Crestwood Health Care Center

Based on observation, interview and record review, the facility failed to update a resident's comprehensive care plan following admission into hospice services (Resident #9). The sample size was 31. The census was 141.Review of the facility's Comprehensive Care plan policy, reviewed 10/31/24, showed:-Purpose: To develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment;-Person centered care: To focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives;-Policy:-The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility as outlined by the comprehensive care plan, shall be competent;-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 record review, the facility failed to ensure care was provided in accordance with professional standards of practice by not following physician's orders when staff administered the wrong medication to one resident (resident #92). The sample size was 31. The census was 141. Review of the facility's Transcription of Orders/Following Physician's Orders policy, revised 5/18/24, showed:-The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed;-To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders;-Clarification of Physician's Orders will be obtained if the order is either unclear or the nurse is uncomfortable in implementation of the Physician's Orders;-The RCC (Resident Care Coordinator)/Unit Manager/Designated Nurse will review all electronic MARs/TARs (Medication Administration Record/Treatment Administration Record) and compare all…

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 ensure residents who needed assistance with nail care, received timely nail care services. The delay in services resulted in long, jagged and unkempt toenails (Resident #107 and Resident #12). The sample was 31. The census was 141.Review of the nail care policy, revised 6/26/24, showed:-Purpose: To provide guidelines for the provision of care to a resident's nails for good grooming and health;-Policy: -Assessments of nails will be conducted on admission and readmission to determine the nail condition, needs, and preferences for nail care: -Report unusual or abnormal conditions of the nails to the physician and the responsible party (curling, color changes, separation from the nail bed, redness, bleeding, pain, odor, and infection); -Obtain history and preferences regarding podiatry; -Identify conditions that increase risk for foot or nail problems, such as diabetes, vascular disease, heart failure, renal disease or stroke; -Routine cleaning and inspection of nails will be provided during daily care on an…

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

Based on interview and record review, the facility failed to ensure the Nurse Aide (NA) registry verifications were checked before allowing four employees to work and provide care to residents (Employees AAA, CCC, DDD, and EEE). The census was 141.Review of the facility's Background Investigations policy, revised on 12/27/24, showed:-Job reference checks, drug screenings, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with this company;-The Human Resource department will conduct all applicable background investigation(s) on each individual making applications for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied;-For all applicants applying for a position as a certified nurse aide, the human resources department will contact the nurse aide registry of the state in which the individual is certified and/or previously employed to verify that the applicant's certification is in good standing;-The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its medication error rate did not exceed five percent or greater. Five errors were observed out of 25 opportunities, with a 20 percent error rate (Residents #5, #16, #23, and #102). The sample was 38. The census was 141.Review of the facility's Medication Administration policy, revised 6/26/24, showed:-Purpose: Medications are administered by licensed staff and as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. It is the policy of the facility to ensure the safe and effective administration of all medications by utilizing practice guidelines;-Policy:-Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and right documentation;-Administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff notified one resident's physician regarding the resident's low blood pressure. In addition, the resident had two antihypertensive medications ordered, and one of those two medications was administered while the resident was hypotensive (blood pressure below 90/60) (Resident #7). The sample was 33. The census was 133.Review of the facility Notification Of Changes Policy, dated [DATE], showed:-Purpose: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification;-Policy: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification;-Circumstances Requiring Notification:2. Significant change in the resident's physical, mental 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when two residents (Residents #1 and #2) were involved in a resident-to-resident altercation. Resident #1 suffered a bloody lip as a result of Resident #2 hitting him/her in the mouth. The sample was 12. The census was 137.The Administrator was notified on 9/23/25 at 4:55 P.M., of the past non-compliance, which occurred on 9/16/25. The facility provided 1:1 for the residents and updated their care plans. The deficiency was corrected on 9/16/25. Review of the facility's Abuse and Neglect Policy, revised 6/12/24, showed:-It is the policy of this facility to report all allegations of abuse to the Administrator of the facility immediately and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, 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.

This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 6/13/25.See the deficiency cited at F584 in Event ID Z3RV-H2.

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow its cleaning policy when staff did not provide residents with a clean, sanitary, and homelike environment. Facility staff failed to thoroughly clean two residents' rooms (Resident #30 and Resident #29). The facility also failed to use proper precautions when handling soiled towels and/or linen, affecting all residents residing at the facility. In addition, the facility also failed to thoroughly clean shower rooms on the 100 and 200 halls after resident use. This had the potential to affect all residents who utilized those shower rooms. The sample was 32. The census was 139. Review of the facility's Housekeeping Deep Cleaning policy, revised 6/29/23, showed: -Purpose: To ensure all rooms are clean; -Policy: Deep cleaning is to be completed as scheduled. This includes complete pull-outs of furniture in rooms, wall cleaning, floor cleaning (scrubbing and waxing included), restrooms to be cleaned and disinfected, cob webs removed, beds and rails to be…

