The Estates At Chateau LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to compressively assess a resident with several mental health diagnoses including post-traumatic stress disorder to ensure, if needed, accurate interventions were in place to prevent traumatization. The facility further failed to ensure collaboration with a resident's outside psychiatric provider for 1 of 2 residents (R8) reviewed for trauma informed care. Findings include:R8's quarterly minimum data set (MDS), dated [DATE], indicated R8 was admitted to the care facility on 3/27/25. The MDS indicated R8 refused to be interview for mental status but was assessed with okay long term and short-term memory and was able to recall season, location, staff names and faces and where she lived. The MDS further indicated R8 was on the following medication types: antipsychotic, antianxiety, hypnotic, hypoglycemic, and anticonvulsant.R8's diagnoses list, dated 3/27/25, indicated R8 had several medical diagnoses including bipolar disorder, major…

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 ensure non-pharmacological interventions were attempted and recorded prior to the administration of as-needed (PRN) narcotic medication to help facilitate person-centered care planning and reduce the risk of complication (i.e., constipation, sedation) for 2 of 6 residents (R1, R46) reviewed for unnecessary medication use.Findings include:R1R1's admission Minimum Data Set (MDS) assessment, dated 8/7/25, identified R1 had intact cognition with no hallucinations, delusions or behaviors. R1 required staff set up for oral hygiene, upper body dressing, bed mobility, and personal hygiene, staff supervision for eating and required moderate staff assistance for toileting, lower body dressing and transfers. In addition, the MDS outlined R1 received both scheduled and PRN pain medications during the review; however, did not receive any non-medication intervention for pain. Further, R1 indicated they had occasional pain which they rated at six (6) out of 10 (10 being the worst possible). R1's care plan, printed…

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 provide rehabilitative services as ordered for 1 of 1 residents (R7) reviewed for therapy services.Findings include:R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact. R7's pertinent diagnoses included central spinal cord syndrome (the spinal cord was bruised or damaged in the middle, at the level of the fourth vertebra in the neck and affects the arms more than the legs). R7's MDS indicated speech therapy was provided from 3/20/25 through 5/15/25, physical therapy (PT) was provided from 3/21/25 through 4/8/25, and R7 received occupational therapy (OT) during the quarterly MDS assessment period.R7's PT notes dated 4/8/25, indicated all goals were met and R7 was care planned for range of motion (ROM). The note identified up for meals and that sitting up was the best ROM for large joints. R7's care plan revised on 5/30/25, directed staff to follow PT instructions and orders, as well as complete passive range of…

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

Based on interview, observation, and record review the facility failed to protect 1 of 3 residents (R1) from staff to resident verbal abuse. Findings include: R1's brief interview for mental status (BIMS) dated 6/5/25 indicated a score of 15/15, indicated no cognitive impairment. R1's care plan dated 5/30/25 indicated medical diagnoses of weakness, schizophrenia, anxiety disorder, depression, chronic pain syndrome. Facility camera footage reviewed on 6/18/25 at 9:44 a.m., revealed on 6/8/25 at approximately 5:04 p.m. R1 was at the kitchen door; R1 foot was holding door open, dietary aide (DA)-B was at door also holding the door open with her body and arm. Exchange of words between R1 and DA-B were visualized however there was no sound capabilities. R1 had sandwich in hand and there was no physical interaction between staff and R1. Facility camera footage failed to cover incident of R1 and DA-A verbal or physical interaction as footage was delayed. When interviewed on 6/17/25 at 1:11 p.m., R1 stated there was an altercation between DA-A due to requesting two sandwiches. R1 stated he…

