Benefis Senior Services - Eastview

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update a resident's code status from Full Code to DNR, in the facility's EHR for 1 (#5) of 23 sampled residents, and this failure increased the risk of the resident being resuscitated in a health crisis, when that was not the resident's preference or documented on the resident's POLST form. Findings include: During an interview on [DATE] at 4:07 p.m., staff member D stated if a resident wanted to change their POLST form status from what was entered on admission, he would go over the form with the resident and make sure it is signed by the provider the resident, or the resident's POA. Staff member D stated he was not the person who updated the residents code status in the facility's EHR. Staff member D further stated it was not his expectation that the residents code status on the information bar in the facility's EHR had not matched their POLST form. During an interview on [DATE] at 4:26 p.m., staff member B stated she didn't think there was a concrete…

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 safeguard a resident's personal property when items were missing or sent to laundry and not returned, for 1 (#30) of 23 sampled residents, and the resident was missing a blanket that was very important to him, which was upsetting, and related to his faith. Findings include: During an interview on 6/16/25 at 3:05 p.m., resident #30 said he was missing a blanket, probably some shirts, and the facility had not made any attempts to replace the missing items. Resident #30 stated, It (dirty laundry) goes and never comes back. Resident #30 said he was concerned about the blanket because it (the blanket) had personal meaning to him. During an interview on 6/18/25 at 8:06 a.m., staff member K said a general inventory of the resident's personal belongings was obtained during the admission process, and the inventory was in the electronic health record. Staff member K stated not every personal item was inventoried. During an interview on 6/18/25 at 9:41 a.m., resident #30 said the blanket he was missing was a Jesus blanket, it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident, and to meet professional standards of quality care, for 1 (#84) of 23 sampled residents. Findings include: Review of resident #84's face sheet reflected resident #84 admitted on [DATE]. Review of resident #84's baseline care plan, effective 3/19/25 - 4/2/25, reflected the care plan was initiated on 3/19/25, eight days after the resident's admission, and finalized on 3/24/25. During an interview on 6/18/25 at 3:00 p.m., staff member B stated she was not aware the baseline care plan was not completed within 48 hours, or why it was not done. A review of resident #84's MDS assessment, dated 3/17/25, showed the resident had impaired cognition, dementia, anxiety, frequent pain, was supervised, set up, or independent for ADL's, he displayed behaviors and was marked as having depression and anxiety.…

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 comprehensive person-centered care plan and follow the care plan for the resident, for 1 (#31) of 23 sampled residents. Findings include: 1. During an observation on 6/16/25 at 4:37 p.m., resident #31 was in another resident's room. Resident #31 was observed rummaging through the other residents' property. She was observed leaning forward, while sitting in her wheelchair, with her head near the floor, and close to falling out of the chair. Staff were not redirecting her out of the room or providing her diversional activities. During an observation on 6/17/25 at 9:12 a.m., resident #31 was observed behind the nursing station. Resident #31 was unable to be interviewed due to advanced dementia. A nurse removed resident #31 after she had been at the nursing station for a period of time. Resident #31 was not offered diversional activities during her time at the nursing station, or after. During an observation on 6/17/25 at 10:18 a.m., resident #31 was observed in the dining room. She was…

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 observations, interviews, and record review, the facility failed to remove access to hand sanitizer containers, or hazardous liquids if consumed, when there was a resident residing in the area who had a recent history of drinking hand sanitizer, for 1 (#40) for 23 sampled residents. Findings include: Review of resident #40's Hospitalist History and Physical, dated 6/30/25, reflected: - . #Alcohol use disorder, with recent hospitalization due to drinking hand sanitizer. During an observation on 6/16/25 at 4:18 p.m., hand sanitizer bottles were found on the top of the unattended medication cart, and two bottles of hand sanitizer were at the nursing station, within reach of anyone passing by. During an observation on 6/17/25 at 7:28 a.m., one alcohol bottle was on top of an unattended medication cart located in the dining room. One bottle of hand sanitizer was within reach of residents at the nursing station. One bottle of [NAME] Diamonds perfume was in an open cabinet at the end of the hall, accessible to residents. During an observation on 6/17/25 at 7:38 a.m., staff member…

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.

2. During an observation on 6/16/25 at 4:37 p.m., resident #31 was in another resident's room. Resident #31 was observed rummaging through the property in the room. Resident #31 was in a wheel chair, and she was wedged between the other resident chair, and the bed. She was observed leaning far forward with her head near the floor, almost falling out of the chair forward. During an observation on 6/17/25 at 9:12 a.m., resident #31 was observed behind a nurse's station. Resident #31 was unable to be interviewed due to advanced dementia. A nurse removed resident #31 after she had been at the nursing station for some time. Resident #31 was not offered diversional activities during the time she was at the nursing station or after. During an interview on 6/17/25 at 2:10 p.m., staff member G said resident #31 cries and wanders down the hall in her chair. The nurse tried a bunch of different medications to help the resident, and said the other residents did get upset at #31. Staff member G stated they, Mostly they yell at her, but they did throw things at her, like tissues because she was…

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 referral was made for cognitive rehabilitation with a speech therapist for 1 (#5) of 23 sampled residents. This deficient practice increased the risk of the resident having a cognitive decline due to the lack of speech therapy treatment. Findings include: A review of a Behavioral Health OP (Outpatient) Psychosocial Evaluation, for resident #5, dated 1/27/25, signed by NF4, and cosigned by NF5, showed: Reason for evaluation: Depression, schizophrenia, bipolar . Plan: According to the information gathered in this evaluation, appears that patient would benefit from cognitive rehabilitation with a speech therapist and medication management with a psychiatrist. Will refer to cognitive rehabilitation with speech therapist [sic] During an interview on 6/18/25 at 11:07 a.m., staff member D stated he could not find speech therapy referrals or notes for resident #5. During an interview on 6/19/25 at 8:53 a.m., NF5 stated she was not able to find a referral for speech therapy from her facility for resident #5. NF5 relayed…

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 have sufficient nursing staff to ensure residents call lights were answered in a timely manner and to address their safety and care needs timely for 4 (#s 1, 3, 4, 5) of 7 sampled residents. This deficient practice had the potential to result in residents not having their needs met. Findings include: 1. During an observation and interview on 12/30/24 at 9:42 a.m., resident #5 was in bed waiting to get up and stated her back was hurting from lying in bed too long. Resident #5 stated the facility did not have enough help. Resident #5 stated she regularly had to wait in bed for a long time to have someone help her up. Resident #5 stated the CNAs came in the room earlier and turned her call light off and stated they would be back as soon as they could. A staff member entered the room to assist resident #5 out of bed and getting her dressed at 10:37 a.m. 2. During an observation and interview on 12/30/24 at 9:51 a.m., resident #3 was in bed and stated he was waiting for staff to get him up for the day. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure ADL cares were provided timely for 3 (#s 3, 4, and 5) of 7 sampled residents. This deficient practice had the potential to increase resident's risk for infections, skin breakdown, pain, and overall decline. Findings include: 1. During an observation and interview on 12/30/24 at 9:42 a.m., resident #5 was in bed waiting to get up and stated her back was hurting from lying in bed too long. Resident #5 stated the facility did not have enough help. Resident #5 stated she regularly had to wait in bed for a long time to have someone help her up. Resident #5 stated the CNAs came in the room earlier, turned her call light off, and stated they would be back as soon as they could. A staff member entered the room to assist resident #5 out of bed and getting her dressed at 10:37 a.m. Review of resident #5's Care Plan, dated 12/30/24, reflected: - . [Resident #5] transfer with a Hoyer lift. [Resident #5] ambulates at w/c level. [Resident #5]…

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 individualize interventions for the dementia residents residing in the memory care unit; failed to assess the efficacy of the wanderguard intervention placed on each resident after an elopement; and failed to follow protocol when obtaining the verbal consent for the wanderguards for 3 (#s 7, 110, and 400) of 3 residents sampled for elopement concerns. Findings include: Review of two Facility Reported Events, initially reported on 8/29/24 and 9/2/24, showed: - Resident #110 eloped from the facility on 8/29/24 by following an environmental services staff member out of the memory care locked unit, and was found on the facility campus. - Review of the Facility Reported Event, dated 9/2/24, showed resident #400, who resided on the demential unit, eloped from the facility by following a staff member out of the activity room, and staff were not watching the activity room door to ensure the dementia resident was safe, when she attended an activity off the secured dementia unit. 1. During an observation on 10/7/24 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 interview and record review, the facility failed to identify, address, and obtain necessary services for the behavioral health care needs; failed to develop and implement person-centered care plans that included and supported the behavioral health care needs; and develop individualized interventions related to the resident's diagnosed conditions, for 2 (#s 13 and 71) of 5 sampled residents. Findings include: Review of a Facility Reported Event, initially reported 9/30/24, showed: Resident #13 was in an altercation with resident #71. In this altercation, both resident #71 and resident #13 had hit one another. The reported findings showed the residents were initially friends, and resident #71 would follow resident #13 around, but due to resident #71's developmental delay, resident #13 lost patience with resident #71, and acted out against him. Review of the PASARR Level 1, dated 11/13/23, showed an updated PASARR Level 1 was not completed for resident #71, after his convalescent stay. Resident #71 had previously had a PASARR Level 2 completed on a previous stay due 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 provide necessary care and services for a dependent resident, and the resident had skin breakdown, was on hospice, needed assistance with toileting/care and repositioning for pressure relief, for 1 (#1) of 4 sampled residents. Without proper timely care, the resident's skin breakdown could worsen. Findings include: During an interview on 1/29/24 at 11:12 a.m., staff member B stated resident #1 had a clipboard in her room, which was a log for staff to complete when toileting occurred for the resident, and for oxygen tank checks. Staff member B stated she emailed NF1 daily with feedback regarding nursing care and concerns. Record review on 1/29/24 at 1:24 p.m., of the facility's, 02 Tank and Continence Monitoring (At least EVERY 2 HOURS) sign in log on the clipboard in resident #1's room, dated 1/27/24 through 1/29/24, showed: - 1/27: 14:00 dry (2:00 p.m.) - 1/28: 2300 wet (11:00 p.m.) - 1/29: 0430 wet (4:30 a.m.) - 1/29: 0630 dry/changed (6:30 a.m.) During an interview on 1/29/24 at 12:12 p.m., staff member C…

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 comprehensive care plan for residents who required oxygen and or nebulizers, for 3 (#s 120, 182, and 189) of 4 sampled residents. Findings include: 1. During an observation and interview on 5/20/23 at 1:29 p.m., resident #120 had an oxygen concentrator in her room with tubing dated 4/10 and a staff members initials. A review of resident #120's Physician Orders, dated 4/11/23, reflected an order to provide two liters of supplemental oxygen at night. A review of resident #120's Care Plan, dated 4/10/23, failed to show a care plan for respiratory care, including oxygen. 2. During an observation and interview on 5/20/23 at 1:55 p.m., resident #182 had a nebulizer machine with tubing, and a mask laying across her bedside table. Resident #182 had oxygen at her bedside. Resident #182 stated she had oxygen for use at night. A review of resident #182's Physician Orders, dated 5/18/23, reflected an order to provide two liters of oxygen at bedtime for comfort. A review of resident #182's Care…

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 change oxygen tubing and supplies for 3 (#s 120, 182, and 189) of 4 residents sampled resident's, increasing the risk for respiratory infections. Findings include: a. During an observation and interview on 5/20/23 at 1:29 p.m., resident #120 had an oxygen concentrator in her room with tubing dated 4/10 and a staff member's initials. b. During an observation and interview on 5/20/23 at 1:55 p.m., resident #182 had a nebulizer machine with tubing and a mask laying across the bedside table. Resident #182 had oxygen at her bedside. Resident #182 stated she had oxygen for use at night. c. During an observation and interview on 5/20/23 at 1:40 p.m., resident #189 had a nebulizer machine at the bedside and was wearing oxygen. Resident #189 stated she used oxygen since she came to the facility. During an interview on 5/21/23 at 7:55 a.m., staff member D stated the tubing was changed weekly by night staff. Staff member D stated they were supposed to date and initial the tubing when it was changed. Review of 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 ensure the resident wheelchair armrests' were repaired, to prevent contamination and the risk of infection, for 2 (#s 88 and 109) of 2 sampled residents. Findings include: During an observation on 5/20/23 at 2:31 p.m., resident #88's wheelchair had two wraps of duct tape on the left armrest, and one wrap of duct tape on the right armrest. During an observation on 5/22/23 at 1:01 p.m., resident #109's left armrest on her wheelchair had cracked and missing vinyl with two areas wrapped with clear packing tape that was rolled up on the sides. During an interview on 5/23/23 at 9:20 a.m., staff member L stated she would expect wheelchairs would be clean. Staff member L stated, she would consider tape on a wheelchair armrest, and cracks in the vinyl on the armrest, to be uncleanable and had a potential for spreading infectious agents. Staff member L further stated, she would expect the CNAs to make a 'fix it order' for maintenance for any damaged wheelchair armrests.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect 2 (#s 181, and 186) of 20 sampled residents from physical neglect by a staff member; and, resident #181 was not turned and position or provided care by a night shift staff member, and #186 was left in the bathroom on a lift, and the staff member did not return to assist the resident timely. Findings include: 1. Review of a Facility Reported Incident, dated 5/21/23, showed an incident where resident #186 complained that she had waited in the bathroom for 30 minutes for someone to help her. Review of a letter dated 5/21/23, received from resident #186, showed she was placed in the [NAME]-Stedy lift on the toilet at about 6:00 a.m. with the wheels locked. Resident #186 stated the call light had been on for about a half hour, and her legs were going to sleep, so she attempted to push the machine off the toilet, to the resident's room, and then was stuck at the threshold of the bathroom door. Resident #186 stated she was then calling out for help…

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 protect residents from further neglect, psysocial harm, or risk of physical harm by a staff member accused of neglect of care, during or after an investigation of neglect allegations. for 2 (#s 181, and 186) of 2 sampled residents, and failed to report a complaint of neglect to the State Survey Agency for 1 (#181) of 1 resident. Findings include: 1. Review of a Facility Reported Incident, dated 5/21/23, showed an incident where resident #186 complained she had waited in the bathroom for 30 minutes for someone to help her. Review of a letter dated 5/21/23, from resident #186 showed she was placed in the [NAME]-Stedy lift on the toilet at about 6:00 a.m. with the wheels locked. Resident #186 stated that the call light had been on for about a half hour and her legs were going to sleep, so she attempted to push the lift off the toilet to the room, and then was stuck on the threshold. Resident #186 stated she was then calling out for help for about fifteen…

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

Based on observation, interview, and record review, facility staff failed to provide the necessary services of fingernail and toenail care for 1 (#42) of 2 sampled residents. Findings include: During an observation and interview on 5/20/23 at 2:12 p.m., NF3 voiced concerns about resident #42's fingernails and toenails not being trimmed. Resident #42's fingernails were long, uneven, and did not appear to have been trimmed recently. Resident #42 was wearing socks and both of her great toe toenails were poking through her socks, causing small holes in the socks. NF3 said she had talked to staff about resident #42's nail care, but nothing had been done. During an interview on 5/23/23 at 9:00 a.m., staff member Q said resident toenails and fingernails were part of the weekly skin assessment done by the nurse. Staff member Q said a certified nurse aide (CNA) would trim resident fingernails and toenails after the weekly skin assessment if the nurse said it needed to be done. Staff member Q said if a resident was diabetic, the CNA would not trim the resident's toenails. Staff member Q said…

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 necessary treatment and services to promote healing of an Unstageable pressure ulcer, by failing to turn and position a resident as ordered, causing the resident fear of her wound worsening, for 1 (#181) of 1 sampled resident; and facility nursing staff failed to follow the Physicians orders for palm guards for a resident with contractures for 1 (#7) of 1 sampled resident. Findings include: 1. During an interview on 5/21/23 at 4:15 p.m., resident #181 stated staff member I did not turn and position her all night. Resident #181 stated, The staff were supposed to be turning me every two hours, but she never came all night. I don't need this wound to get worse and I'm afraid that's what will happen with [staff member I] working. Resident #181 stated she had complained to facility management but staff member I continued to not turn and position her at night and nothing gets done about it. During an interview on 5/22/23 at 8:10 a.m., staff member D stated she talked to resident #181 and re-educated staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility employee failed to ensure a resident (186) was assisted as needed when using the bathroom and a mechanical lift was used, and the resident was left unattended in the lift, of one sampled resident. Findings include: 1. Review of a Facility Reported Incident, dated 5/21/23, showed an incident where resident #186 complained that she had waited in the bathroom for 30 minutes for someone to help her. Review of a letter dated 5/21/23, received from resident #186, showed she was placed in the [NAME]-Stedy lift on the toilet at about 6:00 a.m. with the wheels locked. Resident #186 stated the call light had been on for about a half hour, and her legs were going to sleep, so she attempted to push the machine off the toilet, to the resident's room, and then was stuck at the threshold of the bathroom door. Resident #186 stated she was then calling out for help for about fifteen minutes. Resident #186 stated that staff member I had placed her on the toilet, and then when she…

