Wabasso Restorative Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to investigate a potential crime involving illegal drugs involving 1 of 1 resident (R41). Findings include: Interview on 1/11/26 at 1:00 p.m. with the administrator identified on 1/4/26, there was a concern with alcohol and illegal drugs brought into the facility by R41. Law enforcement were involved. Police were referring the case to the county attorney for review of charges. R41 was not arrested at the time of the incident. R41 has since been discharged and would not be returning to the facility. Review of the 1/4/26 at 1:06 p.m., Redwood County Sheriff's Office Incident Report identified officers arrived at the facility at 1:19 p.m., to investigate the report of a resident possibly under the influence. During interview, R41 admitted to having possession of the crystal-like substance, which was field tested and tested presumptive positive by the sheriff's office as methamphetamine. R41 reported the substance had been given to him by another resident,…

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 notify the responsible party of a hospital transfer for 1 of 4 sampled residents (R7) reviewed for hospitalizations. Findings include: R7's 12/19/25, quarterly accepted Minimum Data Set (MDS) assessment identified she had moderate cognitive impairment. She required moderate staff assistance with activities of daily living (ADLS), impairment on one side upper extremity, uses a wheelchair for mobility, and required extensive staff assistance for toileting, dressing and grooming. R7 received both scheduled and as needed (PRN) pain medication for frequent pain which interfered with her day-to-day activities and was described as severe. She had diagnoses of generalized weakness, psychoactive substance abuse, acute respiratory failure with hypoxia, adult failure to thrive, bipolar and anxiety disorder, and Buerger's disease (inflammatory condition that affects circulation and clotting in small to medium blood vessels of the extremities). R7's 10/31/25, accepted end of stay with return anticipated MDS assessment identified R7…

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 revise 1 of 12 sampled resident's (R4) care plan for behaviors.Findings include: R4's 10/31/25, accepted comprehensive Minimum Data Set (MDS) assessment identified R4's cognition was intact but had verbal behavioral symptoms directed towards others 1 to 3 days during the assessment period. R4 required substantial assistance from staff for cares and transfers. He took pain medication as needed and reported he had occasional moderate pain. R4 was noted to have had 2 or more falls with minor injury. He took an antipsychotic, antidepressant, antibiotic, and anticonvulsant during the assessment period. R4 had been seen by speech therapy and occupational therapy. R4's goal was to return to the community. R4's 1/14/26, Diagnosis Report identified diagnoses of paranoid schizophrenia, spinal stenosis (narrowing of the spine), cognitive communication deficit, dysphagia (difficulty swallowing), abnormal posture, borderline personality disorder, cannabis dependence, difficulty walking, high blood pressure, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to protect 1 of 1 resident (R1) from resident-to-resident physical abuse. Findings include: A Vulnerable Adult Maltreatment report submitted to the State Agency (SA) on 8/21/25 at 9:35 p.m., identified alleged physical abuse when it was reported that at approximately 8:00 a.m. that morning, R2 had pulled R1's hair, struck her in the back of the head, and pushed her wheelchair. R2 admitted that he had pulled R1's hair during a verbal altercation outside in the smoking area however, denied hitting or pushing R1. A Facility Reported Incident (FRI) submitted to the SA on 8/22/25 at 11:35 a.m., alleged abuse when R2 tugged R1's hair and hit her head while outside. The alleged abuse occurred on 8/21/25 at approximately 10:00 a.m.During an interview with R1 on 9/2/25 at 5:55 p.m., R1 indicated on 8/21/25 at approximately 8:00 a.m., R2 hit her in the back of the head, pulled her hair, and pushed her wheelchair into the fence in the smoking area.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report an allegation of abuse timely to the State Agency (SA) for 1 of 1 resident (R1) reviewed for allegations of abuse.Findings include: A Facility Reported Incident (FRI) submitted to the State Agency (SA) on 8/22/25 at 11:35 a.m., alleged abuse when R2 tugged R1's hair and hit her head while outside. The alleged abuse occurred on 8/21/25 at approximately 10:00 a.m. (Approximately 25 1/2 hours prior to reporting to the SA). R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and no behaviors. Identified R1 used a wheelchair for mobility and required substantial staff assist with dressing, transferring, bed mobility, and personal hygiene. A follow up brief interview for mental status on 8/22/25, indicated R1 had moderately impaired cognition. R1's Care Plan Report identified R1 had a potential for abuse due to current health condition that required assistance with activities of daily living (ADL)'s and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure residents were informed of medication changes for 1 of 3 residents (R1) reviewed for pharmacy services.Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had diagnoses including fracture of shaft of left femur (broken thigh bone), anxiety disorder, and opioid dependence. R1 received scheduled and as needed (PRN) pain medication and took opioid medication. R1 had intact cognition, understood others, and made herself understood.R1's physician order dated 6/12/25, was for oxycodone hydrochloride (HCl) (an opioid medication used to treat moderate to severe pain) oral tablet 5 milligrams (mg) with direction to give 5 mg by mouth every eight hours as needed for pain related to fracture of shaft of left femur. The order was discontinued on 6/24/25.R1's medication administration record (MAR) dated 6/1/25 through 6/30/25, identified the 5 mg PRN oxycodone order was last administered on 6/24/25 at 7:13 a.m.R1'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 Based on interview and document review, the facility failed to notify the resident's physician of multiple missed administrations of an opioid pain medication for 1 of 3 residents (R1) reviewed for pharmacy services.Findings include:R1's facesheet dated 7/24/25, indicated she had diagnoses including fracture of shaft of left femur (broken thigh bone), opioid dependence, neuralgia (pain caused by nerve damage or irritation) and neuritis (nerve inflammation), osteoarthritis of left knee, and fibromyalgia (chronic condition causing wide-spread pain throughout the body). R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 received scheduled and as needed (PRN) pain medication, took opioid medication, and had intact cognition. R1's physician order dated 1/14/25, was for methadone hydrochloride (HCl) (an opioid pain medication used to treat severe pain) oral tablet 5 milligrams (mg). It directed, give 0.5 tablet (2.5 mg) by mouth two times a day for pain.R1's medication administration record…