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, observation and record review the facility failed to report an allegation of staff to resident abuse to the State Agency (SA) and administrator for 1 of 3 resident (R1) who had a verbal altercation with a staff member, requiring another staff to intervene and no report was made. Findings include: R1's brief interview for mental status (BIMS) dated 6/5/25 indicated a score of 15/15, indicated no cognitive impairment. R1's care plan dated 5/30/25 indicated medical diagnoses of weakness, schizophrenia, anxiety disorder, depression, chronic pain syndrome. When interviewed on 6/17/25 at 1:11 p.m., R1 stated there was an altercation between DA-A due to requesting two sandwiches. R1 stated he and DA-A were yelling at each other and being disrespectful to each other. R1 stated they both called each other bitches in the altercation, and he could not recall who said bitch first. R1 recalled DA-B coming to the door during the altercation and defused the situation and then he left. R1 added, he was surprised how escalated it got over a request for two sandwiches. When…

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 safe environment for residents by allowing former resident FR4, who had been discharged , to repeatedly gain unauthorized entry through an unsecured door without staff awareness, resulting in unwanted interactions for residents (R)5 and R7. Findings include:The nursing home incident report (NHIR) dated 5/31/25, identified a man FR4 came into R5's room at 4:30 a.m., and R5 woke up to the man kissing her on the forehead. This created difficulty sleeping and mental anguish for R5.FR4's face sheet dated 6/5/25, identified FR4 had diagnoses of major depressive disorder, alcohol dependence in remission, generalized anxiety disorder, and mild cognitive impairment.FR4's comprehensive MDS dated [DATE], identified FR4 had resided at the facility for almost one year. FR4 had no cognitive impairment, no behaviors towards other residents or staff. FR4 was independent with all cares.FR4's progress notes from 5/13/25-5/21/25, identified FR4 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 Based on observation, interview, and document review, the facility failed to protect two residents (R1 and R2) from abuse when R3 had a verbal and physical altercation with R1, which escalated to a physical incident with R2 later that day. R1's face sheet dated 5/31/25, identified diagnoses of multiple fractures of pelvis, alcohol abuse, and open wound on left lower leg.R1's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive issues. R1 had verbal behavior issues directed at others, was independent with all self-cares, and used a wheelchair for mobility.R1's care plan identified that she would remain free from abuse or neglect. Interventions included monitoring for signs of emotional distress or mood and behavior changes, safety monitoring will be implemented as needed to ensure residents safety, staff will continue to follow the facility vulnerable adult and abuse reporting policy.R1's progress note dated 5/26/25 at 11:37 p.m., identified at 6:00 p.m., registered nurse (RN)-D was alerted to 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 document review, the facility failed to report allegations of stolen money immediately (within 24 hours) to the State Agency (SA) for 1 of 3 residents (R2) reviewed for abuse. In addition, the facility did not report the missing money to law enforcement. Findings include: R2's Medicare 5-Day Minimum Data Set (MDS) dated [DATE] indicated R2 was cognitively intact, had no behaviors, and had diagnoses that included multiple fractures and depression. R2's Grievance/Concern Form dated 4/8/25 indicated, Resident stated that 80 dollars was taken from her purse on the night of 4/7. This happened overnight when she was asleep. Resident stated she had her purse next to her, between her arm and window. When resident woke up on 4/8/25, her purse was located on the ground beside her bed. This is when resident became aware that 80 dollars was missing from her purse. The form was signed by social worker (SW)-A, and indicated R2 made a police report. On 5/13/25 at 3:35 p.m., R2 stated staff covered up 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 document review, the facility failed to have a process in place for prior authorization (PA) of medications to ensure resident medications were re-ordered and refilled in a timely manner for 1 of 3 residents (R1) reviewed for medication administration. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, had no behaviors, and diagnoses that included diabetes and heart disease. R1's care plan revised 11/23/22, indicated R1 had a potential for alteration in blood sugar related to a diagnosis of diabetes. The care plan guided nursing staff to administer medication as ordered. R1's Medication Administration Record (MAR) dated 3/2025, indicated a noon medication pass that included Rybelsus (medication used to treat elevated blood sugar) 7 milligrams (mg) oral tablets given at noon daily, ordered 4/16/24. The MAR indicated missed doses continually from 3/13/25 to 3/31/25. R1's MAR dated 4/2025, indicated a noon medication pass that included…

