Ecumen North Branch

Based on observation, interview and document review, the facility failed to store food preparation items in a sanitary manner. This had the potential to affect all residents who resided in the facility. Findings include:During observation and interview on 7/22/25 at 11:15 a.m., a tour of the kitchen was completed with the director of culinary services. During the tour, was a stack of 9 large steam table pans on a storage rack to be used for food preparation. The director of culinary services stated those pans were clean and ready to use for food preparation. Upon examining the stack of steam table pans, 5 of 9 steam table pans were stored with visible moisture on the pans. The director of culinary services stated all dishes in the kitchen are to be completely dry before being stored and it looked like these pans were not completely dry. Once the dishes are washed and air dried, they should have been checked to ensure they are dry before placing them on the storage shelf. When dishes are stored wet there is increased risk for germs and bacteria to grow that cause illness. 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 record review the facility failed to ensure damp laundry was not left in overnight in the washing machines used for resident clothing. This deficient infection prevention practice had the potential to impact all 44 residents who resided at the facility. Findings include: During an observation and interview on 07/22/25 at 11:08 a.m., laundry staff (LS-A) stated bed linen and other laundry was sent out to a service, the facility staff only washed resident clothing and mop heads and cleaning cloths at the facility. LSA stated part of the laundry duties included starting a load of mop hands and cleaning rags in the washing machine before leaving for the day. Staff the next morning were responsible for putting the items in the dryer.During an interview on 7/23/25 at 1:15 p.m., with the DON and the infection prevention nurse, both reviewed the facility policy and did not find cleaning supplies specifically addressed in the laundry policy. Both indicated it was possible for bacteria to grow when things were left damp for a prolonged period of time.During an interview…

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 adhere to the Centers for Disease Control (CDC) recommendations for testing and cohorting during a COVID-19 outbreak for 4 of 5 residents (R7, R31, R36, R39). In addition, the facility failed to ensure staff followed posted transmission-based precaution signs for 2 of 5 residents (R7, R9) reviewed for infection control. These practices had the potential to affect all residents, employees, and visitors of the facility. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 3/18/24, identified for the purposes of this guidance, higher-risk exposures are classified as Healthcare Personal (HCP) who had prolonged close contact with a patient, visitor, or HCP with confirmed SARS-CoV-2 infection and: -HCP was not wearing a respirator (or if wearing a facemask, the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask). -HCP 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 record review the facility failed to ensure residents were comprehensively assessed for self-administration of medications (SAM) for 1 of 5 residents (R26) reviewed for unnecessary medications. Findings include: R26's significant change Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and diagnoses of respiratory failure with hypoxia and hemiplegia and hemiparesis of the left side following a cerebral vascular accident (CVA). The MDS also identified R26 needed set up and clean up assistance for eating and oral hygiene. R26's provider orders dated 7/25/24, identified an order for albuterol sulfate solution to be inhaled via nebulizer treatment three times per day and as needed for shortness of breath and wheezing, an order for oxygen via nasal cannula at one to four liters per minute, but did not contain an order to self-administer medication. R26's care plan dated 7/31/24, didn't identify a plan for self-administration of medications. R26's medical…

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 a baseline care plan was developed and implemented within 48 hours as required to address the individualized needs for 1 of 1 resident (R198) reviewed for recent admission. Findings include: R198's admission orders dated 7/31/24, identified R198 was admitted to the facility from a hospital on 7/31/24, with a primary diagnosis of acute on chronic diastolic (congestive) heart failure. admission orders further identified R198 was on two liters of oxygen via nasal cannula. On 8/7/24 at 2:58 p.m., R198's baseline care plan was found to be blank and lacked any information related to R198's care requirements including but not limited to transfer status, activities of daily living performance, assistive device use, impairments, or special treatments such as use of oxygen. During interview on 8/7/24 at 3:24 p.m., registered nurse (RN)-A verified R198's baseline care plan was blank and was not completed within 48 hours of R198's admission. RN-A stated she was aware baseline care plans should be completed within 48 hours 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 observation, interview, and record review the facility failed to review and revise the care plan with current interventions for the care and prevention of pressure ulcers for 1 of 2 residents (R26) reviewed for pressure ulcer care. Findings include: R26's significant change Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and diagnoses of hypertension, chronic kidney disease, dementia, respiratory failure with hypoxia, peripheral vascular disease (PVD), and hemiplegia and hemiparesis of the left side following a cerebral vascular accident (CVA). The MDS also identified R26 was dependent on staff for assistance with bed mobility, transfers, toilet hygiene, was at risk for and currently had pressure ulcers. R26's provider orders dated 5/23/24, identified orders to care for wounds on the left and right feet, weekly skin checks, weekly wound rounds, shoes only when transferring, and must have Prevalon boots (brand name for padded boots designed to reduce pressure on the heels) on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow provider orders for weekly skin assessments for 1 of 2 residents (R26) reviewed for pressure ulcer care. The facility also failed to follow provider orders for an as-needed medication to be administered in response to clinical weight monitoring for 1 of 5 residents (R26) reviewed for unnecessary medications. Findings include: R26's significant change Minimum Data Set, dated [DATE], identified severely impaired cognition and diagnoses of hypertensive heart and chronic kidney disease with heart failure, chronic heart failure (CHF), hypertension, chronic kidney disease, peripheral vascular disease, and pressure wounds to left and right feet. Provider orders for R26 dated 6/25/24, identified orders for: - furosemide (a medication to help remove extra fluid) 20 milligrams (mg) two times per day, and an additional as-needed (PRN) 20 mg dose for weight gain of two pounds or more in a day. - daily weight monitoring with parameters as noted…

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 appropriate documentation and physician review for an as needed (PRN) opioid medication ordered for 1 of 5 residents (R11) reviewed for unnecessary medications. Findings included R11's quarterly minimum data set (MDS) dated [DATE], identified R11 was cognitively intact. Diagnoses included paraplegia, anxiety, and depression. R11 was on a scheduled pain mediation regimen and had not received any PRN pain medication or non-medication interventions for pain. R11's provider visit notes from 2/6/24 and 2/16/24, lacked documentation as to why PRN Oxycodone would potentially be needed for severe pain. There were no provider notes for a visit performed on 2/23/24 provided when requested. R11's provider orders dated 8/9/24, identified on 2/23/24, Oxycodone 5 mg by mouth twice daily as needed for severe pain was started and still active. R11's pain score charting was reviewed from 2/1/24 to 8/8/24, was reviewed and pain was frequently rated at a zero out…

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 food was stored in accordance with regulations for food safety. The facility failed to label and date resident food, and to remove expired food from unit refrigerators. These practices had the potential to affect any residents storing food at the facility. Findings include: During observation on 8/8/24 at 9:15 a.m., [NAME] unit refrigerator was reviewed. One resident meal labeled with name and dated 7/25/24 found in fridge. During observation on 8/8/24 at 9:44 a.m., Wild River unit refrigerator was reviewed. The following items were found in fridge: -plastic container of blueberries, initials 'JK' on sticker, no open date. -hard plastic container of leftover green beans, with resident name and date of '7/30' on sticker. During observation and interview with culinary director (CD) on 8/9/24 at 8:39 a.m., [NAME] unit fridge was reviewed. CD noted resident meal in plastic bag dated 7/25/24. CD stated 'it could still be good' but…

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 comprehensive care plan was developed, and maintained to ensure appropriate fall interventions were provided for 1 of 3 residents (R2) reviewed for resident safety. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 had impaired cognition, was always continent of bladder and bowel, and had a fall prior to entry. R2's diagnoses included dementia and history of falling. R2's nursing assistant Care Sheet undated indicted R2 was at high risk for falls, but the Care Sheet lacked fall interventions. R2's care plan dated 6/10/24 lacked information related to R2's fall risk and fall interventions. A health status note dated 6/12/24 at 10:16 p.m. indicated R2 was found around 5:15 p.m. sitting on his bathroom floor covered in bowel movement. On 6/14/2024 at 11:58 a.m., nurse practitioner (NP)-A stated all residents should have documented fall interventions. All residents are a fall risk based on previous falls, their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure shared glucometers were sanitized after use for 2 of 8 residents (R6, R79) reviewed for glucometer use; failed to ensure staff completed hand hygiene during medication pass for 2 of 6 residents (R4,R21) observed during medication pass; failed to perform hand hygeine during wound care for 1 of 1 (R15) residents observed for wound care; and failed to display appropirate signage for 1 of 1 resident (R15) who was on contact precautions. Findings include: BLOOD GLUCOSE MONITORING: R79's undated, admission Record identified R79 had a diagnosis of diabetes mellitus with hyperglycemia (elevated blood sugars). R79's undated, Order Summary Report directed to assist R79 with blood sugar checks every day and evening with a start date of 9/19/23. During an observation on 9/26/23 at 11:46 a.m., licensed practical nurse (LPN)-C assisted R79 with checking her blood sugar, LPN-C performed hand hygiene put on gloves, cleaned a tray and then set up…

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 maintain oxygen equipment according to their own policy to help prevent infection by routinely changing a nasal cannula for 1 of 2 residents (R12) reviewed for respiratory care. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and included a diagnosis of congestive heart failure (CHF). R12 was independent with transfers, dressing, eating, toileting and personal hygiene. R12's undated, Medication Review Report identified an order for oxygen at two liters per minute with a start date of 6/15/23; and to change oxygen tubing weekly on Sundays with a start date of 6/18/23 On 9/25/23 at 3:50 p.m., R12's oxygen tubing was dated 9/4/23 and R12 used the oxygen every night. During an interview on 9/27/23 at 11:17 a.m., licensed practical nurse (LPN)-A stated the oxygen tubing was changed out every Sunday. LPN-A confirmed the tubing on R12's oxygen was dated 9/4/23. During an interview on 9/27/23…

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

Based on observation, interview, and record review, the facility failed to utilize antibiotic use protocols to avoid unnecessary or inappropriate antibiotic use for 1 of 1 resident (R15) reviewed for antibiotic use. Findings include: R15's care plan dated 9/5/23, indicated R15 was frequently incontinent of bowel and did not mention Clostridioides difficile (a germ that causes diarrhea and inflammation of the colon; also known as C. difficile) nor antibiotic use. R15's undated, current provider orders included vancomycin HCL (antibiotic) oral capsule 125 mg by mouth every 6 hours for C. difficile for ten days with start date of 9/20/23 and end date of 9/29/23. R15's orders indicated contact precautions for C. difficile every shift with start date of 9/19/23 . R15's health status note by licensed practical nurse (LPN)-B on 9/19/23 at 4:15 p.m., indicated labs were not collected. During interview on 9/26/23 at 1:39 p.m., registered nurse (RN)-A stated R15 was on hospice services and was on an antibiotic for a wound infection. After R15 developed loose bowel movements, R15 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.