Cooney Healthcare And Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure infection control measures were implemented during the transportation of dirty laundry to prevent transmission of communicable diseases, and failed to ensure enhanced barrier precautions and aseptic technique were followed while performing a wound dressing change for 3 (#s 2, 8, and 53). Findings include: 1. During an observation and interview on 9/10/25 at 1:01 p.m., staff member AA was observed rolling a dirty laundry cart from the laundry room on the first floor to the basement, while touching three different doorknobs and one push-button door code, all while wearing the same soiled gloves, and without hand hygiene. Staff member AA stated it was hard to transport dirty laundry to the basement since the elevator broke in October of 2024 and stated she does not know when it is going to be fixed. Staff member AA stated, We need to improve our infection control; I don't like that my dirty gloves are touching everything. We should be better. During an interview on 9/11/25 at 8:03 a.m., staff members B,…

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 educate staff on an antibiotic stewardship program in order to promote the appropriate use of antibiotics. This deficient practice increased the risk for residents to develop drug-resistant organisms and/or complications. Findings include: During an interview on 9/11/25 at 8:03 a.m., staff members B, C, and D stated they did not currently have an antibiotic stewardship program implemented or provide training on the program to staff. Staff members B, C, and D stated the antibiotic stewardship program would be put in place after the next QAPI meeting, which was scheduled for 9/23/25. Review of a facility policy, titled, Antibiotic Stewardship Program, Date Reviewed/Revised 4/9/25, showed: . It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure MDS assessments were submitted timely. This deficient practice was corrected in August 2025. Findings include: Review of the MDS error dashboard, submission dates 1/1/25 - 9/8/25, showed of the 604 assessments counted, there were 190 with errors. Errors included: late MDS transmissions, late care plans for CAA signatures, late admission assessments, and resident information mismatches. Errors by the month included: -[DATE]: 16 errors.-[DATE]: 11 errors.-March 2025: 28 errors.-April 2025: 33 errors.-May 2025 no assessments submitted.-June 2025: 28 errors.-July 2025: 21 errors.-August 2025: three errors.During an observation and interview on 9/10/25 at 1:45 p.m., the facility's MDS dashboard was viewed with no late indicators shown. Staff member HH stated that once an MDS was late, it would trigger many other alerts as well. Resident mismatches were common for various reasons, including a missing middle initial or discrepancies in data from…

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

Based on observation, interview, and record review, the facility failed to ensure staff member F received the appropriate and sufficient education prior to starting a position as a wound care nurse. This deficient practice resulted in staff member F not following enhanced barrier precautions or aseptic technique while performing wound dressing changes for 2 (#s 2, and 8) of 7 sampled residents with wounds; and medication errors for 3 (#s 12, 27, and 32) of 36 medications observed. Findings include:During an interview on 9/10/25 at 8:14 a.m., staff member F explained that their position was new, and staff member F had no prior experience in wound care. Staff member F stated they did not have any wound care certifications as this was a new process (type of position). Staff member F stated they worked as a floor nurse on Mondays and Tuesdays but would work as the wound nurse on Wednesdays. Staff member F stated they often had to work overtime and take work home to finish the work for the wound care position. Staff member F stated for the new position the Weekly Wound Evaluations were…

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 ensure medication error rates remained below five percent, administering medications with the correct dose for 2 (#s 12 and 32); and the correct route for 1 (#27) of 36 sampled medications. The medication error rate was 11 percent. Findings include:1. During an observation and interview on 9/9/25 at 4:04 p.m., staff member G prepared and administered medications for resident #32. The following occurred: Staff member G poured 120 mL of High Cal Med Pass into a cup. The order was for 60 mL of High Cal Med Pass.Staff member G prepared Voltaren Gel by squeezing approximately two drams (1 dram = 1.77 grams) into a medicine cup. Staff member G stated she did not have a way to measure grams of the gel, so she used the drams measurement on the medicine cups. 2. During an observation on 9/9/25 at 4:20 p.m., staff member G prepared and administered medications for resident #12. Staff member G poured 120 mL of High Cal Med Pass into a cup. The order was for 60 mL of High Cal Med Pass.During an interview on 9/10/25 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 observations, interviews and record review, the facility failed to ensure medications stored for use were not expired. The failures could affect any resident using medications or supplies from the storage area. Findings include:During an observation and interview on 9/9/25 at 2:52 p.m., with staff member B, the following items were found in the medication storage room:Hydro gel expired 3/2025 x 2Vancomycin Injection fluid bags with the following expiration dates: 12/2024, 11/2024, 1/2025, 12/2024, 6/2025, 2/2025, 11/2024, 2/2025, 11/2024, and 11/2024A box of Ipratropium Bromide expired 5/2025Covid 19 test kits expired 1/18/24 x 3Lovenox expired 8/2025 x 9Timolol Opthalmic solution expired 1/2025 x 3Bisacodyl suppository expired 1/2025 x 2 boxesLatanoprost Opthalmic solution expired 12/2024 and had no patient name Wound vac supplies stored on the floor x 4 boxesDuring the medication room observations, staff member B stated she was not sure why the medications were missed during the weekly checks or why alcohol was not secured in a locked cupboard. 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.

