Laurel Health & Rehabilitation Center

Based on interview and record review, the facility failed to fully investigate an abuse allegation for 2 (#s 11 and 62) of 34 sampled residents. This deficient practice resulted in psychosocial distress for resident #11 who was feeling scared due to the physical and verbal abuse (with fear of a repeat event occurring with a fellow resident). Findings include: During an observation and interview on 1/27/26 at 9:46 a.m., resident #11 stated on the night of 12/28/25, resident #62 came into her room, held her arms down, tried to get into her bed with her, and yelled, You know who I am, repeatedly at resident #11. Resident #11 stated, (She) screamed for help for quite some time, and no one came. Resident #11 showed her arms were held above her head, crossed, and held down. She stated she tried to hit resident #62 but that did not work. She stated she tried to hit him with her water cup next. She stated she would have hit him with her cane if she could have but it was across the room. She stated resident #62 had been in her room two other times. Both times, resident #62 had urinated in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to permit each resident to remain in the facility and not transfer or discharge the resident from the facility without written notice and a safe discharge plan for 1 (#72) of 3 discharged residents subsampled. Findings include:Review of resident #72's Clinical Census EHR, no date, reflected resident #72 admitted to the facility on [DATE] and discharged from the facility on 12/5/25.Review of resident #72's EHR Progress Notes, dated 11/29/25 - 12/10/25, reflected:-Resident #72 left the facility at 12:30 p.m. on 12/5/25. Resident #72 did not return by midnight. Resident #72 had left the facility with a friend.-Resident #72 called the facility at 1:40 a.m. and left a voicemail stating her car broke down on the way back from visiting her mother and would call again in the morning.-Resident #72's sister called the facility on 12/6/25 and stated resident #72 had car trouble and would not make it back to the facility today but would hopefully make it back by…

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

Based on interview and record review, the facility failed to notify the resident and or the resident's representative, in writing, of the reason for transfer when transferring a resident to the hospital, for 1 (#35) of 34 sampled residents. Findings include:During an interview on 1/26/26 at 4:15 p.m., NF2 stated resident #35 was transferred to the hospital for stroke-like symptoms on 8/26/25. NF2 stated she did not receive a written notice of transfer from the facility.During an interview on 1/29/26 at 2:56 p.m., staff member A stated the social services department would have been responsible for sending the written notice of transfer for resident #35's hospitalization on 8/26/25. Staff member A stated it appeared the letter was not sent because it was not documented in resident #35's electronic medical record.Review of resident #35's electronic medical record failed to include a transfer notice for resident #35's facility-initiated transfer on 8/26/25.On 1/28/26 a request was made for a copy of resident #35's transfer notification, for the 8/26/25 facility-initiated transfer. No…

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's PTSD triggers were noted on the resident's Care Plan for 1 (#61) of 34 sampled residents. Findings include:During an interview on 1/26/26 at 3:35 p.m., resident #61 stated he did have PTSD from the Vietnam and Kuwait War. He stated he did have memories and flashbacks from both wars, and he felt he was triggered from loud noises at times or when a person walked behind him (including when he was seated at a restaurant with people moving behind him). He stated no staff members from the facility had asked him about his triggers, but he felt they were important for staff members to know.Review of resident #61's Care Plan, initiated 7/2/25, showed: behavioral monitoring due to resident #61's PTSD diagnosis, and a revision on 1/27/26 which showed PTSD from Vietnam War - If resident does not want to talk about the stress they're feeling, don't pressure resident, honor their request and notify nurse or social services to follow up for any ongoing support/needs resident may have. Resident #61's Care Plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents with hearing and vision limitations were provided group and individual activities to meet their needs and preferences for 1 (#1) of 34 sampled residents. This deficient practice resulted in resident #1 self-isolating. Findings include:During an interview on 1/26/26 at 3:55 p.m., resident #1 was sitting in her room, in her wheelchair, approximately 1.5 ft away from her television. The volume on the television was turned up very high. The curtains were pulled closed, and the room was dark. Resident #1 stated she tried to participate in activities for a while, but she could not hear or see the activities to actively participate, so she stopped going to the activities. Resident #1 stated there were no activities for someone who is blind and deaf. Resident #1 stated she did not receive regular visits from anyone in activities, so she enjoyed her television to keep busy. Resident #1 had a pocket talker (handheld auditory…