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 follow policy of removing alcohol from residents' room and analyze underlying causes of resident increased aggression for 1 of 1 resident (R3) reviewed for behavioral health when R3 had continued alcohol intoxication with increased behaviors. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE] indicated no cognitive impairment however behaviors of physical behaviors toward others and rejects cares was identified. R3 activities of daily living indicated R3 was independent with mobility, dressing, transfers, eating and toileting. Medical diagnoses were alcohol dependence, alcohol abuse with intoxication, cocaine dependence, major depressive disorder. R3's Care Area Assessments (CAA) dated 8/20/24, triggered behavioral psychosocial wellbeing which indicated verbal behavioral symptoms directed toward others by threatening others, screaming at others, cursing at others. R3's care plan print dated 3/14/25, indicated R3 had 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 record review, the facility failed to produce a care plan that was consistent for one of four residents (R4) reviewed for care plans. R4's care plan stated two staff members were to provide cares for R4 while further down in the care plan it stated one staff was to assist R4 with bathing, dressing, and personal hygiene. Findings include: During an observation on 9/18/24 at 10:02 a.m., nursing assistant (NA)-B changed R4's incontinent brief. NA-B was the only aide who changed R4's incontinent brief. R1's face sheet indicated R4 was admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction due to embolism of bilateral anterior cerebral arteries. R4's additional diagnoses included hemiplegia affecting left dominant side, repeated falls, panic disorder, adjustment disorder with anxiety, and other stimulant abuse. R4's care plan dated 9/29/23 indicated resident needed an assistant of one for bathing, dressing, and personal hygiene. R4's care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to use aseptic technique when providing pericare for one of four residents (R2) observed for pericare, provide timely incontinent cares for two out of four (R1, R4) residents, and provide weekly showers for one of four (R1) residents reviewed for activities of daily living. Findings include: During an observation on 9/18/24 at 9:51 a.m., nursing assistant (NA)-C changed R1's incontinent brief. NA-C did not use aseptic technique while washing R1's perineal area. NA-C wiped R1's perineal from back to front and then took the same washcloth and reused the same washcloth she used for pericare to wash her labia. During an observation on 9/18/24 at 10:02 a.m., NA-B was changing R4's incontinent brief. R4's brief had been saturated with urine. NA-B wiped R4 from back to front using the same washcloth. During the observation NA-B stated R4's linens had been saturated with urine and she needed to change R4's bed linens. NA-B stated she did not know…

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 licensed staff were trained on wound vacuum-assisted closure (VAC) for five of sixteen licensed staff. R1 was admitted to the facility with a wound vac. Findings include: R1 was admitted to the facility on [DATE] with a primary diagnosis of encounter for open fracture type I or II. R4's additional diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side and acquired absence of left leg above knee. R1's wound care progress note dated 9/6/24 indicated advanced practice registered nurse (APRN) order staff to change the wound vac every Monday, Wednesday, and Friday and as needed. R1's care plan dated 9/6/24 indicated R1 had surgical wounds that required the use of a wound vac. R1's provider progress note dated 9/10/24 indicated R1's wound vac had fluid seen in underneath the suction device and stabilizer applicator plastic remained present. The provider indicated the plastic should have been removed…

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 ensure monitoring and timely removal of facility food stored in refrigerators and freezers was completed. In addition, the facility failed to ensure facility food was stored in a manner to reduce the risk of physical cross-contamination and potential foodborne illness. In addition, the facility failed to ensure all food items were properly covered when served to residents to reduce and/or prevent the risk of foodborne illness. These facility failures had the potential to affect all 65 residents who consumed food from the facility kitchen. In addition, the facility failed to ensure the third-floor unit refrigerator temperatures were properly monitored and maintained to reduce the risk of foodborne illness. This had the potential to affect all third-floor residents receiving meal service beverages and/or storing personal food items in the unit refrigerator. Findings include: UNLABELED FOOD During the initial kitchen observation with the dietary manager (DM) on 8/12/24 at 11:37 a.m., the following foods were…

