Good Samaritan Society - Specialty Care Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure professional standards of practice were followed during administration of crushed medications for 1 of 2 residents (R68) observed during medication administration.Findings include: R68's Annual Minimum Data Set (MDS) dated [DATE], identified R68 as exhibiting severe cognitive deficit and was identified as requiring assist with all aspects of activities of daily living (ADLs-dressing, grooming, bathing, and toileting). R6's medical diagnoses included aphasia (difficulty with speaking), anemia (a low blood count of red blood cells or hemoglobin), hypertension (high blood pressure) and non-Alzheimer's dementia (a condition which may cause alteration in thoughts, cognition, and behavior).R68's admission Profile printed 6/4/26, indicated R68 had diagnoses of generalized muscle weakness.R68's Care Plan revised 2/23/26, indicated R68 had limited physical mobility related to history of a stroke with right side weakness and received…

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 physician-ordered parameters were monitored prior to administration of an antihypertensive medication, including failure to obtain blood pressure readings to determine whether a PRN dose of metoprolol was indicated, for 1 of 1 resident (R91) reviewed for medication administration parameters.Findings include:R91's quarterly Minimum Data Set (MDS) dated [DATE] identified R91 had severe cognitive impairment and required assistance with activities of daily living (ADL)'s. R91's diagnoses included schizophrenia (a chronic mental health disorder that affects a person's ability to think clearly, perceive reality, manage emotions, and interact with others). The MDS further identified R91 received antipsychotic medications.R91's physician orders identified an order for Metoprolol Tartrate 12.5 mg (milligram) by mouth every 24 hours as needed for blood pressure greater than 150 related to paranoid schizophrenia. The order was initiated on 3/30/26.R91's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During interview and record review, the facility failed to ensure all residents were offered and up to date on immunizations for 1 of 5 residents (R29) reviewed for immunizations.Findings include:Information on the CDC website: Pneumococcal Disease link, outlined on the CDC website and dated 2/25/26, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This site identified recommendations for those who had never been vaccinated for pneumococcal disease, as well as those who had started the pneumococcal process. Additionally, the link to Influenza (Flu) site dated 9/18/25, identified everyone six months and older should get a flu vaccine every season with rare exceptions.R29's admission minimum data set (MDS) dated [DATE], included an admission date of 4/29/26, and R29 was identified as being [AGE] years of age. R29's medical diagnoses included coronary artery disease (the narrowing of arteries which decreases blood flow to the heart), hypertension (high blood…

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 document review and interview, the facility failed to ensure COVID-19 immunization was offered and/or administered in accordance with current standard of practice for 1 of 5 residents (R29) reviewed for immunizations.Findings include:A Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Guidance updated 11/4/25, indicated individuals should receive recommended COVID-19 vaccinations, including booster doses, when eligible, unless medically contraindicated or refused. Long-term care facilities were responsible for assessing vaccination status and ensuring residents were offered recommended vaccines.R29's admission minimum data set (MDS) dated [DATE], included an admission date of 4/29/26, and R29 was identified as being [AGE] years of age. R29's medical diagnoses included coronary artery disease (the narrowing of arteries which decreases blood flow to the heart), hypertension (high blood pressure), and non-Alzheimer's dementia (loss of memory and other intellectual functions, affecting…

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 promote dignity while providing care for 1 of 3 residents (R1) reviewed who required assistance with activities of daily living. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 admitted to the facility on [DATE], was severely cognitively impaired, required staff assistance for transfers, and had diagnoses that included dementia. During an interview on 5/13/26 at 8:32 a.m., R1's family member (FM)-A stated she had a video of staff yelling at R1 when R1 asked for help. The FM-A stated R1 reported being upset after staff yelled at her. The FM-A did not understand why staff would yell at a resident with the diagnosis of dementia. The FM-A stated it was upsetting to see the video and further stated she wanted R1 cared for by people who wanted to help R1. The staff in the video did not seem like they wanted to help. During an interview on 5/13/26 at 4:04 p.m., the nursing assistant (NA)-C stated staff should…

