The Estates At Lynnhurst LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure urinary drainage bags were maintained in a manner that reduced the risk of contamination during catheter care for 1 of 2 residents (R3) reviewed for indwelling catheter care.Findings include:R3's annual Minimum Data Set (MDS) dated [DATE], identified R3 was rarely/never understood and R3 had a severe cognitive impairment. R3 had diagnoses that included ichthyosis vulgaris (a common inherited skin disorder characterized by dry, thick, and scaly skin resembling fish scales. It is primarily caused by a mutation in the FLG gene, which is responsible for producing filaggrin (a protein that helps your skin retain moisture and forms a healthy protective barrier)), major depressive disorder, mixed obsessional thoughts and acts, bipolar disorder, candidiasis of skin and nails (a yeast infection) and anxiety. R3 used an indwelling catheter.R3's care plan revised 6/8/26, identified R3 had an alteration in elimination due to has indwelling…

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 appropriate dementia care treatment and services by failing to comprehensively evaluate repeated resident-to-resident altercations, identify behavioral triggers, and develop and implement individualized interventions to prevent recurrence for 1 of 6 residents (R41) reviewed for dementia care; and failed to follow established dementia care interventions for 1 of 6 residents (R13) reviewed for dementia care. Findings include: R41 R41's significant change Minimum Data Set (MDS) dated [DATE], identified R41 had moderate cognitive impairment, required supervision or setup with grooming and eating and was independent with dressing, transfer, ambulation and toileting. R41 exhibited behaviors of rejection of care and wandering one to three days in the observation period. Diagnoses included insomnia, dementia, and anxiety. R41's care plan dated 6/4/26, identified R41 had an alteration in mood and behavior which included repetitive…

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 assess pain, and failed to offer or attempt non-pharmacological pain interventions (interventions other than medications), prior to the administration of as-needed (PRN) pain medications for 3 of 4 residents (R1, R2, R4) reviewed for pain. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated no cognitive deficits. R1 had pain that frequently affected sleep, the ability to participate in therapy, and activities of daily living (ADLs). R2 received scheduled pain medication, PRN pain medication, and non-medication interventions for pain.R1's alteration in comfort care plan dated 5/29/26, instructed to provide non-medicinal forms of pain relief such as positioning, rest, massage, pain medication as ordered by medical doctor, and to document on effectiveness of pain medication.A pain evaluation/assessment was requested for R1; however, none was provided. R1's provider order dated 5/21/26, instructed oxycodone-acetaminophen…

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 immediately provide resident protections and initiate an investigation for an allegation of unwanted inappropriate physical contact for 1 of 3 residents (R1) who reported R4 inappropriately touched him.Findings include:R1's face sheet dated 8/12/25, identified diagnoses of alcohol dependence and bipolar disorder.R1's progress note dated 7/31/25, identified social service designee (SSD)-A and director of nursing (DON) met with R1 to ask if he was having an intimate relationship with anyone. R1 stated no and then proceeded to explain that another resident sat on his lap and was kissing on him. R1 stated that he asked this resident not to do that again. R1 stated that she stopped after that. This note was written by SSD-A.R1's care plan dated 11/19/24, identified R1 was at risk for decreased cognitive and physical abilities related to bipolar. R1 would remain free from abuse and neglect at the facility. Interventions included: monitor for signs of emotional distress or mood and behavior changes, safety monitoring…

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 staff failed to report an allegation of sexual abuse to the administrator and to the State Agency (SA) within the two (2) hours for 1 of 1 (R4) resident reviewed who had allegations of sexual abuse. Findings include:Review of facility reported incident #360920, dated 6/25/25 at 1:45 p.m., indicated on 6/23/25 at 7:12 a.m. R4 reported to licensed practical nurse (LPN)-D a man put his fingers in her vagina and as also touching her daughter. R3's admission Minimum Data Set, dated [DATE], indicated R3 did not have impaired cognition and had diagnoses of stroke and metabolic encephalopathy. R3 had periods of inattention but no behaviors. Required partial assist with self-care and hygiene and was independent with mobility and transfers.During an interview on 6/27/25 at 9:40 a.m., LPN-D stated R4 informed her of the allegation of sexual abuse around 7:30 a.m., on 6/23/25 that some man was touching her and putting their fingers into R4's vagina. LPN-D attempted to get…