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 follow their Abuse and Neglect policy when they failed to notify the Department of Health and Senior Services (DHSS) after Certified Medication Technician (CMT) F threw Kool-Aid in Resident #25's face on the morning of 5/28/25. The census was 139. Review of the facility Abuse and Neglect Policy revise on 6/12/25, showed: -Purpose: It is the policy of this facility to report all allegations of abuse/neglect/mistreatment immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames; -Definitions: -Mental Abuse: Mental abuse includes, but is not limited to humiliation, harassment, threats of punishment or deprivation. Mental abuse includes the use of verbal or nonverbal conduct witch causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation; -Mistreatment: Mistreatment is inappropriate treatment or exploitation of a resident; -Notifications: Report 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 record review the facility failed to ensure one resident with a history of elopement was provided with adequate supervision and staff oversight. On 5/14/25, Resident #16 was left unsupervised in the courtyard during a smoking break. The resident used a chair in the courtyard to climb over the fence and was noticed in the road close to the facility by an off duty staff member. On 5/24/25, the resident once again used a chair in the courtyard to climb over the fence. The resident was not noticed missing for three to four hours and was found approximately 3.7 to 4.7 miles from the facility, depending on the route the resident walked. In addition, the Administrator confirmed that one of the two exit doors in the dining room had an alarm that was faint for approximately one month before 6/8/25 when Resident #18 left the facility through the door and was noticed by a staff member in the parking lot. The facility identified 45 residents as a high risk to elope and problems were found…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure staff documented accurate information in Resident #16's electronic medical record (EMR). On 5/24/25 at 9:15 A.M., Registered Nurse (RN) C documented the resident eloped from the facility and was found on the facility parking lot, despite having knowledge staff were actively searching for the resident. The resident was found approximately 3.7 to 4.7 miles from the facility. The census was 139. Review of the facility Documentation in Medical Record policy, revised on 5/30/25, showed: -Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the residents and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation; -Policy Explanation and Compliance Guidelines; -Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance…

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 follow their Bloodborne Pathogens/Exposure Control Plan policy by failing to immediately clean and disinfect a potentially infectious blood spill left overnight on one resident's floor (Resident #34). In addition, the facility failed to follow its Handling Clean and Dirty Linen policy when staff failed to place plastic liners inside the designated soiled linen receptacle located in the 100, 200, and 400 shower rooms and did not place the lid back on top of the soiled linen barrel in the 200 and 400 hall shower rooms. The shower room was a community shower. Twenty-five residents were sampled. The census was 145. Review of the facility's Bloodborne Pathogens/Exposure Control Plan dated 4/6/17, and revised on 6/29/23, showed:-This program applies to all occupational exposures to blood or other potentially infectious materials encountered by personnel employed by the Facility;-Employees are grouped according to their risk of exposure according to the following Exposure Categories: Category I - tasks that involve direct exposure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one resident's (Resident #2's) right to be free from physical abuse was not violated when Resident #1 hit Resident #2 in the head and face with a dismantled towel rack, which caused bruises to Resident #2. The facility also failed to ensure two other residents' rights to be free from abuse were not violated when the residents got into a fight (Resident #3 and #4) and Resident #4 sustained a swollen eye. The sample was eight. The census was 140. The Administrator was notified on 3/25/25, of the past non-compliance. The facility responded appropriately when the incident occurred. The residents were separated and received medical assessment and attention. Resident rooms were changed so Resident #1 no longer resides on the same hall as Resident #2, and Resident #3 no longer resides on the same hall as Resident #4. Counseling services were arranged for Residents #1 and #3. Continued education on behavior de-escalation techniques 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 record review, the facility staff failed to supervise residents while smoking in the designated smoke room (Resident #3, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10). In addition, the facility failed to conduct a thorough investigation in a timely manner on how the residents were able to light the cigarette and smoke unsupervised. The sample was 10. The census was 145. Review of the facility's Smoking Safety Regulations, dated 6/29/23, showed the following: -Purpose: The purpose of this policy is to ensure that all staff and residents are following the safety regulations for smoking as outlined by the Life Safety Code of the National Fire Protection Association and State and Federal Regulations; -Procedure: -The facility will follow all smoking regulations; -The facility will ensure that all designated smoking areas will utilize a non-combustible, self closing container for the residents smoking to ensure cigarette and ashes are disposed of properly; -The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when one resident (Resident #4) and another resident (Resident #5) were in a physical altercation. Resident #4 sold a cellular phone to Resident #5. Resident #5 said the cellular phone did not work and Resident #5 tried to attack Resident #4. Resident #4 hit Resident #5 and gave him/her bruising to the right eye and a laceration to the right eyebrow. The sample was five. The census was 144. The Administrator was notified on 2/19/25 at 10:07 A.M., of the past non-compliance, which occurred on 2/1/25. The facility provided training and in-servicing for all staff regarding the facility's Abuse and Neglect Policy. The facility also updated both residents' care plans to ensure they were educated on not to borrow, sell, or trade with other residents. Both residents gave verbal understanding. The deficiency was corrected on 2/5/25. Review of the facility's Abuse 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 record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when three residents (Residents #1, #2, and #3) were involved in two physical resident to resident altercations (Resident #1 and #2) and (Resident #1 and #3). Resident #1 was involved in a resident to resident altercations two days in a row and suffered a nose bleed as a result of Resident #3 hitting him/her in the nose. The sample was seven. The census was 139. The facility was notified of the past non-compliance on 12/20/24. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. The deficiency was corrected 12/14/24. Review of the facility's Abuse and Neglect Policy, revised 6/12/24, showed: -It is the policy of this facility to report all allegations of abuse to the Administrator of the facility immediately and to other appropriate agencies in accordance with current state and federal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when two residents were involved in physical resident to resident altercation, in which one resident placed their hands around another resident's neck (Residents #3 and #2). The sample was 7. The census was 137. The facility was notified of past non-compliance on 11/6/24. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on abuse and neglect prevention. The deficiency was corrected on 10/28/24. Review of the facility's Abuse and Neglect Policy, revised 6/12/24, showed: -It is the policy of this facility to report all allegations of abuse to the Administrator of the facility immediately and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames; -Abuse is the willful infliction of injury,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when staff failed to effectively intervene while two residents (Resident #1 and Resident #2) were involved in a verbal argument which escalated to a physical altercation, resulting in Resident #1 to be struck in the face by Resident #2. The facility census was 139. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed: -Definitions: -Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Physical abuse: Purposefully beating,…