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, observation, and document review the facility failed to implement care plan interventions for 1 of 3 residents (R1) when staff transferred R1 with pivot transfers (technique for moving a resident from one position to another. While standing, resident moves their feet to turn toward the new surface) instead of with the Stand Aid (non-motorized device to assist a person to a standing position), as indicated in the care plan. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 admitted to the facility on [DATE], was severely cognitively impaired, required staff assistance for transfers, and had diagnoses that included fractures, dementia and multiple traumas. R1's care plan dated 3/23/26 indicated R1 required assistance of one staff for toileting and transferred with a Stand Aid.During an interview on 5/13/26 at 8:32 a.m., R1's family member (FM)-A stated she was concerned about the way staff transferred R1. R1 was transferred by two people moving R1 instead 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 interviews, observations, and document review the facility failed to ensure safe transfers for 1 of 3 residents (R1) who was lifted off the floor following a fall by two staff without using a Hoyer lift (mechanical lift used to transfer residents from one surface to another). In addition, two staff assisted R1 to stand from a wheelchair with a Stand Aid (non-motorized lift used to assist residents from a seated position to a standing position) without a gait belt.Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 admitted to the facility on [DATE], was severely cognitively impaired, required staff assistance for transfers, and had diagnoses that included fractures and dementia. R1's care plan dated 3/23/26, indicated R1 required one staff to assist with toileting and transfers with a Stand Aid. During an interview on 5/13/26 at 8:32 a.m., R1's family member (FM)-A stated she was concerned staff were transferring R1 by two people moving R1 instead of the machine (Stand Aid)…

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 assess, develop and implement person-centered care plans to meet the needs of 6 of 16 residents (R1, R2, R3, R5, R7 and R8) reviewed who received treatment and services related to dementia. Findings include:R1R1's care plan included diagnosis dementia with behavior disturbances. R1's care plan indicated the following areas of concern and interventions:3/24/26 impaired cognitive function/dementia with impaired decision-making, agitation, irritability, cue, orient, and supervise as needed (PRN) and reassess resident for needs like hunger, thirst, toileting needs, discomfort3/24/26 activity of daily living (ADL) deficits: bathing, dressing, oral care, personal hygiene, toilet use, and transfers; one staff to assist with ADLs, and set-up assistance for eating3/24/26 at risk for falls; monitor for significant changes in gait, mobility, balance, and lower extremity joint function, with an actual fall on 3/25/263/24/26 monitor closely during…

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 efforts to resolve a grievance for missing personal possessions was addressed, acted upon, and resolved for 1 of 1 resident (R1) whose family voiced concerns regarding missing personal property. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, and physical and verbal behaviors (hitting, kicking, pushing, screaming at others, grabbing, abusing others sexually), one-to-three days during the seven-days assessment look-back period. These behaviors put the resident and others at significant risk for physical injury and disrupted care or the living environment. R1 wandered four-to-six days during the seven-day look-back period which intruded on the privacy of others. R1's Preferences Evaluation dated 3/26/26, indicated it was very important to have music. R1 had his personal radio in his room. R1's care plan dated 3/31/26, indicated R1 had behavioral symptoms related to dementia including…

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 foods which were a known allergen were not served or provided for 1 of 1 resident (R1) reviewed who complained about repeatedly being served such foods. This could cause an allergic reaction for R1 if she had consumed them. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had intact cognition and demonstrated no delusional thinking. On 7/30/25 at 8:52 a.m., R1 was interviewed in her room. R1 explained she had admitted to the care center a few weeks prior after being hospitalized for a motor vehicle accident (MVA), and she expressed several concerns about her care since admission. R1 stated she was repeatedly being served meals which had food items she was allergic to, such as seafood, which she said was frustrating. R1 stated she often then couldn't eat the meals so she was worried about losing weight. R1 held up a small, yellow-colored notepad and stated she had just that morning wrote out 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.

