Pioneer Care And Rehabilitation

Based on interview and record review, the facility failed to have a designated infection preventionist for the facility. This deficient practice had the potential to affect all residents in the facility. Findings include: Review of the requested entrance conference materials failed to show an infection preventionist certificate or person responsible for the infection control program in the facility. During an interview on 5/8/25 at 12:04 p.m., staff member A stated there was not a current staff member possessing an infection preventionist certification. Staff member A stated the previous infection preventionist was no longer at the facility, and the new hire was just finishing up infection preventionist training.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to address the timely completion or implementation of treatment wishes, specifically related to the Provider Orders for Life-Sustaining Treatment (POLST) forms, and ensure the forms were complete so the document would not be voided, for 3 (#s 9, 16, and 20) and failed to ensure a resident's code status was consistently correct for 1 (#22) of 17 sampled residents. Findings include: 1. Review of resident #9's care plan showed the resident was admitted on [DATE]. Review of resident #9's POLST (Physician Orders for Life-Sustaining Treatment) showed the form did not have a printed name, signature, or date in the mandatory section identifying the person making the decision for life sustaining treatment. The POLST form was signed by a physician on [DATE], without verification of who was making life sustaining choices for resident #9. Resident #9's POLST showed the resident was a full code. The lack of the resident's or responsible party's signature may void 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 a licensed pharmacist sufficiently addressed and documented the monthly medication regimen reviews for 1 (#10) of 17 sampled residents, and the resident received medications for anxiety and depression which fell into the classification of a psychotropics per CMS; and failed to complete the monthly medication regimen reviews with recommendations to ensure residents were provided the appropriate medications and doses to treat their diagnoses, for 4 (#s 3, 22, 24, and 35) of 17 sampled residents. Findings include: 1. Review of resident #10's medication administration record for May 2025 showed the following: - Olanzapine, an atypical antipsychotic, 2.5 mg by mouth, every day, which was ordered on 7/11/24. - Ativan, an benzodiazapine, 1 mg by mouth, every 24 hours as needed, which was ordered on 4/17/25 and discontinued on 4/28/25. - Ativan 1 mg by mouth, every eight hours, was ordered 4/28/25. - Buspirone, an anxiolytic, 5 mg three times a day, for anxiety, which was ordered on 8/16/24, - Escitalopram, 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 interview and record review, the facility failed to use antibiotics in accordance with accepted standards, identify a residents potential colonization of a specific organism causing the resident to be on almost continuous antibiotics for several months, gave two different antibiotics at the same time for the same UTI, and the resident contracted Clostridium difficile for 1 (#35) of 17 sampled residents. Findings include: During an interview on 5/8/25 at 11:44 a.m., staff member B stated resident #35 was on Macrobid antibiotic for sinusitis, currently. Staff member B stated the facility did not administer antibiotics without receiving the culture and sensitivity back for any resident. Staff member B stated the former infection preventionist did not do infection tracking as they should, and the facility did not have an infection preventionist at the time of the survey. Staff member B was unaware of resident #35 being on two different antibiotics at the same time for the same UTI. Review of resident #35's MARs, from 2/1/25 to 5/8/25, showed the following antibiotics were used:…

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

Based on interview and record review, the facility failed to report an allegation of residen to resident abuse, as it was not identified as abuse for 2 (#s 47 and 53); and failed to report two injuries of unknown origin for a resident, one of the injuries was a major injury, for 1 (# 10) within 24 hours of the incidents of 17 sampled residents for abuse reporting. Findings include: 1. Review of resident #10's nurse progress notes, dated 4/25/25 at 12:56 a.m., showed, resident continues with fading bruising scattered purple/blue in color to left lower back. Voiced c/o pain to area. Review of nursing progress notes, from 4/18/25 through 5/25/25, showed resident #10 did not have any falls or sustain injuries. The cause of the bruising was unknown and not identified by the facility. During an interview on 5/7/25 at 4:57 p.m., staff member A said she was not aware of any bruising on resident #10. Staff member A said there was no investigation completed into the cause of the bruising of unknown origin, which is reportable to the State Survey Agency. Staff member A said the facility tried…

