Tsali Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to treat two (2) residents (Resident #6 and #23) in a dignified manner to promote the residents' quality of care and quality of life in a sample size of 23 residents who were reviewed for resident rights. The findings include: 1.Resident #6 was admitted on [DATE] with diagnoses that included vascular dementia, type 2 diabetes, and major depressive disorder. Resident #6’s quarterly Minimum Data Set (MDS) dated [DATE] revealed that he was cognitively impaired, dependent on activities for daily living (ADLs) and required a two person assist Hoyer lift transfer. In a telephone interview with the resident representative for Resident #6 on 07/29/25 at 11:12 AM, she stated she filed a complaint/grievance with Social Worker (SW) #3 regarding an incident that occurred with her uncle while she visited the facility sometime in June. She recounted that, on this day, she requested that the Certified Nurse Aide (CNA) staff put her uncle in his chair so…

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, record review and review of the facility's policy titled (Facility Name) Administrative-Residents Rights for Senior Service, the facility failed to ensure Resident #4 was provided appropriate durable medical equipment (DME) that allowed the use of the bathroom for one (1) of twenty-three (23) sampled residents.The findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses that included obesity, acute respiratory failure, unspecified psychosis, manic episode, and type 2 diabetes.Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed that he was cognitively intact, dependent for activities for daily living (ADLs) and required a one person assist for transfers.During an observation and interview on 07/30/25 at 4:32 PM Resident #4 reported he smashed the pointer finger on his left-hand a couple of months ago while attempting to self-propel his wheelchair (WC) through the threshold of the bathroom to access the sink. He stated, look at the dark marks on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and review of the facility's policy titled Medication Regimen Review, the facility failed to ensure an order for an as needed (PRN) antipsychotic had a stop date and a supporting diagnosis for use for one (1) resident of five (5) sampled for unnecessary medications (Resident #7). The findings include:Resident #7 was admitted to the facility 06/26/25 with diagnoses that included Parkinsonism, type 2 diabetes, insomnia, benign prostatic hyperplasia, and heart failure.Review of the admission Minimum Data Set, dated [DATE] revealed Resident #7 was moderately cognitively impaired; had verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others, and rejected care one (1) to three (3) days during the seven (7) day look back period; did not have any psychiatric or mood disorder diagnoses; and in the past seven (7) days had received antianxiety, antidepressant, and hypnotic medications.Review of the physician's orders revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and a review of the facility's Resident Assessment Instrument policy, facility staff failed to identify and document a skin tear injury on the comprehensive Minimum Data Set (MDS) for one (1) of three (3) residents reviewed for skin integrity (Resident #18). The findings include:Resident #18 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, type 2 diabetes mellitus, vascular dementia without behavior, and encephalopathy.Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #18's skin was intact without notation of skin tears, abrasions, or open wounds/injuries. During an observation and interview on 07/29/25 at 2:41 PM, Resident #18 sat in his room in a recliner chair with both legs elevated engaging with his sister. The skin on his lower legs was dry with dark pin-head size scabs and a two-centimeter redden/open and moist skin tear was visible on his lower left leg/shin.During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the facility's policy titled Pre-admission Screening and Resident Review (PASRR), the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon a new qualifying mental health diagnosis for one (1) out of two (2) residents sampled for PASRR Level II (Resident #4 ). The findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, obesity, and type 2 diabetes.Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed that he was cognitively intact, dependent with activities for daily living (ADLs) and required one person assist for transfers. Review of past MDS revealed a diagnosis of unspecified. psychosis not due to a substance or known physiological condition dated 2/19/2025 and Manic episode, unspecified dated 11/12/24.During an interview on 07/30/25 at 4:20 PM, Resident #4 denied any behavioral health or mental health concern. He reported his mood was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the facility's policy titled Pre-admission Screening and Resident Review (PASRR), the facility failed to ensure the accurate completion of the Level I PASRR and referral for Level II PASRR for a resident with a mental health diagnosis for one (1) out of two (2) residents sampled for PASRR (Resident #5). The findings include:1. Resident #5 was admitted on [DATE] with diagnoses that included delusional disorders, history of left below the knee amputation, peripheral vascular disease, and diabetes.Review of Resident #5's PASRR Level I Assessment, dated 12/05/24, revealed .The individual does not meet the federal definition for mental illness/ mental retardation. No further PASRR screening is required unless a significant change occurs with the individual's status which. suggests a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions.no qualifying mental health diagnosis.Review of Resident #5'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, interviews, and review of the facility's policies Resident Rights for Senior Services, Behavioral Health Services and Trauma-Informed Care, and Care Plans - Nursing Facility, the facility failed to ensure staff developed and/or implemented comprehensive care plans for three (3) of 23 sampled residents reviewed, that included person-centered interventions for behaviors (Resident #7), trauma informed care (Resident #8), and restorative services (Resident #45). The findings include: 1. Resident #7 was admitted to the facility 06/26/25 with diagnoses that included Parkinsonism and insomnia. Review of the admission Minimum Data Set, dated [DATE] revealed Resident #7 was moderately cognitively impaired; had verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others, and rejected care one (1) to three (3) days during the seven (7) day look back period; and required substantial/maximal assistance with personal care and mobility. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, policy review, and review of Up To Date medical reference, the facility: 1. failed to ensure arrangements were made for a dermatology consult in accordance with a physician order for one (1) resident (Resident #27); 2. failed to ensure assessment and treatment for potential insect bites for one (1) resident (Resident #66); and 3. failed to ensure arrangements were made for a speech and language evaluation in accordance with an order for one (1) resident (Resident #21) of 23 sampled residents. The findings include: 1. Resident #27 was admitted to the facility 06/12/25 with diagnoses that included type 2 diabetes, major depressive disorder, anxiety disorder, and adjustment disorder with depressed mood. The resident was cognitively intact. During an interview on 07/28/25 at 5:35 PM, Resident #27 stated she was admitted [DATE] and the only complaint the resident had since being admitted was this itching that won't go away.from head to toe. The resident stated the itching made it…

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, record review, and review of the facility's policy titled Restorative Nursing Care, the facility failed to initiate restorative care nursing services for Activities of Daily Living (ADL) for two (2) residents out six (6) residents sampled for ADL decline and rehabilitation and restorative care (Residents' #3 and #5). The findings include:1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of right hand, adult failure to thrive, and end stage renal disease (ESRD). Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact.During an interview on 07/29/25 at 10:50 AM with Resident #3, she stated that she was not getting any stronger and still weak. She stated she was informed that she would continue with exercises, but the facility staff had done nothing. Review of Resident #3's therapy note dated…