Based on observation, interview and document review, the facility failed to ensure residents knew how to file a grievance and that grievance forms were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 4 of 4 residents (R29, R32, R37 and R39) reviewed for grievances. This had the potential to affect all residents residing in the facility. Findings include: On 2/12/25 at 11:00 a.m., a resident council meeting was held with four residents which included R29, R32, R37 and R39. During the resident council meeting, all four residents indicated they were not aware of how to file a grievance or where to find a grievance form. All four residents stated that they knew they could talk to the previous social worker, but since he left none of them felt they could discuss grievances with social services director (SSD). During interview on 2/13/25 at 9:45 a.m., SSD stated the grievance filing process was often covered in the resident council meetings for those who attended and for everyone else there…

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

Based on observation, interview and document review, the facility failed to ensure dishwasher temperatures were within range to ensure resident dishes were sanitized for 4 of 5 unit (Boundary Waters, Arrowhead, Lakes, Woodland) kitchenettes that housed and utilized dishwashers. In addition, the facility failed to maintain the coffee machine in a sanitary manner to prevent potential food-borne illness. These practices had the potential to affect all residents residing in these units. Findings include: Dishwasher Temperatures: During observation on 2/12/25 at 10:36 a.m., dishwasher temperature log in the Lakes unit kitchenette had temperatures documented for the following dates/meals (breakfast-B, lunch-L, dinner-D): 1/31/25-L, 2/1/25-B, L D, 2/2/25-B and L, and 2/4/25-L. During interview on 2/12/25 at 10:40 a.m., dietary aide (DA)-A stated it was the responsibility of the dietary staff working in the kitchenette for that shift to check and document the dishwasher temperatures. DA-A stated she thought they needed to be checked at least twice a day and confirmed the log in the Lakes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure a self-administration of medication assessment (SAM) was completed to allow residents to safely administer their own medications for 1 of 1 (R140) resident observed with medications at bedside. Findings include: R140's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). If further indicated R140 required partial assistance with most activities of daily living (ADL). R140's physician's orders dated 2/5/25, indicated Breo Ellipta Inhalation Aerosol Powder Breath Activated 200-25 microgram (MCG)/ACT (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day for chronic obstructive pulmonary disease (COPD). Rinse mouth after each use. Notify the nurse manager if R140 refuses or unable to rinse. It further included an order dated 2/5/25, indicating Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90…

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 During observation, interview, and document review the facility failed to clean and maintain residents wheelchairs for 2 of 2 residents (R3, R33). Findings include: R3 R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, and diagnoses of Huntington's disease (HD), dementia, dependence on a wheelchair, and was dependent on staff for most activities of daily living (ADL) and mobility. R3's care plan dated 1/16/25, indicated R33 had limited physical mobility and was at risk for falls related to HD as evidenced by neededing assistance for mobility. Frequently refused to wear shoes, slippers or diabatic shoes. Had a history of putting himself on the floor and scooting. Also had a history of alleging falls and getting himself up from. Assist to propel Broda Chair as needed. It further included an intervention of mobility: Broda Chair with pressure redistribution cushion and self releasing front latching seat beat. Uses Broda chair for ambulation. R33 R33's quarterly Minimum Data…

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 notify the physican of a change in condition for 1 of 2 residents (R6) with a significant weight gain. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of central cord syndrom, spinal stenosis, and chronic pain syndrom. It further indicated R6 required substantial assistance with most activites of daily (ADL) and mobility. R6's physician's orders dated 2/5/25, indicated weekly weights to notify the physician for greater than (>) 5 pound weight gain in a week, (every evening shift every Wednesday) for edema. R6's care plan dated 12/20/24, indicated a nutritional diagnoses of obesity class III related to excessive calorie intake with an intervention to monitor changes in weight. R6's treatment administration record (TAR) for the month of February, indicated on 2/5/25, R6 weighed 397.5 pounds (lbs) and on 2/12/25 weighed 406.1 lbs. This was a weight gain of 8.6 lbs. in one week.…