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 required elements of education, physician and management notifications, and documentation of an AMA discharge, were completed for 1 (#55) of 17 sampled residents. Findings include: Review of a closed record EHR for resident #55 showed discharge on [DATE] as AMA. The resident had admitted on [DATE]. Resident #55's care plan did not have discharge planning until 3/5/25. The care plan only showed the resident wished to go back to the community. No other discharge planning was documented. No information on education and the risks was documented for an AMA discharge, other than they could not give him medications, to take with him on discharge. No notifications were in the EHR of the provider being notified. There was no recapitulation of the residents stay from the provider, or documentation of the facility contacting other entities related to the resident leaving AMA due to risks with the discharge. Review of resident #55's discharge…

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

Based on interview and record review, the facility failed to ensure residents transferring or discharging to the hospital were provided the transfer discharge notice and bedhold for 1 (#3) of 17 sampled residents. Findings include: During an interview on 5/8/25 at 7:57 a.m., staff member A stated the facility did not have the transfer discharge notice for resident #3. Staff member A stated the transfer discharge notices and bedholds were a problem they were working on. Review of resident #3's census showed a hospitalization from 2/10/25 to 3/4/25. There was no documentation of a transfer discharge notice or bedhold form in the resident's record or provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours after admission to reflect the resident's care needs, for 1 (#10) of 17 sampled residents. This increased the risk of staff not providing necessary care and services due to the lack of the baseline care plan. Findings include: Review of resident #10's baseline care plan evaluation showed the resident was admitted on [DATE]. Resident #10's baseline care plan failed to identify the resident's code status. Section F, active diagnoses contributing to the resident's admission were left blank. Resident #10's base line care plan did not identify his risk associated with dementia, weakness, and the use of psychotropic medications. Resident #10's baseline care plan showed the resident had no history of falls. There was no date for completion of the care plan. Section 5. B, on the baseline care plan form, showed a signature and date line for the resident and the representative to sign.…

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 review and provide the needed ADL assistance for dining for 1 (#3) of 17 sampled residents. Findings Include: During an interview on 5/6/25 at 9:59 a.m., resident #3 was in her room sitting in her wheelchair, and she was clearing her throat and coughing, and stated the facility staff 'don't feed me right.' Resident #3 stated she had a hard time with a regular fork and spoon, and she had tried built up (adaptive) silverware in the past, but they had not been tried in a while. Resident #3 stated she was to get a walled (adaptive plate) plate but it did not always happen. During an observation on 5/7/25 at 12:37 p.m., resident #3 was in the assisted dining room at a table with another resident, and a staff member facing away from resident #3. Resident #3 had a large bowl with a mix of food and dinner roll on top. There were three drinks with straws in double handled sippy cups, without lids. Resident #3 was trying to grab the dinner roll from the bowl and could not get her hand to turn the correct way to grasp…

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 accurately monitor a resident's meal intake, feeding abilities, and address suspected scale errors in relation to a resident's severe weight loss, although the weight loss was desireable, for 1 (#22) of 17 sampled residents. Findings include: During an interview on 5/7/25 at 1:00 p.m., NF3 stated resident #22 had been losing weight and was looking a lot thinner. NF3 stated the resident usually ate in the dining room. During an observation on 5/7/25 at 1:08 p.m., resident #22 was lying in bed, wearing only a brief, when his lunch tray was delivered to his room. It was placed on the side table next to his bed and left by the staff member without further setup or assistance provided to the resident. Resident #22 was reaching from a lying position, all the way across the top of his body, to the tray, which was not in front of him, but it was placed on his right side. He struggled to get food onto his utensil from this angle. During an observation on 5/7/25 at 1:36 p.m., resident #22's tray was in the same place…

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 get immediate physician orders for a resident experiencing chest pain and respiratory concerns, who was three days later sent emergently to the hospital, for 1 (#44) of 17 sampled residents. Findings include: During an interview on 5/7/25 at 12:43 p.m., resident #44 stated he had been recently hospitalized for difficulty with breathing. Review of resident #44's EMR showed he was hospitalized from [DATE] - 4/30/25. Review of resident #44's nursing progress notes, dated 4/17/25 - 4/19/25, showed: - 4/17/25 at 5:20 p.m., RT and unit manager expressed concerns about resident c/o CP . phone call placed to [physician call center name] . awaiting call back from Dr. - 4/18/25 at 2:29 a.m., . No new orders at this time . - 4/18/25 at 11:09 a.m., PT notified RT of resident destating down to 86% while on his prescribed 3L [liters] of o2, with little exertion. RT into assess resident and he does continue to have a wet/loose cough and has a pleural rub sounds 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide effective pain management and monitoring for a resident which resulted in her getting more medication than prescribed for 1 (#35) of 17 sampled residents. Findings include: During an observation and interview, on 5/7/25 at 2:48 p.m., staff member K provided the current narcotics log book from the cart. The narcotics log book only had nine total fentanyl patches entered into the log for resident #35, two documented as given on 4/25/25 and 4/27/25, and there was documentation of a destruction date of 5/4/25 for seven fentanyl patches. Staff member K stated he was not the person to ask any specific questions due to being new, and he had not had training for the facility's specific medication management process. He was going off what he had done in prior positions. During an interview on 5/8/25 at 11:38 a.m., staff member B stated resident #35 was having complaints of pain being unmanaged, so the provider was notified, who then…

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

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 (#12) of 17 sampled residents. Findings include: Review of resident #12's nursing progress note, dated 2/25/25, showed the resident had been more confused, including not knowing who her husband was, and putting jelly on her omelet at mealtime. The med tech noticed the resident had two 50mcg Fentanyl patches on. Review of resident #12's medication administration record, February 2025, showed the following orders: 1. fentanyl patch 72-hour 25mcg/hr. apply 2 patch transdermally every 72 hours related to pain . place patches onto the skin Q 72 hours as needed (in the event that 50mcg patches are not available to dispense). - This order was only documented as given on February 22, 2025. All other opportunities were marked as n/a. 2. fentanyl patch 72-hour 50mcg/hr. apply 1 patch transdermally every 72 hours for chronic bilateral lower back pain. During an interview on 5/8/25 at 10:27 a.m., staff member B stated they had put the medication orders in with 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 licensed staff failed to ensure the medication carts were secured and locked when the carts were unattended. This failure increased the risk of drug diversion, or the medication may be taken by a resident as packets of pills were hanging from a cart. This failure could affect any resident at the facility who had medications stored in the unsecured carts. During an observation on 5/6/25 at 5:00 p.m., the med cart in front of the main nursing desk was unlocked. During an observation on 5/7/25 at 8:57 a.m., the med cart in the dining room was unlocked. The nurse was away from the cart giving medications, with the cart behind a pillar, out of sight. During an observation on 5/7/25 at 8:59 a.m., there was a med cart on the 100-hallway unlocked, with the top drawer open, Pill packets were hanging out. There were no staff in the hallway. During an observation on 5/7/25 at 2:04 p.m., two of four medication carts were unlocked with no staff present. During an observation and interview on 5/7/25 at 2:43 p.m., the 300/400 hall medication cart…

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 followed hand hygiene during medication pass; and failed to implement enhanced barrier precautions and signage for 2 (#s 21 and 44) of 17 sampled residents. Findings include: 1. During an observation on 5/6/25 at 7:30 a.m., staff member P was working with one med cart. Staff member P passed medications, including an insulin injection, without performing hand hygiene before or after the medication administration task. During an observation on 5/6/25 at 7:45 a.m., staff member K did not perform hand hygiene prior to or after a resident's medication administration. 2. During an observation on 5/6/25 at 11:45 a.m., resident #21 was hooked up to a wound vac for an Unstageable wound. There was no signage or supplies showing staff should follow enhanced barrier precautions. Review of resident #44's physician orders, dated 4/30/25, showed, Enhanced barrier precautions. During an observation on 5/6/25 at 3:21 p.m., there was no signage or supplies on resident #44's door showing staff should follow enhanced…

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, it was identified the facility abuse education was not adequate to ensure administrative staff had necessary knowledge related to identification of abuse allegations, for a resident who had cognitive deficits, and management of the events for future prevention, for 2 (#s 10 and 53) of 17 sampled residents. Findings include: 1. Review of resident #10's nursing progress notes, dated 4/25/25 at 12:56 a.m., showed the resident had scattered bruising, that was healing, on his left lower back, and the resident had pain with the bruising. A review of nurses notes from 4/18/25 through 5/25/25 showed resident #10 did not have any falls or sustain any injuries. During an interview on 5/7/25 at 4:57 p.m., staff member A said there was no investigation completed into the cause of the bruising and she was still investigating to see if more information was available. Staff member A said she was not notified of bruising to resident #10's lower back. 2. Review of resident #53's nurse's note, dated 3/28/25, showed resident #53 was agitated and threatening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the administration of services were delivered in a manner which encouraged the residents to report concerns or complaints if they had them, without worries of retaliation for 4 (#s 1, 10, 11, and 12) of 14 sampled residents. The facility's leadership team and oversight of recent changes, and specifically the administrator's actions, resulted in concerns among the residents, and they reported it affected their mood, morale, anxiety, feelings of being kicked out of the facility, and some said they isolated to their room more. Resident #s 1, 11, and 12 reported they no longer participated in activities and had not been eating their meals in the dining room. Findings include: 1. During an interview on 2/25/25 at 3:23 p.m. Resident #10 stated things with the new management were not as good as they were prior. Resident #10 stated there had been a high turnover rate of staff, and there was a decline in morale among some of the residents. Resident #10…

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 consistently have physician ordered medications available, to ensure residents did not miss a dose of the ordered medications, for 1 (#1) of 14 sampled residents. Findings include: During an interview on 2/24/25 at 1:20 p.m., staff member B stated insurance for resident #1 does not pay for the physician ordered Methadone. Staff member B stated the facility had planned to consult with the provider to try and obtain another medication the insurance company would pay for. Staff member B stated the resident was being tapered off of Requip, for restless leg syndrome, and was switched to Methadone. During an interview on 2/24/25 at 1:48 p.m., resident #1 stated, from December 2024 through February 2025, he went without the physician ordered Methadone, several times. During an interview on 2/26/25 at 3:36 p.m., staff member G stated the facility frequently had medications unavailable. During an interview on 2/27/25 at 5:19 a.m., staff member H stated there were medications unavailable often. During an interview on 2/27/25 at…

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

Based on observation, interview, and record review, the facility failed to ensure a staff member adhered to proper infection control procedures while assisting a resident with drink service, for 1 (#4) of 5 sampled residents. This deficient practice had the potential to spread infectious pathogens between residents. Findings include: During an observation and interview on 12/4/24 at 12:01 p.m., a resident was observed removing ice with a spoon from her drinking container. The resident was placing ice cubes into a cup full of coffee. Staff member C was observed to be assisting the resident with removing the ice and placing it into the clear coffee cup. The lid on the coffee cup was replaced by staff member C, and the coffee cup was handed to another resident, resident #4. Staff member C stated she had not realized she had cross contaminated the coffee for resident #4. During an interview on 12/4/24 at 2:37 p.m., staff member G stated she performed weekly audits with staff during the serving of meals. Staff member G said it was not acceptable practice to assist residents with 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 follow diet textures for 2 (#s 13 and 22) of 6 residents sampled for diet textures. This deficiency caused resident #13 to have two documented choking episodes and had the potential to cause resident #22 to have choking episodes or aspiration of food. Additionally, the facility failed to follow a low carbohydrate diet with double portions of protein for 1 (#40) of 1 resident sampled for a controlled carbohydrate diet. This deficiency resulted in an increase in resident #40's blood sugar and caused him to be concerned his healing would be delayed and his ability to discharge home from the facility would be delayed. Findings include: 1. During an interview and observation on 5/19/24 at 12:50 p.m., staff member K was preparing lunch trays for the residents. While staff member K was preparing resident #13's meal, she cut up the resident's pork with a knife instead of giving the resident the ground meat as she had for previous plates with soft…

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 record review, the facility failed to store food in accordance with professional standards by failing to label and date food stored in the facility's freezer. Findings include: During an observation on 5/19/24 at 11:24 a.m., the following items were observed in the freezer: 1 bag of waffles, not in original box, not labeled, and not dated. 1 open bag of fish sticks, not in original box, not labeled, and not dated. 1 package of sliced meat, not in original container, not labeled, and not dated. 1 package of shredded/chopped meat, not in original container, not labeled, and not dated. Review of a facility provided document, titled Food and Nutrition Services 'Use by' Date Guidelines showed: The following is a guide to use when establishing a 'use by' date for food items . The manufacturer's expiration date, when available, is the 'use by' date for unopened items . Guidelines apply, regardless of storage location . Frozen Foods stored in the freezer 'Use by' date 45 days after opening and properly closed.

Based on observation, interview, and record review, the facility failed to provide an environment that was clean, well maintained, and safe for 3 (#s 23, 27 and 40) of 23 sampled residents. This deficiency had the potential to affect all residents in the facility who walk or use wheelchairs in the hallways and areas with baseboard heaters and who reside in the facility. Findings include: 1. During an observation and interview on 5/19/24 at 9:59 a.m., resident #27's linens appeared visibly dirty. There were stains on the sheets and his comforter was visibly soiled. Resident #27 stated the CNAs changed the sheets about once a week and sometimes he had to ask them to change them because they were so dirty. Resident #27 said the CNAs were super busy, so he tried not to bother them. During an observation and interview on 5/19/24 at 9:23 a.m., resident #40's linens were visibly dirty with a betadine stain at the foot of the bed. When asked about the stain, resident #40 stated it had been there for two weeks. Resident #40 said sometimes his linens did not get changed for several weeks.…

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 update care plans for 3 (#s 36, 42, and 49) of 23 sampled residents. Resident #36 had repeated behaviors documented and no updates or changes in interventions were made on his care plan resulting in continued behaviors. Residents #42 and #49 had repeated falls documented and no updates or changes in interventions were made on their care plans resulting in repeated falls. Findings include: 1). During an interview on 5/21/24 at 9:55 a.m., staff member G stated, the ADON was responsible for updating care plans. He said care plans should be updated every time a resident has a fall, or any time there are new interventions for any focus area in the care plan. He stated nurses were not involved in revising the care plans. Staff member G said the EMR would show a date for every time the care plan was updated. Care plans were revised yearly or more frequently if necessary for resident needs. Review of resident #36's Behavior notes showed, 44 incidents 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 ensure a resident's dignity and clean appearance by implementing measures or assistance to keep his clothing free of food debris for 1 (#42) of 23 sampled residents. Findings include: During an observation on 5/18/24 at 12:46 p.m., resident #42 was eating lunch in the dining room. He was struggling to navigate the fork to his mouth. Food had fallen off of the fork and was splattered all over his clothes and the nearby floor. Residents around him were wearing clothing protectors. During an observation on 5/19/24 at 1:07 p.m., resident #42 was eating lunch in the dining room. He was struggling with a shaky fork and had fruit salad down the front of his shirt and on his lap. During an interview on 5/20/24 at 1:25 p.m., NF2 stated they weren't complaining, but did wish the facility would offer resident #42 a clothing protector at meals. Review of resident #42's Quarterly MDS with an ARD of 12/1/23, showed under Section GG Functional Abilities and Goals, the resident was marked as independent. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide behavioral health services for 2 (#s 6 and 36) of 2 residents sampled for behavioral concerns. This deficiency had the potential to lead to psychological harm for resident #s 6 and 36. Findings include: 1. A review of a Patient Health Questionnaire-9 (PHQ-9) for resident #6 in the facility's EHR, dated [DATE], showed a score of 12, which is indicative of a moderate depressive disorder. A review of resident #6's care plan showed: - Focus: [Resident #6] has depression. [Resident #6] will be free of signs of depression including: exit seeking, agitation, crying, and verbal outbursts with an initiated date of [DATE], and a revision date of [DATE]. - Focus: [Resident #6] has depression r/t Vascular Dementia, Hx CVA without residual deficits, Hx TIA's, PTSD, with an initiated date of [DATE], and a revision date of [DATE]. Goal: I will remain free of s/sx of distress, symptoms of depression, anxiety or sad mood by/through review date.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide medical social services for 1 (#36) of 2 residents sampled for behavioral concerns. This deficiency had the potential to negatively impact the resident's psychological and mental wellbeing. Findings include: During an interview on [DATE] at 10:59 a.m., staff member J stated, I have been here about a month and a half, I don't have a degree or anything. I was hired on, to learn as I go. Staff member J stated she would intervene when resident #36 was agitated. She stated she had spoken to the doctor about medication changes to decrease behaviors, but it had not helped with resident #36's behaviors. Staff member J stated resident #36's behaviors had gotten worse since she had worked at the facility. Staff member J stated, There has not been any medical social services for [resident #36]. She said the only changes the facility had made for him was to request the doctor make changes to his medication. A request was made for mental health, and/or…