Based on observation, interview, and record review the facility failed to ensure resident catheter bags were covered in public areas for 1 (#25) of 2 sampled residents with catheters. Findings include:During an observation on 9/8/25 at 2:53 p.m., resident #25 was in the dining room socializing. His catheter bag was under his wheelchair. Urine was visible in the catheter bag, and there was no dignity cover.During an observation on 9/9/25 at 8:00 a.m., resident #25 was in the dining room eating breakfast. His catheter bag was under his wheelchair. Urine was visible in the catheter bag, and there was no dignity cover.During an observation on 9/10/25 at 12:20 p.m., resident #25 was in the main lobby area socializing. His catheter bag was under his wheelchair. Urine was visible in the catheter bag, and there was no dignity cover.During an interview on 9/11/25 at 3:00 p.m., staff member C stated resident #25 was care planned to not have a dignity bag cover because he would refuse.Review of resident #25's care plan, with an initiation date of 3/5/24, failed to show the refusal of a dignity…

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 exceeded the required two hour window for reporting alleged sexual abuse to the State Survey Agency for 1 (#59) of 26 sampled residents. This deficient practice increased the risk for all residents to be unprotected from the alleged sexual abuse perpetrator. Findings include: During an interview on 9/8/25 at 12:56 p.m., NF3 stated she reported an incident which appeared sexual in nature to staff member D, and the incident made her feel uncomfortable. NF3 reported it to staff member D on 9/3/25 at approximately 10:30 a.m. NF3 stated she had expressed to staff member D when she walked into resident #59's room, at approximately 10:00 a.m., she saw what appeared to be romantic relations between resident #59 and a man she thought could be her husband. NF3 stated when she saw the incident, she immediately went into the hallway and waited for approximately 30 minutes. NF3 stated, I left to give them privacy, then began to worry resident #59 was being taken advantage of, and reported the incident to staff member D. NF3 stated when she went…

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 put effective measures in place to ensure further potential abuse did not occur while an investigation was in process for 1 (#59) of 26 sampled residents. This deficient practice allowed the alleged perpetrator to have continued access to the alleged victim and/or other vulnerable residents. Findings include:Review of the Facility Reported Incident #2608463, showed the State Survey Agency received the report of potential sexual abuse for resident #59 at 12:00 p.m. on 9/4/25. Resident #59 has a BIMS of 9; moderate cognitive impairment. During an interview on 9/8/25 at 1:39 p.m., staff member A stated it was harder at night to prevent resident #59's son from coming in, but it was easier during the day because the receptionist was always there. Staff member A stated even though they had never had a problem before, they were potentially going to start locking all doors to the facility at night.During an observation and interview on 9/8/2025 at 8:04 p.m., the facility's front doors were unlocked. Staff member H…

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 the resident or the resident's representative, in writing, of the facility's bed hold policy when transferring a resident to the hospital; and failed to provide all pertinent information to the receiving hospital for 1 (#5) of 26 sampled residents. Findings include:During an interview on 9/9/25 at 2:00 p.m., staff member C stated the facility did not provide a notice of transfer or bed hold to resident #5 or resident #5's representative; and was not able to provide any documentation showing the receiving hospital was given a report of all pertinent information for resident #5. Staff member C stated they should have provided the information as per facility policy and did not.Review of a facility policy, titled, Transfer and Discharge (including AMA), Date Reviewed/Revised 6/10/25, showed: . 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative. 8. For a transfer to another provider, for any reason, the following information must be provided to the receiving…

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 resident care plans were updated with relevant care information for 1 (#4) of 26 sampled residents. Findings include:During an observation on 9/8/25 at 4:18 p.m., resident #4 was lying in bed and pointed to a small heart monitor on his chest. Resident #4 stated he had been to the hospital because of his heart rate and there was some discussion about needing a pacemaker.Review of resident #4's hospital records, dated 7/31/25 - 8/3/25, showed the resident had experienced symptomatic bradycardia [heart rate into the 40s] while at the facility, which led to his hospitalization and ICU stay.Review of resident #4's care plan, with a most recent review date 5/28/25, failed to show any information about his bradycardia or heart monitor care.During an interview on 9/11/25 at 9:22 a.m., staff member Z stated resident #4's cardiac monitor had been blinking, so she needed to change the batteries. Staff member Z stated another nurse had shown her how to change the batteries and document any symptoms and the heart…

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

Based on interviews and record review, the facility failed to ensure that a resident who was incontinent of bowel received appropriate services to restore as much normal bowel function as possible for 1 (#11) of 26 sampled residents. This deficient practice resulted in resident #11 feeling humiliated and frustrated. Findings include:During an interview on 9/8/25 at 2:53 p.m., resident #11 stated he had several incontinence incidents since his admission because staff do not arrive timely enough to assist him to the toilet. Resident #11 stated CNAs would come in during the night, turn off the call light, and state they would return to help him, but would not return. Resident #11 stated he had bowel movements in his bed as a result. Resident #11 stated it often took move than 30 minutes to get assistance when he needed to use the toilet. Resident #11 stated he was normally continent of both bowel and bladder and found the incontinence episodes to be . humiliating and frustrating.Review of resident #11's Care Plan, dated 8/13/25, reflected resident #11 required moderate to substantial…

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

Based on observation, interview, and record review, the facility failed to ensure residents had fluids readily available for 1 (#55) of 26 sampled residents. Findings include:During an observation and interview on 9/8/25 at 11:26 a.m., resident #55 stated, They never let me get out of bed, I guess I'm just gonna lie around all day. Resident #55 was propped up in bed, with an empty table in front of him. There was no water pitcher or glass for the resident on the table in front of him. An old coffee mug on the side table out of reach had dried residue at the bottom.During an observation on 9/9/25 at 12:12 p.m., resident #55 was asleep in bed with his bedside table across the room. There were no beverages or beverage containers on his side of the room.During an observation on 9/10/25 at 9:11 a.m., resident #55 was lying awake in bed. There were no fluids on either of his tables.During an observation and interview on 9/11/25 at 9:20 a.m., resident #55 was lying in bed with a glass of water and a straw by his bedside. Staff member T stated resident #55 was capable of drinking from a…

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

Based on interview and record review, the facility failed to ensure psychotropic medications were used with appropriate diagnoses and behavioral monitoring for 1 (#72) of 26 sampled residents. Findings include:Review of resident #72's medication administration record, September 2025, showed the resident received 25mg of Seroquel [an antipsychotic] for a diagnosis of dementia.Review of resident #72's medical record, dated 9/5/25 to current, did not show any behavioral notes or other indications for Seroquel.During an interview on 9/8/25 at 2:59 p.m., NF2 stated resident #72 had been started on Seroquel while in the hospital due to some delirium at night.During an interview on 9/10/25 at 8:20 p.m., staff member BB stated they had not heard of resident #72 having behaviors at night and would have to check her progress notes.During an interview on 9/11/25 at 3:48 p.m., NF8 stated when reviewing medications for appropriateness they would look at diagnoses, review progress notes for behaviors, and ask for clarification on the dementia aspect. NF8 stated resident #72's current dementia…