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 revise skin integrity care plan for 1 of 3 residents (R2) reviewed for pressure ulcers who had refusal of pressure relieving interventions. R2's face sheet dated 6/26/25, identified the following diagnoses, diabetes, heart failure, presence of prosthetic heart valve, chronic right heel wound, and status post open reduction internal fixation of right hip following a fall.R2's quarterly Minimum Data Set, dated [DATE], indicated intact cognition. R2 had limitations to one side of his lower extremities and used a walker and wheelchair. R2 required maximal assist for person and toilet hygiene, shower and bathing, and transfers. R4 did not walk due to medical condition. R2 had diabetic foot ulcer(s) and surgical wound(s) and received surgical wound cares and application of dressings to feet.R2's wound care order dated 5/29/25, indicated right heel ulcer, R2 to wear suspension boots when in bed.R2's wound care order dated 6/13/25, indicated to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to comprehensively assess, monitor, and implement pressure relieving interventions to prevent and/or reduce the risk of re-current pressure ulcers, new pressure ulcers, and/or deterioration for 1 of 3 residents (R3) reviewed for pressure ulcers. Deep-Tissue Injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue.Unstageable pressure ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.R3's quarterly Minimum Data Set, dated [DATE], indicated severe impaired cognition, with diagnoses of Alzheimer's left femur fracture and schizophrenia. R3 was noted to be inattentive and have disorganized thinking that comes and goes and continuous altered level of consciousness. R3 was incontinent 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 and document review the facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service since 3/26/24, which had the potential to affect all 65 residents who resided in the facility. During interview on 4/9/25 at 11:30 a.m., the registered dietician (RD) stated she worked full time, overseeing 5 buildings but only worked 8 hours a week at this facility. During interview on 4/9/25 at 11:45 a.m., the Culinary Director (CD) stated he had been working for the facility for almost a year and had been asked about starting training for his Certified Dietary Manager's certificate (CDM) but he wanted to wait a little bit and wasn't ready to start the training yet. During interview on 4/10/25 at 12:44 p.m. the administrator stated he expected the Culinary Director to either have their CDM upon hire or within the first 3 months. He further verified the CD's date of hire was 3/26/24 and he'd been working at the facility for almost over a year.

Based on observation, interview, and document review the facility failed to ensure dietary staff was wearing beard guards when preparing food This had the potential to affect all 65 residents who reside at the facility and consume food from the kitchen. During observation on 10/7/25 at 11:49 a.m. the Culinary Director (CD) was in the kitchen cutting up fruit. He had a beard but was not wearing a beard guard/restraint. During interview on 4/9/25 at 10:41 a.m., the CD verified he was not wearing a beard guard/restraint while prepping food stating it was hard to determine if the facility wanted staff to wear them or not. The CD further stated the facility did not have any beard guards for staff to wear, but he could get some if needed. During interview on 4/10/25 at 12:44 p.m., the administrator stated dietary staff (who had beards) were expected to be wearing beard guards/restraints when preparing food and this was important for infection control purposes. A policy regarding infection control in the kitchen was requested but not received.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident and resident guardian's participation in the development and review of care plans 1 of 1 residents, (R8) reviewed who voiced concerns about care conference participation. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], identified she could make herself understood, was independent with eating, required supervision with transfers and bed mobility. R8's interview for preferences identified it was very important to choose what clothing to wear and take care of personal belongings. Diagnoses included heart failure, diabetes and dementia. R8's MHM BIMS (Brief Interview of Mental Status) Staff assessment dated [DATE], identified five- minute and long past memory recall was ok and R8 was able to recall the current season, her own room, staff name and faces and that she was in a nursing home. R8 had modified independence with daily decision making. R8's discharge care plan dated 2/19/25, identified resident and family would…

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 timely provide the required liability and appeal rights notices prior to discharge from Medicare Part A services for 1 of 3 residents (R170) reviewed for beneficiary notices. Findings include: R170's last day of covered Medicare Part A Skilled Services was 1/22/25, as identified on the form CMS-20052 (SNF [skilled nursing facility] Beneficiary Protection Notification Review). R170's Notice of Medicare Non-Coverage (NOMNC, form CMS-10123) was signed by the resident on 1/30/25. R170's Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN, form CMS-10055) was signed by the resident on 1/30/25, and lacked indication of which option (regarding the appeal process) he had chosen. During interview on 4/10/25 at 3:30 p.m., the administrator stated the expectation was to have the residents sign the CMS-10123 and CMS-10055 at least 2 days before the last day of covered Medicare part A Skilled Services and ensure an option regarding the appeal process was indicated. A facility policy regarding BNP notices dated 2/20/23,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure personal privacy was maintained for 1 of 2 residents (R29) who required staff assistance with personal cares. Findings include: R29's admission Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition and was dependent on staff assistance for toileting hygiene and required partial to moderate assistance with personal hygiene cares. The MDS reported he was frequently incontinent of urine and bowel. The MDS listed his diagnoses as hemiparesis (one-sided weakness) or hemiplegia (one-sided paralysis), chronic lung disease, and chronic obstructive pulmonary disease (COPD, a chronic restrictive lung and breathing condition). R29's Care Area Assessment (CAA) for functional abilities dated 2/12/25, reported he received limited assistance with rolling left and right in bed, and extensive assist with bathing, upper body dressing. The CAA further identified his dependence on staff for toileting hygiene. R29'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 document review, the facility failed to review and revise the care plan with input from the resident to meet a resident's vision needs for 1 of 1 residents reviewed for reassessment of the care plan. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had moderately impaired cognition, did not reject cares, and was usually able to make himself understood and usually able to understand others. The MDS indicated his vision was adequate and he did not wear corrective lenses. The MDS identified diagnoses including aphasia (a condition in which language function is disordered), and cataracts (a progressive disorder of the lens of the eye characterized by a loss of transparency with a white/yellow/brown tinge to the lens). R21's Care Area Assessment (CAA) for visual function dated 6/19/24, was triggered due to his cataracts and indicated he had the potential for impaired visual function related to his diagnosis of bilateral (left and right)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure residents were provided incontinence care in a timely manner for 1 of 1 resident (R9) reviewed for activities of daily living (ADL). Findings include: R9's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD), chronic atrial fibrillation (A-fib), and pancreatitis. It further indicated R9 was dependent on staff for toileting and was frequently incontinent of bowel and bladder. R9's care plan dated [DATE], indicated alteration in elimination d/t limited mobility secondary to COPD and alcohol dependence with the following interventions: -Assist of 2 with toileting. -Provide assistance with peri-cares morning (AM), hour of sleep (HS) and as needed (PRN). -Provide incontinent products and assist to change PRN During observation on [DATE] at 3:22 p.m., R9 was sitting in his wheelchair by the door to his room, waiting to go in. He asked nursing assistant…

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 follow up on 1 of 1 residents (R55) Urology referral. Finding include: R55's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of paraplegia and neuromuscular disfunction of the bladder. It further indicated R55 required substantial assistance with bed mobility, was dependent on staff for transfers, had a catheter, and was always incontinent of bowel. R55's care plan dated 3/25/25, indicated alteration in elimination related to diagnoses of motor vehicle crash, neurogenic bladder, convulsions, etc. Resident admitted with foley catheter 20 French (F) 30 cubic centimeters (cc) for neurogenic bladder and assist of 1 with toileting. It further indicated the following interventions: -Prefers to notify staff when incontinent to have brief changed -Monitor foley catheter output every shift. -Change foley catheter monthly per order. -Foley catheter care per policy. -Monitor BM's as they occur. -Administer bowel…

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-up on consults for vision-related appointments for 1 of 3 residents (R21) and failed to provide assistive devices to maintain hearing for 1 of 3 residents (R29) reviewed for communication. Findings include: R21 Glasses and Cataracts Consults R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had moderately impaired cognition, did not reject cares, and was usually able to make himself understood and usually able to understand others. The MDS indicated his vision was adequate and he did not wear corrective lenses. The MDS identified diagnoses including aphasia (a condition in which language function is disordered), one-side weakness or one-sided paralysis (hemiparesis or hemiplegia, respectively), anxiety, and cataracts (a progressive disorder of the lens of the eye characterized by a loss of transparency with a white/yellow/brown tinge to the lens). R21's Care Area Assessment (CAA) for visual function dated 6/19/24,…

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 podiatry services were obtained or 1 of 1 resident (R8) reviewed for foot care. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], identified she could make herself understood, was independent with eating, required supervision with transfers and bed mobility. R8's interview for preferences identified it was very important to choose what clothing to wear and take care of personal belongings. Diagnoses included heart failure, diabetes and dementia. R8's MHM BIMS Staff Assessment (staff assessment of cognition) dated 2/18/25, identified memory recall was ok after five minutes and R8 seemed to recall long past. R8 was able to recall the current season, location of own room, staff name and faces and that they were in a nursing home. R8 required modified independence regarding tasks of daily life. R8's care plan dated 2/19/24, identified she had a self care deficit related to neuropathy and type two diabetes mellitus.…

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 fall prevention interventions were implemented consistently according to the comprehensive care plan for 1 of 1 residents (47) reviewed for falls. Findings include: R47's quarterly Minimum Data Set (MDS) dated [DATE], indicated he was sometimes able to make himself understood and was able to understand others with clear comprehension. The MDS reported he had severe impairment in his cognitive skills for daily decision making and required substantial to maximal staff assistance with bed mobility but was dependent on staff for transfers. The MDS identified his diagnoses including hemiplegia (one-sided weakness) or hemiparesis (one-sided paralysis), stroke, seizure disorder, and malnutrition. R21's Care Area Assessment for falls dated 6/28/24, was triggered due to his fall history and indicated the care plan was ongoing as he was observed for changes in his mobility. A quarterly fall review evaluation dated 9/20/24, indicated 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 interview and document review the facility failed to ensure an antipsychotic medication had an appropriate indication for use for 1 of 5 residents (R6) reviewed for unnecessary medications. Findings include: R6's annual Minimum Data Set (MDS) dated [DATE], identified no behaviors or rejection of care. Medications taken included antipsychotic, antidepressant and anticonvulsant. Diagnoses included dementia, depression and anxiety. R6 had intact cognition. R6's Order Summary Report dated 4/10/25, identified the following antipsychotic medications currently in use: 1. Quetiapine fumarate 25 milligrams (mg) by mouth two times a day for dx (diagnosis) depression. 2. Quetiapine fumarate 50 mg by mouth at bedtime related to anxiety disorder. R6's Pharmacist's Recommendation to Prescriber form dated 2/3/25, recommended the prescriber address the diagnosis for quetiapine fumarate and update order to an approved CMS indication, or consider a GDR (gradual dosage reduction) or taper plan. R6's prescriber visit note…

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 proper personal protective equipment (PPE) was utilized for 1 of 2 residents (R14) reviewed for enhanced barrier precautions (EBP). Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified no behaviors or rejection of care. Dependent on staff for eating, hygiene, toileting hygiene, bathing and dressing. Diagnoses included dementia, seizure disorder, and contractures of right and left hand. R14's care plan dated 4/7/25 identified resident is currently on EBP R/T (related to) wound on coccyx. Resident will remain free from infection. Staff to follow EBP. R14's wound care progress note dated 4/3/25, identified resident was seen for new area of sacrum MASD (moisture associated skin damage). The wound measured 2.9 centimeters (cm) long, 2.2 cm wide, 0.1 cm deep with scant serosanguinous exudate (wound drainage with serous fluid and blood). During an observation and interview on 4/07/25 at 11:59 a.m., R14's name…

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 personal refrigerator was monitored and kept sanitary in a resident's (R47) shared room. Findings include: R47's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had severe impairment in his cognitive skills for daily decision making and required substantial to maximal staff assistance with bed mobility but was dependent on staff for transfers. The MDS identified his diagnoses including hemiplegia (one-sided weakness) or hemiparesis (one-sided paralysis), stroke, seizure disorder, and malnutrition. Per observation on 4/7/25 at 12:50 p.m., of R47's room, there was a black mini refrigerator on a nightstand on his side of the privacy curtain. There was a Record of Refrigerator Temperatures sign posted on the door of the mini refrigerator dated July 2024 and there were temperatures documented for the dates of 7/1/24 - 7/23/24. The other entries were blank. There was a second Record of Refrigerator Temperatures taped…

