Heritage Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement the facility's policy and procedure for the monthly drug regimen review by failing to ensure the physician or designee responded to the pharmacy recommendation timely for nine residents (Residents #2, #7, #11, #72, #64, #13, #67, #35 and #85). The sample was 43. The census was 105.Review of the facility's Medication Regimen Review (MRR) policy, dated 6/26/24, showed: -Purpose: the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the medical chart;-Policy: -MRR or drug regimen review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: -Review of the medical record in order to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities; -Collaboration with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer and vaccinate, as desired, eligible residents with the pneumococcal (pneumonia) and influenza (flu) vaccine for 5 out of 5 residents sampled for immunizations (Residents #85, #72, #67, #54 and #45). The sample was 43. The census was 105. Review of the influenza and pneumococcal immunization policy, revised 5/14/24, showed:-Purpose: to ensure that all residents residing in the facility are offered influenza and pneumococcal immunizations to prevent infection and the spread of communicable disease;-Procedure: -At admission, the resident and/or the resident's legal representative will be provided education on the benefits and potential side effects of both the influenza and pneumococcal immunizations; -The resident or their legal representative will be informed that the influenza immunization are provided yearly between October 1st and March 31, unless the immunization is medically contraindicated, the facility has evidence that the resident has…

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 a resident who experienced bilateral (both sides) finger amputations, had an accessible device to call for staff assistance (Resident #40). The sample was 43. The census was 105. Review of Resident #40's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/11/25, showed:-Cognitively intact;-Able to make needs and wants known;-Required physical assistance for eating; -Required brace for eating;-Required physical assistance for hygiene, eating, transfers and daily care;-Diagnoses included superficial frostbite of the left and right hand (a mild to moderate form of frostbite where ice crystals form in the top layers of the skin, making the skin appear pale, waxy, and feel stiff or hard), schizoaffective disorder (a 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), bipolar type (hallucinations with…

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

Based on interview and record review, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 98 residents. The census was 105. Review of the facility's Resident Trust policy, dated 6/12/25, showed Resident Trust clerk must reconcile the cash left in the box with the receipts in the box by completing the Resident Trust Petty Cash Reconciliation Form. Attach all receipts in the petty cash box to the Resident Trust Petty Cash Reconciliation form. The administrator signs reconciliation form for approval.Review of the facility-maintained bank statements for the months 4/25 through 7/25, showed no documentation of reconciliations.Review of the facility-maintained attempted reconciliation forms, dated 4/25 through 7/25, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of the attempted…

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 one resident's right to be free from physical abuse was not violated when one resident was placed in a head lock by Floor Tech N (Resident #39). The sample was 43. The census was 105. Review of the facility's Abuse and Neglect Policy, dated 6/12/24, showed the following:-Purpose: -It is the policy of this facility ensure all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Physical Abuse: -Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Physical abuse also includes, but is not limited 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 interview and record review, facility staff failed to prevent the misappropriation of one resident's patient trust funds, which was used without authorization of the resident. The funds were withdrawn from resident's patient trust account between the dates of 4/10 and 4/17/25, with total withdrawals of $7,877.01 (Resident #20). The census was 105. Review of the facility's policy titled, Abuse and Neglect, dated 6/12/24, showed:-Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of resident's belongings or money without the resident's consent;-Theft of money from bank accounts;-Unauthorized or coerced purchases from resident's funds;-The Administrator will conduct all investigations. A formal investigation shall begin immediately and include interviews with all staff, interview facility residents and document that interviews were completed. Review of Resident #20's Mental Status Exam, dated 8/18/25, showed:-No cognitive…

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 notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital and the facility's bed hold policy at the time of transfer for three residents who were discharged to the hospital (Residents #119, #69 and #114) out of three residents sampled for bed hold notification. The census was 105.Review of the facility's undated admission agreement, showed facility offers a bed hold policy which assures you of re-occupation to your bed during a temporary absence from facility due to therapeutic leave or hospital admission. If you choose not to hold the bed during an absence from the facility, that bed shall be considered vacant and facility may place another resident in it for occupancy. If your personal belongings have not been removed and it becomes necessary to occupy that room with another resident, facility will package all personal items and place them in storage for a period not to exceed two (2) weeks. Upon…

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 two residents received an accurate assessment, reflective of the residents' status at the time of assessment, by failing to identify the residents' hospice admission (Residents #10 and #36). The facility identified three residents receiving hospice services, two were sampled. The census was 105. 1. Review of Resident #10's face sheet, showed his/her diagnoses included malignant neoplasm (cancerous tumors) of cecum (pouch that forms the first part of the large intestine), secondary malignant neoplasm of liver and intrahepatic bile duct, and secondary malignant neoplasm of left lung.Review of the resident's Physician's Orders Sheet (POS), showed an order, dated 5/20/25, okay for hospice to evaluate and treat. Review of the resident's care plan, in use during survey, showed:-Problem: Resident receiving chemotherapy related to cancer that has metastasized (mets, spread to other parts of the body) to several areas of his/her body;-Desired Outcome:…