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 have Registered Nurses (RNs) on each shift daily. Review of the Payroll Based Journal (PBJ) Staffing Report CASPER Report from CMS dated FY Quarter 1 2024 (October 1 - December 31, 2023) revealed a One Star Staffing Rating for excessively low weekend staffing. An interview with the Staffing Coordinator and the Human Resources Manager for the facility on 6/19/24 at 1:00 p.m. in the conference room revealed there was no RN coverage on the night shift (11 p.m. until 7 a.m.) documented on the daily staffing forms provided for Saturday, 6/15/24, Sunday, 6/16/24, and upcoming shifts for evening or night shifts for 6/20/24. The Staffing Coordinator stated the Licensed Practical Nurses (LPNs) take charge and notify the Physicians, call families and emergency personnel in the event of emergencies.

Based on observation, interview and record review the facility failed to ensure foods were stored, prepared and distributed under sanitary conditions as evidenced by: 1.) Failure to ensure food preparation areas and distribution equipment were stored under clean and sanitary conditions, 2.) Failure to ensure foods temperature logs were maintained to ensure the appropriate cooking temperatures were reached, and 3.) Monitor temperature and sanitizer concentration for the dish machine. Failure to meet these requirements could place residents at risk for food borne illness. The findings include: 1. Failure to ensure food was stored, prepared, and distributed under sanitary conditions. On 6/18/24 between 10:20 a.m. and 10:40 a.m., during a joint tour of the kitchen with the Dietary Manager (DM), the following observations were noted: Two (2) plastic bins which contained serving utensils (approximately 10-15) were observed under a food preparation counter. The bin lids were open and black colored crumbs and food crumbs were observed scattered in and around the utensils. Bins with lids…

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 provide and maintain complete and accurate accounting records, regarding the reconciliation of petty cash kept on hand, for the resident trust account. The census was 144. Review of the facility's Resident Trust Policy, dated 2/2/24, showed the following: -Purpose: Complete Procedures on Resident Trust Responsibilities; -Resident Trust Petty Cash: -The facility will maintain a Resident petty cash fund for resident trust transactions only. The Petty Cash Clerk will be a facility employee designated by the Administrator at each facility. The Petty Cash Clerk will be someone other than the Resident Trust Clerk and the Administrator and will not be authorized to sign checks. On a daily basis usually at the end of the day, the Resident Trust Clerk must enter into the banking system all transactions into and out of the petty cash box; -Sign and date the form and obtain the Administrator's signature on the form to confirm that he/she has approved the reconciliation. Review of the bank statements for the 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 record review, the facility failed to maintain an adequate surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 11 months. The census was 144. Review of the facility's Resident Trust Policy, dated 2/2/24, showed the following: -Purpose: Complete Procedures on Resident Trust Responsibilities; -General Information Regarding Responsibilities of Holding Resident Funds: -The facility shall provide assurance of financial security by means of a surety bond. The bond shall be in an amount equal to at least one and one-half times the average total of the reconciled monthly balances. A copy of the current bond shall be kept in a file in the facility by the Resident Trust Clerk. Review of the bond report for approved facility bonds by the Department of Health and Senior Services (DHSS), showed an approved bond of $175,000.00, dated 9/20/23. Review of the resident trust current balance report for April 2024, showed an amount of $120,901.84 in the trust account. During an interview on 6/25/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the residents' rooms and bathrooms and interviews with Residents #93 and #130, Houskeeper A and the Housekeeping Supervisor, the facility failed to provide a safe, clean, comfortable and homelike environment. An observation and interview with Resident #93 in his/her room on 6/20/24 at 10 a.m. revealed that his/her room (room [ROOM NUMBER]) and bathroom had not been cleaned thoroughly. Observation of the bathroom and his/her bedroom revealed the walls had brown stains, the floors were dirty, the commode in the bathroom had a brown substance around it's base and had stains on the floor and the walls and baseboard behind the commode. There was a dark brown substance on the vents of the exhaust fan above the commode. An observation of room [ROOM NUMBER], Resident #130's room on 6/21/24 at 10:03 a.m. revealed dark stained tile at the entrance to the resident's room, debris behind the bedroom door, debris under the air conditioning unit, water damaged grout stained brown behind the toilet…

