Whitefish Care And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to complete a baseline care plan within 48 hours for 1 (#102) of 25 sampled residents. This deficient practice resulted in staff difficulty communicating with resident #102, causing frustration and anger for resident #102. Findings include:During an observation and interview on 3/9/26 at 3:28 p.m., resident #102 was in his room with NF4, and he was yelling loudly. Multiple staff members entered the room and attempted to calm resident #102 but were unable to understand what he wanted or was saying. NF4 stated she thought he was angry because he wanted to go home. NF4 stated she attempted to explain to him that he could not safely go home yet, and he became angrier. NF4 stated resident #102 needed speech therapy because he could not be understood since his stroke. During an interview and review of resident #102's CNA Kiosk information on 3/11/26 at 10:25 a.m., staff member H showed this surveyor that resident #102 did not have a baseline…

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 consistently implement fall prevention interventions for a resident with previous fall(s) and poor safety awareness for 1 (#77) of 25 sampled residents. This deficient practice placed resident #77 at risk of additional falls. Findings include: During an observation and interview on 3/9/26 at 2:43 p.m., resident #77 was in bed lying flat on his back with his call light clipped to the foot of the bed, resting. Resident #77 stated there were a couple of people who shouldn't work at the facility. He stated, They would leave you sitting in a pile of shit. Yesterday, they (CNAs) kept saying they would come back to change me from 10:00 a.m. in the morning until 8:00 p.m. at night and never changed me. They ignore call lights because you rang it too many times. I saw it happen to another resident across the hall, too. Resident #77 stated he did not know how to work the bed remote and could not reach his call light. Resident #77 stated he had a couple of falls since he had been in the facility but did not remember…

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 medically related social services were provided to meet resident needs by failing to implement discharge planning services and failing to assist with securing Social Security benefits for 1 (#81) of 25 sampled residents. This deficient practice resulted in resident #81 remaining in the facility without progress toward his expressed discharge goal of returning to North Dakota and without receiving Social Security income needed to meet personal financial needs, causing the resident to rely on family members for financial support. Findings include:1. During an interview on 3/10/26 at 8:45 a.m., resident #81 reported he was from North Dakota and desired to be discharged back to North Dakota because his family lived there and he had no support system in Montana.During an interview on 3/11/26 at 1:51 p.m., NF8 stated it had been resident #81's goal to return to North Dakota. NF8 stated, The facility kept telling us they were working on it. NF8 further reported he had spoken with staff member A during a visit during 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 ensure residents felt respected and cared for due to concerns with staffing customer service approach for 9 (#s 1, 5, 6, 8, 9, 10, 11, 12, and 15) of 12 sampled residents. This deficient practice resulted in residents feeling: disrespected, not properly cared for, and that their needs were not all met. Findings include:During an interview and observation on 12/3/25 at 8:00 a.m., resident #9 stated he did not have his teeth brushed yet for the morning. He stated, They're (staff) always busy too. They can't just help one person (at a time). Resident #9 stated the staff members often would come to his room to respond to a call light, take care of one need, but then would get called to another room without taking care of all the requested needs. He stated staff members would rarely offer to brush his teeth or wash his face in the morning, and some staff members would make him feel like he was bothering them if he asked for too much.During an interview on 12/3/25 at 8:58 a.m., resident #10 stated some of the staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure scheduled showers were consistently completed and documented for 4 (#s 1, 5, 6, 7) residents of 12 sampled residents. Findings include:1. During an interview on 12/3/25 at 1:26 p.m., NF1 stated the staff members did not take care of resident #5's overall hygienic needs including showering, shaving, hair trimming, and fingernail clipping frequently enough which resulted in NF1 doing these cares. NF1 stated resident #5 would refuse a shower sometimes and stated resident #5 refused a shower yesterday (12/2/25).Review of the [Facility Name] Shower Schedule, no date, showed resident #5 had showers scheduled for Tuesdays and Fridays.Review of resident #5's EHR showed nursing notes regarding showers from 11/11/25 to 12/2/25:-11/11/25 (Tuesday), a shower was documented,-11/19/25 (Wednesday), a shower was documented. Eight days later,-11/25/25 (Tuesday), a shower was documented. Six days later,-12/2/25 (Tuesday) no documentation of a given or refused…

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 place call lights in reachable and seen areas for 1 (#5); ensure there was safety during showers for 1 (#6); and ensure all call lights worked consistently and appropriately for 8 (#s 1, 8, 9, 10, 11, 12, 13, 14) of 12 sampled residents leading to residents feeling their needs were unmet. Findings include:1. During an observation on 12/3/25 at 8:32 a.m., resident #5 had his call light draped over the fall mat located next to the nightstand. Resident #5 was sitting at the edge of his bed, unable to locate his call light, and was attempting to reach his shoes at the end of the bed. The resident was a fall risk. During an interview on 12/3/25 at 1:26 p.m., NF1 stated that in the past, and for a long time now, resident #5's call light did not have a clip on it to hold it in a location. During an observation and interview on 12/3/25 at 6:28 p.m., staff member G attached the call light for resident #5 at an arm's length away to the left of the resident. The call light was clipped to the bed linen. When asked if 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 ensure a clean room for 3 (#s 5, 7, and 9) of 12 sampled residents. Findings include:a. During an observation on 12/2/25 at 2:33 p.m., resident #5's floor was dirty with visible dirt near the area right by the bed. There were little pieces of paper underneath resident #5's bed.During an interview on 12/3/25 at 1:26 p.m., NF1 stated there was garbage on the floor constantly in resident #5's room. NF1 stated they have never seen a staff member clean underneath the beds and stated they find garbage located there.b. During an observation and interview on 12/2/25 at 3:22 p.m., resident #7's floor had visible dirt where the resident and the wheelchair was located. Resident #7 stated, They could do a better job (with cleaning). Resident #7 stated the cleaning depended on the person and stated he often went outside and would drag dirt in so he felt bad for the cleaners and would never complain.During an interview on 12/3/25 at 5:40 p.m., staff member L stated some staff members were better at cleaning than others.…

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 basic ADL (activities of daily living) of teeth brushing was completed and documented for 1 (#9) of 12 sampled residents. Findings include:During an interview and observation on 12/3/25 at 8:00 a.m., resident #9 stated he had not brushed his teeth yet for the day, but wanted to wait until he was done eating breakfast. There was a piece of paper hanging off of resident #9's light shade on the wall. This piece of paper showed: . Complete/assist w/ oral care . Thank you, Speech TherapyDuring an interview on 12/3/25 at 12:48 p.m., resident #9 stated no staff member had helped him brush his teeth yet. He stated one staff member talked about doing it but because of an interruption with physical therapy, the task was not completed. Resident #9 stated interruptions in care were not a new issue. He stated he felt he had no consistent schedule in the day and stated physical therapy had never offered to help him brush his teeth.During an interview on 12/3/25 at 4:38 p.m., resident #9 stated he had not brushed…

