Athene Nursing And Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (tube that drains the urine from the bladder) had physician orders to include catheter care instructions, for two of three residents sampled with indwelling urinary catheters (Residents #182 and #10). The facility identified 12 residents with indwelling urinary catheters. The sample was 47. The census was 166.Review of the facility's Catheter Care policy, revised 8/1/25, showed:-It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;-Catheter care will be performed every shift and as needed by nursing personnel;-Empty drainage bags when bag is half-full or every three to six hours;-Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. 1. Review of Resident #10's electronic Physician's Orders Sheet (ePOS), dated November 2025, showed:-An order dated 11/22/25, to discontinue order for change…

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

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The sample was 47. The facility census was 166.Review of the facility's 2025 QAPI Plan, showed:-Establish a facility-wide process to identify opportunities of improvement through continuous attention to quality of care, quality of life and resident safety;-Address gaps in systems or processes;-Ensure adequate provision of staffing, time, equipment and technical training resources;-Establish clear expectations around safety, quality, rights, choice and respect;-Continually improve the quality of care and services provided to our residents;-The facility conducts performance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow current infection control best practices and facility infection control policy for three of 47 sampled residents who were receiving antibiotic therapy. Concerns were noted with the indications for use in the antibiotic orders for all three residents (Residents #69, #166 and #26). The facility census was 166. Review of the facility's Antibiotic Stewardship Program Policy, revised 7/2/25, showed:-The Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' efforts by working with the Infection Preventionist (IP). The IP utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms;-The program includes antibiotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 acceptable nursing practice when facility staff left medication in one resident's room (Resident #135), who did not have a physician order for self-administration or medications to be left at the bedside. The sample was 47. The census was 166.Review of the facility's Resident Self Administration of Medications policy, last revised, 8/1/25, showed;-Policy: It is the policy of this facility to support each resident's right to self-administer medication; a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely;-Policy explanation and Compliance Guidelines: -When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: -The medications appropriate and safe for self-administration; -The resident's physical capacity to swallow without difficulty, open medication bottles, administer injections; -The resident's 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 ensure bed hold notices were provided for two of four residents investigated for discharge (Residents #166 and #177). The sample was 47. The census was 166. Review of the facility's Bed Hold Notice Upon Transfer policy, dated 8/1/25, showed:-Policy: at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed;-The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. 1. Review of Resident #166's medical record, showed: -Discharge to the hospital on [DATE];-No filled out and signed bed hold notice provided by the facility for the date of 10/16/25. 2. Review of Resident #177's, medical record, showed:-Discharge 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident care plans included revisions to address individual care needs for two of 47 sampled residents, when the facility included incorrect information about diet orders and code status on resident care plans (Residents #12 and #143). The facility census was 166.Review of the facility's Care Planning - Resident Participation Policy, revised 8/1/25, showed:-The care planning process should include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care;-The facility will encourage and assist the resident and/or representative to participate in choosing care and treatment options including: initial decisions about treatment, decisions about changes in treatment, and the right to refuse treatment;-If participation of the resident or resident's representative is determined not practicable for the development of a resident's care plan, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services provided met professional standards when staff failed to obtain weights as ordered for two residents (Residents #175 and #177). The facility also failed to ensure physician's orders for hemodialysis (a life sustaining treatment for kidney failure that removes waste and extra fluids from the blood) assessments were obtained for one resident out of three residents sampled for hemodialysis (Resident #5). The sample was 47. The census was 166. Review of the facility's Weight Monitoring policy, revised 9/1/25, showed:-Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;-Compliance guidelines: Weights should be recorded at the time obtained. Newly admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff attempted to communicate with a resident, who was non-English dominate speaking resident, in in a form and manner that the resident can understand. The facility did not provide an activity calendar in his/her dominate language, a communication board, or use a translation application to communicate with the resident (Resident #176). The sample was 47. The census was 166.Review of the facility's Culturally Competent Care policy, revised 4/23/25, showed:-Policy: to provide culturally competent care in accordance with professional standards of practice. The facility has established a culture that treats each resident with respect and dignity as an individual, as well as addresses, supports and/or enhances his/her feelings of self-worth including personal control over choices and cultural preference;-Effective communication: describes a process of dialogue between individuals. The skills include speaking to others in a way they can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 safety and adequate monitoring were provided during meals for two residents who had recommendations from Speech Therapy regarding proper positioning, type of required assistance during meals and/or monitoring during meals (Resident #109 and #11). The resident sample was 47. The census was 166.Review of the facility's Activities of Daily Living (ADLs) policy, revised 4/23/25, showed:-The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.-Care and services will be provided for the following activities of daily living: Eating to include meals and snacks;-Terminology for ADL evaluation and documentation will follow definitions from the State's Resident Assessment Instrument Manual: Partial/moderate assistance: if the helper does LESS THAN HALF the effort. Helper lifts, holds, 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, the facility failed to ensure one resident that had a gastrostomy tube (g-tube, a tube that is surgically inserted into the abdomen to administer fluids, liquid nutrition, and medications) received the correct water flush during medication administration (Resident # 178). The sample was 47. The census was 166. Review of the facility's policy for Medication Administration via Enteral tube (feeding tube), date last revised 5/1/25, showed:-Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines;-Procedure: Verify physician orders for medication and enteral tube flush amount; Flush enteral tube with at least 15 milters (ml) of water prior to administering medications unless otherwise ordered by prescriber; Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe greater than 30 ml in size; Flush the tube again with at least 5 ml of water takin into account resident's volume status; Repeat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident's' behavior (Resident #177). The sample was 47. The census was 166.Review of the facility's Behavior Management policy, last revised, 8/1/25, showed:-Policy: Residents who exhibit behavioral concerns may require a behavioral management care plan to ensure they are receiving appropriate service sand interventions to meet their needs; The interdisciplinary team, including the family member, should develop a behavioral plan for each resident with identified behaviors; The plan should reflect the resident' personal preferences and usual routine, to the extent possible; the plan should include the recreation schedule, non-pharmacological interventions, and environment adjustments needed to help the resident meet his or her highest practicable well-being;-Policy explanation and compliance guidelines: -Upon admission of a new resident, the Unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 narcotic medication was under a double lock and counted when a resident admitted and destroyed when the resident discharged from the facility (Resident #179). The sample was 47. The census was 166. Review of the facility's medication administration policy, dated 2/7/24, showed: -Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of Resident #179's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/27/25, showed: -Diagnoses included chronic kidney disease, muscle weakness, and dementia; -Moderately impaired cognition. Review of the resident's progress notes, showed: -A note, dated 12/18/25, resident discharged with all personal belongings, escorted to long term care facility in personal vehicle by his/her son. Discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assure that residents receive meals with appropriate nutritive content as prescribed by a physician to support the resident's treatment and plan of care, in accordance with his/her goals and preferences by failing to assure one resident received an appropriate substitute for starches (Resident #5). The sample was 47. The census was 166.Review of the facility's Assisted Nutrition and Hydration policy, revised 8/1/25, showed:-The facility will: Provide nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment;-Recognize, evaluate, and address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration;-Provide a therapeutic diet taking into account the resident's clinical condition and preferences;-Based on the resident's comprehensive assessment, the facility will ensure each resident: Maintains acceptable parameters of nutritional and status, such as usual body weight 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, the facility failed to follow current CDC (Centers for Disease Control and Prevention) guidelines and the facility's infection control policies for two of 47 sampled residents. Staff failed to use an adequate disinfectant on reusable medical equipment during a resident's dressing change (Resident #9). Staff failed to use adequate Enhanced Barrier Precaution (EBP, precautions requiring the use of additional protective equipment by staff when providing care to reduce the spread of certain infections) interventions when providing direct care to a resident with a catheter (thin flexible tube) (Resident #135). The facility census was 166. Review of the facility's Enhanced Barrier Precautions policy, revised 4/23/25, showed: -The policy is designed to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs); -An order for Enhanced Barrier Precautions will be placed for residents with any of the following conditions: wounds, wounds such as chronic pressure ulcers, diabetic foot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their personal needs by not providing baths/showers for two residents (Residents #13 and #12). In addition, the facility failed to ensure staff had enough towels and linen to assist residents timely with personal care as needed when staff and residents reported a towel and linen shortage. The resident sample was 16. The census was 166.1. Review of the facility's Resident Rights policy, dated 9/1/24, showed:-The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents;-The resident has the right to a dignified existence;-The resident has the right to be treated with respect and dignity, including the right to reside and receive services in the facility with reasonable accommodation of resident needs 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 follow acceptable standards of practice for infection control when staff failed to use Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and gloves use during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing) as recommended by the Centers for Disease and Prevention (CDC) and required by Centers for Medicare and Medicaid Services (CMS) for two out of two residents observed for wound care (Resident #2 and Resident #1) and when one resident's catheter drainage bag (a medical device that collects urine from a urinary catheter) lay on the floor (Resident #2). In addition, staff failed to cover food when transporting a cart of plated food onto the elevator. The sample was 16. The Census was 166.Review of the facility's Enhanced Barrier Precautions Policy, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided met acceptable professional standards of care when staff failed to accurately document one resident's tube feedings (nutrition provided through a gastric tube (g-tube) a tube that is surgically inserted into the stomach) for one resident (Resident #8). In addition, staff failed to obtain and document a resident's blood pressure prior to the administration of Hydrochlorothiazide (used to treat high blood pressure) (Resident #14). The sample was 16. The census was 166.Review of the facility's Documentation in the Medical Record Policy, dated 8/1/25, showed:-Licensed staff and interdisciplinary team (IDT) members shall document all assessments, pertinent observations, and services provided in the resident's medical record in accordance with state law and facility policy;-Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 receive treatment and care in accordance with professional standards of practice when staff failed to transcribe new treatment orders timely and failed to accurately document treatments for three sampled residents (Resident #7, #3, and #8). Staff failed to obtain a physician order for a wound vacuum (wound vac, medical device that used suction to promote wound healing) for one resident (Resident #7). Staff failed to identify a deep tissue injury (DTI, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues), upon admission for one resident (Resident #3). The sample was 16. The census was 166. Review of the facility's Wound Treatment Management Policy, dated 5/1/25, showed:-Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 monitor a resident's nutritional status and effectiveness of interventions when staff failed to obtain admission weights and weekly weights as ordered for one resident with a diagnosis of severe protein calorie malnutrition upon admission (Resident #14). The sample was 16. The census was 166.Review of the facility's Weight Monitoring policy, dated 9/1/25, showed:-Based on the resident's comprehensive assessment, the facility will ensure all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;-Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period time) may indicate a nutritional problem;-The facility will utilize a systemic approach to optimize a resident's nutritional status. This process…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide the necessary behavioral health care services for one resident (Resident #14). The resident was admitted with a diagnosis of vascular dementia (type of dementia caused by damage to the blood vessels in the brain) with behavioral disturbances. The facility failed to administer the resident's psychotropic medications as ordered and accurately document the administration of the medication or refusal. In addition, the facility failed to code the resident's behaviors accurately by documenting no behaviors even though there were reports of behaviors such as refusals, hitting, and attempting to walk without assistance. The sample was 16. The census is 166.Review of the facility's Behavior Management policy, revised 8/1/25, showed:-Residents who exhibit behavioral concerns may require a behavior management care plan to ensure they are receiving appropriate services and interventions to meet their needs. The interdisciplinary team, including the family members, should develop a behavioral plan for each resident 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 thoroughly assess a resident after a fall with a head injury. Staff failed to document neurological (neuro) checks after the head injury. The resident was sent to the hospital via 911 and diagnosed with a subdural hematoma (pool of blood between the brain and the outermost covering) twelve days after the fall (Resident #1). The sample size was three. The census was 152. The Administrator was notified on 7/31/25 of the past non-compliance. The facility had already started in-servicing staff on falls, interventions and documenting prior to the investigation. The facility was in compliance on 7/1/25. Review of the facility's Head Injury policy, dated 9/1/21, showed:-Policy: It is the policy of the facility to report potential head injuries to the physician and implement interventions to prevent further injury;-Policy Explanation and Compliance Guidelines: --Assess resident following a known, suspected or verbalized head injury. The assessment shall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate an altercation between Resident #1 and several staff members which resulted in the resident sustaining scratches on both sides of his/her neck and on his/her left hand. A registered nurse asked for written statements from the staff members involved and then read each others statements in front of each other. The next day, Certified Nurse Aide F reported to the Director of Nursing his/her statement was not correct and provided a new statement of events alleging CMT C had assaulted the resident. The DON did not investigate the incident further, including interviewing the resident and other staff members privately regarding the incident or advise the Administrator of the revised statement. This deficient practice affected one out of five sampled residents. The census was 158. Review of the facility's Abuse, Neglect and Exploitation policy revised 8/22/22, showed: -Policy Explanation and Compliance Guidelines: 1. The…

