Sweet Memorial Nursing Home

Based on observation, interview, and record review, the facility failed to ensure an occupational therapy evaluation was completed to assess wheelchair positioning and the need for a seatbelt following resident falls and instead implemented a seatbelt without the proper evaluation when the family declined therapy due to the cost, for 1 (#3) of 20 sampled residents. The deficient practice resulted in the use of a positioning device without an appropriate assessment to ensure the resident's safety and effectiveness. Findings include:During an interview on 1/27/26 at 10:45 a.m., NF2 stated resident #3's seat belt should be buckled when she is in the wheelchair. NF2 further stated, They say it's a restraint and that's what I want, I want her to stay off the floor.During an observation on 1/27/26 at 11:14 a.m., resident #3 was observed in a wheelchair positioned in a tilted backward/reclined position. A seat belt was present on the wheelchair; however, the belt was not fastened around the resident. The resident remained seated in the wheelchair during the observation.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Facility Assessment was reviewed and updated annually, and when necessary to update memorandums of understandings for laboratory services, and emergency operations plan. This deficient practice increased the risk of negative outcomes for residents residing at the facility. Findings include:Review of the facility's Facility Assessment updates showed: - 10/2025: [staff member G] to help review/update.- 12/2025: name updates, [etcetera].- 1/2026: [staff member G] suggested updated [NAME] with [name of local hospital] for lab. Also, need updated [NAME] for EOP evacuation to [name of local hospital].Review of the facility's Facility Assessment did not show the facility's assessment was updated since September 2024 and suggested updates for 2025 and 2026 were not completed.During an interview on 1/29/26 at 8:13 a.m., staff member A stated she needed some help on updating the Facility Assessment. She stated staff member G had reviewed 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 vulnerable residents were free from physical abuse by another resident for 5 (#s 9, 13, 34, 73, and 98); and protect residents from misappropriation of medications for four (#s 34, 40, 57 and 67) of 16 sampled residents. Resident #9 was involved in 5 resident-to-resident altercations within the last five months. Findings include:1. Resident to Resident Abuse Events:a. Review of resident #13's nursing progress notes, dated 7/27/25, showed that resident #13 was crying and upset. Resident #9 had grabbed #13's face and would not let it go. The nurse intervened and removed resident #9, but resident #13 was instantly upset. The progress notes did not contain any information regarding interventions for the prevention of abuse for #13, by resident #9. During an interview on 8/7/25 at 8:20 a.m., staff member B said the event between residents #9 and #13 was not reported to the State Survey Agency as abuse. Staff member B said resident #13 is either usually very happy or she cries. The staff thought her crying was just part…

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

Based on interviews and record reviews, the facility failed to report initial allegations or final summaries of abuse or misappropriation of property to the State Survey Agency in the required timelines established by the federal regulations, to meet the initial or final summary reporting requirements, for 7 (#s 5, 9, 13, 21, 34, 73, and 98) of 16 sampled residents. Findings include: 1. Review of a drug investigation packet, provided to the surveyor by the facility, showed that potential drug diversion occurred with resident medications, with the investigation starting in May 2025. The facility did not report the allegation or suspicion of drug diversion immediately at the time of the event. A review of the facility's Facility Reported Events showed they reported the drug diversion to the State Survey Agency on 7/30/25; they were delayed in reporting. During an interview on 8/5/25 at 9:11 a.m., with staff members B and C, staff member B said that starting in May 2025, resident #46 ran out of Seroquel, which was about 14 days earlier than she should have. These were the first missing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 thoroughly investigate resident-to-resident altercations, alleged to be abuse, for 5 (#s 9, 13, 34, 73, and 98) and failed to investigate bruising of unknown origin, for 1 (#5) of 16 sampled. Findings include:1. Review of an untitled facility report, dated 6/11/25, showed resident #5 had a bruise on her left foot, right thigh, and left upper calf. The bruises were of an unknown origin. A Facility Reported Incident was submitted on 6/11/25 to the State Survey Agency.Review of Resident #5's nursing progress notes showed there was no progress note written to clearly identify or describe the bruises or the causes for them in resident #5's medical record. During an interview on 8/5/25 at 1:50 p.m., staff member B said she had talked to resident #5's family member, and he said the resident always bruised easily. Staff member B said there was no further investigation completed as to the cause of the bruises. A thorough investigation into potential