Cabarrus Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident representative and staff interviews, the facility failed to provide nail care and shave facial hair for 1 of 11 residents reviewed for activities of daily living (ADL) (Resident #56). The findings included: Resident #56 was admitted to the facility 2/24/25 and readmitted [DATE]. Diagnoses for Resident #56 included stroke and diabetes. A care plan developed on 2/26/25 and revised on 3/21/25 documented Resident # 56 required assistance with all ADL and included the goal that Resident #56 would maintain a clean, neat, odor-free appearance, and be free from discomfort. The significant change Minimum Data Set (MDS) assessment completed 5/7/25 documented Resident #56 as severely cognitively impaired, and he was dependent on others for all ADL care. Resident #56 was observed on 6/16/25 at 12:17 PM. Resident #56 had a full beard that appeared to be approximately 1/2 inch in length, and the hair was very dense and curly. Resident #56's fingernails extended past his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, physician, and staff interviews, the facility failed to change a suprapubic catheter per the Urologist's order for 1 of 2 residents reviewed for catheter care (Resident #56). The findings included: Resident #56 was admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses for Resident #56 included stroke and obstructive reflux uropathy (a blockage in the urinary tract that causes urine to flow backwards into the kidneys). A care plan dated 2/28/25 and revised on 3/25/25 addressed Resident #56's suprapubic catheter and indicated that the catheter would be changed according to physician orders. A Urologist note for Resident #56 dated 4/15/25 included an order to continue suprapubic tube changes at the facility once per month or as needed for clinical indications (blockage, leakage, signs of infection or malfunction). Review of the medical record revealed no record of the Urologists order to continue monthly suprapubic catheter changes. Hospital discharge orders dated 5/2/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff and Responsible Party interviews the facility failed to store an enteral feeding syringe with the plunger separated from the syringe for 1 of 4 resident (Resident #60) reviewed for enteral feeding management. This deficient practice has the potential for bacterial growth and contamination.Findings included:A physician's order dated 3/22/2025 indicated Resident #60's enteral feeding (intake of food through the gastrointestinal tract when you can't eat regularly by mouth) tube should be flushed with 30 milliliters of water before and after each medication administration.Resident #60 was admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses of dementia and gastrostomy (surgical procedure that involves creating an artificial opening in the abdomen to insert a tube directly into the stomach).A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #60 was severely cognitively impaired and received 51% or more…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and resident, hospice nurse, physician, physician assistant (PA), and staff interviews, the facility failed to effectively manage a hospice resident's pain and administer an ordered scheduled pain medication for 1 of 2 residents reviewed for pain control (Resident #100).The findings included: Resident #100 was admitted to the facility on [DATE] with diagnoses including breast cancer with metastasis, chronic pain syndrome, and neuralgia (nerve pain). A physician order dated 1/15/25 for gabapentin (a medication used to control nerve pain) 100 milligrams (mg) three times per day with administration times of 9:00 AM, 2:00 PM, and 9:00 PM. Review of the medication administration record for June 2025 revealed Resident #100 received gabapentin three times per day as ordered. The significant change Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #100 to be cognitively intact. The MDS documented Resident #100 received scheduled and as needed pain medications, 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, observation, and resident, Responsible Party, and staff interviews the facility failed to honor a resident's preference for sandwiches for 1 of 9 residents reviewed for nutritional status (Resident #26). Findings included: Resident #28 was admitted to the facility on [DATE] with heart disease and anemia. A Food Preference List dated 3/12/2025 indicated Resident #28 requested peanut butter and mayonnaise sandwiches at lunch. The Food Preference List also had a note that stated add peanut butter and mayonnaise sandwiches to lunch and dinner tray, and the resident stated she has not been getting the sandwich as requested. On 6/17/2025 at 3:02 pm an interview with Resident #28 was conducted with her Responsible Party was present. Resident #28 was sitting on the side of the bed eating food the Responsible Party brought from home. Resident #28 stated she cannot eat the food from the facility because it was too spicy, and the meat was too hard to chew. Resident #28 stated she had asked for 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.