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 record review, interview, and review of the facility policies titled Bathing and Dressing Policy and Activities of Daily Living (ADLs) Policy, the facility failed to ensure showers were provided at least twice a week as scheduled for one (1) resident of three (3) sampled residents for ADLs (Resident #66). The findings include:Resident #66 was admitted to the facility 11/14/24 with diagnoses that included unspecified atrial fibrillation, cerebrovascular disease, and moderate persistent asthma. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #66 was cognitively intact. Resident #66 did not exhibit any mood or behavior symptoms and did not resist or refuse care. The resident required partial/moderate assistance with showering/bathing. During an interview on 07/29/25 at 11:48 AM, Resident #66 stated that she had trouble getting showers twice a week, mostly on nights when there was a male and a female Certified Nurse Aide (CNA) scheduled to work. She stated sometimes the female…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, and review of the facility's Wound Care and Dressing Change-Clinical Protocol policy, facility staff failed to identify, treat, and/or implement appropriate measures to prevent friction-related skin tear/injuries during showering or personal care, in accordance with professional standards of practice for one (1) of three (3) residents reviewed, with fragile skin susceptible to injury (Resident #18).The findings include:1. Resident #18 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, type 2 diabetes mellitus, vascular dementia without behavioral, peripheral vascular disease and glaucoma. During an observation and interview on 07/29/25 at 2:41 PM, Resident #18 sat in his room in a recliner chair with both legs elevated engaging with his sister. The resident's ankles were swollen and the skin on his lower legs were dry with dark pin-head size scabs. There was a two-centimeter redden/open and moist area on his left lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, and review of the facility's Restorative Nursing Care, policy, facility staff failed to provide or re-evaluate appropriate restorative treatment and services to increase, maintain and/or prevent decrease in range of motion (ROM) and/or mobility for one (1) of three (3) residents reviewed for limited ROM and/or mobility (Resident #s 45).The findings include: Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following unspecified cerebrovascular disease affecting the left non-dominate side, morbid obesity, spinal stenosis and chronic respiratory failure. Review of the Comprehensive Minimum Data Set (MDS) dated [DATE] revealed the Resident #45's cognition was moderately impaired. The resident was dependent on staff to assist with activities of daily living (ADLs), for substantial assistance for bed mobility and transfers. During an observation and interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of the facility's policy titled Fall Risk Reduction and Management, the facility staff failed to ensure fall prevention interventions were resident-centered, practicable, consistently implemented, and that adequate supervision was provided to prevent falls for two (2) of two (2) residents reviewed with a history of multiple falls (Residents' #18 and #33). Additionally, staff failed to document its assessment and safety education for the use of smokeless (chewing) tobacco and offer nicotine cessation alternatives for one (1) of one (1) resident who used smokeless tobacco (Resident #71). The findings include: 1. Resident #18 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, type 2 diabetes mellitus, vascular dementia without behavioral, peripheral vascular disease and glaucoma. Review of the comprehensive Minimum Data Assessment (MDS) dated [DATE] revealed Resident #18's cognition was severely impaired. The ambulated…

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, record review, and review of the facility's policy titled Dialysis Services and the Nursing Home Dialysis Transfer Agreement, the facility failed to ensure one (1) of one (1) sampled residents reviewed for dialysis services had coordinated care with the dialysis center to include communication between both facilities regarding the assessment of the resident pre and post dialysis for any changes in condition and/or for any complications and providing updates to the health care provider and dialysis center regarding missed dialysis visits to ensure appropriate interventions were developed and followed (Resident #3) . The findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD) requiring hemodialysis three days per week, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of right hand, and adult failure to thrive. Review of the Medication Administration…

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, record review and review of the facility's policy titled Social Services-Behavioral Health Services and Trauma-Informed Care, the facility failed to assess the needs of a resident with a history of post-traumatic stress disorder (PTSD) for one (1) of twenty-three (23) sampled residents (Resident# 8).The findings include:Resident #8 was admitted to the facility 06/24/24 with diagnoses that included schizoaffective disorder, bipolar type; post-traumatic stress disorder (PTSD); depression and type 2 diabetes.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had mild cognitive impairment and a diagnosis of PTSD; no behaviors during seven-day (7) day look back period and was independent with activities of daily living (ADLS).Review of the medical record revealed, there were no specific assessment that addressed Resident #8's specific needs to related to the PTSD diagnosis to minimize triggers and to prevent re-traumatization of the resident.During observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and a review of the facility's Referrals to Outside Agencies policy, facility staff failed to assess residents' dental care needs and did not assist with coordinating, scheduling, or rescheduling routine or emergency dental evaluations for two (2) of three (3) residents reviewed. This included one resident with a missing upper denture (Resident #45) and another with broken and decayed teeth (Resident #70). The findings include: 1.Resident #70 was admitted to the facility 10/07/24 with diagnoses that included acute osteomyelitis left ankle and foot, heart failure, and Alzheimer's disease, chronic diastolic (congestive) heart failure. Review of the significant change in status Minimum Data Set (MDS) dated [DATE] revealed Resident #70 had moderately impaired cognition, required partial/moderate assistance with eating and substantial/maximal assistance with oral hygiene, had obvious or likely cavities or broken natural teeth, and had not lost weight. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and review of facility documents, the facility failed to ensure one (1) of three (3) residents were provided their visitation rights. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Complete Traumatic Amputation to Left Lower Leg and Type 1 Diabetes Mellitus. He was cognitively intact. During and interview on 3/10/25 at 3:52 PM, Resident #1's wife stated she was not allowed to visit her husband at the facility inside or outside of the facility. She stated she had been visiting her husband several days prior to the interview and was stung or bitten by something in the resident's room. It must have come through the screen of the window we had open. She indicated she had been sitting in the window seat. She stated she began itching and having an allergic reaction to the bite so I told the staff. Resident #1's wife indicated that the facility Administrator, told her at the time of the incident, You must have some type of parasite and need to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of facility documents, and review of the facility policy entitled Transfers and Discharges Policy, the facility failed to ensure one (1) of three (3) residents (Resident #1) was provided a discharge notice giving at least a 30-day notice of discharge and contained the necessary information required in the notice. Resident #1 was given a 48- hour discharge notice. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Complete Traumatic Amputation to Left Lower Leg and Type 1 Diabetes Mellitus. He was cognitively intact. During an interview on 4/8/25 at 9:00 AM, Resident #1 stated on 3/21/25, he was given a 48-hour discharge notice by the Assistant Administrator (AA) with no explanation. He stated later that afternoon, he was provided a 30-day discharge notice, with no explanation other than she had stated to him. He stated he was not provided information on an appeals process in either notices he received. He stated the notices informed…

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, record review, review of facility documents, and review of the facility policy entitled TCC Nursing Services - Care Plans - Nursing Facility Policy, the facility failed to ensure one (1) of three (3) residents (Resident #1) or the resident's representative received notification of care plan meetings. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Complete Traumatic Amputation to Left Lower Leg and Type 1 Diabetes Mellitus. He was cognitively intact. During an interview on 3/10/25 at 3:52 PM, Resident #1's wife stated she had never received a notice of a care plan meeting. She stated she specifically asked to be invited to the care plan meeting on Resident #1's admission to the facility. She stated Resident #1 had not received a notice of a care plan meeting. During an interview on 4/8/25 at 9:00 AM, Resident #1 stated he and not received a notice of a care plan meeting. He stated I finally have a care plan now. They had a meeting…

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 medical record review, interview, and review of the facility's policy titled Wound Care and Dressing Changes - Clinical Protocol Policy, the failed to ensure one (1) of three (3) sampled residents (Resident #6) received wound care daily as ordered by the physician. The findings include: Resident #6 was admitted to the facility 01/08/25 with diagnoses including heart failure, peripheral vascular disease, type 2 diabetes mellitus, and end stage renal disease. Review of the admission Minimum Data Set, dated [DATE] revealed Resident #6 had moderately impaired cognition and had one (1) stage 2 pressure ulcer and two (2) unstageable deep tissue injuries. Review of the Initial Evaluation Note from the facility physician revealed Resident #6 was transferred from a hospital and admitted to the facility for short-term rehab. The resident had a history of triple vessel coronary artery disease and was not a candidate for surgery. The resident was on dialysis for chronic kidney disease stage 5, chronic renal…

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 medical record review, interview, and review of the facility policy titled General Guidelines for Medication Administration Policy, the facility failed to ensure a resident received three (3) doses of an ordered medication that was required to prevent an allergic reaction during a procedure for one (1) resident of 10 residents reviewed (Resident #6). The finding included: Resident #6 was admitted to the facility 01/08/25 with diagnoses that included: heart failure, peripheral vascular disease, type 2 diabetes mellitus, and end stage renal disease. Review of the electronic health record revealed Resident #6 was allergic to iodine, iodine containing products, and Conray (radiopaque contrast dye used in radiographic procedures). The resident had moderate cognitive impairment. Review of a Nurses Note for Resident #6 dated 03/26/25 at 10:22 PM, written by Registered Nurse (RN) #2 revealed, .Received call from [Vascular physician office] regarding an appointment on 3/30/25. Pre op instructions faxed over to writer, emailed to ADON [Assistant Director of Nursing] and to transport.…

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 review of the facility policy entitled Cleaning and Disinfection Policies and Practices Policy, the facility failed to ensure a blood glucose monitor was properly cleaned and disinfected for one (1) of one (1) resident (Resident #2) observed after a blood glucose monitoring. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus. He was moderately cognitively impaired. During an observation and simultaneous interview on 4/8/25 at 8:54 AM, Registered Nurse (RN) #1 was observed exiting room [ROOM NUMBER] and returning to an insulin cart with a glucometer. She wiped the glucometer with an Oxivir TB wipe for five (5) seconds and then immediately placed the glucometer inside the cart into a plastic cup. She stated the proper amount of time to clean and disinfect the glucometer was one (1) minute. She confirmed she had not cleaned and disinfected the glucometer for the full one (1) minute wet/contact time.…

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

Based on observation and test tray evaluation, the facility failed to ensure food and beverages were served at an appetizing temperature for residents who ate breakfast in their rooms and had the potential to affect 55 of 55 residents in the facility. The findings include: Review of an anonymous complaint revealed residents who ate breakfast in their room did not receive hot food. Review of the Resident Council Meeting Minutes from February 2024 through July 2024 revealed the resident council met on a regular basis and the Activity Director documented the meeting minutes and attendance. Concerns regarding food included the following: 07/30/24 - Food trays are still coming out late and cold - will follow up with dietary supervisor. 06/27/24 - Food trays are still coming out late and cold - will follow up with dietary supervisor. Residents are concerned about the food trays coming out late and cold. (Name of Dietary Manager) spoke with residents about staffing issues and why trays are late on the halls. 05/28/24 - Breakfast and lunch trays are late residents say at times. 04/25/24 -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, confidential interviews, staff interview, and review of the Nursing Home Dialysis Transfer Agreement and Nursing Services-Dialysis Services Policy, the facility failed to ensure one (1) of two (2) sampled residents (Resident A) reviewed for dialysis services had coordinated care with the dialysis center and communication between both facilities was established to ensure any changes in condition, complications and/or changes in the plan of care were monitored to ensure appropriate interventions were developed and followed. The findings include: Resident A was admitted to the facility 9/26/24 with diagnoses of End Stage Renal Disease, Hypertension, Anemia, Dementia, Absence of Left Foot, Anxiety and Type II Diabetes. The resident was discharged to an acute care hospital on [DATE]. Resident A was readmitted to the facility on [DATE]. A Minimum Data Set had not been completed. During a confidential interview on 10/11/24 at 1:37 p.m., an anonymous complainant reported Resident A was taken to…

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

Based on interview, review of facility documents, and review of a facility policy entitled TCC Administrative - Advance Beneficiary Notices, Beneficiary Appeal Rights, and Expedited Review Policy, the facility failed to ensure residents were issued a Notice of Medicare Non-Coverage form for 12 of 12 residents (Resident #s 15, 20, 29, 32, 46, 51, 112, 259, 260, 261, 262, 263) who no longer qualified for Medicare part A and had days remaining. The findings include: During an interview on 08/22/24 at 12:41 PM, the [NAME] Specialist stated she started at the facility on 08/05/24. She stated since she began as [NAME] Specialist, she had not sent any NOMNC (Notice of Medicare Non-Coverage) notices. She stated she was not aware it was her responsibility to send out NOMNC notices and had no understanding of the NOMNC and who should have received them. During an interview on 08/22/24 at 01:13 PM, the Administrator stated the [NAME] Specialist was responsible for making sure NOMNC notices were sent out. She stated she was unaware NOMNCs were not being sent. She confirmed the above listed 12…

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 staff interview and review of the Facility Assessment the facility failed to ensure the required parties were involved in developing the Facility Assessment, failed to ensure the staffing plan was provided per unit as required, failed to address resources necessary to grandfather residents who smoke, and did not clearly state staff competencies and required training, which had the potential to affect 56 of 56 residents. The findings include: Review of the Facility Assessment revealed it was revised 4/1/24 and updated 7/25/24. The persons involved in completing the assessment were listed as the Administrator, the Director of Nursing (DON), the Medical Director and a Governing Board Member. There was no indication that direct care staff were involved in completing the assessment or that the facility solicited and considered input from residents, resident representatives and family members. Further review revealed that the staffing plan listed the number of Floor Nurses (Registered Nurse or Licensed Practical Nurse), Medication Aides, Certified Nursing Assistants (CNAs) 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 observations, interview, review of the dish machine operation manual, review of dish machine temperature logs, review of work orders, and review of the facility's policy TCC Dining Services - Warewashing - Dish Machine Policy, the facility failed to ensure the dish machine in the dietary department had a functioning wash temperature gauge which affected 56 of 56 residents in the facility. The findings include: During an observation and interview in the dietary department on 08/21/24 at 9:40 AM, the dish machine had two gauges, one for the wash cycle and one for the rinse cycle. The wash cycle gauge had a minimum required temperature of 150 degrees Fahrenheit (F) stamped under the dial. The kitchen staff ran a rack of dishes through the dish machine and the wash temperature read 146 F on the gauge. The staff ran a second rack of dishes through the washer, and the wash temperature on the gauge read 144 F. The Assistant Dietary Manager (ADM) confirmed the instructions on the machine indicated the wash temperature was to be 150 F minimum and stated the wash temperature never…