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 ensure the preplanned menus and Diet Spreadsheets (which identified which foods and portion serving sizes should be served to each diet). Failure to ensure the preplanned menu was followed could place residents at risk for weight loss. The findings include: On 6/18/2024 between 11:30 am and 1:00 pm, during observation of the meal service in the main dining room, the meal served included creamed corn, baked beans, and pulled pork served on a hamburger bun. Review of the Week at a Glance - Week 1 menu revealed corn casserole and cornbread were included with the meal, however, these items were not observed being served. On 6/19/24 at 8:27 a.m., during observation of breakfast trayline, Dietary Aide (DA) D was observed plating foods to be served to residents seated in the main dining room. The entrée item for the meal included sausage gravy served over biscuits. A white handled ladle was used to serve sausage and gravy over a biscuit, the DA D added one (1) ladle full of the entrée to the plates being served. 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 record review, facility staff failed to sanitize their hands before they entered the room, during medication administration, and after they exited the room to prevent the spread of infection. This action affected two (2) residents (Resident #89 and Resident #83). Additionally, facility staff failed to remove their gloves and sanitize or wash their hands after they placed plastic liners into trash cans to be delivered to resident rooms. The findings include: Review of a facility policy titled, Medication Administration, undated, documented the following: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Guidelines: 4. Wash hands prior to administering medication per facility protocol and product. On 6/19/24 at 8:24 a.m., Medication Administration was observed on Hall 200. Certified Medication Technician (CMT) HH…

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 one (1) of six (6) medication carts was locked and all drugs and biologicals were in secured and locked compartments, on one (1) of six (6) floors outside of the nurse's station. This action did not ensure that these drugs and biologicals were not accessible to cognitively impaired residents. The findings include: Review of facility policy titled, Medication Storage Policy, dated 5/18/24 noted the following: Policy: I. General Guidelines: 1. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 2. Only authorized personnel will have access to the keys to locked compartments. 3. During medication pass, medications must be under direct observation of the person administering medications or locked in the medication storage area/cart. During facility tour and observation outside the nurse's station facing the 4th floor on 6/18/24 at 11:33 a.m., the medication cart was observed to be left unlocked 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 Please refer to Event ID 7FZ113. Based on interview and record review, the facility failed to follow their abuse and neglect policy by not reporting timely after an allegation of physical abuse was made for one resident and an allegation of sexual abuse was made for another resident. This affected two residents (Resident #101 and Resident #109). The sample was 11. The census was 146. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: --To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. -Reporting to Supervisor/Administrator/Director…

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 Please refer to Event ID 7FZ113. Based on interview and record review, the facility failed to follow their abuse and neglect policy by not reporting timely after an allegation of physical abuse was made for one resident and an allegation of sexual abuse was made for another resident. This affected two residents (Resident #101 and Resident #109). The sample was 11. The census was 146. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: --To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. -Reporting to Supervisor/Administrator/Director…

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 follow their policy to report to the Department of Health and Senior Services (DHSS) and investigate physical abuse between two residents which occurred when one resident wandered into another resident's room. The first altercation was not reported to DHSS and investigated. A second altercation occurred the next day, when the resident again wandered into the other resident's room. Both times, the resident hit the other resident in the mouth (Residents #3 and #4). The sample size was 5. The census was 139. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY See F689 cited at 7FZ112. Based on observation, interview and record review, the facility failed to provide protective oversight to one resident (Resident #30) with a known history of wandering and elopement, who resided on a locked unit. The resident eloped from the facility on 1/17/24, out of an alarmed door. Staff did not realize the resident had left until the resident was found at a gas station and brought back by the police over an hour after he/she was last seen by staff . In addition, the facility failed to complete elopement assessments per protocol, to include interventions to be implemented. The sample size was 22. The census was 140. Review of the facility's Elopement Protocol policy, last revised 1/19/22, showed: -Purpose: An elopement will be defined as any time a resident is missing from the facility or there is a possibility that a resident has left the facility without appropriate supervision and their whereabouts are unknown; -Procedure: The first person aware of an elopement will call a Code…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when residents were abused by other residents (Resident #1, #2, #3, and #4) for four of five sampled residents. The facility census was 136 residents. The Administrator was notified on 1/10/24 of the past non-compliance. The facility immediately began investigations of the incidents, separated and assessed the residents, as well as contacted all responsible parties and physicians, and sent the residents out for evaluations following the altercations. Upon the residents' return to the facility, the facility had interventions in place to ensure no further altercations would take place, which included: Medication adjustments (while at the hospital), room changes, frequent meetings, and social services follow up. In addition, abuse and neglect inservicing had been completed with staff, which included resident to resident abuse. The noncompliance was corrected on 12/23/23. Review of the…

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

Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary physical restraint when, in an attempt to keep a resident from wandering (Resident #20), Certified Nurse Aide (CNA) E picked the resident up, placed the resident over his/her shoulder and carried the resident to a chair. CNA E then tied a sheet to the chair, around the resident, to prevent the resident from getting up. The sample was 20. The facility census was 135. Review of the facility Abuse and Neglect Policy, dated 4/7/2017, revised on 1/19/2022, showed: -PURPOSE: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/ property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is…

