The Shores Of Worthington

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate care and services were provided to prevent urinary tract infections to the extent possible for 1 of 2 residents (R1) who had an indwelling urinary catheter. Findings include: R1's face sheet dated 4/15/25, identified diagnoses of overactive bladder (urgent need to urinate), atrophy of testes (shrinkage of one or both testes), benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms (frequent/urgent need to urinate). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R1 was dependent with cares on lower body. Had an indwelling urinary catheter, always incontinent of bowels. R1 had behaviors both verbal and physical directed at others and rejected cares frequently. R1's care plan dated 4/4/25, identified risk for urinary retention with foley catheter to be replaced monthly and as needed. Interventions included to evaluate for urinary complaints. R1 insisted…

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 perform appropriate hand hygiene during cares for 4 of 4 residents (R3, R4, R5, and R10) observed for personal cares. Findings include: R3 R3's face sheet dated 4/15/25, identified diagnoses of intertrochanteric fracture of left femur (broken hip). R3's care plan dated 3/25/25, identified personal hygiene required extensive assistance from staff. During an observation on 4/10/25 at 7:46 a.m., R3 was in bed. nursing assistant (NA)-A filled basin with water and applied gloves. Cleansed top half of body and face. Had R3 turn to the side and wiped bowel movement with wipes. NA-A without performing hand hygiene, returned to the front of R3 and cleaned penis pulling down foreskin and wiping away white particles with a washcloth. NA-A then took off gloves and without performing hand hygiene left and returned to R3's room and without performing hand hygiene put new gloves on. NA-A instructed R3 to turn and washed bottom with wipe. NA-A then took the washcloth to remove the remaining stool from R3's bottom. NA-A put…

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 9 of 15 sampled residents (R1, R5, R7, R8, R18, R20, R28, R41, and R42) care plans were developed and able to be revised as necessary. This has the potential to affect all 56 residents. Findings include: R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs. R41's 11/25/24, quarterly Minimum Data Set (MDS) identified R41 was admitted to the facility (from the now closed sister facility) in September 2024. R1 was noted to have delusions with no behaviors identified. R41's 11/19/24, physician progress note identified the PCP noted additional diagnoses from the previous visit of chronic hepatitis C,…

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

Based on observation, interview, and document review, the facility failed to ensure the ice machine, kitchen and food prep areas were kept clean and sanitary. This has the ability to affect all 56 residents. Findings include: Observation and interview on 2/25/25 at 7:15 a.m., during the initial kitchen tour a stainless-steel food prep counter across from the stove had a lower shelf directly below. The lower shelf was used to store cutting boards, oatmeal, oil, cooking spray, and small cups used for serving condiments. The shelf had a dry black/brown substance on it and a brown liquid substance covering a large area of the shelf. In addition, approximately the first 3-5 inches from the edge of the shelf nearest to the stove and covering the full length of the shelf had a greasy, sticky build-up. The area had dirt and grime stuck to the greasy area. The shelf had a plastic container containing condiment cups, the container was visibly dirty with unknown brown substance. Food crumbs could be seen laying in the bottom of the container. On 2/25/25 at 4:45 p.m., during a follow up…

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

Based on interview and document review, 1 of 1 Governing Body failed to provied appropriate oversight to ensure deficient practice had been corrected and coompliance achieved. Refer to F636, F656, F684, F758, F812, F842, F865, F880, F882, and F944. Findings include: Review of the QAPI meeting minute attendance from the 3/25/25 QAPI Meeting (meetings are held monthly) identified attendees present were the administrator, the director of nursing (DON) the assistant director of nursing (ADON), the infection preventionist (IP) the social services designee (SSD) and the pharmacist. The medical director was absent for this meeting. During the meeting, topics discussed were as follows: 1) Pressure Ulcers: There were 14 active pressure ulcers involving 5 residents. The facility goal was to have 5% pressure ulcer rate. Current facility percentage was left blank. After discussion, actions present were the facility was working on care plans and turning and repositioning, working on healing wounds. There was no measurable action or presentation of evaluation of the data to define commonalities…

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 implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed. This has the ability to affect all 56 residents. Findings include: Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth Interview on 3/04/25 at 2:26 p.m., with administrator identified the merge of two nursing homes, that included residents and staff, added an extra layer of challenges the facility was currently navigating. He identified updates of the facility assessment, had not yet been implemented, including staff education. However, He identified there was decisions made in relation to resident cares, resources and services that were to relay to all staff the facility's operational goals and performance improvement projects (PIP). Review of August 2024 Facility Assessment Tool identified the leadership team would discuss goals 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.

Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 Quality Assurance Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 56 residents. Findings include: Review QAPI minutes from February 2024 through January 2025, identified department heads were bringing data forth to QAPI on various topics such as infection control, falls, incident reports, vaccinations, etc. However, there was no documented benchmarks for goals the facility was trying to achieve, nor monitoring to determine if goals were met or QAPI needed to continue monitoring to ensure compliance. Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth. Interview on 3/04/25 at 2:09 p.m., with administrator identified the merge of two nursing homes, that includes residents and staff, added an extra layer 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's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility specific concerns, implement an action plan to correct the identified concerns or to ensure the committee participated in the development and oversight of implementation of systems, and to ensure quality of life and quality of care were maintained for 57 residents residing in the facility. Findings include: Review of QAPI minutes from February 2024 to January 2025, identified on 4/19/24 the facility was to implement a performance improvement project (PIP) of abuse allegations. There was no mention on how the facility would meet goals, monitor progress or evaluate current measures to ensure compliance. Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth. Interview on 3/04/25 at 2:26 p.m., with administrator identified the merge of two nursing homes, that includes residents and staff, added an extra layer…

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 off document and interview, the facility failed to ensure 1 of 1 resident (R41) with a highly infectious disease (Hepatitis C) was placed into the infection control (IC) surveillance data for monitoring. In addition, the facility failed to ensure oversight of the IC program was maintained for tracking, trending, and analysis of data to prevent potential spread of infection. The facility also failed to include staff return to work information in surveillance to identify if they were appropriately vetted before their return for 1 of 3 months (January 2025) reviewed. This has the potential to affect all 56 residents. Findings include: R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, 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 off document and interview, the facility failed to ensure oversight of the IC program was maintained to provide appropriate oversight for tracking, trending, and analysis of data to prevent potential spread of infection. This had the ability to affect all 56 residents. Based off document and interview, the facility failed to ensure 1 of 1 resident (R41) with a highly infectious disease (Hepatitis C) was placed into the infection control (IC) surveillance data for monitoring. In addition, the facility failed to ensure oversight of the IC program was maintained for tracking, trending, and analysis of data to prevent potential spread of infection. The facility also failed to include staff return to work information in surveillance to identify if they were appropriately vetted before their return for 1 of 3 months (January 2025) reviewed. This has the potential to affect all 56 residents. Findings include: R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism…

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 specific Quality Assurance Performance Improvement (QAPI) Program 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 to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. This had the ability to affect all 57 residents. Findings include: Interview on 3/03/25 at 2:58 p.m., with Registered nurse (RN)-B and RN-D identified the facility held scheduled meetings for residents and staff. Both RN-B and RN-D had not attended QAPI meetings and was not aware of any facility specific performance improvement projects. Interview on 3/03/25 at 3:04 p.m., with admission coordinator identified the facility plan was to prevent further infection control outbreaks related to COVID and respiratory syncytial virus (RSV). Interview on 3/03/25 at 3:09 p.m., with licensed practical nurse (LPN)-A identified she was not aware of QAPI meetings held…

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 include the run/communication report from dialysis in the facility medical record for 2 of 2 residents (R18 and R42) reviewed for dialysis, in addition the facility failed to transcribe physician order for 1 of 1 resident (R44) following an appointment. Findings include: R18's admission Record identified R18 was admitted to the facility at the end of January 2025. R18 had the following diagnoses of chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency. R18's 1/29/25, admission Minimum Data Set (MDS) assessment identified R18's cognition was intact. R18 had no behavior and required moderate assistance with cares. R18 took a daily anticoagulant, diuretic, and antiplatelet. R18 attended dialysis. R18's 1/24/25, care plan identified R18 required hemodialysis related to renal failure. Staff were to encourage her to attend dialysis. The care plan lacked identification of dialysis schedule or where R18 attended dialysis. R18's electronic medical record, point click care (PCC) identified R18…

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 physician signed a Provider Order for Life-Sustaining Treatment (POLST) order for 1 of 15 residents (R37) following admission. Findings include: R37's 1/15/25, admission Minimum Data Set (MDS) identified R37 was cognitively alert and required substantial/maximal assistance with activities of daily living (ADLs). R37 had a diagnoses of malnutrition, anxiety, diabetes and cirrhosis. R37's 1/08/25 POLST, identified R37 was to be full code. There was no mention on the consent R37's wishes were communicated to the primary physician and was not signed within 30 days of admisson on rounds. Interview on 2/26/25 at 8:40 a.m., with Registered nurse (RN)-B identified residents POLST would be obtained during admissions with social service department and was to be signed by the primary physician and was to be updated on the resident medical record to ensure it matched admission orders and the resident had not changed or wished to change their status upon admission. Interview on 2/26/25 at 8:46 a.m., with director 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 interview and document review, the facility failed to ensure 1 of 1 resident (R41) was accurately and comprehensively assessed when R41 exhibited behaviors or refusal of all cares, medication, treatment and evaluation. Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 manual identified The RAI process has multiple regulatory requirements. Federal regulations require the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. In addition, an accurate assessment requires collecting information from multiple sources. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, and/or other legally authorized representative, 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 interview and record review, the facility failed to accurately and thoroughly assess 1 of 1 resident (R40) for a history of trauma related to a diagnosis of Post-Traumatic Stress Syndrome (PTSD). Findings include: R40's 1/4/25, quarterly Minimum Data Set (MDS) assessment identified her cognition was severely impaired, she felt down, depressed or hopeless 2-6 days a week, and she displayed verbal behaviors directed towards others such as screaming, threatening, or cursing 1-3 days a week. R40 had a diagnosis of PTSD, anxiety, and a psychotic disorder. She was dependent on staff for all activities of daily living (ADL's). R40's 9/11/24, PTSD Resident Screening assessment identified the first question was: Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide. R40 answered no. The facility assessment indicated if 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 1 of 1 resident (R41) was accurately and comprehensively assessed as certified when it was R41 exhibited behaviors and refusal of all cares, medication, treatment and evaluation. Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 manual identified The RAI process has multiple regulatory requirements. Federal regulations require the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. In addition, an accurate assessment requires collecting information from multiple sources. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, and/or other legally authorized…

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 notify the State Mental Health Authority ([NAME] County) for 1 of 1 resident with a diagnosis of major neurocognitive disorder with known behaviors and inpatient psychiatric stay 3 months prior to admission. Findings include: R41's face sheet identified he was admitted to the facility in September 2024. R41 had diagnoses recorded of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs. R141's previous Preadmission Assessment Screening and Resident Review (PASARR) Level I was done previously at the now closed sister facility on 5/23/24, prior to R41's transfer to the facility. The questions answered at that time were: 1) Has this person had any of the following: A mental…

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 2 of 2 residents (R7 and R44) care plan after receiving new orders directing facility to ensure R44's legs were elevated as much as possible and to reposition R7 at least every 2 hours. Findings include: R44's 1/28/25, admission Minimum Data Set assessment identified her cognition was moderately impaired. She required extensive assistance with her activities of daily living (ADL)'s. R44 had diagnosis of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), heart failure, renal insufficiency, dementia, anxiety, depression, and morbid obesity. Interview on 2/27/25 at 9:18 a.m., with FM-H identified that R44 had seen a physician last week and at the appointment R44 had increased swelling to her lower legs. The physician placed orders to add a water pill to decrease fluid in legs, and for staff to wrap her legs or put compression stocking on daily. He reported that on 2/23/25 he went to the facility to visit and R44 did not have any leg wraps on. FM-H spoke…

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 implement physician orders for 1 of 1 resident (R44). Findings include: R44's 1/28/25, admission Minimum Data Set assessment identified her cognition was moderately impaired. She required extensive assistance with her activities of daily living (ADL)'s. R44 had diagnosis of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), heart failure, renal insufficiency, dementia, anxiety, depression, and morbid obesity. Interview on 2/27/25 at 9:18 a.m., with FM-H identified that R44 had seen a physician last week and at the appointment R44 had increased swelling to her lower legs. The physician placed orders to add a water pill to decrease fluid in legs, and for staff to wrap her legs or put compression stocking on daily. He reported that on 2/23/25 he went to the facility to visit and R44 did not have any leg wraps on. FM-H spoke with the charge nurse, and she identified she was not aware of the new orders but would check into it. Observation on 3/3/25 at 9:50 a.m., R44…