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 physician wound orders were followed correctly for 1 (#1) of 12 sampled residents. Findings include:During an observation and interview on 12/3/25 at 11:49 a.m., staff member M removed resident #1's old wound dressing. Observation of the old wound dressing showed a yellow substance similar to xeroform, along with the old gauze and tape dressing supplies. Staff member M stated the substance was calcium alginate. Staff member M stated they added this to resident #1's wounds, as the wound had not been healing, and staff member M felt the calcium alginate would help. Staff member M stated they were not wound certified, and this was not what the wound certified PT had ordered for resident #1's wound treatment. Staff member M stated resident #1 had been at the facility for several months, with no wound improvement, and thought this addition would help with the drainage from the wound. Additionally, during the dressing change, staff member M did not perform proper hand hygiene after the old dressing had been…

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 shower room contained a pull cord attached to the call light system for 1 (#6), appropriate interventions were consistently in place to prevent falls for 1 (#5), and failed to ensure 1 (#10) had appropriate interventions resulting in falls with head injuries for 12 sampled residents. Findings include:1. Resident #6During an interview on 12/3/25 at 4:21 p.m., resident #6 stated he was left alone in the shower room for 45 minutes on 11/10/25. He stated there was no pull cord and he was wheelchair bound.During an observation and interview on 12/3/25 at 6:18 p.m., the shower room that resident #6 mentioned had no pull cord for the call light station on the wall. The call light station was also out of reach to staff members as there were shower chairs in the walkway. Staff member H stated no resident should be left in the shower room unattended as that was an unsafe practice. The shower room, without the call light availability and shower chairs, created a hazardous area. 2. Resident #5During 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 record review and interview, the facility failed to ensure necessary dental services were provided for a resident with a documented dental abscess who was pending Medicaid approval for insurance coverage, for 1 (#3) or 4 sampled residents. This deficient practice caused resident #3 to have difficulty eating with a resulting severe weight loss. Findings include:Record review of resident #3's admission history and physical, dated 9/5/25, showed resident #3 had a dental infection and was to complete a 10-day course of two different antibiotics. Resident #3 was scheduled for a follow-up dental appointment before her hospital discharge.During an interview on 10/21/25 at 3:55 p.m., staff member I said Medicaid would cover dental services for residents, and when a resident was unable to cover the expense of medically necessary dental services, the facility had other resources available to pay for the services. Staff member I said she did the initial social services assessment when resident #3 was admitted to the facility. Part of the admission assessment for a resident assesses if…

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

Based on interview and record review, the facility failed to provide covid vaccines in a timely manner for 2 (#s 5 and 8) who both got sick with covid, but the facility offered a covid vaccine to 1 (#9) of 12 sampled residents. The failure could have contributed to the size of the COVID-19 outbreak or its spread of it. Findings include:During an interview on 12/2/25 at 2:40 p.m., resident #8 stated she was supposed to be getting the COVID-19 (coronavirus disease of 2019) vaccine. Resident #8 stated she was asked about a month ago if she wanted the vaccine, but she had not received it yet. She stated she wanted the COVID-19 vaccine and said it was . because I don't want to get it (Covid) again.During an interview on 12/3/25 at 4:55 p.m., NF1 stated they had asked the facility three times for resident #5 to get the COVID-19 vaccine. NF1 stated resident #5 was never given a consent or declination form for the COVID-19 vaccination. NF1 stated they were upset no vaccine was given or offered, which could have prevented resident #5 from getting sick when the facility had a COVID-19…

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 an initial report within two hours to the State Survey Agency for a suspected resident to resident sexual abuse event, for 2 (#s 1 and 2) of 8 sampled residents. Findings include:A review of a facility reported incident, dated 8/24/25 at 1:30 a.m., showed resident #1 was found in resident #2's room by two staff members. Resident #2 was lying in his bed with his brief undone, and resident #1 had her hand on his penis. The reportable incident was received by the State Survey Agency on 8/24/25 at 9:20 p.m., over 21 hours after the incident occurred. The report did not meet the required reporting timeline for abuse. During an interview on 9/9/25 at 9:58 a.m., staff member B stated she called the police sometime between 2:30 and 3:00 a.m. on 8/24/25. Staff member B further relayed that the incident was submitted to the State Survey Agency later that evening, on 8/24/25.During an interview on 9/9/25 at 2:03 p.m., staff member A relayed that he thought serious bodily injury resulting from abuse had to be reported to the…

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

Based on interview and record review, the facility failed to complete a thorough investigation and take necessary action to protect a resident from ongoing abuse for a resident-to-resident sexual incident, and the facility failed to implement monitoring for the initiating resident, and failed to incorporate staff education for the prevention of abuse, for 2 (#s 1 and 2) of 8 sampled residents. Findings include:A review of a facility reported incident, dated 8/24/25, showed resident #1 was found in resident #2's room by two staff members. Resident # 2 was lying in his bed with his brief undone, and resident #1 had her hand on his penis. Resident #1 was redirected to her room, and both residents were assessed for injury.During an interview on 9/9/25 at 9:58 a.m., staff member B stated she received a call early in the morning on 8/24/25, from the ADON at the facility, informing her of a resident-to-resident sexual incident between the two residents, #1 and #2. She stated she went to the facility to start an investigation.A review of the facility's investigation documents, dated 8/24/25…

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 update a resident's care plan to include sexual behaviors towards others, which could be abuse, for 1(#1) of 8 sampled residents. Findings include:Based on interview and record review, the facility failed to update a resident care plan to include sexual behaviors directed towards others which could be abuse, for 1 (#1) of # sampled residents. Findings include:A review of a facility reported incident, dated 8/24/25, showed resident #1 was found in resident #2's room by two staff member, and resident #2 had her hand on resident #1's genitals. A review of resident #1's current comprehensive care plan, accessed on 9/9/25, showed: Behaviors: [Resident #1] has had some manifestations of her Bi-polar, she has been shouting out and wandering with the efforts to elope., with a date Initiated of 08/07/2024 and a revision on 12/01/2024. Resident #1's care plan failed to show a focus area, goals, or interventions for sexual behaviors or potential sexual abuse towards others.During an interview on 9/9/25 at 2:03 p.m., staff member B…

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

Based on interview and record review, the facility failed to maintain documentation in which each staff member was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine, that staff members were offered information on obtaining the COVID-19 vaccine, and records of the COVID-19 vaccine status of each staff member. Findings include: During an interview on 3/12/25 at 2:26 p.m., staff member B stated she would look for staff COVID-19 documentation, but did not believe there was documentation on any of the facility staff related to the COVID-19 vaccine. During an interview on 3/12/25 at 5:15 p.m., staff member A stated, regarding staff COVID-19 vaccination status or declination, We don't have it. A written request was made to the facility on 3/12/25 at 9:20 a.m., for five random staff members' documentation on COVID-19 vaccine education and vaccine status. No documentation was provided to the State Survey Agency prior to the survey exit on 3/13/25. Review of the facility's policy titled, COVID-19 Vaccination, undated, showed: - 19. The facility…