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 follow their abuse and neglect policy by not reporting timely after an allegation of physical abuse was made for one resident and an allegation of sexual abuse was made for another resident. This affected two residents (Resident #101 and Resident #109). The sample was 11. The census was 146. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: --To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. -Reporting to Supervisor/Administrator/Director of Nursing: --Employee 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 record review, the facility failed to follow their policy when staff observed a staff member (Certified Nurse Aide (CNA) E) use a sheet to restrain a resident (Resident #20) to a chair because the resident wandered. The facility also failed to ensure staff were aware of their Abuse and Neglect Policy when Nurse Aide (NA) D observed the resident restrained and did not immediately report it because he/she was unsure if restraints were allowed. In addition, Certified Medication Technician (CMT) C observed CNA E pick up the resident and carry him/her to a different area. CNA E asked CMT C for medication to make the resident stop wandering. CMT C failed to immediately report this. Upon being made aware of the allegations, staff failed to immediately send CNA E home. Instead, staff assigned CNA E to a different area, and he/she continued to provide resident care for approximately twenty minutes. The census was 135. Review of the facility Abuse and Neglect Policy, dated 4/7/2017, revised on revised on 1/19/2022, showed: -PURPOSE: To outline procedures for reporting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide protective oversight to one resident (Resident #30) with a known history of wandering and elopement, who resided on a locked unit. The resident eloped from the facility on 1/17/24, out of an alarmed door. Staff did not realize the resident had left until the resident was found at a gas station and brought back by the police over an hour after he/she was last seen by staff . In addition, the facility failed to complete elopement assessments per protocol, to include interventions to be implemented. The sample size was 22. The census was 140. Review of the facility's Elopement Protocol policy, last revised 1/19/22, showed: -Purpose: An elopement will be defined as any time a resident is missing from the facility or there is a possibility that a resident has left the facility without appropriate supervision and their whereabouts are unknown; -Procedure: The first person aware of an elopement will call a Code White to the area of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure sufficient skilled and competent staff worked effectively with behavioral health residents when a staff person, who was assigned to provide one on one (1:1) intensive supervision to a resident (Resident #12) left the hall, leaving the hall insufficiently staffed. Soon after, a resident to resident altercation occurred between two residents (Resident's #11 and #12). The sample was 20. The facility census was 135. Review of the facility Abuse and Neglect Policy, dated 4/7/2017, revised on revised on 1/19/2022, showed: -PURPOSE: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/ property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies. To establish actions related to the alleged perpetrator…

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 services provided met professional standards of practice by not following physician's order and documenting the administration of orders for insulin (a naturally occurring hormone made by your pancreas that helps your body use sugar for energy) for one resident (Resident #1). The sample was five. The census was 139. Review of the facility's Blood Glucose Monitoring and Insulin Administration policy, last revised on 6/29/23, included: -Affected Personnel: Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Insulin Certified Medication Technicians (CMTs); -Purpose: To define accurate procedures to be followed when checking a blood sugar (measures the level of glucose (sugar) in your blood). To identify what measures will be taken in the event that a blood sugar falls out of the defined therapeutic range; -Procedure: Checking Blood Sugar: 1. The blood sugar monitoring/accucheck (blood sugar test) orders will be obtained from the physician, including the recommended time and frequency of the…

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

Based on observation and interview, the facility failed to maintain the overall cleanliness of the kitchen's floor, walk-in refrigerator and freezer, and label and date opened food items in the walk-in freezer. The facility staff also failed to wear hair restraints while in the kitchen and practice adequate infection control while handling food items. Additionally, the facility failed to maintain the cleanliness of the dining room. This deficient practice affected all residents who ate at the facility. The census was 132. 1. Observations on 7/7/21 at 8:29 A.M., 7/8/21 at 6:52 A.M., 7/13/21 at 5:21 P.M., 7/14/21 at 11:11 A.M. and 7/15/21 at 8:04 A.M., showed dried food debris, white speckles and grime near the food preparation area, outside of the walk-in refrigerator, and in the dry storage area throughout the kitchen floor. During an interview on 7/15/21 at 8:41 A.M., Regional Corporate Chef (RCC) O said the dishwashers and cooks were responsible for cleaning the kitchen and floors. The floors were not cleaned and should be. The facility planned to have the floors stripped and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to provide reasonable accommodations of individual needs and preferences by failing to ensure an acceptable table tray to encourage meal independence for seven residents (Residents #23, #90, #81, #62, #21, #75 and #142). The census was 132. Review of the facility's Resident Rights policy, revised 4/29/21, showed the resident has the right to reside and receive services with reasonable accommodation of individual needs and preferences, except when the health and safety of the individual or other residents would be endangered. 1. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/3/21, showed: -admitted : 6/1/07; -Diagnoses included: anemia (decreased number of red blood cells), bipolar disease (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)) and schizophrenia (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 interview and record review, the facility failed to ensure residents and/or responsible parties received quarterly statements to show the residents' activity regarding their trust fund. This affected 124 residents whose funds were handled by the facility. The census was 132. Review of the facility's Resident Trust policy regarding resident statements, revised on April 2018, showed: -A detailed written account of all transactions affecting each resident's trust account shall be maintained and made available upon request. All accounts shall be reconciled monthly. The individual financial record shall be made available by statements on a quarterly basis; -The Resident Trust Clerk is responsible for sending out quarterly statements; -Make copies of all statements and date stamp them with the date they were mailed. Retain the copies for your files; -Statements should be sent to the resident and his/her legal guardian or legal representative. During interviews and record review on 7/14/21 at 10:05 A.M. and 12:35 P.M., Employee LL, who oversees the resident trust account, said…