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

Based on interview and document review the facility failed to assess weight loss to determine the cause for 1 of 4 residents (R8) reviewed for nutrition. Findings include: R8's 1/11/25, quarterly Minimum Data Set (MDS) assessment identified R8's cognition was intact. R8 was independent with eating. R8 had behaviors and refused cares. R8 was identified to have a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. R8 was identified for weight loss that was not a physician-prescribed weight -loss regimen. R8 did not have a therapeutic diet. Section L Oral/Dental Status of the assessment was not completed. R8 had pain and took scheduled pain medication. R8 had one stage 3 pressure ulcer, two unstageable pressure ulcers and tow venous ulcers. R8's 2/26/25, Order Summary Report identified R8 was on a regular diet with regular texture. R8 was to be weighed monthly. R8 took Arginade Powder 1 packet by mouth one time a day for wound healing. There was no mention that R8 was on a supplement related to weight loss. R8's Weight Summary report identified R8'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.

Based on observation, interview and document review, the facility failed to consistently monitor and assess a resident for potential complications related to dialysis treatment post treatment for 2 of 2 resident (R18 and R42) reviewed for dialysis. Findings include: R18's admission Record identified R18 was admitted to the facility at the end of January 2025. R18 had the following diagnoses of chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency. R18's 1/29/25, admission Minimum Data Set (MDS) assessment identified R18's cognition was intact. R18 had no behavior and required moderate assistance with cares. R18 took a daily anticoagulant, diuretic, and antiplatelet. R18 attended dialysis. Observation on 2/25/25 at 7:45 a.m., R18 showed a dialysis port in her right upper chest. R18 2/27/25, Order Summary Report identified R18 was on a renal diet and consistent carbohydrate diet. The order summary had no mention of monitoring access site for signs and symptoms of infection, no mention of location of access site, and no mention of dialysis schedule.…

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 medical director for 1 of 1 resident (R41) who exhibited increased and ongoing behaviors since shortly after admission, with no mental health intervention to receive appropriate treatment and services and had questionable mental ability to refuse cares and treatment. Findings include: R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs. R41's 11/25/24, quarterly Minimum Data Set (MDS) identified R41 was admitted to the facility (from the now closed sister facility) in September 2024. R1 was noted to have delusions with no…

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 include an appropriate diagnosis for the use of an antipsychotic medication for 1 of 5 residents (R6) reviewed for unnecessary medication. Findings include: R6's 12/10/24, quarterly Minimum Data Set (MDS) assessment identified her cognition was severely impaired, she had no behaviors and was dependent on staff for activities of daily living (ADL)'s. R6 had diagnosis of Alzheimer's disease late onset, non-traumatic brain disorder, and adult failure to thrive. She had been administered antipsychotic medication and antidepressant medication on a routine basis. R6's medication administration record (MAR) identified she was administered quetiapine (antipsychotic) 75 milligrams (mg) in the morning, 25 mg at noon, and 100 mg at bedtime for Alzheimer's Disease with late onset, and sertraline 50 mg daily for dementia with other behavioral disturbances. R6's electronic medical record diagnosis list identified Alzheimer's disease with late onset, and adult failure to thrive. R6's care plan identified she was taking…

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 controlled medications were reconciled according to the facility protocol to prevent potential diversion for 1 of 1 emergency kits reviewed. Findings include: Observation and interview on 3/3/25 at 3:36 p.m., with registered nurse (RN)-C of the medication room on first floor. Observed was a refrigerator with a paddle lock on it with the key being on the nurse's key ring. Located inside the refrigerator was a clear box with 2 vials of Lorazepam 2 milligrams/milliliter (MG/ML) an antianxiety medication and a red plastic tag with the number 0501539. RN-C reported that the Lorazepam was from the emergency kit and counted each shift. The count was documented in the narcotic log located on the medication cart. Review of the narcotic logbook with RN-C found he was unable to find that the Lorazepam had been reconciled and documented. RN-C revealed that at shift change they had not checked the emergency Lorazepam from the refrigerator. RN-C confirmed that the nurses should be confirming the red plastic tag…