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

Based on interview and record review, the facility delayed physical therapy services for a post stroke resident for 1 (#47) of 1 resident sampled for physical therapy services. This deficient practice resulted in the resident not receiving physical therapy for 47 days after admission to the facility. Findings include: During an interview on 5/20/24 at 8:24 a.m., NF1 stated PT let her down. She was starting to walk at [Hospital name] before she came to the facility. NF1 further stated that resident #47 had to be able to stand to get in her wheelchair before she would be able to come home for him to take care of her. During an interview on 5/20/24 at 1:41 p.m. staff member D stated the facility did not have a physical therapy program for the last four years. Staff member D further stated that resident #47 was making progress overall, but not making progress to stand and pivot. During an interview on 5/20/24 at 2:54 p.m., staff member D stated resident #47's initial PT evaluation was 2/12/24 because the facility did not have a physical therapist prior to that. During an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer pneumococcal vaccinations for 1 (#44) of 5 residents sampled for pneumococcal vaccination or declination. Findings include: Review of resident #44's medical record failed to show the resident had received or declined the pneumococcal vaccination. Resident #44 was admitted to the facility on [DATE]. During an interview on 5/21/24 at 9:10 a.m., staff member C stated she was waiting on ImMTrax (Montana Immunization Service) login credentials to verify who had and who still needed various vaccinations. During an interview on 5/21/24 at 10:13 a.m., staff member C stated she was needing to discuss vaccinations with resident #44's POA.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer Covid-19 vaccinations to 1 (#44) of 5 residents sampled for Covid-19 vaccination or declination. Findings include: Review of resident #44's medical record failed to show the resident had received or declined the Covid-19 vaccination. Resident #44 was admitted to the facility on [DATE]. During an interview on 5/21/24 at 9:10 a.m., staff member C stated she was waiting on ImMTrax login credentials to verify who had and who still needed various vaccinations. During an interview on 5/21/24 at 10:13 a.m., staff member C stated she was needing to discuss vaccinations with resident #44's POA.

Based on interview and record review, the facility failed to document the basis for a resident's facility-initiated immediate transfer and discharge, for 1 (#2) of 1 resident sampled for discharge concerns. This deficient practice resulted in the resident being improperly discharged from the facility, to the hospital, and then the facility would not accept the resident for readmission. This resulted in the resident being discharged to a location 4 hours away. Findings include: Review of resident #2's nursing progress notes, dated 2/1/24, showed, .she (resident #2) rounded the nurses station and went into the med room . I tried to calm her down and she grabbed my throat and tried to shove me out of the way. I pried her fingers off my throat . she tried to head butt me . Following this incident, resident #2 was sent to the hospital via police and ambulance services where she was admitted for medication adjustment. Review of resident #2's MDS Discharge Assessment-Return not anticipated, dated 2/1/24, showed the facility intended to discharge the resident. However, resident #2 returned…

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 follow and adhere to transfer and discharge notification requirements, for a facility-initiated, immediate discharge, for 1 (#2) of 1 resident sampled for improper discharge concerns. Findings include: Review of an anonymous complaint, submitted to the State Survey Agency on 2/13/24, showed the facility sent resident #2 to the hospital on 2/6/24, and refused to allow the resident to return to the facility. The complaint alleged, hospital staff were told the resident had been discharged . The hospital staff were told the facility would only take the resident back if she was, sedated sufficiently so her behaviors don't have to be managed by their team. Review of resident #2's EMR, accessed on 2/26/24, did not show the reason for the resident's immediate facility-initiated discharge. There was no documentation the resident or representative were given a proper discharge notice, including regulatory components for an immediate discharge, such as: (i) The reason for transfer or discharge; (ii) The effective date of transfer or…