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

Based on observation, interview, and record review, the facility failed to ensure staff member Z provided care consistent with professional standards during medication administration, resulting in residents possibly receiving the wrong medication(s) and having adverse outcomes from pre-poured and unlabeled medications, for 9 (#s 24, 27, 36, 43, 50, 58, 64, 65, 77) of 12 residents sampled for medication administration. Findings include: During observation and interview, on 3/12/25 at 1:40 p.m., staff member Z performed a medication pass for residents #27 and #36 from unlabeled medication cups found in the top right drawer of the medication cart. There were 12 unlabeled medication cups in the top right drawer of the medication cart with various pills in them. Staff member Z stated, I know who they belong to, I could not find them at the time. Staff member Z stated she thought the residents, who the unlabeled medication cups belonged to, were in an activity, and she didn't want to leave the cups of medications in the resident's room. During observation and interview on 3/12/25 at 1:55…

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

Based on observation, interview, and record review, the facility failed to ensure staff member N followed enhanced barrier precautions during the administration of medications via enteral tube feeding for 1 (#2) of 1 sampled enteral tube feeding resident; failed to ensure staff members N and Z adhered to proper infection control practices related to hand hygiene when changing of gloves and during medication administration for 6 (#s 2, 24, 58, 64, 67, and 77) of 30 sampled residents; failed to ensure staff member O adhered to proper infection control practices during wound care for 1 (#67) of 1 sampled resident for wound care; and failed to ensure staff member V followed infection control procedures to prevent potential contact transmission of an infectious agent or communicable disease for 1 (#38) of 8 sampled smoking residents. Findings include: 1. Enteral Tube Feeding Medication Administration During an observation on 3/11/25 at 8:18 a.m., staff member N entered resident #2's room with medications to be administered via PEG tube. On the wall, next to the entrance into 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 failed to ensure residents who were screened and consented to pneumococcal immunizations (Prevnar13, Prevnar20, and PPSV23) were provided the vaccine for 3 (#s 2, 8, and 67) of 5 sampled residents for immunizations (influenza, COVID-19, and pneumococcal). Findings include: Review of resident #2's EHR document titled, Immunization Informed Consent Record, dated 2/5/25, showed the resident had consented to the pneumococcal vaccine. Review of resident #2's EHR document titled, Immunization Report, printed 3/12/25, showed no pneumococcal vaccine was administered. Review of resident #8's EHR document titled, Immunization Informed Consent Record, dated 2/10/25, showed the resident had consented to the pneumococcal vaccine. Review of resident #8's EHR document titled, Immunization Report, printed 3/12/25, showed no pneumococcal vaccine was administered. Review of resident #67's EHR document titled, Immunization Informed Consent Record, dated 2/10/25, showed the resident had consented to the pneumococcal vaccine. Review of resident #67'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 maintain dignity for other residents when providing postmortem discharge of a resident for 1 (#47) of 30 sampled residents, which caused feelings of sadness; and failed to maintain dignity of a resident during an incontinent episode for 1 (#36) of 30 sampled residents, which caused them to be frustrated and angry. Findings include: 1. During an observation on 3/10/25 at 2:37 p.m., resident #47 was observed in the 300-wing hallway. Two unidentified individuals entered the room and came out with a resident on a stretcher covered fully with a blanket. They walked the stretcher past the nursing station where other residents were sitting. Resident #47 stated, What did I just see? Was that a dead body? An unidentified staff member stated, Yes, the resident passed away. During an observation on 3/10/25 at 2:40 p.m., two unidentified visitors were walking down the 300 wing, and one said to the other, Do you know what that was? It was a dead body. During an observation and interview on 3/13/25 at 8:06 a.m., 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 observation, interview, and record review, the facility failed to supervise the self-administration of a metered-dose inhaler for 1 (#6) and two pain pills for 1 (#35) of 30 sampled residents. This deficient practice increased the risk for medication errors to resident's #6 and #35, as well as to confused residents, who may have wandered into resident #6 and #35's rooms. Findings include: During an observation and interview on 3/10/25 at 3:23 p.m., two blue pills were on resident #35's bedside table, in a plastic medicine cup, with no staff in the room. Resident #35 stated they were his Ibuprofen and Tramadol. Resident #35 stated some nurses offer to leave the medications so he can take them later, and some do not. During an observation and interview on 3/11/25 at 8:38 a.m., a metered-dose inhaler was sitting on resident #6's bedside table with no staff in the room. Resident #6 stated it was her rescue inhaler, she rarely used, but liked to have in her room just in case. During an interview on 3/12/25 at 9:30 a.m., staff member W stated when she administered medications, I…

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 it had an effective process in place for the most current and accurate code status and advance directives to be readily known and available to staff, in the event of an emergency, for 1 (#7) of 30 sampled residents. Findings include: During an interview on [DATE] at 11:12 a.m., staff member I stated a resident's advance directives were requested on admission and updated ongoing during care conferences. Staff member I stated multiple personnel could potentially get the POLST or advance directive information from the residents. Staff member I stated the current copies would be found uploaded in the electronic medical record. During an observation and interview on [DATE] at 4:33 p.m., staff member E stated on admission resident #7 did not have advance directives. Staff member E assisted resident #7 in filling out a POLST form as a brief full code. Staff member E turned it in to the doctor to sign. Staff member E stated she 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 observation, interview, and record review, the facility failed to provide an environment that was clean and well-maintained for 3 (#s 24, 30, and 36) of 30 sampled residents. This deficient practice bothered resident #30, wheelchairs were not cleaned for residents as needed, and unpainted surfaces were not corrected. Findings include: 1. During an observation and interview on 3/10/25 at 2:32 p.m., resident #30's wall, next to her roommate's bed, had paint chips along most of the wall. The bathroom was missing paint just above where the linoleum ends around the area of the sink, creating a non-cleanable surface. Resident #30 stated it was probably due to the wheelchairs hitting the wall. Resident #30 stated, It doesn't look good, which kind of bothers me. 2. During an observation on 3/10/25 at 2:46 p.m., resident #24's wheelchair had brown-colored debris covering the metal, around the footrest, near the front wheels of the wheelchair. Resident #24's bathroom was missing paint down, to the drywall just above the linoleum, on the wall around the sink. This was not a cleanable…