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 offer and ensure hearing aids were properly working for 1 (#63) of 34 sampled residents. Findings include:During an observation and interview on 1/26/26 at 12:57 p.m., resident #63 was very hard of hearing and stated he wanted his hearing aids fixed. Resident #63 stated whenever he requested anything, the facility took a long time to get anything fixed. During a follow up interview (on 1/27/26 at 8:13 a.m.), resident #63 stated his hearing aids were broken, and the facility would not help him in getting to the VA to have them fixed. Resident #63 stated he was unable to converse with anyone, including any healthcare workers that worked with him or his physician. Resident #63 stated there was no social worker at the facility who was able to help with the process of getting to the VA.Review of resident #63's EHR showed resident #63 had an admission date to the facility of 8/29/25.During an interview on 1/28/26 8:59 a.m., with staff members A and B, staff member A stated they recently had their 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure incontinent residents received treatment and services to prevent urinary tract infections, avoid skin breakdown, and maintain continence to the degree possible for 3 (#s 7, 18, and 21) of 34 sampled residents. This deficient practice may have contributed to resident #21 developing a urinary tract infection and resident #7 developing a red, inflamed rash in two areas above and below her pannus. Findings include: 1. During an interview on 1/26/26 at 4:41 p.m., resident #21 stated she often was left wet with a pad added to her brief at night so the staff would not have to change her brief so often. Resident #21 stated she was currently on antibiotics for a Escherichia Coli urinary tract infection because CNAs were not changing her during the night and cleaning her properly. Resident #21 stated the night CNA would answer her call light and say she would come back but never did, and she wet herself and her bed, on 1/25/26. Resident #21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offer fluids and nutrition to a dependent resident for 1 (#59) of 34 sampled residents. Findings include:During an observation and interview on 1/26/26 at 4:49 p.m., NF7 stated resident #59 was not getting enough fluids or food throughout the day and was worried about resident #59. NF7 stated resident #59 did not void yesterday and when NF7 asked the staff about the frequency of her previous voids, the staff were unable to answer or would disappear and/or forget to come back with an answer. NF7 stated the staff members . don't come enough, resulting in resident #59 not eating or drinking enough. NF7 looked into resident #59's mouth and found a small amount of food sitting in between both bicuspids. NF7 was upset, removed the food and stated resident #59 did not even have the right type of diet for her current ability. NF7 stated the food should be cut up really small because resident #59 was having a hard time chewing lately. NF7 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 observation, interview, and record review, the facility failed to ensure tube feed bags were changed every 24 hours for 1 (#11) of 2 sampled residents receiving tube feedings. Findings include: During an observation on 1/27/26 at 9:46 a.m., resident #11's continuous tube feed bag was dated 1/26/26 and did not have any staff initials on it.During an observation and interview on 1/28/26 at 8:12 a.m. and at 10:17 a.m., resident #11's continuous tube feed bag was dated 1/26/26. There was spilled tube feed formula on the outside of the tube feed bag, as well as a significant amount of tube feed formula spilled on the floor. Resident #11 stated she did not know if new tubing was used every day, but stated she had seen staff refill the same bag before.During an interview on 1/28/26 at 8:15 a.m., staff member L stated they changed the tube feed bag every 24 hours. Staff member L stated, That's what I have always done.During an interview on 1/29/2026 at 7:40 a.m., staff member U stated tube feed bags and tubing needed to be changed every 24 hours because of what staff member U had…