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

Based on interview and record review, the facility failed to provide necessary medications as ordered by the physician for one of seven sampled residents (Resident #5). The facility failed to provide twice daily anti-seizure medication to the resident nine out of ten times over a five-day period. Facility staff also failed to notify nursing management and the physician of the medication errors. The facility census was 158. 1. Review of the Facility's Medication Administration Policy, revised 9/1/22, showed: -Medication carts should be stocked with adequate supplies of medications; -If expired medications are noted and cannot be administered, the nurse manager should be notified; -Any adverse side effects or refusals of medications should be documented and reported; -Discrepancies with orders or supplies of medication should be corrected and reported to the nurse manager. Review of the Facility's e-kit (Emergency Kit, a standard stock of commonly prescribed life-saving medications to be used in an emergency situation) Inventory on 6/12/25, showed: -A minimum of four tablets of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors. The facility failed to ensure one resident's medication dose for Depakote (divalproex sodium, medication used to treat seizures and mood disorders) was entered correctly from the hospital after admission to the facility (Resident #3). This failure resulted in the resident receiving a lower dose of the medication for six days. The facility also failed to follow manufacturer and pharmacy recommendations and crushed a medication prior to administration for two residents (Resident #5 and Resident #1). One of the residents was hospitalized and found to have a low therapeutic level of the medication (Resident #1). The sample was 6. The census was 158. Review of the facility's Medication Administration policy, revised 9/1/22, included: -Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 were treated with dignity and respect when one employee used profanity while using their personal cell phone and providing feeding assistance to one resident (Resident #1), and four residents reported issues with staff being on their phones while working (Residents #2, #3, #5 and #4). The census was 143. Review of the facility's Professionalism - Customer Service policy, dated 9/1/21, showed: -Policy: It is the policy of this facility to provide professional, courteous service to our customers. Every employee is accountable for conducting themselves in a professional manner at all times. This facility strives to create an environment where the resident always comes first; -The facility is the resident's home and will be regarded as such. Each resident will be treated with compassion and respect at all times. Review of the facility's Personal Cell Phones policy, undated, showed: -Policy: It is the policy of this facility to…

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

Based on observation, interview and record review, the facility failed to serve food that was palatable and ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F). Three of six residents complained that hot foods were served cold (Residents #13, #15 and #16). This deficient practice had the potential to affect all residents who ate their meals in their room. The census was 143. During an interview on 1/9/25 at 10:27 A.M., Resident #13 said he/she eats in his/her room. The food is usually cold by the time he/she gets it. Staff will heat it up in the microwave if you ask. During an interview on 1/9/25 at 11:19 A.M., Resident #15 and Resident #16 both said the food is improving. As far as food being warm when it is served, sometimes it's warm enough and sometimes it's not. Observation on 1/13/25 at 12:30 P.M., showed dietary staff brought the tray cart (a warming cart that can be plugged in to keep the trays warm until ready to serve) and left it in the hall. The plates contained roasted chicken, a scoop of mashed potatoes and a scoop of spinach.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store and serve food in accordance with professional standards for food service safety by failing to date opened packages of food. The facility also failed to ensure dining room furniture was clean and free of roaches and failed to keep kitchen equipment clean when staff failed to clean the wells of a steam table used to serve resident's food. The sample size was 25. The census was 143. Review of the facility's Food Safety Requirements, dated 9/1/21, showed: Policy: Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety; Definitions: -Food service: the process involved in actively serving food to the resident; -Food service safety: refers to handling, preparing, and storing food in ways that prevent foodborne illness; -Policy Explanation and Compliance Guidelines: Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food 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 ensure prepared food items were served at a safe and appetizing temperature when the staff failed to maintain the internal temperatures of hot food items placed in hot holding at 135 degrees Fahrenheit (F) or higher to prevent the growth of food-borne pathogens and potential food-borne illness. This deficient practice had the potential to affect all residents who ate food from the facility's kitchen. The facility census was 138. Review of the facility's Food Temperatures Policy, dated 9/1/21, copyright 2021, showed: -Policy: It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled; Definitions: -Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens such as bacterial or viral organisms capable of causing disease; Policy Explanation and Compliance Guidelines: -Food temperatures will be checked on all…

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

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors, when staff failed to administer one resident's diabetes medications for several days (Resident #2). The sample was 5. The census was 131. The Administrator was notified on 8/2/24, of the past non-compliance which began on 7/21/24. The facility began an investigation, audited resident medications, reviewed all new admissions orders, interviewed staff and residents, had a meeting with the pharmacy, and in-serviced staff on following physician orders, the protocols when a medication is not available, and verifying medications for new admissions. The deficiency was corrected on 7/31/24. Review of the facility's Medical Provider Order Policy, revised 4/7/22, showed: -This facility shall use uniform guidelines for the ordering and following of medical provider orders; -Policy Explanation and Compliance Guidelines: -Medications and/or Treatments should be administered only upon the signed order of a person lawfully authorized to prescribe. -Verbal orders should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure four of six sampled residents were free from physical abuse. The residents' right to be free from physical abuse were violated when during two separate incidents a resident (Resident #2) hit four residents (Resident #5, Resident #6, Resident #3 and #4) in the face and stomach. The census was 92. On 7/1/24 at 5:00 P.M., the Administrator was notified of the past noncompliance, which occurred on 6/28/24. On 6/28/24, 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 Abuse and Neglect Policy. Resident #2 was discharged to the hospital and is not expected to return. Appropriate corrective actions were taken. The deficiency was corrected on 6/30/24. Review of the…

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

Based on interview and record review, the facility failed to ensure pre-admission screenings were completed timely and failed to incorporate the recommendations from the Pre-admission screening and resident review (PASARR) Level II determination and the PASARR evaluation report for one of six sampled resident's (Resident #1's) plan of care. The census was 92. Review of the facility's Resident Assessment-Coordination with PASARR Program policy, revised on 9/1/21, showed: -This facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs; -All applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening; a. PASARR Level 1- initial pre-screening that is completed prior to admission; -Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission; b.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, which included verbal aggression, for one sampled resident (Resident #1) out of six sampled residents. The facility failed to inform staff how to handle the resident's escalating behaviors. The facility census was 92 residents. Review of the facility's Comprehensive Care Plan policy revised on 9/1/21, showed: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment: -Person centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives; -The comprehensive care plan will describe, at a minimum, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident #2 was free from financial misappropriation resulting in the resident's credit card being taken by two staff members. The census was 134. The Administrator was notified on 6/4/24 of the past non-compliance, which began on 5/31/24. The facility immediately began an investigation of the incident and removed the staff members who misappropriated the resident's funds pending an investigation. The administrator began in-servicing staff on abuse, neglect, and misappropriation. The noncompliance was corrected on 6/3/24. Review of the facility's abuse, neglect and exploitation policy, dated 8/22/22, showed: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Definitions: Misappropriation of resident property means 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 the facility policy review, the facility failed to ensure food was labeled and dated properly according to professional standards for food prepared from the facility's kitchen. This failure had the potential to affect 126 of 127 residents consuming food from the kitchen. Findings include: Review of the facility's policy titled, Food Storage Sanitation and Food Safety, dated August 2024, revealed that all food stock and products were stored in approved sanitary storage containers, and all contents were covered, with contents labeled and dated. During an observation, alongside the Assistant Administrator, on 02/12/24 at 9:32 AM, the refrigerator contained food items not labeled or dated. The refrigerator had large containers of cooked and uncooked chicken quarters, cooked chicken patties, a large container of cooked hot dogs, multiple packages of opened lunch meat, multiple packages of opened sliced cheese and shredded cheese, an opened container of sour cream, an opened container of apple sauce, and a large pan of Jello/fruit dessert that was not…