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 residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200 social security (SSI) limit or when the resident's account was over the SSI limit ($5,000). The facility also failed to update their policy to include the increase in the Medicaid limit. This affected 11 residents who received Medicaid benefits (Residents #606, #603, #610, #604, #605, #608, #609, #601, #600, #607 and #602). The census was 132. Review of the facility's Resident Trust Policy regarding monitoring resident trust balances, revised on 4/2018, showed: -The Resident Trust Clerk must monitor account balances. Medicaid residents are allowed to keep 999.99 in non-exempt resources. Any Medicaid resident who reaches a balance of 799.99 should be notified in writing that he/she is within $200 of the allowable non-exempt resource limit set forth and may lose their eligibility if they accumulate excess funds. The administrator and facility social worker should be advised of all account balances 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 record review, the facility failed to post the results of the most recent survey of the facility in a place readily accessible to residents, family members and legal representatives of residents. The sample was 26. The census was 132. Review of the facility's Resident Rights policy, revised 4/29/21, showed the resident has the right to examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility. The results must be made available by the facility and readily accessible to residents and the facility must post a notice of their availability. Observation on 7/7/21 at 8:58 P.M., 7/8/21 at 7:20 A.M., 7/9/21 at 8:00 A.M., 7/13/21 at 11:00 A.M. and 7/15/21 at 8:00 A.M., showed a sign behind the receptionist's desk that read, survey binder upon request. During an interview on 7/15/21 at 8:00 A.M., the receptionist was asked where the survey binder was located. He/she did not know where the survey binder was because he/she was new at the facility. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment by not ensuring walls, floors, furniture, exhaust vents and equipment were clean and in good repair in resident rooms and common areas for 7 out of 26 sampled residents (Residents #81, #28, #74, #118, #42, #110 and #39). The census was 132. 1. Review of Resident #81's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/15/21, showed the following: -admission date 2/18/21; -Cognitively intact; -Diagnoses included anemia, schizophrenia (a mental disorder leading to faulty perception, inappropriate actions and feelings and withdrawal from reality) and chronic obstructive lung disease. Observations on 7/7/21 at 9:15 A.M., 7/9/21 9:25 A.M. and 7/14/21 at 12:35 P.M., of resident's room, showed a single sink with a green and blue plaid pad underneath the sink that was wet to touch and the backboard was off below the sink, exposing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely checks were completed for criminal backgrounds, the employment disqualification list, and federal indicator checks and follow their policy for seven of ten employee records reviewed. In addition, the facility failed to implement abuse and neglect policies and procedures, in accordance with federal requirements, that addressed resident to resident sexual activity. The facility failed to ensure the resident's capacity to consent forms were signed all required parties for three residents (Residents #503, #39, and #58). The census was 132. 1. Review of the facility's Screening-Applicant employee, volunteer staff and Vendor policy revised on 4/29/21, under pre-employment screening, showed: -Human Resources department (HR) will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider on any federal or state healthcare programs, is eligible to work in the United…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report allegations of abuse to the Department of Health and Senior Services (DHSS) as required, within a two-hour time frame, for 7 residents (Residents #1, #92, #30, #20, #111, #142 and #9). The sample was 26. The census was 132. Review of the facility's Abuse and Neglect Policy, dated as last reviewed and approved 7/18/20, showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, to define terms of types of abuse/neglect and misappropriation of funds and property, and to ensure that a due process for appeals to the accused is outlined. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed; -It is the policy of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse for 12 of 26 sampled residents (Residents #503, #502, #92, #1, #493, #4, #28, #30, #20, #110, #62 and #34) who were involved in resident altercations. Appropriate witnesses and resident interviews were not documented or provided. This failure resulted in the facility not determining what actions are necessary for the protection of residents. The census was 132. Review of the facility's Abuse and Neglect Policy, dated last reviewed and approved 7/18/20, showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, to define terms of types of abuse/neglect and misappropriation of funds and property, and to ensure that a due process for appeals to the accused is outlined. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies. 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 record review, the facility failed to ensure care and services were provided according to acceptable standards of clinical practice. The facility failed to provide a low bed and administer medications as ordered by the physician, document a fall, notify the physician and responsible party (RP) of the fall, and complete post fall follow ups (Resident #23). The facility failed to complete post fall follow ups, daily weights and notify the physician that daily weights were not being completed (Residents #64 and #28). The facility failed to ensure physician orders were followed by not administering medication as ordered (Residents #6, #75, #116, #142, #69 and #33). The facility also failed to complete daily weights (Resident #101) and provide nutritional supplements as ordered (Resident #51). In addition, the facility failed to complete and document wound treatments as ordered (Resident # 99). The sample size was 26. The census was 132. 1. Review of the facility's Post Fall…