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 pressure ulcer (PU) prevention interventions were in place for 1 of 2 residents (R66) reviewed for pressure ulcers. Findings include: R66's admission Minimum Data Set (MDS) dated [DATE], indicated R66 was cognitively intact, required partial to moderate assistance with mobility and most activities of daily living (ADLs), had one or more unhealed PU and at risk for developing more, and did not exhibit rejection of care behaviors. R66's diagnoses included congestive heart failure (CHF), type 2 diabetes mellitus, and dementia without behavioral, psychotic, or mood disturbance. R66's care plan dated 1/23/25, indicated R66 had an actual impairment to skin integrity due to diagnoses and had potential for further PU development due to decreased mobility. The care plan instructed staff to elevate heels off bed with heel protector boot to left leg. R66's Braden assessment (predicting pressure sore risk) dated 2/11/25, indicated R66 was 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 ensure a urinary catheter was secured to facilitate urine flow and positioned below the bladder for 1 of 1 resident reviewed for catheter cares. ensure the proper use of a catheter for 1 of 1 resident (R68). Findings include: R68's annual Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of chronic kidney disease and retention of urine. It further indicated R68 required setup/cleanup assistance with toileting, was independent with mobility, had a catheter, was occasionally incontinent of bowel. R68's physician's order dated 1/9/25, indicated Foley catheter:16F catheter 10cc balloon change as necessary every 45-90 days, as needed for urinary retention. The order lacked documentation R68's leg bag did not need to be positioned below the bladder. R68's care plan dated 10/16/24, indicated R68 had an indwelling catheter related to an acute kidney injury (AKI) evidenced by urinary retention. It further…

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 beverages were served in the appropriate consistency for 1 of 1 resident (R12) reviewed for therapeutic diets. Findings include: R12's State Optional Minimum Data Set (MDS) dated [DATE], indicated R12 had severe cognitive impairment, was independent after set-up with meals, worked with speech therapy from 1/15/25 through 1/27/25, and did not exhibit rejection of care behavior. R12's diagnoses included pneumonitis due to inhalation of food and vomit, other symptoms and signs concerning food and fluid intake, and type 2 diabetes. R12's annual MDS dated [DATE], indicated R12 required Mechanically altered diet - require change in texture of food or liquids [e.g. pureed food, thickened liquids]. R12's nutrition care area assessment (CAA) dated 1/19/25, indicated R12 required pureed textures and mildly thick liquids due to dysphagia. R12's care plan last revised 2/6/25, indicated R12 was at risk for altered nutrition/hydration 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.

Based on observation, interview and document review, the facility failed to provide medication as ordered by the physician for 1 of 3 residents (R4) reviewed for pharmacy services. Findings include: R4's Diagnosis List dated 1/14/25, indicated R4 had hepatic encephalopathy (a loss of brain function as a result of failure to remove toxins form the blood due to liver damage) and alcoholic cirrhosis of the liver (liver disease). R4's Physician's Orders dated 1/14/25, directed to give rifaximin (used to prevent liver failure) 550 milligrams (mg) two times a day starting 1/14/25. On 1/14/25 at 9:23 p.m., a progress note written by registered nurse (RN)-A indicated R4's rifaximin was on order from the pharmacy. On 1/15/25 at 10:15 a.m., a progress note written by licensed practical nurse (LPN)-A indicated R4's rifaximin needed price approved by the facility before it would be sent. On 1/16/25 at 10:47 a.m., an email written by the director of nursing (DON) to nurse practitioner (NP)-A indicated a need for the rifaximin to be reviewed by NP-A. On 1/16/25 at 11:41 a.m., an email written by…

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 Facility Assessment identified the facility's staffing needs based on the care needs of the resident population. This deficient practice had the potential to affect all 92 residents who resided in the facility. Findings include: Review of Facility assessment dated [DATE], indicated the assessment was organized in six parts: demographics and census, facility resources, core requirements, competencies, plan, and measuring and monitoring. Further, the assessments indicated the facility assessment would serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources and may include the operating budget necessary to carry out the facility functions. However, the Facility Assessment lacked information on staffing levels needed for specific shifts, such as day, evening, and night and adjusted as necessary based on changes to resident population. On 12/23/24 at 3:32 p.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 ensure a baseline care plan was developed, within 48 hours that included goals and interventions to address resident's current needs, as required for 1 of 1 residents (R1) reviewed. Findings include: R1's entry Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included hemiplegia and hemiparesis, dysarthria (speech disorder/difficulty speaking); type 2 diabetes, dysphagia (difficulty swallowing) following cerebral infarction (ischemic stroke); aphasia (language difficulties because of a stroke), nontraumatic intracranial hemorrhage (bleeding in the brain that occurs without trauma or surgery), and tremor. R1's Nursing Admit Re-Admit Data Collection ([NAME]) was completed on 12/5/24, day of admission, and indicated R1 was admitted from the hospital following an ischemic cerebrovascular accident (stroke). Further, [NAME] indicated the following skilled services would be provided: medication and treatment administration, skilled…

