River Ridge Rehabilitation And Nursing LLC

Based on observation, interview, and record review, the facility failed to initiate and provide rehabilitation therapy ordered by a physician for 1 (#34) of 29 sampled residents, which increased the risk of a decline for the resident related to the areas therapy should have been treating. Findings include:During an observation and interview on 1/12/26 at 2:12 p.m., resident #34 was sitting up in a motorized wheelchair in his room. When asked how things were going, resident #34 said they would be a lot better if he was getting therapy. Resident #34 said he was not sure why he had not been getting therapy, but he thought maybe it had something to do with his Medicaid application (which was pending).During an interview on 1/14/26 at 10:18 a.m., staff member F stated she did not know anything about resident #34's therapy until she received a request to evaluate him on 1/13/26. Staff member F stated she did the therapy evaluation at 8:00 p.m. on 1/13/26. Staff member F stated she did not know why the evaluation was not completed sooner. Staff member F stated a therapy evaluation could be…

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

Based on observation, interview, and record review, the facility failed to ensure dietary staff followed safe and sanitary conditions by donning hair coverings and beard nets while preparing resident meals in the facility kitchen. This failure put all residents receiving meals at risk for sanitation issues related to the uncovered hair if it were to get into food. Findings include: During an observation on 3/24/25 at 4:38 p.m., staff member I was in the facility kitchen, not wearing a hair covering or beard net. Staff member I was working at the kitchen grill and preparing food on a serving area. During an observation on 3/25/25 at 7:50 a.m., staff member I was in the facility kitchen, not wearing a hair covering or beard net. Staff member I was dishing food from a pan, onto a plate, preparing breakfast for residents. During an interview on 3/25/25 at 2:15 p.m., staff member D stated dietary staff working in the kitchen are expected to wear hair coverings and a beard net if they have facial hair. Staff member D stated staff member I moved into the cooking role recently and did 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, and record review, the facility failed to implement a system to ensure an interdisciplinary team was involved in determining if a resident was safe to self-administer medication and failed to implement a system to ensure an as needed medication was secured in a resident's room for 1 (#6) of 9 sampled residents. This deficient practiced caused resident #6 a temporary burning sensation under her right arm. Findings include: During an observation and interview on 3/25/25 at 4:10 p.m., resident #6 was in her room sitting in a wheelchair. Resident #6 stated she had limited mobility in her extremities because of multiple health conditions and required assistance with daily care. Resident #6 was observed to have minimal movement in her hands and was unable to lift her arms. Resident #6 stated in late January 2025, staff member E spoke to her about a medication called Blu Emu cream for muscle soreness. Resident #6 stated a nurse left a sample of the Blu Emu cream in a 30cc plastic medication cup on her bedside table and told her to use it when she needed it.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff failed to meet professional standards of practice by not providing safe administration of a scheduled topical medication for 1 (#6) of 9 sampled residents. This deficient practice caused resident #6 a temporary burning sensation under her right arm. Findings include: During an interview on 3/25/25 at 4:10 p.m., resident #6 stated on 1/29/25 staff member K brought a plastic 30cc medication cup into her room. Resident #6 stated the medication cup contained a white cream the medical provider had ordered for her due to skin irritation under her left and right underarms. Resident #6 stated staff member K administered her oral medication but left the cream on her bedside table for the certified nursing assistant to apply to the affected area when she went to bed for the evening. Resident #6 stated staff member J helped her prepare for bed around 11:30 p.m. on 1/29/25. Resident #6 requested staff member J apply the cream under her arms. Resident #6 stated after staff member J applied the cream to her right underarm she…