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 observations, interview and record review, the facility failed to assist a resident in making appointments and transportation to and from the dental services for dentures, for 1 (#2) of 26 sampled residents. This deficient practice prevented a resident from eating her preferred diet. Findings include:During an observation and interview on 9/9/25 at 7:54 a.m., resident #2 stated she had been waiting for a denture appointment for a long time. Resident #2 stated she was missing her dentures and could not eat the foods she preferred. Resident #2 stated she was told the facility was scheduling her denture appointment when she was admitted on [DATE] but had not heard anything since. During an interview on 9/9/25 at 10:18 a.m., staff member E stated she told transport about the denture appointment two weeks ago. Staff member E stated the dentures had already been paid for and she only needed to go into the denture clinic for fittings. During the interview, staff member E called the transportation department…

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 fully investigate, have a consistent process of investigating, and document the investigations for four Facility Reported Incidents (FRI) that were reviewed during the time of survey for 4 (#s 1, 3, 4, and 5) residents out of the 5 sampled, and resident injuries occurred for some of those residents. This deficient practice had the potential to result in a higher occurrence of similar incidents, as the root cause may have never been identified. Findings include: Review of a facility policy, titled Incidents and Accidents, not dated, showed: - Policy: It is the policy of this facility to utilize Bounds and PCC . to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property or may involve or allegedly involve a resident. -The purpose of incident reporting can include: . Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences. [sic]-15. If an incident/accident 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 new and existing staff: were properly educated concerning the transportation of residents; yearly evaluations were completed and documented; and written job titles and duties were located in the staff files. This deficient practice had the potential to result in staff feeling unprepared and potentially not knowing their roles. Findings include:During an interview on 8/5/25 at 2:49 p.m., staff member G stated all onboarding trainings, job titles, and job duties should be located in the staff files. Staff member G stated clinical trainings were located in a separate file in staff member B's office.During an interview on 8/5/25 at 3:13 p.m., staff member B stated all onboarding documentation should be signed and dated by the staff. Staff member B stated all staff were educated on the new transportation policy, including what to do in a scenario where a resident fell, and checking with Rehabilitation Therapy and the DON before transferring a resident outside of the facility.Review of staff member F's employee file…

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 comprehensive person-centered care plan was in place for 2 residents (#s 1 and 2) of 3 sampled residents. This resulted in one resident falling in the parking lot while using her motorized wheelchair while she was outside of the facility. Findings include:1. Review of resident #1's care plan, with an initiation date of 8/9/23, showed:- Focus: (resident #1) has physical functioning deficit related to weakness, recent acute illness, activity intolerance, and obesity. -Interventions/Tasks: Electric and manual w/c . The care plan did not mention if the resident was able to leave the building for appointments using her motorized wheelchair with or without the accompaniment of staff. The care plan did not distinguish specific staff that were required to accompany the resident and did not address the need for verbal cues that was mentioned on the occupational therapy evaluation.Review of resident #1's occupational therapy assessment showed Power-Mobility Indoor Driving Assessment: Score Sheet. The written score was a 96%…

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 safety by providing the appropriate competencies to all staff regarding transportation services when staff were assisting outside the facility. This deficient practice resulted in a resident falling in the parking lot, being ejected from their motorized wheelchair, and this resulted in 1 (#1) resident being transferred to the hospital. Findings include:During an interview on 8/5/25 at 2:49 p.m., staff member G stated all onboarding trainings, job titles, and job duties should be located in the staff files. Staff member G stated that clinical trainings were located in a separate file in staff member B's office.During an interview on 8/5/25 at 3:13 p.m., staff member B stated all onboarding documentation should be signed and dated by the staff member. Staff member B stated all staff were educated on the new transportation policy, including what to do in a scenario where a resident fell, and also checking in with Rehabilitation Therapy and the DON before transferring a resident outside of the facility.Review…

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 provide oversight to ensure the nursing scope of practice was being followed appropriately for 1 (staff member C) of 5 staff sampled, and failed to uphold disciplinary action for an LPN license on probation, and there were restrictions on the license staff member C. Findings include: During an interview on 10/3/24 at 10:44 a.m., staff member F stated they had concerns about the care of the residents at [Facility Name] and some of the management was teaching the staff to provide a substandard quality of care. Staff member F gave an example where they described an incident where an overweight resident fell, and CNAs were instructed to get a resident off the floor, without checking the resident's vitals first and without using a lift. Staff member F also stated there was an incident where they had tried to contact staff member C and was later told staff member C did not answer because the phone was in a lake. Staff member F had called due to an emergency at that time. Staff member F stated staff member C 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 interviews and record review, the facility failed to ensure staff were performing cares within their scope of practice and without necessary training, for 1 (#12) of 3 sampled residents. This practice increased the risk of negative outcomes for those residents who received care from staff member C. Findings include: During an interview on 10/3/24 at 10:44 a.m., staff member F stated staff member C was able to fire staff, work on the floor, create the schedule, and perform duties as the wound specialist. During an interview on 10/3/24 at 1:09 p.m. staff member H stated staff member C had been a wound nurse, floor nurse, manager and scheduler, all without RN supervision. During an interview on 10/3/24 at 3:15 p.m., staff member C stated she did make determine measurements and recommendations about a resident's wound, on her own. Review of resident #12's, A Weekly Wound Review, dated 9/22/24, reflected measurements of a left ear pressure ulcer, at a stage II, with measurements of 0.5 cm x 0.25 cm x 0.1 cm. The report reflected: - % Epithelial 25-50; - % Grandulation 25-50; - %…