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 adequate supervision during a meal for 1 of 1 residents (R1) reviewed, who required supervision due to swallowing disorder. Findings include: R1's entry Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included hemiplegia and hemiparesis, dysarthria (speech disorder/difficulty speaking); type 2 diabetes, dysphagia (difficulty swallowing) following cerebral infarction (ischemic stroke); aphasia (language difficulties because of a stroke), nontraumatic intracranial hemorrhage (bleeding in the brain that occurs without trauma or surgery), and tremor. R1's Order Summary dated 12/24/24, indicated R1 required a regular diet, soft and bite-sized texture, and moderately thick liquids as of 12/5/24. R1's Functional abilities and Goals- Admission/Start of Skilled Care assessment dated [DATE], revealed eating which was the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once…

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 call lights, or another means to request assistance were accessible for 4 of 4 residents (R5, R6, R7, and R8) reviewed who were dependent on staff for mobility. Findings include: R5's care plan revision date of 10/23/24 indicated to keep call light and television remote in place especially when R5 was in bed due to falls. R5's quarterly Minimum Data Set (MDS) dated [DATE] indicated R5 had a Brief Inventory of Mental Status of zero indicating severe cognitive impairment. R5 was totally dependent on staff for eating, oral and toileting hygiene, dressing and transferring. R5 was always incontinent of bowel and bladder. R5's pertinent diagnosis was Huntington's disease (an inherited disease in which nerve cells break down over time.) R5 had falls in the facility. Upon continuous observation on 12/6/24 at 9:14 a.m. R5 completed breakfast at 9:20 a.m. R5 was taken to her room by NA-C. R5 was in her Broda wheelchair (a medical device chair…

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 complete a proper assessment, care planning, and ongoing re-evaluation for the use of physical restraints for 5 of 5 residents (R4, R5, R6, R7, and R8) reviewed to ensure the imposed restraint were used to treat the resident's medical symptoms, is not used for convenience or discipline, is the least restrictive alternative for the least amount of time and document ongoing re-evaluation for the need of restraints. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE] indicated R4's Brief Inventory of Mental Status (BIMs) score of 1 indicated severe cognitive impairment. R4 required maximum assistance with personal hygiene, transferring and dressing. R4's pertinent diagnoses were Alzheimer's disease, adult failure to thrive (a syndrome in older adults characterized by unexplained weight loss, poor nutrition, inactivity and a decline in physical and mental functioning, pulmonary fibrosis (a lung disease which causes scarring…

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 treat with dignity for 1 of 3 residents (R7) reviewed for resident rights. A nursing assistant (NA)-C was observed speaking to R7 in a belittling manner while providing cares. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE] indicated R7 had unclear speech, slurred or mumbled words. R7 could usually make himself understood. R7 did not have difficulty understanding others. R7's Brief Inventory of Mental Status (BIMs) of three indicating R7 was severely cognitively impaired. R7 was totally dependent on staff for eating, oral hygiene, toileting hygiene, showers, and dressing. R7 required extensive assistance with rolling left and right sitting to lying and sit to stand transfers. R7 was always incontinent of bowel and urine. R7's pertinent diagnoses were Huntington's disease (an inherited disease where the nerve cells in the brain break down), dysphagia (difficulty swallowing foods), and dorsalgia (back pain).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement the person-centered care plan for 2 of 4 residents (R5 and R7) reviewed to meet the resident's needs. In addition, the facility failed to complete a person-centered care plan for 2 of 4 residents (R4 and R6) to describe the residents medical needs. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE] indicated R4's Brief Inventory of Mental Status (BIMs) score of 1 indicated severe cognitive impairment. R4 required maximum assistance with personal hygiene, transferring and dressing. R4's pertinent diagnoses were Alzheimer's disease, adult failure to thrive (a syndrome in older adults characterized by unexplained weight loss, poor nutrition, inactivity and a decline in physical and mental functioning, pulmonary fibrosis (a lung disease which causes scarring making it difficult to breathe), and hallucinations. R4's physician order dated 10/25/24 indicated R4 used a Broda chair (a medical device chair that provides…