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

Based on interview and record review, the facility failed to ensure staff members followed appropriate protocols for the safe transfer of residents while using a Hoyer lift for 1 (#6) of 9 sampled residents. Findings include: Review of a facility grievance, dated 1/29/25, showed resident #6 reported staff member J used a Hoyer lift, without assistance from another staff member, to transfer her to bed from her wheelchair, when providing care at night. During an interview on 3/26/25 at 9:05 a.m., staff member B stated newly hired nursing staff received education on lifts. Staff member B stated the facility requires two staff when using lifts for resident transfers. Staff member B stated there was a nursing in-service meeting in September 2024, which included lift training. Staff member B stated staff member P provided education on appropriate lift protocols for resident transfers to staff member J. During an interview on 3/27/25 at 9:19 a.m., staff member J stated the facility was strict about having two staff transfer a resident with lifts. Staff member J stated the facility required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 pharmaceutical services to ensure safe administration of a scheduled topical medication for 1 (#6) of 9 sampled residents. This deficient practice caused resident #6 a temporary burning sensation under her right arm. Findings include: During an interview on 3/25/25 at 4:10 p.m., resident #6 stated on 1/29/25 at approximately 11:30 p.m., staff member J helped her prepare for bed. Resident #6 requested staff member J apply a cream under her arms due to irritation she had been experiencing the last two days. Resident #6 stated after staff member J applied the cream to her right underarm she started to feel a burning sensation. Staff member J then applied a cold cloth to her underarm, but she had no relief. Resident #6 said she asked staff member J to go and get the nurse and also asked him if he had applied the white cream, and he responded, No, it was blue. Resident #6 stated staff member J then washed her underarms with soap and warm water which provided relief from the burning sensation. Resident #6 stated staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 enhanced barrier precaution practices were utilized by staff while performing high-contact resident care during a transfer, for 1 (#5) of 9 sampled residents. Findings include: During an observation on 3/25/25 at 3:32 p.m., staff member N and staff member L transferred resident #5 in his room from the bed to his wheelchair. Staff member N and staff member L had gloves on before they started to transfer resident #5 with the sit-to-stand lift. Staff member N and staff member L did not don gowns prior to the transfer. Staff member N and staff member L's uniforms had direct contact with resident #5's upper and lower body during his transfer with the sit-to-stand lift. During an interview on 3/25/25 at 3:44 p.m., resident #5 stated nursing staff wear gowns and gloves when they perform his catheter care, but not when he is transferred with the sit-to-stand lift. During an interview on 3/26/25 at 9:15 a.m., staff member B stated she was the infection preventionist for the facility, and she provided education…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store food in accordance with professional standards by failing to label and date food stored in the facility's walk-in cooler and nutrition room refrigerators; failed to prevent or clean dirty surfaces in the walk-in cooler; and failed to maintain or complete routine monitoring of refrigerators and freezers on the Rosebud Hall, which could negatively affect any resident receiving services related to, or foods from, the equipment or areas of concern identified. Findings include: 1. During an observation on 11/4/24 at 12:16 p.m., the following were observed in the walk-in cooler: - Cheese slices wrapped in plastic wrap, not labeled or dated. - Cool whip opened with no date on it and not covered. - A square tub of red liquid, no label or date on it. - Walk-in cooler floors had splatter marks and debris on them. - The bottom shelves in the walk-in cooler had spill marks and debris. During an observation on 11/6/24 at 7:32 a.m., a tub of…

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

Based on observation, interview, and record review, the facility failed to follow appropriate infection control practices which included: proper hand hygiene for 4 (#s 3, 11, 17, and 20); proper use of isolation masks; disinfecting equipment after use; environmental cleanliness for 1 (#14); enhanced barrier precautions for 1 (#20); and dietary infection control of 36 sampled residents. Findings include: 1. Hand Hygiene During an observation on 11/6/24 at 9:38 a.m., staff member I and staff member Q were changing a brief for resident #3, who was to receive medication administered via tube feeding after the brief change. Staff members I and Q did not change gloves or use hand hygiene after removing the dirty brief and before putting a clean shirt on the resident. The shirt covered the feeding tube site on resident #3's abdomen. During an interview on 11/6/24 at 9:50 a.m., staff member I stated there were usually glove boxes on the walls in a resident's room. She stated she will grab a pair of gloves from the box, and lay a clean pair on the bed, when changing a resident's brief. Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notice of the reason for a facility-initiated transfer to a resident or the resident's representative, for 3 (#s 18, 64, and 78) of 36 sampled residents, and staff were not aware of the process or need for completion of the transfer notices. Findings include: 1. Review of resident #18's medical record showed the resident was transported to the hospital for an acute change in condition on 11/7/23 and 8/19/24. The medical record failed to show the required written notice of the reason for the transfer was provided to the resident or representative. During an interview on 11/6/24, staff member L stated she was unfamiliar with the federal regulation and facility policy for written resident notification of transfer. Staff member L stated, Well, we do tell them they are going to the hospital, and we complete a transfer form for the receiving hospital, but I am unfamiliar with any form or document that needs to be filled out for the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the required bed hold notice to the resident or the resident's representatives prior to, or timely after, a transfer, for 3 (#s 18, 64, and 78) of 36 sampled residents. Findings include: 1. Review of resident #18's medical record showed the resident was transported to the hospital for acute changes in condition on 11/7/23 and 8/19/24. There was no documentation in the medical record to show the resident or his representative was provided or notified of the required written bed hold notice. During an interview on 11/6/24 at 2:10 p.m., staff member L stated, I guess I don't know who is responsible for the bed hold documentation or how that (process) works. I have seen them in the record once in a while, but I have never completed one. A request for bed hold notifications for resident #18's hospital transfers on 11/7/23 and 8/19/24 was requested on 11/6/24. No bed hold notification documentation was received for the transfers prior to the end of…

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

Based on interview and record review the facility failed to employ a qualified activity professional to direct the activity program, which may affect all residents receiving or participating in activities at the facility. Findings include: During an interview on 11/6/24 at 11:52 a.m., staff member F stated she was hired in September (2024), has not completed, and was not currently enrolled in an activities professional training program. Review of staff member F's resume showed she did not meet the minimum qualifications to direct the activity program.