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 Assessment (QAA) program identified and implemented ongoing, effective actions or monitoring to promote proper food storage (i.e., labeling, dating) and handling in 1 of 1 main production kitchen and various unit-based refrigerators despite known quality issues in this area and similar, repeated non-compliance with Federal regulations being identified for multiple years in a row during the recertification survey process. This had potential to affect all 65 residents, staff and visitors who consumed food at the care center. Findings include: A provided QAPI (Quality Assessment and Performance Improvement) Plan, reviewed last 8/23, identified the principles of QA would be integrated across all the care and services areas of the care center, with each area having a QAPI representative on the committee. The plan outlined the facility' would review data from areas the organization believed it needed to monitor on a routine basis; and it outlined a process for how Performance Improvement…

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 meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 3 of 3 residents (R16, R35, R44) reviewed for dining. This had the the potential to affect 24 residents identified to reside on the unit where the meal was served. Findings include: R16's quarterly Minimum Data Set (MDS), dated [DATE], identified R16 had intact cognition and demonstrated no delusional thinking. When interviewed on 8/12/24 at 1:04 p.m., R16 stated the meals served were always cold and they didn't like it. R35's admission MDS, dated [DATE], identified R35 had intact cognition and demonstrated no delusional thinking. When interviewed on 8/12/24 at 12:58 p.m., R35 stated the meals served were not good and always seemed to be cold, especially the breakfast meal. R44's quarterly MDS, dated [DATE], identified R44 had intact cognition and demonstrated no delusional thinking. When interviewed on 8/12/24 at 12:47 p.m., R44…

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 and maintain personal dignity for 1 of 1 residents (R16) reviewed for dignity with personal care. Findings include: R16's quarterly Minimum Data Set (MDS) assessment, dated 8/16/24, documented an admission date to the facility on [DATE] and indicated R16 had intact cognition. R16 required maximal staff assistance for toileting, showering, lower body dressing and putting on/taking off footwear along with transfers. R16's diagnoses included: bilateral primary osteoarthritis of knee (a degenerative joint disease), heart failure (heart cannot pump or fill adequately), diabetes (chronic disease where body doesn't produce enough insulin or can't use insulin properly), and chronic pain. R16's care plan (CP), printed 8/14/24, indicated self-care deficit related to physical impairment: assist of 1 with dressing. In addition, a revision was made 8/13/24 (after survey entrance), alteration in psychosocial well-being .resident wears hospital…

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 necessary maintenance services were performed to provide a home-like environment for 1 of 1 residents (R41) with a broken overhead light. Findings include: R41's significant change Minimum Data Set (MDS) dated [DATE], indicated R41 had intact cognition, required supervision for oral hygiene and personal hygiene, and was independent with transfers. The facility's Closed Work Order report dated 7/1/24 through 7/30/24, included a request for R41 to get a mattress that fit correctly on the bed and indicated the light over the bed did not work. The facility order delivery report dated 8/6/24, included a picture of what appeared to be light bulbs and indicated the package was delivered on 8/6/24 and signed for by the maintenance director (MAD). During an interview on 8/12/24 at 1:05 p.m., R41 stated her overhead light had not worked since she had moved into her room, at least a few works ago, and the maintenance staff told her they…

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 care-planned interventions for substance use were implemented and documented to provide continuity of care for 2 of 2 residents (R44, R1); and failed to individualize the care plan to include target behaviors for psychotropic medication use for 1 of 5 (R48) residents reviewed for unnecessary medication use. Findings include: R44 R44's quarterly Minimum Data Set (MDS), dated [DATE], identified R44 had intact cognition and multiple medical conditions including heart failure, high blood pressure, and kidney disease. Further, the MDS outlined R44 consumed diuretic and opioid medications. R44's care plan, printed 8/13/24, identified R44's assessed problems or concerns along with corresponding interventions for each. The care plan outlined R44 was a current, independent smoker and had a history of substance abuse including, . has diagnosis of alcohol dependence with withdrawal unspecified. Reports drinking a fifth of alcohol every other day .…