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

Based on interview and review of facility documentation, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive quality assurance (QA) measures which addressed resident care and safety, quality of life, and resident choice. This failure had the potential to affect all 127 residents who currently lived in the facility. (Cross Reference F868) Findings include: Review of a document provided by the facility titled Quality Assurance and Performance Improvement (QAPI), dated 09/01/21, indicated .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcome of care and quality of life. The QAPI plan will address the following elements.Design and scope of the facility's QAPI program and QAA Committee responsibilities and actions.Policies and procedures for feedback, data collection systems, and monitoring.Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document review, interview, and review of facility policy, the facility failed to ensure that the quality assessment and assurance (QAA) committee met at least quarterly. This had the potential to affect the care and services for each of the 127 residents in the facility. Findings include: Review of a document provided by the facility titled Quality Assurance and Performance Improvement (QAPI), dated 09/01/21, indicated .The QAA Committee shall be interdisciplinary and shall.Consist at a minimum of.The Director of Nursing Services.The Medical Director or his/her designee.Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program. During an interview on 02/15/24 at 1:28 PM the Administrator stated he had no evidence to present to indicate the attendees conducted prior quarterly QAPI meetings. During this interview he presented the following documents: A document titled QAPI Meeting Agenda and Minutes, dated 11/08/23, indicated the following mandatory staff members were in attendance: The Administrator, Assistant 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 observations, interviews, record review, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility for 127 of 127 census residents. In addition, the facility failed to ensure the Certified Nursing Assistant (CNA) 5 performed hand hygiene after doffing (removing) gloves and failed to ensure a serving of applesauce was replaced, after being contaminated, for one of one resident (Resident (R) 83) of 29 sampled residents. Findings include: Review of a document titled, Centers for Disease Control (CDC) .National Healthcare Safety Network (NHSN) .Long Term Care Facility Component Tracking Infections in Long-Term Care Facilities ., located at https://www.cdc.gov/nhsn/pdfs/ltc/ltcf-manual-508.pdf, dated 01/20,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility failed to implement their system to monitor the use of antibiotics for 127 of 127 census residents. Specifically, the facility failed to monitor and evaluate antibiotic use and track measures of antibiotic usage in the facility. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], revised 09/01/22, revealed .Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program . During an interview on 02/14/24 at 3:55 PM, the Infection Preventionist (IP) stated she started her position as IP near the beginning of November 2023 and confirmed she completed the certification process on 10/26/23. The IP was asked to provide the facility's documentation of the antibiotic stewardship program from 01/01/23 through 02/01/24. The IP provided documentation dated…

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

Based on interview, record review, and facility policy review, the facility failed to ensure grievances shared at the monthly meetings by seven of the members of resident council who regularly attend (Residents (R) 7, R17, R29, R70, R92, R101, and R104) were resolved or a rational provided. Findings include: Review of the facility policy titled, Resident and Family Grievances, dated 09/01/21, revealed Policy: It is the policy of this facility to support each resident's and family member's right to voice a grievance without discrimination, reprisal or fear of discrimination or reprisal. Community Administrator has been designated as the Grievance Official. g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written a written decision on the grievance to the resident or representative at the conclusion of the investigation. 12. The facility will make prompt efforts to resolve grievances. Review of the monthly Resident Council minutes provided by the facility, dated August 2023 through January 2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident council minutes review, and facility policy review, the facility failed to review resident rights with seven of the members of resident council who regularly attend (Residents (R) 7, R17, R29, R70, R92, R101, and R104) of 29 sampled residents. Findings include: Review of the facility policy titled, Resident Rights, dated 09/01/21, revealed Policy: The facility will inform the resident both orally and in writing in a language the resident understands of his or her rights and all rules and regulations goyering [sic] resident conduct and responsibilities during the stay in the facility . Review of the facility policy titled, Resident Council Meetings, dated 09/01/21, revealed .The policy provides guidance to promoting structure, order, and productivity in these meetings .Example of meeting topics Resident rights . Review of the monthly Resident Council minutes provided by the facility, dated August 2023 through January 2024, revealed reoccurring grievances every month with call lights not being answered timely by nursing staff, food being cold from dietary,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, interviews, and facility policy review, the facility failed to ensure activities were provided to the residents who resided in the secured unit when the Activity Assistant was not assigned to work. In addition, the facility failed to provide individual activities to three out of seven residents (Resident (R) 130, R23 and R25) of 29 sampled residents. Findings include: Review of a facility's policy titled, Activities, dated 09/01/21, indicated .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community . 1. Review of R130's electronic medical record (EMR) titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, the facility failed to ensure that electrical equipment with exposed cord was not used in a dementia secured unit with the potential to cause accident hazards, such as tripping and/or falling of 26 residents who ambulated and wandered within the unit. Findings include: Review of a facility's policy provided by the facility titled Resident Environment Quality, dated 09/01/21, indicated .It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents and the public . During an observation on 02/12/24 at 10:39 AM, an exposed (approximately eight feet) extension cord went through the center of a room. The room was open except for an L shaped floor to ceiling column. The column was open to an adjacent room between open areas and had a television in front. The extension cord was medical grade, and the television cord was plugged into the device. The cord had bright orange tape covering it, but the center of the tape was…