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 establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation for two out of three narcotic books reviewed. The census was 132. 1 Review of the controlled substance logs, dated 5/1/21 through 7/6/21, for the 500/600 halls, showed the following: -No signature recorded by the on-coming nurse, a total of 18 shifts; -No signature recorded by the off-going nurse, a total of 28 shifts; -Out of 201 shifts, narcotic count not recorded as completed a total of 57 times. 2 .Review of the controlled substance logs, dated 5/1/21 through 7/6/21, for the 100/400 halls, showed the following: -No signature recorded by the on-coming nurse, a total of 30 times; -No signature recorded by the off-going nurse, a total of 39 times; -Out of 201 shifts, narcotic count not recorded as completed a total of 72 times. During an interview on 7/7/21 at 9:12 A.M., Licensed Practical Nurse (LPN) A said narcotic counts should be completed at the beginning and end of each shift with the nurse reporting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident is offered an influenza immunization between October 1st through March 31st annually, unless contraindicated and failed to ensure the resident's medical record includes documentation that indicates at a minimum the resident or resident representative was provided education and either received or refused the immunization. This affected four of five residents sampled for immunizations (Residents #28, #81, #62 and #37). The census was 132. Review of the facility's Influenza and Pneumococcal immunization policy, last revised on 2/24/21, showed: -The purpose of this policy is to ensure that all residents residing in the facility are offered influenza and pneumococcal immunizations to prevent infection and the spread of communicable disease; -As part of the admission process, the resident or the resident's legal representative will be provided education on the benefits and potential side effects of both the influenza and pneumococcal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent gnats in resident common areas and resident rooms for 9 out of 26 sampled residents (Residents #23, #37, #51, #39, #118, #74, #110, #92 and #42). The census was 132. 1. Review of the facility's pest control logs from April through July 2021, showed: -On 4/12/21, inspected and treated interior and exterior. Paid special attention to kitchen area; -On 4/16/21, 4/23/21, and 4/30/21, service call backs. No further information regarding treatment or observations; -On 5/10/21, inspected fly light on normal pest service ticket; -On 6/4/21, inspected and treated interior and exterior. Additional treatment applied in kitchen; -On 6/9/21, 6/15/21, and 7/1/21, service call backs; -On 7/12/21, inspected and treated areas of concern. 2. Observations of the main dining room, showed: -On 7/7/21 at 12:01 P.M., approximately 16 residents sat throughout the dining room, eating lunch. Flies and gnats flew…

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 assess a resident's ability to safely self-administer their own medications for one resident with a history of drug seeking when staff left medications at the bedside (Resident #69). The sample was 26. The census was 132. Review of the facility's Resident Rights policy, revised 4/29/21, showed an individual resident may self-administer drugs if the interdisciplinary team, as defined by Section of Regulations of the Health Care Financing Administration, has determined this practice is safe. Review of Resident #69's medical record, showed the following: -An admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/21, showed diagnoses of hypertension (high blood pressure), acid reflux, arthritis, manic depression and schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves). -No order to self-administer medications; -No assessment for the ability to self-administer medications. Review of the resident's care plan, in use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect and facilitate residents' right to communicate with individuals and entities within and external to the facility, including reasonable access to a telephone for three residents (Residents # 115, #59 and #507) out of a sample of 26 residents. The census was 132. 1. Review of Resident #115's 5 day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/25/21, showed the following: -Wheelchair mobility; -Diagnoses included medically complex conditions, dementia, Parkinson's disease, asthma and chronic obstructive pulmonary disease (COPD, a lung disease which makes it difficult to breathe); -Required set up and supervision with bed mobility and eating; -Required limited assistance of one with transfers, ambulation, dressing, toilet use, personal hygiene and bathing. During an interview on 7/15/21 11:22 A.M., the resident said he/she was confined to his/her bed (on unit 100) most of the…

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

Based on interview and record review, the facility failed to inform the resident of the facility bed hold policy at the time of transfer to the hospital for one resident (Resident #135) hospitalized three times in June 2021. The sample was 26. The census was 132. Review of the facility's Resident Transfer/Discharge, Immediate Discharge policy, approved 4/29/21, showed: -When a resident is transferred to the hospital or other location or when a resident goes on therapeutic leave, the facility must provide to the resident or their legal representative, a written copy of the bed hold policy; -This notice must be given at the time of transfer or therapeutic leave. For emergency transfers, the notice must be given within 24 hours of the transfers; -If the emergency transfer was to a hospital, the facility may send copy of bed hold policy to the resident in the hospital if a hospital representative such as a social worker, agrees and will confirm resident received the copy in an email that will be kept in the medical record.; -Documentation that the bed hold policy was provided must be…

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 complete a preadmission screening for individuals with a mental disorder and individuals with intellectual disability by failing to ensure a resident had a DA-124 Level I screening (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) Level II screening is required) as required, for one of one sampled resident reviewed for PASARR (Resident #75). The census was 132. Review of Resident #75's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/3/21, showed the following: -Date of admission on [DATE]; -No screening information regarding PASARR, Level II PASARR, or conditions related to serious mental illness/intellectual disabilities/related conditions; -Diagnoses included depression, psychotic disorder and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and/or implement person-centered comprehensive care plans for one resident with a history of depression and self-harm (Resident #118) and one resident with behaviors of acting out (Resident #34). The sample size was 26. The census was 132. 1. Review of Resident #118's medical record, showed: -admitted [DATE]; -Diagnoses included schizoaffective disorder (chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), suicidal ideations, depressive episodes, insomnia and nightmare disorder (disturbing or scary dreams that awaken you, causing distress or preventing adequate sleep). Review of the resident's psychiatrist visit note, dated 1/20/21, showed: -Chief complaint: Staff report patient is attention-seeking. Will frequently say he/she is suicidal and make superficial cuts on his/her arms. Resident: I 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive discharge summary for one of three discharged residents (Resident #99). The census was 132. Review of Resident #99's closed medical record, showed he/she discharged to another facility on 6/27/21. Review of the resident's Interdisciplinary Discharge summary, dated [DATE], showed no information regarding the final summary of the resident's status, no reconciliation of all pre and post-discharge medication and no post discharge plan of care, including discharge instructions. During an interview on 7/15/21 at 10:24 A.M., the Social Services Director said he completed the social services portion of the discharge summary. Nursing should have completed their part regarding the medication and post-discharge instructions. During an interview on 7/16/21 at 12:39 P.M., Corporate Nurse C said the Discharge Summary showed the resident's medications were destroyed per facility protocol. The final summary of the resident's status and post…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received proper assistance with showers and nail care for two of 26 sampled residents. The census was 132. 1. Review of the facility's Shower and Bath Policy, revised 5/15/20, showed: -Purpose: To ensure all residents receive scheduled showers and baths and as needed/requested. Each resident must be scheduled for at least two showers or baths per week. Review of Resident #127's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/11/21, showed: -Cognitively intact; -Independent with personal hygiene; -Diagnoses that included high blood pressure, seizures, anxiety, manic depression (mental disorder that causes extreme mood swings) and psychotic disorder (mental disorder). Review of resident's medical record, showed he/she had right ankle surgery on 6/3/21, and diagnoses that included pain to the right ankle and joints of right foot. Review of the resident's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one resident (Resident #505) out of 26 sampled residents received treatment and care in accordance with professional standards of practice by not providing adequate supervision to prevent falls and not implementing restorative nursing programs in a timely manner which would enable the resident to maintain progress made in physical therapy. The resident's care plan showed that most of his/her falls were attributed to seizure activity, yet the facility failed to consistently document administration of his/her medications, in order to ensure the resident was receiving his/her seizure medications per his/her physician's orders. On 5/14/21, the resident had an a witnessed fall during the day and then an unwitnessed fall at night, resulting in a 3 centimeter (cm) right frontal contusion (a scattered area of bleeding on the surface of the brain, which occurs when the brain strikes a ridge on the skull or a fold in the dura mater- the brain's tough…