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 the resident group interview, review of resident council meeting minutes, and staff interview, the facility failed to ensure grievances voiced in the group meeting were promptly acted upon and responded back to the resident group to address issues regarding cold food for six (6) of nine (9) residents who attended and participated in the group interview. The findings include: Review of the Resident Council Meeting Minutes from February 2024 through July 2024 revealed the resident council met on a regular basis and the Activity Director documented the meeting minutes and attendance. Concerns regarding food included the following: 07/30/24 - Food trays are still coming out late and cold - will follow up with dietary supervisor. 06/27/24 - Food trays are still coming out late and cold - will follow up with dietary supervisor. Residents are concerned about the food trays coming out late and cold. (Name of Dietary Manager) spoke with residents about staffing issues and why trays are late on the halls. 05/28/24 - Breakfast and lunch trays are late residents say at times. 04/25/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide residents an opportunity to formulate advanced directives for four (4) residents of 18 sample residents (Residents #33, #31, #112 and #9). The findings include: 1. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including non-ST elevation (NSTEMI) myocardial infarction (heart attack). Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of the Advance Directive and Code Status Acknowledgement of Receipt form in Resident #33's chart revealed Resident #33 signed the form 05/01/24 and marked I have chosen to formulate and issue Advance Directives. The resident indicated on the document that a Living Will and Do Not Resuscitate had been formulated. The form was signed by the admission Coordinator on 05/01/24. Review of the electronic medical record and the resident's chart revealed there were no copies of a Living Will available. A Do Not Resuscitate 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.

Based on observation, staff interview and review of facility policy the facility failed to ensure the medication error rate was below 5%. There were five (5) medication errors out of 31 opportunities for a medication error rate of 16.13%. The findings include: On 08/19/24 at 4:45 PM Licensed Practical Nurse ((LPN) #3 was observed administering 12 units of LISPRO Insulin to Resident #49 using an insulin pen. LPN #3 did not prime the insulin pen prior to administration. On 08/19/24 at 5:00 PM Registered Nurse (RN) #3 was observed administering 22 units of FIASP Insulin to Resident #4 using an insulin pen. RN #3 did not prime the insulin pen prior to administration. During an interview on 08/19/24 at 5:58 PM LPN #3 confirmed she just dialed up the 12 units of insulin and administered the insulin. She confirmed she did not prime the insulin pen and stated that she was not aware it needed to be primed. During an interview on 08/19/24 at 6:10 PM RN #3 confirmed she dialed up the 22 units of insulin and administered the insulin without priming the insulin pen. She confirmend that she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and review of the facility's Resident Rights, the facility failed to promote dignity by ensuring a resident was dressed for one (1) resident of 19 sample residents (Resident #112). The findings include: Resident #112 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of acute pyelonephritis (kidney infection) and methicillin resistant Staphylococcus aureus (MRSA) infection. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. During an observation and interview on 08/20/24 at 09:45 AM, Resident #112 was in bed with a cover pulled up to his chin. The resident stated he didn't have any clothes on because his clothes had gotten dirty. He stated he had clean shirts in his closet, but staff had not helped him get dressed and he would like to have clothes on. The resident pulled the cover down to show his shoulders and chest were bare. The resident stated all he was wearing was a pull up…

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 medical record review, resident and staff interviews, and facility policy titled, Resident Funds Policy, the facility failed to ensure a quarterly statement was provided to one (1) of three (3) residents reviewed for personal funds (Resident #9). The findings include: Resident #9 was readmitted to the facility on [DATE]. The Minimum Data Set (MDS) completed on 07/16/24 revealed that the resident was cognitively intact. The MDS revealed that Resident #9 was the primary respondent. The resident's face sheet revealed Resident #9 was his own responsible party. The medical record did not reflect that Resident #9 had requested or appointed another representative to receive the personal fund statements, nor an appointed legal financial representative. During an interview on 08/20/24 at 10:34 AM, Resident #9 stated he did not receive a quarterly statement of his monies. During an interview on 08/22/24 at 12:56 PM, [NAME] Specialist #1 stated she had been in her role for two weeks and was still determining…

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

Based on observation and staff interview the facility failed to ensure a worn and soiled mattress was replaced and failed to ensure a soiled slipper pan was cleaned or replaced for one (1) of 22 sampled residents (Resident #14). The findings include: On 08/20/24 at 10:46 AM Resident #14's mattress was observed. There was an approximately 3 foot long by 2 foot wide worn discolored area on her mattress. The mattress was green, but the worn area was grey brown and appeared dirty. There was also a slipper pan in her bathroom that had brown matter residue inside the slipper pan. It was sitting on top of a package of briefs. Photographic evidence obtained. On 08/22/24 at 6:40 PM the Director of Nursing (DON) observed the photos of Resident #14's mattress and slipper pan and stated that the Certified Nursing Assistants should have reported the poor condition of the mattress, and it should have been changed out for a new one. She also stated that the slipper pan should have been discarded and replaced with a new one.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of the facility's procedure entitled Instructions for Residents to Transfer to Hospital, and review of the facility's policy TCC Social Services - Transfers and Discharges Policy, the facility failed to ensure a resident received notification of the reason for transfer to the hospital for one (1) resident of three (3) sample residents (Resident #112). The findings include: Resident #112 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute pyelonephritis (kidney infection) and methicillin resistant Staphylococcus aureus (MRSA) infection. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Review of a Nurses Note dated 07/03/24 at 07:47 PM revealed, CNA [Certified Nurse Aide] staff reported to this nurse resident was not responding appropriately to them. Immediately assessed resident and resident was unable to speak, eyes were not reactive to light, resident unable to grip bilaterally,…

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 record review, interview, and review of the facility's procedure entitled Instructions for Residents to Transfer to Hospital, the facility failed to ensure a resident received notification of the facility's bed hold policy on transfer to the hospital for one (1) resident of three (3) sample residents (Resident #112). The findings include: Resident #112 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute pyelonephritis (kidney infection) and methicillin resistant Staphylococcus aureus (MRSA) infection. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Review of a Nurses Note dated 07/03/24 at 07:47 PM revealed, CNA [Certified Nurse Aide] staff reported to this nurse resident was not responding appropriately to them. Immediately assessed resident and resident was unable to speak, eyes were not reactive to light, resident unable to grip bilaterally, upper extremities flaccid, and respiration was shallow .Notified…

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 staff interview and record review the facility failed to submit a referral for Level 2 PASSAR (Pre-admission Screening and Resident Review) Evaluation for one (1) of one (1) resident (Resident #42) with an expired Level 2 PASSAR who remained in the facility. The findings include: Resident #42 was admitted [DATE] with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms; anxiety disorder; post-traumatic stress disorder; and type 2 diabetes mellites. He was admitted for orthopedic aftercare following surgical amputation. Review of the admission Record revealed Resident #42 was admitted with a PASSAR Level 2 for short term admission which expired [DATE]. The most recent PASSAR Level 2 approval was also for short term admission and expired [DATE]. There was no evidence within the medical record to indicate the facility had submitted a referral for another Level 2 evaluation to extend approval past the [DATE] expiration date. During an interview with the Social Worker on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, observations, and review of the facility policy TCC Nursing Services - Safe Lifting and Moving of Residents Policy, the facility failed to revise the care plan for 1. falls interventions, and 2. after a change in condition for two (2) residents of 19 sample residents (Residents #51 and #112). The findings include: 1. Resident #51 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment, was not ambulatory, required substantial/maximal assistance for transfers, and had a history of falls. Review of a Fall Risk assessment dated [DATE] for Resident #51 revealed a fall risk score of 12, with a score of 10 or greater indicating the resident was a high risk for falls. Review of an Incident Note dated 02/08/2024 at 06:58 PM revealed, The nurse was alerted to the dayroom by a CNA [Certified Nurse Aide].…

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 record review, interview, observations, and review of staff training, the facility failed to ensure Certified Nurse Aides were competent to report changes in condition to the nurse for one (1) resident of 19 sample residents (Resident #112). The findings include: Resident #112 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute pyelonephritis (kidney infection) and methicillin resistant Staphylococcus aureus (MRSA) infection. Review of the significant change MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Functional ability for sit to stand, chair/bed-to-chair transfer, and toilet transfer was not assessed due to the resident's medical condition or safety concerns. Resident #122 was dependent for tub/shower transfer. Review of Resident #112's care plan last revised 07/22/24 revealed the resident required assistance of one (1) person for transfers. During an observation and interview on 08/20/24 at 09:45 AM, Resident #112 stated that…

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

Based on staff and Medical Director interview, record review, and review of facility policy the facility failed to 1) ensure medication was available as ordered for two (2) of five (5) residents (Resident #s 14 and 9) reviewed for unnecessary medications and failed to 2) ensure a staff member followed facility policy to sign off the controlled count sheet immediately after dispensing a controlled medication for one (1) of two (2) staff observed dispensing controlled medication. The findings include: 1) Review of the August 2024 Medication Administration Record for Resident #14 revealed the resident's Duloxetine DR 20 mg (milligram) capsules twice daily for anxiety was documented as not given due to waiting on pharmacy, three (3) evenings in a row on August 13th, 14th and 15th. Review of the August 2024 Medication Administration Record for Resident #9 revealed the resident's Xifaxan 550 mg 1 tablet twice daily for liver disease was documented as not given due to meds not available from pharmacy, or waiting on pharmacy, or on order on 5 evenings August 1st, 2nd and 3rd and August 17th…

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, staff interview, and review of the manufacturer's Prescribing Information the facility failed to ensure in-use insulin was dated when opened and dated with an accurate Do Not Use After date, and failed to ensure an inhaler medication was dated when opened for one (1) of three (3) medication carts (Hall D). The findings include: On 8/19/24 at 4:30 PM Licensed Practical Nurse (LPN) #3 was observed opening a new LISPRO Insulin Pen for Resident #49. LPN #3 wrote the opened date as 08/19/24 and the Do Not Use After date as 10/18/24 (60 days after opened date). During an interview on 08/19/24 at 5:48 PM LPN #3 confirmed she had documented the discard date for Resident #49's LISPRO Insulin Pen as 60 days after opening because she thought that was how long it could still be used after opening. After looking up the information she confirmed 60 days was not correct and the opened LISPRO could only be used for 28 days. She revised the Do Not Use After date to 9/16/24 (28 days). An observation of the Hall D medication cart on 08/19/24 at 6:07 PM, with LPN #3 present,…

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, medical record review, staff interviews, and facility policy titled Enhanced Barrier Precautions, the facility failed to 1) implement Enhanced Barrier Precautions (EBP) for one (1) of one (1) resident admitted with a pressure ulcer (Resident #31); and failed to 2) ensure a single resident use glucometer was cleaned and disinfected according to facility policy and the sanitizing wipes manufacturers instructions for one (1) of two (2) residents (Resident #49). The findings include: 1. Resident #31 was admitted to the facility on [DATE]. The resident's diagnoses included pressure ulcers. The Minimum Data Set (MDS) completed on 08/01/24 revealed Resident #31 was admitted with one (1) stage 2 and one (1) stage 3 pressure ulcer. The MDS reflected that the resident had one (1) unstageable pressure ulcer with slough and/or eschar and one (1) unstageable pressure ulcer with suspected deep tissue injury in evolution present on admission. The MDS Care Area Assessment revealed that pressure ulcers were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident, family and staff interview and review of the Facility Assessment, the facility failed to have sufficient nurse staffing to meet activities of daily living needs and preferences of residents for five (5) of seven (7) sample residents (Resident #'s 1, 2, 3, 4, and 5) and failed to meet the facility's planned Certified Nursing Assistant (CNA) staffing ratio of 1:13 on the night shift (7:00 PM - 7:00 AM) on seven (7) of 56 nights. In addition, on the A and D halls the ratio was consistently over 1:13. The facility also failed to meet the planned number of Nurses on night shift for 16 of 56 nights during the period 5/18/24 - 7/20/24. The findings include: During an interview with Resident #2 on 7/16/24 at 7:25 PM, she stated that she liked to receive showers on night shift around 3:00 or 4:00 AM (as care planned) but on Sunday (7/14/24) she was unable get her shower because the CNA (Certified Nursing Assistant) was too busy. She stated that there were not enough 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 observations, interviews, and review of facility Resident's Rights document, the facility failed to ensure the resident's dignity was maintained during medication administration for one (1) of two (2) residents reviewed (Resident #8). Additionally, the facility failed to ensure staff did not call out from across the room to prompt/encourage residents to eat for four (4) of nine (9) sampled residents (Resident #s 2, 3, 4, and 8); and did not engage in personal conversation or discuss another resident, while assisting Resident #5 with her meal. The findings include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's and non-traumatic brain dysfunction. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was severely impaired. During an observation on 04/15/24 at 12:27 PM, Certified Nursing Assistant (CNA) #1 assisted Resident #5 with lunch and simultaneously discussed funeral arrangements for Resident #1 (who had expired on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and review of the facility's policies, titled Handwashing and Hand Hygiene and Cleaning of Glucometer, the facility failed to ensure staff cleaned and disinfected the glucometers prior to use for two (2) of two (2) residents observed (Resident #s 3 and 8). The facility also failed to ensure staff washed/sanitized their hands between direct contact with four (4) of nine (9) sampled residents (Resident #s 2, 3, 4, and 5), and assisted residents with hand hygiene before and after the meal for nine (9) of nine (9) residents in the Memory Care Unit's dining room, (Resident #s 2, 3, 4, 5, 6, 7, 8, 9 and 11). The findings include: 1. Resident #5 was admitted on [DATE] with diagnoses that included Alzheimer's and non-traumatic brain dysfunction. Review of the MDS dated [DATE] revealed Resident #5's cognition was severely impaired, and the resident was fully dependent on staff for personal hygiene . Including washing/drying face and hands . 2. Resident #4 was admitted to the facility on…

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

Based on record review, interview, review of facility policy, and review of the IDF (International Diabetes Federation) Clinical Practice Recommendations for Managing Type 2 Diabetes in Primary Care - 2017, the facility failed to ensure medications were administered according to facility policy and standard of practice for 21 of 25 residents reviewed (Residents #1, #2, #3, #4, #7, #8, #9, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25). The findings include: Resident #1 was admitted to the facility 08/08/19 with diagnoses including type 2 diabetes mellitus, asthma, and insomnia. Review of Resident #1's Medication Administration Record (MAR) for September 2023 revealed the following physician's orders: Accu Check (fingerstick blood sugar check) check blood sugar before meals and at bedtime, written 12/31/20. Basaglar 100 units/milliliter (ml) Kwikpen (long-acting insulin) inject 34 units every day for diabetes mellitus, written 09/08/23. Novolog Flexpen 100 units/ml (short-acting insulin) inject 20 units with breakfast and lunch, and inject 18 units 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 record review, interview, review of staffing schedules, and review of facility policy, the facility failed to ensure adequate staff were available to administer medications within the 2-hour medication administration time for 21 of 25 residents reviewed (Residents #1, #2, #3, #4, #7, #8, #9, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25). Cross reference to F-658 all examples. The findings include: Resident #1 was admitted to the facility 08/08/19 with diagnoses including type 2 diabetes mellitus, asthma, and insomnia. Review of Resident #1's Medication Administration Record (MAR) and Med Pass Details for September 2023 revealed the resident's medications were not administered according to scheduled times on 09/17/23, 09/26/23, and 09/27/23 with deviations ranging up to 2 hours and 44 minutes from the scheduled medication administration time. Resident #2 was admitted to the facility 02/15/22 with diagnoses including anxiety disorder, senile degeneration of the brain, dementia, angina, major depressive disorder, and anxiety disorder. Review of…

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

Based on record review, interview, and review of facility policy, the facility failed to ensure the Quality Assessment and Performance Improvement committee implemented a plan to correct repeated occurrences of nursing staff failing to administer medications within the established 2-hour medication administration time for 21 of 25 residents reviewed (Residents #1, #2, #3, #4, #7, #8, #9, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25). Cross reference to F-658 and F-725 all examples. The findings include: Review of Resident #1's Medication Administration Record (MAR) and Med Pass Details for September 2023 revealed the resident's medications were not administered according to scheduled times for 3 of 9 days reviewed: 09/17/23, 09/26/23, and 09/27/23. Review of Resident #2's MARs and Med Pass Details for September and October 2023 revealed the resident's medications were not administered according to scheduled times for 3 of 9 days reviewed: 09/19/23, 09/25/23, and 10/11/23. Review of Resident #3's MARs and Med Pass Details for August, September, and October…

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 review of the facility policy entitled Medication Storge, the facility failed to ensure unattended medications were secure on two (2) of three (3) hallways. The findings include: During an observation on 10/11/23 at 08:23 PM of the Memory Care Unit day room, the medication cart was observed unlocked and unattended. Registered Nurse (RN) #1 was not in the day room where the cart was located. There were two (2) Certified Nurse Aides (CNAs) in and out of the day room during this observation. During an interview on 10/11/23 at 08:30 PM, RN #1 stated the medication cart was to be locked when she left the room. During an interview on 10/11/23 at 08:48 PM, the Director of Nursing (DON) stated it was her expectation medication carts were to be locked when not in use. During an interview with Resident #14 on 10/12/23 at 5:15 PM, Resident #14 stated that a medication bottle had been left in his room on his nightstand last night. Resident #14 stated that he had given the medication to License Practical Nurse (LPN) #3 this morning. Interview with LPN #3 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and review of the facility's surety bond, the facility failed to ensure to balances for the resident trust account did not exceed insured amount for 12 of 13 months reviewed. The findings include: Resident #6 was admitted to the facility 01/04/06 with diagnoses including: Other Hemorrhagic Disorder Due to Intrinsic Circulating Anticoagulants, Antibodies, or Inhibitors, Hypertension, and Chronic Ischemic Heart Disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. During an interview on 09/21/23 at 01:15 PM, the Skilled Nursing Facility [NAME] Specialist stated they were bonded up to $80,000 to cover resident fund losses. She confirmed June, July, August, October, November, and December of 2022 and January - July of 2023, the facility's resident accounts had exceeded the amount of the surety bond. During an interview on 09/21/23 at 02:56 PM the Interim Director confirmed resident accounts for the months listed above were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, review of the facility documents, and review of the facility policy entitled Resident Funds Accounting, the facility failed to ensure funds in excess of $50 were in an interest-bearing account for one (1) of three (3) residents (Resident #6) reviewed. The findings include: Resident #6 was admitted to the facility 01/04/06 with diagnoses including: Other Hemorrhagic Disorder Due to Intrinsic Circulating Anticoagulants, Antibodies, or Inhibitors, Hypertension, and Chronic Ischemic Heart Disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. During an interview on 09/18/23 at 09:03 AM, the Skilled Nursing Facility [NAME] Specialist stated on June 9, 2023 a concern was discovered with Resident #6's billing account. She stated it was found Resident #6 had $69,852.69 in his billing account. She stated this concern began in October 2019. She stated all resident money should be in an interest-bearing account. She confirmed…

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, record reviews, review of the facility documents, and review of the facility policy entitled Resident Funds Accounting, the facility failed to maintain a system that assured a full and complete accounting, according to generally accepted accounting principles for resident's personal funds entrusted to the facility on the resident's behalf for one (1) of three (3) residents (Resident #6) reviewed for personal funds accounting. The findings include: Resident #6 was admitted to the facility 01/04/06 with diagnoses including: Other Hemorrhagic Disorder Due to Intrinsic Circulating Anticoagulants, Antibodies, or Inhibitors, Hypertension, and Chronic Ischemic Heart Disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. During and interview on 09/18/23 at 09:03 AM, the Skilled Nursing Facility [NAME] Specialist stated that during a recent training session with a consultant, it was discovered Resident #6 had a large amount of money in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the facility policy entitled Resident Funds Accounting, the facility failed to ensure residents were notified when resident accounts reached $200 less than the Social Security Income (SSI) resource limit for one person for one (1) of three (3) residents (Resident #6) reviewed for resident trust accounts. The findings include: Resident #6 was admitted to the facility 01/04/06 with diagnoses including: Other Hemorrhagic Disorder Due to Intrinsic Circulating Anticoagulants, Antibodies, or Inhibitors, Hypertension, and Chronic Ischemic Heart Disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. During an interview on 09/18/23 at 09:03 AM, the Skilled Nursing Facility [NAME] Specialist stated on June 9th it was discovered Resident #6's had $69,852.69 in his billing account and $24,491.33 in his trust account. She stated Resident #6 had reached the maximum limit of $2000 in October 2019. She confirmed 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 observation, interview and policy review, the facility failed to allow six (6) of sixteen (16) residents to choose where to eat their evening meal (Resident #'s 2, 13, 22, 32, 43, and 47). The findings include: During an observation on 09/18/23 at 05:10 PM, there were many residents moving in the hallways; some were coming from the dining room towards their rooms, talking to one another and with other residents, and discussing or informing other residents that they had been informed by staff residents were eating in their rooms that evening. Residents that overheard and/or were seen moving back to their rooms included Residents #2, #13, #22, #32, #43, #47. Resident #47 appeared confused asking where she was supposed to go and telling Resident #25 they were eating in their room. Resident #13 stated all the residents had to eat in their room tonight, but did not know why and was not given an explanation. They just said we are eating in our rooms tonight. She preferred to eat in the dining room on this night. During an interview on 09/18/23 at 05:23 PM, Certified Nursing…

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 the resident group interview, review of resident council meeting minutes, and staff interview, the facility failed to ensure grievances voiced in the group meeting were promptly acted upon and responded back to the resident group to address issues regarding missing items, menus, wander guards, and mail delivery for twelve (12) of fifty (50) residents who attended the group interview. The findings include: A review of the resident council meeting minutes from January 2023-June 2023 revealed the resident council met on a regular basis and staff documented the meeting minutes. The minutes recorded staff and resident attendance but did not include documentation for old business, resident rights, changes to facility policy, all which were sections on the form. In January 2023, the staff member taking the notes did document the group inquired about the menu change, but the following month, there was no documentation of follow up in the minutes. A group interview was conducted on 07/11/23 at 1:32 PM. Twelve (12) alert and oriented residents participated in the discussion (two…

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

Based on record review and resident group and staff interview, the facility failed to ensure twelve (12) of twelve (12) residents that attended the group interview out of the fifty (50) residents that resided in the facility, were aware of resident's rights (Resident #s' 4, 5, 15, 16, 17, 22, 25, 28, 32, 34, 36, and 43). The findings include: During the group interview, conducted on 07/11/23 at 1:32 PM, twelve (12) of twelve (12) residents in attendance indicated the facility did not discuss resident's rights with them and they were unaware of their rights. Review of the resident council meeting minutes form, revealed a section entitled Resident Rights Reviewed. This section was left blank on all meeting minutes dated back to January 2023. During an interview on 07/12/23 at 7:58 AM, the Activities Director (AD) indicated he was new to his position and had not discussed resident's rights at the meeting he conducted but would do so at future meetings.

Based on record review and resident group and staff interview, the facility failed to ensure ten (10) of twelve (12) residents in the group interview were aware they had the right to review their medical record. The findings include: During the group interview, conducted on 07/11/23 at 1:32 PM, ten (10) of twelve (12) residents indicated they were not allowed to view their own medical record. Resident Z said, They tell us it is confidential. I would like to see my medications. Resident A said, Since it is on the computer, they won't let us see. Six (6) of the ten (10) residents who were unaware they could view their medical record indicated they would like to see their record. During an interview on 07/12/23 at 7:58 AM, the Activities Director (AD) indicated he was new to the position and had not discussed medical records with the Resident Council. He confirmed a discussion about medical record review was not included in the last six months of resident council meeting minutes.

Based on record review and resident group and staff interview, the facility failed to ensure twelve (12) of twelve (12) residents that attended the group interview out of the fifty (50) residents that resided in the facility, were aware of how to contact pertinent regulatory agencies to file a complaint, were aware of the Ombudsman program and how to contact the Ombudsman, and were unaware of any posting in the facility on how to contact regulatory agencies. The findings include: During the group interview, conducted on 07/11/23 at 1:32 PM, twelve (12) of twelve (12) residents indicated they were unaware of how to contact pertinent regulatory agencies to file a complaint, were unaware of the Ombudsman program or how to contact the Ombudsman, and were unaware of any posting in the facility on how to contact regulatory agencies. Resident Z said, What is an Ombudsman? I've never heard of it. Resident A said, I think you just have to report to the big boss. During an interview on 07/12/23 at 7:58 AM, the Activities Director (AD) indicated he was new to the position and had not discussed…

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 resident group and staff interview, the facility failed to ensure twelve (12) of twelve (12) residents that attended the group interview out of the fifty (50) residents that resided in the facility, were aware of their right to review the facility's inspection results and were aware of the location of the inspection results. The findings include: During the group interview, conducted on 07/11/23 at 1:32 PM, twelve (12) of twelve (12) residents indicated they were not unaware of where the inspection results were located or that they could review the results. Resident F said, I would like to read them. Can you give me a copy? The Resident Council President asked, Could the report be read in our meeting? I want a copy too. Resident Z said, They really don't want us to know if something happens here. They are afraid we will tell our family. During an interview on 07/12/23 at 7:58 AM, the Activities Director (AD) confirmed a discussion about the facility's inspection results was not included in the last six (6) months of resident council meeting minutes.

Based on interview and review of the facility's policy titled Advance Beneficiary Notices, Beneficiary Appeal Rights, and Expedited Review, the facility failed to provide a Notice of Medicare Non Coverage for three (3) of three (3) residents (Resident #'s 5, 34, and 53) reviewed for Notice of Medicare Non-Coverage. The findings include: During an interview on 07/13/23 at 3:25 PM, the Fiscal Coordinator (FC) stated she was unaware of the Notice of Medicare Non Coverage (NOMNC) form until today (07/13/23). She stated Resident #'s 5, 34, and 53 were not provided a NOMNC form two (2) days prior to services ending. During an interview on 07/13/23 at 3:40 PM, the Administrator in Training (AIT) #2 confirmed Resident #'s 5, 34, and 53 were not provided a NOMNC form. She confirmed residents would have no way of knowing their Medicare coverage had ended until they received a bill. During an interview on 07/13/23 at 3:50 PM, the Administrator stated she was informed today, 07/13/23, that NOMNC forms were not being completed. She stated she was aware of the process and confirmed it was 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 the group interview, record review, and staff interview, the facility failed to ensure an ongoing program to support residents in their choice for evening and weekend activities for ten (10) of twelve (12) residents in the group interview. The findings include: During the group interview, conducted on 07/11/23 at 1:32 PM, ten (10) residents in attendance complained there were no evening or weekend activities. Resident C said, There is nothing to do after the administrative staff goes home. The activities end at 3 PM. Resident Z said, All we can do is go to our room. Resident A said, We love the new Activities Director, but we would like to have more outings and things on the weekend. Review of the May 2023 activity calendar revealed that on three (3) days in May no activities were planned after 10:30 AM during the weekdays and then on the remaining days no activities were planned after 2:30 PM. On Saturdays, the exact same activities were offered each week: 9:00 AM Coffee Cart, 10:30 AM Puzzles/Coloring and 2:30 PM Slushies and Snack. On Sundays, the following was offered:…

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 staff interview, the facility failed to ensure a qualified activities professional, to direct the provision of activities to residents, was employed by the facility which had the potential to affect forty-three (43) of fifty (50) residents who regularly attended activities in the facility. The findings include: During an interview with the Activities Director (AD) and Administrator on 07/12/23 at 7:58 AM, the AD indicated he had been in the position since June of 2023. He further indicated he was not a certified recreational therapist and had no recreational program experience. He also indicated he did not have a consultant. The Administrator indicated that the facility had attempted to enroll the AD in a certification program, but he had been wait listed for the class. At the time of the interview, the facility did not have a date the AD would participate in the class. The Administrator indicated she had many years of experience and was assisting the AD with learning the position. She confirmed the facility did not have a qualified consultant for the activities department…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to promote quality of life and promote dignity for two (2) of eighteen (18) sampled residents. Resident #43 was not given an explanation when a wander guard was placed on her ankle which embarrassed her and made her feel like she didn't want to leave her room at the facility. Resident #12 was not provided dignity in dining when staff stood over the resident during meal observations. The findings include: Resident #43 was admitted to the facility 03/22/23 with diagnoses of Chronic Obstructive Pulmonary Disorder, Hypertension, Insomnia, Heart Failure and Major Depressive Disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had some short-term and long-term memory problems, was independent with most activities of daily living, had no wander/elopement alarm used, it was very important for her to go outside for fresh air, and had no behaviors. During an interview with Resident #43 on 07/10/23 at 3:25 PM, she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility's policy titled Advance Directive, the facility failed to formulate or provide an opportunity to formulate an advance directive for two (2) of seven (7) residents reviewed for advanced directives (Resident's #11 and 13). The findings include: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that include Post-Traumatic Stress Disorder, Psychotic Disorder with Hallucinations due to known physical condition, and Hypertension. Review of Resident #11's medical record revealed a Full Code status, but no information about advance directives documentation. 2. Resident #13 was admitted to the facility on [DATE] with diagnoses that include Benign Neoplasm of the Meninges, Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, and Depression. Review of Resident #13's medical record revealed the Tsali Care Center Advanced Directive and Code Status Acknowledgement of Receipt form was incomplete. There was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to refer residents for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for specialized services, for two (2) of two (2) residents admitted with serious mental disorder(s) (Resident's #16 and 28). The findings include: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses that include Post-Traumatic Stress Disorder and Anxiety. Review of Resident #16 's medical record revealed a PASARR history that included the resident's last submitted PASARR Level I on 03/25/15. There was no referral or completed Level II PASARR evaluation since that date. 2. Resident #28 was admitted to the facility on [DATE] with diagnoses that include Post-Traumatic Stress Disorder and Major Depressive disorder. Review of Resident #28's medical record revealed a PASRR history that included the resident last submitted PASARR Level I on 10/26/18. There was no referral or completed Level II PASARR evaluation since…

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, record review, and staff interview, the facility failed to develop a person-centered care plan with realistic interventions for one (1) of eighteen (18) sampled residents (Resident #43) related to elopement risk and use of a wander guard. The findings include: Resident #43 was admitted to the facility 03/22/23 with diagnoses of Chronic Obstructive Pulmonary Disorder, Hypertension, Insomnia, Heart Failure and Major Depressive Disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had some short-term and long-term memory problems, was independent with most activities of daily living, had no wander/elopement alarm used, it was very important for her to go outside for fresh air, and had no behaviors. During an interview with Resident #43 on 07/10/23 at 3:25 PM, she stated that she had a wander guard placed on her ankle. She said, They told me I had to wear it. I was not given a choice. I don't try to leave. I don't go where I am not supposed to go. I feel like a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure Oxygen in Use signs were posted for two (2) out of five (5) residents observed who received Oxygen (Resident's #13 and #254). The findings include: 1.Resident #13 was admitted to the facility on [DATE] with diagnoses that included Benign Neoplasm of the Meninges, Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD) and Depression. Review of Resident #13's medical record revealed an order dated 06/01/23, May use oxygen (O2) at two (2) Liters per minute (LPM) prn as needed for Shortness of Breath (SOB), may titrate up to 4 LPM to keep oxygen saturations (the measurement of oxygen in the blood) greater than (>) 89 % and a care plan for Oxygen therapy. Resident #13 was observed sitting in the bed on 07/11/23 at 8:48 AM and 07/13/23 at 9:25 AM wearing oxygen at two (2) LPM via nasal cannula. During those observations there was no Oxygen…

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 record review, staff interview, and review of facility policy, the facility failed to ensure administrative staff and the provider on-call were notified to address a possible change in emotional well-being and difficulty adjusting to living in a skilled nursing facility for (1) of eighteen (18) sampled residents (Resident #34). The findings include: Resident #34 was admitted to the facility 06/16/23 with diagnoses of Right Below Knee Amputation, Heart Failure, Hypertension, Type 2 Diabetes, and Adjustment Disorder with Anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive deficits and had no mood or behavioral issues. Review of the resident's medical record revealed the following Nurses Note, dated 07/08/23, CNA (Certified Nursing Assistant) reported to nurse while setting his tray up and cutting up his cabbage roll, resident became agitated .Tray ended up on floor. Nurse came and deescalated situation. Explained to resident staff was trying to make it easier…

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, record review, staff interview, and review of the facility's policies, the facility failed to ensure that the indwelling catheter tubing was not on the floor for one (1) of three (3) residents sampled for indwelling catheters (Resident #34) and that staff performed hand hygiene and changed gloves during wound care for one (1) of one (1) resident sampled for pressure ulcers (Resident #23). The findings include: 1. Resident #34 was admitted to the facility 06/16/23 with diagnoses of Right Below Knee Amputation, Heart Failure, Hypertension, Type 2 Diabetes, and Adjustment Disorder with Anxiety. Review of the resident's medical record revealed a Minimum Data Set (MDS) dated [DATE]. The MDS revealed the resident had a Urinary Tract Infection (UTI) in the past 30 days. Resident #34 was observed on 07/11/23 at 1:30 PM seated in his wheelchair in the day room. The resident's catheter tubing was dragging the floor under his wheelchair. The tubing was filled with cloudy urine that had sediment. 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.