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) received ordered therapeutic diet to maintain or improve their nutritional status. Findings include: R18's admission Record identified R18 was admitted to the facility at the end of January 2025. R18 had the following diagnoses of chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency. R18's 1/29/25, admission Minimum Data Set (MDS) assessment identified R18's cognition was intact. R18 had no behavior and required moderate assistance with cares. R18 took a daily anticoagulant, diuretic, and antiplatelet. R18 attended dialysis. Review of the 5/14/24, Centers for Disease Control (CDC), Diabetes and Kidney Disease: What to Eat?: article located at, https://www.cdc.gov/diabetes/healthy-eating/diabetes-and-kidney-disease-food.html, identified, A healthy diabetes diet looks pretty much like a healthy diet for anyone. Eat lots of fruits, veggies, healthy fats, and lean protein. Eat less salt, sugar, and foods high in refined carbs. With a chronic kidney disease…

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 4 nursing assistants (NA-T, NA-D, NA-G, and NA-U) reviewed were deemed competent to complete cares for residents. This had the potential to affect all 45 residents residing in the facility. Findings include: Review of the facility job description Non-Certified Nursing Assistant (NA) and training requirements dated August 2021, indicated the primary purpose of this position is to provide resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as directed by supervisors. After completing facility competency training, all residents' lifts, transfers and activity of daily living (ADL) care, the non-certified aide must complete these tasks with the assistance of a facility Certified Nurse Aid (CNA). Review of NA-T's employee record indicated NA-T was hired on 9/10/24. NA-T's orientation sign off sheet was not completed with the date and sign off sections for training completed were left blank. Further, NA-T's file did not include competency training…

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 alleged violations involving abuse/neglect were reported to the State Agency (SA) timely for 2 of 2 resident (R5, R7) reviewed for abuse/neglect. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment and dependent for dressing, grooming and hygiene. R5's care plan focus dated 12/5/24, identified R5 was at end of life and utilizing hospice. Interventions included coordinate care with hospice and other end of life services. During an interview on 12/12/24 at 8:43 a.m., hospice registered nurse (HRN)-D stated R5 was recently certified for hospice care. HRN-D visited R5 in the facility on 12/8/24 at 11:30 a.m. HRN-D reported when she entered R5's room, R5 was in bed and unresponsive, both eyes were matted shut and dark brown material on both corners of her mouth. HRN-D stated R5 appeared to be in same position she had placed her the day prior, R5's bed linens were soiled and incontinent pad 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 interview and document review the facility failed to accurately comprehensively assess pressure ulcers in order to determine, develop, and implement individualized interventions to reduce the risk and/or prevent new pressure ulcers and/or deterioration of existing pressure ulcers for 2 of 3 residents (R3, R4) reviewed for pressure ulcers. Findings include Definitions: Pressure ulcer/Injury (PU/PI): localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear. Deep tissue pressure injury: Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at 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 have a clear communication process between hospice and the facility of a change in hospice services to be provided and to designate a member of the facility's interdisciplinary team to coordinate care to the resident by the facility and hospice staff for 1 of 1 (R5) resident who received hospice services. Findings include: R5's face sheet dated 12/16/24, identified diagnoses of malnutrition (condition where body does not get enough nutrients), chronic kidney disease (condition where kidneys have been damaged), osteoarthritis (condition with joint pain and stiffness), and weakness. R5's quarterly Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment and dependent for dressing, grooming and hygiene. During an interview on 12/10/24 at 4:08 p.m., registered nurse (RN)-H reported that R5 was seen by hospice registered nurse (HRN)-D on 12/8/24. RN-H stated she did not receive any new recommendations about R5's plan of care from HRN-D…

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 observations, interview and documents review the facility failed to ensure enhanced barrier precautions (EBP-where gown and gloves used for high contact resident care activities) was used for 1 of 1 resident (R7). In addition, the facility failed to ensure handwashing/hand hygiene was implemented for 2 of 2 residents (R7, R9) observed for handwashing/hand hygiene. Findings include: R9's admission Minimum Data Set (MDS) dated [DATE], identified diagnosis of dementia and was dependent on staff for all mobility, grooming and hygiene. During an observation and interview on 12/11/24 at 10:16 a.m., R9 was in bed and nursing assistant (NA-N) and registered nurse (RN-F) were performing peri care for an incontinent bowel movement. RN-F did not perform hand hygiene prior to placing gloves on. RN-F removed R9's soiled pad, then completed incontinence cares on R9. RN-F placed soiled pad in trash, then removed gloves without performing hand hygiene. RN-F stated that hand washing/hand hygiene should be done before…