causes or interventions to prevent the unknown bruising or potential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and individualize comprehensive care plans to reflect the individualized needs or interventions to protect residents, for 6 (#s 5, 9, 13, 34, 73, 98) of 16 sampled residents, and the staff responsible for updating the care plans were not aware of what to add to the care plans for resident concerns related to abuse or protecting the resident. Findings include: 1. Review of resident #98's nursing progress notes, dated 7/5/25 at 3:34 p.m., showed the resident was found on the floor in the bathroom. Review of #98's untitled facility risk management report for the fall failed to show that a root cause was identified. The resident sustained a laceration to her face. The fall was not investigated for a cause, and there was no evidence that the facility reviewed the fall to prevent further falls. Review of resident #98's care plan with a revision date of 6/16/25, failed to show if the care plan was reviewed or updated related to the fall with injury on 7/5/25, or if interventions were identified to prevent future falls. 2.…

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

Based on interview, and record review, the facility failed to maintain a system to store and monitor controlled drugs was in a manner to contain sufficient detail to enable an accurate reconciliation; and prevent diversion for 5 (#'s 34, 40, 46, 57, and 67) of 16 sampled residents. 1. Review of a facility investigation file showed the facility began an investigation for missing medications in May of 2025. 2. During an interview on 8/5/25 at 9:11 a.m., staff members B and C were present for the interview. Staff member B said beginning in May 2025, resident #46 ran out of Seroquel about 14 days earlier than she should have. This was the first missing medication identified. Staff member B said she emailed the Drug Enforcement Agency for guidance but has not received any feedback from them. 3. During an interview on 8/5/25 at 12:32 p.m., staff member B said the investigation continued through 7/ 30/25. Staff member B said the common denominator with all the missing medication was NF5. Staff nurse NF5 continued working and signing for narcotics until she was terminated 7/30/25, over two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents' highest practicable level of physical and psychosocial well-being was met for 2 (#s 13 and 34) related to medically related social services, of 16 sampled residents. Resident #34 felt isolated after her move, and #13 was upset over an abuse event; neither resident had a social service follow-up after the abuse event. Findings include:During an interview on 8/5/25 at 1:00 p.m., resident #34 said she did have some problems with another resident coming into her room. Resident #34 said the other resident was in her room, and stated, She squirted my eyes with some hand sanitizer. Resident #34 said she is still having problems with her left eye being blurry. Resident #34 said it made her feel very vulnerable. Resident #34 said she was moved to another area of the building, and she feels isolated now. Review of resident #34's progress notes showed no additional interventions related to social services or the resident's emotional well-being, following the physical abuse by resident #9. A review of 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 thoroughly investigate resident to resident altercations, alleged to be abuse, for 3 (#s 19, 29, and 30) of 19 sampled and supplemental residents. Findings include: 1. During an interview on 12/4/24 at 2:50 p.m., staff member A stated she submitted the initial report and findings for the incident, which occurred on 10/17/24. The incident involved an injury of unkown orgin for resident #19. Staff member A felt the injury of unknown origin found on resident #19's forehead was not from an unwitnessed fall. Staff member A stated if resident #19 had fallen, she would not have been able to get back in her wheelchair without assistance. Staff member A stated there were no reports of any unwitnessed falls for resident #19. Staff member A stated resident #19 and resident #29 were roommates on 10/17/24 when resident #29 was observed being the aggressor in an altercation with another resident. Staff member A stated she felt there was a possibility the injury to resident #19 was sustained during an unwitnessed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise an individualized comprehensive care plan to reflect the discontinuation of a catheter for 1 (#18); the use of oxygen for 1 (#15); the use of bed rails for 3 (#s 12, 18, and 27) of 12 sampled residents; and failed to involve the resident or the resident's representative in the care planning process for 1 (#20) of 12 sampled residents. Findings include: 1. During an observation on 12/2/24 at 3:14 p.m., resident #18 was sleeping in her bed and did not have a catheter in place. Review of resident #18's physicians order, dated 11/12/24, showed, Begin bladder training, Clamp for 2 hours, unclamp for 2 hours. After 24-48 hours, discontinue the foley catheter in the morning. Dx: Foley catheter, TTWB as 'ok'd' by ortho. [sic] Review of resident #18's care plan, with a revision date of 7/29/24, showed, The resident has Foley Catheter: s/p repair