Based on observation, interview, and record review, the facility failed to sufficiently and accurately document pressure ulcers for 3 (#s 11, 57, and 76) of 36 sampled residents. Findings include: a. During an interview on 11/6/24 at 12:16 p.m., resident #57 stated, I'm hurting. Resident #57 had stated she needed to be cleaned up as she had a bowel movement about 30 minutes ago. Review of resident #57's EHR showed Morphine Sulfate 20 mg/mL and Tramadol 50 mg was available PRN. During an observation and interview on 11/6/24 at 12:25 p.m., resident #57 had a previous 4x4 optifoam dressing and a wound to her coccyx. Staff member M stated she did not have this wound a month ago when staff member M last saw resident #57. When asking both staff members what the redness and raised bumps were to resident #57's right thigh, staff member J stated they would have to check with the nurse as they did not typically work on this wing. Staff member M stated they thought it looked like a rash. Staff member M stated they had seen slight redness to this area the last time they worked with resident…

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

Based on observation, interview, and record review, the facility failed to follow physician orders, for 2 (#s 3 and 20); failed to follow enhanced barrier precautions for 1 (#20); and failed to measure and record the total fluid volume administered for 2 (#s 3 and 20) of 2 sampled residents with a PEG tube. Findings include: 1. During an interview and observation, on 11/6/24 at 9:16 a.m., staff member H was administering medications to resident #3 through a PEG tube. Staff member H measured the individual fluid amounts, but was not observed to write down a final total fluid volume. During the medication administration, staff member H had given a -30 mL (initial flush) of water. Staff member H stated she felt resistance when flushing #3's PEG tube, but stated this was normal. Staff member H stated she had held the tube feed prior to the medication administration, as resident #3 had not been tolerating the tube feeds. Staff member H was observed to administer fluid amounts of: -15 mL (with medications) -15 mL -15 mL (with medications) -15 mL -15 mL (with medications) During an…

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

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored; failed to properly dispose of expired medications; failed to ensure medication carts were locked when staff was not by them; and failed to monitor medication refrigerator and freezer temperatures. These failures could negatively affect a resident receiving improperly stored or expired medications, or from the refrigerator or freezer if temperatures were not maintained in a safe manner. Findings include: During an observation on 11/6/24 at 10:48 a.m., a medication cart had scattered loose pills on the top shelf where stock medication bottles were stored. The medication cart had the following opened and undated medication containers and bottles: - Stool softener docusate 100 mg, - Vitamin B Complex, - Zinc 50 mg, - Folic Acid 1000 mcg, - Senna 8.6 mg, - Aspirin 325 mg, - Milk of Magnesia opened with a date of 6/3/24, and - Mylanta opened with a date of 7/5/24. During an interview on 11/6/24 at 10:52 a.m., staff member L stated when staff opened over 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 timely fix items in resident's rooms for 2 (#s 17, and 44) of 36 sampled residents; and failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff in the Rosebud nursing unit area of the building. Findings include: During an interview on 11/4/24 at 2:51 p.m., resident #44 stated the curtains in his room were broken for over a year. Resident #44's curtains were not able to twist which would allow for more or less light to come in through the window. Resident #44 stated the ability to have functional curtains would be beneficial. During an interview on 11/4/24 at 2:36 p.m., resident #17 stated her windowsill was broken forever. Resident #17 stated she had been in the facility for over two years and the windowsill was broken when she had moved in. Resident #17 stated she had told many staff members about this issue. During an interview and observation on 11/6/24 at 11:41 a.m., staff member G stated other staff members would text staff member G through the WhatsApp 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 a safe, clean, and comfortable environment for 1 (#14) of 36 sampled residents. Findings include: During an observation on 11/5/24 at 9:56 a.m., there was a dried, crusty brown substance near an electrical outlet on the wall next to resident #14's bed. There was a visible large amount of white, dried crusted substance on the top blanket of resident #14's bedding. During an observation on 11/5/24 at 2:29 p.m., there was still a dried, crusty brown substance near an electrical outlet on the wall next to resident #14's bed. During an observation on 11/6/24 at 8:52 a.m., there was still a dried, crusty brown substance near an electrical outlet on the wall next to resident #14's bed. There was a dried sticky area of debris on the floor alongside resident #14's bed, which was seen and heard when walking on the section of the floor. The privacy curtain next to resident #14's recliner had dark brown, dried stains on it. During an observation and interview on 11/6/24 at 9:43 a.m., staff member Q observed 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 complete a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences within 14 days of admission for 1 (#233) of 36 sampled residents. Findings include: During an observation and interview on 11/4/24 at 2:10 p.m., resident #233 was observed to have wounds on both legs and the left arm. Resident #233 was eating lunch and her left hand was laying in the food on her plate. Resident #233 stated, I have trouble eating sometimes, but it is getting better. Review of a facility provided document titled Matrix, resident #233 did not trigger for any medical conditions including wounds. Review of resident #233's medical record showed resident #233 was admitted to the facility on [DATE]. The ARD for the completion of the comprehensive admission MDS assessment was 8/22/24. The comprehensive admission MDS assessment was open and showed in progress. This assessment should have been completed and submitted within 14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurately complete the admission Minimum Data Set (MDS) assessment for the resident's oral status, for 1 (#8) of 36 sampled residents. Findings include: During an observation and interview on 11/4/24 at 2:02 p.m., resident #8 was observed to have no natural teeth and no dentures. Resident #8 stated she did not have teeth when she was admitted to the facility, as she had them removed around July of 2024, and had not yet had dentures fitted. Resident #8 stated she was admitted to the facility on [DATE]. During an interview on 11/6/24 at 9:06 a.m., staff member E stated resident #8 did not have teeth on admission to the facility and has had several appointments for denture fittings since her admission. During an interview on 11/6/24 at 2:25 p.m., staff member D stated she was responsible for MDS assessments and was in the process of getting all the resident MDS information updated and accurate. Staff member D stated the MDS assessment…