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 timely discharge notification in writing to the resident/resident representative, and the Ombudsman for 1 of 1 residents (R1) reviewed for discharge. Findings include: R1's face sheet printed 5/1/24, identified diagnoses of Alzheimer's, dementia, and senile degeneration (mental deterioration associated with age) of the brain. R1's admission Minimum Data Set (MDS) dated [DATE], identified an admission date of 2/24, severe cognitive impairment with inattention, diabetes, atherosclerotic heart disease, diverticulitis, hypertension, falls, urine retention, hyperlipidemia, disorganized thinking, daily wandering behaviors, and was on hospice. R1's care plan dated 2/16/24, identified a focus that R1 chose to remain at the facility for long-term care cognitive impairment/hospice care. R1's progress note dated 4/22/24 at 8:18 p.m., identified that R1's son was called and R1 would be admitted to a dementia unit. Son stated that he would rather R1 stay…

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 expired foods were disposed of, ensure staff followed their process to log cooked food temperatures to ensure appropriate oversight of cooked foods, and monitor refrigerator and freezer temperatures as indicated per policy. The facility also failed to log the results of their chemical test strips and dishwasher per policy to ensure dishes were sanitized correctly. In addition, the facility failed to ensure the dry storage area was maintained in a clean, sanitary manner and in was in good repair. This had the potential to affect all 31 residents. Findings include: Observation on 12/18/23 at 11:20 during the initial kitchen tour with the dietary manager (DM) identified the following: 1. The walk in refrigerator had a container of potato salad with a use by date of November 2023 and a bag with sliced ham leftovers that was undated. 2. The 3 compartment sink was visibly dirty, with a black unknown substance and food particles scattered throughout the bottom of the sink. A tin can containing grease was…

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

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility specific concerns, implement action plans for improvement, or ensure the committee participated in the development and oversight of implementation of systems, to ensure quality of life and quality of care were maintained for 31 of 31 residents residing in the facility. Findings include: Review of the QAPI meeting minutes from January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, and November 2023. No QAPI meetings documented as taking place for July 2023, August 2023, September 2023, and October 2023. The minutes failed to identify facility specific concerns, action plans for improvement, and/or analysis of any actions taken previously. Interview on 12/20/23 at 5:26 p.m., with the administrator reported he was not certain how frequently QAPI meetings were held prior to his starting at the facility, but he did not find evidence of meetings for July through October 2023. He identified the facility needed to identify…

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 the facility's Quality Assurance Program Improvement (QAPI) Program that included facility specific goals, elements of the program, how the facility intended to implement the program, in addition to the staff's role in the facility QAPI program. The facility also failed to provide education on how staff could communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. In addition, the current December 5, 2019, facility policy failed to identify the mandatory component of providing staff education on the facility specific QAPI program. Findings include: Interview on 12/20/23 at 9:38 a.m., with trained medication aide (TMA)-B reported she had been employed at the facility for 4 years and reported she had not received any QAPI training or recalled any facility specific programs, such as a performance improvement project (PIP). Interview on 12/20/23 at 9:42 a.m., with licensed practical nurse (LPN)-A reported she was aware the facility had a QAPI program but…

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

Based on observation, interview and document review the facility failed to have a method to identify when oxygen tubing needed to be changed for 4 of 4 residents (R18, R25, R27, and R183). The policy also failed to include documentation of the frequency for oxygen equipment changes for residents receiving oxygen. Findings include: R27's 12/6/23, Significant Change Minimum Data Set (MDS) assessment, identified R27 had intact cognition, and had diagnoses of malignant neoplasm of the lung (cancer), chronic obstructive lung disease (COPD), and required oxygen therapy. R27's, required oxygen at 2 liters (L) / minute (Min) continuously via nasal cannula for hypoxemia (a low level of oxygen in the blood). Observation on 12/18/23 through 12/20/23 identified an oxygen concentrator with a nasal cannula attached to a long tubing going from the concentrator to R27. Neither the tubing or concentrator contained a date of when it had last been changed or replaced. Interview on 12/19/23 at 9:04 a.m. with R27 reported she always needed her oxygen on, and she did not know when staff had last changed…

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.