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 who re-admitted to the facility on [DATE] with a recommended hospice evaluation received the ordered hospice evaluation. The resident's physician assessed the resident on 7/18/25 and documented the resident received hospice services. On 7/30/25, the resident experienced a change in condition. Staff discovered the resident had not been enrolled into hospice services and did not notify the physician of the discovery. The resident expired at the facility approximately three hours after the change in condition (Resident #118). The census was 105. Review of the notifying clinician's policy, revised 6/26/24, showed:-Purpose: to ensure clinicians are properly notified of a resident's change in condition and overall, health and mental status;-Policy: -Process for notification: -Before calling the physician, the nurse must ensure they have all pertinent/situational information on the resident readily available; -The clinician shall be notified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete smoking assessments for two residents, to evaluate their smoking behavior risks. Both residents were smoking in their rooms. In addition, the facility failed to develop and implement appropriate safety interventions (Residents #7 and #108). The census was 105.Review of the facility's policy entitled, Smoking Safety Regulations, dated 6/23, showed:-Policy: to ensure staff and residents are following the safety regulations for smoking as outlined by the Life Safety Code of the National Fire Protections Association (NFPA).-Facility will provide direct supervision for smoking by patients classified as not responsible.Review of the facility's undated admission agreement, showed:-Section M, entitled Smoking: smoking is allowed only in designated smoking areas and times set forth by the facility. Residents shall only be permitted to smoke in accordance with the resident assessment and plan of care. Review of Resident #7's annual Minimum…

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 implement an effective pain management regime for one sampled resident (Resident #90). Staff failed to ensure Resident #90, who experienced pain related to chronic osteomyelitis with drainage sinus, right tibia and fibula involvement (a long-standing bone infection affecting the shinbone) and chronic pain most severe on the right knee, received physician prescribed Percocet (narcotic which treats moderate to moderately severe pain). The sample was 21. The census was 105.Review of the facility's Pain Management Policy, revised 6/26/24, included:-Recognized when the resident is experiencing pain and identify circumstances when the pain can be anticipated;-Evaluate the resident for the pain and the cause(s) upon admission, during ongoing scheduled assessments, and when significant change of condition or status occurs (after fall, change in behavior or mental statues, new pain or exacerbation of pain);-Manage or prevent, consistent with the comprehensive assessment and plan of care, current professional standards,…

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 are free from significant medication errors. Staff attempted incorrect administration technique for one resident, when he/she did not prime the insulin Flex pen in accordance with facility policy (Resident #2). The census was 105.Review of the facility's medication administration of insulin policy, revised May 2024, showed:-Prepare an insulin dose, before administering insulin, perform two nurse verifications of the correct resident, dose calculations, and correct route of administration.-Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir,-Dial 2 units (U) by turning the dose selector clockwise,-With the needle pointed up, push the plunger and watch to see that at least one drop (gtt) appears. Review of Resident #2's medical record, showed his/her diagnoses included diabetes, morbidly obese (severe), chronic obstructive pulmonary disease (COPD, lung disease that causes difficulty breathing), metabolic encephalopathy (altered brain function) 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 failed to maintain controlled substances in a restricted area until appropriate medical staff could destroy them. The Registered Nurse (RN) and Licensed Practical Nurse (LPN) medication cart assigned to the B and D halls held two discharged residents' narcotics for several weeks (Residents #114 and #117). The census was 105. Review of the facility's Narcotic Destruction Policy, revision date 6/24, showed:-All controlled substances shall be retained in a securely locked area with restricted access until authorized nursing personnel destroy them;-Any medication that is to be destroyed is to be locked in a separate cabinet and labeled to be destroyed. No other items, medications or treatments are allowed to be stores in the to be destroyed cabinet;-Medications should not be placed in the pocket or in an unsecured medication drawer to be handled at a later time. It must immediately be in the to be destroyed cabinet;-Destruction shall be completed as…

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.

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Based on observation, interview and record review, the facility failed to implement an effective pain management regime for one of three sampled residents (Resident #1). Staff failed to administer a stronger physician ordered pain medication for Resident #1, who complained of severe back pain. The census was 112. Review of the facility's Pain Management Policy, updated 6/26/24, showed the following: -Purpose: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person centered care plan and the resident's goals and preferences; -Policy: The facility will utilize a systemic approach for recognition, assessment, treatment and monitoring of pain; -Recognition of Pain: 1 a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. 1 c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences; -Pain Assessment:…

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.

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Based on interview and record review, the facility failed to facilitate residents' rights to have reasonable reliable access to and privacy in their use of electronic communications such as email and video communications, for internet research and to watch television when the facility failed to provide WiFi services. This had the potential to affect all residents at the facility. The sample was 7. The census was 106. Review of facility's Internet Provider documentation, showed: -Notice of Material Breach: -The facility was sent notification on/or around 9/16/24 by the Internet Provider that detailed the facility's violation of their Acceptable User Policy and the agreement. The facility shared its business/office only internet with the residents living at the facility. The residents then hooked up their personal devices to the business/office only internet. The facility allowed the continued use of the business/office only internet by the residents even after multiple Internet Provider notifications. The facility was given a timeframe to add a resident internet service package…

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 effective pest control by ensuring resident rooms were free from mice and/or mice excrement in Residents #9, #10, and #11's rooms. In addition the facility failed to ensure the common/activity area on C-Hall was free from roaches. The sample was eleven. The census was 106. Review of the facility's Pest Control policy, last reviewed 5/14/24, showed: -Purpose: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; -Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats); -Policy: Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. Review of the facility's pest control vendor invoices, showed: -Dated 1/31/25,…

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 before the facility transferred or discharged a resident, they notified the resident, who was his/her own responsible party, of the transfer or discharge and the reasons for the move in writing. The facility failed to ensure the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged , and that the discharge or transfer notice included the reason for transfer or discharge, effective date, location in which the resident would be discharged , and the resident's right to appeal for one resident (Resident #5). The sample was 5. The census was 111. Review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy, revised 5/14/24, showed: -Purpose: Establish policy and procedure regarding the transfer/discharge of residents; -Definitions: -Facility Initiated Transfer or discharge: A transfer or discharge which the resident objects to, which did not originate through a resident's verbal or written request, and/or 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.