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 a list of a resident's personal items and identify and investigate a grievance brought forth by a resident and their representative related to missing clothing for 1 (#85) of 30 sampled residents. Findings include: During an interview on 3/12/25 at 8:50 a.m., NF1 stated the family was concerned with missing items of clothing after the resident's discharge. The facility was aware of the concerns. During an interview on 3/12/25 at 4:13 p.m., NF3 stated, I didn't realize resident #85 didn't have all his clothes when I picked him up. We have expressed our concerns to the facility and haven't received a response. During an interview on 3/13/25 at 8:10 a.m., staff member DD stated, Staff fill out an inventory list of resident items when they are admitted , and then the nurse double-checks them. The lists should be scanned into the resident's chart. During an interview on 3/13/25 at 8:17 a.m., staff member H stated the CNAs usually fill out the inventory lists of personal items when a resident was admitted to the…

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

Based on interview and record review, the facility failed to ensure the care plan was accurate for a residents' code status change, for 1 (#7) of 30 sampled residents. Findings include: During an interview on 3/12/25 at 12:05 p.m., staff member I stated care plan updates were done by the department affected, and in the morning standup meeting someone would be assigned if a care plan update was needed. Review of resident #7's care plan focus of code status initiated on 2/14/25, and updated on 2/18/25, showed she was a full code per her POLST in her referral packet. Interventions included requesting copies of advance directives on admission and reviewing with the resident and responsible party on admission and at least quarterly. Review of resident #7's most recent POLST, signed by the provider on 2/17/25, showed the election of DNR.

Based on observation, interview, and record review, the facility staff failed to provide regular showers for 2 (#s 28 and 30) of 30 sampled residents, which made the residents feel dirty and/or upset. Findings include: 1. During an observation and interview on 3/10/25 at 2:57 p.m., resident #28's hair was oily and stringy. Resident #28 stated, Baths have not been consistent since I've been here. I have been here around seven months. Resident #28 stated, I prefer baths, but when they aren't available, I do my own little baths. The worst is my oily hair, and those dry shampoo rinses just don't do it for me. Review of resident #28's electronic medical record showed resident #28 had two baths in a 30-day look-back period. Review of resident #28's care plan, with a revision date of 2/17/25, showed, Interventions: BATHING/SHOWERING: [Resident name] requires set-up for showers/bathing. 2. During an observation and interview on 3/10/25 at 2:32 p.m., resident #30 was sitting on her bed, and her hair was oily and matted down. Resident #30 stated, We don't get baths on a regular basis. I'm 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 observation, interview, and record review, staff member N failed to follow provider orders for the administration of medications via gastrostomy tube (GT) and check for placement of the GT prior to administration of medications for 1 (#2) of 1 sampled enteral tube feeding observation. Findings include: During an observation on 3/11/25 at 8:15 a.m., staff member N had placed into a medication cup the following medications and liquids: - ferrous sulfate 325 mg, crushed, - oxybutynin chloride 5 mg, crushed, - ursodiol 300 mg capsule, contents of capsule emptied into medication cup, - methenamine hippurate 1 gm tablet, crushed, - metoclopramide HCL oral solution (liquid) 5 mg/5 ml, and - 10 ml of water. During an observation on 3/11/25 at 8:18 a.m., staff member N placed a medication cup, with all medications, a new enteral syringe, and an empty graduated measuring container on resident #2's bedside table. Staff member N filled the graduated measuring container with an unmeasured amount of tap water, in resident #2's bathroom, then placed the water filled container onto 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 administer seven medications per prescriber's orders for 2 (#s 2 and 58) residents, out of 35 sampled resident medication orders, which led to a 20% medication error rate. Findings include: During and observation and interview on 3/12/25 at 2:11 p.m., staff member Z administered midodrine 2.5 mg to resident #58. The MAR for resident #58 showed midodrine 2.5 mg with meals. Staff member Z stated she did not know if resident #58 had eaten his lunch already. Staff member Z stated, The nurses have told me it is okay for him to take the midodrine without eating. During review of facility's policy, Medication Administration, dated 2024, showed, Medications are administered . as ordered by the physician . 10. Ensure that the six rights of medication administration are followed: .e. Right time . During an observation on 3/11/25 at 8:18 a.m., staff member N administered the following medications and liquid to resident #2 via PEG tube: - ferrous sulfate 325 mg, crushed, - oxybutynin chloride 5 mg, crushed, - ursodiol…

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 staff member X administered insulin in a safe manner resulting in a significant medication error, which put the resident's health and safety at risk and requiring immediate transfer to an emergency room for 1 (#6) resident of 30 sampled residents. Findings include: During an interview on 3/10/25 at 2:50 p.m., resident #6 stated she went to the hospital overnight because the nurse made a mistake and gave her another resident's insulin on top of her own insulin. During a telephone interview on 3/12/25 at 8:40 a.m., staff member X stated he had an issue giving insulin 3 weeks ago. Staff member X stated he was distracted doing different things and brought two pre-filled insulin pens into resident #6's room. Staff member X stated one pen was filled with 18 units of long-acting insulin meant for resident #6, and the other pen was filled with 42 units of fast-acting insulin meant for resident #6's roommate. Staff member X stated he gave both doses to resident #6, then realized his error and spoke with staff member Y before…

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

Based on interview and record review, the facility failed to ensure the Facility Assessment was reviewed and updated as necessary when a new pulmonary program was planned and initiated. This deficient practice increased the risk of any resident needing pulmonary care and services to have a negative outcome, which did occur, and cited in other deficient practice areas. Findings include: Review of the Facility Assessment, dated 1/7/25, failed to show any information related to Respiratory Care and Services or the addition of a Pulmonary Program. The assessment did not include: - The type of care, services, or contracted services provided to the resident in the area of Respiratory Therapy Services and a Pulmonary Program. - Changes in staffing as a result of adding Pulmonary Program. - Equipment needed for residents who participated in the Pulmonary Program. - No staff training or competencies addressing the Pulmonary Program. - The medical supplies section did not address CPAP, BIPAP, or any emergency respiratory supplies, such as Ambu bags. During an interview on 1/15/25 at 2:10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was an affective training program for new staff, existing staff, staff providing contracted services; failed to ensure staff received training during orientation, and ongoing through employment, related to supply locations, supply ordering procedures, the crash cart, and CPR certification for 6 (staff members D, E, H, Q, M, and one anonymous staff member) of 26 staff sampled. This deficient practice increased the risk of any resident having a negative outcome related to the lack of training. Findings include: During an interview on [DATE] at 1:09 p.m., staff member D stated she was contracted staff employee. Staff member D stated she had not been educated to where extra supplies were kept or how to get supplies ordered. Staff member D stated, I was told that if supplies were needed to write it down. I was not shown where supplies were kept or where the order page was when I started here. During an interview on [DATE] at 7:08 p.m., 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 new staff, existing staff, and contracted staff were trained on the facility's infection prevention and control program standards, policies, and procedures. This deficient practice increased the risk of a negative outcome for all residents in the facility. Findings include: During an interview on 1/22/25 at 8:58 a.m., staff member P stated she had just started working at the facility. Staff member P stated she was not provided any education on infection prevention or hand hygiene policies and procedures, and she was just doing what I know. Staff member P stated she was not aware of who the Infection Preventionist was. During an interview on 1/22/25 at 12:20 p.m., staff member D stated she was contracted staff and had been working in the facility for over one month, and she had not been provided any education on infection prevention or hand hygiene policies and procedures. Staff member D stated she was not aware who the Infection Preventionist was. During an interview on 1/22/25 at 12:25 p.m., staff member U 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 adhere to accepted standards of practice by administering medications and not following physician's medication orders for 3 (#s 18, 23, and 24) of 26 sampled residents, when standards of practice and physician's orders dictated the medication should not have been administered. Findings include: a. Review of resident #18's physician's orders dated 1/1/25, showed: Midodrine HCL oral tablet 2.5 Mg Give 2.5 mg by mouth three times a day hold if systolic >120, diastolic >60 related to ORTHOSTATIC HYPERTENSION. Notify provider for held medications. [sic] A review of resident #18's medication administration record, dated January 2025, showed: Midodrine HCL 2.5 mg was administered 20 times while blood pressure measurements were outside of ordered parameters. During an interview on 1/22/25 at 12:50 p.m., staff member Y stated vital signs should be done before administering a medication with ordered parameters. Staff member Y said, You never give a medication with parameters if the vital signs are not recent, and you follow the…