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

Based on observation, staff interview, and facility policy review, the facility failed to ensure medications were stored in a locked storage area when left unattended for one of five medication rooms in the facility. Findings include: Review of the facility's policy titled, Medication Storage, last revised 09/01/21, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .Only authorized personnel will have access to the keys to locked compartments. During an observation on 02/12/24 at 11:10 AM, the Emergency Medication Room was observed to be unlocked on the third floor near the dining room. Inside was noted to have a secured Nexsys system [automated medication dispensing cabinet],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and facility policy review, the facility failed to ensure three residents (Resident (R) 109, R24, and R39), out of 31 residents on the secured unit, were provided a timely scheduled lunch meal. As a result, three residents complained of being hungry and were not aware of an unplanned change in the schedule for meal delivery. Findings include: Review of the facility's undated policy titled, Accommodation of Needs, indicated .The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences or a resident, except when the health and safety of the individual or other residents would be endangered . 1. Review of R109's electronic medical record (EMR) titled admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of R109's EMR titled annual Minimum Data Set (MDS) with an Assessment Reference…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and facility policy review, the facility failed to maintain a safe, clean, comfortable, and homelike environment, including but not limited to ensuring housekeeping and maintenance services were conducted as necessary to maintain a sanitary, orderly, and comfortable interior. This had the potential to affect 127 of 127 residents who resided at the facility. Findings include: Review of the facility's policy titled, Safe and Homelike Environment, last revised 09/01/21, revealed In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extend possible .Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to Housekeeping Department .Report any unresolved…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and facility policy review, the facility failed to respect two of 29 sampled residents' (Resident (R) 23 and R104) right to be treated with respect and dignity. R23 was brought to the common area and dining area of his unit without trousers on, and R104's urinary catheter drainage bag was left uncovered. Findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, revised 09/01/21, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .Groom and dress residents according to resident preference .Maintain resident privacy . 1. Review of R23's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R23 was admitted to the facility on [DATE] 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 interviews, record review, and facility policy review, the facility failed to ensure the physician was notified of a significant weight loss for one of four residents (Resident (R) 98) reviewed for nutrition of 29 sampled residents. (Cross Reference F641, F657, R692, F726, and F777) Findings include: Review of a facility's policy titled, Notification of Changes, 09/01/21, indicated .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Review of R98's electronic medical records (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of protein-calorie malnutrition. Review of R98's EMR titled admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/24 indicated the resident had a Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to assess a Broda chair (a positioning wheelchair) as a restraint and failed to obtain a physician's order, provide a medical symptom, and obtain consent for the use of a restraint for one of one resident (Resident (R) 23) reviewed for restraints of 29 sampled residents. Findings include: Review of the facility's policy titled, Restraint Free Environment, revised 09/01/21, revealed .It is the policy of this facility that each resident shall attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .'Physical Restraint' refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 23) reviewed for chemical restraints did not receive a chemical restraint as a convenience to treat behaviors. R23 was prescribed Haldol and Seroquel, both antipsychotic medications, for behaviors and without a medical symptom for their use. Findings include: Review of the facility's policy titled, Restraint Free Environment, revised 09/01/21, revealed, .It is the policy of this facility that each resident shall attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .'Chemical Restraint' refers to any medication that is used for discipline or staff convenience, and not required to treat medical symptoms . 'Convenience' refers to any action taken by the facility 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 record review, interview, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 94) and/or responsible party (RP) were given a written bed hold policy at the time the resident was transferred/discharged to the hospital of 29 sampled residents. Findings include: Review of a facility's policy provided by the facility titled, Bed Hold Notice Upon Transfer, dated 09/01/21, indicated .At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed.Before a resident is transferred to the hospital or goes on therapeutic leave, the facility shall provide to the resident and/or the resident representative information on the bed hold policy . Review of R94's electronic medical record (EMR) titled admission Record located under the Profile tab,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three residents (Resident (R) 98, R94, and R23) out of 29 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate assessment and care planning of the resident. Findings include: Review of the RAI Manual, dated 10/01/19, indicated .It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT (Interdisciplinary Team) completing the assessment .page 237 showed: Coding Instructions .F0300: Should Interview for Daily and Activity Preferences Be Conducted .Coding Instructions .Code 0, no .This option should be selected for residents who are rarely/never understood . 1. Review of R98'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, record review, and facility policy review, the facility failed to complete Pre-admission Screening and Resident Reviews (PASARR) as required for two of four sampled residents (Resident (R) 118 and R6) reviewed for PASARRs. R118 was admitted on [DATE] with a 30-day PASARR exception but was still a resident on 02/12/24. The facility did not perform a Level I PASARR screening after 30 days or refer for a Level II PASARR, if necessary, within 40 days of the resident's admission. Findings include: Review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program, revised December 2022, revealed .Exceptions to the preadmission screening program include those individuals who .Are admitted directly from a hospital, require nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of the Resident Assessment Instrument (RAI) Manual, and facility policy review the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans for three of 29 sampled residents (Resident (R) 130, R68, and R77) reviewed for care plans. Findings include: Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2019, indicated .Care Area Assessment (CAA) Process. This process is designed to assist the assessor to systematically interpret the information recorded on the MDS .The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident .Specific components of the CAA process include: - Care Area Triggers (CATs) are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or are at risk for developing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of facility policy, the facility failed to ensure one of five residents (Resident) (R) 98) and/or their representative was invited to participate in the resident's quarterly care plan meeting and the facility failed to update the activity care plan for one of seven residents (R23) reviewed for activities of 29 sampled residents. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 09/01/21, revealed, .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . The policy failed to contain information that the resident and/or the resident representative was to be invited on a quarterly basis. 1. Review of R98's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R98's EMR titled admission Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and facility policy review, the facility failed to provide timely incontinent care; assistance with eating, drinking, and dressing; complete transfers in a safe manner; and/or provide showers as scheduled for two of four residents (Resident (R) 23 and R186) reviewed for activities of daily living (ADLs) of 29 sampled residents. R23 and R186 were dependent on staff for meeting their ADL needs. R23 was not provided incontinent care or offered and/or encouraged to have fluids during a three-hour observation, was not assisted with dining during one observation, and was not transferred in a safe manner. R186 was not assisted with showers twice weekly as care planned. Findings include: Review of the facility's policy titled, Safe Resident Handling/Transfers, dated 2021, revealed .It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interviews, the facility failed to ensure physician orders were followed for two of 29 sampled residents (Resident (R)186, and R88). This failed deficiency had the potential to allow residents to go without needs being met or care being provided when physician's orders were not in place. Findings include: Review of the facility's policy titled, Blood Glucose Monitoring, dated 09/01/21, indicated It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders .The facility will perform blood glucose monitoring as per physician's orders .Report critical test results to physician timely. Review of the facility's policy titled, Hypoglycemia Management, last revised 10/03/23, indicated It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic episode .The facility will identify residents that are at risk for hypoglycemia and observe them for signs and symptoms of low blood glucose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, staff interviews, and facility policy review, the facility failed to create a care plan, with specific approaches, which addressed one of four residents (Resident (R) 98)'s diagnosis of malnutrition upon admission. The facility failed to ensure a dietary intervention was properly implemented as directed by the resident's care plan that addressed potential weight loss. The facility failed to ensure the physician provided a clinical rationale for the resident's significant weight loss. This had the potential to increase the resident's opportunity for unintended weight loss. Findings include: Review of the facility's policy titled, Weight Management, dated 09/01/22, indicated .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not…