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 observations, interviews, and record review, the facility failed to report an incident of potential abuse for two residents (#s 1 and 2) to the State Survey Agency, or the resident's representative, of 5 sampled residents. This failure increased the risk of other events occurring related to the two residents, due to preventive measures not being taken, and one resident displayed overly attentive behavior towards males. Findings include: Review of a complaint filed on 8/20/24 reflected the following concern: - Staff member C gave staff member F report, explaining resident #1 had, .wandered into, [Resident #2's] room and climbed into bed with him. [Resident #2] was very mad and went after [Resident #1] with his wheelchair. Staff member C stated she was not going to report it because it's too much work. During an interview on 10/3/24 at 10:50 a.m., resident #2 was sitting in the common area talking to staff and residents in the common area. Resident #2 appeared pleasantly confused. Resident #2 stated he…

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 adequate staffing resulting in residents not recieving scheduled showers for 1 (#132) of 31 sampled residents, call lights not answered in an adequate timeframe for 5 (#s 11, 12, 27, 37, 132) of 31 sampled residents, increased risk of dehydration in residents, and negative impact on resident's wound treatments and services. These failures increased the risk of negative outcomes of psychosocial harm due to residents feeling embarrassed and their needs not being met from missed showers and long call light wait times. Findings include: During an interview on 8/12/24 at 12:09 p.m., resident #12 stated the facility was . always short of help at night. During an interview on 8/13/24 at 12:50 p.m., resident #27 stated she can wait up to 45 minutes for help. Resident #27 stated, This is very dependent on the CNAs that are on. During an interview on 8/13/24 at 1:04 p.m., resident #132 stated she can wait as long as 30 minutes for a staff member to answer her call light, and this can occur as often as three…

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 label and date food items in the refrigerator located in the A-hall; and failed to ensure food stored in the walk-in freezer was stored at a temperature to keep the food frozen solid. This deficient practice increased the risk of residents receiving contaminated food due to improper food storage. Findings include: 1. During an observation on 8/14/24 at 2:27 p.m., the following items were found in the A-Hall refrigerator: - a rectangle shaped container with a blue lid, which contained a red colored food item, labeled, misty 102, undated, - a round container with a blue lid containing an unknown food substance, not labeled or dated, - a ripped, brown paper bag, with a 'Subway' logo, and it contained a food item wrapped in paper, not labeled or dated, - one Sysco Imperial Med Plus NSA 1.7 Vanilla Nutritional Drink, opened and half empty, not labeled or dated; and, - one Premier Protein high protein shake, not labeled or dated. During an interview on 8/14/24 at 2:29 p.m., staff member K stated perishable food…

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 proper infection control practices while in a COVID-19 outbreak for 3 (#s 21, 70 and 74) of 31 sampled residents; failed to provide notification and a screening process for visitors entering the facility; failed to train staff on the proper PPE process for transmission based precautions; failed to encourage residents to wear facemask's while out of their rooms; and failed to properly dress a wound with aseptic technique for 1 (#32) of 1 sampled resident. The facility was in Covid-19 outbreak status during the survey with 10 active resident cases of Covid-19. Findings include: A. During an observation on 8/12/24 at 9:44 a.m., upon entering the facility, no signage was noted on the entry doors notifying visitors the facility was experiencing a COVID-19 outbreak. The facility had hand sanitizer and masks located on the entry desk. A resident, when asked, informed the surveyors of the outbreak status. During an interview on 8/12/24 at 1:42 p.m., staff member A said the facility did not currently have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the current Do Not Resuscitate order was reflected in the code status of the electronic health record and care plan for 2 (#49 and #57) of 31 sampled residents. This deficient practice increased the risk of the individual choices not being honored for the Do Not Resuscitate. Findings include: 1. A review of resident #57's Montana Provider Orders for Life-Sustaining Treatment (POLST), dated [DATE], showed, YES CPR: Attempt Resuscitation. A review of resident #57's care plan showed: . Patient has an advance Directive as evidenced by: Do not Resuscitate, Date Initiated: [DATE], Patient's wishes will be honored, Target date: [DATE], . Follow facility protocol for identification of code status, Date Initiated [DATE] . Review code status quarterly, Date Initiated [DATE] . A review of resident #57's EHR dashboard showed, Code Status: POLST Do Not Resuscitate (DNR: No CPR). Resident #57's current POLST did not match the code status in the care plan or…

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

Based on observation, interview, and record review, the facility failed to revise individualized comprehensive care plans to reflect the bathing preference for 1 (#132) of 3 sampled residents for baths and to reflect current transfer methods for 2 (#s 35 and 55) of 3 sampled residents for transfers. Findings include: 1. During an observation and interview on 8/12/24 at 11:12 a.m., resident #132's hair was greasy, and she stated she doesn't get baths on a regular basis. Review of resident #132's Social Services note, dated 8/12/24, showed the resident, prefers bed baths. Review of resident #132's care plan failed to show bathing preferences and how often she prefers to be bathed. During an interview on 8/15/24 at 7:46 a.m., staff member O stated, Resident preferences for bathing should be in the care plan, and it is also on the bath schedule. During an interview on 8/15/24 at 7:51 a.m., staff member P stated, We do not add bathing preferences to the care plan unless it is an extenuating circumstance, such as refusing to shower. 2. During an interview on 8/12/24 at 11:45 a.m.,…

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

Based on interview and record review, the facility failed to provide a safe environment while using a lift, and anticipate and assess the residents needs related to transfers, for 1 (#35) of 3 sampled residents. This resulted in the resident being transferred with the wrong lift and the lift failing, and the resident was dropped from the lift to the bed. Findings include: During an interview on 8/12/24 at 11:45 a.m., resident #35 stated, . staff were transferring me recently with the Hoyer lift, and the lift gave out, and dropped me. Thankfully, I was over the bed when this happened. I'm not sure why it happened; the staff member that was assisting me said they just pushed the down button and it dropped. During an interview on 8/14/24 at 10:28 a.m., staff member L stated, . when the lift gave out with (resident #35), staff were using the smaller Hoyer lift with the scale on it. I hadn't seen the 700-pound lift before until that incident happened. I think it was stored downstairs. It looks old. Review of resident #35's progress notes showed this incident happened on 7/19/24. Review…