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

Based on interview and record review, the facility failed to properly administer medications with physician-ordered parameters for 3 (#s 18, 23, and 24) of 26 sampled residents. This deficient practice increased the risk of a negative outcome as failing to follow the physician's order could cause an increase or decrease in a resident's blood pressure. Findings include: 1.Review of resident #18's physician's orders dated 1/1/25, showed: Midodrine HCL oral tablet 2.5 Mg Give 2.5 mg by mouth three times a-day for hold if systolic >120, diastolic >60 related to ORTHOSTATIC HYPERTENSION. Notify provider for held medications. [sic] A review of resident #18's medication administration record, dated January 2025, showed Midodrine HCL 2.5 mg was given 20 times, on the following dates, while blood pressure measurements were outside of ordered parameters. - 1/1/25 at 6:00 a.m., with a blood pressure of 121/80, and 2:00 p.m., with a blood pressure of 142/67, - 1/2/25 at 6:00 a.m., with a blood pressure of 127/71, and at 2:00 p.m., with a blood pressure of 140/63, - 1/3/25 at 2:00 p.m., 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 observation, interview, and record review, the facility staff failed to adhere to standards of infection prevention and control practices, and hand hygiene, for 5 (#s 16, 17, 18, 19, and 20), and for enhanced barrier precautions, for 1 (#25) of 26 sampled residents. This deficient practice had the ability to negatively affect all residents in the facility by increasing the risk for spreading infection. Findings include: During an observation on 1/22/25 at 8:42 a.m., staff member P was walking down the hallway heading back to the medication cart. Staff member P was carrying a clear plastic medication cup, and a small plastic cup of water. Staff member P set the two cups onto the medication cart and started touching the computer located on top of the medication cart. Staff member P locked the medication cart, picked up the two plastic cups, walked into resident #16's room, and administered the medications to resident #16. No hand hygiene was performed prior to entering or exiting resident #16's room, and the staff member touched unclean surfaces prior to entering the 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 proper indwelling Foley catheter care daily to 2 (#s 21 and 26) of 26 sampled residents. This deficient practice caused resident discomfort and had the potential for an increased risk of catheter associated urinary tract infections. Findings include: During an observation and interview on 1/22/25 at 8:10 a.m., resident #26 was sitting in a wheelchair with a Foley catheter drain bag attached to the wheelchair. Resident #26 went down to his room and continued to sit in the wheelchair for the observation. Resident #26 had an indwelling Foley catheter. A foul urine odor was present. Resident #26's penile meatus was red, and there was a crusty solid like material on the Foley catheter, near the penile opening. Resident #26 pointed to the catheter and stated it hurt. During an observation and interview on 1/22/25 at 10:20 a.m., resident #21 way lying in bed, dressed in a hospital gown. Resident #21 stated staff were pretty good about doing his cares, but staff would get busy and forget at times. 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 failed: to ensure a staff member's job duties were current and accurate; to ensure a staff member was practicing within their scope of practice/job description shown in a social services note in 1 (#12)'s chart; and to follow up for 1 (#15) and attempt to prevent or improve for the 21 AMA discharges in the facility from January 2024 to current; and to provide behavioral health services for 1 (#4) of 15 sampled residents. Findings include: 1. Review of resident #12's EHR showed a social service's note written by staff member F, dated 11/20/24: .has agreed to stay till this coming Wednesday, Dr. has been alerted and consulted. [Staff Name] and [Staff Name] will act as the primary nursing with [Staff Name] to dispense meds . is aware and has agreed to this plan of care for him. During an interview on 11/20/24 at 3:30 p.m., staff member F stated they were not able to hire nor fire staff, orient new staff, or provide leadership training. Review of staff member F's job duties, showed: . Terminate employees when necessary, documenting and…

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

Based on interview and record review, the facility failed to professionally, properly, and sufficiently document the situation regarding AMA discharges for 2 (#s 4 and 12); provide proper notice before discharge for 2 (#s 4 and 12); and report the AMA discharge to the appropriate entities for 1 (#4) of 15 sampled residents. This deficient practice resulted in 3 residents (#s 3, 4, 12) not trusting staff member F, and 2 (#s 4 and 12) residents requesting to leave AMA from the facility. Findings include: Review of a facility provided document, titled Admission/Discharge To/From Report, dated 11/18/24, showed: 21 discharges (January 2024 to current). 1. A summary of resident #4's AMA situation showed no nursing documentation was completed, no statement, wishes, preferences, or requests were included in the documentation of resident #4, and APS was not contacted. Review of resident #4's EHR showed a note, dated 9/18/24 at 3:10 p.m.: [staff member G] and [staff member F] spoke with [resident #4] at 3pm (3:00 p.m.). [Staff member F] spoke with (resident representative) earlier this…