Based on interview and record review, the facility failed to meet professional standards when staff did not clarify the instructions on one resident's discharge paperwork with the eye clinic after his/her eye appointment, which resulted in his/her eye surgery not being scheduled (Resident #6). The sample was 5. The census was 111. Review of the facility's Transcription of Orders/Following Physician's Order policy, revised 5/18/24, showed: -Purpose: 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; -Procedure: 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. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, target date 2/26/25, showed: -Cognitively intact; -Wheelchair; -Diagnoses included,…

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 complete a comprehensive discharge summary for one discharged resident record reviewed (Resident #5). The sample was 5. The census was 111. Review of the facility's Nursing Discharge Summary policy, revised 5/14/24, showed: -Purpose: It is the policy of this facility to ensure that a discharge summary is provided upon a resident's discharge which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies; -Definitions: -Anticipated discharge means that the discharge is planned and not due to the resident's death or an emergency; -Continuing care provider means the entity or person who will assume responsibility for the resident's care after discharge. This includes licensed facilities, agencies, physicians, practitioners, and/or other licensed caregivers; -Recapitulation of stay means a concise summary of the resident's stay and course of treatment in the facility; -Reconciliation of…

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

Based on interview and record review, the facility failed to ensure there were sufficient and competent staff to care for one resident who required 1:1 staff supervision for safety and behaviors (Resident #1). Staff failed to follow the resident's care plan intervention of avoiding power struggles when the resident wanted to go to bed but was told there was not enough staff to take him/her. This contributed to the resident's escalated aggressive behavior which resulted in the resident being sent out to the hospital via ambulance. The sample was 8. The census was 106. Review of the facility's Sufficient Staff policy, revised 5/18/24, showed: -Purpose: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment; -Policy: -The facility will supply services by sufficient numbers of each…

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 This citation is uncorrected. See the narrative at Event ID WGJ612 This deficiency is uncorrected. For previous examples, please see the Statement of Deficiencies dated [DATE]. Based on interview and record review, the facility failed to follow their abuse and neglect policy by failing to conduct a thorough investigation for one resident (Resident #7) who had an order for a mechanical soft diet and was served a regular diet. The resident choked and later expired in the hospital. The sample was 10. The census was 110.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure they followed their abuse and neglect policy by failing to conduct a thorough investigation into one resident (Resident #8) who was found to have unknown pills in his/her possession and allegedly drank a solution of magnesium citrate (a salt that contains magnesium and citrate ions which is commonly used as a laxative to treat occasional constipation). The sample was eight. The census was 110. Review of the facility's policy, When to Notify Management, dated 8/2/24, showed the following: -Purpose: The purpose of this policy is to ensure that the facility management and Regional Director are notified for concerns related to the protective oversight of residents and facility operations. Review of the facility's Abuse and Neglect Policy, dated 6/12/24, showed the following: -Purpose: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation…

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 #2) and another resident (Resident #3) were involved in three resident to resident altercations before Resident #2 was moved to another hall. In addition, the facility did not update the residents' care plans with interventions after each resident to resident altercation. The sample was five. The census was 112. Review of the facility's Abuse and Neglect Policy, dated 6/12/24, showed the following: -Purpose: -It is the policy of this facility ensure all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames; -Physical Abuse: -Purposefully beating, striking, wounding, or…

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

Based on observation, interview and record review, facility staff failed to follow acceptable infection control practices to prevent the spread of infection, Covid 19 (respiratory virus spread by breathing, coughing and sneezing). The facility had active Covid 19 infections on all halls per signage upon entering. The signs instructed all visitors and staff to wear an N95 mask. Visitors and staff failed to wear N95 masks and or failed to wear them appropriately. This had the potential to affect all residents. The census was 112. Review of the facility's policy on Personal Protective Equipment, updated 6/26/24, showed the following: -Purpose: Thee facility promotes appropriate use of personal protective equipment (PPE) to prevent the transmission of pathogens to residents, visitors and other staff; -Policy: A. All staff who have contact with residents and or their environments must wear PPE equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids or potential infectious materials in the facility; -Respiratory protection: 1.…

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 a medication error rate of less than 5%. Out of 27 opportunities for errors, six errors occurred, resulting in an 22.22% medication error rate (Resident #6). The census was 112. Review of the facility's Medication Administration Policy, dated 6/26/24, showed the following: -Purpose: Medications are administered by licensed nurses and 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. It is the policy of this facility to ensure the safe and effective administration of of all medications by utilizing best practice guidelines; -Policy: General Medication Administration Practice: C. Identify resident by photo in the medication administration record (MAR). J. Ensure that the six rights of medication administration are followed: 1. Right resident, 2. Right drug, 3. Right dosage, 4. Right route, 5. Right time, 6. Right documentation. K. Review MAR to identify medication to be administered. L. Compare 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, interview and record review, the facility failed to prevent a significant medication error. Staff failed to transcribe antipsychotic medication as ordered for one of six sampled residents, resulting in the resident receiving the incorrect dosage of an antipsychotic medication (Resident #6). The census was 112. Review of Resident #6's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/4/24, showed the following: -Diagnoses of high blood pressure, anxiety and depression; -No cognitive impairment; -No mood problems; -No behavior problems; -Receives antipsychotic medicine: yes. Review of the facility's Medication Administration Policy, dated 6/26/24, showed the following: -Purpose: Medications are administered by licensed nurses and 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. It is the policy of this facility to ensure the safe and effective administration of of all medications by utilizing best practice…