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

Based on observation, interview, record review and facility policy review, the facility failed to ensure the oxygen concentrator was cleaned, had a filter on the inlet where the air came into the machine, and ensured an E cylinder was secured for one of one resident (Resident (R) 77) of 29 sampled residents. This deficient practice had the potential to allow for an increased chance of infection and the improper storage of the cylinder causing severe injury. Findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident- Care Equipment, dated 09/01/21, revealed Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control] recommendations in order to break the chain of infection . Review of the facility's policy titled, Oxygen Concentrator, dated 09/01/21, revealed Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators.5. Care of the Concentrator:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, document review, interviews, and review of the facility assessment, the facility failed to ensure one Licensed Practical Nurse (LPN) 3 was competently trained to read the results of a radiology report for one of one resident (Resident (R) 98) of 29 sampled residents. (Cross Reference F777). Findings include: Review of a document provided by the facility titled Facility Assessment Tool, dated 12/06/23, indicated .Staff training, education is conducted by in-services, 1 on l training, and education packets with posttests . Review of LPN3's employee file indicated the staff member was hired on 12/14/23. Review of a document provided by the facility titled Position Description for an LPN, dated 11/20/16, indicated .Works under direct supervision in accordance with the state-specific Nurse Practice Act, facility Policies and Procedures, and nursing judgment .Delivers nursing care to patients/residents requiring long-term or rehabilitative care .Collects patient/resident data, makes observations, and reports pertinent information related to the care of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medication irregularities were identified and reported by the Consultant Pharmacist for one of six residents (Resident (R) 23) reviewed for medication regimens of 29 sampled residents. R23 was prescribed Haldol and Seroquel, both antipsychotic medications with Black Box Warnings, without adequate indication for use. (Cross Reference F605) Findings include: Review of R23's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities. Review of R23's Medication Administration Records (MARs) and Treatment Administration Records (TARs), dated October 2023 and located under the Orders tab of the EMR, revealed no documentation R23 had displayed any behaviors, agitation, or physical aggression towards others. Review of R23's Progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, hospital record review, manufacturer guideline review, interview, and facility policy review, the facility failed to ensure one of five residents (Resident (R) 130) reviewed for unnecessary medications of 29 sampled residents had appropriate indications for use for an antipsychotic (Thorazine), failed to have proper black box warnings, and failed to ensure behaviors and side effects were monitored associated with this medication. Findings include: Review of a facility's policy titled, Use of Psychotropic Drugs, dated 09/01/21, indicated .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . Review of the National Institute of Health at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policy, the facility failed to ensure the radiology report was read correctly for one of one resident (Resident (R) 98), by one Licensed Practical Nurse (LPN) 3 and as a result there was a delay in care after the resident sustained an acute fracture of the proximal humerus. Findings include: Review of the facility's policy titled, Laboratory Services and Reporting, dated 09/01/21, indicated .The facility must provide or obtain laboratory services when ordered by a physician, physician assistance, nurse practitioner, or clinical nurse specialist in accordance with state law.Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. Review of R98's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R98's EMR titled admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and facility policy review, the facility failed to provide influenza vaccines for two of five residents (Resident (R) 23 and R118) reviewed for immunizations of 29 sampled residents. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program, revised 09/01/22, revealed .Influenza .Immunization: a. Residents will be offered the influenza vaccine each year between October 1 and March 31 unless contraindicated or received the vaccine elsewhere during that time . 1. Review of R23's admission Record located under the Profile tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, epilepsy, and unspecified intellectual disabilities. Review of R23's Physician Orders, dated 06/26/21 and located under the Orders tab of the EMR, revealed a physician's order for R23 to have the influenza vaccination yearly unless contraindicated. Review of R23's…

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

Based on record review and interview, 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 five residents (Resident #14, #15, #16, #17 and #18). Additionally, the facility failed to allow residents access to petty cash on an ongoing basis. The facility census was 133. 1. Record review of the facility maintained Accounts Receivable Aging Report, dated 11/09/23, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #14 $725.04 #15 $246.00 #16 $2,788.00 #17 $2,547.66 #18 $1,230.00 Total $7,536.70 During an interview on 11/09/23 at 2:10 P.M., the Business Office Manager (BOM) #1 said he/she was transferred from a sister facility to this facility on 09/26/23 to clean up the resident trust accounts. The BOM #1 was not sure why the previous Business Office Manager did not refund the money and was starting to work 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 record review and interview, 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 80 residents. The facility census was 133. 1. Record review of the facility maintained bank statements for the months 01/2023 through 08/2023 showed no documentation showing any reconciliations. Record review of the facility maintained 09/2023 reconciliation forms, dated 10/05/23, showed the attempted reconciliation had a difference of negative $1,136.62. Record review of the facility maintained 10/2023 reconciliation forms, dated 11/02/23, showed the attempted reconciliation had a difference of negative $403.56. During an interview on 11/09/23 at 10:22 A.M., the Business Office Manager (BOM) #2 said resident fund reconciliations were not being done prior to him/her coming to the facility in 09/2023. The BOM #2 said he/she did not know why 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 record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 133. 1. Record review of the facility maintained Resident Trust Bank Statements and Resident Trust Balance Reports for the period 01/2023 through 10/2023, showed an average monthly balance of $214,759.12. Record review of the facility maintained Accounts Receivable A/R Aging Report, dated 11/09/23, showed the facility held an average balance of resident funds in the amount of $7,536.70 in the facility operating account. Record review on 11/09/23, of the Department of Health and Senior Services approved bond list showed the facility did not have an approved bond, making the bond insufficient by $324,000. During an interview on 11/09/23 at 4:10 P.M., the Regional Director of Business Office Systems said the previous owners had a resident trust bond but was not sure if there was a new bond.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one resident (Resident #13) was free from misappropriation of resident property when the former Social Services Assistant (SSA) A used resident funds for his/her personal use. The facility census was 133. 1. Record review of the facility maintained Resident Trust Statement for the period 05/05/23 through 11/09/23, showed the following withdrawal from Resident #13's account: Date Amount Description 08/22/23 $3,300.00 Personal Needs Items Record review of the facility maintained Resident Face Sheet shows Resident #13 is his/her own responsible party. Record review of the facility maintained paperwork for Resident #13's Resident Trust Statement, showed written authorization for the $3,300.00 withdrawal was not obtained until 10/20/23. Record review of the Facility Self Report on 11/09/23, showed the Social Services Director (SSD), SSA A, and the admissions staff members had a conversation on 10/19/23 about Resident #13 needing clothing, and money…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify Resident #4 of all rules and regulations governing resident conduct and responsibilities during his/her stay at the facility. The facility failed to disclose information to the resident regarding a prohibition of cannabis products in the facility and failed to establish a written policy for residents to review and understand prior to or upon admission, as appropriate during the resident's stay, and when the facility's rules change. The census was 131. 1. Review of the Resident #4's quarterly MDS, dated [DATE], showed the following: -admitted on [DATE]; -Cognitively intact; -No behaviors noted; -Diagnoses included depression, osteoarthritis (inflammation of the bone) of hips, and pain in unspecified joint; -Received antidepressants and opioids every day for seven days. Review of the resident's medical record, showed the following: -The resident was his/her own responsible party; -On 7/7/23 at 2:10 P.M., a social services note showed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for 13 of 14 residents investigated for activities (Residents #68, #84, #7, #94, #38, #40, #8, #31, #41, #90, #15, #11, and #86). The facility failed to have activity staff in sufficient numbers to provide a complete activities program, and failed to ensure the facility assessment addressed activity staff under their staffing plan and/or staff training/education. The facility failed to provide one on one activities to residents, failed to ensure evening activities occurred or have activity staff available to assist residents in attending weekend activities. This had the potential to affect all residents who reside in the facility. The sample was 20. The census was 96. 1. Review of the facility's Statement of Resident Rights, provided to residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staffing was sufficient to serve meals to residents in a timely manner and meet the needs and preferences of the residents wanting to eat in the dining room. This deficient practice had the potential to affect all residents who ate at the facility. The census was 96. Review of the resident council meeting minutes, dated 6/30/21, showed the following for dietary: -One resident said: it sucks; -One resident said: They're not cooking it, they're short staffed down there; -One resident said: No cooks down there in the evening; -Two residents said: Meals get to rooms considerably later, sometimes lunch is at 2:00, any day, weekends are worse; -One resident said: the dream of eating in the dining room; -Response: We are short staffed, so when we fix our concerns, then we can get back to the dining room. During an interview on 8/19/21 at 8:36 A.M., the dietary manager (DM) said breakfast was served at 8:00 A.M., lunch was served at 12:00 P.M. and dinner was served at 4:30 P.M. The residents received meals…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 serve food that was palatable and ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F). Seven of seven residents attending the resident council meeting complained about the food, the lack of choices, and the food temperatures. In addition, two residents complained about the food during individual interviews (Resident's #47 and #99). Furthermore, the facility failed to follow standardized recipes for preparing pureed foods. These deficient practices had the potential to affect all residents who ate at the facility. The census was 96. 1. Review of the resident council meeting minutes, dated April 28, 2021, showed the following for dietary: -Food is icky, I stopped eating it; -No documentation which resident in attendance voiced this concern; -He/she got sick the same day I did. Saturday and Sunday. I know it was off the food; -No documentation which resident in attendance voiced this concern; -Food is always cold; -Lots of unintended weight loss; -The kitchen has not been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide resident council members with verbal and written responses, actions and rationale taken regarding their concerns. In addition, the facility failed to provide a timely written response to a grievance regarding missing personal items for one of 20 sampled residents (Resident #11), in accordance with the facility's grievance policy. The census was 96. Review of the facility's Grievance/Complaints, Filing, revised April 2017, showed the following: -Policy Statement: Resident and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the state Ombudsman). -Policy Interpretation and Implementation: -Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not…

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

Based on interview and record review, the facility failed to maintain a 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 sample size was 20. The census was 96. Review of the resident trust account for the past 8 months, from December 2020 through July 2021, showed an average monthly balance of $118,000.00. This would yield a required bond in the amount of $177,000.00 (one and one half times the average monthly balance). Review of the bond report for approved facility bonds by the Department of Health and Senior Services (DHSS), dated 2/26/21, showed an approved bond of $175,000.00. During an interview on 8/23/21 at 8:00 A.M., the administrator said it was possibly due to the residents receiving their stimulus checks, which is why the current surety bond is short.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment was followed, in the event the resident was found without signs of life, when the facility failed to maintain accurate, congruent, and easily accessible documentation of advance directives for five residents investigated for accuracy of code status (Residents #15, #11, #71, #100, and #32). The sample was 20. The census was 96. 1. Review of the facility's census and room roster, showed Residents #15 and #11 identified as residing in the locked memory care unit. Observation of the code status book, located at the nurse's station on the locked unit, reviewed on 8/30/21 at 7:45 A.M., showed (Residents #15 and #11) did not have hard copies of advance directive information in it. Review of Resident #15's electronic medical record (EMR), showed the code status listed as do not resuscitate (DNR, no life saving measures performed if the resident were to be found with no signs of life). Review of the documents tab, showed no signed code 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a sufficient amount of supplies to meet the care needs of residents in a dignified manner. This deficient practice had the potential to affect all residents receiving bathing services in the facility. The census was 96. Review of the Resident's Handbook, revised in 2018, provided upon admission, showed: -admission Agreement; -Our responsibilities: We will provide you with room and board, nursing services, personal and housekeeping services, and routine supplies required by your condition; -Appendix 5, Items and Services Included in the Daily Rate: -Private pay: Items and services included in the daily rate, include nursing services, bathing services, and linen, housekeeping and maintenance services; -Medicare Part A: If you are eligible to receive benefits under the Medicare Part A program, the following services will be covered by the daily rate paid to us, include nursing services, bathing services, and linen, housekeeping, 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 establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation when four out of four controlled substance shift change count sheets, for August 2021, were observed to lack consistent documentation of the count of controlled substances at shift change. The census was 96. Review of the facility's Controlled Substances policy, revised 12/2012, showed: -Policy statement included: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together; -Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any…

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

Based on observation, interview, and record review, the facility failed to ensure the proper storage of medications in three of three treatment carts, and three of four medication carts observed. The treatment carts had medications not labeled properly. The medication carts contained spills over supplement containers, opened food, and improperly labeled medications. The facility had five medication carts and three treatment carts. The census was 96. Review of the facility's Storage of Medications policy, revised 4/2007, showed: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Drugs shall be stored in the packaging, containers, or other dispensing systems in which they are received; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; -The facility shall not use discontinued, outdated, or deteriorated drugs 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, the facility failed to provide for requests of additional food at meal times and failed to offer nourishing snacks at bedtime. This had the potential to affect all residents. The census was 96. 1. Review of the resident council meeting minutes, dated April 28, 2021, showed the following for dietary: -Food is icky, I stopped eating it; -No documentation which resident in attendance voiced this concern; -He/she got sick the same day I did. Saturday and Sunday. I know it was off the food; -No documentation which resident in attendance voiced this concern; -Food is always cold; -Lots of unintended weight loss; -The kitchen has not been serving fresh fruit. There used to be fruit available anytime. Maybe COVID is an issue. Would bananas and oranges be safer due to their skins?; -We want to use the dining room again. 2. Review of the resident council meeting minutes, dated May 26, 2021, showed the following for dietary: -Dietary food stinks; -What would make it better; -Starting June 21, new dietary manger; -One resident said: I don't eat…

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

Based on interview and record review, the facility failed to ensure the quality assurance and performance improvement (QAPI) program committee developed and implemented appropriate plans of action to correct identified quality of life deficiencies related to dietary and activity concerns. This had the potential to affect all residents in the facility. The census was 96. Review of the facility Quality Assurance and Performance Improvement (QAPI) Program policy, dated 2001 and revised on 2/2020, showed: Policy Statement: -This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents; Policy Interpretation and Implementation: The objective of the QAPI program are to: -Provide a means to measure current and potential indicators for outcomes of care and quality of life; -Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; -Reinforce and build upon effective systems 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 an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff received the required tuberculosis (TB) screening as required per their policy, perform proper hand hygiene when providing personal care for two residents (Residents #16 and #84), ensure a shared electric razor was disinfected between uses (Resident #9), and ensure staff appropriately wore masks to cover both their nose and mouth when around residents or other staff. The census was 96. 1. Review of the facility's Tuberculosis Infection Control Program Policy, revised January 2012, showed: -Policy Statement: The facility recognizes that TB transmission has been identified as a risk in healthcare settings. To try to prevent nosocomial (acquired in house) transmission of TB, our facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed frames, mattresses and bed/side rails as part of a regular maintenance program to identify areas of possible entrapment for six residents (Residents #16, #13, #49, #47, #19 and #39) with side rails to reduce the risks of accidents. The facility identified 22 residents with side rails in use. Residents #16 and #13 were not identified by the facility as having side rails. The sample was 20. The census was 96. Review of the FDA (Federal Drug Administration) documents, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed bed rails, also called side rails, may be used as a restraint, reminder, or assistive device. Evaluating the gaps in hospital beds is one component of a mitigation strategy to reduce entrapment. Hospital beds have seven potential entrapment zones. The neck, head, and chest are the key body parts at risk for life-threatening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two of two sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #47 and #93). The sample was 20. The census was 96. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -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 potential liability for payment for the non-covered services. The SNF's responsibility to provide notice 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report allegations of abuse to the Department of Health and Senior Services (DHSS) as required, within a two-hour time frame, for three residents (Residents #304, #7, and #73). The sample was 20. The census was 96. Review of the facility's Abuse Investigation and Reporting policy, revised July 2017, showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -Role of the Administrator: If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual; -Role of the Investigator: The individual conducting the investigation will, as a minimum: -Review the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation for two residents discharged from the facility (Residents #550 and #303). The census was 96. 1. Review of Resident #550's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/7/20, showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Extensive assistance required for ambulation, transfers, bed mobility and personal hygiene; -Impairment to bilateral legs; -Received physical therapy (PT) four days a week and occupational therapy (OT) five days a week. -Diagnoses included progressive neurological conditions, high blood pressure and diabetes. Review of the medical record, showed a notice of Medicare non-coverage issued on 4/6/21 with the effective date on non-coverage as 4/8/21. The resident signed the form on 4/6/21 to verify he/she received the notice. Review of the…

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

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care for one of 20 sampled residents (Resident #310). The resident's care plan did not address his/her wounds, pressure ulcers, potential for pain, refusal of care and did not specify the amount of staff assistance needed with his/her activities of daily living (ADLs). The census was 96. Review of Resident #310's progress notes, dated 9/1/20 at 11:17 P.M., showed he/she was admitted around 6:30 P.M. The resident's admitting diagnoses were respiratory failure and septic shock (a life-threatening condition that happens when blood pressure drops to a dangerously low level after an infection). The resident had a large wound to his/her lower right abdomen fold stretching to his/her groin area along with a quarter sized open area to his/her coccyx (a small triangular bone at the base of the spinal column) and another one right below it. The resident had generalized weakness, flaccid (hanging loosely or limply) right arm and edema to his/her bilateral lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received showers as scheduled/desired. Twenty residents were sampled and problems were identified with three (Residents #19, #94 and #99). In addition, one resident selected as an expanded sample complained of not receiving showers (Resident #39). The census was 96. 1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/16/21, showed: -Adequate hearing and vision; -Clear speech - distinct intelligible words; -Ability to express ideas and wants: Understood; -Ability to understand others: Understands - clear comprehension; -Brief Interview for Mental Status (BIMS, a cognitive assessment) score of 15 of 15, which indicates intact cognition; -Rejection of care: Behavior not exhibited; -Total dependence of two (+) persons required for bed mobility, transfers, dressing and toilet use; -Total dependence of one person required for 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 observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to monitor the effectiveness of medication, and to notify the physician to address the abnormal medication level, for a one resident (Resident #84). The resident had a seizure disorder and required the use of anti-seizure medications. The facility failed to ensure the medication was administered in sufficient amount to ensure a therapeutic level. This resulted in the lab test, used to determine if the medication was at a therapeutic level, showing the levels as below therapeutic range. The facility failed to notify the physician that the levels were below therapeutic range. This resulted in the resident having seizure activity resulting an abrasion to the head. The facility census was 96. Review of Resident #84's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/21, showed neurological issues with aphasia (inability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible and to ensure each resident received adequate supervision and assistance devices to prevent accidents for 19 residents who resided on the secured unit when the facility failed to ensure water temperatures were maintained at a safe level below 120 degrees (°) Fahrenheit (F). In addition, staff failed to implement a care planned intervention to encourage the resident to use a walker for ambulation, and left one resident on the toilet unattended who required supervision (Resident's #41, and #94). The census was 96. 1. Review of facility's Safety of Water Temperatures policy, undated and reviewed on 8/23/21 at 8:03 A.M., showed water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120°F or the maximum allowable temperature per state regulation. Observation of the third floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff positioned two residents' urinary catheter drainage bags off the floor. The facility identified seven residents with indwelling urinary catheters (a tube inserted into the bladder to drain the bladder of urine. Urine is collected in a drainage bag until emptying). Of those seven, five were sampled and problems were identified with two. (Residents #99 and #57). The census was 96. Review of the facility Catheter Care, Urinary policy, dated 2001 and revised on 2014, showed: Purpose: -The purpose of this procedure is to prevent catheter-associated urinary tract infection;; Infection Control: -Use standard precautions when handling or manipulating the drainage system; -Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag; -Be sure the catheter tubing and drainage bag are kept off the floor; -Empty the drainage bag at least every eight hours. 1. Review of Resident #99's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for two of five residents investigated for nutrition (Resident #68 and #86). This resulted in both residents experiencing a significant weight loss. The sample was 20. The census was 96. 1. Review of Resident #68's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/2/21, showed: -Severely impaired cognition; -Extensive assistance with eating; -Diagnoses included progressive neurological conditions including aphasia (difficulty forming and expressing spoken words) and Multiple Sclerosis (a progressive decline in neuromuscular function); -Recorded weight of 131 pounds (lbs); -Care Area Assessment Summary (CAAS): Cognitive loss/dementia and nutritional status triggered. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Extensive assistance with eating;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 using bed/side rails, had adequate assessments to determine the side rails were appropriate and safe to be used and/or had physician's orders. The facility identified 22 residents with side rails in use. Two of 20 sampled residents (Residents #16 and #63) and one expanded resident (Resident #13) had side rails but were not identified by the facility as having them. The census was 96. Review of the facility's Proper Use of Side Rails policy, revised December 2016, showed: -The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; -Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records on residents that are complete and readily accessible in accordance with accepted professional standards and practices for two of 20 sampled residents (Residents #251 and #250). The census was 96. 1. Review of Resident #251's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/20, showed: -admission date: 10/26/20; -Severe cognitive impairment; -No moods or behaviors; -Total dependence with activities of daily living; -Diagnoses of medically complex conditions, high blood pressure, diabetes, Alzheimer's disease, Parkinson's disease and asthma; -Feeding tube; -Tracheostomy Care (an opening in the front of the neck so a tube may be inserted so the person can breathe). Review of the resident's hospital record, dated 1/16/21, showed: -Chief complaint: Dislodged trachea; -History of Present Illness: The resident was unable to give any history. The resident's family member provided history over the phone. It is unclear how…

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