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 In addition, a resident (R1) was observed to have flies in his room and there were flies flying around throughout the facility. R1's admission Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, disorganized thinking, hallucinations, delusions, and a diagnosis of schizoaffective disorder. It further indicated, R1 required substantial assistance from staff with most activities of daily living (ADL) and mobility. During observation on 7/22/24 at 10:20 a.m., R1 was sitting in his room in his wheelchair. The light on the wall next to his closet had approximately 20-30 small flies on it and there were several flying around the room. During observation and interview on 7/22/24 at 10:25 a.m., licensed practical nurse (LPN)-A verified there were flies on the light in R1's room stating they are (the facility) working with an exterminator. During interview on 7/22/24 at 2:28 p.m., family member (FM)-A stated he visited R1 approximately every other day and the only issue he had with the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to revise and update a care plan to ensure it was individualized and comprehensive after a resident was admitted on to a locked behavioral unit for 1 of 1 resident (R1) reviewed for transfer from non-secure to secure unit. Findings include: R1's Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted on [DATE] with diagnoses including non-Alzheimer's dementia, unspecified symptoms and signs with cognitive functions and awareness (an unspecified neurocognitive disorder), hoarding disorder, and other symptoms and sings involving appearance and behavior. R1 was cognitively intact. R1 was ambulatory and required assistance with bathing/showering and toileting hygiene but was otherwise independent with activities of daily living. R1's provider note dated 2/16/24, noted R1 had a history of agitation and behavioral issues and at a previous assisted living facility R1 became combative, police were called and patient was transferred to hospital. R1's care…

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 Assessment and Assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in implementing appropriate action plans to correct quality deficiencies identified in previous surveys related to environmental concerns and medication errors which resulted in deficiencies identified during this survey. This deficient practice had the potential to affect all 65 residents residing in the facility. Findings include: During an interview on 2/7/23 at 1:02 p.m., administrator-A and administrator-B reviewed findings from previous survey and compared them to findings from current survey, which included ongoing citations for medication errors and environmental concerns: 1. 2/7/24, medication errors and environmental concerns cited 2. 5/11/23, medication errors and environmental concerns cited 3. 10/14/21, environmental concerns cited 4. 8/29/19, medication errors and environmental concerns cited 5. 7/12/18, medication errors and environmental concerns cited. Administrator-B stated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 4 of 5 residents (R7, R19, R45, and R114) whose vaccinations histories were reviewed. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. One graph identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. An additional graph labeled, Adults 19-[AGE] years old with chronic health conditions ., listed multiple columns to reference with which vaccine(s) had already been given and, from that, which were now recommended. 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 During observation and interview, the facility failed to ensure handrails on the second floor were securely attached to the wall and in good repair. This had the potential to affect resident R40 and all residents, staff, and visitors who had access to the handrails. Findings include: R40's quarterly Minimum Data Set, dated [DATE], indicated they were moderately cognitively impaired, had a diagnosis of dementia, and walked independently. R40's care plan dated 12/14/21, included they had a potential for falls related to unsteady balance and pacing in the hallways. During observation on 2/6/24 at 8:57 a.m., R40 was repeatedly walking down on one side of the hallway and back on the other while dragging their right hand along the top of each handrail as they walked. During observation on 2/6/24 at 9:15 a.m., the handrail in the hallway between rooms [ROOM NUMBERS] was affixed to the wall by two brackets, each approximately one foot from each end. The right bracket was loose, allowing the rail to move up and down at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to allow active residents and resident representatives participation in the development and review of care plan for 2 of 2 residents (R19 and R113) reviewed for care conferences. Findings include: R19's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of schizoaffective disorder, adult failure to thrive, and chronic pain. R19's care plan dated 10/21/22, indicated R19 plans to remain in the facility for long term care. The resident and family will be invited to care conferences quarterly or as needed and discharge planning options will be discussed as needed. R19's care conference form indicated her last quarterly care conference was on 3/29/23. R19's progress note dated 11/14/23, indicated a care conference was scheduled for 11/27 at 2:00 p.m., however lacked documentation a care conference actually took place. During interview on 2/04/24 at 7:15 p.m., R19 stated she'd been living at the facility for a year and 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 ensure a self-administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 1 of 1 resident (R7) observed with medications at bedside. Findings included: R7's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition with behaviors of inattention, disorganized thinking, delusions, and hallucinations. It further indicated diagnoses of schizoaffective disorder, dementia, and psychosis. R7 was dependent on staff for activities of daily living (ADL) and mobility. R7's physicians orders dated 12/11/23, indicated Ipratropium-Albuterol Inhalation Solution 0.5-2.5 3 milligrams (mg) per milliliters (ml) (Ipratropium-Albuterol), 3 ml inhale orally three times a day for shortness of breath. R7's physician's orders lacked an order to SAM. R7's medical record lacked an assessment to SAM. R7's progress note dated 2/4/2024, indicated the resident was found with…