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 of seven sampled residents was free from physical abuse. The resident's right to be free from physical abuse (Resident #5) was violated when another resident (Resident #4) hit the resident in the face and knocked him/her to the floor. The census was 113. On [DATE] at 3:30 P.M., the Administrator was notified of the past noncompliance, which occurred on [DATE]. On [DATE], the Administrator was notified by staff of the incident and an investigation was started. The facility immediately took steps to protect the residents and set interventions in place to prevent further abuse. The alleged violation was reported within the required timeframe. Facility staff received education on the facility's Behavioral Emergency Policy and Abuse and Neglect Policy. Both residents' care plans were updated. Appropriate corrective actions were taken. The deficiency was corrected on [DATE]. Review of the facility's Abuse and Neglect policy, revised…

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 the deficiency cited at Event 6lBE12. Based on observation, interview and record review, the facility failed to provide a safe, comfortable and homelike environment by staff using an employee break room as a smoking area for both residents and staff. The employee break room was not an approved, designated smoking area for the facility. The sample was 11. The census was 111. Review of the facility's resident smoking policy, last reviewed December 2023, showed: -Guidelines: The residents will be safe and have protective oversight during smoke breaks; -The staff will ensure the residents are appropriately dressed for the weather during smoke break times; -There was nothing found in the policy regarding only using designated smoking areas. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/23, showed: -Cognitively intact; During an interview on 1/24/24 at 1:29 P.M., the resident said: -His/Her room was located on the same…

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.

See the deficiency cited at Event 6lBE12. Based on interview and record review, the facility failed to immediately report an allegation of staff to resident abuse involving Resident #1 and Hall Monitor A to the Department of Health of Senior Services within the required two-hour time frame. The sample was 14. The census was 111. Review of the facility's abuse and neglect policy, dated revised 1/5/23, 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. 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. -The facility must ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, or sexual assault including injuries of unknown source and misappropriation of resident property, are…

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.

See the deficiency cited at Event 6lBE12. Based on interview and record review, the facility failed to complete a thorough investigation and to prevent further potential abuse while the investigation was in progress, after being notified by Resident #1 of an allegation of physical abuse. The sample was 14. The census was 111. Review of the facility's Abuse and Neglect policy, dated revised 1/5/23, 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. 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. - Protection of residents: Employees of this facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results 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 provide a safe, comfortable and homelike environment by staff using an employee break room as a smoking area for both residents and staff. The employee break room was not an approved, designated smoking area for the facility. The sample was 11. The census was 111. Review of the facility's resident smoking policy, last reviewed December 2023, showed: -Guidelines: The residents will be safe and have protective oversight during smoke breaks; -The staff will ensure the residents are appropriately dressed for the weather during smoke break times; -There was nothing found in the policy regarding only using designated smoking areas. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/23, showed: -Cognitively intact; During an interview on 1/24/24 at 1:29 P.M., the resident said: -His/Her room was located on the same hall as the staff break room and he/she…

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

Based on interview and record review, the facility failed to immediately report an allegation of staff to resident abuse involving Resident #1 and Hall Monitor A to the Department of Health of Senior Services within the required two-hour time frame. The sample was 14. The census was 111. Review of the facility's abuse and neglect policy, dated revised 1/5/23, 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. 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. -The facility must ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, or sexual assault including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than…

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 complete a thorough investigation and to prevent further potential abuse while the investigation was in progress, after being notified by Resident #1 of an allegation of physical abuse. The sample was 14. The census was 111. Review of the facility's Abuse and Neglect policy, dated revised 1/5/23, 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. 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. - Protection of residents: Employees of this facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results of the investigation and review by administrator.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide behavioral health services according to the resident's plan of care for one resident (Resident #2). During an episode of resident agitation, a staff member completed a one-person hold and brought the resident to the floor by him/herself, which was against facility policy. The facility also failed to follow the resident's care plan which instructed staff not to use the Crisis, Alleviation, Lessons and Methods (per facility policy, CALM) physical intervention with this resident. The sample was four. The census was 114. The Administrator was notified on 12/12/23 of the past non-compliance. The facility immediately began an investigation of the incident, removed the staff member who initiated the physical intervention from the building, and inserviced staff regarding the Behavioral Emergency Policy, the Supportive Techniques Oversight Protection (STOP) Program and the Abuse/Neglect Policy. The resident received a medical assessment at the hospital.…

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 observations, interviews, and facility record and policy reviews, the facility failed to store foods off the floor and away from chemicals, ensure employees wore hair restraints, and failed to maintain the ice machine to prevent dirt/grime build up for all residents who received nourishment from the kitchen. The facility census was 108. Findings included: 1. Review of a facility policy titled, Dietary - Receiving and Storing Food and Supplies, revised on 06/30/2023, indicated, All foods should be stored away from the walls and off the floor. The policy further indicated, Cleaning supplies must be stored in a separate area away from all food. On 09/18/2023 beginning at 8:46 A.M., the surveyor observed an outside storage shed with bottled water, pot and pan detergent, a can of diced tomatoes, and a can of diced peaches on the floor. An unopened bag of bowtie pasta was stored on a shelf next to a bottle of sanitizer. The Dietary Manager (DM) stated the facility used the outside storage for dry goods, including food, since she had started working at the facility. The DM stated…

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 keep residents accounts from going into a negative balance which allowed the residents to spend another resident's money without written authorization. The facility managed funds for 82 residents. A sample of six were chosen and the practice affected three residents (Residents #6, #9, and #10). Additionally, the facility failed to ensure resident funds were placed in an account, separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 14 residents (Residents #1, #2, #3, #4, #5, #11, #12, #14, #18, #20, #45, #102, #108, and #411). The census was 108. Review of the facility's Resident Trust Policy, dated January 2020, showed the following: -Purpose: Policy and Procedure on Resident Trust Responsibilities; -Resident Trust Petty Cash; -When a resident requests a cash withdrawal from his/her personal funds, the petty cash clerk will first verify that the funds are available. This is to be done by obtaining an Open…

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 a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not reconciling all outstanding checks each month dating back to 2012. The facility managed funds for 82 residents. The census was 108. Review of the facility's Resident Trust Policy, dated January 2020, showed the following: -Purpose: Policy and Procedure on Resident Trust Responsibilities; -Resident Trust Bank Reconciliation: -A reconciliation of the bank statement will be completed by the Corporate Management Company staff accountant. Exceptions may be considered on a case by case basis. The reconciliation must be done by someone other than the Resident Trust Clerk; -On the first day of every month the Resident Trust Clerk must prepare a log of all checks that were written from the resident trust account during the prior month. The list should include the date, check number, payee and amount of the check. This list should be sent to the Corporate Management Company staff accountant responsible for…

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

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 12 months. The census was 108. Review of the facility's Resident Trust Policy, revised dated January 2020, showed the following: -Purpose: Policy and Procedure on Resident Trust Responsibilities; -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 (1 & 1/2) times the average total of 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 facility's maintained Accounts Receivable (A/R) Aging Report for the period 1/23/23 through 9/23023, dated September 2023, showed the facility held an average balance of resident funds in the amount of $13,345.46 in the facility operating account. Review of the resident trust account for the past 12 months, from September 2022 through August 2023, showed 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 observations, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. Specifically, the facility's medication error rate was 19.23%, with 5 errors out of 26 opportunities. This affected three (Resident #24, #35, and #59) of six sampled residents reviewed for medication administration. The facility census was 108. Findings included: A review of the facility policy titled, Medication Administration and Monitoring, revised 09/17/2021, specified, Procedure: Medications are to be given per doctor's orders. The policy revealed The nurse or C.M.T. will check each medication to the MAR [Medication Administration Record] noting correct name of medication, correct resident name, correct dose, correct time and correct route of administration. MAR's will be opened to the residents name during dispensing of medications. The policy revealed It is imperative that all medications are given using the seven rights to medications administration and that the professional caregiver ensures that medications are swallowed. a. Right Resident b. Right…

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

Based on interview, record review, and facility policy review, the facility failed to immediately notify the Responsible Party of a change in condition, hospitalization, and room changes for one (Resident #29) of three residents reviewed for notification. Specifically, the facility failed to notify Resident #29's Responsible Party (RP) of the resident's change in condition and transfer to the hospital in a timely manner and failed to notify Resident #29's RP when the resident was moved to a different room. The census was 108. Findings included: Review of a facility policy titled, Resident's Rights, revised 07/05/2023, revealed, 1. Facility must immediately inform Resident, consult with Resident's physician, and if known, notify Resident's legal representative or an interested family member when there is: i. An accident involving Resident which results in injury and has the potential for requiring physician intervention; ii. A significant change in Resident's physical, mental or psychosocial status (i.e. [such as], a deterioration in health, mental, or psychosocial status in either…

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 interviews, record review, and facility policy review, the facility failed to report three injuries of an unknown origin to the state survey agency for one (Resident #68) of two residents reviewed for abuse. The census was 108. Findings included: A review of the facility's policy titled, Abuse and Neglect Policy, with a revision date of 01/05/2023, revealed 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. The policy specified, Injuries of unknown source - An injury should be classified as an injury of unknown source when both of the following conditions are met: - The source of injury was not observed by any person or could not be explained by the resident - The injury is suspicious because of the extent of the injury, the location of the injury on 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 interviews, record review, and facility policy review, the facility failed to thoroughly investigate an allegation of injuries of an unknown origin for one (Resident #68) of two sampled residents reviewed for abuse. The census was 108. Findings included: A review of the facility's Abuse and Neglect Policy, with a revision date of 01/05/2023, revealed 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. The policy specified, D. Investigation Upon learning of the report of abuse or neglect, the Administrator shall initiate an incident investigation. A review of Resident #68's admission Record revealed the facility admitted the resident on 09/16/2020 with diagnoses that included unspecified dementia, schizoaffective disorder, and major depressive disorder. A review of Resident #68's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2023, revealed the Staff Assessment for Mental Status…