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 accurately and comprehensively assess for smoking practices for 1 of 1 residents (R35) reviewed for smoking. Findings include: R35's admission Minimum Data Set (MDS) assessment, 7/19/24, indicated R35 had intact cognition. Diagnoses included: paraplegia (chronic condition that causes loss of function and sensation in the lower half of the body), and diabetes (chronic disease that occurs when body doesn't produce enough insulin or can't use insulin properly). In section GG Functional Abilities and Goals: under section GG0130 self-care: indicated R35 needed partial/moderate assistance from staff with eating. Other areas of activities of daily living (ADLs), R35's level of assistance range from partial/moderate assistance to dependent on staff assistance. Furthermore, in section J Health Conditions: under section J1300 current tobacco use: indicated R35 uses tobacco by a check mark in the yes box. R35's Smoking Evaluation, dated 7/13/24, indicated R35 does not identify as a smoker. The remaining questions 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 document review, the facility failed to comprehensively assess and, if needed, develop or implement interventions with newly developed back pain for 1 of 2 residents (R11) reviewed for pain management. Findings include: R11's quarterly Minimum Data Set (MDS), dated [DATE], identified R11 had moderate cognitive impairment and required, at least, partial/moderate assistance with sitting up or transferring. Further, under Section J - Health Conditions, the MDS identified R11 consumed no scheduled or as-needed (i.e., PRN) pain medication; but reported pain on a frequent basis which interfered with day-to-day activities. The MDS recorded a pain rating level, 02. R11's most recent MHM (Monarch Healthcare Management) Pain Evaluations V3, dated 6/25/24, identified R11 did not consume scheduled or PRN pain medication, however, received non-pharmacological interventions for pain. The evaluation outlined R11 had reported pain which occurred, Frequently, and did interfere with day-to-day…

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 physician-ordered medications were re-ordered timely to prevent delay in administration and reduce the risk of complication for 1 of 6 residents (R34) observed to receive medication during the survey. Findings include: R34's annual Minimum Data Set (MDS) dated [DATE], indicated R34 had intact cognition and was diagnosed with asthma. R34 required maximal assistance with eating and oral hygiene. R34's Order Summary Report dated 8/15/24, indicated R34 had an order for two puffs of 50 micrograms (mcg)/five mcg of Dulera (an inhaler used to control symptoms of asthma) two times a day. R34's Medication Administration Record (MAR) dated 8/1/24 through 8/14/24, indicated R34 had received two puffs of 50 mcg/five mcg of Dulera two times a day except for on 8/13/24 where a 9 was coded meaning other/ see nurse notes for the morning administration. During an observation and interview on 8/13/24 at 8:50 a.m., licensed practical nurse (LPN)-B…

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 adequate blood sugar monitoring was completed and documented to reduce the risk for potential unnecessary administration or associated complications related to insulin (medication used to lower blood sugar levels) use for 1 of 5 residents (R8) reviewed for unnecessary medications. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 had intact cognition and had no rejection of care behaviors during the look-back period (LBP). The MDS indicated R8 was diagnosed with diabetes, depression, and schizophrenia (a severe mental illness that affects how people perceive and interact with reality, often causing hallucinations and delusions). R8's Medication Administration Record (MAR) dated 8/1/24 through 8/12/24, included an order dated 7/23/24 for 18 units of subcutaneous insulin glargine (long-acting insulin) for diabetes that was received every morning during the period. The MAR did not include corresponding…

