Beartooth Rehabilitation And Nursing LLC

Based on observation, interview and record review, the facility failed to ensure the resident's care plan was reviewed and revised by an interdisciplinary team when a resident had a change in condition for 1 (#4); failed to ensure the resident representative was involved in the care planning process or invite the resident's representative to care plan meetings for 1 (#8) of 30 sampled residents, and failed to ensure a resident-centered care plan was updated to include information about oxygen and safety precautions for 2 (#s 12 and 20) of 6 residents sampled for smoking. These deficient practices limited the staff's ability to perform care and communicate effectively, limited the resident representative's involvement in treatment and care decisions, and posed hazards related to unsafe smoking for residents. Findings include:1. During an observation and interview on 2/8/26 at 2:43 p.m., NF3 said resident #4 uses her cell phone to type messages. NF3 said the staff can usually communicate and understand her messages. During the interview, resident #4 was observed texting on her cell…

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 binding arbitration agreements were presented in a manner allowing informed and voluntary consent, and failed to ensure arbitration agreements were not effectively treated as routine admission paperwork, for 3 (#s 6, 12, and 25) of 30 sampled residents. The failure placed the residents at elevated risk for signing binding legal agreements without informed choice and limiting access to the court system. Findings include:1. During an interview on 2/8/26 at 10:14 a.m., staff member A stated there were currently no signed arbitration agreements in the facility. During an interview on 2/8/26 at 3:40 p.m., staff member F stated she was somewhat familiar with the admission packet and had completed the admission process with families a few times since she started working at the facility. Staff member F stated she did not separately review each individual document with the family unless questions were asked. Staff member F stated she was not familiar with what an arbitration agreement was or why someone would sign one, 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 notify a resident's representative of changes in resident care and treatment for 1 (#25) of 30 sampled residents. The failure resulted in the POA's missed opportunity to be informed of changes to the resident's care and treatment. Findings include:Review of resident #25's nurse's note dated 11/8/25 at 3:52 a.m., showed resident #25 had a fall and was found on the floor next to the bed. The note showed the day shift staff would be responsible for alerting resident #25's power of attorney.Review of the nurse's notes for the remainder of 11/8/25 failed to show resident #25's power of attorney was notified about the fall.Review of resident #25's nurse's note, dated 12/5/25, showed resident #25 was started on an antibiotic for a urinary tract infection. There was no documentation showing resident #25's power of attorney was contacted regarding the change in treatment necessary to treat an infection.During an interview on 2/10/26 at 11:17 a.m., NF2 said the facility had not called her about any falls, and she 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 interview and record review, the facility failed to ensure a thorough investigation of facility-reported events for 1 (#46) of 8 residents sampled for facility-reported events. The failure placed the resident at risk for inadequate protection from harm. Findings include:Review of a facility reported incidents, dated 10/24/25, 11/1/25 at 10:20 a.m., 11/1/25 at 5:40 p.m., 12/3/25, and 12/6/25, showed resident #46 had left the facility premises without the facility knowledge. The investigative files presented for review failed to include a thorough investigation of one resident who had multiple elopements. No staff interviews were included in the files.During an interview on 2/7/26 at 4:10 p.m., staff member J said resident #46 had lived in a homeless shelter and was potentially in a witness protection program. Staff member J said the resident would be outside smoking unattended because the facility did not have the manpower to watch and supervise residents who smoked. Staff member J said the facility changed resident #46's activity care plan, but staff member J said 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address the limited range of motion of the right hand for 1 (#1) of 30 sampled residents. This deficient practice increased the risk for further decline in the resident's functional ability and range of motion. Findings include:During an observation and interview on 2/8/26 at 10:04 a.m., resident #1 was observed seated in a wheelchair with her right hand in a flexed position with her fingers curled into the palm. When resident #1 was asked if she was able to open her fist, she stated, No. Resident #1 used her left hand to grasp the fingers of the flexed right hand and attempted to pull them open; the fingers did not fully extend.During an observation and interview on 2/9/26 at 8:03 a.m., resident #1 was observed during breakfast. Staff member L spoon-fed the resident. Resident #1 did not use her hands to assist with the meal. When asked about finger foods, staff member L…