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 interviews, record review, and facility policy review, the facility failed to ensure one (Resident #68) of four sampled residents reviewed for discharge, was allowed to remain in the facility without appropriate justification and documentation for a facility-initiated immediate discharge. The facility failed to provide evidence of physician documentation to indicate the basis for Resident #68's facility-initiated discharge from the facility or any resident's needs the facility was not able to provide. The census was 108. Findings included: A review of the facility's policy titled, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, revised 06/30/2023 revealed, Purpose: Establish policy and procedure regarding the transfer/discharge of residents Definitions: I. 'Facility-initiated transfer or discharge': A transfer or discharge which the resident objects to, which did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. The policy specified, I. A.…

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

Based on interviews, record review, and facility policy review, the facility failed to ensure one (Resident #68) of four sampled residents reviewed for discharge, received a 30-day notice of discharge when the facility initiated a discharge to another long-term care facility. The census was 108. Findings included: A review of the facility's policy titled, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, revised 06/30/2023, revealed Purpose: Establish policy and procedure regarding the transfer/discharge of residents Definitions: I. 'Facility-initiated transfer or discharge': A transfer or discharge which the resident objects to, which did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. The policy specified, B. What Notice Must Include The written notice shall include the following information: 1. Reason for the transfer or discharge; 2. Effective date of the transfer or discharge; 3. Location to which the resident is being transferred or discharged ,…

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 observations, record review, and interviews, the facility failed to ensure one (Resident #54) of three residents reviewed for activities of daily living (ADLs) had a comprehensive care plan to address the resident's ADL status and assistance required. The census was 108. Findings included: A facility policy for care plans was not provided by the facility. A review of an admission Record showed the facility admitted Resident #54 on 08/11/2023. The admission record showed the resident had diagnoses which included Parkinson's disease, bipolar type schizoaffective disorder, muscle weakness, and drug-induced subacute dyskinesia (uncontrolled, involuntary movements of the face, arms, or legs). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/2023, showed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 15, assessing the resident as cognitively intact. The MDS assessed Resident #54 as independent with bed mobility, transfers, walking in the room and corridor, locomotion on the unit, dressing, eating, toilet use, and personal…

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 record review, interviews, and facility policy review, the facility failed to ensure pressure ulcer wound care was provided as ordered by the physician for one (Resident #311) of two residents reviewed with pressure ulcers. The census was 108. Findings included: The facility's policy titled, Pressure Ulcers, revised on 06/29/2023, revealed The purpose of this policy is to provide a description of pressure ulcers and give protocols for providing care and treatment to the resident with a pressure ulcer. The policy indicated, 7. Residents that present with a Stage IV [four] pressure are can [sic] have the following implemented but not limited to: b. If the resident has a non-draining wound, the Physician may order a wet to dry dressing or follow the recommendations of the Wound Nurse Consultant. c. If the resident has moderate to heavy drainage, the Physician may order a wound vac or wet to dry dressings which are changed more frequently. The Physician may also follow the recommendations from the Wound Nurse Consultant. A review of Resident #311's admission Record showed 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 observations, record review, and interview, the facility failed to ensure the medical record for two (Resident #161 and Resident #311) of two sampled residents reviewed for urinary incontinence included the providers clinical indication for use of an indwelling urinary catheter and a physicians' orders for care of the residents' catheter. In addition, there was no documented evidence indwelling urinary catheter care was provided for Resident #311 from admission on [DATE] through April 2022. The facility census was 108. Findings included: Review of a facility policy titled, Catheter Care, with a revision date of 06/29/2023, indicated, Purpose: The facility will ensure any resident with a urinary catheter will be maintained to prevent infection. Procedure: 1. Residents who have a urinary catheter will have physician's orders for the catheter, care, and diagnosis, i.e. [for example], neurogenic bladder, urinary retention, decubitus ulcer; to support the use of the catheter. 2. Residents with indwelling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to obtain orders for the use and care of a colostomy (a surgical procedure that diverted stool to an opening in the abdominal wall) for one (Resident #311) of two residents reviewed for colostomy care. Facility documentation failed to show evidence of colostomy care being provided from admission on [DATE] through April 2022. The facility census was 108. Findings included: A facility policy titled, Ostomy Care (Colostomy, Urostomy, Ileostomy), dated 07/15/2019, specified, Purpose: To keep Ostomy site area clean & pouch application to provide clean ostomy pouch for fecal/urine evacuation. Reduces odor from overuse of pouch. A review of Resident #311's admission Record showed the facility admitted the resident on 03/30/2022 with diagnoses that included quadriplegia (paralysis of all four limbs and the torso). A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/07/2022, showed Resident #311…

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 observations, record review, and interviews, the facility failed to ensure one (Resident #7) of two sampled residents reviewed for respiratory care had orders for the use and care of a continuous positive airway pressure (CPAP) device. The facility further failed to ensure the CPAP contained water for use and that staff cleaned and stored the CPAP equipment appropriately. The facility census was 108. Findings included: A review of an admission Record showed the facility admitted Resident #7 on 05/27/2022. Per the admission Record, Resident #7 had a medical history to include diagnoses of sleep apnea (a condition in which breathing stopped and restarted while sleeping), acute respiratory failure with hypoxia (oxygen deficiency), and chronic obstructive pulmonary disease (COPD). A review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/15/2023, showed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS assessed Resident #7 as receiving oxygen therapy. A review of…