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, interviews, and record review the facility failed to provide 1 of 3 residents (R3) reviewed who was unable to carry out activities of daily living (ADL's) the necessary services to maintain proper personal hygiene. Findings include: A facility grievance log dated 8/23/24 indicated R3 had complaints regarding cares indicating a resolution date of 9/12/24. No further documentation was provided upon request. A facility grievance log dated 10/8/24 indicated R3 had complaints regarding cares with a resolution date of 10/28/24. No further documentation was provided upon request. R3's physician orders dated 10/22/24 indicated to keep peri area clean and dry every shift. R3's hospital Discharge summary dated [DATE] indicated R3 was septic due to catheter related urinary tract infection. R3 was discharged back to the facility on [DATE]. R3's care plan revision dated 11/15/24 indicated R3 had an ADL self-care performance deficit related to central cord syndrome at C5 (spinal cord injury which 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 record review the facility failed to provide professional standards of practice for 2 or 3 residents (R6 and R9) reviewed when residents were observed wearing two incontinence briefs placed on them at the same time. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE] indicated R6 had a BIMS score of 11 indicating cognitive impairment. R6 was dependent upon staff for oral and toileting hygiene, dressing and transferring. R6 was always incontinent of bowel and bladder. R6's pertinent diagnosis was Huntington's disease. R6's care plan dated 10/26/24 indicated for staff to check and change R6's incontinent brief every two hours. The care plan did not indicate R6 was to wear two incontinent briefs at the same time. Upon observation and interview on 12/6/24 at 11:05 a.m. hospice nursing assistant (NA)-D completed a bed bath on R6 and stated she had soaked through both briefs the facility had put on her. NA-D showed surveyor two saturated incontinent briefs in 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 appropriately assess and initiate interventions to minimize the risk for pressure ulcer development for 1 of 3 residents (R1) reviewed. Findings include: According to the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 08-08-2024, indicated: -Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. - Avoidable…

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 the proper temperature of food was served at breakfast on the 2nd floor WL unit. This had the potential to affect all 16 residents. Findings include: During observation on 12/6/24 at 8:41 a.m. staff was in the kitchenette area where scrambled eggs in steam tables. At 9:00 a.m. two nursing assistants and one trained medication assistant were dishing and serving breakfast. At 9:06 a.m. R6 was given pureed eggs to feed herself. She was heard shouting her eggs were cold, R6 was not offered to have her food heated up. At 9:10 a.m. surveyor tasted a spoonful of eggs that were sitting outside on a plate of the steam tables and the eggs were cold. Upon interview on 12/6/24 at 9:11 R9 nodded yes that her breakfast was cold. Upon observation and interview on 12/6/24 at 9:46 a.m. R7 stated his breakfast cold and always is. R7's food was sat on the table at 9:14 and he was fed at 9:21. R7's food was not covered on the table. Upon interview on 12/6/24 at 2:15 a.m. trained medication assistant (TMA) stated breakfast…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report an allegation of staff to resident abuse to the state agency (SA) within two hours after the allegation was made for 1 of 3 residents (R2) reviewed for abuse when the facility reviewed a video taken by a family member. Findings include: R2's care plan dated 9/26/23, indicated he needed extensive help from two staff for bathing, bed mobility, transfers from bed to wheelchair and dressing, R2's care plan dated 9/29/23, indicated he had impaired cognition, dementia, and delirium. Staff were directed to ask him yes and no questions and introduce one thought at a time. R2's significant change Minimum Data Set (MDS) dated [DATE], indicated he had severe impaired cognition. He had dementia, encephalopathy (a condition causing confusion, memory loss, and personality changes), cancer, protein malnutrition, weight loss, anemia, and received hospice care. He took antipsychotic and antidepressant medication. R2's care plan dated 7/1/24, indicated 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 maintain wheelchairs in clean and sanitary manner for 4 of 4 residents (R3, R27, R36 and R57) reviewed who utilized wheelchairs. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment with a diagnosis of dementia and Huntington's disease and was dependent on staff for activities of daily living (ADLs). During observation on 12/5/23 at 10:37 a.m., R3's wheelchair was observed to be soiled with an unknown white and brown substance that was dried and splattered on both armrests and wheels. R27's quarterly MDS dated [DATE], indicated significant cognitive impairment with a diagnosis of Huntington's disease (causes progressive breakdown of nerve cells in the brain) and was dependent on staff for ADLs. During observation on 12/5/23 at 10:32 a.m., R27's wheelchair was observed to be soiled with an unknown white and brown substance that was dried and splattered on both armrests and was…