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 an activity program to meet the individual needs and interests for 2 (#s 9 and 29) of 30 sampled residents. The failure resulted in resident dissatisfaction with the activities program and boredom. Findings include. During an observation on 2/7/26 from 2:00 p.m. until 4:00 p.m., three residents were observed in the activity room doing a self-initiated activity.During an interview on 2/7/26 at 2:18 p.m., resident #29 said she was tired of Bingo, so she just stayed in her room and read. Resident #29 said there was not much to do at the facility when discussing her activity participation.During an interview on 2/7/26 at 2:33 p.m., resident #9 said the only thing to do for activities was to go to Bingo. Resident #9 said the activity director was new, and she did not know what to do for activities. Resident #9 said things were going on sometimes, but it the activities were not what she was interested in. Resident #9 said there were no activities going on during the weekend, except an occasional church…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and services to prevent a decline in range of motion for 1 (#1) of 30 sampled residents, and the range of motion limitations affected the resident and her ability to complete or participate in ADL care and increased the resident's risk of a continued deterioration in the resident's range of motion. Findings include: During an observation and interview on 2/8/26 at 10:04 a.m., resident #1 was observed seated in a wheelchair with her right hand in a flexed position with her fingers curled into the palm. When resident #1 was asked if she was able to open her fist, she stated, No. Resident #1 used her left hand to grasp the fingers of the flexed right hand and attempted to pull them open. The fingers did not fully extend during the attempt.During an observation and interview on 2/9/26 at 8:03 a.m., resident #1 was observed during breakfast. Staff member L spoon-fed the resident. The resident did not use her hands to…

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

Based on observation, interview, and record review, the facility failed to assess and provide services for 1 (#41) of 30 residents who exhibited signs of depression and was having a difficult time adjusting to the facility. The failure resulted in the resident feeling lonely, isolated and depressed. Findings include: During an observation and interview on 2/7/26 3:24 pm., resident #41 repeatedly told the surveyor he was sad and lonely. Resident #41 said he was basically kidnapped and placed here (at facility), as he did not know he was being left at the facility. Resident #41 said he was lonely; he missed his daughter and missed his granddaughter's dog. Resident #41 said he had a friend at the facility, but they kicked her out. Resident #41 said he cries every day. Resident #41 said he doesn't sleep well because he is lonely and cries almost every night. Resident #41 said he does sleep in the day to get some rest. Resident #41 said he goes to the dining room, but there is a group of residents who stare at him and talk about him. Resident #41 said that when the other residents talk…

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

Based on observation, interview, and record review, the facility failed to maintain complete and accurate clinical records by failing to include a documented admission agreement in the medical record for 1 (resident #17) of 30 sampled residents. The failure placed the resident at elevated risk for lack of clarity regarding services, responsibilities, and resident rights. Findings include:During an interview on 2/8/26 at 2:44 p.m., staff member A stated admission paperwork should be completed at the time of admission, and the paperwork would be the responsibility of herself, or staff member K. Staff member A stated at the time of resident #17's admission, she would have been responsible for his admission paperwork.During an interview on 2/8/26 at 9:40 a.m., staff member B stated that resident #17's admission paperwork could not be located.Review of resident #17's electronic medical record showed an admission date of 11/25/24. The medical record lacked admission documentation, including information for billing, and resident rights and responsibilities.Review of resident #17's social…

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 documentation and demonstrate evidence of its ongoing QAPI program that meets the regulatory requirements, and show systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility failed to implement a comprehensive QAPI plan that would sufficiently identify and correct quality concerns, and this failure may affect all residents of the facility. Findings include: During an interview on 9/4/25 at 11:20 a.m., staff member A stated the facility did not have a QAPI plan in place, but they are working on implementing one. Staff member A stated, Documentation is important, and we are trying to utilize the risk management system, but we are still seeing a lot of errors in the process. We are not getting a lot of feedback. I know we need to get more people involved, but it's so hard being so small. We are…