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 grievances were provided with a written response for 2 of 4 residents (R1, R3) reviewed for grievances. Findings include:R1's face sheet dated 6/24/25, identified diagnoses of depression (a mood disorder that causes persistent sadness) and anxiety (an emotion that causes feelings of fear, dread, and unease).R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and had no behaviors.During an interview on 7/23/25 at 11:23 a.m., R1 stated the week prior she had completed two different grievance forms about concerns with two staff members. One of the grievances was regarding a staff member performing wound care on a resident in a public area and not performing proper hand hygiene. The second grievance was about a staff member with body odor and being on their personal cell phone for an extended period, while they were supposed to be working. R1had given one of the grievances to an unidentified 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 revise the care plan for wake-up and/or medication administration times for 1 of 4 residents (R4) who demonstrated new behaviors when her medications were not provided in accordance with her preferences. Findings include R4's face sheet dated 7/24/25, identified diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear) , borderline personality disorder (a mental disorder characterized by unstable moods and behaviors), and delusional disorder (a serious mental disorder where a person cannot tell what is real from what is imaginary).R4's annual Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and no behaviors. During an observation on 7/23/25 at 11:29 a.m., R4 was in the day room standing next to the medication cart talking in a loud voice to trained medication aide (TMA)-A, I want my medications, it is my right to get my medications that are prescribed. R4…

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 resident was appropriately assessed and monitored for potential effects of an opioid pain medication that was not administered as ordered for two and a half days for 1 of 3 residents (R1) reviewed for pharmacy services.Findings include: R1's facesheet dated 7/24/25, indicated she had diagnoses including fracture of shaft of left femur (broken thigh bone), opioid dependence, neuralgia (pain caused by nerve damage or irritation) and neuritis (nerve inflammation), generalized anxiety disorder, insomnia, other muscle spasm, osteoarthritis of left knee, and fibromyalgia (chronic condition causing wide-spread pain throughout the body). R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 received scheduled and as needed (PRN) pain medication, took opioid medication, and had intact cognition.R1's care plan focus dated 8/6/24, identified R1 had pain related to muscle spasms, left femur fracture, migraine, hammer toe,…

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 medications were available to be administered in accordance with physician orders and failed to identify and report a medication error for 1 of 3 (R1) residents reviewed for pharmacy services. Findings include:R1's facesheet dated 7/24/25, indicated she had diagnoses including fracture of shaft of left femur (broken thigh bone), opioid dependence, neuralgia (pain caused by nerve damage or irritation) and neuritis (nerve inflammation), generalized anxiety disorder, insomnia, other muscle spasm, osteoarthritis of left knee, and fibromyalgia (chronic condition causing wide-spread pain throughout the body). R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated . R1 received scheduled and as needed (PRN) pain medication, took opioid medication, and had intact cognition.R1's physician order dated 1/14/25, was for methadone hydrochloride (HCl) (an opioid medication used to severe pain) oral tablet 5 milligrams (mg). It directed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to report allegations of abuse timely to the State Agency for 1 of 1 resident (R1) reviewed for allegations of abuse and neglect. The allegations occurred on 3/27/25, 4/2/25, 4/27/25, 5/3/25, and 5/15/25. Findings include: A Vulnerable Adult Maltreatment Report submitted to the State Agency (SA) on 5/16/25 at 12:00 p.m., alleged abuse and neglect to R1 when R1 reported feeling unsafe at the facility due to R2 being sexually inappropriate, sexually harassing, and making unwanted sexual advances by writing letters and talking about sexual desires that he had with R1. Several of the female resident stated they did not feel safe in the facility because of R2's behaviors. Residents stated that the Director of Nursing Services told the residents that she will not be babysitting and that they are all adults and that this other resident [R2] has the right to Freedom of Speech. After [R1] reported her concerns to staff they moved [R2] closer to her room which…

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 thoroughly investigate and protect residents for an allegation of sexual abuse for 1 of 3 residents (R1) reviewed for abuse. Findings include: A Vulnerable Adult Maltreatment Report submitted to the State Agency (SA) on 5/16/25 at 12:00 p.m., alleged abuse and neglect to R1 when R1 reported feeling unsafe at the facility due to R2 being sexually inappropriate, sexually harassing, and making unwanted sexual advances by writing letters and talking about sexual desires that he had with R1. Several of the female resident stated they did not feel safe in the facility because of R2's behaviors. Residents stated that the Director of Nursing Services told the residents that she will not be babysitting and that they are all adults and that this other resident [R2] has the right to Freedom of Speech. After [R1] reported her concerns to staff they moved [R2] closer to her room which makes her even more uncomfortable. Several of the other resident's report that…