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

Based on observation, interview and document review, the facility failed to follow standards of practice related to medication administration for 1 of 1 residents (R35) observed to receive an inhalation medication. Findings include: R35's admission Record printed 12/7/23, indicated diagnoses of chronic obstructive pulmonary disease (COPD- a condition that blocks airflow and make it difficult to breathe), memory deficit following cerebral infarction (stroke), and bipolar disorder. R35's Order Summary Report printed 12/7/23, included budesonide-formoterol fumarate aerosol 160-4.5 mcg/act (medication used to prevent swelling in the lungs) 2 puffs inhaled orally two times a day for COPD, rinse mouth after each use. During observation on 12/5/23 at 8:14 a.m., licensed practical nurse (LPN)-B administered R35's morning medications, which included the budesonide inhaler. LPN-B handed the inhaler to R35 to complete two puffs. R35 completed the two puffs as ordered and handed back inhaler to LPN-B. LPN-B did not offer fluids or ask R35 to rinse mouth. LPN-B stated R35 often refused cares.…

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 to assure safety with smoking for 1 of 2 residents (R8) who was smoking outside the facility. Findings include: R35's significant change Minimum Data Set (MDS) dated [DATE], indicated R35 was cognitively intact, was not a current tobacco user and was independent with activities of daily living (ADLs). R35's diagnoses included cerebrovascular accident/stroke, seizure disorder, traumatic brain injury and chronic obstructive pulmonary disorder. During the facility entrance conference on 12/4/23 at 12:23 p.m. the administrator and the director of nursing (DON) stated the facility only had one resident who smoked off the balcony of his unit. R35's care plan printed 12/6/23, did not indicate R35 smoked. On 12/5/23 at 10:32 a.m., R35 was sitting in a wheelchair on the sidewalk in front of the building smoking a cigarette. Tremors were noted while holding the cigarette and bringing cigarette to his mouth. On 12/6/23 at…

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

Based on observation, interview, and document review, the facility failed to ensure appropriate management and routine care of an indwelling urinary catheter was provided for 1 of 1 resident (R49) reviewed for catheter care. Findings include: R49's significant change Minimum Data Set (MDS) assessment date 9/14/23, indicated R49 was cognitively intact, required moderate assistance with dressing and showering, substantial/maximal assistance with toileting hygiene and had an indwelling urinary catheter. R49's diagnoses included transient cerebral ischemic attack (a stroke that last only a few minutes), mild cognitive impairment, benign prostatic hyperplasia (noncancerous enlargement of the prostate gland), renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease), type 2 diabetes and long-term use of insulin. R49's physician orders included: Change indwelling Foley with 16F Cauda Catheter 10cc balloon in the morning starting on the 2nd and ending on the 2nd every month related to Benign prostatic…