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 nail care for 1 of 2 residents (R15) reviewed for activities of daily living (ADL). Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition with diagnoses of paranoid schizophrenia, neuroleptic induced parkinsonism, and type II diabetes. It further indicated R15 was independent with activities of daily living (ADL). R15's care plan dated 9/9/23, indicated R15 had the potential for self-care deficit related to dementia and cognitive impairment. R15 was able to complete his own cares however, refused to do so. The care plan further indicated an intervention to provide nail care as needed (PRN). During observation and interview on 2/4/24 at 12:16 p.m., R15 was laying in bed, his fingernails were approximately a half an inch long on both hands and the thumb nail on his left hand was broken and jagged. R15 stated he would like his nails to be cut and showed the surveyor his left thumb. 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 observation, interview, and document review, the facility failed to ensure timely assistance with repositioning for 1 of 1 resident (R4) who was at risk for skin breakdown. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 was rarely/never understood, rejected cares one to three days during look-back period, and had impairments to all extremities. R4 was dependent on staff for dressing, mobility, and toileting and personal hygiene. R7 had diagnoses of anxiety, depression, schizophrenia, post traumatic stress disorder, and diabetes mellitus. R4's significant change Care Area Assessment (CAA) dated 9/20/23, triggered pressure ulcer/injury related to R4 requiring extensive assistance with bed mobility and indicated R4 was always incontinent of bladder and bowel and at risk for developing pressure ulcers. R4's care plan for pressure ulcer/injury directed staff to turn and reposition R4 every two to three hours and as needed with start date of 5/1/23. During observation 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 ensure a residents knee brace was applied per doctor's orders for 1 of 1 resident (R6) reviewed for mobility and range of motion. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 had severe cognitive impairment and diagnoses of cerbrovascular disease, dementia, and hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side. It further indicated R6 was dependent on staff for mobility. R6's physician's orders dated 3/1/23 indicated R6 was to wear a left knee brace continuously for 8-10 hours daily and to monitor the skin under the brace before and after removal, twice a day for contracture. On at 1400 (2:00 p.m.) and off 2200 (10:00 p.m.). R6's care plan dated 10/26/22 indicated R6 had an alteration in mobility related to diagnoses of cerebral infarction, cerebral vascular accident (CVA), hemiplegia, chronic pain syndrome, and headaches. R6 needs extensive assist with bed…

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 catheter drainage bags were maintained in accordance with professional standards of practice for 1 of 1 resident (R25) reviewed for catheters. The Center for Disease Control (CDC) Catheter-Associated Urinary Tract Infections (CAUTI) guideline dated 11/5/2015, identified after aseptic insertion of the urinary catheter, a closed drainage system should be maintained. If the aseptic technique was broken, disconnected, or if leakage occurred, the catheter and collecting system should be replaced with aseptic technique and sterile equipment used R25's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of obstructive uropathy. R38 had an indwelling catheter and required supervision with one person assist for toileting. R25's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 11/6/23, identified an indwelling catheter was in place for diagnosis of urinary…

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 rationale was documented for the extended order of an as needed (PRN) psychotropic medication beyond 14 days for 1 of 2 residents (R25) reviewed who had PRN psychotropic medications ordered. Findings include: R25's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition, no behaviors or rejection of care and diagnoses which included anxiety and bipolar disorder. R25 took antianxiety medications, antidepressant and antipsychotic. R25's Care Area Assessment (CAA) dated 11/6/23, identified a trigger for psychotropic drug use related to use of psychotropic medications. Side effect monitoring was in place for these medications. R25's care plan dated 9/24/20, identified a potential for psychotropic drug adverse drug reactions (ADRs) related to daily use of psychotropic medication. Administer medication as ordered monitoring for ADRs. R25's orders dated 11/26/23 with no end date, identified lorazepam (psychotropic…