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 provide 1 of 2 residents (R2) with choices for discharge, right to an appeal process, ability to stay at facility during an appeal process, review and take into account substance use disorder and mental health diagnoses that would impair judgement on the decision to transfer, and allow the resident time to process the discharge prior to discharging. R2's face sheet dated 5/23/25, identified diagnoses of emotional lability (tendency to shift rapidly and dramatically between different emotional states), alcohol use, cognitive communication deficit (challenges with language comprehension, expression, reasoning, attention, memory, and organization), depression, anxiety disorder, and osteonecrosis (death of the bone due to lack of blood supply) to right and left femur. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R2 had moderately impaired cognition, no hallucinations or delusions, and had verbal behaviors directed towards…

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 record review, the facility failed to implement trauma-informed care for 2 of 3 residents (R1, R2) identified with a diagnosis of post-traumatic stress disorder (PTSD) reviewed for PTSD-related care. Findings include: R1's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had severe cognitive impairment, minimal depression, no behaviors, and no hallucinations or delusions. Diagnoses included Wernicke's encephalopathy (brain and memory disorder), insomnia, history of suicidal behavior, anxiety, depression, post-traumatic stress disorder (PTSD), and alcoholic hepatitis (inflammation of the liver). R1's admission Trauma Informed Care History dated 10/16/24 identified R1 was molested as a child. Triggers that make it worse were indicated as use to have a lot of them but overcame them with counseling. R1's care plan initiated on 10/16/24, identify a potential for ineffective coping related to PTSD and reported history of traumatic event(s) from her…

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 residents who were seen during routine physician visits every 30-60-90 days had physician documentation in the medical record for 1 of 1 (R1) resident, reviewed during the extended survey. Findings include: R1's significant change MDS dated [DATE]; indicated severe impaired cognition; diagnoses of anxiety, depression, post traumatic stress disorder (PTSD). Required supervision with walking greater than 150 feet and set up for shower/bathe. Took antidepressants. R1's medical record identified R1 had physician visits on 10/29/24, 11/18/24, 2/6/25, 3/18/25, and 4/23/25. R1's medical record lacked documentation of routine 60-90-day routine visits from 11/18/24 to 2/6/25. During an interview on 5/29/25 at 11:05 a.m., director of nursing (DON) stated the physician saw the resident and signed the physician orders but did not know why he did not write a note. DON verified with physician that he saw resident, knew he had to write a note but did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and document review, the facility failed to implement comprehensive assessment and person-centered planning to ensure residents individualized behavioral health needs were met for 2 of 2 residents (R1, R2) reviewed for behavioral health services. Findings include: R1's New admission Information dated 10/15/24, indicated R1 had diagnoses of Alcoholic encephalopathy, Post Traumatic Stress Disorder (PTSD), anxiety, and depression. R1's cognition was confused, and behaviors were confused but pleasant. The form also identified R1 was independent with activities of daily living (ADL'S). The facility was to provide occupational therapy (OT), speech therapy (ST), and substance abuse treatment. R1 was admitted with a commitment order (court ordered mandate to be involuntarily place in an institution for treatment or care). Additional information included R1 had poor cognition, very forgetful, needs reminders that R1 had completed tasks. R1's significant change Minimum Data Set (MDS)…

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 1 of 1 resident (R1) with a known history of substance use/abuse to identify signs and symptoms and potential affects from substance abuse, identify efforts to prevent substance use, and revise his care plan when R1 was found to be intoxicated from alcohol after having been on day-leave from the facility. Findings include: Review of the [DATE] at 5:17 p.m., report to the State Agency (SA), identified R1 was wheelchair bound when he had left the facility. R1 was discovered by law enforcement at the bar and was found to be intoxicated. R1 had left the bar and proceeded to make his way back to the facility in his wheelchair and was found 3 blocks away, from the nursing home, in the middle of the road. Law enforcement had assisted R1 to the nursing home when facility staff did not assist R1 back to the facility. R1's [DATE] at 7:42 p.m., progress note identified R1 had arrived at the facility intoxicated and was asleep. 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.

Based on observation, interview, and document review, the facility failed to provide information to 5 of 5 residents (R1, R9, R15, R26 and R42) who attended the resident council group meeting regarding the Ombudsman services as advocates for residents residing in the facility. This had the potential to affect all 42 residents residing in the facility. Findings include: During the resident group meeting held on 11/07/24 at 3:30 p.m., with state surveyor, Ombudsman and R1, R9, R15, R26 and R42 were in attendance. Upon asking, R1, R9, R15, R26 and R42 indicated they were not aware of where to find the telephone number to contact the Ombudsman if needed and had not seen postings on the wall of her contact information. Review of resident council minutes from 6/06/24 through 11/07/24, revealed no information regarding how to contact the Ombudsman was found in the minutes. Observations on 11/13/24 at 4:29 p.m., identified the Ombudsman information was found posted on the wall next to the resident's grievance poster located by the main entrance of the building. Interview on 11/13/24 at 4:34…

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.