of left leg fracture and impaired mobility. [sic] Resident #18's comprehensive care plan failed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication error rate was less than 5% for 3 (#s 5, 23, and 30) of 19 sampled and supplemental residents. The calculated medication error rate was 8.16%. Findings include: 1. Review of resident #30's MAR, dated 12/4/24, showed the resident was supposed to be receiving 1 ml (50 mg) of a gabapentin 250 mg/5 ml liquid, in the morning. During a medication administration observation on 12/4/24 at 7:35 a.m., staff member G prepared the gabapentin medication for resident #30. The medication bottle had a label which showed the strength of the gabapentin was 250 mg/5 ml. Staff member G used a 1 ml syringe and filled the syringe to the 0.1 ml line. Staff member G put the 0.1 ml of gabapentin liquid into a drinking cup and added water. Staff member G gave the cup to resident #30, and the resident drank all the mixture. When asked what size syringe was used, staff member G pointed to a 1 ml syringe which was stored in the medication cart. After being shown the packaging for the syringe, staff member G stated,…

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

Based on observation and interview, the facility failed to provide proper oversight for the use of personal refrigerators in a resident's rooms for 3 (#s 1, 3, and 4) of 3 sampled residents with personal refrigerators. The deficient practice put any resident with a personal refrigerator at risk for consuming food not stored at safe temperatures and consuming outdated food. Findings include: During an observation on 12/3/24 at 8:27 resident #4's personal refrigerator contained no means to measure the temperature of the refrigerator. The freezer contained an unidentified substance in a clear plastic bag that was not labeled or dated. The freezer had a thick layer of ice built up inside and outside of the freezer compartment. There was an unidentified food item wrapped in a napkin in the refrigerator door which did not have a label or date. There was a food item wrapped in brown deli paper with no label or date. There were two green, plastic bags, which contained what resembled fruit which were not labeled or dated. A request was made on 12/3/24 at 1:10 p.m. for the facility's 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 and interview, the facility staff failed to perform hand hygiene when passing medications to residents for 3 (#s 13, 21, and 23) of 19 sampled and supplemental residents. Findings include: During an observation in the main dining room, on 12/5/24 at 7:45 a.m., staff member H administered medications to resident #13. After completion, staff member H returned to the medication cart and began the preparation of medications for another resident. Staff member H did not perform hand hygiene between residents. During an observation on 12/5/24 at 7:48 a.m., staff member H prepared the medications for resident #23. Staff member H administered the resident's medications, returned to the medication cart, and began preparation of medications for another resident. Staff member H did not perform hand hygiene between residents. During an observation on 12/5/24 at 7:55 a.m., staff member H prepared the medications for resident #21. After administering the resident's medications, staff member H returned to the medication cart and began preparation of medications for another…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a vulnerable resident was free from physical abuse by another resident for 2 (#s 29 and 30) of 19 sampled residents and supplemental residents. Resident #30 was struck on two separate occasions by resident #29. Findings include: During an observation on 12/4/24 at 10:13 a.m., resident #30 was wandering throughout the facility, including going behind the nursing station. Resident #30 mumbled nonsensical words to herself, while ambulating alone, in the hallways. The resident was also wandering around the activity room during story time. Resident #30 would not sit down in the activity room or listen to the story being read. Review of a Facility-Reported Incident, dated 10/17/24, submitted to the State Survey Agency, showed resident #30 was struck on her right shoulder by resident #29. The report showed resident #29 was having difficulty adjusting to her new environment. Neither of the residents were able to recall or discuss 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 a copy of the baseline care plan to the resident or resident's representative for 1 (#20) of 12 sampled residents. Findings include: During an interview on 12/2/24 at 3:08 p.m., resident #20 stated she did not receive any information or communication regarding her baseline care plan from the facility. During an interview on 12/3/24 at 4:10 p.m., NF1 stated she had not received any communication from the facility regarding resident #20's baseline care plan. Review of resident #20's medical record lacked documentation or evidence the baseline care plan was provided to the resident, or the resident's representative. A request was made on 12/4/24 at 1:08 p.m. for documentation regarding the provision of a copy of the baseline care plan, which was to be given to resident #20 and NF1. There was no information or documentation provided prior to the end of the survey.

