Kalispell Rehabilitation And Nursing LLC

Based on interview and record review the facility failed to schedule timely care conferences with the POA (Power of Attorney) for a resident who resides on the memory care unit, for 1 (#84) of 41 sampled residents. Findings include:During an interview on 3/9/26 at 4:02 p.m., NF1 stated she had not been notified or involved in a care conference for [Resident #84] since August 2025.During an interview on 3/10/26 at 2:22 p.m., staff member E stated she scheduled care conferences within 48 hours of admission and then annually. Staff member E further stated there was no documentation of invitations to care conferences for NF1.During an interview on 3/11/26 at 9:05 a.m., staff member E stated she was unaware that care conferences for residents was supposed to be conducted quarterly and had only been having them annually. Staff member E stated she was unaware she was supposed to invite the POA to the care conference. Staff member E further stated she did not know a care conference should have been held if a resident had a change of condition.During an interview on 3/11/26 at 10:45 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to submit an initial incident report for an allegation of neglect to the State Survey Agency, for 1 (#11) of 38 sampled residents. The resident did not receive the necessary care and services related to a nephrostomy tube and the tube being dislodged during care, which was later identified to be an accident. Findings include:Review of resident #11's progress note, created on 2/23/26 at 4:46 p.m., showed: Secure Message:[DATE] . The tube is out 5 inches from the stitches; no urine output. resident stated tube was pulled out by a CNA on Wed or Thur. and stopped draining urine today. [sic]During an interview on 3/11/26 at 3:09 p.m., staff member C stated he was aware of the allegation that a CNA had caused resident #11's nephrostomy tube to become dislodged. Staff member C stated he did not report this to staff member A. Staff member C stated it should have been reported to staff member A. Staff member C stated that's not my job.During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify and investigate an allegation of potential neglect of care for 1 (#11) of 38 sampled residents. The allegation was later found to be an accident, but the reporting timeline was not met for an allegation of neglect, and the investigation was not immediately initiated for neglect of care, in an attempt to rule out neglect of care. Findings include:A review of resident #11's progress note, created on 2/23/26 at 4:46 p.m., showed: Secure Message:[DATE]Rachael Garrey. The tube is out 5 inches from the stitches; no urine output. resident stated tube was pulled out by a CNA on Wed or Thur. and stopped draining urine today. [sic]During an interview on 3/11/26 at 3:15 p.m., Staff member A stated the facility had not investigated the allegation to rule out neglect because the IDT did not feel that it was a reportable incident.A review of resident #11's progress note, with an effective date of 3/11/26 at 3:29 p.m., showed: NHA spoke with resident 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.

Based on observation, interview, and record review, the facility failed to implement safe interventions for swallowing medications and food for 1 (#73) of 38 sampled residents. This deficient practice resulted in resident #73 feeling rushed when taking his medications, coughing on the medications, and potentially vomiting. Findings include:During an interview and observation on 3/10/26 at 9:36 a.m., resident #73 stated only the physical therapist helped him sit up in the day to eat, but they would not visit him until early afternoon. He stated he had already eaten breakfast. Resident #73 was lying flat on his back with his head kinked forward. He stated he would often choke or throw up from taking the medications if a nurse rushed him, but had no problem swallowing food. He stated he swallowed the medications better at home because he had been sitting up in a chair before taking the pills.During an interview and observation on 3/10/26 at 9:51 a.m., resident #73 was about to be given his morning medications, and he asked staff member X, Can you adjust my head, so I don't choke?…

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

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to independently carry out activities of daily living (ADL) for self-grooming and showering was provided a regular shower and the removal of female facial hair for 1 (#6) of 4 sampled residents for ADL services. Findings include:During an observation and interview on 3/9/26 at 3:49 p.m., resident #6 was lying in her bed on her back, with a sheet covering her lower body. She had numerous sporadic gray chin and neck hairs, which were approximately 1 to 1.5 inches long. When asked if the resident preferred to have her facial hair removed, the resident nodded her head yes, as she stated, Yes. When asked if she needed help with shaving her face, the resident nodded and said, Yes, please. The resident had a moderate amount of dried white scaly and moist yellow eye rheum in both eyes. She had a slight musty odor emanating from her person. During an observation on 3/10/26 at 11:20 a.m., resident #6 was sitting in the common day room across from the E-Hall nurses' station. 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 interview and record review, the facility failed to provide the necessary care and services (including preferences, goals, and standards of care) to meet the resident's physical, mental, and psychosocial needs for 1 (#74) of 38 sampled residents. This deficient practice resulted in resident #74 feeling uncared for, crying about the food (or lack of) served to her, NF5 upset about the care provided to resident #74, and resident #74 requesting to be discharged from the facility. Findings include:During an interview on 3/9/26 at 4:02 p.m., resident #74 stated the facility could improve the food as it was . terrible. Resident #74 stated she could never eat the eggs at the facility. She stated the eggs were served as two big scoops of ice cream and had no taste. She stated she was served a pork chop that she had to eat with her fingers, and was once served a plate full of cooked carrots and no other items on the tray other than soup. Resident #74 stated she was often hungry at the facility, and she was not served enough calorie-dense or filling foods. She stated she did not like…

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 resident with necessary respiratory care and services in accordance with professional standards of practice and physician orders and failed to ensure a portable oxygen tank was replaced when the metered volume was empty for 1 (#6) of 4 residents sampled for oxygen therapy. This deficient practice increased the risk of negative outcomes related to hypercapnia (a condition characterized by abnormally high levels of carbon dioxide in the blood, typically caused by hypoventilation, chronic lung diseases, like COPD, or breathing issues resulting in confusion, fatigue, and shortness of breath). Findings include:During an observation and interview on 3/9/26 at 3:49 p.m., resident #6 was laying on her back turned slightly on her right side. The head of the bed was in the lowest position and was not elevated. There was an oxygen concentrator next to her bed. The oxygen concentrator was turned off, and there was no oxygen tubing attached to the oxygen concentrator. Resident #6 was not wearing any oxygen while…

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 staff had the competencies and skills to provide care for 1 (#11) of 38 sampled residents. The deficient practice caused the resident concerns for safety and had potential to cause the resident infection, harm, pain and unmet care needs. Findings include:During an interview on 3/11/26 at 11:10 a.m., resident #11 stated staff had at times pulled on his nephrostomy tubes during care. Resident #11 stated that staff needed training on the care of nephrostomy tubes and that one of his nephrostomy tubes had been dislodged as a result.During an interview on 3/11/26 at 11:21 a.m., staff member J and staff member P stated they had not received training on the care of a resident with nephrostomy tubes. Staff member P stated they were shown how to empty urine and to notify the nurse if it wasn't draining.During an interview on 3/11/26 at 11:25 a.m., staff member Q stated she had not received training from the facility on how to care for a resident with 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 have an updated written agreement with a hospice, which was signed by an authorized representative of both the hospice and the facility, before hospice care was furnished at the facility to ensure coordination and communication of care was provided as ordered for 2 (#s 29 and 65) of 3 residents sampled for hospice services. This deficient practice increased the risk to any resident receiving hospice services. Findings include:Review of the facility's hospice agreements provided during the Entrance Conference, showed an agreement signed and dated on 6/24/00, for Coordination of Services Agreement Between [NF7] and [NF8]. (Neither company exists any longer).During an interview on 3/11/26 at 8:15 a.m., staff member A stated the hospice agreement provided was representative of the agreement the facility had between NF6 Hospice and the facility. Staff member A stated they currently did not have an updated hospice agreement. Staff member A stated it was the expectation for the facility to have an updated and current hospice…