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

Based on interviews, record review, and facility document and policy review, the facility failed to have ongoing communication and collaboration with the dialysis facility and provide care in accordance with facility policy for one (Resident #102) of one resident reviewed for dialysis services. The facility census was 108. Findings included: Review of a facility policy titled, Dialysis, dated 11/28/2017 and revised on 03/18/2022, indicated, 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 residents' goals and preferences. The facility will ensure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including the: 1. Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. 3. Ongoing assessment and oversight of the resident before and after…

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, interviews, and facility document reviews, the facility failed to ensure Licensed Practical Nurse (LPN) #1 had the skills and competencies to perform duties as required. Specifically, the facility failed to ensure LPN #1 was competent to check one (Resident #28) of six sampled residents reviewed for medication administration blood glucose levels and maintain infection control standards. The facility census was 108. Findings included: A review of the facility Nursing Services Orientation Licensed Practical Nurse/Registered Nurse indicated, 4. Skills must be performed under the Nurse providing orientation. 5. Review will take place after your orientation or at the end of your probationary period. The document further indicated, 7. The record will be kept in your file in the Human Resources Office. A review of the Check Off List for Orientation revealed competency for the skills/techniques for blood glucose monitor and standard and universal precautions were required. During medication administration observation on 09/20/2023 at 8:05 A.M., LPN #1 was observed…

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 one resident (Resident #3) was free from unneccesary drugs when facility staff administered an intramuscular injection of an antipsychotic medication without adequate indications for use, when the resident became upset after requesting to speak to the administrator and being denied. Facility staff administered an antipsychotic drug medication, Haldol (used to manage positive symptoms of schizophrenia, such as hallucinations and delusions), prior to an order being obtained. The sample was three. The census was 108. Review of the facility's Indication for Use of Antipsychotic Drugs, dated July 2023, showed the following: -Policy: It is the facility's policy that each resident's drug regimen is free from unnecessary drugs, including antipsychotic drugs without adequate indications for use; -Procedure: 1. The indications for initiating, withdrawing, or withholding medications(s), as well as the use of non-pharmacological approaches, will be determined by assessing the resident's underlying condition, current signs and…

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

Based on observation, interview and record review, the facility failed to follow their abuse policy to protect all residents from physical abuse when a member of the nursing staff physically assaulted a resident by striking the resident's head during care (Resident #17). The sample size was three. The census was 106. The Administrator was notified on 8/23/23, of the past non-compliance. The facility has educated all staff on their abuse and neglect policy, how and when to use therapeutic techniques for de-escalating behaviors, when to utilize their Code Green (the facility's response to emergent or emergency situation related to behaviors) and when to report incidents of abuse. The deficiency was corrected on 8/18/23. Review of the facility's abuse policy, dated 11/28/16 and last revised on 1/5/23, showed the following: -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…

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 infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmissions of communicable disease and infections by failing to provide perineal care according to professional standards for two (Resident #40 and #86) out of three residents observed to receive perineal care and failing to provide clean, sanitary laundry service room(s). The census was 111. Review of the facility's perineal care (cleansing the portion of the body in the pelvis occupied by urogenital passages and the rectum) policy, dated 4/6/17, showed: -Purpose: To ensure that the female and male resident genital area is kept clean and proper techniques are used to prevent skin break down, infections, or any other impairments that can be caused from not using proper aseptic techniques; -Always wash from front to back to prevent spreading fecal matter from the anal area to 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 maintain an effective pest control program to prevent gnats in the kitchen, including in the food preparation area and in the dish machine room. This had the potential to affect all residents who ate from the facility kitchen. The census was 111. Observation on 7/21/19 at 6:48 A.M., showed gnats observed to fly around in the dry storage area. The dietary manager left the dry storage and returned with a can of pesticide spray. She began spraying the pesticide spray in the dry storage area, directing the can over the drain in the center of the floor. Within two feet of the drain, sacks of flour and other paper packaged items sat on the shelves. As she sprayed the can of pesticide spray, the surveyor could smell and taste the chemical in the air. The dietary manager said she controlled the gnats by spraying over all the drains in the kitchen. You have to keep on them, so staff spray this over the drains. She continued to spray around the door and along the doorway inside the dry storage area. The food preparation…

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 had complete, accurate and individualized care plans, to address hospice services and palliative care and failed to address residents future discharge plans and goals. For 21 of 23 sampled residents (Residents #82, #109, #112, #43, #98, #19, #73, #66, #70, #28, #81, #69, #92, #53, #34, #60, #80, #87, #32, #105, and #6). The census was 111. 1. Review of Resident #82's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/25/19, showed: -Brief interview of mental status (BIMS) score of 12 out of a possible score of 15; -A BIMS score of 8-15, showed the resident understands and is able to make self-understood; -Independent for bed mobility, transfers, walking in room, toilet use, and dressing; -Set up help only for walk in corridor and locomotion on and off the unit; -Uses wheelchair; -Steady at all times for balance during transitions and walking; -Continent of bowel…

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

Based on observation and interview, the facility failed to ensure food was prepared by methods that conserve nutritive value, flavor, and appearance and failed to ensure food and drink that is palatable, attractive, and at a safe and appetizing temperature by failing to ensure food was cooked thoroughly, tasted appetizing, temperatures on the steam table were maintained at least at 140 degrees Fahrenheit (F), and tray service temperatures were maintained at least at 120 degrees F. The census was 111. Observation of residents during the lunch meal service in the main dining room, on 7/24/19 at 1:02 P.M., showed several residents observed to pick up their entrée of stuffed green peppers and eat the pepper like a sandwich. Upon closer observation, the contents of the suffered pepper appeared white and filled with rice. The green pepper appeared firm and the meat not easily discernable within the rice. A test tray was requested, which showed the food tasted cold, the rice tasted and the texture felt undercooked with bits of hard rice that crunched as the surveyor chewed. The sauce…