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 sufficient hydration for 1 (#50) of 31 sampled. This failure had the potential to affect all of the residents with a BIMS less than 7 in the facility and required encouragement from staff to drink a sufficient amount of fluids throughout the day. Findings include: During an observation and interview on 8/12/24 at 12:19 p.m., resident #50 had dried lips, and when asked if he was getting enough water throughout the day, resident #50 reached for the cup of water and stated, Oh yeah, I do need this (the water). Resident #50 then took three big gulps of water and laid back down on the bed. Review of resident #50's EHR showed a readmission on [DATE] after being hospitalized for a small bowel obstruction on 7/26/24. During an observation on 8/14/24 at 9:27 a.m., resident #50 was laying in his bed sleeping with no fluids at the bedside. During an interview on 8/14/24 at 10:56 a.m., staff member F stated if a resident had a history of a…

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

Based on interview and record review, the facility failed to ensure medication regimen reviews were completed monthly and documented in the electronic health record for 2 (#42 and 74) of 3 sampled residents for medication review. Findings include: Record review of resident #74's medical record showed an admission date of 5/28/24. Review of resident #74's progress notes showed a medication review was performed on 5/28/24, with no irregularities found. No other medication reviews were located in the EHR or medication review documents, or provided. Record review of resident #42's medical record showed an admission date of 2/7/24. Review of resident #42's progress notes showed a review was completed on 2/21/24, 4/11/24, 5/21/24, and 6/26/24. No medication review was found or provided for 2/7/24 (on admission), March 2024, or July 2024. During an interview on 8/15/24 at 8:01 a.m., staff member A said a medication regimen review was done monthly by the pharmacy. The pharmacist sends the review to the facility in batches, they are reviewed by QAPI and the physician. Staff member A said he…

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 medication error rate of less than 5%. The observed error rate was 20.69% for 3 (#s 73, 74, and 101) of 4 residents sampled for medication administration. Findings include: 1. During an observation and interview on 8/14/24 at 7:59 a.m., staff member J removed single dose medication cards for resident #101. Staff member J compared the medication order on the EHR medication administration record (MAR). Staff member J did not verify the physician admission order with the order listed in resident #101's MAR when a discrepancy was found with resident #101's provided medication. The order was: Aripiprazole 2 mg, physician order; give 2 tablets per day. Medication label on card; give 3 tablets per day, (the card only had one tablet remaining), staff member J dispensed 1 tablet into the medication cup for the resident. Losartan 100 mg, physician order; give 1, 50 mg tablet per day. Medication label on the card; Losartan 100 mg, give 1 tablet per day. Staff member J was going to break the unscored pill in…

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

Based on interview and record review, the facility failed to ensure the designated infection preventionist was qualified through an approved certification program, prior to assuming the role, of the infection preventionist. The deficient practice increased the risk of infection control concerns not being identified or addressed for all residents and staff within the facility. Findings include: During an interview on 8/13/24 at 10:48 a.m., staff member EE stated, I have been in this position for about one month. I have started the CDC training, but I haven't completed it. I know that we have issues with infection control. I was aware of that when I was hired. We are working on them. Review of staff member EE's training record showed only three modules out of fifteen had been completed prior to the start of survey. Review of staff member EE's job description showed, . Education and Experience Required: Certification in Infection Control and Epidemiology . Refer to F880, Infection Control, for overall failures identified related to COVID-19.

Based on observation, interview, and record review, the facility failed to place the call light button within reach for 2 (#18 and #46) of 31 sampled residents. This deficient practice caused resident #18 to call out for help and resident #46 to feel panicked and afraid. Findings include: 1. During an observation and interview on 8/12/24 at 2:51 p.m., resident #46 was observed to be lying in her bed with the call light across the room, draped on a pedal exercise device on the floor. Resident #46 was on Transmission Based Precautions for testing COVID-19 positive. She was dozing off during conversation and said she was very tired and weak from COVID-19 symptoms. During an observation and interview on 8/14/24 at 3:16 p.m., resident #46 was lying in bed and stated she was feeling much better. Resident #46 said she felt a little panicked and scared the night of 8/13/24. The call light had been over the foot of the bed, lying on the floor, she was unable to reach the device. Resident #46 said she had attempted to reach for the device several times and was unable. Resident #46 said staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nursing staff followed professional standards of practice for identifying a resident's change in condition, for the assessment and implementation of supplemental oxygen for a resident's saturations of 75%, for the assessment and implementation of interventions for non-verbal indicators of pain, for the assessment of intake and output for weight loss, monitoring of vital signs, and accuracy of, per physician orders, and monitoring of bowel movements for abnormalities, for 1 (#1) of 8 sampled residents. These cumulative failures, which occurred over multiple shifts and included various staff disciplines, contributed to the residents negative outcomes identified in F684 - Quality of Care, and the Immediate Jeopardy announced on 5/2/24. Findings include: During an interview on 5/1/24 at 9:43 a.m., staff member F stated non-verbal signs of pain are grimacing, inability to talk, agitation, and a resident may not stay seated, and would be moving up 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 ensure each resident received a weekly head to toe skin assessment, to assess for any new skin issues and to evaluate existing wounds, for 3 (#s 1, 4 and 5) of 4 sampled residents for skin concerns. Findings include: 1. Review of resident #1's Weekly Wound Review showed an assessment was completed on 2/15/24 for a pressure ulcer to the right heel with measurements of 0.8 x 0.9 x 0.2 cm. The assessment showed the wound was a Stage IV. There was no additional Wound Review documentation provided by the end of the survey. Review of documentation of resident #1's visits to the Wound Care Center showed weekly dressing changes from 1/4/24 - 2/15/24. The Wound Care Center documentation showed the following: - 1/25/24 Diabetic wound/ulcer of the lower extremity. Right foot, pressure injury. Measurements were 1.9 x 3 x 0.3 cm. - 2/1/24 Diabetic wound/ulcer of the lower extremity. Right foot, pressure injury. Measurements were 2.5 x 2.9 x 0.2 cm. - 2/8/24 Diabetic wound/ulcer of the lower extremity. Right foot, pressure injury.…