R37 R37's admission Minimum Data Set (MDS) assessment identified his cognition was intact, he was independent with activities of daily living (ADLs) and received therapy services of Occupational (OT) and Speech (ST) therapies. R37 also had orders for physical therapy (PT) which he received until the end of August 2024, when the facility no longer had PT services available. R37 had diagnoses of metabolic encephalopathy, alcohol abuse, ADHD, degeneration of his nervous system due to alcohol, cognitive communication deficit, history of falling, weakness, and difficulty walking. R37's current, undated care plan identified he was dependent on staff for meeting emotional, intellectual, physical, and social needs due to his physical limitation. He had MD orders for PT/OT evaluation and treatment. Staff were to encourage R37 to participate in activities that promoted exercise, physical activity for strengthening and improved mobility. Interview on 11/12/24 at 10:05 a.m. with the ST reported the facility did not currently have PT available, and she thought it had ended at the end of August.…

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 binding arbitration agreement was fully explained in a manner that 16 of 32 residents (R1, R5, R9, R10, R15, R16, R18, R26, R30, R32, R33, R37, R40, R42, R148, and R246) and/or their representatives understood and had been explained their right to not sign the agreement. This had the potential to affect all 32 residents. Findings include: During the 11/12/24 entrance conference at 9:14 a.m., the social service designee (SSD) identified the arbitration agreement was not a pre-condition for admission and there had been no residents who had signed one. Review of Resident and Facility Arbitration Agreement identified it was not a condition of admission. The parties understood and agreed that this contract contained a binding arbitration provision which may be enforced by the parties, and that by entering into this arbitration agreement, the parties would be giving up and waiving their constitutional right to have any claim decided in a court 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 implement enhanced barrier precautions for 1 of 1 resident (R148) who had surgical wounds and a PICC line. Additionally, the facility failed to have appropriate infection control surveillance to monitor infections through to resolution for 3 of 3 months reviewed. This had the potential to affect all 32 residents. Findings include: R148 was a new admission within the last 6 days prior to the survey. R148's 11/9/24, care plan identified risk for transmitting an infection, enhanced barrier precautions per CDC guidelines. Interview on 11/12/24 at 10:08 a.m., with R148 identified he had surgical wound on both feet from amputation of bilateral toes, partial left heel removed, he reported he had major infection and they surgically removed that. He reported all the surgery was related to him getting frostbite last winter and he spent months in the hospital. He also was observed to have an orthopedic metal pin device in his left lower shin which…

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 policies to ensure there was no fear of retaliation for 2 of 2 residents (R37 and R40) in addition to some resident council members who also voiced fear of retaliation from facility staff. Findings include: R37 R37's admission Minimum Data Set (MDS) assessment identified his cognition was intact, he was independent with activities of daily living (ADLs) and was receiving therapy services of Occupational (OT) and Speech (ST) therapies. R3 also was receiving physical therapy (PT) until the end of August 2024, when the facility no longer had available PT services. R37 was admitted [DATE] following acute hospitalization for diagnoses including metabolic encephalopathy, alcohol abuse, ADHD, degeneration of nervous system due to alcohol, cognitive communication deficit, history of falling, weakness, difficulty walking, hepatic encephalopathy, hypotension, alcoholic hepatitis with ascites, hypomagnesemia, and high blood pressure. Interview 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.

R5's 10/27/24, quarterly Minimum Data Set (MDS) assessment identified he was cognitively intact with diagnoses of stroke, heart failure, renal insufficiency, diabetes, anxiety, and depression. R5's care plan identified he was a smoker. The goal was that he would not suffer injury from unsafe smoking practices through the review date. Staff were to notify the charge nurse immediately if it is suspected he had violated the facility smoking policy. R5 was able to smoke independently. Interview on 11/12/24 at 10:45 a.m., with R5 identified he was a smoker and kept his cigarettes in a unlocked drawer in his room. He identified that he used to have a locked drawer but that someone took the key that he had hung on the back of his wheelchair before going to bed at night, so he now keeps them in an unlocked drawer. R5 identified staff had never asked him to turn in his lighter. Review of the 10/15/24, Resident Smoking policy identified smoking was prohibited in all areas except the designated smoking area. Safety measures for the designated smoking area included protection from weather…

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 required number of staff determined by their facility assessment had been scheduled and maintained on the weekends. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D quarter 3 (April 1st through June 30th) identified excessively low weekend staffing had triggered. Review of the August 2024, Facility Assessment identified the facility had only 2 shifts day shift 6:00 a.m. to 6:00 p.m. and night shift 6:00 p.m. to 6:00 a.m., the staffing plan for basic number of staff, the departments' daily staff, except the manager's position was as follows: Day shift 6:00 a.m. to 6:00 p.m. Registered nurse (RN) or licensed practical nurse (LPN) charge nurse=2 Trained medication aide (TMA) and/or nursing assistant (NA) direct care staff =3 Night shift 6:00 p.m. to 6:00 a.m. RN or LPN = 1 TMA/NA direct care staff =2 Review of the working schedules and timecards for weekend days during quarter 3 identified less than the amount of identified staff worked for 12 of 26 weekend dates. 1) 4/13/24…