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 that there were accurate orders in place for oxygen (O2) usage for 1 of 1 resident (R20) reviewed for oxygen therapy. Findings include: R20's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R20 had impaired cognition and required assistance with all activities of daily living (ADL)'s. R20's diagnoses included non-Alzheimer's Dementia (the loss of memory and other mental abilities severe enough to interfere with daily life), renal failure (one or both of the kidneys no longer function well on their own), chronic obstructive pulmonary disorder (condition involving constriction of the airways and difficulty or discomfort in breathing, and dependence on supplemental oxygen. During observation and interview on 12/4/23 at 2:12 p.m., R20 was sitting on the side of the bed and had oxygen nasal cannula placed in both nares. R20 was ashen in color and was taking short, quick breaths through pursed lips while…

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 The facility failed to ensure the accurate administration of medications to meet resident needs for 1 of 2 (R21) reviewed for medication errors. Findings include: R21's quarterly Minimum Data set (MDS) dated , 10/26/23 identified resident as being [AGE] years old and having moderately impaired cognition and diagnoses of methicillin susceptible staphylococcus aureus infection (MRSA- nfections caused by specific bacteria that are resistant to commonly used antibiotics), staphylococcal arthritis (infection that spread to the joints through the bloodstream), type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, depression, unspecified radiculopathy cervical region (a nerve in the neck is pinched or irritated), restless leg syndrome , chronic pain syndrome and allergic rhinitis (runny nose due to allergies). R21's medication order summary report dated 12/7/23, indicated resident active orders for: - Buspirone hydrochloride (an antianxiety medication) 10 milligrams 3 times a day for anxiety disorder -…

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 resident's drug regimen were free of drugs used for excessive duration for 1 of 5 residents (R21) reviewed for unnecessary medications. Findings include: R21's quarterly Minimum Data set (MDS) dated , 10/26/23 identified resident as being [AGE] years old and having moderately impaired cognition. R21's care plan dated 5/30/23, indicated resident needed assistance with all decision making, R21's medication orders dated 4/1/23, indicated resident had a medication order for Aspirin (ASA) 81 milligrams one time a day for supplement with a start date of 8/9/22. R21's consultant pharmacist's (Pharm D) medication review dated 4/27/23, indicated resident medical record did not demonstrate a need for ASA supplementation because resident had no history of coronary artery disease, acute coronary syndrome, angina, myocardial infarction, heart failure or stroke. The [NAME] D medication review also indicated ASA used in patients who did not have vascular…

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 properly store and label an insulin pen for 1 of 2 residents (R49) reviewed who received insulin. In addition, the facility failed to ensure medications were properly labeled with directions for use for 1 of 4 residents (R34) reviewed for eye drop storage on Arrowhead unit. Findings include: R49's significant change Minimum Data Set (MDS) dated [DATE], indicated R49 was cognitively intact and needed extensive assist with activities of daily living (ADLs). R49's diagnoses included transient cerebral ischemic attack (a stroke that last only a few minutes), mild cognitive impairment, benign prostatic hyperplasia (noncancerous enlargement of the prostate gland), renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease), type 2 diabetes and long term use of insulin. During observation on [DATE] at 3:14 p.m., an opened insulin aspart pen (fast acting insulin) was observed in…

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 resident was free and protected from ongoing verbal and physical abuse by a nursing assistant (NA)-A, for 1 of 1 resident (R1) who verbalized staff abuse. Findings include: A Facility Reported Incident (FRI) submitted to the State Agency (SA) dated 11/16/23 at 1:04 p.m., included an allegation of emotional or mental abuse that occurred on 11/16/23 at 11:15 a.m. The report indicated staff overheard NA-A yell at R1 while providing cares. NA-A said is that what you want? and this is how it's going to be in a raised voice before leaving the room and slamming the door. In a common space NA-A yelled she just kicked me in the head and NA-A asked about R1's discharge plan. An email to human relations specialist (HRS) from director of nursing (DON) dated 11/16/23, at 1:22 p.m. indicated nursing assistant (NA)-A was suspended pending further investigation of an allegation of verbal abuse. An email to human resource specialist (HRS) and administrator dated 11/17/23, at 4:06 p.m. indicated social worker (SW), therapy, 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.