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

Based on observation, interview, and record review, the facility failed to implement a comprehensive, resident-centered care plan which identified the resident's physical and psychosocial needs to help the resident reach their highest practicable level, for 1 (#8) of 36 sampled residents. Findings include: During an observation and interview on 11/4/24 at 2:02 p.m., resident #8 was observed to have no natural teeth and no dentures. Resident #8's voice was impaired by the absence of teeth, with difficulty making s and t sounds. Resident #8 stated she was embarrassed by not having teeth, and stated, I feel like people don't like me because I look funny without my teeth, and I am hard to understand. I am supposed to be getting dentures, but it is taking a while because I guess I have some jaw problems. The dentist fitted me a couple of times but so far, no teeth. I am hoping maybe by Thanksgiving. Resident #8 also stated she had some difficulty eating, even with the bite-sized diet the facility was providing. Resident #8 was also observed during this interview to be wearing one hearing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise an individualized comprehensive care plan to reflect a mental health diagnosis, for 1 (#233) of 36 sampled residents. Findings include: Review of resident #233's physician's order, dated 10/3/24, showed, Please call to schedule appt with Encounter Telehealth Psychiatry for bipolar disorder, depression. [sic] Review of resident #233's care plan, with an initiation date of 9/3/24, failed to show any information for a Focus, Goals, or Interventions for a diagnosis of bipolar depression. Review of the most recent H&P, dated 1/30/24, showed bipolar depression as an active diagnosis for resident #233. Review of resident #233's medical record, showed the facility submitted a letter requesting a PASARR Level II for resident #233 on 9/13/24, due to a history of bipolar depression. No further documentation was provided by the end of the survey period to show a PASARR Level II was performed. During an interview on 11/6/24 at 12:34 p.m., staff member D stated resident care plans should be completed upon admission, quarterly, or…

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

Based on interview and record review, the facility failed to complete a trauma-informed assessment to identify, manage, avoid potential triggers, and maintain the highest practicable well-being, for 1 (#8) of 1 resident with a diagnosis of post-traumatic stress disorder (PTSD). Findings include: During an interview on 11/4/24 at 2:02 p.m., resident #8 stated she did have a PTSD diagnosis related to so much abuse. Resident #8 stated she gets nightmares pretty regularly, and stated no one from the facility had talked to her about her PTSD since she was admitted . During an interview on 11/6/24 at 4:10 p.m., Staff member K stated she did not think a trauma informed assessment was necessary for resident #8, as the PTSD diagnosis was not included in the PASARR Level II evaluation, and the PTSD was not an active diagnosis. Review of resident #8's PASARR Level II evaluation, dated 10/22/24, showed resident #8 had a history of abuse as a child that still affected her. Review of a psychiatric telehealth note, dated 10/30/24, showed resident #8 was seen for an initial consultation for the…

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

Based on interview and record review, the facility failed to assure the Director of Nursing did not work as a charge nurse when the average daily census was more than 60 residents, which may negatively affect any resident. Findings include: Review of the facility nursing schedules showed staff member B was scheduled to work as charge nurse on the following days: . 4/27/24 on day shift from 6-12 . 4/28/24 on day shift from 3-6 . 10/4/24 on night shift from 10-6 Review of the [Facility Name] Daily Nursing Staff Posting and Census showed the census on 4/27/24 was 69, on 4/28/24 the census was 69, and on 10/4/24 the census was 76. Review of a Facility Assessment Tool, Date(s) of assessment or update 9/26/24 - 10/17/24, showed, . Part 1: Our Resident Profile . 1.2. Indicate your average daily census: (enter a range) _ 74.5_. [sic] During an interview on 11/7/24 at 8:53 a.m., staff member B stated, This last week and half I had to work on the floor more, but this was the last week. The facility was going to hire two more nurses, then I should not have to work the floor (as a charge nurse).