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 complete Quarterly MDS (Minimum Data Set) Assessments for 4 (#s 2, 4, 6, and 7), failed to complete an Annual MDS Assessment for 1 (# 5), and failed to complete a Discharge MDS for 1 (#4) of 15 sampled residents. Findings include: During an interview on 11/19/24 at 2:24 p.m., staff members H and I stated they were the MDS coordinators. Staff member H stated she started working as an MDS coordinator in June 2024 and staff member I stated she started working as an MDS coordinator in September 2024. Staff member H stated they were currently behind on completing MDS's. Staff member I stated, We are playing catch up. Staff members H and I stated they follow the guidelines in the RAI (Resident Assessment Instrument) manual. Staff members H and I stated they were not sure how many days they had to complete an MDS. 1. Review of resident #2's Quarterly MDS, with an ARD (Assessment Reference Date) of 9/22/24, was not completed. The Quarterly MDS was 44 days overdue. Review of resident #4's Quarterly MDS, with an ARD of 9/10/24, 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 submit MDS information within 14 days of completion for 5 (#s 2, 4, 5, 6, and 7) of 15 sampled residents. Findings include: During an interview on 9/19/24 at 3:34 p.m., staff member J stated she was aware the MDS assessments were late. Staff member J stated the two MDS coordinators were new to the MDS process and had no prior MDS experience. During an interview on 9/20/24 at 9:45 a.m., staff member A stated she was aware the MDS assessments were late. Staff member A stated there had not been consistent oversight in the building, but it was her responsibility to make sure things were done and accurate. Review of resident #2's Quarterly MDS, with an ARD (Assessment Reference Date) of 9/22/24, was not completed. The Quarterly MDS was 44 days overdue. Review of resident #4's Quarterly MDS, with an ARD of 9/10/24, was not completed. The Quarterly MDS was 56 days overdue. Review of resident #6's Quarterly MDS, with an ARD of 9/5/24, was not completed. The Quarterly MDS was 61 days overdue. Review of resident #7's Quarterly 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 quality assurance and performance improvement committee failed to identify and act on concerns for why a high number of residents discharged against medical advice during the last year, which included 1 (#15), and there was a total of 21 residents who discharged AMA during this time period. All 21 residents were at risk for a negative outcome due to each one leaving without a physician's discharge approval or a completed plan of care. Findings include: During an interview on 11/20/24 at 12:42 p.m., resident #15 stated they had a bad feeling about [Facility Name]. Resident #15 proceeded to provide examples of the stay at the facility, which was for less than 24 hours, and then the resident left AMA. Resident #15 stated feeling unsafe, stated staff were rude, the resident felt like a burden when the nurse scoffed at the resident for asking what pills the resident was encouraged to take, and felt the food was horrible. Resident #15 stated expressing concerns when leaving the [Facility Name], but resident #15 stated no one had ever…

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 smoking at a minimum of 25 feet away from the facility doors for 1 (#14); to ensure residents with a low BIMS score were not independently smoking for 2 (#s 6 and 13); and ensure all smoking materials were stored in the appropriate place for 1 (#5) of 15 sampled residents. Findings include: During an interview on 11/19/24 at 10:55 a.m., staff member C stated smoking assessments were completed upon admission and as needed if there was a change in condition. Staff member C stated the smoking supplies were locked up and only nurses and the social services department had the keys. During an interview on 11/20/24 at 10:16 a.m., staff member O stated residents were allowed to smoke in a designated smoking area, located outside the door, from the activities room. During an interview on 11/20/24 at 10:26 a.m., resident #5 showed personal tobacco, which was located in the resident's room, and the resident would smoke the tobacco. During an observation on 11/20/24 at 10:46 a.m., resident #14 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 ensure the residents or resident representatives understood the risks and benefits of psychotropic medication for 2 (#s 6 and 9) of 15 sampled residents. Findings include: During an observation and interview on 11/18/24 at 4:33 p.m., resident #6 was sitting in his room. Resident #6 stated, I know I take a lot of medications, and some are for my mood, but I don't know the names of them. Resident #6 stated he did not know the side effects or any benefits of any of the medications he took. Resident #6 stated, Nobody has ever come and given me any information on my medications. During an observation and interview on 11/19/24 at 10:15 a.m., resident #9 was sitting in an electric wheelchair. Resident #9 stated she was her own person and handles all her medical and financial decisions and she does not have a power of attorney. Resident #9 stated, I take medications for anxiety and depression, but I have no idea what the side effects are. No one has ever come in and talked to me about any of my medications or what…

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 MDS assessments were coded correctly for resident diagnoses and psychotropic medications used, for 2 (#s 9 and 10) of 15 sampled residents. Findings include: 1. A review of a physician's progress note, dated 8/6/24, showed resident #9 had a diagnosis of Anxiety and Depression. Review of resident #9's Quarterly MDS, with an ARD of 8/18/24, showed: Section I, Active Diagnosis, Psychiatric/Mood Disorders- questions I5700 anxiety, I5800 depression, were not completed. Section N, Medications- N0415. High-Risk Drug Classes, showed antipsychotic, antianxiety, and antidepressant medication was taken during the look back period. N0450. Antipsychotic Medication Review, was not completed. The area was left blank and did not show antipsychotic medication had been given. 2. Review of resident #10's MDS, with an ARD of 8/24/24, showed: Section I, Active Diagnosis, Psychiatric/Mood Disorders, was not completed. No psychiatric or mood diagnosis was marked. Section N, Medications- N0415. High-Risk Drug Classes, showed antipsychotic…

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 an appropriate discharge plan consisting of sufficient and thorough documentation throughout the discharge planning process for 1 (#12) of 15 sampled residents. Findings include: During an interview on 11/20/24 at 10:42 a.m., staff member C stated, I keep getting told by (social services), that we have a plan for that person (to discharge), and they are not going through with it. Staff member C stated resident #12 was supposed to be discharged today (November 20th). Staff member C stated, I feel like he was kind of pressured. During an interview on 11/20/24 at 1:24 p.m., NF5 stated, From what I understood, he (resident #12) was getting discharged . NF5 stated, They (the facility) never talked about why he was appropriate for discharge (due to medical aquity). NF5 stated he then wanted to leave because he was upset. NF5 stated, I was confused too. NF5 stated, Yesterday was the first day I had talked to anyone about his discharge and about his condition. I did not get to talk to them as long as I had hoped. NF5…

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 any DSM diagnoses on the Resident Matrix; or consistently document behaviors and offer behavioral health services to residents with a DSM diagnosis, for 1 (#4) of 15 sampled residents. Findings include: Review of a facility document, titled Resident Matrix, dated 11/18/24, showed no residents residing in the facility had a mental disability, intellectual disability, or required a PASARR Level 2. Review of resident #4's EHR showed a diagnosis of anxiety disorder and major depressive disorder. Review of resident #4's EHR showed the last psychological evaluation was 3/3/21. Review of resident #4's EHR showed an assessment, titled Social Services - Trauma Informed Care Evaluation, dated 6/10/24, which included: . 1. Repeated, disturbing memories, thoughts, or images of a stressful experience from the past? . A little bit . . 4. Feeling irritable or having angry outbursts? . Moderately . During an interview on 11/19/24 at 7:58 a.m., NF1 stated no behavioral health services were offered to resident #4 while the 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 failed to provide evidence of a thorough investigation for allegations of abuse for 5 (#s 1, 2, 4, 7, and 10) of 7 sampled residents for abuse. This deficient practice had the potential to allow residents to be exposed to further abuse. Findings include: 1. Review of a facility reported incident for resident #7, dated 6/2/24, showed an unidentified CNA reported an allegation of abuse occurred at breakfast with another unidentified CNA forcing a resident to drink water. Review of a written statement by a facility CNA, showed resident #7 was not done eating, and another CNA came to take her to her room. The reporting CNA witnessed resident #7 being forced to drink fluids by the CNA coming to get resident #7. Review of an Adult Protective Service Investigation Report, resident showed #7 was unable to drink fluids herself, nor voice any concerns for hydration. No abuse was substantiated by Adult Protective Services. Review of a facility document, Abuse Allegations, not dated, showed the investigation was conducted, residents and 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 interview and record review, the facility failed to report allegations of abuse within 24 hours of the incident for 2 (#s 1 and 4) of 7 sampled residents for abuse. This deficient practice had the potential to delay investigation activities to identify the presence of abuse. Findings include: 1. Review of a facility reported incident for resident #1, dated 6/8/24, showed resident #1 complained of being verbally assaulted by a nurse when he asked her to turn down her music. The nurse was playing music on a personal device while dispensing medication. The incident was witnessed by other staff members. The incident was reported to the State Survey Agency on 6/10/24. 2. Review of a facility reported incident for resident #4, dated 9/1/24, showed resident #4 was involved in a verbal altercation with a staff member D. The police were called to the facility. The incident was reported to the State Survey Agency on 9/4/24. During an interview on 10/23/24 at 3:42 p.m., staff member B said she expected to be notified immediately when any allegations of abuse was suspected or reported.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide ordered medications for 8 (#s 1, 3, 5, 10, 11, 12, 14, and 16) of 16 sampled residents, which resulted in significant discomfort for at least 1 (#5) resident. Findings include: During an interview on 5/8/24 at 11:58 a.m., staff member C stated, The meds are still not getting here. A resident left AMA [against medical advice] because she was not getting medications or receiving treatment. During an interview on 5/8/24 at 12:40 p.m., staff member D stated, Residents have complained about not getting medications. Sometimes it is days before they [their medications] get here. 1. Review of resident #1's EMR nursing note showed he was admitted to the facility on [DATE] with medication orders received by the facility at 12:50 p.m. on that day. 1. a. The following medications were not available to resident #1 on 4/26/24, at 9:00 p.m. when they were scheduled to be given: -Gabapentin 300mg, at bedtime for sleep, -Doxycycline Hyclate 100mg, twice a day…

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 a certified director of food and nutrition services in the absence of a full-time qualified dietician. This deficient practice had the potential to affect all residents. Findings include: During an interview on 3/11/24 at 1:47 p.m., staff member F stated she had been employed with the nursing facility sometime at the end of March or beginning of April of 2023. During an interview on 3/14/24 at 7:47 a.m., staff member N stated her hours were split between two nursing facilities. Staff member N stated her hours fluctuated from week to week between the two buildings. Staff member N stated .if I had to guess, I work 25-30 hours (per week) here (this facility). During an interview on 3/14/24 at 8:01 a.m., staff member F stated her prior certification was expired. Staff member F stated she had no current certification in dietary or food service management. During an interview on 3/14/24 at 8:39 a.m., staff member F stated she had no college degree in food service management or hospitality. Staff member F stated she had 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 observation, interview, and record review, the facility failed to post signs to alert family members and visitors of a COVID-19 outbreak; failed to properly wear PPE throughout the facility; failed to wear appropriate PPE in a room with droplet precautions for a COVID-19 outbreak; failed to maintain isolation for 1 (#72) of 42 sampled residents; failed to implement preventative measures for monitoring and prevention of Legionella in the facility's water supply; and failed to analyze surveillance data to address patterns/trends of infections. These deficient practices had the potential to affect all residents in the facility. Findings include: 1. During an observation on 3/11/24 at 1:40 p.m., there was no alert signage on the entry doors showing the facility was experiencing a COVID-19 outbreak. During an observation on 3/11/24 at 3:20 p.m., there was no alert signage on the entry doors showing the facility was experiencing a COVID-19 outbreak. There was a box of isolation masks at the front counter. During an interview on 3/12/24 at 12:01 p.m., staff member A stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain comfortable and safe temperatures in resident rooms for 7 (#s 3, 9, 39, 44, 55, 57, and 180) of 42 residents sampled. Findings include: During an observation and interview on 3/11/24 at 4:05 p.m., resident #39's room felt cool upon entering the room. Resident #39 was sitting on the bed, with a space heater next to the bed, and it was turned on. Resident #39 stated she was cold. Resident #39 stated she did not recall room changes being offered when her room was cold. During an observation and interview on 3/11/24 at 4:16 p.m., resident #57's room felt cold. Resident #57 was sitting in his recliner, he was covered with a blanket, and was shivering. Resident #57 stated he was cold. Resident #57 stated he was not offered a room change when the heating system broke at the facility. During an observation and interview on 3/11/24 at 4:24 p.m., resident #9 was lying in her bed, covered in several blankets, which were pulled up to her…

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 or arrange for respiratory care, according to standards of quality, for 1 (#49), resulting in resident #49 feeling distressed; and failed to change oxygen tubing and respiratory supplies for 8 (#s 9, 16, 18, 20, 41, 45, 57, and 179), increasing the risk of respiratory infections, of 9 sampled residents with respiratory care needs. Findings include: 1. Review of resident #49's admission orders, dated 1/22/24 showed, .These are your current medications to keep taking at home .(DME) PaP . Review of resident #49's care plan, dated 1/29/24, showed, .[Resident #49] has a CPAP r/t dx of sleep apnea .Encourage [Resident #49] to wear CPAP nightly . Review of resident #49's hospital discharge orders, dated 1/22/24, showed, .Continued: (DME) PaP Device, See Rx instructions . Review of resident #49's physician orders showed the first order for a CPAP machine was entered on 2/22/24, one month after admission. During an observation and interview on 3/11/24 at 3:47 p.m., resident #49 appeared distressed, and there…

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 promote and implement a facility-wide system to monitor the use of antibiotics to improve resident outcomes. This deficient practice had the potential to affect residents taking antibiotics. Findings include: During an interview on 3/13/24 at 12:59 p.m., staff member M reviewed the antibiotic stewardship tracking book with the surveyor and stated, UTI's just haven't been properly handled. There are glaring signs of issues so this will be a great opportunity to get on track . Staff member M stated the facility used McGeer's criteria for antibiotic stewardship. Staff member M stated the nurses on the units should be filling out the surveillance data collection form, before they contact the physician, with the resident symptoms. Staff member M stated the current process in the facility consisted of nurses contacting the physician, without the form completed, and the Director of Nursing or Infection Preventionist would complete the form later when reviewing infection control duties. Staff member M stated many were not reviewed…

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 residents non-disposable cutlery during meals for 3 (#s 10, 13, and 27) of 42 sampled residents. The residents voiced this made them sad or embarrassed, and #27 felt having to use plastic utensils was an insult. Findings include: During an interview on 3/11/24 at 3:57 p.m., resident #s 10 and 13 stated they often received plastic cutlery during their meals and it made them feel sad. The residents stated it was rare that they received real plates, and they often received Styrofoam plates to use. The residents stated they had to use plastic cutlery because the facility's dishwasher was broken. During an observation and interview on 3/12/24 at 1:05 p.m., resident #s 10 and 13 were eating lunch in their room, consisting of soup, a sandwich, and chopped fruit. Both residents were using plastic cutlery. Resident #13 stated using the plastic spoon made it hard to eat the soup, and she would have preferred a real (metal) spoon. During an observation and interview on 3/13/24 at 9:16 a.m., resident #s 10 and 13…

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 written grievances received had a full investigation, to include decisions/resolutions decided upon and documented, and residents notified of the resolution, for 2 (#s 31 and 227) of 42 sampled residents. Findings include: 1. A review of the facility's Grievance Concern Form, dated 11/20/23, reflected staff member Q found resident #31, .in bed with a wet bed liner, wet pants, & t-shirt (urine soaked). Brief found to be wet and heavy upon its removal (>2lb. weight). The report reflected the findings of the review included, Staff education on residents being wet and being changed timely. The grievance documentation lacked evidence failed to show the facility considered, nor investigated, the lack of ADL assistance as potential neglect of care. During an interview on 3/14/24 at 8:09 a.m., staff member Q stated resident #31 was soaked with urine at the time she arrived to complete therapy with him, when he was in his room at 1:50 p.m. on 11/20/23. Staff member Q stated resident #31 required one to two person assist with…

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 accurately code clopidogrel as an antiplatelet in the MDS assessment for 1 (#50 ) of 42 sampled residents. Findings include: A review of resident #50's Quarterly MDS, with an ARD of 2/18/24, showed, resident #50 was administered seven days of an anticoagulant. The MDS did not show resident #50 was taking an antiplatelet. A review of resident #50's physicians order, dated 5/11/23, showed, Clopidogrel 75 milligrams by mouth daily. During an interview on 3/14/24 at 8:13 a.m., staff Member M stated, Clopidogrel was an antiplatelet and should not be coded as an anticoagulant. A review of the Resident Assessment Instrument, dated October 2023, showed: .N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at anytime during the 7-day observation period (or since admission/entry or reentry if less than 7 days).

Based on interview and record review, the facility failed to enter physician orders, in the resident's EMR, received upon admission, for 1 (#49) of 1 sampled residents. This deficient practice resulted in the resident not receiving prescribed respiratory treatments. Findings include: Review of resident #49's admission orders, dated 1/22/24 showed, .These are your current medications to keep taking at home .(DME) PaP . Review of resident #49's care plan, dated 1/29/24, showed, .[Resident #49] has a CPAP r/t dx of sleep apnea .Encourage [Resident #49] to wear CPAP nightly . This information on the CPAP was not reflected in the physician orders in the resident's electronic medical record. Review of resident #49's physician orders showed the first order for a CPAP machine was entered on 2/22/24, almost one month later. Review of resident #49's physician orders showed the first order for a noninvasive ventilator was entered into the resident's EMR on 3/12/24 at 9:00 p.m. During an interview on 3/13/24 at 11:31 a.m., staff member I stated, Usually which ever nurse was working on that hall…

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

Based on interview and record review, the facility failed to implement a GDR for 1 (#50) of 42 sampled residents. Findings include: Review of resident #50's Note to Attending Physician/Prescriber, for 1/25/24 - 2/26/24, showed, Psychotropic medications due for potential GDR review: Fluoxetine 40 mg daily for depression. Recommendation: Please consider a gradual dose reduction, or update this letter with a risk versus benefit analysis if a reduction is clinically contraindicated. A new order to decrease the Fluoxetine to 30 mg QD, dated on 3/5/24, was written on the Note to Attending Physician/Prescriber. Review of resident #50's MAR, dated March 2024, showed resident #50 was currently taking Fluoxetine 40 mg daily. During an interview on 3/13/24 at 10:30 a.m., staff member B stated after the provider reviewed and responded to any GDR recommendations given by the pharmacist, the GDR document went to the Director of Nursing for orders to be entered into the EMR if necessary. Staff member B stated she had been interim DON for three weeks, however, did not see the provider order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect residents from misappropriation of their narcotic pain medications for 8 (#s 1, 2, 3, 4 , 5, 6, 7, and 8) of 8 sampled residents causing unnecessary pain for residents #s 2 and 4, and the potential for unnecessary pain for residents #s 1, 3, 5, 6, 7, and 8, and including any other resident who had physician ordered narcotic pain medications during staff member C's shifts. This deficiency had the potential to cause the residents to be charged for medications they did not receive. The facility also failed to protect additional residents from being affected by not removing the nurse from her duties and handling medications after the suspicion of drug diversion was reported. Findings include: Review of facility documents titled Individual Narcotic Logs and Medication Administration Records for residents #s 1, 2, 3, 4, 5, 6, 7, and 8, showed: - Resident #1's Individual Narcotic Log for Oxycodone 10 mg tablets, showed staff member C removed one…

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 licensed nurse failed to provide adequate pain relief for 2 (#s 2 and 4) of 8 sampled residents, who had pain medications misappropriated. Findings include: Review of resident #2's Individual Narcotic Log, for the physician ordered Norco 5-325 mg tablets, showed a staff member removed one tablet on 7/14/23 at 6:50 p.m., 7/15/23 at 12:20 a.m., and 6:00 a.m. Resident #2's MAR failed to show those medications were administered to the resident. Resident #4's Individual Narcotic Log for Norco 10/325 mg tablets, showed staff member C removed: - One tablet on 7/14/23 at 7:00 p.m., and 11:00 p.m., - 7/15/23 at 5:00 a.m., - 7/21/23 at 10:00 p.m., - 7/22/23 at 12:10 a.m., and 5:30 a.m., - 7/26/23 at 6:40 p.m., and 10:30 p.m., - 7/27/23 at 2:15 a.m., 5:30 a.m., and 9:30 p.m.; and, - 7/28/23 at 12:05 a.m., and 4:50 a.m. Resident #4's MAR failed to show those medications were given to the resident. Review of resident #2's Pain Assessment for the month of July 2023 showed, she rated her pain an 8 out of 10 on 7/12/23 and 7/13/23. The pain…

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.