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 with post-traumatic stress disorder received trauma-informed care, accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 (#61) of 34 sampled residents. Findings include:Review of resident #61's EHR showed a medical diagnosis of PTSD.During an interview on 1/26/26 at 3:35 p.m., resident #61 stated he did have PTSD from the Vietnam and Kuwait War. He stated he did have memories and flashbacks from both wars and he felt he was triggered by loud noises at times or when a person walked behind him (including when he was seated at a restaurant with people moving behind him). He stated no staff members from the facility had asked him about his triggers, but he felt knowing the triggers were important for staff members to know.Review of resident #61's Care Plan, initiated 7/2/25, showed: behavioral monitoring due to resident #61's PTSD diagnosis, and a revision made on 1/27/26 which showed PTSD from Vietnam War - If…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5% during 2 (#s 25 and 74) of 26 observed medication administrations. There was an observed medication error rate of 7.41%. Findings include:1. During an observation and interview on 1/27/26 at 7:52 a.m., staff member S prepared morning medications for resident #74. Staff member S looked at the medication bottle, Nephro Vitamins. The contents listed on the back of the medication bottle were:-Vitamin C, 60 mg-Vitamin B-1, 1.5 mg-Vitamin B-2, 1.7 mg-Niacin, 20 mg-Vitamin B-6, 10 mg-Folate, (800 mcg folic acid)-Vitamin B-12, 6 mcg-Biotin, 300 mcg-Pantothenic acid, 10 mgStaff member S looked at the MAR, hesitated, and stated the medication on the back of the bottle and the MAR were different. The MAR showed: Nephro-Vite Oral Tablet 0.8 MG (B-Complex w/C & Folic Acid). Staff member S stated, That's a good question, when answering how much of the medication they were supposed to give based on the order in the MAR and all the doses listed on the back of the Nephro Vitamin…

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 dental services were offered in a timely manner for 2 (#'s 4 and 57) of 34 sampled residents. The failure placed residents at elevated risk for oral pain, infection, impaired nutrition, and decline in oral health. Findings include: 1. During an observation and interview on 1/28/26 at 2:31 p.m., resident #4 stated he would like to go see a dentist if that option was available to him. He stated no one ever asked him since he had been at the facility. Resident #4 had broken, missing teeth, and blackened areas on his front teeth. Resident #4 stated he would avoid hard foods because they hurt when he tried to chew them. The surveyor requested information related to resident #4's dental appointments, referrals, notes, and information provided showed: Review of a facility document, not titled or dated, showed in pen: [Resident #4] . 1/29/26: Doesn't want dental appointment at this time. Review of resident #4's Care Conference, dated 1/4/26, showed: . Referrals or Recommendations for Mental Health, Podiatry,…

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 preference for Jello to 1 (#11) of 34 sampled residents. Findings include:During an interview on 1/27/26 at 9:46 a.m., resident #11 stated the facility would often run out of Jello in the facility. She also stated she was able to have applesauce, pudding, and Jello in the hospital, but staff at the facility told her she was only able to have Jello at the facility. She stated, Jello was the most important thing. That's the only thing I can eat (besides resident #11's continuous tube feed). Resident #11 stated she had a tumor in her throat that would not allow her to swallow other foods. Resident #11 stated strawberry Jello was her favorite and the facility never had that flavor available to her. She stated if they had Jello, the flavor was always orange.During an interview on 1/28/26 at 2:38 p.m., staff member G stated the facility had at least four or five flavors of Jello (cherry, lime, orange, and strawberry). Staff member G stated the facility had to make it from scratch as it was less…

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

Based on interview and record review, the facility failed to identify or correct deficient practice(s) through the utilization of their QAPI process related to facility-reported events and personal belongings inventory management for 1 (#57) of 6 sampled residents. The deficient practice placed all residents at elevated risk for theft or loss of personal belongings. Findings include: During an interview on 5/5/25 at 12:02 p.m., staff member C stated the QAPI committee reviewed reportable events as part of their monthly agenda. Staff member C stated the previous administrator would have been responsible for resident #57's facility-reportable event submission, tracking, and reporting to QAPI, however the previous administrator was no longer employed by the facility. Staff member C stated the new administrator was out of town and unavailable for interview. Review of a facility-reported event, submitted to the State Survey Agency on 12/30/24, showed resident #57's family reported missing approximately $800 in cash that was inventoried on admission. The family reported the missing cash…

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 exercise reasonable care for the protection of a cognitively impaired resident's property from loss or theft, when the resident admitted with a very large sum of money, which was in his possession, but was not returned or found upon the resident's death, for 1 (#57) of 6 sampled residents. Findings include: Review of a facility-reported event, submitted to the State Survey Agency on 12/31/24, showed resident #57 was admitted to the facility on [DATE] and passed away on 11/30/24; the resident had $891.00 in cash which was noted on the resident's inventory on his admission, and there was $833.00 unaccounted for when resident #57's wallet was returned to the resident's spouse. During an interview on 5/6/25 at 2:22 p.m., NF1 stated #57 was at the facility for 12 days, and passed away on 11/30/24. NF1 stated when the resident was admitted , she was not asked to address the safekeeping of the $891.00 in cash in the resident's possession. NF1 stated after #57…

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

Based on interview and record review, facility staff failed to report investigative findings for a reportable event, within the required timeframe, for 1 (#4) of 6 sampled residents. Findings include: Review of a facility-reported incident, submitted to the State Survey Agency on 3/11/25, showed resident #4 had an unwitnessed fall in the bathroom, and #4 sustained a humerus fracture. The facility's investigative findings were not reported to the State Survey Agency until 3/19/25; one day after the submission deadline. During an interview on 5/7/25 at 1:23 p.m., staff member B stated she had been responsible for submitting the facility's reportable incidents through the Bounds system after the previous Administrator resigned. Staff member B stated the findings for all investigations should be reported to the State Survey Agency within five working days of the date the incident occurred. Staff member B stated she was aware of the delay in completing the investigative report of findings on the 3/11/25 fall incident, but did not recall why the delay occurred. During an interview on…

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

Based on interview and record review, the facility failed to submit the mandatory staffing information for the fourth quarter of federal fiscal year 2024, as required by the Centers for Medicare and Medicaid. Findings include: Review of a CMS report titled, PBJ Staffing Data Report, dated 12/10/24, showed the facility triggered for the failure to submit data for the quarter, and for, One Star Staffing Rating. The facility was notified on 12/16/24, during the entrance conference, the facility triggered for the failure to submit staffing data for the fourth quarter of federal fiscal year 2024 (July, August, and September of 2024). Staff member B stated they would provide copies of the staffing reports, which were submitted by staff member I. During an observation and interview on 12/19/24 at 8:45 a.m., staff member I demonstrated how she submitted the mandatory staffing data required by CMS. Staff member I accessed the Monthly Nursing Home Staffing Report link on the Montana DPHHS website, to submit the facility's staffing data. The link used to submit the data was a Montana state…

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 all controlled substance medications were accurately administered, accounted, and documented for 4 (#s 24, 27, 38, and 109) of 4 sampled and supplemental residents receiving physician ordered controlled substances. Findings include: Review of the Facility Reported Incident, submitted to the State Survey Agency, dated 9/27/24, showed an investigation was initiated and completed by the facility in response to an internal audit of medication reconciliation for controlled substances. Review of the Facility Reported Incident investigative file, provided by the facility on 12/18/24, showed the following: - Three licensed nursing staff members (NF4, NF5, and NF6) were suspended during the investigation and all three were subsequently terminated following completion of the investigation by the facility. - The information identified during the investigation was submitted to the Montana State Board of Nursing. - Residents #24, 27, 38, and 109 were investigated by staff to determine if the errors with controlled substances and…

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

Based on observation, interview, and record review, the facility failed to ensure staff practiced proper hand hygiene and appropriate use of personal protective equipment, during care of residents on enhanced barrier precautions, for 1 (#43) of 18 sampled residents. During an observation on 12/18/24 at 9:04 a.m., staff member F was training a new staff nurse, staff member G, on medication pass for residents. Staff member F went into resident #43's room to set up an area to administer scheduled medications by enteral (tube) feeding. Staff member F put on a pair of gloves before entering resident #43's room to administer the medications. Staff member F left resident #43's room to go to a supply room to obtain supplies for the tube feeding with the same pair of gloves on. Staff member F returned to resident #43's room to administer the medications, and did not change the gloves worn out of the room to the supply area, or back. No hand hygiene was performed. Staff member F did not use a gown when the tube feeding was started. The tube feeding was performed without comment from 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 interview and record review, the facility nursing staff failed to meet professional standards of quality by not ensuring all controlled substance medications were accurately accounted for and documented in a resident's EHR, for 3 (#s 1, 4, and 7) of 3 sampled residents for medications. This deficient practice affected the accuracy of medication administration records, had the potential to result in administration errors, and to allow unidentified controlled substance diversion to occur. Findings include: 1. Review of resident #1's MARs, dated January and February of 2024, showed five days all doses of hydromorphone, one-half of a 5 mg tablet, were removed and signed out by either staff member D or staff member E, and not documented on resident #1's MAR. Days included: 1/18/24, 1/19/24, 1/19/24, 1/20/24, 1/23/24. Refer to F755 for detailed information for dates/times for resident #1. There were no negative outcomes identified for the resident. 2. Review of resident #4's MARs, dated January and February of 2024, showed seven days not all doses of oxycodone-acetaminophen,…

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 develop and implement a system that accounted for all Schedule II controlled substance medications, from receipt to administration or destruction, for 3 (#s 1, 4, and 7) of 3 sampled residents for medications. The deficient practice resulted in a discrepancy between the number of doses removed from secure storage, and the number of doses administered to a resident, which allowed for an increased risk for diversion of controlled substance medications. Findings include: 1. Review of resident #1's Individual Narcotic Records, dated 1/17/24 and 1/19/24, showed 50 total doses were removed from secure storage. The following 11 doses of hydromorphone one-half of a 2 mg tablets did not have a corresponding administration documented on the resident's MAR: - 1/18/24 at 11:45 a.m., two halves of a 2 mg tablet, 2 mg dose, - 1/19/24 at 6:30 a.m., two halves of a 2 mg tablet, 2 mg dose, - 1/19/24 at 4:00 p.m., one-half of a 2 mg tablet, 1 mg dose, - 1/19/24 at 4:00 p.m., one-half of a 2 mg tablet, 1 mg dose, - 1/20/24 at 8:45 a.m., two…

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 free from abuse by a staff member for 1 (#2) of 3 sampled residents. Findings include: A review of a Facility Reported Incident, dated 1/3/24, showed resident #2 had an interaction with staff member J. The incident showed resident #2 was joking with (staff member J) and she was joking back and hit his arm and it hurt. Resident #2 stated he did not think the staff member intended to inflict pain, but did not know why staff member J did it. The report showed staff member J was terminated after the investigation was completed. During an observation and interview on 2/13/24 at 12:15 p.m., resident #2 was in the dining room for a meal. Resident #2 was smiling and visiting with other residents. Resident #2 stated he remembered the incident, but could not remember what they were joking about, and did not know why staff member J hit him. Review of the investigative file, for the incident which occurred on 1/3/24, showed staff member J was suspended during the investigation. Resident #2 was…

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

Based on interview and record review, the facility failed to ensure resident medications were accurately coded on the resident's MDS for 1 (#21) of 5 sampled residents. Findings include: Review of resident #21's Significant Change MDS, with an ARD of 10/1/23, showed the resident had received insulin on one day during the seven-day lookback period. Review of resident #21's MAR, dated December of 2023, showed the resident did not have an order for insulin to be administered. The resident's MAR showed an order, dated 10/1/23, for Trulicity 0.75 mg injections to be given every Sunday. During an interview on 12/6/23 at 12:47 p.m., staff member C stated she coded Trulicity, a non-insulin medication used with insulin for glycemic control. After researching the drug classification for Trulicity, staff member C stated she thought the medication was insulin and had incorrectly coded it on the Significant Change MDS, with an ARD of 10/1/23.