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

Based on observation, interview, and record review, the facility failed to have sufficient staff to adequately supervise and provide non-pharmacological interventions for a resident on the memory care unit, for 1 (#60) of 32 residents residing on the unit. Findings include: During an observation on 5/22/23 at 9:38 a.m., resident #60 was in her room on her bed crying out mommy. The alarm on the bed was going off. During an observation on 5/22/23 at 9:45 a.m., the alarm in resident #60's room was still going off. During an observation on 5/22/23 at 9:46 a.m., the nurse was in the dining room administering medications. The alarm could not be heard from the dining room or the other end of the unit. During an observation on 5/22/23 at 9:53 a.m., the alarm was still going off in resident #60's room. The nurse was administering medications to residents in the dining room. One staff member was assisting residents to eat. During an interview on 5/23/23 at 10:18 a.m., staff member C stated resident #60 cries mommy, mommy most days. Staff member C stated the resident had the behaviors before…

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 care and interventions for a resident who had a history of trauma, mood disorder, anxiety, and depression for 1 (#60) of 32 sampled residents. Findings include: 1. During an observation on 5/20/23 at 3:37 p.m., resident #60 was wheeling herself around the unit in her wheelchair and was crying, and hollering out for her mommy. During an interview on 5/23/23 at 10:21 a.m., staff member C stated the staff received Alzheimer and dementia training annually. Staff member C stated some employees had chosen to go on and get a certification for dementia care. During an interview on 5/23/23 at 10:30 a.m., staff member C stated resident #60 needed supervision up to total care depending on her needs. Staff member C stated resident #60 needed total care with ADLs. During an interview on 5/23/23 at 10:33 a.m., staff member N stated sometimes a 1:1 was necessary to calm resident #60 down. Staff member N stated one intervention was to get resident #60 to do an activity and orient her to the day. Staff member N stated…

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

Based on interview and record review, the pharmacist failed to ensure a monthly medication regimen review was conducted for 1 (#75) of 5 sampled residents. Findings include: Resident #75 was selected for an unnecessary medication review. Monthly medication regimen reviews and gradual dose reduction documentation for the last six months was requested for resident #75. This information was requested in writing on 5/21/23 at 3:30 p.m The information was verbally requested again from staff member L on 5/22/23 at 8:46 a.m The failure by the pharmacist to conduct a monthly medication review for resident #75 had the potential to lead to adverse effects and reactions, and/or medication duplications. During an interview on 5/22/23 at 8:46 a.m., staff member L said she was waiting for the information to be sent over from the main campus related to the medication reviews. The medication regimen review and gradual dose reduction information was verbally requested from staff member A for a third time on 5/23/23 at 7:46 a.m The requested information was not provided prior to the end of the survey…

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 limit a psychotropic medication to 14 days or write a rationale for the continued duration of the medication for 1 (#77) of 1 sampled resident. Findings include: Review of resident #77's medication administration record, dated 3/1/23, showed, 2/3/23 Lorazepam 2 MG/ML oral co .take the contents of 1 syringe (0.5 MG) by mouth or under tongue every 6 hours if needed for anxiety, GDR 07/23 and 1/24 . [sic] Review of pharmacy recommendations, titled CMS-Required PRN Psychotropic or Antipsychotic Medication Review, dated 2/7/23, showed, .This resident (#77) has an order for prn lorazepam 0.5 mg q6hr prn, a PRN psychotropic medication which needs to be re-evaluated. This PRN order expires 2/16/2023. PRN Psychotropic: PRN orders for psychotropic medications which are not antipsychotics are limited to 14 days. The prescriber may extend the order beyond 14 days if deemed clinically appropriate. To extend PRN psychotropic therapy beyond 14 days, the prescriber must document rationale and specific duration of therapy in patient…

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 coordinate a plan of care between the facility and hospice provider for 1 (#58) of 1 sampled resident. Findings include: During an observation and interview on 5/22/23 at 9:56 a.m., staff member C and other staff could not find a hospice care plan or hospice visit notes for resident #58 at the nurse's station. Staff member C stated she did not see where the hospice records were kept, and she would call hospice. During an interview on 5/22/23 at 10:10 a.m., NF2 stated she was one of the hospice nurses providing care to resident #58. NF2 stated she had her own hospice care plan to follow, but there was no copy of it at the facility, and she did not have a facility care plan. NF2 stated hospice did not provide any of their visit notes to the facility, but could send the notes if they were needed. NF2 stated she did not have a specific staff member to coordinate with at the facility. NF2 stated she would talk to whoever she found on the floor, when at the facility, for resident #58's hospice visits. During an…

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