Based on interview and record review, the facility failed to provide dental services for 1 (#17) of 36 sampled residents. Findings include: During an interview on 11/4/24 at 2:36 p.m., resident #17 stated she felt she had a cracked wisdom tooth. Resident #17 stated she was not aware of an appointment made for her, but she had told many of the staff about her tooth concerns. When asked, resident #17 stated staff have not asked her if she needed dental, hearing, or eye appointments regularly scheduled. During an interview on 11/7/24 at 9:26 a.m., staff member E stated they were aware of resident #17's need for a dental cleaning appointment, but they were not aware of an issue concerning resident #17's wisdom tooth. Staff member E stated the appointment had been communicated to staff member P, as staff member P made the appointments. When staff member E looked for the scheduled appointment, and the communication text to staff member P, staff member E was unable to find the information. Staff member E stated they must have told staff member P verbally that resident #17 needed a dental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dietary department failed to have sufficient staffing to safely and effectively carry out the functions of the food and nutritional services department, by serving meals cold and late. This failure may negatively affect any resident receiving services from the dietary department. Findings include: During an observation and interview, on 11/4/24 at 12:16 p.m., staff member S was serving trays to residents in the dining room. Staff member S stated, I would walk around with you, but I am in the middle of serving. A dietary staff member showed the surveyor where the dry storage was kept, and stated, We are so short staffed. Why is it so hard to get people to work nowadays? Review of a facility document titled, Yellowstone Dining Room Meal Service Times, showed: Breakfast 7:45 a.m. Lunch 11:45 a.m. Dinner 4:45 p.m. During an observation on 11/05/24 at 8:01 a.m., residents were in the dining room waiting to be served breakfast. During an observation on 11/05/24 at 8:15 a.m., residents were still in the dining room waiting to be…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist had the necessary certification for oversight of the infection control program. This failure would affect any resident who had an infection, was at risk of an infection, or for how the facility upheld and monitored infection prevention strategies. Findings include: During an observation on 11/6/24 at 3:41 p.m., staff member D stated she worked at the facility starting in February 2024. Staff member D stated she completed the infection preventionist certification in 2019, but due to a tornado in another state, she was were unable to find the certification. Review of the facility request sheet, dated 11/7/24 at 9:53 a.m., showed the facility documented, Infection Preventionist Certification. No certification or supporting information was provided to the survey team prior to the end of the survey.

Based on interview and record review, the facility failed to provide a pneumococcal and Covid-19 vaccine for 1 (#74) of 7 sampled residents for immunizations. Findings include: During an interview on 11/6/24 at 3:41 p.m., staff member D stated all immunizations were documented in the EHR, and there was no other documentation located outside of the EHR, concerning immunizations. Review of a facility provided document, titled Consent Form For Pneumococcal Vaccine, dated 9/24/24, showed resident #74 had consent given for the vaccine. Review of a facility provided document, titled Consent Form For SARS-COV-2 (COVID-19) Vaccine, dated 9/24/24, showed consent given for Covid-19 vaccine for resident #74. Review of resident #74's EHR showed no record of Covid-19 or pneumococcal vaccines given. The resident immunization record were requested on 11/7/24 at 9:53 a.m.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to act promptly to resolve grievances brought forth by residents; provide access to allow residents to file grievances anonymously; take immediate action to protect and prevent further potential violations of any resident rights or potential abuse; and ensure a thorough investigation into the grievances were completed and documented for 6 (#s 1, 6, 9, 10, 15, and 16) of 17 sampled residents. Findings include: 1. During an interview on 7/30/24 at 3:30 p.m., NF2 reported resident #1 was not treated with dignity and respect during her stay at the facility beginning 5/2/24. NF2 stated resident #1's call lights were not answered on multiple occasions during the weekend, she was left in her hospital gown for five days, there was no hot water for a bath, and the facility did not give her a refund within the 30-day requirement. NF2 reported when she arrived on 5/6/24, resident #1 was crying and depressed. NF2 stated she and NF3 requested immediate discharge from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protect residents who voiced concerns related to alleged abuse or neglect of care; failed to report neglect allegations to the State Survey Agency within the required 24 hours for 3 (#s 1, 14, 15); and failed to report the investigative findings of their reported incidents to the State Survey Agency within five days for 3 (#s 5, 8, 16) of 17 sampled residents. Findings include: 1. Review of a facility reported incident, dated 7/2/24, showed a resident to resident altercation occurred for resident #5. Investigative findings were not reported until 7/8/24, one day out of the reporting window. 2. During an interview on 7/31/24 at 11:12 a.m., NF4 stated resident #15 had not had his brief changed for approximately 13 hours, and was left in a feces filled brief all day. NF4 stated she complained to the nurse on duty when she returned and found resident #15 had not had his brief changed. NF4 stated his brief was overflowing with feces. During an interview on 7/31/24 at 9:17 a.m., staff member C stated she reported resident #15'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 interviews and record review, the facility failed to refund a resident representative within 30 days of the resident's date of discharge for 1 (#1) of 3 reviewed for timely refunds at discharge. Findings include: During an interview on 7/30/24 at 3:30 p.m., NF2 stated the facility had not sent a refund check to her until 6/19/24. Review of resident #1's Discharge summary, dated [DATE], reflected resident #1 was discharged on 5/6/24. Review of a facility provided refund check, dated 6/10/24, reflected NF2 cashed the check on 6/21/24. Review of the facility's Standard Admissions Agreement, revised 3/1/19, reflected: -Refunds - .Refunds will be made within thirty (30) days of the Resident's death, transfer, or discharge.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents were appropriately assessed to be outside independently, and failed to ensure residents were inside the facility at night for 1(#13) of 17 sampled residents. This deficient practice had the potential to cause harm to a resident driving their wheelchair down a dark road. Findings include: Review of resident #13's nursing progress notes, dated 7/21/24, showed, Patient with new scooter and outside privileges. Routine monitoring while patient is outside. Nurse does not feel patient is safe to be outside, he was given privileges to go outside by another staff member . Review of resident #13's nursing progress notes, dated 7/27/24, showed the resident was outside driving his motorized scooter down the road. A motorist called the facility asking if they had lost a resident, and there was a car and motorcycle following the motorized scooter. During an interview on 8/1/24 at 10:25 a.m., staff member B stated resident #13 had left the facility…

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

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion or mobility received the restorative services necessary to maintain their highest level of functioning for 4 (#s 1, 3, 8, and 13) of 4 residents sampled for restorative services and mobility. Findings include: A request was made on 4/23/24 for a list of all residents who were supposed to be receiving restorative services. A list of 16 residents who received restorative services was provided on 7/23/24. During an interview on 4/25/24 at 10:38 a.m., when asked how she ensured residents received restorative services as needed, staff member D stated she could not tell which residents received these services or when these services were provided. During an interview on 4/25/24 at 11:10 a.m., staff member H stated she was not sure how restorative services were provided when the RA (Restorative Aide) was pulled to work the floor due to staffing shortages. Staff member H stated she thought there were tasks in the EHR associated with restorative services so CNAs could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 there was sufficient staffing available to allow for the consistent provision of restorative nursing services for 4 (#s 1, 3, 8, and 13) of 16 sampled residents receiving restorative services. This deficient practice had the potential to affect any resident identified as needing restorative nursing services. Findings include: During an interview on 4/25/24 at 10:38 a.m., staff member D stated the facility had a Restorative Aide who was often pulled from the provision of restorative services to work the floor because of short staffing. During an interview on 4/25/24 at 11:10 a.m., staff member H stated it has been challenging to ensure restorative services are consistently provided. Staff member H stated this was because the Restorative Aide frequently got pulled to work and provide resident care rather than providing restorative services. During an interview on 4/25/24 at 11:15 a.m., staff member E stated when the Restorative Aide is pulled to work the floor, there is no one else to provide restorative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, a staff member failed to provide necessary care and services for a dependent resident, for 1 (#19) of 19 sampled residents. The deficient practice caused the resident to initially be upset and tearful. Findings include: A review of a Facility-Reported Incident, submitted to the State Survey Agency, dated 3/22/24, showed resident #19 reported a staff member refused to assist him with getting out of bed to a chair. The resident also asked the staff member to get his call light. The staff member refused. Resident #19 stated the staff member stretched his urinary catheter tubing, causing discomfort. During an interview on 4/25/24 at 11:10 a.m., staff B stated he investigated the allegation made by resident #19 and determined the staff member did not assist resident #19. Staff member B stated the staff member voluntarily resigned and did not return to work. A review of resident #19's admission MDS, with an ARD of 3/13/24, showed the resident needed assistance with his Activities of Daily Living (ADL), such as partial to moderate, or substantial to…

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

Based on observation and interview, the facility failed to prepare food in sanitary conditions, putting residents at risk for foodborne illness. Findings include: During a observation on 10/23/23 at 3:00 p.m., the kitchen showed large, dried meat on the meat slicer. The can opener was covered with old sticky food debris. The microwave had food splatters. The steam table had crumbs and food debris on and around it. The floor was dirty with old lids, napkins, and crumbs. The dishwasher appeared to have caked on debris on the tank. The dishwasher racks were stained and black. During an interview on 10/24/23 at 9:40 a.m., staff member M stated she had implemented a cleaning schedule for staff on Wednesday 10/18/23, but did not know if the staff had started to clean, based on the new schedule.

Based on observation, interview, and record review, the facility failed to provide routine bathing for dependent residents for 4 (#s 2, 6, 27, and 44) of 23 sampled residents. Findings include: 1. During an interview on 10/24/23 at 8:20 a.m., resident #44 stated the shower aide was frequently moved from helping with resident showers to work the floor. She stated, You don't always get your shower. Review of resident #44's bathing records, dated August 2023 to October 2023, showed: - Resident #44 had a shower on 8/23/23, documented as, Physical help in part of bathing .one-person physical assist. - Resident #44 went 21 days until her next shower on 9/14/23. She received one additional shower in September, 13 days later on 9/28/23. - Resident #44 went 17 days between her last September shower and her October shower dated 10/16/23. - Resident #44 has had one shower in October of 2023. - There was no documentation that showed a bed bath had occurred during the intervals without a shower. 2. During an interview on 10/24/23 at 9:08 a.m., resident #6 stated she often went two weeks between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 formulate an advanced directive for 1 (#205) of 23 sampled residents. Findings include: During an interview on [DATE] at 10:57 a.m., resident #205 stated she had not filled out an advanced directive since her admission on [DATE]. Resident #205 stated she was very familiar with advanced directives and would have liked to fill one out. Resident #205 was adamant she did not want to be resuscitated or to receive any life support. When asked if the facility had discussed completing an advanced directive, resident #205 replied, No, never. When asked how the facility knew resident #205's resuscitation preference, resident #205 replied, They don't. During an interview on [DATE] at 11:38 a.m., staff member C was asked how the facility would know a resident's advanced directive status, and who would be responsible for entering it in the chart. Staff member C stated the advanced directive would be put in the electronic medical record as an order, based on the new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident representative of a significant weight loss for 1 (#303) of 23 sampled residents. Findings include: During an interview on 10/25/23 at 9:29 a.m., NF3 stated she was not aware of resident #303's weight loss until he was hospitalized on [DATE]. NF3 stated the facility did notify her of resident #303's frequent falls, but nothing regarding the resident's significant weight loss, which was identified on 9/5/23. NF3 stated she was made aware of resident #303's weight loss when the facility called to tell her resident #303 was being transferred to the hospital for care on 9/23/23. NF3 stated if she had known, she would have come to the facility to help him eat. Review of resident #303's weights, dated 7/11/23 and 9/5/23 respectively, showed weights of 165.8 pounds and 152 pounds, which calculated to an 8.32% weight loss in two months, and was a significant weight loss. Review of resident #303's nursing progress notes, dated between 9/5/23…

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 observation, interview, and record review, the nursing staff failed to provide privacy by leaving the window blinds open while providing perineal care for 1 (#14) of 23 sampled residents. Findings include: During an observation on 10/25/23 at 8:11 a.m., staff member H provided perineal care to resident #14 in bed. The blinds of the window in resident #14's room were open, providing no privacy from the parking lot which the window faced. Staff member H then assisted resident #14 from the bed to her wheelchair, while the blinds remained open. During an interview on 10/25/23 at 8:40 a.m., resident #14 stated, People walk back and forth all of the time, outside her window. During an interview on 10/25/23 at 2:39 p.m., staff member C stated the blinds of the windows should be closed when staff were providing care for the residents. During an interview on 10/25/23 at 5:20 p.m., staff member B stated she did not have completed orientation checklists for staff member H or staff member I. Review of the facility document titled, Nursing Competency Checklist, not dated, 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.

Based on interview and record review, the facility failed to report and investigate a bruise alleged by the resident to be caused by another individual for 1 (#6) of 1 sampled residents. Findings include: Review of resident #6's nursing progress notes, dated 6/4/23, showed, [Resident #6] complained to the aide about the bruising on the inside of her right thigh . [Resident #6] explained that someone grabbed her really hard on both thighs, and that's why the bruising was there. The bruising did not look like finger/hand prints . [sic] Review of resident #6's Quarterly MDS, with an ARD of 7/20/23, showed she had a BIMS of 15, showed intact cognition. During an interview on 10/25/23 at 2:25 p.m., staff member B stated resident #6's bruise and comments should have been reported by the nurse to management so they could be investigated. She stated they did abuse and reporting training with staff monthly.

Based on interview and record review, the facility failed to complete a Significant Change MDS within 14 days of a resident's change in condition for 1 (#47) of 1 sampled resident who received hospice services. Findings include: During an interview on 10/25/23 at 2:56 p.m., staff member C stated a Significant Change MDS was completed two months late, for resident #47 on 6/5/23. Staff member C stated that she was new to her position and did not know the resident was receiving hospice services. Review of resident #47's medical record showed a physician order for hospice services on 4/05/23. Review of resident #47's MDS showed an admission assessment completed, with an ARD of 3/27/23. The next update to the MDS was a Significant Change assessment with an ARD of 6/5/23. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User ' s Manual, October 2023, For Use Effective October 1, 2023, showed: An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 develop and implement a baseline care plan within 48 hours of admission for 2 (#205 and #304) of 23 sampled residents. Findings include: 1. During an interview on 10/24/23 at 11:39 a.m., resident #304 stated she was admitted to the facility a few weeks ago. Resident #304 stated she was not asked her preferences and was not asked to participate in a care plan meeting. NF1, who was seated at resident #304's bedside at the time of the interview, stated he had not been included in any care planning or care need discussion. During an interview on 10/25/23 at 8:12 a.m., staff member B reported staff member C was responsible for initiating the baseline care plan, and care plan updates were completed at IDT meetings. During an interview on 10/25/23 at 10:29 a.m., staff member C reported the nursing staff was responsible for completing the baseline care plan. Staff member C provided a document titled, Assessment Names and Documentation Requirements 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.

Based on observation, interview, and record review, the facility failed to follow care plan interventions to protect a resident's room from being entered by other residents for 1 (#6) of 1 sampled resident. Findings include: During an interview on 10/24/23 at 9:08 a.m., resident #6 stated another resident had wandered into her room and used her bathroom. She stated she was worried about someone coming in while she was asleep. Resident #6 stated there was supposed to be a sign on her door to keep other residents out. During an observation on 10/23/23 at 4:45 p.m., there was no stop sign for the doorway of resident #6's room alerting others to keep out. During an observation on 10/24/23 at 9:00 a.m., there was no stop sign for the doorway of resident #6's room alerting others to keep out. During an observation on 10/25/23 at 8:37 a.m., there was no stop sign for the doorway of resident #6's room alerting others to keep out. Review of resident #6's nursing progress notes, dated 6/11/23 and 8/8/23, showed there had been several instances of a man standing directly outside/entering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of quality by failing to follow a physician's order to hold insulin for a blood glucose value less than 100 mg/dL for 1 (#2) of 23 sampled residents. Finding include: During an observation on 10/23/23 at 4:42 p.m., staff member K administered an insulin injection to resident #2. Staff member K told resident #2 he was giving her seven units of Humalog insulin. Review of resident #2's physician orders, dated 12/22/22, showed an order for blood glucose checks before meals and at bedtime. The physician orders also showed an order, dated 7/18/23, to give seven units of Humalog insulin before meals and to hold the insulin if the blood sugar was less than 100 mg/dL. Review of resident #2's MAR, dated 10/23/23, showed the blood sugar before supper was 88 mg/dL. The MAR also showed staff member K gave seven units of insulin before supper. During an interview on 10/24/23 at 7:54 a.m., staff member K stated he performed resident #2's blood sugar check before supper on 10/23/23. Staff member K…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing staff failed to follow a physician's order for a resident's continuous tube feeding administration; failed to label the enteral and free water bags used during the continuous tube feeding; and failed to consistently and accurately document the resident's enteral and free water intake for 1 (#19) of 23 sampled residents. The deficient practice had the potential to place the resident at risk for inadequate caloric and free water intake. Findings include: 1. Follow Physician Order During an observation on 10/23/23 at 4:21 p.m., resident #19 was lying in her bed with two collapsible fluid bags, attached to the feeding tube pumps, and connected to the resident's gastric feeding tube. Neither of the feeding tube pumps were turned on or infusing any fluid. During a follow-up observation on 10/23/23 at 5:00 p.m., the feeding tube bags were connected to the resident's gastric feeding tube, and the pumps were still not turned on. During an interview on 10/24/23 at 10:29 a.m., staff member K stated resident #19's tube feeding, and…

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

Based on interview and record review, the facility failed to have an RN scheduled for eight hours per day. This deficient practice had the potential to impact all residents in the facility receiving nursing services. Findings include: During an interview on 10/25/23 at 2:30 p.m., staff member B stated the DON and ADON alternated being the RN coverage on the weekends. Review of PBJ data, dated FY Quarter 3, showed the facility had submitted no RN coverage for dates: 4/2/23, 4/8/23, 4/15/23, 4/16/23, 4/22/23, 4/29/23, 5/6/23, 5/7/23, 5/13/23, 5/27/23, 5/28/23, and 5/29/23. Review of facility documents titled, Daily Posting of Hours, each dated as listed above, showed a line through the designated RN coverage, indicating no RN hours for the day. Only dates 4/16/23 and 5/7/23 showed RN hours documented as a salary employee in the building.

Based on observation and interview, the facility failed to post daily staffing numbers. This deficient practice had the potential to leave family and visitors uninformed of the facility's daily census and number of licensed staff members working. Findings include: During an observation on 10/23/23 at 4:45 p.m., staffing numbers were posted on the board near the reception desk. The dates posted were 10/16/23 and 10/22/23. There was no information about resident census or number and license of staff working for the current date. During an observation on 10/25/23 at 11:07 a.m., staffing numbers were posted with a date of 10/24/23. There was no information about resident census or number and license of staff working for the current date. During an observation on 10/26/23 at 7:30 a.m., staffing numbers were posted with a date of 10/24/23. There was no information about resident census or number and license of staff working for the current date. During an interview on 10/26/23 at 9:15 a.m. staff member G stated the nurses were responsible for posting the information on weekdays 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 and interview, the facility failed to keep a foley catheter and tubing from dragging on the floor, increasing the risk for infection for 1 (#24) of 4 sampled residents; and nursing staff failed to follow infection control standards by placing urine-soaked bed linens on the floor during a bed linen change for 1 (#14) of 23 sampled residents. This deficient practice has the potential to increase the risk of infection to residents and staff. Findings include: 1.During an observation on 10/24/23 at 9:46 a.m., resident #24 was in the dining room with his catheter bag and the tubing on the floor. During an observation on 10/25/23 at 11:45 a.m., resident #24 continued to have his foley catheter bag and tubing dragging on the floor. During an interview on 10/25/23, at 12:10 p.m., staff member I stated she tried to fix the catheter, and resident #24 freaked out and would not let her adjust it. During an interview on on 10/25/23 at 11:59 a.m., resident #24 agreed his catheter bag should be hung higher, so it was not on the ground. Staff member B did find a solution, 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.