Based on interview and record review, the facility failed to revise a resident's care plan after completion of a course of antibiotics for tooth pain, for 1 (#22) of 1 sampled residents. Findings include: Review of resident #22's physician order, dated 8/29/23, showed an order for amoxicillin 500 mg three times a day for seven days. Review of resident #12's MAR, dated September of 2023, showed the amoxicillin was completed on 9/3/23. Review of resident #22's care plan, dated 9/5/23, showed the resident had a problem related to antibiotic therapy for tooth pain, and interventions involved the administration of the ordered antibiotic, monitoring for effectiveness, and any adverse effects associated with the administration of the antibiotic. The care plan, accessed on 12/6/23, failed to show resolution of the problem after the antibiotics were completed. During an interview on 12/6/23 at 2:24 p.m., staff member B stated resident #22's care plan should have been revised to show the resolution of the antibiotics for tooth pain in September of 2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the bathing and dining needs were completed for those residents requiring assistance for 5 (#s 6, 8, 10, 13, and 14) of 14 sampled residents. This failure resulted in a delay of residents receiving showers, and a delay in residents receiving meals and assistance, in a timely manner. Findings include: 1. Bathing: During an interview on 10/11/23 at 2:36 p.m., resident #8 said his shower days were Monday and Thursday. He said he had just moved back to his room from staying in the COVID unit. Resident #8 said a CNA on the COVID unit told him he would not be getting a shower while on the unit because he would spread COVID to the shower and other residents. Resident #8 said he stinks and was hoping to get a shower and not have to wait until his regular shower day. Resident #8 has a diagnosis of spina bifida and neurogenic bladder. Review of resident #8's care plan, dated 3/21/19, showed resident #8 would like two baths per week. Bathing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an adequate number of staff were available for necessary care and services for bathing and dining needs for 5 (#s 6, 8, 10, 13, and 14) of 14 sampled residents. This failure resulted in residents not receiving showers and a delay in residents receiving meals and assistance in a timely manner. Findings include: 1. Bathing: During an interview on 10/11/23 at 2:36 p.m., resident #8 said his shower days were Monday and Thursday. He said he had just moved back to his room from staying in the COVID unit. Resident #8 said a CNA on the COVID unit told him he would not be getting a shower because the staff were busy due to COVID related illness in the building. Resident #8 said he stinks and was hoping to get a shower and not have to wait until his regular shower day. Resident #8 stated there is not enough staff on the weekends and they only have two CNAs to get everybody up in the morning. During an interview on 10/11/23 at 9:30 a.m.,…

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

Based on interview and record review, the facility failed to protect a resident from neglect by a staff member by not providing care when answering a call light for 1 (#8) of 5 sampled residents. Findings include: A review of a facility reported incident showed resident #8 alleged on 4/4/23, NF1 came into answer the call light, turned it off, and left without talking to him. Resident #8 said it was not the first time his call light was turned off and he was not provided care by NF1. Review of the facility investigation for the allegations made on 4/4/23, showed the facility suspended and interviewed NF1. Staff member A interviewed NF1 on 4/4/23 regarding the allegation of turning off call lights without providing resident care. NF1 admitted to turning off resident call lights without providing care. NF1 considered repeated use of the call light to be a resident behavior. The facility reported the allegation to the local police, Adult Protective Services Agency, State Survey Agency, and the staffing agency. Staff member F interviewed all residents assigned to NF1 on 4/4/23. 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, the facility failed to ensure a wheel chair was evaluated as a possible restraint for 1 (#10) of 14 sampled residents. Resident #10 was not able to use the wheel chair for mobility and relied on staff to get her from her room to activities and meals. Findings include: During an observation and interview on 10/11/23 at 9:30 a.m., resident #10 stated she cannot touch the floor with her feet while seated in her wheel chair. Resident #10 stated she no longer goes to the dining room for meals because she would have to wait 30-45 minutes for staff to wheel her back to her room. Resident #10 stated she could wheel herself if her feet would touch the floor. Resident #10 stated she spends from 6:30 a.m. to 9:30 p.m. seated in her wheel chair. Resident #10 stated she would like to be able to propel herself independently around the facility and visit with other residents because she was the resident council president. Observation of the resident seated in her wheel chair showed her feet did not touch the floor. Resident #10 stated 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.