6) Interview on 12/18/23 at 5:10 p.m., with R25 revealed she had to wait 15 to 30 minutes for staff response to the call light when needing assistance to the bathroom. R25 stated she didn't feel important when having to wait for assistance from staff. R25's 9/22/23, quarterly Minimum Data Set (MDS) identified R25 had mildly impaired cognition. R25 had diagnosis of hemiplegia (total or complete paralysis on one side of the body). R25 was dependent on staff for toileting and cares. R25 had impairment bilaterally in lower extremities. R25 had no toileting program and was frequently incontinent of bladder and always incontinent of bowel and took scheduled pain medication in the last 5 days. Interview and document review on 12/21/23 at 8:21 a.m., with the director of nursing (DON) identified her expectation for the staffing level in the facility was for it to be in accordance with the listed facility staffing pattern identified in the Facility Assessment noted above. Review of the reported staffing data report (PBJ) identified the DON agreed staffing had not been provided according 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.

Based on observation and interview the facility failed to ensure privacy of resident medical information for 1 of 2 facility medication carts which involved 10 of 31 residents (R2, R24, R22, R11, R28, R15, R1, R26, R183, and R19). This had the potential to be viewed by any resident and visitor passing by on the C wing unit. Findings include: Observation on 12/18/23 at 4:54 p.m., of 1 of 2 facility medication cart located on the C wing unit, displayed personal and medical information of the following residents: R2, R24, R22, R11, R28, R15, R1, R26, R183, and R19. The facility medication cart was left unattended with no staff personnel on the unit. Observation and interview on 12/18/23 at 4:59 p.m., with director of nursing (DON)-A stated her expectations would be for all residents information to be secured at all times. DON-A then closed the computer screen of the C wing medication cart. Interview on 12/20/23 at 10:01 a.m., with administrator (ADM-A) stated his expectations would be for the employees to keep residents' electronic medical records confidential and private when not in…

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

Based on interview and document review the facility failed to report an allegation of potential abuse timely to the facility management staff and the State Agency for 1 of 1 resident (R8) reviewed. Findings include: R8's 10/21/23, annual Minimum Data Set (MDS) identified R8 had moderately impaired cognition. R8 was dependent on staff for toileting and cares. R8 had impairment bilaterally in her lower extremities. R8 had inattention and disorganized thinking that fluctuated. R8 had verbal behaviors directed towards others 1-3 days and other behaviors not directed towards others such as screaming, 1-3 days. R8 had no toileting program and was frequently incontinent of bladder and always incontinent of bowel. R8 took a daily anti-psychotic, anti-anxiety, and anti-depressant. R8's 11/30/23, Significant Change MDS assessment identified R8 had severe cognitive deficit. R8's 5/5/23, care plan identified R8 preferred to use bedpan for toileting and refused to sit on a commode most of the time. R8 required 1 staff assist with bed mobility and was able to assist with turning by using the grab…

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

Based on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status and needs for 1 of 1 resident (R9) for depression. Findings include: R9's undated, current care plan identified R9 would be free from discomfort or adverse reactions to antidepressant medication through the review date. Staff were to administer antidepressant medication as ordered by physician. Staff were to monitor and document side effects and effectiveness of medication every shift and report adverse reactions of medications and consult Southwest Mental Health for services. The care plan identified side effects for antidepressant medication but lacked identification of target symptoms that were to be monitored for effectiveness. R9's 10/02/23 Southwestern Mental Health Center Standard Diagnostic Assessment identified R9 had a depression disorder. R9's 11/09/23, quarterly Minimum Data Set (MDS) assessment identified R9 had no cognitive impairment. R9 had little interest in doing things, feeling down, depressed, or hopeless,…

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 an integrated hospice care plan for 1 of 1 resident (R27). Findings include: R27's 12/6/23, Significant Change Minimum Data Set (MDS) assessment, identified diagnoses of malignant neoplasm of the lung (cancer), chronic obstructive lung disease (COPD), required oxygen therapy and was admitted to hospice care. R27's current, undated care plan identified there was no mention R27 was on hospice services, what services the facility was to provide, nor services the hospice agency was to provide. Interview and document review on 12/19/23 at 10:02 a.m., with LPN-A identified R27's care plan failed to contain documentation of any hospice services, R27's oxygen use, or use of a Foley catheter which should have been documented and included ont he facility care plan. LPN-A agreed it was not documented on what services hospice was to provide. Interview on 12/19/23, at 10:14 a.m., with the director of nursing (DON) confirmed her expectation for coordination of services between hospice providers and the facility. She confirmed 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 ensure staff sanitized a gastronomy tube (G-tube) port prior to initializing enteral feeding (nutrition provided thru a tube directly into the stomach) for 1 of 1 resident (R14) during 2 of 2 observations. Findings include: R14's undated, current Medical Diagnosis identified diverticulitis (small bulging pouches in the digestive tract that become inflamed or infected) of intestine, disease of digestive system, neutropenia (abnormally low count of a type of white blood cell), malignant neoplasm (cancerous tumor) of lip, oral cavity and pharynx and mild cognitive impairment. R14's undated care plan, identified R9 had potential for alteration in nutrition and dehydration due to malignant neoplasm. Staff were to monitor the G-tube site for signs of infection and would provide enteral feeding and water flushes as ordered. R14's 10/1023, quarterly Minimum Data Set (MDS) identified R14 had a feeding tube. R14 would receive 51% or more of total calories and 501 milliliters (ml) a day or more of fluid intake through…