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 interview and document review the facility failed to ensure 5 of 6 nursing staff were competnet to identify an emergent change in condition and the need to transfer to hospital for emergency medical evaluation for 1 of 1 resident (R33). The facility also failed to follow the facility assessment and/or develop policies and procedures and ensure staff had demonstrated competencies to perform care for residents. Findings include: Review of the [DATE], Centers for Disease Control, About Heart Attack Symptoms, Risk, and Recovery, located at https://www.cdc.gov/heart-disease/about/heart-attack.html#:~:text=The%20major%20symptoms%20of%20a%20heart%20attack%20are%3A,arms%20or%20shoulders.%205%20Shortness%20of%20breath.%20, identified a heart attack, also called a myocardial infarction, happens when a part of the heart muscle doesn't get enough blood. The more time that passes without treatment to restore blood flow, the greater the damage to the heart muscle. The major symptoms of a heart attack are: 1) Chest…

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 up on a verbal grievance for 1 of 1 resident (R5). R5's 10/27/24 quarterly Minimum Data Set (MDS) assessment identified his cognition was intact and had diagnosis of stroke, heart failure, renal insufficiency, and diabetes mellitus. Interview on 11/12/24 at 10:45 a.m., with R5 identified that about 5 months ago he had some gel pens go missing. He reported it to the social service director (SDD) but reports nothing was done. He also reports he is missing the key to his locked drawer and a stylist that was kept on the same string that his key was on. Observation and interview on 11/18/24, at 12:45 p.m., with R5 in the hallway near the dining room, where the SSD director was walking down the hall, R5 stopped her and stated I told you about the gel pen's, can you tell her . R5 pointed to the surveyor. The SSD replied, I don't recall that. R5 asked the SSD, don't you remember I hung a big note on your door with one of the pictures I colored?. The SSD asked R5 if he filled out a grievance, he replied yes.…

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 1 of 1 resident (R18) was provided communication with the county care coordinator (CC) and those communications were not discouraged or obstructed, when multiple attempts were made to contact R18 without success. Findings include: Review of a 5/20/24, State Agency (SA) report identified on 5/26/24 the care coordinator (CC) for R18 had telephoned the facility and spoke with an unidentified charge nurse leaving contact information for R18 to return the call. The social services designee (SSD) then emailed CC that R18 had attempted to return her call, but she was on another line. The CC then received another email from the SSD, which stated, I have asked you repeatedly to direct these types of needs to me and only me, please honor and respect this. Our nurses are extremely busy providing cares to our resident and cannot be available to get resident for phone calls that are not time sensitive or family members. If I am out of the office, you will get a notification who to direct your request to. If you have any…

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 completed Minimum Data Set (MDS) was accurately coded for 1 of 1 resident (R26) reviewed for wounds. Findings include: The CMS Long-Term Care Facility RAI (resident assessment instrument) 3.0 User's Manual, dated 10/2023, indicates under Section M: Skin conditions to record any type of pressure ulcers and/or skin injuries the resident received during the 7-day observation period. R26 was admitted in September of 2023. R26's medical diagnosis form identified abscess (pus filled pocket that develops in the body's tissues of buttocks), non pressure chronic ulcer of buttocks with fat layer exposed, protein-calorie malnutrition, and end stage renal disease. R26's 9/21/24, Significant change Minimum Data Set (MDS) identified he was cognitively intact. Under section M, itidentified he had received an application of nonsurgical dressing other than to feet. There was no mention that R26 had a non-pressure skin ulcer on the MDS. R26's 9/29/23, History and Physical identified he had obtained a left buttock abscess 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 interview and document review, the facility failed to revise the care plan for 2 of 2 residents (R33 and R40). R33 to include daily weights and R40 to include target behaviors for monitoring. Findings include: R40 R40's 10/9/24, admission Minimum Data Set (MDS) assessment identified her cognition was intact, she was independent or needed some supervision with ADLs. She received both medication and non-medication intervention for pain which she described as almost constant. R40 wore an upper body brace due to back surgery, had a pressure reducing device for her bed, received surgical wound care, and medications that included antidepressant, antibiotic, and opioids. R40 had diagnoses which included Vertebrogenic low back pain, (chronic pain that occurs when the vertebral endplates of the spine are damaged), muscle spasm, sheltered homelessness, alcohol abuse, and other psychoactive substance abuse. Review of R40's current undated care plan failed to identify target behaviors to be monitored and documented. The care plan identified she received anti-anxiety medication 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 interview and document review the facility failed to comprehensively assess and identify target behaviors and non-pharmacological interventions for scheduled antidepressant and antipsychotic medication for 3 of 5 residents (R8, R42 and R246)) reviewed for unnecessary medication usage. Findings include: R8 R8's 10/29/24, significant change Minimum Data Set (MDS) assessment identified R8 had severely impaired cognition, he was independent with activities of daily living (ADLs), and he demonstrated behaviors including hallucinations, physical and verbal behaviors, and intruded on the privacy and activities of others. R8's behaviors have worsened compared to the previous assessment. His medications included antipsychotic, antianxiety, antidepressant, and antiplatelet medications. R8's current undated care plan identified he had a behavior problem related to mental health with interventions listed as anticipate and meet resident needs. If reasonable discuss the resident's behavior, explain/reinforce why behavior is inappropriate and/or unacceptable. The care plan identified R8…

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 2 of 2 opened vials of Tuberculin (TB) purified protein derivative (PPD) solution (used to detect tuberculosis)( (TB)) were appropriately labeled according to manufacturer's guidelines with an open date. Findings include: Observation on 11/13/24 at 10:53 a.m. with licensed practical nurse (LPN)-A identified 2 open vials of PPD solution stored in the refrigerator of the medication room. The pharmacy labeled bag containing the vials was dated as dispensed from the pharmacy on 9/28/24. Neither of the 2 vials had been dated as to when they had been opened. Review of the provided pharmacy list for outdates after opening identified the solution was good for 30 days from the date opened. Interview on 11/13/24 at 10:55 a.m. with licensed practical nurse (LPN)-A reported medications were supposed to be dated when opened, and confirmed there was no date identifying when either of the 2 vials of PPD solution had been opened. LPN-A retrieved the facility list of medication outdates after opening and identified 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.

Based on observation, interview, and document review, the facility failed to provide schedule routine dental services upon request for 1 of 1 resident (R5). Findings include: R5's 10/27/24 quarterly Minimum Data Set (MDS) assessment identified his cognition was intact and had diagnosis of stroke, heart failure, renal insufficiency, and diabetes militias. Interview on 11/12/24 at 10:48 a.m., with R5 identified he had requested a dentist appointment a long time ago when he had first admitted to the facility. He stated, I'm missing all my molars. R5 reported he thought he would benefit from a partial denture. Interview and observation on 11/18/24 at 12:36 p.m., R5 identified for the second time during the survey that he had requested a dental appointment, he stated look at all the teeth I'm missing. He opened his mouth and pointed to his upper molars. Surveyor observed R5 had all but 1 upper molar missing. R5's 6/4/24, 7/27/24, and 10/25/24, oral assessments completed by RN-A identified R5 had requested a dental appointment during each assessment. Interview on 11/18/24 at 1:47 p.m.,…

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

Based on observation, interview and document review the facility failed to provide physician ordered physical therapy (PT) services for 2 of 2 residents (R20 and R37). Findings include: R37 R37's admission Minimum Data Set (MDS) assessment identified his cognition was intact, he was independent with activities of daily living (ADLs) and received therapy services of Occupational (OT) and Speech (ST) therapies. R37 also had orders for physical therapy (PT) which he received until the end of August 2024, when the facility no longer had PT services available. R37 had diagnoses of metabolic encephalopathy, alcohol abuse, ADHD, degeneration of his nervous system due to alcohol, cognitive communication deficit, history of falling, weakness, and difficulty walking. R37's current, undated care plan identified he was dependent on staff for meeting emotional, intellectual, physical, and social needs due to his physical limitation. He had MD orders for PT/OT evaluation and treatment. Staff were to encourage R37 to participate in activities that promoted exercise, physical activity for…

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 1 of 1 director of nursing (DON)/infection preventionist (IP) had appropriate training and oversight of the infection control program to management by performing surveillance activities, maintain documentation of incidents, findings, and any corrective actions required. Findings include: Review of the infection control surveillance from August 2024 through November 2024 provide identified columns as follows: 1) Resident 2) Admit/entry date 3) Onset date. 4) Infection diagnosis (dx). 5) Site. 6) Healthcare acquired infection (HAI) to be checked yes or no. 7) Isolated: If Yes: Date, or No for selections. 8) Culture: If Yes: Date, or No for selections. 9) Organism. 10) Antibiotic. 11) Re-culture date. 12) X-ray date. 13) Date resolved. Interview and surveillance review on 11/18/24 at 3:35 p.m. with the director of nursing (DON)/infection preventionist (IP) identified the DON was new to her role as both DON and the IP. She had only been in her…

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 residents were free and protected from physical abuse for 2 of 3 residents (R2 and R3) reviewed for resident-to-resident abuse when on two separate occasions R1 physically abused R2 and R3. Additionally failed to implement protection measures according to R1's care plan to prevent re-current physical abuse. Findings Include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, did not have sign/symptoms of delirium, and did not have behaviors. The MDS further indicated R1 was independent with walking, toileting, transferring, and personal cares with no upper or lower body impairments. Diagnoses included anemia, diabetes, depression, histrionic personality disorder (a mental health condition characterized by overwhelming desire to be noticed and dramatic behavior), nicotine dependence, and mild cognitive impairment. R1's care plan last updated 6/7/24, indicated R1 was at risk for abuse due 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 implement and provide adequate supervision and safety interventions for 1 of 3 residents (R1) reviewed for smoking. Findings include R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, did not have sign/symptoms of delirium, and did not have behaviors. The MDS further indicated R1 was independent with walking, toileting, transferring, and personal cares with no upper or lower body impairments. Diagnoses included anemia, diabetes, depression, histrionic personality disorder (a mental health condition characterized by overwhelming desire to be noticed and dramatic behavior), nicotine dependence, and mild cognitive impairment. R1's care plan last updated 8/29/24, indicated R1 had been deemed unsafe to smoke by her physician. The goal was that R1 will not smoke. The interventions were to review smoking policy as needed and with any changes, R1 cannot smoke unsupervised and independently, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to report an allegation of abuse to the State Agency (SA) for 1 of 1 resident (R1) reviewed for allegations of neglect. Findings include: A Vulnerable Adult Maltreatment Report submitted to the State Agency on 4/26/24, by an undisclosed person alleged R1 was sexually and physically abused in the facility. R1's Quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment and no noted behaviors. R1 required staff assist with eating, toileting, and transferring. The facility's Incident Report Log identified on 4/29/24, alleged abuse of R1 with the comment, MAARC report filed against us. The facility's investigative note dated 4/29/24, indicated the social service designee (SSD) was notified by the county's sheriff department of the allegation of abuse at 11:48 a.m. The director of nursing and administrator were notified. During an interview on 5/21/24 at 12:15 p.m., the SSD stated the county sheriff came to the facility 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.

Based on interview and document review the facility failed to have evidence of analysis and evaluation of the identified Performance Improvement Project (PIP) concerns for 1 of 1 Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of the 5/25/23, QAPI meeting minutes identified the facility had a performance improvement project (PIP) for notifying the ombudsman of discharges, giving proper notice of discharge in an emergency, ensuring TeleMed MD visits were documented in point click care the facility electronic medical record, and ensure new residents were seen in-person by MD and were on a correct rounding schedule. These PIP projects were reviewed and discontinued at the meeting. Continued PIP project was to ensure new admission completed a Mantoux Skin Test and the process was followed correctly. Review of the 9/28/23, QAPI meeting minutes lacked identification of the Mantoux PIP project or analysis of the PIP project to ensure new admission completed a Mantoux Skin Test and the process was followed correctly and if the project would continue or…

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 and interview, the facility failed to ensure all 8 licensed nursing staff were appropriately trained and deemed competent to administer insulin. Findings include: Observation and interview on 4/24/24 at 8:37 a.m., with licensed practical nurse (LPN)-A identified she completed a blood sugar check on R7 with blood sugar registering at 113. LPN-A identified that based on her blood sugar she would only receive her Lantus injection. LPN-A dialed the Lantus pen to 50 units, removed the cap and used an alcohol wipe to clean the pen hub, then attached a disposable needle tip. LPN-A then administered the insulin subcutaneously to R7. LPN-A did not prime the insulin pen with 2 units of insulin prior to dialing up the ordered dose. LPN-A identified she was surprised she had forgot to prime the pen. R7's April 2024, Medication Administration Record (MAR) identified R7 was administered Novolog (a rapid acting insulin) 5 units subcutaneously 2 times daily at 8:00 a.m., and 12:00 p.m., and 7 units one time daily at 4:30 p.m., R7 also received Lantus (long-acting insulin) 50…

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 provide mandatory training on 1 of 1 facility's specific Quality Assurance Performance Improvement (QAPI) Program to all staff to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how staff was to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. Findings include: Interview on 4/24/24 at 7:39 a.m., with NA-B identified the QAPI committee was working on different things however, she was unsure of what specific QAPI items they were working on. She reported she did not believe there was training on Relias (online generalized QAPI training) about the facility's QAPI or QAPI in general . If the committee was training staff following their meetings, she was unaware of that and had never had training. Interview on 4/24/24 at 8:07 a.m., with maintenance supervisor identified he was part of the QAPI committee, and each department would bring up issues and they would discuss together 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 interview and document review the facility failed to ensure 4 of 9 staff (director of nursing (DON), licensed practical nurse (LPN)-A, nursing assistant (NA)-A, and NA-C) received initial and annual training on Alzheimer's disease or related disorders, assistance with activities of daily living (ADL), problem solving with challenging behaviors, and communication skills. Findings include: Review of the DON's employee file identified the DON had a hire date of 10/16/23. Review of her Alzheimer's training records identified she had completed training on ADL care, communication needs, and behaviors. The DON training record lacked identification that she had completed training on Alzheimer's disease and related disorders upon hire. Review of LPN-A's employee file identified LPN-A had a hire date of 3/21/24. Review of LPN-A's Alzheimer's training records identified LPN-A had completed training on Alzheimer's disease and related disorders, ADLs, and behaviors. LPN-A's training record lacked identification she had completed training on communication needs upon hire. Review 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 observation, interview, and document review, the facility failed to ensure 1 of 24 residents (R3) appropriately disposed of cigarette butts after use. This had the potential to affect 23 other residents who also smoked. Findings include: Interview on 4/22/24 at 10:55 a.m., during initial interview with R3 stated after she smoked, she would store her used cigarette butts in her jacket pocket after use and discarded that cigarette butts in the trash bin in her room. R3 was aware of a receptacle outside to dispose of cigarette butts. Observation on 4/22/24 at 11:39 a.m., of facility entrance door to the designated smoking area had signs posted for residents to pick up their cigarette butts and place in proper receptacle when they were finished smoking. The designated smoking area had a smoking receptacle near the door for cigarette butt disposal. Observation and interview on 4/22/24 at 3:49 p.m., outside in the designated smoking area identified R3 walked away from the designated smoking area. R3 opened her jacket pocket and showed her used cigarette butts in her jacket…

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 1 of 3 (R8) residents oxygen (O2) had been administered per physician orders. Findings include: R8's 3/15/24, quarterly Minimum Data Assessment (MDS) identified R8 had moderate cognitive impairment and had a diagnosis of pneumonia, anxiety, depression, and respiratory failure. R8 had partial/moderate assistance related to her activities of daily living and was independent with walking 10 to 50 feet. R8's Section O of the MDS identified R8 had oxygen. Review of R8's, current, undated, Order Summary Report identified R8 was to receive 2 liters of O2 at rest and 5 liters of O2 with activities. Observation on 4/22/24 at 11:51 a.m., with R8 asleep in bed. R8 had her nasal cannula on with her O2 set on 4 liters. Observation on 4/22/24 at 2:53 p.m., with R8 watching television with her O2 set at 4 liters. Observation on 4/22/24 at 4:39 p.m., with R8 eating a meal with her O2 set at 4 liters. Observation and interview on 4/22/24 at 4:55 p.m., with nursing assistant (NA)-C stated R8 should be on 2 liters 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 observation and interview, the facility failed to ensure an insulin pen was appropriately primed prior to administration for 1 of 1 resident (R7). Findings include: Observation and interview on 4/24/24 at 8:37 a.m., with licensed practical nurse (LPN)-A identified she completed a blood sugar check on R7 with blood sugar registering at 113. LPN-A identified that based on her blood sugar she would only receive her Lantus injection. LPN-A dialed the Lantus pen to 50 units, removed the cap and used an alcohol wipe to clean the pen hub, then attached a disposable needle tip. LPN-A then administered the insulin subcutaneously to R7. LPN-A did not prime the insulin pen with 2 units of insulin prior to dialing up the ordered dose. LPN-A identified she was surprised she had forgot to prime the pen. R7's April 2024, Medication Administration Record (MAR) identified R7 was administered Novolog (a rapid acting insulin) 5 units subcutaneously 2 times daily at 8:00 a.m., and 12:00 p.m., and 7 units one time daily at 4:30 p.m., R7 also received Lantus (long-acting insulin) 50 units…

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 room change notice including the reason for the room change for 3 of 3 residents (R10, R11, R12) reviewed for room change. Findings include: R10's admission Minimum Data Set (MDS) dated [DATE], identified R10 was admitted to the facility on [DATE], and had intact cognition. During an interview on 2/27/24 at 12:40 p.m., R10 indicated the previous day (2/26/24) she was coming out of her bathroom and an unknown facility staff person was packing up her stuff. R10 stated the unknown staff person did not know why she was being moved to another room but was told to move her stuff. R10 stated she had just been moved to that room the day before (2/25/24) from her original room she was admitted to and did not know why she was being moved again. R10 verified she had changed rooms twice since her admission without notice or a reason why. R10 stated she asked the social worker (SW) and was told a new admission needed the room more than she…

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 notification to the resident and/or resident representative of the facility's bed hold policy at the time of emergency transfer and hospitalization for 1 of 1 (R2) residents reviewed for hospitalization. Findings include: R2's admission Minimal Data Set (MDS) dated [DATE], indicated R2 had a diagnoses of end stage renal disease, fluid overload, and dependence on renal dialysis. R2's care plan dated 8/19/22, indicated R2 was independent with activities of daily living (ADLs) such as ambulation, dressing, toileting, and grooming. Further, care plan identified R2 as exhibiting behaviors such as noncompliance with medically needed treatment. R2's Census List dated 2/28/24, revealed R2 had been transferred to the hospital on 1/29/24, 1/15/24, 1/1/24, 12/19/23, 11/24/23, 10/6/23, 9/7/23, 8/19/23, and 7/18/23. R2's progress notes identified R2 was transferred to the hospital nine times between 7/19/23 through 1/29/24. In review of R2's record it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure a comprehensive discharge summary that included all four components (recapitulation of stay, final summary of resident's status, medication reconciliation, and post-discharge plan) as required for 2 of 2 residents (R2, R9) who were discharged to the community. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included alcohol induced acute pancreatitis, alcoholic hepatitis, and was cognitively intact. Further, MDS revealed R1 did not exhibit any behaviors and wished to discharge to the community. R1's progress note dated 11/20/23, indicated R1 was going to discharge to her grandmother's home on this day, and was going to be transported by her aunt until R1 was accepted into an inpatient chemical dependency facility. R1's Social Services- Discharge summary dated [DATE], revealed R1 discharge to community with family, and was working on possible admission to an inpatient chemical dependency…

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 complete comprehensive analysis/assessment for potential causal factors/root cause to identify and implement individualized interventions and failed to revise the care plan with identified interventions to prevent and/or mitigate the risk of falls or falls with serious injury for 1 of 3 residents (R7) reviewed for falls. Finding include: R7's admission record identified she was admitted to the facility on [DATE] and had the following diagnoses: diabetes, urinary incontinence, osteoporosis, difficulty in walking, reduced mobility, history of falls, sleepwalking, muscle weakness. R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated staff completed R7's cognition assessment that identified short and long term memory were ok and had some difficulty in making decisions regarding activities of daily life. MDS further identified R7 was independent with activities of daily living including those involving mobility, however did have…

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.