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

Based on interview and record review, the facility failed to allow a resident to return and resume residence at the facility for 1 (#2) of 1 resident sampled for discharge concerns, after a facility initiated discharge to the hospital. Findings include: Review of resident #2's EMR, accessed on 2/26/24, did not show the resident or their representative had recieved a notice of the facility's intent to discharge her. This lack of notice had the potential to leave the resident unaware of her right to an appeal on the facility decision or locate suitable placement. Review of an anonymous complaint, submitted 2/13/24, showed resident #2 was not permitted to return to the facility when the hospital wanted to transfer the resident back to the facility, and then the facility refused her transfer and need to return. During an interview on 2/26/24 at 3:41 p.m., staff member B stated there was no physician documentation regarding resident #2's discharge from the facility. During an interview on 2/26/24 at 5:10 p.m., staff member A stated resident #2 was discharged and not permitted to return…

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 resident cash was protected from theft or misuse for 1 (#4) of 5 sampled residents. Findings include: During an interview on 1/3/24 at 12:30 p.m., NF1 stated $4,700 in cash was found in resident #4's personal safe upon his death. During an interview on 1/4/24 at 9:30 a.m., staff member D stated when the cash was found they had two staff members count the money and place it into an envelope which was then signed and locked in the business office. She stated the business office was in charge of all resident money. During an interview on 1/4/24 at 9:46 a.m., staff member A stated he had wondered if they could use resident #4's money for the staff Christmas party and gave staff member F permission to use the funds on 11/29/23. Staff member A stated the funds were never accessed by staff member F because corporate had quickly stated they could not use the money for that purpose. Review of resident #4's EMR, accessed 1/4/24, showed he was his responsible for his own finances, and he did not have any involved family.…

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 report a suspected misappropriation of resident money to the State Survey Agency within the required time frame for 1 (#4) of 5 sampled residents. Findings include: During an interview on 1/3/24 at 12:30 p.m., NF1 stated after resident #4 had passed away a large sum of money had been found in his personal lockbox that was kept in his room. The money was counted, put into an envelope signed by two staff members, and locked in the business office. NF1 stated staff member A had given permission to staff member F to use the money for a company Christmas party. NF1 stated some time later it was discovered $2,500 was missing from the envelope. NF1 stated staff member E had told everyone not to call the cops, and the money was replaced, and the incident was swept under the rug. During an observation and interview on 1/4/24 at 9:46 a.m., staff member A stated corporate managed the investigation into the missing money since he had been considered to have a conflict of interest. Staff member A stated he had wondered if…

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, facility staff failed to revise a care plan to include a deep brain stimulator for the treatment of Parkinson's symptoms for 1 (#1) of 5 sampled residents. Findings include: During an interview on 10/25/23 at 7:30 a.m., staff member B said to address the resident whole person centered care plan resident #1's care plan should show he had a deep brain stimulator in place for treatment of his Parkinson's symptoms. During an interview on 10/25/23 at 10:50 a.m., staff member B said review of social service notes from a care conference on 10/17/23 showed family members brought up resident #1 deep brain stimulator. Review of resident #1's Parkinson's care plan, interventions last revised on 10/25/22, failed to identify or have interventions in place for the resident's deep brain stimulator to assist in controlling his Parkinson's symptoms.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to address and obtain services for 1 (#1) of 5 sampled residents with an implanted deep brain stimulator. Findings include: During an interview on 10/24/23 at 1:30 p.m., NF3 said resident #1 had a deep brain stimulator, and it had been placed by a neurologist in 2004. NF3 said resident #1 had Parkinson's disease, and he was one of the first people in the State to have a deep brain stimulator implanted. NF3 said she was at the facility June of 2023 to visit resident #1. She said it was the first time she had been to visit the resident since his admission in July of 2022. NF3 said resident #1 had more confusion, and was having more problems performing his activities of daily living than she had seen before. NF3 said when the resident was living at home, and had experienced problems like this he had a wand that could be used to adjust the deep brain stimulator. NF3 said she found the wand in a nightstand drawer beside the resident's bed. NF3 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.