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 address the lack of housekeeping services and concerns with missing laundry, which had been complained about in the resident council for several months, but the issues were ongoing. This failure affected any resident who did not have their concerns addressed or whose room/area they were in was not maintained by housekeeping. Findings include: Review of Resident Council minutes from September 2025 to December 2025 showed:-September - requests/concerns for laundry and housekeeping, and the residents requested deeper cleaning in their rooms, especially the toilets, and the dining room. -October - request/concerns for laundry and housekeeping, to include continuing to want deeper cleaning in the resident rooms, with a focus on fixtures and toilets, and missing laundry items, which were gone for up to a month or more. -November - requests/concerns for laundry/housekeeping were that laundry items continue to go missing for long periods of time, and residents again requested deeper cleaning pf their rooms.-December -…

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 a clean environment for the residents and failed to ensure the laundry for the residents was managed and returned to them in a timely manner; including not providing the labeled clothing to the correct resident(s), which resulted in an altercation between 2 (#s 1 and 2) of 24 sampled residents. Findings include:Laundry:During an observation and interview on 12/16/25 at 12:20 p.m., staff member R stated the resident's personal laundry was put in bins for the respective units. The laundry department had tried different ways to limit laundry issues, including using mesh labeled bags, but the bags were not consistently used by nursing to ensure the correct laundry made it back to the resident(s). Staff member R was observed putting labels on several items for the residents, and stated when they knew whose clothes they were, they would label them (with the resident's name), but a lot of the clothes came in unlabeled. Then the laundry staff would not know who the clothes belonged to. Staff member R 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 facility failed to report allegations and findings of abuse timely to the State Survey Agency, for 3 (#s 10, 11, and 21) of 24 sampled residents. Findings include: Resident #21: Review of a facility reported incident, dated 6/7/25, showed an alleged incident of physical abuse occurred between staff members NF6 and NF7, and resident #21, on 6/6/25 at 2:25 a.m. The event was an abuse allegation, but not reported to the State Survey Agency within the required two-hour time frame, and the final findings for the reported incident were not submitted within the required five working days. During an interview on 12/17/25 at 3:33 p.m., staff member A stated there were technical issues with the abuse reporting system that caused the initial reporting delay for the incident that occurred on 6/6/25, with resident #21. Residents #10 and 11: During an interview on 12/17/25 at 4:32 p.m., staff member A stated facility staff were to report abuse to him immediately, but tried to have the report received no later than two hours after it occurred. 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.

Based on interviews and record reviews, the facility failed to ensure a care plan contained dementia-related interventions, other than nonspecific redirection strategies, for a resident who displayed aggressive behaviors, wandering, had frequent falls, pain, and was an elopement risk, for 1 (#15); and the lack of activities affected 2 others (#s 19 and 20) of 24 sampled residents. This deficient practice resulted in the staff lacking clear guidance on how to effectively meet a resident's needs, placing the resident at risk for inconsistent and unsafe care and unmet psychosocial needs. Findings include:During an interview on 12/15/25 at 3:26 p.m., NF3 stated, I told them she liked crossword puzzles and reading books, but I never saw anyone do activities with her, or anyone that lives there (in the locked memory care unit) for that matter.During an interview on 12/16/25 at 11:31 a.m., staff member C stated he was involved regularly with the interdisciplinary team meetings and risk management meetings. Staff member C stated, I knew of resident #15's aggressions towards other residents…

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 an ongoing program of daily, individualized or group activities, and meaningful engagement consistent with the cognitive needs and interests of residents with dementia residing on the secure memory care unit. to include for 3 (#s 15, 19, and 20) residents, for those sampled on the secure unit. Findings include:During an observation on 12/15/25 at 2:33 p.m., several residents were sitting in the common room of the secured memory care unit. The common room was noted to be quiet, and no music, movies, or television shows were playing on the TV. There were no interactive, engaging activities or conversations occurring with any of the residents.During an interview on 12/15/25 at 3:26 p.m., NF3 stated, I never saw any activities going on with my mom or anyone when I would go to visit on the weekends.During an interview on 12/16/25 at 10:52 a.m., staff member H stated she worked on the secured memory care unit frequently and said there were no consistent activities for the residents, then stated, Sometimes…

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 accurately identify wandering behaviors on the MDS Resident Assessments for 1 (#15) of 24 sampled residents. This failure limited the facility's ability to implement appropriate care planned interventions to prevent foreseeable harm to a resident with dementia and a known behavior of wandering daily. Findings include:During an interview on 12/16/25 at 11:51 a.m., staff member C stated he was not aware resident #15 had a history of wandering before being admitted to the facility on [DATE]. Staff member C stated he assumed the questions on the admission MDS Resident Assessment Instrument pertained to only current behaviors in the facility, not behaviors before admission. Staff member C stated he did not review resident #15's medical diagnoses when filling out the admission MDS Resident Assessment. He did review all the progress notes in resident #15's electronic medical record. Staff member C stated he was aware of the importance of an accurate MDS…

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's call lights were answered timely for 6 (#s 10, 12, 26, 29, 30, 32) of 40 sampled and supplemental residents, leading residents to feel their pain was not adequately managed. Findings include: 1. During an interview on 1/13/25 at 4:17 p.m., resident #30 stated he often waited over 30 minutes for his call light to be answered. He stated he waited the longest for his call light to be answered at night, and he felt the facility and staff were understaffed and overworked. During an interview on 1/13/25 at 4:29 p.m., resident #32 stated he felt the facility was understaffed as he frequently waited 30 minutes for his call light to be answered. During an interview on 1/13/25 at 4:33 p.m., resident #10 stated he often waited over 30 minutes 15 times in a week for his call light to be answered. Resident #10 also stated the longest call light wait time was over an hour. During an interview on 1/13/25 at 3:56 p.m., resident #12 stated the facility only had two CNAs at night. She stated, I'm sick and tired of them…

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 transmission-based precautions were accurate and followed; failed to ensure documentation and notification of Covid tracing in residents was completed; and failed to have a system in place to prevent and monitor water borne illnesses. These infection control failures could affect any resident at the facility, to include 8 (#s 1, 6, 10, 20, 27, 31, 32, and 280) of 40 sampled and supplemental residents; and the failure to have a waterborne pathogen program in place which could affect any resident residing at the facility. Findings include: 1. During an observation on 1/15/25 at 8:51 a.m. staff member K was observed in resident #280's room. The sign on the door showed the resident was under contact precautions, and staff were required to wear gown and gloves. The resident was also on Enhanced Barrier Precautions for direct care activities. Staff member K was not wearing any personal protective equipment in the room. During an observation on 1/15/25 at 9:39 a.m., staff members K and C were in resident…

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

Based on observations, interviews, and record reviews, the facility failed to provide a clean environment in resident showers; and failed to exercise reasonable care of resident clothing and other personal resident items from loss or theft, and failed to utilize a grievance process to address lost/missing items, for 4 (#s 5, 33, 67 and 69) of 25 sampled residents. Findings include: 1. During an interview on 1/15/25 at 9:55 a.m., staff member P stated the facility shower rooms needed a deep clean. During an observation on 1/15/25 at 1:11 p.m., the shower room outside of the memory care unit had a sign on the door showing, Lost/missing clothes kept in A & E shower room. Inside the shower room, in the shower stall, was a used wet washcloth on the floor and pooled dirt near the drain. In the second room was a rack full of clothes, and a tabletop overflowing with clothing. There was a sign posted to remind staff to clean and disinfect the shower stall between residents for infection control reasons. During an observation on 1/16/25 at 10:27 a.m., the shower room outside of the memory…

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 an affective grievance program to address resident concerns, specifically related to ongoing problems with lost resident belongings. This deficient practice increased the risk of a negative outcome for all residents who had concerns with grievances or lost items not elevated to a grievance level by management. Findings include: Review of a Grievance Report Form, dated 3/1/24, showed: Why do we fill out grievances? Nothing changes. Review of Grievance Report Form, dated 3/1/24, showed: Grievances not being addressed. During an interview on 1/15/25 at 3:56 p.m., staff member C said he was the grievance officer and stated the administrator and director of nursing determine what gets elevated to a grievance as it related to missing items. During an interview on 1/15/24 @ 4:21 p.m., Staff member A said social services handles the grievances, and the prior social worker was not very strong in her skillset. Staff member A said the grievance log for August 2024 was missing. During an interview on 1/15/24 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 observation, interview, and record review, the facility failed to ensure there was adequate staff supervision on the memory care unit for 3 (#s 22, 45, and 62); failed to identify, implement, and provide sufficient interventions for a resident who eloped, for 1 (#276) ; and failed to ensure 2 (#s 2 and 28) were properly positioned when eating food for 40 sampled and supplemental residents. Findings include: 1. During an interview on 1/13/25 at 3:00 p.m., staff members G and H stated the unit currently had a lot of residents with behaviors. They stated there were three staff scheduled for the mornings and two in the afternoons. Staff members G and H stated it was not enough staff with so many ressidents with behaviors and explained that there always needs to be one person supervising in the day room, so if a resident needed assistance in their room, staff would be spread pretty thin. During an observation on 1/14/25 at 10:00 a.m., resident #45 was standing in resident #62's doorway. Resident #62 was very agitated and wheeling towards resident #45, making verbal threats…

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 pain was routinely assessed and treated according to professional standards for 3 (#s 10, 29, and 30), especially concerning pain management for a resident with advanced dementia for 1 (#14); and failed to failed to properly follow physician orders regarding pain monitoring documentation for 1 (#10) of 25 sampled and supplemental residents. Findings include: 1. During an observation and interview on 1/13/25 at 3:24 p.m., resident #14 was sitting at the table in the memory care unit main area. She had a distressed look on her face and was rocking in the chair. Staff member G stated resident #14 was restless and cried a lot. During an interview on 1/15/25 at 9:04 a.m., staff member C stated there were usually med aides staffed on the memory care unit, which required the nurse to run around the building doing treatments and prn medication assessments. During an observation on 1/16/25 at 8:30 a.m., resident #14 was sitting at the table with a full plate of food in front of her. She wasn't eating, but 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 follow up on referrals for dental care for 5 (#s 3, 5, 6, 48, 280) of 40 sampled and supplemental residents. Findings include: 1. Review of resident #5's nursing progress notes, dated 4/15/24, showed the resident had been seen by the dental hygienist, and the concerns identified included: - Possible decay of 5, 6, 11, 23, 24, 25, 26, 27, 28. - Broken teeth 21 and 22. - Root tips present 3, 4, 7, 8, 10, 14, 20, 30, 31. Review of resident #5's EHR, accessed on 1/13/25, showed there was a physician's order for a dental referral dated 4/15/24. Review of the resident's EHR failed to show any progress notes or followup referrals or treatment for the resident's identified dental concerns. During an interview on 1/15/25 at 8:33 a.m., staff member B stated the facility had the referral in May (2024), but did not follow up, and they would make the appointment today (1/15/25). 2. a. During an interview on 1/13/25 at 4:37 p.m., resident #48 stated some of the foods (like chicken) were tough to eat, and she had a hard…

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 dietary department and staff failed to serve food timely, and follow the posted meal times, and food was often served late which resulted in cold food, for 5 (#s 6, 10, 28, 35, and 41) of 40 sampled and supplemental residents; and 3 (#s 29, 48, 49) of 25 sampled and supplemental residents stated they disliked the food. Findings include: 1. Review of a facility document, titled Mealtimes, showed, .Dining room [ROOM NUMBER]:00 (a.m.) Breakfast . During an observation on 1/14/25 at 8:28 a.m., breakfast was being served in the dining room. During an interview on 1/14/25 at 8:31 a.m., resident #6 stated the food was typically served 30 minutes late, but could be served up to an hour late. Resident #6 stated yesterday breakfast was 30 minutes late in the dining room. Review of a facility document, titled Mealtimes, showed, .E and D Wing 8:30 (a.m.) Breakfast . During an interview on 1/15/25 at 8:07 a.m., resident #41 stated her food was served later…

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 refer resident #62 for a PASARR Level II when the diagnosis of Post Traumatic Stress Disorder was added for 1 (#62) of 25 sampled residents. Findings include: Review of resident #62's PASARR Level I, dated 6/21/24 lacked the diagnosis of Post Traumatic Stress Disorder. Review of resident #62's history and physical, dated 6/16/24 showed, .Social History .He does state he was in the special forces in the Korean war and Vietnam war, and at one point was a prisoner of war for 60 days, but escaped . [sic] Review of resident #62's MDS, with an ARD of 6/27/24, section I6100 showed the resident did not have a diagnosis of Post Traumatic Stress Disorder. Review of resident #62's MDS, with an ARD of 9/22/24, section I6100 showed the resident did have a diagnosis of Post Traumatic Stress Disorder. During an interview on 1/16/25 at 8:45 a.m., staff member C stated when the diagnosis of PTSD was added to the resident's diagnoses, a new PASRR Level 1 should have been completed. The Level 1 would then show if a Level II was necessary. 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 include on a resident's baseline care plan that the resident received enteral tube feedings, for 1 (#281) of 25 sampled residents. This deficient practice increased the risk of the resident not receiving proper tube feedings, or receiving food items, and the resident was NPO. Findings include: A review of a facility document, titled Respite Resident . [Resident #281], showed: Daily routine and how to care for patient while he's ready, This report is from his wife. Hx of spinal cord injury, parkinson's (communication is minimal), aspiration pneumonia, . - Nothing by patients mouth d/t aspiration pneumonia. [sic] A review of resident #281's diagnoses in the facility's EHR showed: Dysphagia, Oropharyngeal Phase . Pneumonitis Due to Inhalation of Food and Vomit . A review of resident #281's provider orders in the facility's EHR, showed: Tube feeding instructions: Isosource 1.5 @ 70 ml/hr. Continuous, With 50 ml/hr free water flush. Every shift for Continuous G tube feedings. [sic] A review of resident #281's baseline care plan…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received the required assistance at meals, for 1 (#5); and failed to ensure a resident received assistance with toileting and dressing for 1 (#58) of 25 sampled residents. Findings include: 1. During an observation and interview on 1/14/25 at 7:57 a.m., staff member G stated they were the only staff member available to pass medications and food trays. Staff member G stated they would have to stop med pass if there was a resident who required assistance with eating. Resident #5 was sitting at a table attempting to feed himself. During an observation on 1/14/25 at 8:30 a.m., resident #5 was still eating breakfast, only now with staff assistance. During an observation on 1/15/25 at 8:21 a.m., resident #5 was attempting to eat a yogurt. He was bringing the empty spoon from the yogurt container to his mouth. He was not receiving any staff assistance or cueing. During an observation on 1/15/25 at 12:20 p.m., resident #5 was trying to use the handle of a spoon as a straw to consume fluids at lunch.…

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 hospice referrals were completed timely for 2 (#s 14 and 29) of 3 residents sampled for hospice concerns. Findings include: 1. Review of resident #14's nursing progress notes, dated 12/15/24, showed an order was received for a hospice referral, dated 12/10/24, due to weight loss and senile degeneration of the brain. This was also shown on the resident's physician orders, dated 12/10/24. Review of resident #14's IDT progress notes, dated 12/16/24, showed the resident had a significant fall and was sent to the ER. Preventative measures listed for further fall prevention showed, She will be transitioning to hospice. Review of resident #14's nursing progress notes, dated 12/29/24, show a hospice referral order was signed by the provider and placed on 12/21/24. This was eleven days after the first hospice order was completed. Review of resident #14's nursing progress notes, dated 1/12/25, showed the residents POA wanted to start hospice for the resident. This progress note was one month after the initial order. 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 interview and record review, the facility failed to ensure a resident received services for the treatment of post traumatic stress disorder, for 1 (#62) of 25 sampled residents. Findings include: During an interview on 1/13/25 at 4:14 p.m., resident #62 stated he was a Veteran; and, I saw a lot of combat in Korea and Vietnam. I have PTSD. Review of resident #62's history and physical, dated 6/16/24 showed, .Social History . He does state that he was in the special forces in the Korean War in Vietnam war and at one point was a prisoner of war for 60 days but escaped[sic] During an interview on 1/15/25 at 8:14 a.m., resident #62 stated, I need to see a psychiatrist or a counselor for my PTSD. Review of resident #62's list of diagnoses list showed the resident had a medical diagnosis of post-traumatic stress disorder. During an interview on 1/16/25 at 8:45 a.m., staff member C stated resident #62 had not been referred for treatment related to the post traumatic stress disorder. A request was made for documentation showing a referral was made for the treatment of resident #62's…

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

Based on interview and record review, facility nursing staff failed to administer two medications during the evening medication administration time, that were ordered to be given two times a day for 1 (#76) of 25 sampled residents. This resulted in a 6.4 percent medication error rate. This deficient practice had the potential to adversely affect the resident who was taking an antibiotic two times a day for pneumonia, and Potassium Chloride two times a day for encephalopathy. Findings include: A review of resident #76's EHR showed a physician's order for the antibiotic, Cefdinir, 300 mg., with an order date of 9/6/2024 at 12:40 p.m., which showed, Give 1 capsule by mouth two time a day related to Pneumonia . A review of a medication order in resident #76's EHR showed an order for Potassium Chloride, 10 meq. with, an order date of 9/6/2024 at 3:27 p.m., which was, Give 2 capsule by mouth two times a day related to Encephalopathy . [sic] A review of resident #76's MAR showed the medications, Cefdinir and Potassium Chloride, was not documented as given for the 9/6/24 medication pass 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 and record review, the facility failed to follow the posted menu for two meals of the three observed meals, which could affect any resident wishing to utilize the posted menu's. Findings include: During three observations on 1/14/25 at 8:33 a.m., 8:37 a.m., and 8:41 a.m., whole grain toast was not observed on a resident's plate. Review of the 1/14/25 breakfast menu showed: . Whole grain toast During an observation on 1/15/25 at 12:37 p.m., the following foods were served for lunch: - Potato soup - Ham and cheese on a croissant - Watermelon - Cupcake Review of the 1/15/25 Lunch Menu showed: Garden vegetable soup Classic beef stroganoff Lemon buttered broccoli Baked roll Raspberry jello salad The menu items posed were not what was served that day.

Based on observations, interviews, and record review, the facility failed to ensure the physician ordered therapeutic diet was followed for 3 (#s 12, 48, 280) of 40 sampled and supplemental residents. Findings include: a. During an interview on 1/13/25 at 3:56 p.m., resident #12 stated, (It was) unfortunate that the kitchen is not required to do a better job for diabetics. Resident #12 stated her blood sugar was commonly very high since being admitted to the facility, and she would often bring her own food. Resident #12 stated lunch that day was chili, coleslaw, spiced apples, yogurt (not low sugar), and carrot cake. Resident #12 stated this was too many carbohydrates for her to eat as a diabetic. Review of resident #12's EHR showed: CCHO diet. b. During an interview on 1/13/25 at 4:37 p.m., resident #48 stated she had to remind the staff to give her sugar free syrup because she stated they would forget and serve her regular syrup with breakfast, such as with waffles. Review of resident #48's EHR showed: CCHO diet. During an interview on 1/14/25 at 9:26 a.m., staff member F 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 facility failed to maintain clinical records in accordance with professional standards and practices for 13 (#s 1, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) of 13 sampled residents. This deficiency had the potential to affect the resident's safety from sexual abuse. Findings include: During an interview on 10/29/24 at 12:44 p.m., staff member A said he completed the audits for residents #s 1, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17. Staff member A said he did not know why his audits showed these residents did not have a Sexual Activity Capacity for Consent assessment on 9/24/24 but all of those residents did have a Sexual Activity Capacity assessment completed on 9/19/24. He stated he just trusted the social services director, and she must have given him false information. During an interview on 10/29/24 at 2:00 p.m., staff member A saw a white binder with completed Sexual Activity Capacity for Consent assessments dated 9/19/24 in the surveyor's possession. He stated, where did you get those, you should not have been given that…

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 identify and report an incident of suspected medical neglect of care by a staff member, for 1 (#1); and failed to identify and report an incident of inappropriate sexual contact, involving 2 (#s 5 and 7) to the State Survey Agency, of 11 sampled residents. Findings include: 1. During a telephone interview on 8/27/24 at 1:59 p.m., staff member H said she accidentally gave resident #1 the wrong medications on 7/27/24. She said she gave resident #1 a 10 mg Vicodin and 60 mg of OxyContin by mistake. She said she called the provider right away. She did not put the resident on a continuous oxygen saturation monitor and did not take vital signs immediately. She said the provider told her to take vital signs every four hours. She said about three hours later, the resident was found unresponsive. She said she gave resident #1 Narcan and called 911. During an interview on 8/28/24 at 11:14 a.m., staff member C said he was the administrator for the facility when the medication error occurred on 7/27/24. He stated, We do…

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 fully investigate an incident involving a significant medication error when medical neglect occurred after the error, for 1 (#1) resident; failed to fully investigate an incident involving sexual contact between 2 (#s 5 and 7) residents who were not assessed to ensure it was consensual contact, and ensure other residents were protected, which allowed ongoing sexual behaviors to go unaddressed as needed. This negatively affected a resident (#6), who would then not leave her room or go to the dining room due the male's approaches and comments to her, of 4 sampled residents. Findings include: 1. During a telephone interview on 8/27/24 at 2:37 p.m., staff member H said she was administering medications on 7/27/24, and she accidentally gave resident #1 a 10 mg Vicodin and 60 mg OxyContin, neither were ordered for her. Resident #1 was later found later unconscious and hypoxic. Staff member H said she gave resident #1 Narcan to reverse the effects of the opioid medications and called 911. Staff member H said 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 observation, interview, and record review, the facility failed to provide clean resident rooms for 12 (#s 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 13, and 14) of 14 sampled residents. This deficient practice had the potential to affect all residents residing in the facility. Findings include: During an observation on 6/4/24 at 8:30 a.m., resident #1's room had dried spaghetti and unidentifiable food chunks next to the bed and scattered around the room. A used, disposable tooth flosser was on the floor between dressers. Under the bed, were multiple items with dust bunnies and dried food particles. Several areas on the floor had dirt covered, sticky substance spots. The bathroom in resident #1's room had dried urine on the toilet seat. During an observation and interview on 6/4/24 at 8:35 a.m., resident #2 stated she was unsure of the timing of how often she saw housekeeping in her room. Resident #3 stated housekeeping was in their room maybe once a week. Resident #2's and #3's toilet had dried feces on the toilet seat and scattered, dried food on the floor of the room. 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 and interview, the facility failed to provide a structured activities program, to meet each residents' individual preferences and needs in the secured, memory care unit. This deficient practice had the potential to affect all residents residing in the secured care unit. Findings include: During an interview on 6/4/24 at 9:17 a.m., resident #5 (who resided on the general care unit) stated residents from the memory care unit did not participate in activities outside of their unit. She stated she participated often in activities, and had not witnessed anyone from the memory care unit in activities. During an interview on 6/4/24 at 11:22 a.m., staff member B stated the CNA's in the memory care unit did activities with the residents. She stated the CNA's did coloring, puzzles, adult bowling, balloon toss, and television programming with the residents. During an interview on 6/4/24 at 11:47 a.m., staff member H stated staff member F did not do activities with residents in the memory care unit. Staff member H stated staff member F occasionally brought coloring pages…

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

Based on observation, interview, and record review, staff member M failed to provide services which met professional standards of quality by not priming an insulin pen prior to the administration of insulin for 1 (#6) of 14 sampled residents. Findings include: During an observation on 6/4/24 at 9:57 a.m., staff member M entered resident #6's and performed a blood glucose monitoring test. Resident #6's blood glucose reading was 163. During an observation on 6/4/24 at 10:04 a.m., staff member M had retrieved two new insulin pens for resident #6, from a medication room. Staff member M labeled each insulin pen with an opening date. Staff member M dialed the Tresiba FlexTouch insulin pen to 40 units, then set the pen on top of the medication cart. Staff member M then dialed the Novolog insulin pen to 2 units. Staff member M did not prime either the Tresiba or the Novolog insulin pen with 2 units of insulin to clear any air from the pens. During an interview on 6/4/24 at 10:10 a.m., staff member M stated she had never heard of priming an insulin pen and did not know anything about 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 necessary care and services for a dependent resident for 1 (#9) of 14 sampled residents. This deficient practice caused the resident to feel unsafe, dirty, and embarrassed. Findings include: During an interview on 6/4/24 at 8:11 a.m., staff member H stated the scheduling of staff on the units was usually consistent for the residents, so staff were familiar with their care needs. She stated not all residents knew to use their call lights, so staff needed to check in with the residents to see if they needed help, such as repositioning or transfers. During an interview on 6/4/24 at 9:24 a.m., staff member E stated the staff repositioned residents who needed assistance with their positioning usually every two hours, or as needed. The staff also helped with transfers when residents used their call lights. During an interview on 6/4/24 at 1:26 p.m., NF1 stated resident #9 was admitted to the facility on [DATE] for rehabilitation to increase 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.

Based on observation, interview, and record review, staff member M failed to perform proper hand hygiene when entering/exiting a resident's room, during blood glucose monitoring, during insulin administration, and during administration of eye drops for 1 (#6) of 14 sampled residents; failed to utilize a protective barrier during blood glucose monitoring; and failed to clean a glucose monitoring device (glucometer) after use. This deficient practice had the potential to increase the risk of bloodborne pathogens spread to other residents using the same glucometer. Findings include: During an observation on 6/4/24 at 9:54 a.m., staff member M entered resident #6's room to administer medications and perform blood glucose monitoring. Staff member M did not sanitize her hands upon entering resident #6's room. Staff member M placed the glucometer and supplies onto resident #6's over the bed table, which also had the breakfast food tray on the table. Staff member M did not place a protective barrier underneath the glucometer and supplies. Staff member M administered resident #6's…

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

Based on observation, interview, and record review, the facility failed to ensure the floors and rooms were clean for 10 (#s 1, 2, 3, 4, 6, 7, 9, 10, 12, and 15) of 14 sampled residents for a clean environment. This deficient practice caused resident #3 to feel discouraged and frustrated. Findings include: During an interview on 4/8/24 at 10:50 a.m., resident #10 stated CNAs left soiled diapers in residents rooms, and the floors were dirty most of the time. During an observation on 4/8/24 at 10:55 a.m., resident #s 2 and 7 had 3 food wrappers on their floor, with 2 of the wrappers under resident #7's bed. During an observation on 4/8/24 at 11:00 a.m., resident #4's floor had dirt-like looking clumps by the bathroom. During an observation on 4/8/24 at 11:10 a.m., the hallway outside of resident #9's room contained four, medium sized spots of dried coffee spills. During an interview on 4/8/24 at 1:57 p.m., staff members G and I stated housekeeping was short staffed, and floor cleaning often did not get done on the weekends or after 3:30 p.m., because there were no staff scheduled…

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

Based on observation, interview, and record review, the facility failed to implement care planned fall interventions for 1 (#4) of 2 sampled residents for falls. Findings include: Review of resident #4's Care Plan showed the following interventions for the resident's risk for falls: - 2/5/24: Ensure that lighting is adequate, and lights are functioning, including night lights. - 2/5/24: Ensure that the clothing does not cause tripping; and that rubber soled, heeled shoes or non-skid slippers are worn. - 3/6/24: Provide a fall mat for safety as resident will often attempt getting up on her own. Due to dementia resident does not remember to use call light and/or ask for assistance. - 4/1/24: Non-slip strips to be added to floor in front of recliner. During an observation on 4/8/24 at 11:00 a.m., resident #4 was sitting on the floor at the side of her bed, yelling out for help. The floor was wet with urine and did not have non-skid stripping or a fall mat. Resident #4 did not have footwear on, her sheets were soaked with urine, and the light was dim. During an interview on 4/8/24 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 observation, interview, and record review, the facility failed to implement interventions to prevent a fall for 1 (#4) of 2 sampled residents for falls. Findings include: Review of a Facility Reported Incident, dated 3/16/24, showed resident #4 had a fall resulting in an acute distal clavicle fracture. Resident #4 was admitted to the facility as she had a prior history of falls at home. Review of the facility's fall log showed resident #4 had seven falls from 2/8/24-4/8/24. Review of resident #4's Progress Notes, dated 4/1/24, showed resident #4 had a fall on 4/1/24, resulting in a 4 cm laceration to the left side of her scalp, requiring staples. During an observation on 4/8/24 at 11:00 a.m., resident #4 was sitting on the floor on the side of her bed, with her knees bent up to her chin, barefoot, quietly yelling for help. The resident was not wearing a brief or bottoms. The floor was wet with urine, and resident #4's bedsheets were soaked with urine. The room's lighting was dim. The floor did not have non-skid strips or a fall mat. During an interview on 4/8/24 at 1:40…

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 honor a resident's preference of sleeping in a recliner instead of a bed, for 1 (#53) of 1 sampled resident, which caused concern for the resident related to her safety and comfort. Findings include: Review of an incident reported to the State Survey Agency, dated 1/2/24, showed: . Interview of staff . he stated, 'I put the resident to bed, all was fine, no episodes noted of delirium at that time.' He stated, 'no other care givers were in the room on this night.' [Employee title] is a prn employee; resident traditionally sleeps in her recliner not in her bed and this may have caused some confusion as well [sic] During an observation and interview on 1/31/24 at 9:39 a.m., resident #53 was sitting in a wheelchair conversing with a visitor, and there was a recliner in the center of the room. Resident #53 stated she always sleeps in a recliner, and said, I have a fear of falling out of the bed, and a fear I can't get out of bed. I have slept in a recliner for a long time. During an interview on 1/31/24 at 2:24…

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, a facility staff member neglected to communicate a resident's pain concerns to the nurse on more than one occasion, and over a 1 to 2 hour time span; and, during an interaction the staff member verbally mistreated the resident, and used a hand gesture to slap in the resident's face being mean and disrespectful, for 1 (#333) of 1 sampled resident. Findings include: A review of a Grievance Report Form, dated 1/25/24, from resident #333, showed: I asked for my pain meds about midnight last night, 12:01 a.m. The young lady that came in is [NF1]. I asked her to let the nurse know may pain med is due and I was in a lot of pain. I had major back surgery six to seven weeks earlier. She didn't respond much at all. An hour went by and I called back and asked again. She came back and acted as if I was just bothering her. She slapped her hand in my face, as to tell me to just sit there and shut up! When all I did was to remind her I asked her an hour ago for pain med. after two hours went by. I call her again. She showed me no respect at all and asked me…

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

Based on interview and record review, facility nursing staff failed to follow a provider order for donning and doffing anti-embolism stockings, 1 (#53) of 1 sampled resident, Findings include: Review of an incident reported to the State Survey Agency, dated 12/28/23, showed: Resident found on floor in her room beside her bed. She was wearing compression socks at the time and these were removed. Resident also noted to be wearing compression hose at the time of the fall, proper footwear or slip grip socks to be worn over them to prevent falls is recommended. Review of resident #53's progress note, dated, 12/28/23 at 07:23 a.m., and authored by staff member D, showed, Resident had an unwitnessed fall in her room beside her bed.She was wearing compression socks at the time and these were removed. A review of a provider order for resident#53, dated 5/25/2023, showed: Order Summary TED Hose Every day and night shift for edema [NAME] in am, doff @ HS [sic] During an interview on 1/31/24 at 2:42 p.m., Staff member B stated it was the CNAs responsibility to remove resident #53's TED hose at…

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

Based on observation and interview, facility dietary staff failed to ensure dry food storage was in line with identified safe food handling guidelines, and failed to have processes in place to identify and maintain a clean environment in the kitchen, as evidenced by the lack of a cleaning schedule, and unsanitary conditions in the kitchen. This deficient practice had the potential to affect all residents receiving food from the kitchen. Findings include: During an observation on 12/19/23 at 8:22 a.m., the following was found: - a 24 oz package of orange gelatin was opened- sealed with a paper clip and not dated, - a 16 oz bag of oreo cookies pieces was open and not dated, - a 16 oz bag of mini marshmallows was open and not dated, - a two pound bag of elbow macaroni was open and not dated, - a five pound bag of yellow cornmeal was open and not sealed or dated; and, - a four pound bag of cocoa powder was open and not sealed or dated. The other opened dry foods in the storage area were dated with a month and day, none of the dates included the year. A four oz individual container of…

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

Based on interview and record review, the facility failed to provide and submit complete and accurate Payroll Based Journal information for all required data for Fiscal Year 2023. Findings include: Review of the CASPER report showed a concern for low weekend staffing, licensed nurses for 24 hours per day, and a 1 star staffing rating for Quarter 4 of Fiscal Year 2023. Review of the time punches for the following dates: 7/8/23, 7/15/23, 7/22/23, 7/29/23, 8/5/23, 8/12/23, 8/13/23, 8/20/23, 8/26/23, and 9/9/23, showed there were licensed nursing staff in the facility 24 hours each day. During an interview on 12/20/23 at 9:34 a.m., staff member M stated the submissions to the PBJ were done by payroll, based on time clock punches. Staff member M stated the facility was purchased by a new company and payroll was screwed up because the time clock was not in. Staff member M stated punches were put in later so staff could be paid, but they did not correct the PBJ.

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary environment in the laundry facility. This deficient practice had the potential to affect residents requiring laundry services; and failed to ensure a residents soiled bed sheet was replaced for 1 (#227) of 35 sampled residents. Findings include: 1. During an observation and interview on 12/19/23 at 11:04 a.m., the soiled laundry sorting room door was propped open between the soiled laundry sorting room and the washing machines. There was a strong smell of feces and urine coming from the washing machine area. There was the sound of water pouring and splashing coming from behind the washing machines. There was a warm breeze, that smelled of feces and urine coming from behind the washing machines. Upon inspection, behind the washing machines, there was dirty wash water pouring out from pipes on the back of the washing machines into an open concrete trough. The wall by the drain trough was splashed with dirty wash water. There were two wire coat hangers, that had been straightened,…

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 timely submission of resident MDSs for 7 (#s 16, 63, 64, 73, 223, 225, and 227) of 35 sampled residents. Findings include: 1. Review of resident #64's admission MDS, with an ARD of 11/7/23, showed it was not completed until 11/21/23. 2. Review of resident #63's Quarterly MDS, with an ARD of 11/23/23, showed it was not completed until 12/11/23. 3. Review of resident #73's admission MDS, with an ARD of 11/27/23, showed three of the areas were not completed until 12/15/23. 4. Review of resident #16's Annual MDS, with an ARD of 12/3/23, showed two of the areas were not completed until 12/18/23. 5. Review of resident #223's admission MDS, with an ARD of 12/11/23, showed the assessment was eight days overdue. 6. Review of resident #227's admission MDS, with an ARD of 12/11/2023, showed the assessment only had 6 out of 18 sections completed, and was eight days overdue. 7. Review of resident #225's admission MDS, with an ARD of 12/14/23, showed the assessment was five days overdue. During an interview on 12/19/23 at 2:28…

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 were assisted with transfers in a timely manner for 3 (#s 2, 66, and 227) of 35 sampled residents. This deficient practice resulted in resident #2 feeling scared and delayed care for others. Findings include: 1. During an observation and interview on 12/18/23 at 2:13 p.m., resident #66 was lying in bed. Resident #66 stated he had been in bed all day, and the staff had not helped him to his chair. Resident #66 stated the staff were to use a hoyer lift to transfer him. Resident #66 stated he had called the staff to help transfer him multiple times that day, but they had not helped him. During an observation and interview on 12/19/23 at 11:39 a.m., resident #66 was lying in bed. Resident #66 stated he had used his call light multiple times because had been trying to find out when his shower was for the past three hours, because his family was coming for lunch that day. Resident #66 stated he had not been out of bed yet that morning. During an interview on 12/19/23 at 2:18 p.m., staff member J…

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 enough staff to assist residents with ADL needs and tasks, and complete MDSs, resulting in long resident wait times and incompletion of assistance and tasks for 6 (#s 2, 37, 39, 66, 223, and 227), causing resident #66 to be scared; and late MDS submissions for 7 (#s 16, 63, 64, 73, 223, 225, and 227) of 35 sampled residents. Findings include: During an observation and interview on 12/18/23 at 2:13 p.m., resident #66 was lying in bed. Resident #66 stated he had been in bed all day, and the staff had not helped him to his chair. Resident #66 stated the staff were to use a Hoyer lift to transfer him. Resident #66 stated he had called the staff to help transfer him multiple times, but they did not help him. Resident #66 stated he thought the facility needed more staff because he could not get the help he needed. During an interview on 12/18/23 at 2:44 p.m., resident #227 stated the facility was, .extremely short handed. Now one girl (CNA) is doing everything because they are short at night. If you need…

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 honor bathing preferences for 2 (#s 39 and 40) residents, who felt it was important due to skin concerns and comfort, of 35 sampled residents. Findings include: 1. During an observation and interview on 12/18/23 at 1:23 p.m., resident #40 said she got a shower once a week, but her preference was at least two showers a week, due to her size, numerous skin folds, and her potential for skin breakdown, especially on her buttocks due to sitting all the time. Resident #40 said she had a rash on her buttocks. Review of resident #40's Quarterly MDS, with an ARD of 11/7/23, Section C, showed the resident was cognitively intact. Section H showed the resident was always incontinent of urine and bowel. Section K showed the resident's weight as 391 pounds. Review of resident #40's care plan, last reviewed on 9/26/23, showed the resident had a focus for her ADL self-care performance deficit related to her changing cognitive status, mood decline, her use of psychoactive medications, and physical limitations such as…

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 notify the physician of a change in a resident's increased depression for 1 (#53); and failed to notify the physician of a missed antibiotic for 1 (#53) of 35 sampled residents. Findings include: 1. During an interview and observation on 12/18/23 at 2:48 p.m., resident #53 was in her room, and was observed to be crying on interview. Review of resident #53's Annual MDS, with an ARD of 6/7/23, showed the resident had a PHQ-9 score of 7, which indicated the presence of mild depression. Review of resident #53's Quarterly MDS, with an ARD of 8/21/23, showed the resident had a PHQ-9 score of 10, which indicated the presence of moderate depression. Review of resident #53's medical records progress notes, dated 6/1/23 to 12/20/23, failed to show the resident's physician had been notified of resident #53's increased depression. During an interview on 12/21/23 at 8:21 a.m., staff member G said the team would discuss contacting the physician for medication interventions for a resident's increased depression. Staff…

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

Based on observation, interview, and record review, facility staff failed to develop and implement a comprehensive, personalized care plan for 1 (#53) of 35 sampled residents. Findings include: During an observation and interview on 12/18/23 at 2:48 p.m., resident #53 was leaning forward over her walker, moaning. During the interview the resident started crying as she was talking about getting married, her three divorces, and the death of a child. Review of resident #53's Annual MDS, with an ARD of 6/7/23, showed the resident had a PHQ-9 score of 7, which indicated the presence of mild depression. Section V, Care Area Assessment Summary, showed the Mood State care area had triggered and should be care planned. Review of a Mood State care area assessment (CAA) worksheet, completed in conjunction with the Annual MDS, with an ARD of 6/7/23, showed resident #53 had mild depression. The Care Plan Considerations section of the CAA worksheet showed her mood state would be addressed in her care plan, and the overall objective was for an improvement Review of resident #53's care plan,…

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

Based on observation, interview, and record review, facility staff failed to revise a care plan with focus, goals, and interventions for increased depression for 1 (#53) of 35 sampled residents. Findings include: During an observation and interview on 12/18/23 at 2:48 p.m., resident #53 was in her room. The resident was leaning forward over her walker and moaning. The resident started talking about getting married, her previous three divorces, and the death of a child. The resident began to cry during the interview. The interview was stopped due to the resident crying, and she became unintelligible. Review of resident #53's Quarterly MDS, with an ARD of 8/21/23, showed the resident had a PHQ-9 score of 10, which had increased from the previous score of 7, which reflected the presence of moderate depression, but the resident's depression had increased. Review of resident #53's care plan, dated 12/6/23, failed to show a revised focus, goals, or interventions related to resident #53's change in the severity of her depression. Review of resident #53's August through December 2023…

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, facility staff failed to maintain professional standards due to failure to follow ¹physician orders for 1 (#53) of 35 sampled residents. Findings include: Review of resident #53's August 2023 medication administration record (MAR) showed the resident had been prescribed the antibiotic Macrobid, 100 mg, once a day, for five days. The MAR showed doses of the antibiotic were not given on 8/13/23 or 8/14/23. Review of resident #53's nursing progress note, dated 8/14/23, showed, . Reviewed MAR and noted that resident had two doses of antibiotics for UTI [urinary tract infection] and then missed two doses. Gave today's missed dose this evening and updated schedule on MAR to give the last two doses in the evenings and end on 8/16/2023. Resident resting now and showing no signs of distress. During an interview on 12/21/23 at 8:58 a.m., staff member I said physician orders should always be followed. ¹ Nurses are obligated to follow the orders of a licensed physician or other…

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 complete root cause analysis was completed post fall for 1 (#65) of 35 sampled residents. This deficient practice could negatively affect a resident and hinder efforts for fall prevention in the future, if appropriate interventions related to root causes of falls were not identified, and addressed. Findings include: During an interview on 12/21/23 at 9:52 a.m., staff member B stated staff member M was to train the management staff on completing a root cause analysis for incidents (related to falls). Staff member M stated she gave the team the root cause analysis form and showed them how to complete it. Staff member B stated she could not remember the last time she was trained on the '5 Whys' root cause analysis, and staff member M stated she could not remember the last time she trained the staff on how to perform a root cause analysis. Review of a facility document titled, 5 Why's Root Cause Analysis Tool Template, for a facility reported incident for a fall involving resident #65 on 11/18/23, in which 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, facility staff failed to identify and address behavioral health service needs for 1 (#53) of 35 sampled residents. Findings include: During an interview and observation on 12/18/23 at 2:48 p.m., resident #53 was in her room. The resident was leaning forward over her walker and moaning. When asked if she was okay, resident #53 started crying, and her voice became unintelligible. Resident #53 was able to voice she was getting married, and the man was [AGE] years old. She said she had been divorced three times in the past. Resident #53 then said something about her child dying years ago, and she started crying more. At that point the interview was stopped due to the resident being inconsolable. Review of resident #53's Annual MDS, with an ARD of 6/7/23, showed the resident had a PHQ-9 score of 7, which reflected the presence of mild depression. Review of resident #53's Quarterly MDS, with an ARD of 8/21/23, showed the resident had a PHQ-9 score of 10, which…

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 provide dental services for 1 (#64) of 35 sampled residents, resulting in a delay of treatment for the resident. Findings include: During an interview on 12/20/23 at 8:17 a.m., staff member G stated the nurses would be responsible for making referrals for dental work for the reisdents. There was a standing physician order for dental referrals for residents. Review of resident #64's care plan, dated 11/7/23, showed an intervention of, obtain order for dental consult. Review of resident #64's nutritional assessment, dated 11/11/23, showed he was missing and/or had broken teeth. Review of resident #64's electronic medical record had no documentation to show the resident was seen by a dentist or if a dental appointment or dental services had been obtained for him. Review of the facility policy titled, Dental Services, revised December 2016, showed: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and care plan . 6. Social Services…

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

Based on interview and record review the facility failed to allow 1 resident (#1) of 2 sampled residents to refuse a recommended medical treatment by having her sign a behavioral contract stating she would go to counseling services she had previously refused to attend. Findings include: During an interview on 10/11/23 at 10:03 a.m., resident #1 stated, One day 6 or 7 people from administration came into my room. They were loud and it felt intimidating with them standing all around and above me. [Staff member C] told me I had to sign a document, or I would be evicted. I signed it but I didn't agree with it. Resident #1 stated, It felt like they were retaliating against me for speaking up. I am afraid if I complain about anything anymore, they will be able to kick me out of my home. During an interview on 10/12/23 at 8:56 a.m., staff member C said, his interpretation of the letter was to establish boundaries. If the contract wasn't followed, the resident would be given a 30-day notice of discharge. During an interview on 10/12/23 at 10:42 a.m., staff member B said, resident #1 did not…

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

Based on interview and record review the facility failed to allow 1 resident (#1) of 2 sampled residents to voice grievances without fear of reprisal. Findings include: During an interview on 10/11/23 at 10:03 a.m., resident #1 stated, One day six or seven people from administration came into my room. They were loud and it felt intimidating with them standing all around and above me. [Staff member C] told me I had to sign a document, or I would be evicted. I signed it but I didn't agree with it. Resident #1 stated, It felt like they were retaliating against me for speaking up. I am afraid if I complain about anything anymore, they will be able to kick me out of my home. During an interview on 10/12/23 at 8:56 a.m., staff member C said, he read the agreement to resident #1 out loud. Staff member C said there were five members of administration in resident #1's room when he read the letter to her. Staff member C said, his interpretation of the letter was to establish boundaries. If the contract wasn't followed, the resident would be given a 30-day notice of discharge. 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 anticipate the risk and protect one resident (#2) of 1 sampled resident from sexual abuse by another resident (#3) causing #2 to yell out and appear frightened, and the facility failed to protect one resident (#1) of 1 sampled resident from intimidation by staff, causing the resident emotional distress to include slapping herself in the face. Findings include: 1. During an observation on 10/11/23 at 4:00 a.m. resident #3 was in his room and appeared to be sleeping. Resident #3 was the only resident on that hall, and his room was in front of the nursing station. Review of resident #3's Telehealth Encounter, dated 10/6/23, showed, The staff may be moving him to the Memory Care Unit to better observe and provide more intense care for [Resident #3], though I think this will be of benefit for the overall care of [Resident #3] there is a degree of risk that other residents .might wander into [Resident #3]'s room or come in close proximity to him. Though [Resident #3] hasn't had any inappropriate touching over 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 sufficient staffing to care for residents for 4 night shifts between 8/1/23 and 8/23/23. This deficiency caused 6 (#s 1, 2, 3, 4, 5, and 6) of 7 sampled residents to have call light wait times over thirty minutes for all, and over an hour for 4 of the 6 residents; and for 2 residents (#s 6 and 9) of 7 sampled residents to feel neglected and fearful they would not get help in a timely manner. This deficiency had the potential to affect all residents in the facility. Findings include: During an interview on 8/30/23 at 10:36 a.m., resident #9 stated, I do worry about if I really needed someone to come fast, I'm not sure they could. If I was having a hard time breathing or something I could be in real trouble before anyone even saw me. During an interview on 8/30/23 at 10:39 p.m., NF 1 stated, They are understaffed especially on Saturday and Sunday, even during the day but definitely at night. During an observation and interview on 8/30/23 at 10:19 a.m., resident #6 was sitting in her chair in her room.…

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

Based on observation, interview, and record review, the facility failed to provide timely care for 1 resident #6 of 1 sampled resident causing resident #6 to feel neglected. Findings include: During an observation and interview on 8/30/23 at 10:19 a.m., resident #6 was sitting in her chair in her room. The room appeared cluttered and smelled of old urine. Resident #6 stated there were several days when she was left in bed until noon. Resident #6 stated, I like to get up in the morning and have my coffee. I couldn't get out of bed by myself, and it would take forever for someone to come help me. By the time someone would finally come, I was drenched in urine. That is just very upsetting to me. One night a few weeks ago, I went eleven hours without getting changed when I was wet. There are many times it takes longer than 25 minutes for anyone to come help me when I push my call light. It really is neglectful and when I say something they make me feel like I am an awful person . there was a CNA that would come in and turn off my call light and leave or she would say there are seven…

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.