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 provide services in the facility with reasonable accommodation of resident needs and preferences related to religion and medical appointments for 1 (#1) of 7 sampled residents. Findings include: During an interview on 1/16/24 at 7:50 a.m., resident #1 stated he needed a sleep study for his apnea, and no one would allow him to have one, the facility refused to let him see cardiology and neurology, and the facility staff did not respect his Muslim religion. During an interview on 1/16/24 at 9:50 a.m., staff member H stated resident #1 could not have the sleep study because, nursing stated he could not do it. Staff member H stated resident # 1 had cardiology and neurology consults when he was in the hospital, before coming to facility and did not need another visit as far as she was aware. During an interview on 1/16/24 at 10:08 a.m., staff member C stated resident #1's new sleep study order and colonoscopy order were sent back to the doctor for…

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 identify, investigate, and document grievances for 1 (#1) of 7 sampled residents. Findings include: During an interview on 1/16/24 at 7:50 a.m., resident #1 stated he had reached out to the Ombudsman and police to get out of the facility. Resident #1 stated he did not feel safe in the facility because the heat did not work, people were hitting his hand during the night, he needed a sleep study and no one would allow him to have one, the facility refused to let him see cardiology and neurology, no one helped him when his call light was broken, and the facility staff did not respect his Muslim religion. Resident #1 stated he wanted to discharge to [City] to be closer to family. During an interview on 1/16/24 at 9:50 a.m., staff member H stated resident #1 could not have the sleep study because, Nursing stated he could not do it (sleep study). Staff member H stated resident # 1 had cardiology and neurology consults when he was in the hospital, 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 ensure medication labels matched the physician's orders for 2 (#s 3 and 32) of 5 sampled residents, increasing the risk for medication errors, and staff failed to remove expired medications and supplies from the medication room. Findings include: 1. During an observation and interview on 8/16/23 at 7:30 a.m., staff member F had set up medications for resident #32. The physician's order read Sirolimus 1 mg po Qday, Give 3 tablets. The medication card showed, Sirolimus 1 mg po Qday. Give 4 tablets. Staff member F stated, I never look at the medication cards. I look at what is in the computer. There are a lot of labels that do not match the orders. During an observation and interview on 8/16/23 at 11:40 a.m., staff member H had set up medications for resident #3. The physician's order showed, Hydrocodone 5/325 mg, give 1 tablet TID. The instructions on the medication bottle showed to give 1-2 tablets every 6 hours PRN. Staff member H stated she did not know why the bottle and the computer had different…

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

Based on observation, interview, and record review, the facility staff failed to ensure residents were safe to self-administer medications, before leaving the medications at bedside, causing an increased potential for medications not being taken as the physician ordered, for 3 (#s 18, 32, and 71) of 15 sampled residents. Findings include: During an observation and interview on 8/15/23 at 8:38 a.m., resident #71 was lying in bed waiting for breakfast. An inhaler was on her bedside table. Resident #71 stated, The nurses just leave this in here for me to take, and I take it. During an observation and interview on 8/15/23 at 9:03 a.m., resident #32 was lying in bed waiting for her breakfast. There was a clear, medication cup containing multiple medications, on resident #32's bedside table. Resident #32 stated, The nurse just sets my meds on my table, and I can take them when I am ready to. Resident #32 stated she did forget to take her medications on occasion. During an observation and interview on 8/15/23 at 9:09 a.m., resident #18 was sitting in her room. She had a clear medication…

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 staff failed to implement a baseline care plan within 48 hours of admission for 3 (#s 33, 87, and 247) of 10 sampled residents. Findings include: Review of the facility's policy, Care Plans- Baseline, revised March 2023, showed, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Review of resident #33's electronic medical record showed her admission date was on 7/18/23. Resident #33 had bipolar disorder, diabetes, cognitive impairment, incontinence, and end stage renal disease with dialysis. There was one baseline care plan entry on 7/18/23, related to a risk for falls. However, no other baseline care plan interventions were initiated until 8/1/23. Review of resident #247's electronic medical record showed his admission date was on 8/2/23. Resident #247 had glaucoma, depression, celiac disease, cognitive impairment, and a history of falls. There was one baseline care plan entry on 8/2/23 related to a potential for infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility licensed staff failed to set up and administer medications without errors, increasing the potential for medication side effects, for 5 (#s 5, 20, 21, 26, and 32) of 5 sampled residents. Findings include: 1. During an observation and interview on [DATE] at 7:30 a.m., staff member F set up resident #32's medications. Staff member F pulled out a tube of Diclofeac 1% cream. Staff member F did not check the name on the tube. Staff member F used resident #5's Diclofenac 1% Cream. Staff member F squeezed the cream into a clear medication cup. Staff member F did not use the measuring device that came with the medication to ensure proper dosing of the medication. Staff member F stated, I never use that thing. 2. During an observation and interview on [DATE] at 8:03 a.m., staff member G set up resident #26's medications for administration. Staff member G pulled out a Novolog insulin pen from the medication cart. The insulin pen did not have a name or date on 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 infection control standards while administering insulin for 1(#32) of 5 sampled residents, perform hand hygiene during clean to dirty tasks (putting clean laundry away) in room #s 102 and 104, and have a water treatment plan or policy in place for Legionella's Disease, increasing the risk for infection to residents and staff. Findings include: 1. During an observation and interview on 8/16/23 at 7:30 a.m., staff member F was in resident #32's room and placed her insulin pen on the bedside table. Staff member F knocked the insulin pen off the bedside table and on to the floor. Staff member F picked up the insulin pen and cleaned it with an alcohol pad. Staff member F used the same alcohol pad she used to clean the dirty insulin pen to clean resident #32's abdomen and gave the insulin injection. Staff member F stated she was nervous and did not realize that she had cleaned resident #32's abdomen with the dirty alcohol wipe. 2. During…