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 they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 8% with 2 errors out of 25 opportunities involving 2 of 7 residents (R115 and R12) who were observed during medication administration. Findings include: R115's order summary report printed 2/7/24, included diagnoses of hypokalemia (low potassium) and iron deficiency anemia (too few healthy red blood cells due to low iron in the blood). R115's medication administration summary (MAR) for February 2024, identified the following orders: -start date 1/23/24, potassium chloride oral tablet extended release give 20 milliequivalent (mEq) by mouth two time a day related to hypokalemia. - start date 1/24/24, ferrous sulfate (iron supplement) 325 milligram (mg) tablet give one tablet by mouth in the afternoon with a meal related to iron deficiency anemia. During an observation and interview on 2/5/24, at 12:10 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 observation and interview the facility failed to ensure call lights were accessible to residents for 2 of 2 residents (R15, R190) Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 had intact cognition and diagnoses of paranoid schizophrenia, neuroleptic induced parkinsonism (Parkinsonism caused by antipsychotic medication), and type II diabetes. It further indicated R15 was independent with activities of daily living (ADL) and mobility. R15's care plan dated 9/9/23, indicated R15 had the potential for self-care deficit related to dementia and cognitive impairment with an intervention of putting the call light within reach. R15's care plan further indicated a revision made on 2/4/24 (survey entrance date) indicating R15 prefers to have the call light over light and hanging. During observation on 2/04/24 at 12:16 p.m., R15 was laying in bed and the call light was hanging across the overhead light. R15 was able to access the call light while in bed but would not be able…

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 failed to follow the comprehensive care plan for supervision for 1 of 1 resident (R2) reviewed for accidents. Findings include: R2's Face Sheet identified R3 had the following diagnoses: Dementia and symptoms and signs involving cognitive functions and awareness. R2's significant change Minimum Data Set (MDS) dated [DATE] identified R2 was dependent on staff for all transfers including the ability to go from sit to standing position. R2's care plan dated 7/22/22 identified R2 was at risk for elopement due to cognitive impairment and staff were to allow R2 to crawl with supervision due to inability to redirect and risk of falls. R2's care plan dated 9/28/23 identified R2 was at risk of self-care deficits due to cognitive deficits and staff were to keep R2's bedroom door open, the wheelchair removed from the room when R2 was crawling on the floor, trash can emptied immediately after use and ensure surroundings are clear. During observation…

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 skin for 1 of 1 resident (R4) who had injury of unknown source, additionally failed to notify physician in a timely manner. Findings include: R4's Face Sheet identified R10 had a diagnoses which included schizophrenia and seizures R4's care plan dated 11/6/23 identified R4 was at risk for skin alteration. The care plan directed staff to monitor R4's skin integrity during cares, weekly skin inspections by the nurse, and provide treatment to open areas per order. R4's admission Minimum Data Set (MDS) dated [DATE] does not identify skin tears or other open lesions. R4's order dated 11/20/23 identified for staff to monitor scab to right inner thigh for signs/symptoms of infection until healed. Update nurse practitioner as needed. R4's Skin assessment dated [DATE], identified redness to R4's bottom and feeding tube site. No open areas noted. During interview on 11/16/23 at 1:22 p.m. family member (FM)-A expressed…

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, document review the facility failed to follow the care plan for pressure reducing/relieving interventions to prevent or mitigate the risk of deterioration or prevention of new pressure ulcer development for 1 of 1 residents (R4) who had impaired skin integrity and was at high risk for pressure ulcers. Findings include: R4's Face Sheet identified R4 had the following diagnoses: Aphasia following a cerebral infarction. R4's admission assessment Minimum Data Set (MDS) dated [DATE] identified R4 was at risk of pressure ulcers, had no unhealed pressure ulcers, and had moisture related skin damage (MASD). Skin and ulcer treatments included application of non-surgical dressings and application of ointments or medications. R4's care plan dated 11/6/23, identified R4 was at risk of alteration in skin integrity due to diagnosis. R4 admitted with MASD on coccyx , preferred to lay on back and frequently refused turning and repositioning. Removes heel protectors if attempting to apply. Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure safe transfers for 1 of 1 residents (R2) who had to be lowered to the floor by staff because wheelchair breaks were not locked prior to the transfer. Findings include: R2's Face Sheet identified R3 had the following diagnoses: dementia and symptoms and signs involving cognitive functions and awareness. R2's significant change Minimum Data Set (MDS) dated [DATE] identified R2 was dependent on staff for all transfers including the ability to go from sit to standing position. R2's care plan dated 6/9/22 identified R2 had a potential for falls due to unsteady balance and daily use of antidepressant medication. R2 will intermittently sit or kneel on the floor unassisted and will attempt to stand up independently at times. R2 is restless and often attempts to get out of wheelchair and crawl on the floor. R2 becomes agitated and resistive when redirected not to crawl on the floor. Staff were to place R2 by the nursing station for close…

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 a functional, clean and sanitary environment in 23 of resident 66 rooms (105, 106, 108, 109, 110, 114, 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, and 216) and common areas including second floor dining area, shower room (room [ROOM NUMBER]) and hallways reviewed for environment. In addition, the facility failed to provide sanitary environment in the food storage area causing pest infestation with the potential to affect all residents in the facility. On 8/17/23 at 1:00 p.m., a full facility walk through was completed with the director of maintenance (DM)-A. The following was identified: First Floor: room [ROOM NUMBER]: Plastic over windows (polyethylene film used for winter to keep the warmth in) room [ROOM NUMBER]: Bathroom light did not work room [ROOM NUMBER]: Floor lamp without lampshade room [ROOM NUMBER]: Bucket next to bed with contents of food that required refrigeration room [ROOM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement an effective pest control program to eliminate mice and insects in the building. This had the potential to affect all 66 residents who resided in the facility. On 8/17/23 at 12:20 p.m., the director of maintenance (DM)-A stated he was aware the facility had a fly and gnat problem. DM-A stated they have been on top of the situation and installed fly machines (light boxes) to attract the bugs, and did have their pest control service involved as well. DM-A stated he was also aware their were mice in the facility. DM-A stated the pest control service was at the facility on 8/16/23, and did not find any concerns. On 8/17/23 at 1:00 p.m. and 8/18/23 at 7:42 a.m., the kitchen door leading to the outside was noted to be propped open. The door did not have a screen on it. On 8/17/23 at 6:00 p.m., cook (C)- B stated the kitchen doors were only propped open when staff took out the trash, received deliveries or went outside for a break.…

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 a dignified living experience for 1 of 6 resident (R3) reviewed for dignity. R3's Face Sheet identified R3 had the following diagnoses: vascular dementia, hallucinations, borderline personality disorder dementia, unspecified symptoms and signs involving cognitive function and awareness. R3's quarterly Minimum Data Set (MDS) dated [DATE] indicated R3 had severely impaired cognition. R3's care plan dated 9/29/22, indicated R3 had an altercation in skin integrity due to crawling on the floor, hitting hard on the floor with knees, and slapping/hitting face, chest when agitated. R3 had a history of bruising face around her eyes, and bursa to her knees due to crawling. R3 also had pressure ulcers to both knees due to frequent crawling on the floor. Interventions in place were to monitor skin integrity with weekly skin inspections, apply elbow, knee pad, and hand gloves as ordered. Monitor for skin breakdown for signs/symptoms 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 ensure functioning call lights, bedroom lights and bathroom lights or an acceptable alternative was provided or implemented to promote safety and allow for 2 of 3 residents (R5, R4) observed to not have a functional bathroom light. Findings include: R5's Face Sheet indicated R5's diagnoses included repeated falls. R5's admission Minimum Data Set (MDS) dated [DATE] indicated R5 was cognitively intact, and required assistance of one staff for toilet use. On 8/17/23 at 12:32 p.m., R5 stated she had concerns for her safety. R5 stated the bathroom light had not worked for five days. R5 stated she notified staff on 8/12/23 and it had yet to be fixed. R5 stated she was afraid she was going to fall attempting to use the bathroom due to not having a light. R5 stated she was at the facility for rehabilitation and she was a high fall risk. R5 stated the facility had provided her a commode in her room, but she would rather use the actual bathroom…

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.