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 have a qualifying diagnosis for routine use of an antipsychotic medication and failed to complete an abnormal involuntary movement scale (AIMS) for 1 of 1 resident (R48) reviewed for unnecessary medications. Findings include: R48's printed medical diagnosis list identified she had depression, encephalopathy, alcohol abuse, and cocaine abuse. R48's 7/18/24, Minimum Data Set (MDS) identified an admission date of 4/12/24. R48 was cognitively intact and had no behaviors. R48 had little interest or pleasure in doing things and felt down, depressed, or hopeless never to 1 day. R48 had taken antipsychotics, antianxiety and antidepressant on a routine basis. R48's 8/2024, Medication Administration Record (MAR) identified R48 had taken olanzapine (an antipsychotic medication to treat schizophrenia and bipolar disorders) 5 milligrams (mg) twice a day for anxiety with a start date of 7/03/24. R48 had received 58 doses of olanzapine medication from 7/3/24 to 7/31/24 and 27 doses from 8/01/24 to 8/14/24. R48's medical record lacked 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 interviews and document review the facility failed to ensure residents right to be free from abuse, provide adequate supervision, and develop a comprehensive care plan including interventions for two of two residents (R1, R2) reviewed for abuse. R1 and R2 had a history of resident-to-resident altercations while intoxicated and physically assaulted each other while under the influence of alcohol and intoxication. Findings Include: R1's care plan indicated on 1/24/24, R1 was involved in an altercation with another resident while intoxicated on 1/24/24. R1's care plan indicated R1 actively uses alcohol while living at the facility. R1's care plan instructed staff need to monitor R1 while intoxicated. R1's Minimum Data Set for facility entry dated 5/9/24 indicated R1 was admitted to the facility on [DATE]. R1's relevant diagnoses included acute pancreatitis, type 2 diabetes mellitus, and alcohol abuse. R1 was ambulatory without any adaptive equipment and was independent with his activities of daily living.…

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 nutrient and/or calorie substantive snacks were offered and readily available to reduce the risk of resident-associated complication (i.e., low blood glucose, hunger) after the dinner hour (i.e., bedtime) on 1 of 3 units reviewed. This had potential to affect 21 of 21 residents identified to reside on the third floor, and numerous residents identified who had voiced concern about a lack of bedtime snacks at the Resident Council meeting. In addition, the facility failed to ensure 1 of 1 resident (R12) reviewed for dialysis was provided meals prior to treatment (i.e., outside of traditional hours) to prevent a greater than 14 hour lapse in time between dinner and breakfast times. Findings include: LACK OF SNACKS: R14's quarterly Minimum Data Set (MDS), dated [DATE], identified R14 had intact cognition. On 9/19/23 at 11:29 a.m., R14 was interviewed and expressed frustration as the nursing home had stopped serving a bedtime snack…

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 ensure food stored in the kitchen freezers and refrigerators were labeled and dated to ensure expired food was not served. In addition, the facility also failed to ensure 1 of 1 commercial can opener was kept in a clean and sanitary manner. These findings had potential to affect all 58 residents, staff, and visitors who consumed food from the facility kitchen. In addition, the facility failed to ensure the food stored in the floor kitchenettes refrigerators was properly stored. These findings had the potential to affect the residents who consumed food from these refrigerators. Findings include: During the initial kitchen tour on 9/19/23 at 8:15 a.m., the following items were identified: 1. Four-door freezer used to store meats, labeled #1 - One opened, undated bag of fish sticks. - Five packets of expired tortillas in August 2023 - One opened, undated bag of meat balls. - One opened, undated bag of finger strips. - Two opened, undated bags containing cooked pieces of chicken. - One opened, undated bag…