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, record review the facility failed to provide resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual for one resident (Resident #82) out of 23 sampled residents. The census was 111. Review of Resident #82's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/25/19, showed: -Brief interview of mental status (BIMS) score of 12 out of a possible score of 15; -A BIMS score of 8-15, showed the resident understands and able to make self-understood. Review of the MDS coordinator notes, dated 3/27/19, showed the resident asked about his/her medical records and he/she was told the facility has them and when the time comes for him/her to leave the facility, his/her attorney will ask for the records. Review of the resident's letter of guardianship from [NAME] County, Missouri dated 1/1/17, showed: -The guardian 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 maintain and implement written policies and procedures regarding the residents' right to formulate an advance directive and refuse medical treatment by failing to ensure residents' code status matched the code status listed on the physician's order sheet, for one of 23 sampled residents (Residents #92). The census was 111. Review of the facility's advance directive policy, date 3/21/17, showed: -There shall be documented in the resident's medical record whether the resident has executed any advance directives, and copies shall be made a permanent part of the resident's medical record; -Advance directive includes any of the following which relate to providing of health care to a resident while he/she is incapacitated: -Living will; -Durable power of attorney for health care; -Any other written document executed by the resident, signed, and dated that express the individual's health care treatment decisions; -Notification of physician: The resident's attending physician shall be timely notified by the Director of Nursing…

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 issue a Notice of Medicare Non-Coverage (NOMNC) for three of three sampled residents (Resident #53, #163, and #93) who remained in the facility upon discharge from Medicare A services for rehabilitation services. The facility census was 111. 1. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline, for four residents out of 23 sampled residents (Resident #67, #88, #101, and #109). The census was 111. Review of the facility's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Care Assessment and Individualized Care Plans policy, dated 10/1/10, showed: -Section I in the MDS is to be completed by nursing staff. The most important part of this sections deals with active diagnoses. It gives an accurate picture of the resident's health status; -Only the current diagnosis in which is being treated or monitored under doctor care and nursing assessment should be listed in this area. Must be an active diagnosis 1. Review of Resident #67's annual MDS,…

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

Based on observation, interview, and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by not providing grief counseling for one resident who experienced the death of a sibling and was unable to attend the funeral (Resident #82) out of 23 sampled residents. The census was 111. Review of Resident #82's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/25/19, showed: -Brief interview of mental status (BIMS) score of 12 out of a possible score of 15; -A BIMS score of 8-15, showed the resident understands and is able to make self-understood; -No behaviors listed; -Active diagnoses included bipolar disorder (psychiatric illness characterized by both manic and depressive episodes, or manic ones only), seizures, and atrial fibrillation (A-fib, irregular heart rhythm). Record review of the resident's progress notes, showed: -On 1/18/19, the Social Worker was made aware the resident's brother…

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's drug regimen was free from unnecessary psychotropic drugs by failing to document a reason for placing one resident (Resident #6) on Ambien as well as failure to provide a rationale for reordering the Ambien. In addition, the facility failed to obtain qualifying diagnoses for the use of antipsychotic medications for five residents (#6, #88, #101, #32, and #67) of eight residents investigated for unnecessary psychotropic medications. The sample size was 23. The census was 111. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/22/19, showed the following: -Cognitively intact; -Independent with toileting and transfers; -Required set up assistance only from staff for hygiene and dressing; -Diagnoses included orthostatic hypotension (a drop in blood pressure when changing position), diabetes, depression, and schizophrenia (a mental disorder);…

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

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards in two out of seven medication/treatment carts. The census was 111. Review of the facility's Medication Rooms and Medication Carts Monthly Inspections Policy, dated 4/6/19, showed: -Purpose: to ensure that the facility is monitoring the labeling and storage of all medications within the facility on a routine monthly basis; -The facility will utilize a pharmacy consultant to review all resident's medication regimen and the facility's storage of medications. This will include inspections of the medication carts, treatment carts and medication rooms; -The medication carts, treatment carts, and medication rooms will be reviewed for the following areas: -Cleanliness; -Correct labeling; -Expiration dates; -Open, dated items and timeframe to be destroyed after opening. Review of the facility's Insulin Storage Policy, dated 9/22/17, showed: -Staff must date all bottles, cartridges, and pens after they are…

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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete and accurately documented by not documenting diagnoses for medications on the physician order sheets for three (Resident #88, #101 and #109) residents out of 23 sampled residents. The census was 111. 1. Review of Resident #88's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/16/19, showed: -Active diagnoses included heart failure, diabetes mellitus, and depression. Review of the resident's physician order sheet (POS), dated July 2019, showed: -Order dated 3/8/19, for Eliquis (anticoagulant) 2.5 milligram (mg), give one tablet twice a day; -Order dated 4/16/19, for Novolin (short acting insulin) 70-30 100 units per milliliter (ml), inject subcutaneous (under the skin) 37 units every morning; -The facility failed to include diagnoses for the use of the medications. 2.…

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.