignant neoplasm (uncontrolled growth and division of abnormal cells) of upper lobe of lung, malignant neoplasm of bone and heart failure. R52's admission significant change, Minimum Data Set (MDS) dated [DATE], section O, K1 under special treatments and programs, did not include hospice care services. Section J 1400 Prognosis: conditions or chronic diseases that may result in a life expectancy of less than 6 months was marked as yes. R52's provider order dated 2/29/24, indicated hospice was to evaluate. During interview on 4/8/24 at 12:42 p.m., R52 indicated she is receiving hospice services but was not sure who the hospice agency was. During interview on 4/9/24 at 8:56 a.m., registered…

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/provide a summary of the baseline care plan to the resident and/or resident representative for 3 of 3 residents (R29, R57, R112 ) reviewed who were newly admitted . Findings include: R112's admission Record identified an admission date of 3/22/24, with diagnoses of displaced fracture of head of right radius (bone of forearm) and fracture (break) around internal prosthetic right hip joint (hip replacement). R112's admission Minimum Data Set (MDS) dated [DATE], identified R112 as having a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. R112's activities of daily living MDS section was not completed. R112's baseline care plan indicated R112 required staff will assist with dressing grooming with extensive to limited assistance as R112 is non weight bearing on right leg. Comments included use pivot disc and assist of two from wheelchair to bed or recliner. When interviewed on 4/8/24 at 4:15 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 observation, interview and document review, the facility failed to ensure individualized activities were provided for 1 of 1 resident (R29) reviewed for activities. Findings include: R29's admission Minimum Data Set (MDS) dated [DATE], indicated R29 was admitted to the facility 3/5/24, had moderately intact cognition, dependent on staff for toileting and transfers, required substantial/maximal assistance with shower/bathe and dressing, required supervision with eating and oral hygiene, identified it was very important to do his favorite activities, keep up with the news, participate in religious services, and go outside to get fresh air, and somewhat important to have reading material, listen to music, and do things with groups of people and diagnoses included pneumonia, urinary tract infection, and mild cognitive impairment, . R29's care plan dated 3/5/24, did not include R29's activities, interests or interventions related to activities. R29's baseline care plan dated 3/5/24, activities coordinator…

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 services were coordinated with the hospice agency for 1 of 1 resident (R52) reviewed who received hospice services. Findings include: R52's significant change Minimum Data Set (MDS) dated [DATE], required substantial to maximum staff assistance with all activities of daily living except set up assist for eating and oral hygiene. R52's Brief Interview for Mental Status (BIMS), indicated intact cognition and understands and is understood. R52's facility care plan, dated 3/21/24, included the resident is at the end stage of life and is utilizing hospice services. Intervention included coordinate care with hospice and other end of life services. R52's (local hospice agency) current plan of care, dated 3/28/24, indicated a registered nurse (RN) would provide services 1-2 times times a week (1-2 x/wk) and the home health aide (HHA) 2 times per week. The care plan indicated R52 is her own person, and does not need calls prior to visits.…

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 the facility failed to ensure a range of motion program for upper extremities was implemented, wrist brace was applied correctly, and edema glove was on for 1 of 2 residents (R14) who had limited range of motion to prevent contractures. Findings include: R14's face sheet printed 4/10/24, included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness one on side of the body) following cerebral infarction (central nervous system injury) affecting left non-dominate side, osteoarthritis, and muscle weakness. R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated R14 had intact cognition, dependent on staff for transfers, dressing, and personal hygiene, and limited range of motion (ROM) on one side. R14's provider orders dated 5/7/21, included apply resting hand splint on when in wheelchair and at bedtime. Document refusals. Apply edema glove during the day and off at bedtime. Document refusals. R14's plan of care last revised…

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 properly assess disposing of cigarettes for 1 of 1 resident (R57) reviewed for smoking. Findings include: R57's admission Minimum Data Assessment (MDS) dated [DATE], indicated R57 had severe cognitive impairment, required supervision with personal hygiene, sit to stand, chair transfer, and walking and diagnoses included aphasia (ability to understand or express speech), hemiplegia following cerebral infract (paralysis of partial or total body function on one side of the body after a stroke) affecting right side, tobacco use, muscle weakness, anxiety disorder, depression, and diabetes. R57's care plan revised 4/8/24, indicated R57 would like to smoke while residing at this care community, was offered smoking cessation options and declined, (was on nicotine patch when first admitted , requested for them to be stopped d/t being ineffective for him), will not smoke unless directly supervised by family/responsible party/staff as evidenced…

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 insulin was administered per physician orders for 1 of 3 residents (R1) reviewed for medication administration. Findings include: R1's significant change Minimum Data Set (MDS) indicated R1 was cognitively intact, had a diagnosis of diabetes, and required insulin 7 of 7 days in the lookback period. R1's care plan dated [DATE], indicated R1 would be free of signs or symptoms of hypoglycemia (a condition in which the body's blood sugar level goes below the standard range) and monitor for sweating, tremor, increased heart rate, confusion, slurred speech, lack of coordination, and staggering gait. R1's Physician's orders dated [DATE] directed detemir insulin (Levemir) inject 34 units subcutaneously (under the skin) at bedtime related to diabetes. R1's Physician's orders for insulin glargine dated [DATE] directed inject 40 units subq at bedtime related to diabetes. The order further directed, Start when Levemir is used up. On [DATE] at 11:50 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.

Based on interview and document review the facility failed to ensure 7 of 7 nursing assistant students (NA-F, NA-J, NA-K, NA-L, NA-M, NA-N and NA-O) involved in the facility's nursing assistant student training program included a system to ensure return demonstration competency for mechanical lift transfers were evaluated by qualified staff to ensure students were adequately trained to safely operate mechanical lifts. This had the potential to affect all 44 of 65 residents who used mechanical lifts in the facility. Findings include Document titled Ecumen 75 hour Nursing Assistant Course indicates students are to complete a satisfactory demonstration of the skills on the performance record which are required in the laboratory prior to clinical experience. Instructors will evaluate students' performance according to the state approved checklist. Students will not be assigned to clinical if requirements are not met. During interview on 10/20/23 at 8:20 a.m. program training coordinator (PTC)-A indicated she assisted in initiating the nursing assistant training program at the facility…

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.