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 dignity was maintained for 2 of 2 residents (R1, R41) who utilized an indwelling catheter. Findings include: R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 required extensive assistance of two staff members for bed mobility, dressing, toileting, personal hygiene and had an indwelling catheter. R1's diagnoses included paraplegia (paralysis that affects the lower half of the body), schizophrenia (a mental disorder that affects how a person perceives and interprets reality), major depression, and neurogenic bladder (urinary bladder problem due to disease or injury involving the control of urination). R1's care plan dated 12/23/21, directed R1's catheter care to be done per protocol. During observation on 9/19/23 at 9:07 a.m., R1's uncovered foley catheter bag was observed connected to the bed rail facing the hallway while R1 was in bed napping. During interview with R1 on 9/21/23 at 9:19 a.m., R1 stated he 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure self-administration of medications was assessed for safety and care planned accordingly to reduce the risk of adverse events for 2 of 2 residents (R21, R23) reviewed for self adminstration of medications. Findings include: R21's quarterly Minimum Data Set, dated [DATE], indicated R21 had moderate cognitive impairment and was independent with all activities of daily living. R21's Diagnoses List, dated 3/21/23, indicated R21 had several medical diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and alcohol abuse. R21's Physician Orders, dated 3/21/23, indicated an order for Fluticasone-Salmeterol Aerosol Powder. Give 1 puff by mouth two times a day related to chronic obstructive pulmonary disease and encourage resident to rinse mouth after use. R21's electronic medical record (EMR) lacked evidence of an assessment, an order and care planned…

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 provider orders were followed and physical therapy (PT) services were offered for 1 of 1 residents (R15) who had surgery related to a fractured ankle treated with a boot brace. Findings include: R15's annual Minimum Data Set (MDS) dated [DATE], indicated R15 had intact cognition. R15's quarterly MDS dated [DATE], indicated R15 required supervision for dressing and personal hygiene and was independent with all other activities of daily living (ADLs). R15's diagnoses included diabetes, left lower leg fracture, and alcoholic cirrhosis (liver disease related to alcohol use) of the liver, hepatic encephalopathy (a loss of brain function due to liver damage). R15's Care Area Assessment (CAA) dated 1/3/23, indicated R15 triggered for falls, pressure ulcer and ADL function. R15's care plan dated 7/26/22, indicated R15 was at risk for falls related to antidepressant use and alcohol intoxication. Interventions included physical therapy (PT)…

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 comprehensively assess and implement appropriate and updated interventions for 1 of 1 resident (R21) with multiple falls with injury related to alcohol use. The facility further failed to implement behavioral health specialist's (Licensed Social Worker) recommendations regarding managing continued substance abuse which may have reduced the risk of falls for 1 of 1 resident (R21) who sustained a laceration to his forehead requiring emergency room intervention. Findings include: R21's quarterly Minimum Data Set, dated [DATE], indicated R21 had moderate cognitive impairment and was independent with all activities of daily living. R21's care plan, dated 3/22/23, indicated R21 was a fall risk related to generalized weakness and alcohol abuse. The care plan indicated two main, repeated interventions that included educating R21 on the Substance Use policy and re-approaching about the facility's chemical dependency program. R21's Incident Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure humidifier and oxygen tubing was changed in a timely manner for 3 of 3 residents (R2, R12, and R36) reviewed for respiratory care. Findings include: R2 R2's quarterly Minimum Data Set (MDS) dated [DATE] indicated R2 had intact cognition and required supervision with all cares. R12's diagnoses include lung disease and received oxygen therapy. During an observation on 9/19/23 at 8:45 a.m., R2 was lying in bed with humidified oxygen being delivered by nasal cannula. The bubbler contained water and was dated 6/25. During an observation on 9/20/23 at 9:21 a.m., R2's oxygen tank was on and delivering 2 liters per minute (lpm) of oxygen through a nasal cannula that was lying on R2's bed. The tubing was attached to the bubbler that was dated 6/25. R2 was not in the room. During an interview and observation on 9/20/23 at 9:30 a.m., licensed practical nurse (LPN)-B stated oxygen tubing and bubblers were to be changed every week but 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and document review the facility failed to assess and monitor for complications per standard of practice before and after dialysis for 1 of 1 resident (R12) reviewed for dialysis care. Findings include: R12's annual Minimum Data Set (MDS) dated [DATE], indicated R12 with intact cognition and required limited assistance with dressing. R12's diagnoses included hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, renal dialysis, schizophrenia, diabetes, and legal blindness. R12's provider orders (PO) dated 2/12/19, indicated remove dressing from fistula site no later than bedtime on dialysis days and make up dialysis days. Every evening shift for dialysis days . In addition, PO dated 11/1/17 indicated, check right fistula for bruit and thrill (+/+)/ signs of infection. Notify dialysis/MD for signs of infection or negative for bruit or thrill every shift . R12's care plan (CP) dated 2/7/14 indicated Check access site daily. AV loop graft…