Based on interview and record review, the facility failed to create a comprehensive resident centered care plan for 1 (#20) of 12 sampled residents. Findings include: During an observation on 12/2/24 at 3:08 p.m., resident #20 was observed to have broken teeth in her lower jaw. Review of resident #20's Social Service History & Initial Assessment, dated 9/10/24, showed, . 13. Are you having any dental problems? The response was marked, A. Yes . 13a. If yes, specify: broken and decayed teeth . During an interview on 12/4/24 at 12 :47 p.m., staff member C stated when a resident was assessed to have broken or decayed teeth it would be care planned. Review of resident #20's care plan, dated 9/12/24, lacked any documentation related to broken or decayed teeth or dental services.

Based on observation, interview, and record review, the facility failed to identify and assess wheelchair positioning needs for 1 (#20) of 12 sampled residents. This deficient practice caused the resident discomfort due to a poor fitting wheelchair. Findings include: During an interview on 12/2/24 at 3:08 p.m., resident #20 stated her wheelchair was too narrow, and the oxygen tank was positioned on the back of her wheelchair causing her discomfort. During an interview on 12/3/24 at 10:12 a.m., when asked if she had informed anyone of the pain, resident #20 stated she had informed the CNAs. During an interview on 12/4/24 at 11:23 a.m., staff member E said she had not had any communication or awareness of resident #20 caused by her poorly fitted wheelchair. During an interview on 12/5/24 at 8:16 a.m., staff member L stated resident #20 had informed her of pain from the position of the oxygen tank on her wheelchair. Staff member L stated she had informed the maintenance department regarding the resident's wheelchair. During an interview on 12/5/24 @ 8:47 a.m., staff member K stated,…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received proper foot care for 1 (#20) of 12 sampled residents. The deficient practice resulted in the resident experiencing pain due to a callus. Findings include: During an interview on 12/2/24 at 3:08 p.m., resident #20 stated she had pain in her left foot because of a callus. Resident #20 stated the facility had done nothing about it. Review of resident #20's progress note, dated 9/6/24, showed, . There is a callus located at mid plantar surface of the left foot. The foot clinic has been treating the callus most recently and resident states they wanted [podiatrist name] to evaluate the residual callus . During an observation on 12/4/24 at 8:25 a.m., there appeared to be a callus on the bottom of resident #20's left foot. Review of resident #20's physician order, dated 9/9/24, showed . Podiatry appointment/consult for callus on pad of L foot . During an interview on 12/4/24 at 11:14 a.m., staff member D stated she scheduled resident appointments after the doctor entered an order for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an as needed antipsychotic medication was limited to 14 days unless evaluated by the physician, and reordered, for 1 (#29) of 5 sampled residents reviewed for unnecessary medications. Findings include: During an observation and interview on 12/3/24 at 8:53 a.m., resident #29 was sitting in her room. She stated she liked to clean and cook. Resident #29 stated she knew she was not at home and did not know why. Resident #29 stated she lived alone prior to coming to the facility. Review of resident #29's EHR showed the resident was admitted to the facility on [DATE], with diagnoses of dementia with other behavioral disturbance, anxiety, and depression. Review of resident #29's physician orders, dated 9/20/24, showed an order for olanzapine 2.5 mg twice daily, as needed, for agitation. The order did not contain a duration or stop date. Review of resident #29's MAR, dated September of 2024, showed the resident received six doses 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 and interview, the facility failed to discard numerous containers of Half and Half stored in the facility's walk-in cooler, by the use by date. Findings include: During an observation on 12/4/24 at 8:05 a.m., 11 cartons of Half and Half, with a use by date of 12/3/24, were observed on the top shelf, to the right of the entrance, in the walk-in cooler. During an observation on 12/5/24 at 8:07 a.m., eight cartons of Half and Half, with a use by date of 12/3/24, were observed on the top shelf, to the right of the entrance, in the walk-in cooler. During an interview on 12/5/24 at 8:09 a.m., staff member I said dairy products should have been discarded by the use by date.

Based on interview and record review, the facility failed to ensure residents were screened for the pneumococcal vaccines (Prevnar 13, Prevnar 20, and PPSV23), and failed to offer or obtain a declination for the vaccines, for 2 (#s 16 and 27) of 5 residents sampled for immunizations (influenza, COVID-19, and pneumococcal). Findings include: 1. Review of resident #27's vaccination history, not dated, failed to show the resident received any pneumococcal vaccines. During an interview on 12/5/24 at 9:27 a.m., staff member J stated she had only been responsible for resident immunizations for two months. Staff member J stated she did not have any other information regarding the offering, receipt, or declination of any of the pneumococcal vaccinations, since the resident's admission to the facility, on 10/30/23. 2. Review of resident #16's vaccination history, not dated, showed the resident received the Prevnar 13 vaccine on 1/14/20. The history form failed to show either the Prevnar 20 or the Pneumovax 23 was offered, given, or declined by the resident or their representative. 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 staff failed to complete proper hand hygiene during resident medication pass, properly wear masks during a facility outbreak of COVID-19, and sanitize a mechanical lift after resident use, prior to storing. This deficient practice has the potential to spread infection to all residents in the facility. Findings include: During an observation and interview on 12/5/23 at 8:46 a.m., staff member R was observed passing medication to multiple residents without performing hand hygiene between residents. Staff member R said she knows she was not good about performing hand hygiene and should be either hand sanitizing or doing a full wash with soap and water. During an observation on 12/5/23 at 8:05 a.m., staff member P entered the dining room, no hand hygiene was completed upon entering the dining room, and staff member P had her mask was positioned below her nose. Staff member P left the dining room at 8:06 a.m. No hand hygiene was completed. During an observation on 12/5/23 at 8:07 a.m., staff member P walked back into 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 have an antibiotic stewardship program in place. This deficient practice had the potential to affect all residents residing in the facility. Findings include: During an interview on 12/4/23 at 2:06 p.m., staff member A stated the facility was in outbreak status for COVID-19. Staff member A stated no residents tested positive, but one staff member was positive. During an interview on 12/4/23 at 3:06 p.m., staff members A and B stated they would be the back up for the infection prevention program. Staff members A and B were unsure how staff member H was tracking antibiotics, or what kind of criteria or programs she used. Staff member A stated they did not have a current antibiotic stewardship program and staff member H was in the process of implementing one. A review of a facility document titled, Infection control: Antimicrobial stewardship Program (ASP), was in draft form and had not been approved by the QAPI comittee or the facilities Board of Directors for use at that time. During an interview on 12/6/23 at 11:45 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to keep residents free from physical restraints for 3 (#s 12, 28, and 36) of 19 sampled residents. This deficient practice caused the residents the inability to move independently. Findings include: 1. During an observation on 12/4/23 at 3:33 p.m., resident #36 was in her room sitting in a recliner. Resident #36 was trying to get out of her recliner and was yelling out. During an observation on 12/4/23 at 4:25 p.m., resident #36 was sitting in a high-back, reclining type wheelchair. Resident #36 had a seatbelt across her lap. During an observation on 12/5/23 at 8:45 a.m., resident #36 was sitting in her wheelchair with a seatbelt fastened across her lap, by the nurse's station. Resident #36 was trying to unlock her wheelchair brakes and climb over the side of her wheelchair. Resident #36 was unable to release the seatbelt on her own. During an interview on 12/5/23 at 8:47 a.m., staff member M stated the seatbelt was to help keep resident #36 in her wheelchair, so she did not fall. Staff member M stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete a thorough investigation involving elopement for 2 (#s 19 and 26); and falls for 1 (#36) of 19 sampled residents. This deficient practice failed to included interventions to prevent further elopements or falls, root cause analysis, or staff education. Findings include: 1. A review of a Facility Reported Incident, dated 11/3/23 showed, Incident Description: 0742 resident had left the dining room after breakfast attempted to open the boiler room door, [NAME] room door and shower room door, proceeded to the South hall attempted to open the interior boiler room door in south hall than tried to open the south door exit and proceeded out to the smoking area. resident was found by staff 0750 at the boiler room exterior exit after his wheelchair became stuck. staff alerted by dining room staff that resident was seen through the dining room windows prior to becoming stuck, but no nursing staff was notified. Charge nurse was notified 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 implement a baseline care plan within 48 hours of resident admissions for 3 (#s 33, 36 and 142) of 19 sampled residents. This deficient practice had the potential for the residents not to receive the required care needed. Findings include: 1. During an interview on 12/6/23 at 13:20 p.m., staff member B stated, The baseline care plan for [resident #33] is the Kardex and CNA care sheets. During an interview on 12/5/23 at 11:10 a.m., NF2 stated she did not recall anybody asking her about how to care for resident #33 on admission. NF2 stated it was not until later in the month at a care planning meeting where she was asked questions about resident #33. 2. During an interview on 12/6/23 at 13:20 p.m., staff member B stated, The baseline care plan for [resident #36] is the Kardex and CNA care sheets. On 12/5/23 at 11:07 a.m., a call was placed to resident #36's POA. No call back was received prior to the end of the survey. Baseline care plans were requested for resident #33 and #36. An untitled, undated document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete a person-centered, comprehensive care plan for 2 (#s 3 and 29) for UTI and indwelling catheter interventions; interventions for repeated falls for 1 (#17); and elopement interventions for 1 (#26) of 19 sampled residents. Findings include: 1. During an observation on 12/5/23 at 8:06 a.m., resident #29 was seated in his recliner, in his room, the door to the room was open over halfway. Resident #29 was only wearing a shirt. During an observation and interview on 12/5/23 at 8:22 a.m., resident #29 was seated in his recliner, in his room. He was awake and had a foley catheter draining to a large drain bag. Resident #29 said he had been waiting for someone to come change out his catheter drain bag so he could get dressed and go to breakfast with his wife. During an interview on 12/5/23 at 8:29 a.m., staff member R said resident #29 was waiting for his catheter drain bag to be changed out to a leg bag for day use. Staff member R would let the CNA know so it could be switched to a leg bag. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to revise and implement new focus, goals, and interventions on care plans for 7 (#s 1, 12, 17, 19, 28, 33, and 36) of 19 sampled residents. Findings include: 1. During an observation on 12/4/23 at 3:41 p.m., resident #28 was wearing a blue vest type device. The device crisscrossed her back, and the straps going over her shoulders were hooked around the handles of her wheelchair. This device prevented the resident from rising out of her wheelchair. The releases for the device which resemble lift and release seatbelt catches were behind her. Resident #28 could not release the device on her own. During an observation on 12/5/23 at 8:20 a.m., resident #28 was wheeling herself past the nurse's station. She was not wearing her restraint device. During an observation on 12/6/23 at 8:40 a.m., resident #28 was wearing the restraint device at breakfast. During an observation on 12/6/23 at 9:11 a.m., resident #28 was brought to the unit from 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 keep residents safe from falls for 2 (#s 12 and 142); and elopements for 2 (#s 19 and 26) of 19 sampled residents. Findings include: 1. During an observation on 12/6/23 at 9:16 a.m., resident #12 was seated in a wheelchair. She was wearing a seatbelt. Staff member G and staff member J were putting foot rests on the wheelchair resident #12 was seated in. The resident repeatedly tried to stand up from the wheelchair. During an interview on 12/6/23 at 9:22 a.m., staff member I said the doctor ordered the wheelchair and the seatbelt for resident #12 because of her recent falls. Review of resident #12's nursing progress notes showed: - 12/4/23 at 3:25 p.m., Rt (resident) was found sitting on their floor next to their bed alert and w/o (without) injuries. Assisted to their feet and then to couch to rest. - 12/4/23 at 10:47 a.m., At 1030 (10:30 a.m.) resident was walking over to her couch and tripped over her baby doll stroller in her room. -…

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

Based on observation, interview, and record review, facility staff failed to identify and address dignity concerns for 1 (#16) of 19 sampled residents. Findings include: During an observation on 12/4/23 at 1:50 p.m., staff member I and staff member G were in the process of completing peri-care for resident #16. Resident #16 was lying on her right side; staff member G was in front of her, and staff member I was behind resident #16. Both staff members spoke to the resident, covered the resident with her comforter, and left the room. The staff members did not put a brief or pants on resident #16 prior to leaving the room. During an interview on 12/4/23 at 1:52 p.m., resident #16 said she did not like not having bottoms on when she was in bed. Resident #16 said she had a couple of sores on her bottom, and staff would leave her in bed with no bottoms on. During an interview on 12/6/23 at 3:37 p.m., staff member B said she was not aware resident #16 was embarrassed to not have bottoms on when she was in bed. Staff member B said staff left resident #16's bottoms off in order to leave 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 accuately code a restraint on a resident's Minimum Data Set for 1 (#36) of 19 sampled residents. Findings include: During an observation on 12/4/23 at 4:25 p.m., resident #36 was seated in a high-backed, reclining type wheelchair. Resident #36 had a seatbelt across her lap. A review of the Significant Change Minimum Data Set, with an ARD of 10/3/23, showed: Resident #36 was not coded for any type of restraint in section P. During an interview on 12/6/23 at 1:05 p.m., staff member B stated the restraint should have been coded on the MDS. A review of a facility document titled, POINT CLICK CARE CP & MDS, with a revision date of 2/1/22, showed: . The guidelines for the resident assessment are consistent with the requirements for the State-specified Resident Assessment Instrument (RAI) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide on-going daily care and monitoring of indwelling urinary catheters based on recommended standards, which increased the risk of catheter associated urinary tract infections for 2 (#s 3 and 29) of 19 sampled residents. Findings include: During an interview on [DATE] at 8:38 a.m., staff member L said she was not sure who was responsible for indwelling catheter assessments for residents. She thought it might be the treatment nurse but staff member B would be able to answer who was responsible. During an interview on [DATE] at 9:19 a.m., staff member G said she was not sure who does the catheter assessments and documents them in the resident chart. Staff member G said she had never documented an assessment for a resident with an indwelling catheter and assumed the treatment nurse would do the assessment and it would be documented on the TAR. Staff member G reviewed resident #3's TAR and the foley catheter irrigation had 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 observation and interview, the facility failed to label a vinegar bottle with the date opened, the mixture concentration, and the individual mixing the concentration for 1 (#29) of 19 sampled residents. Findings include: During an observation and interview on 12/6/23 at 1:24 p.m., staff member I said catheter care was provided for resident #29 when the foley drain bag was changed over to a leg drain bag and the large drain bag was rinsed. A gallon of irrigation was sitting in a plastic basin next to the toilet and on the floor. The gallon container had no lid, was not dated, no initials were present, no solution concentration was written on a label, and the only label was for vinegar. The gallon was ¼ full. Staff member I did not know what the solution concentration was or who had mixed the solution for irrigation. During an interview on 12/6/23 at 2:15 p.m., staff member G said she was not familiar with the protocol for the urine drain bag mixture. Staff member G said she did not know if the vinegar was diluted to flush the bag or if it was full strength. 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.