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

Based on interview and record review, the facility failed to have the required members for attendance and participation in Quality Assurance and Performance Improvement (QAPI) meetings, including the Medical Director (or Designee), which were at a minimum, required to be completed quarterly. This deficient practice had the potential to affect all residents who received care in the facility. Findings include: During an interview on 9/3/25 at 5:07 p.m., staff member B stated she attended the QAPI meetings. Staff member B stated, I just show up and do what I need to do and give my input. That is all.During an interview on 9/4/25 at 11:20 a.m., staff member A stated herself, and staff member B, attend the QAPI meetings, and that sometimes staff member C joins the meeting via phone call but does not attend all the meetings. Staff member A stated Staff member G does not attend the meetings in person, but staff member G is presented with the information fromn the QAPI meeting after the fact, via a phone call. Staff member A stated, We only have [Staff member G] onsite once a month. 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 interview and record review, the facility failed to ensure a routine written notification of a resident transfer and discharge was completed and maintained, with information regarding the transfer and discharge to the local Ombudsman for 4 (#s 3, 4, 10, and 12) of 12 sampled residents reviewed for a transfer and or discharge from the facility. The deficient practice increased the risk of residents being inappropriately transferred or discharged due to the lack of communication to the resident or advocate. Findings include:Review of a facility list of resident transfers and discharges, dated 8/25/25 at 3:31 p.m., showed:- Resident #4 transferred to a hospital on 4/11/25.- Resident #12 transferred to a hospital on 6/20/25.- Resident #10 transferred to a hospital on 5/4/25 and 6/17/25; and,- Resident #3 discharged from the facility on 8/8/25 due to the resident's death.During an interview on 8/26/25 at 10:33 a.m., NF1 stated staff member A did not send her the notices for the resident transfers and discharges. NF1 stated that staff member A mentioned to her that resident #3…

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 implement and uphold policies and procedures for the reporting of an unwitnessed fall, for a resident who was not a reliable reporter, and the resident sustained a hip fracture, had surgery, and was hospitalized for it, or 1 (#4) of 6 residents sampled for falls; and facility staff neglected to provide necessary services to the resident after the fall, which was not identified as neglect of care, and reported to the State Survey Agency following the event. Findings include:On 8/25/25, it was identified that the facility had no documented facility reported incidents submitted to the State Survey Agency. The facility was not able to provide any prepared or completed investigations for any facility reported events submitted to the State Survey Agency. The facility had an initial certification survey in December 2024, and a complaint survey in July 2025, and no reportable events were submitted to the State Survey Agency iduring this time. During an interview on 8/26/25 at 10:04 a.m., staff member A stated she had been working…

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 initiate an abuse or neglect investigation following an event when a resident experienced an unwitnessed fall resulting in major injury, which required surgery and hospitalization for 1 (#4) of 6 residents sampled for falls, and the licensed nursing staff failed to ensure the resident was provided necessary care and services related to the fall and negative outcomes from it, or follow the facility policies or procedures, or standards of practice for nursing care. This deficient practice caused a delay of the allegation of abuse or neglect being sent to the State Survey Agency and increased the risk for residents in the facility due to the facility not identifying, thoroughly investigating, and failing to report facility reported events. Findings include:On 8/25/25, the facility was under inspection for a complaint and revisit survey, and it was noted that there were no documented facility reported incidents that were either reported or submitted to the…

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

Based on observation, interview, and record review, the facility failed to complete a Significant Change MDS for a resident's decline, for 1 (#4) of 12 sampled residents. This deficient practice increased the risk of the resident not receiving necessary care due to the lack of changes being identified using the MDS assessment process. Findings include:During an observation on 9/2/25 at 5:33 p.m., resident #4 was sitting in a wheelchair in the dining room. Resident #4 would roll back from the dining room table, then roll back up to the dining room table, without assistance. During an interview on 9/3/25 at 5:07 p.m., staff member B stated she was responsible for completing the MDS assessments. Staff member B stated the facility had an interdisciplinary team meeting after resident #4's fall (on 4/10/25). Staff member B stated, When [Resident #4] returned from the hospital on 4/16/25, she was non-ambulatory, so there was nothing to change. Staff member B stated she should have done a Significant Change MDS instead of a Quarterly MDS. Staff member B stated she would look at the RAI…