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 1 of 5 residents (R23) reviewed for unnecessary medication usage. Findings include: R23's 11/30/23, significant change Minimum Data Set (MDS) assessment identified R23 had moderately impaired cognition. R23 had no behaviors identified. R23 had diagnosis of thyroid disorder, fracture, seizure disorder, depression, and manic depression bipolar type. R23 took a daily antidepressant and antipsychotic. R23's 9/11/23, care plan identified R23 used an antidepressant for depression. R23 would be free from discomfort or adverse reactions to antidepressant medication through the review date. Staff were to administer antidepressant medication as ordered by physician. Staff were to monitor and document side effects and effectiveness of medication every shift. The care plan identified side effects for antidepressant medication but lacked identification of target symptoms that were 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 ensure coordinated hospice services were documented as scheduled for 1 of 1 resident (R27), have a clear communication process for hospice to notify the facility of their updates, for the facility to notify the hospice of changes to R27's health status, need of potential transfers for care, or delineation of hospice services to be provided. Findings include: R27's 12/6/23, Significant Change, Minimum Data Set (MDS) identified R27's diagnoses of malignant neoplasm of the lung (cancer), chronic obstructive lung disease (COPD), and received oxygen. R27's cognition was intact, and she required limited to extensive assistance for most cares and would attempt to self-transfer at times and required a gait belt, walker, and assistance of one for ambulation. R27's progress notes identified R27 was hospitalized on [DATE] through 12/1/23 following a fall when she attempted to self-transfer. She returned to the facility on [DATE] and was admitted…

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, that facility failed to use appropriate infection control technique during 1 of 1 dressing change for resident (R28). In addition, the facility failed to ensure appropriate Infection control (IC) signage was posted outside 2 of 6 resident (R8, and R 103 x 2) rooms that had been placed on transmission-based precautions (TBP). Findings include: DRESSING CHANGE Observation and interview on 12/19/23 at 12:19 p.m., with licensed practical nurse (LPN)-A as she performed a dressing change on R28's right shin, and right and left foot wounds identified R28 was seated in his recliner with both feet wrapped and resting on the floor. LPN-A obtained a plastic carrier with dressing supplies, placed it on the uncovered floor, placed a chux on the floor and picked up the plastic carrier and set it on the chux. She then applied gloves and sat on the floor to begin removing the stockinet from R28's right shin. A quarter sized area of dried red drainage was noted on the stockinet which was removed and placed on the chux on the floor. LPN-A removed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to offer and provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 2 of 5 residents (R8, R9) reviewed for immunizations. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year…

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

Based on interview and record review, the facility failed to ensure that 1 of 1 agency staff (nursing assistant (NA)-G) was oriented to the facility policies and procedures including Abuse, Neglect, Exploitation or Misappropriation, Reporting, and Investigating. Findings include: Interview on 12/19/23 at 10:31 a.m., with NA-G revealed he had worked with R8 on 12/18/23 and confirmed R8 had accused him of being rough when he turned her on her side. NA-G revealed the nurse had come and talked to him about R8 accusing him of being rough. NA-G reported R8 was in a bad mood and was cursing at him while he assisted her to turn on her side. NA-G revealed he had not told anyone that R8 had accused him of being rough during cares as R8 was fine after he had changed her incontinent product and even had him assist her to call her husband. Review of NA-G training records obtained from the agency NA-G was employed by included a copy of an employee handbook and policies that covered the NA job description, resident abuse, neglect, and reporting. NA-G had a signature that was time stamped at 3:26…

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.