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

Based on observation and interview, the facility staff failed to respect the residents dignity, by not knocking prior to entering a residents room, for 2 (#s 18 and 68) of 10 sampled residents, causing the residents to feel like they had no privacy; and by leaving a resident on a bedside commode for an extended period of time for 1 (#18) of 10 sampled residents, causing the resident to feel hopeless. Findings include: 1. During an observation and interview on 8/14/23 at 3:48 p.m., resident #68 was sitting on her bed. Resident #68 stated staff just walked in and did not knock or announce themselves before entering. Resident #68 had BIMS of 15 and was considered cognitively intact. During an observation and interview on 8/14/23 at 3:53 p.m., staff member N did not knock on the door to resident #68's room before entering. Staff member N could not verbalize any of the resident rights and could not state why she did not knock. Staff member N stated, Sorry and walked out. During an interview on 8/14/23 at 3:55 p.m., resident #68 stated, See what I mean, they never knock. I have complained…

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 responsible party of a significant weight loss for 1 (#8) of 1 sampled resident. Findings include: During an interview on 8/15/23 at 10:01 a.m., NF1 stated she felt there was a disconnect with the facility regarding notifying her when resident #8 had any incidents. NF1 stated she had not been alerted resident #8 was having any weight loss. NF1 stated she had asked the facility's social worker to update resident #8's chart to enable the resident's daughter to get updates. During an interview on 8/15/23 at 10:07 a.m., NF2 stated the facility had never called her or contacted her with changes regarding resident #8. NF2 stated she visited resident #8 frequently, and could tell she was losing weight. During an interview on 8/15/23 at 3:31 p.m., staff member L stated resident #8 had a responsible party who was contacted with any updates or changes for the resident. Staff member L stated NF1 would be notified if resident #8 had weight changes. Staff member L stated NF2 visited resident #8 frequently, but 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 interview and record review, the facility failed to provide freedom from misappropriation of property for 2 (#s 20 and 250) of 2 sampled residents, resulting in a loss of medication for 1 resident and exploitation of funds for 1 resident. Findings include: 1. Review of a facility reported incident, dated 7/7/23, showed resident #20 had given staff member NF9 money for a lamp the staff member had made. During an interview on 8/15/23 at 9:15 a.m., resident #20 stated she had purchased a lamp from NF9 as a gift for her son. Resident #20 stated she had not realized staff members could not sell things in the facility. Resident #20 stated the facility gave her back her money. Resident #20 stated she was not the first person to buy from NF9, and there were a few other residents who bought things also. A review of NF9's employee file showed, NF9 signed she understood resident's rights, and the abuse training provided upon hire. NF9 was no longer employed by the facility. 2. Review of a facility reported…

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.

During observation, interview, and record review, the facility failed to assess the use of a restraint and obtain a consent for the use of it, causing an increased potential for injury, inability to get out of a wheelchair, and skin breakdown, for 1 (#45) of 7 sampled residents. Findings include: During an observation on 8/14/23 at 4:40 p.m., resident #45 was sitting in his electric wheelchair with a seat belt across his abdomen. During an interview on 8/14/23 at 4:45 p.m., resident #45 stated he had to have the seat belt on the wheelchair, or he would fall out. Resident #45 stated nursing staff had never asked him to show he could release the seat belt. Resident #45 stated staff had never checked his skin where the seat belt rested across his abdomen. Resident #45 stated at times his abdomen did get sore from having the seat belt on. A review of Resident #45's electronic medical record, from June 2023 to August 16th, 2023, showed no physicians order for the use of a seat belt, no restraint assessment, no restraint consent form, and no skin assessment of the resident's abdomen 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 interview and record review, the facility failed to submit the required final summary for investigations, within the required reporting timelines, for reportable events, for 2 (#s 24 and 248) of 5 sampled residents. Findings include: Review of a facility reported incident for resident #24, showed on 7/12/23 at 11:50 p.m. and incident of abuse occurred. The investigation summary of findings was not submitted to the State Survey Agency until 7/20/23, eight days after the incident took place. Review of a facility reported incident for resident #248 showed the incident, which consisted of a fall, occurred on 3/2/23 at 4:00 p.m The incident's summary of findings was not submitted to the State Survey Agency until 3/11/23, nine days after the incident took place. During an interview on 8/17/23 at 8:48 a.m., staff member A and staff member E stated they were aware reporting incident findings timely was a problem, and they were aware they had five days to report the results of incident investigations to the State Survey Agency. A reason for the delay of incident result reporting 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 observation, interview, and record review, the facility failed to develope a complete, comprehensive care plan, that addressed resident care needs, for 2 (#s 18 and 45) of 10 sampled residents. Findings include: 1. During an observation and interview on 8/15/23 at 10:00 a.m., resident #18 was sitting in her room. A CPAP machine was on the night stand next to the bed. The face piece and tubing for the CPAP were coated in a white, crusty substance, and the oxygen tubing was lying on the floor and was brown in color, with crusty debris around the nasal cannula. A review of resident #18's comprehensive care plan, with a revision date of 4/11/22, did not show any cleaning interventions for the CPAP machine or details related to it, such as cleaning, changing tubing, or if saturations would be monitored. 2. During an observation on 8/14/23 at 4:40 p.m., resident #45 was sitting in his electric wheelchair with a seat belt across his abdomen. During an interview on 8/14/23 at 4:45 p.m., resident #45 stated he had to have the seat belt on the chair, or he would fall out. During an…