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 submit a Quarterly MDS (Minimum Data Set) assessment within the required time frame for 1 (#3) of 12 sampled residents. Findings include:Review of resident #3's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 7/11/2025, showed a completion date of 7/25/25. The assessment was not submitted and accepted until 8/19/25, 11 days past the required submission date. During an interview on 9/3/25 at 5:07 p.m., staff member B stated she was the staff member responsible for completing the MDS (Minimum Data Set). Staff member B stated she knew there were some MDS (Minimum Data Set) assessments that were late. Staff member B stated, I just have so much on my plate. I also was having to help cover shifts on the floor, so there were things (assessments) that were late. We have hired someone to help me, and that will take some tasks off my plate.Review of a facility policy titled Resident Assessment-RAI, with an implementation date of 4/11/25, showed: Policy: This facility makes a comprehensive 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 interview and record review, the facility failed to code medications accurately on the MDS assessment for 1 (#3) of 12 sampled residents. Findings include:Review of resident #3's Quarterly MDS, with an ARD of 7/11/25, showed question N0300. Injections-Record the number of days injections of any type were received during the last 7 days or since admission or reentry if less than 7 days. A 0 was marked. Section N0350. Insulin was disabled by question N0300. Section N0410, for the High-Risk Drug Classes, Use and Indication, showed, J. Hypoglycemic (including insulin), was marked No.Review of the Resident Assessment Instrument, dated October 2024, showed: . Insulin injections are counted in this item as well as in Item N0350. Record the number of days that any type of injection (e.g., subcutaneous, intramuscular, or intradermal) was received. N0415J1. Hypoglycemic (including insulin): Check if a hypoglycemic medication was taken by the resident anytime during the observation period .Review of resident #3's Physician Orders, dated 6/1/25 to 8/8/25, showed, Lantus Solostar…

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 a comprehensive care plan to include behavioral health services being provided for 1 (#3) of 12 sampled residents. This deficient practice increased the risk of the resident not receiving necessary services for mental health. Findings include: During an interview on 9/4/25 at 9:04 a.m., staff member A stated she had been working as the facility Administrator, Social Worker, and Business Office Manager. Staff member A stated that resident #3 was seeing a mental health provider via tele-health services.During an interview on 9/4/25 at 11:20 a.m., staff member B stated care plans should include mental health concerns. Staff member B stated, If a resident had mental health concerns, the care plan would address the non-pharmacological interventions, as well as the pharmacological interventions, any triggers the resident may have had, and any other pertinent behavioral health information. Staff member B stated, I know that the care plans are lacking.Review of patient #3's comprehensive care plan, dated 4/15/25, 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 observation, interview, and record review, the facility failed to develop and implement a facility policy which contained the name and contact information for the grievance official; failed to provide residents with readily available grievance forms; and failed to provide residents with the option to file grievances anonymously for 2 (#s 1 and 7) of 8 sampled residents. This deficient practice affected current residents residing in the facility who wished to know information for, review the information from, or use, the grievance process. Findings include:During an observation on 7/28/25 at 4:00 p.m., a walkthrough of the facility's common areas was conducted. No grievance forms were found to be readily available to residents; No posting of the name and contact information of the grievance official was found; and no secure receptacle was identified to file an anonymous grievance.During an interview on 7/28/25 at 4:30 p.m., staff member A stated grievance forms were in her office. Staff member A stated grievance forms had been in a hanging file on the wall after entering 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 and interview, the facility failed to post the results of the most recent certification survey in an area readily accessible to residents, family members, and residents' legal representatives. This deficient practice had the potential to affect all residents or resident representatives wishing to view the most recent certification survey results. Findings include:During an observation on 7/28/25 at 4:30 p.m., no binder containing the most recent certification survey results were found within the common areas of the long-term facility.During an interview on 7/28/25 at 4:30 p.m., staff member A stated the survey information was removed when the facility underwent renovations recently. Staff member A stated she had not reposted the survey results after the renovations occurred.During an interview on 7/29/25 at 11:57 a.m., resident #1 stated she was not aware of the location of a binder that contained the most recent certification survey results.

Based on observation, interview, and record review, the facility failed to ensure a resident's room was kept clean and hazard-free as needed, and this concerned the resident and family, for 1 (#7) of 8 sampled residents. Findings include:During an interview on 7/29/25 at 1:30 p.m., staff member G stated resident rooms were cleaned daily, which included sweeping, mopping, cleaning bathroom toilets, and surface areas.During an observation and interview on 7/30/25 at 10:00 a.m., upon entering resident #7's room, it was observed the air conditioning unit's front panel had been completely removed, leaving the internal components exposed. A heavy accumulation of brown debris, resembling dust and grime buildup, was present across the surface of the unit, indicating prolonged lack of cleaning or maintenance. Additionally, an electrical wire within the unit was visibly exposed, posing a potential safety hazard to resident #7 and staff. Resident 7's bathroom toilet was soiled with urine and feces on the inside and outside of the toilet bowl. The floor around the area of the resident's…

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

Based on observation, interview, and record review, the facility failed to implement a comprehensive, resident-centered care plan which identified residents' physical and psychosocial needs to help the residents reach their highest practicable level of well-being, and failed to identify preventative interventions, for 4 (#s 155, 156, 157 and 163) of 13 sampled residents. Findings include: 1. During an observation and interview, on 12/2/24 at 12:22 p.m., resident #155 was sitting on his bed. In reply to questions, resident #155 initially stated, Yeah, no, yeah, or Ayy. On further questioning, and providing adequate time to answer, resident #155 was able to answer some questions with occasional single word answers or yes/no responses, but he was unable to converse easily. Review of resident #155's medical record showed a diagnosis of traumatic brain injury. Review of resident #155's care plan did not show a focus area or interventions for a communication deficit or interventions for staff to utilize when communicating with the resident. 2. During an observation and interview, on…

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

Based on observation, interview, and record review, the facility failed to ensure staff member H adhered to proper infection prevention and control practices during medication administration for 1 (#157) of 4 sampled residents for medication administration; failed to ensure enhanced barrier precautions were implemented and followed, for 3 (#s 154, 156, and 157) of 13 sampled residents; and failed to follow proper infection control practices were used when transferring dirty and clean laundry. Findings include: 1. During an observation on 12/4/24 at 7:34 a.m., staff member H, who was a licensed nurse training with staff member E, entered resident #157's room to administer medications. After entering resident #157's room, staff member H laid down the following medications onto the top of a clothing dresser: - Fluticasone Propionate Nasal Suspension 50 mcg, - Novolog Injection Solution 100 Units/ml - 30 U, and - Combivent Respimat Inhalation Aerosol Solution 20-100 mcg. Staff member H did not clean the top surface of the clothing dresser or lay down any form of protective barrier prior…

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 clean and sanitary environment for 2 (#s 151 and 155) of 13 sampled residents. Findings include: 1. During an interview on 12/2/24 at 4:40 p.m., NF1 stated resident #151's toilet was sometimes dirty when he visited. During an interview on 12/3/24 at 7:57 a.m., staff member B stated cleaning (of the bathroom) was done every day. During an observation on 12/3/24 at 9:25 a.m., resident #151's toilet had brown specks splattered (apppeared to be feces) on the front part of the toilet bowl. During an observation on 12/3/24 at 2:46 p.m., resident #151's toilet still had brown specks splattered on the front part of the toilet bowl. During an observation on 12/4/24 at 8:01 a.m., resident #151's toilet had brown specks splattered on the front part of the toilet bowl, it did not appear to have been cleaned in the last 24 hours. 2. During an observation and interview on 12/2/24 at 12:22 p.m., resident #155 reported the facility did not clean the bathrooms enough and pointed to the toilet. The toilet in 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 update resident care plans when changes to the resident's care occurred for 2 (#s 157 and 164) of 13 sampled residents. Findings include: 1. During an observation and interview on 12/2/24 at 1:40 p.m., resident #157 was sitting in his wheelchair, and a urinary catheter tubing was observed across his abdomen, and draining urine into a catheter bag, attached to the side of the chair. Resident #157 reported he previously had an indwelling catheter, but it was causing more pain and infections, therefore it was recently changed to a suprapubic catheter. Resident #157 stated the nurses changed the dressing around the catheter every day. Review of resident #157's nursing progress notes showed the resident was transferred to the hospital for suprapubic catheter insertion on 10/1/24, and the resident returned to the facility on the same day. Review of resident #157's physician orders showed an order for a suprapubic catheter dressing change, once per shift, beginning on 10/1/24. Review of resident #157's care plan,…

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, staff member F failed to adhere to professional standards of practice by crushing a delayed release medication not recommended to crush, for 1 (#155) of 4 sampled residents for medication administration. Findings include: During an observation on 12/3/24 at 4:56 p.m., staff member F had removed the following medications out of the individual bubble packs for administration to resident #155: - metFORMIN HCl Oral Tablet 1000 MG (Metformin HCl) Give 1000 mg by mouth two times a day ., and - Depakote Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 500 mg by mouth two times a day . with an order date of 11/25/24. During an observation and interview on 12/3/24 at 4:57 p.m., staff member F crushed both metformin and Depakote for resident #155. Staff member F stated the Depakote was crushed all the time so resident #155 could swallow the medication. Staff member F stated she usually did not crush delayed or extended-release medications. Staff member F proceeded to administer the crushed medications, in pudding, to 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 ensure a dependent resident was getting turned frequently enough to prevent skin breakdown, for 1 (#154) of 13 sampled residents, and the resident was identified to have new skin redness to the coccyx and perineum. Findings include: Review of resident #154's EHR showed an admission date of 11/27/24. Review of resident #154's EHR showed a medical diagnosis of Amyotrophic Lateral Sclerosis (ALS). Review of resident #154's EHR showed an assessment, titled Admit/Readmit Screener, dated 11/27/24. In this assessment, resident #154's skin integrity was addressed, and no coccyx or buttock redness was documented: . color: normal . temperature . warm . turgor . normal . skin assessment . Right knee (front) Abrasion, Left knee (front) Abrasion. Review of resident #154's EHR showed a nursing note, dated 11/27/24, included: some redness noted to coccyx and perineum. [sic] During an interview on 12/2/24 at 1:36 p.m., resident #154 stated she had pain to her coccyx and buttock area. Resident #154 was positioned in the…

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

Based on observation, interview, and record review, the facility failed to ensure BiPAP parameter orders were in place for 1 (#154) of 3 sampled residents with respiratory concerns. Findings include: During an interview and observation on 12/2/24 at 1:31 p.m., resident #154 stated she was unsure if she had oxygen bled into her BiPAP. No oxygen tank was located in resident #154's room. During an interview on 12/4/24 at 12:54 p.m., staff member E stated the BiPAP machine did not have any oxygen bled into the system for resident #154. Review of resident #154's EHR showed no physician's order was placed for the BiPAP parameters. BiPAP parameters consist of: oxygen delivery (FiO2), distending pressure to help recruit alveoli (EPAP), high pressure to augment the patient's normal breath (IPAP), and respiration rate. During an interview on 12/4/24 at 1:10 p.m., staff member H stated they were unable to find the oxygen parameter order for resident #154's BiPAP. Staff member H stated not knowing the orders could be dangerous if there was a power outage or if the parameters were changed on…

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 prn psychotropic medications were limited to 14 days, for 1 (#156) of 13 sampled residents. Findings include: During an interview on 12/2/24 at 1:40 p.m., resident #156 stated he sometimes took diazepam for anxiety and mood. During an interview on 12/4/24 at 3:30 p.m., staff member B stated she was not sure why the prn diazepam did not have a stop date, and stated, I will get a stop date put on it today. Review of resident #156's physician orders showed an order on 10/2/24 for diazepam, 5mg, every eight hours, prn, without a stop date noted. Resident #156's MARs for October 2024 and November 2024, showed he received prn diazepam on 23 occasions in October 2024, and 23 occasions in November 2024. The order for prn diazepam remained active as of 12/4/24. Review of resident #156's medical record failed to show an initial evaluation or re-evaluation of the resident's need for diazepam on a prn basis. The review of resident #156's medical record showed the diazepam was ordered and used on an prn basis over a 2-month…

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.