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 obtain a dialysis contract for one of one residents receiving dialysis (the process of filtering the blood for individuals with kidney failure) services (Resident #37). The facility also failed to notify the physician timely when the facility scale malfunctioned and staff were unable to obtain daily weights as ordered. The facility also failed to monitor the resident's bruit and thrill (the sound heard and vibration felt as the blood pumps through the dialysis access site) every shift, per the facility's policy. The sample was 26. The census was 132. Review of the facility's Dialysis Policy, approved date 12/1/19, showed: -Purpose: Ensure that residents who require dialysis receive such services as ordered by physicians; -The facility will ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences; -The facility will ensure that each resident receives care and services for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the drug use of a resident with a known history of drug dependence (Resident #69). The resident was hospitalized after taking an unknown drug substance and was placed on 1:1 monitoring after returning to the facility. The facility also failed to ensure necessary care services were person-centered and reflected the resident's need for safety, personal well-being, and to address drug addiction. The sample was 26. The census was 132. Review of the Facility's Assessment, showed the facility identified no residents with active or current substance use disorders. Review of Resident #69's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Rarely understood; -Diagnoses include hypertension (high blood pressure), acid reflux, arthritis, manic depression…

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 have ongoing monitoring of the effectiveness of the psychotropic medications for one out of seven residents investigated for unnecessary medications (Resident #6). The census was 132. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/15/21, showed: -Cognitively intact; -Diagnoses include anxiety and schizophrenia (serious mental illness that affects how a person thinks, feels and behaves). Review of the resident's care plan, dated 6/3/21, showed: -Focus: The resident has impaired cognitive function/dementia or impaired thought processes related to the diagnosis of moderate intellectual disabilities; -Goal: The resident will maintain current level of cognitive function; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; -Ask yes/no questions in order to determine the resident's needs; -Monitor/document/report as needed (PRN) any changes in cognitive function, specifically…

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 ensure medication error rates are not 5 percent or greater. Out of 33 opportunities observed, there were five errors, resulting in a 15.15% medication error rate (Residents #4 and #116). The census was 132. Review of the facility's Medication Administration and Monitoring Policy, last revised on 4/6/17, showed the following: -Procedure: Medications are to be given per doctor's orders. All medications are recorded on the Medication Administration Record (MAR) and signed immediately after the resident has taken the medications. (The nurse/Certified Medication Technician (CMT) has ensured that the medications were swallowed by the resident). The nurse/CMT will check each medication to the MAR noting correct name of the medication, correct name of the resident and correct time, dose and route of administration. If the medication is not available or the resident refuses the medication, the nurse/CMT will initial and circle the time of the medication in question. On the back of the MAR, the reason for the medication…

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 residents in shared rooms were provided with curtains which fully extended around the bed in order to provide total visual privacy, affecting four residents (Residents #39, #97, #110 and #74). The sample size was 26. The census was 132. 1. Observation on 7/7/21 at 11:52 A.M., 7/8/21 at 7:22 A.M., 7/9/21 at 6:31 A.M., 7/13/21 at 4:55 P.M. and 7/14/21 at 7:11 A.M., showed a room shared by Resident #39 and Resident #97, with Resident #39's bed next to the window. A privacy curtain hung from the ceiling and extended to the foot of the resident's bed, leaving the left side of the bed exposed and facing Resident #97's bed. No privacy curtain hung on Resident #97's side of the room. During an interview on 7/15/21 at 7:53 A.M., Resident #39 said the curtains in his/her room have been broken for a while. His/her curtain stops at the foot of his/her bed and there is nothing in between the residents' beds to give them privacy. He/she would like a curtain hung for privacy. 2. Observation on 7/13/21 at 5:27 P.M., showed a room…

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