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

Based on observation, interview, and record review, the facility failed to update and revise individual care plans for 1 (#11) and failed to notify a resident's representative of care conferences for 1 (#8) of 8 sampled residents. Findings include: 1. During an observation and interview on 8/15/23 at 10:00 a.m., resident #11 was sitting in a recliner in his room. There was a helmet by his bedside. Resident #11 stated he did not like to wear the helmet but knew he should. Resident #11 also stated when he had a seizure and staff came in, they had a magnet they used to help stop the seizures. During an interview on 8/16/23 at 3:35 p.m., NF6 stated resident #11 had epilepsy and had severe seizures. NF6 stated resident #11 was not always compliant with safety measures, like the helmet. NF6 stated resident #11 had only been back at the facility since the end of July 2023 because he was in Utah for medical management of the seizures. A review of resident #11's care plan, dated 8/7/23, showed no revisions or interventions made to the care plan regarding resident #11 refusing to wear his…

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 implement physician orders for an existing catheter and care for it, for 1 (#83) of 3 sampled residents. This increased the risk of urinary tract infections for the resident. Findings include: During an observation and interview on 8/15/23 at 8:49 a.m., resident #83 was sitting in a wheelchair in the dining room, with a catheter secured to his wheelchair. There was yellow urine in the tubing. Resident #83 stated he had the catheter in place when he was admitted to the facility in July 2023. During an interview on 8/16/23 at 3:55 p.m., staff member F stated resident #83 had his catheter in place since his admission on [DATE]. Staff member F stated nursing staff would know when to replace the catheter because an alert would pop up on the MAR from the resident's physician orders. Staff member F stated catheter care would be ordered on the TAR, and if the orders were not there, they should be put in resident #83's EMR. 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.

Based on observation and interview, the facility failed to provide adequate staffing throughout the facility to ensure residents were assisted timely with toileting, causing a resident to feel hopeless, for 3 (#s 3, 18, and 68) of 11 sampled residents. Findings include: 1. During an interview on 8/14/23 at 3:48 p.m., resident #68 stated she called the ombudsman all the time regarding staffing issues. Resident #68 stated ADLs were not getting done, and resident transfers were an issue. During an observation and interview on 8/15/23 at 9:09 a.m., resident #18 was sitting on the commode, with no pants on. Resident #18 stated she had been on the commode for a while and was waiting for breakfast to come. During an interview on 8/15/23 at 9:22 a.m., resident #3 stated the facility did not have enough staff, and the staff were struggling to get daily tasks done. Resident #3 stated they had to wait an hour at times to get transferred. During an observation and interview on 8/15/23 at 10:00 a.m., resident #18 was still sitting on the commode, with no pants on, with a breakfast tray in front…

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 Monthly Regimen Review (MRR) and a Gradual Dose Reduction (GDR) was completed for a resident taking a psychotropic medication for 1 (#57) of 5 sampled residents. Findings include: During an interview on 8/16/23 at 3:51 p.m., staff member B stated the pharmacist was responsible for identifying GDR needs during the monthly medication review. If a GDR need was identified, the pharmacist contacted the provider and DON ideally, and the provider provided a rationale to continue or decrease the dose of the medication. Staff member B stated the facility should have a system in place to make sure GDRs happen, and a QAPI project (performance improvement) was being done about a GDR issue. Review of resident #57's MAR showed the resident started Aripiprazole (Abilify) 5 mg on 11/1/22. A request was made by the survey team for resident #57's MRRs and GDRs for the past six months on 8/15/23 at 2:25 p.m. The June MRR and GDRs were not provided by the end of the survey. Review of an e-mail from NF4 to the facility, dated 8/16/23,…

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

Based on observation, interview, and record review, the facility failed to provide a physician ordered diet for 1 (#52) of 8 sampled residents, increasing the risk for weight loss. Findings include: During an observation on 8/15/23 at 9:00 a.m., resident #52 was sitting at a table in the dining room, with her breakfast tray in front of her. No peanut butter sandwich was on the tray, which was ordered to be given at each meal. Resident #52 appeared to be asleep. There was no attempt by the staff to wake resident #52. During an observation on 8/16/23 at 12:58 p.m., resident #52 was sitting at the dining room table, with her meal tray in front of her. On her tray was uncut, long fettucine noodles with light sauce, large sized broccoli florets, a full uncut bread stick, and a glass of water. Resident #52 had picked up the bread stick and tried to take a bite. She put the bread stick down, unable to eat it. Resident #58 tried to eat some of the fettucine noodles and started to cough. The lunch ticket on resident #52's tray showed she was to have a regular mechanical soft level three…

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

Based on interview and record review, the facility failed to provide or receive declinations for influenza and pneumococcal vaccines, increasing the risk of influenza or pneumonia, for 2 (#s 13 and 57) of 5 sampled residents. Findings include: During an interview on 8/17/23 at 8:07 a.m., staff member D stated the facility offered and vaccinated residents for influenza on a yearly basis, and pneumonia vaccines were offered if the resident qualified for it. A review of resident #s 13 and 57's immunization records revealed there were no influenza or pneumococcal vaccines given, and there were no signed declinations by either resident for either vaccine. During an interview on 8/17/23 at 11:00 a.m., staff member E stated there were no consents or declinations signed for resident #s 13 and 57. Staff member E stated staff were currently getting the consents or declinations signed because they were not done upon admission. A review of a facility document, titled, Influenza Vaccine, with a revision date of March 2022, showed: All residents and employees who have no medical contraindications…

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 staff failed to obtain a consent or declination for a Covid immunization, increasing the risk for Covid-19 in a vulnerable resident, for 1 (#13) of 5 sampled residents. Findings include: During an interview on 8/17/23 at 8:07 a.m., staff member D stated the facility was still offering Covid-19 vaccinations for residents and staff. During a review of resident #13's immunization records, there was no signed consent or declination for the Covid-19 vaccination. During an interview on 8/17/23 at 10:30 a.m., staff member E stated resident #13 does not have his Covid-19 vaccinations, and there was no consent or declination signed. A review of a facility document, titled, Coronavirus Disease (COVID-19)-Vaccination of Residents, with a revision date of 3/2023, showed: Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized.