The Nichols Center

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan to address a stage two pressure ulcer for one (1) of (1) residents reviewed for care planning. Resident #38. Findings Include:Record review of the facility's Care Plan policy updated 2/20/20 revealed Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provide care .7. The care plan will be reviewed and/or revised at quarterly intervals in conjunction with the completion of MDS assessments (quarterly), significant change, annual and with changes in residents' condition as needed .On 03/26/2026 12:54 PM, in an interview with Registered Nurse (RN) #2/ Minimum Data Set (MDS) nurse stated that care plans are supposed to be updated by nurses on the floor when they receive a new physician order. She stated they discuss care plans in clinical and if it is not updated then she updates it. She stated the comprehensive care plan is used by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 psychiatric services in accordance with professional standards of practice for one (1) of three (3) residents reviewed for unnecessary medications, Resident #53. Findings Include: Record review of the facility policy Behavioral Health Services dated 4/01/18 revealed, It is the policy of this facility that all residents receive care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. Record review of the Progress Notes dated 2/3/26 through 3/12/26 revealed no psychiatric follow up notes were available and a behavior was marked YES on the progress notes indicating behaviors had been present. During an interview on 3/26/26 at 10:45 AM, the Director of Nursing (DON), stated Resident #53 was not being followed by psychiatric services despite receiving an antipsychotic medication. She stated the facility manages short term residents differently 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 record review, staff and responsible party (RP) interview and facility policy review, the facility failed to ensure a resident was treated with dignity and respect for one (1) of four (4) residents reviewed for resident rights. Resident #1. Findings included:Record review of facility policy Resident Rights, dated 10/24/25, revealed Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility.Record review of the facility investigation dated 10/06/25, revealed Resident #1 reported on 10/3/25 at 2:00 AM, that he called for assistance and Certified Nursing Assistant (CNA) #1 told him to use his brief for his incontinence and that she would return to change him. The resident waited an hour and a half before CNA #1 returned. CNA #1 told the resident, You are in rehab and should be walking. CNA #1 was placed on investigative leave on 10/6/25 and terminated on 10/8/25.Record review of an additional facility investigation revealed that on 10/6/25, Resident #1's RP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interviews, record review, and facility policy review, the facility failed to implement a care plan for monitoring for side effects and behavior monitoring with the use of psychotropic medications for (1) one of 16 resident care plans reviewed. Resident #38 Findings include: Review of the policy titled, Care Plans, updated 2/20/20, revealed, Policy: Each resident will have a person-centered plan of care to identify problems, needs and strength that will identify how the interdisciplinary team will provide care . Record review of the March 2024 Medication Administration Record for Resident #38 revealed no monitoring for side effects or targeted behaviors related to antipsychotic, antianxiety, and antidepressant medications. Record review of the care plan titled, Antipsychotic drug use: at risk for side effects, with start date 5/1/23 revealed, Interventions: Monitor patterns of targeted behaviors .Assess for adverse side effects, document, and report . Record review of the care plan titled, Antianxiety drug use: at risk for side effects, with a start date of 5/1/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, record review, and policy review the facility failed to provide services or care that accepted standards of quality dictate should have been provided when staff administered an as needed (prn) antipsychotic medication every 12 hours scheduled for (1) one of (9) nine residents whose medication regimen was reviewed. (Resident #104) Finding include: Review of the policy titled, Medication Administration General Guidelines revealed, .Procedure: . 2. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications, and professional standards of practice .18. Prior to administration, the medication and dosage schedule on the resident MAR (Medication Administration Record) is compared with the medication label, this information should be checked at least three times during the medication preparation process. If the the label and the MAR are different, the physician's orders are checked for the correct dosage schedule prior to administering . Record review of the Physician Order List…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, record review, and policy review the facility failed to ensure residents were free from unnecessary drug use as evidenced by no targeted behavior or side effect monitoring for the use of psychotropic medications (Resident #38) and administered an as needed (PRN) antipsychotic medication with no documented targeted behaviors (Resident #104) for two (2) of five (5) residents reviewed for unnecessary medication use. Findings include: Review of the policy titled, Behavior Management and Psych-Pharmacological Medication Monitoring Protocol, revealed Policy: Residents who receive antipsychotic, anti-depressant, sedative/hypnotic, or anti-anxiety medications are to be maintained at the safest lowest dosage necessary to manage the residents' condition. Residents will be reviewed routinely for effectiveness and monitored for side effects.Purpose: Interventions developed will only include the use of medications when the assessment by the physician and interdisciplinary team have validated that non-chemical interventions alone are not successful. Resident #38 Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record/video surveillance review, personnel record review, and facility policy review, the facility failed to prevent diversion of controlled substances by a nurse for one (1) of four (4) residents reviewed, Resident #1. Findings include: Policy/procedure review of the facility's Abuse, Neglect and Exploitation policy dated 10/24/2022 revealed, 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. The definition of Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Interview with the Administrator on 12/18/23 at 11:00 AM revealed that administrative staff was notified on 12/6/23 on the 3-11 shift by Resident #4 about Licensed Practical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and resident interview, record review and facility policy review the facility failed to date oxygen, nebulizer tubing, and humidifier bottles and place oxygen signage on the doors for three (3) of 14 residents reviewed for oxygen administration. Resident #2, Resident #100, and Resident #149 and no physician order for oxygen for two (2) of three (3) residents. Resident #2 and Resident #149 Findings include: Resident #2 A record review of the facility's policy titled Oxygen-Administration, Concentrator, Storage & Assemblage, dated August 17, 2015, revealed the Purpose: To provide adequate tissue oxygenation by providing supplemental oxygen. Oxygen Safety: 14. Post the NO SMOKING -OXYGEN IN USE sign on the door in the resident's room. Instructions for Humidifier bottle: 1. When bottle is empty or essentially empty, detach the flow gauge and date and reattach a new prefilled bottle. A record review of the facility's policy titled Physician Orders-Transcribing and Implementing, 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.