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 alternate interventions were assessed and/or attempted prior to side rail installation for 1 of 1 resident (R19) reviewed who had a bariatric bed with bilateral, metallic one-half (1/2) side rails installed. Findings include: R19's quarterly Minimum Data Set (MDS), dated [DATE], identified R19 had intact cognition and requires supervision with bed mobility. Further, the MDS outlined R19 had a functional limitation in range of motion (ROM) on their bilateral lower extremities, however, had no limitations or impairment with their bilateral upper extremities. On 9/19/23 at 9:19 a.m., R19's room was observed. R19 was not present, however, a bariatric bed was positioned along the wall which had visible, bilateral one-half (1/2) metal side rails installed and in the raised position. The rails had several large (i.e., 4 inch) gaps present in the metallic tubing and the rail positioned on the 'open' side of the bed (i.e., to get in/out 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 document review, the facility failed to follow behavioral health specialist's (Licensed Social Worker) recommendations regarding managing continued substance abuse for 1 of 1 resident (R21) reviewed for behavioral health services. In addition, the facility failed to update the primary physician and the facility medical director regarding the behavioral health recommendations of attempting to limit alcohol consumption and attempting to manage cravings by attempting medications to manage the substance abuse for 1 of 1 resident (R21). Findings include: R21's quarterly Minimum Data Set, dated [DATE], indicated R21 had moderate cognitive impairment and was independent with all activities of daily living. R21's care plan, dated 3/22/23, indicated R21 was a fall risk related to generalized weakness and alcohol abuse with interventions that included educating R21 on the Substance Use policy and re-approaching about the facility's chemical dependency program. R21's Incident Review 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 appropriate side effect monitoring was completed, in accordance with the care plan and standard of care, for consumed antipsychotic medication for 1 of 5 residents (R14) reviewed for unnecessary medication use. Findings include: A National Library of Medicine (NIH) Management of Commons Adverse Effects of Antipsychotic Medication article, dated 9/2018, identified the elderly were at risk of adverse effects (i.e., falls) of antipsychotic medication. The article outlined, All antipsychotics carry some risk of orthostatic hypotension . [which can] lead to dizziness, syncope, falls . it should be evaluated by both history and measurement . Risk factors include systemic diseases causing autonomic instability (e.g., diabetes, alcohol dependence, Parkinson's disease), dehydration, drug-drug interactions, and age. R14's quarterly Minimum Data Set (MDS), dated [DATE], identified R14 had intact cognition and was independent with bed mobility, transfers,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure proper infection control practices were implemented during wound care for R1 reviewed for wound care. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 required extensive assistance of two for bed mobility, transfer, toileting, and personal hygiene. In addition, indicated R1 had diagnoses of neurogenic bladder (bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves), paraplegia (paralysis of all or part of the trunk, legs and pelvic organs), two stage four pressure ulcers (full thickness skin and tissue loss with exposed tissue, muscle or bone) on both of his hips and buttocks, chronic osteomyelitis (infection to the bone) and required a foley catheter and received pressure ulcer care. R1's care plan (CP) dated 2/24/21, indicated, resident has risk for recurrent infection to Stage IV wound ulcers to bilateral trochanters [top of upper leg bone]. Interventions include…

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.