2. A review of Resident #85's physician orders revealed an order on 3/17/25 for acetaminophen 325 milligrams (mg) orally two tablets every 8 hours as need for pain management status post fall for 3 days. A review of the nursing progress note dated 3/18/25 at 6:19 AM and authored by Nurse #8, indicated Resident #85 fell on 3/17/25 at 10:00 PM. The note further indicated Resident #85 had pain in his right leg and received an order for acetaminophen which was already given, (meaning the medication had been administered). A review of the administration progress note dated 3/18/25 at 10:05 PM indicated Nurse #8 administered acetaminophen 325 mg 2 tablets for pain. A review of progress notes dated 3/19/25 revealed a note authored by Nurse #8 that indicated she administered acetaminophen 325 mg 2 tablets for pain management at 7:27 PM and it was effective. A review of Resident #85's March 2025 Medication Administration Record (MAR) revealed acetaminophen 325 mg 2 tablets for pain was administered on 3/18/25 at 10:05 PM by Nurse #8. Resident #85 was documented to have pain at level 4 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 record review and staff, Nurse Practitioner, Medical Director, and Responsible Party interviews, the facility failed to notify the Physician and the Responsible Party immediately of Resident #1's change in condition after an unwitnessed fall for 1 of 3 residents reviewed for accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia and osteoarthritis. Review of incident report dated 3/27/25, written by Nurse #1 on 3/28/25, revealed Resident #1 had an unwitnessed fall in her room . A physical assessment was completed , no injury or reports of pain and Nurse #1 and Nursing Assistant (NA #1) transferred resident to her bed. An interview was conducted with Nurse #3 on 4/9/25 3:43 PM and revealed she was the assigned nurse for Resident #1 on 3/27/25 from 7:00 PM - 7:00 AM. Nurse #3 indicated she was not made aware of Resident #1's fall earlier in the day and therefore did not know to document or monitor changes related to a fall.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff, Responsible Party, and Nurse Practitioner interviews, the facility failed to provide complete, thorough and ongoing assessments after a fall which caused a delay in receiving treatment for 1 of 3 sampled residents reviewed for accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia, osteoarthritis and left hip fracture. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired and was dependent on staff for transfers. Review of Resident #1's care plan created on 8/27/24 with a revision date of 3/12/25 revealed a focus area for at risk for falls related to combativeness during care and dependency. Interventions included reminding resident to use call light for assistance. A telephone interview was conducted with Nurse Aide (NA) #1 on 04/9/25 at 6:25 PM . She revealed on 3/27/25 between 1:00 PM- 2:00 PM she observed Resident #1 in her room,…

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

Based on record review and staff interview facility failed to submit a 5-day investigative report to the State Agency within the required time frame for 1 of 4 allegations of abuse (Resident #1 and Resident#2) reviewed for resident to resident abuse. The findings included: 1. Review of the facility policy dated 1/23/20 patient protection section abuse/neglect/misappropriation/crime stated there was a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the health and rehabilitation care. The procedures included: 5. The Administrator must thoroughly investigate and file a complete written report of the investigation of the submitted facility reported incident (FRI) to the State Agency within five (5) working days of the incident. Review of the initial allegation report (24-hour report) dated 12/7/24 revealed an allegation of abuse. The details of the report stated Resident #1 pulled Resident #2 from his bed while he was asleep. Resident #1 began striking Resident #2 in the throat. Resident #2 attacked Resident #1 for 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 record review, observations, resident, physician, and staff interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #7). Nursing assistant (NA) #1 rolled Resident #7 away from her during incontinence care, and Resident #7 fell out of bed sustaining bruising to his face and skin tears to his arms. Resident #7 was prescribed an antiplatelet medication, which thins the blood. The findings included: Resident #7 was admitted to the facility 5/10/23 with diagnoses including respiratory failure, heart failure, peripheral vascular disease, right above the knee amputation, and atrial fibrillation. A physician order dated 5/10/23 ordered clopidogrel (an antiplatelet drug that prevents blood clots) 75 milligrams to be administered once daily. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #7 to be cognitively intact without behaviors. The MDS assessed Resident #7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff and resident interviews and observations, the facility failed to protect 1 of 4 residents (Resident #8) the right to be free of physical abuse when Resident #7 struck Resident #8 on the left hand with a metal bar that resulted in redness, swelling and a skin tear to Resident #8's left hand and wrist. Findings included: Resident #7 was admitted to the facility 1/10/23 with diagnoses that included anxiety, depression, hallucinations, and schizoaffective disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 had no cognitive impairment. Resident #7 exhibited verbal behavior symptoms and rejected care 1 to 3 days of the MDS assessment review period. Resident #7 was independent for transfers and wheelchair mobility. Review of care plans for Resident #7 included he was verbally aggressive toward other residents The care plan for Resident #7 initiated 7/18/24 included Resident #7 was verbally aggressive toward other residents and staff by yelling 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 staff interviews and record review, the facility failed to submit an initial report within 2 hours to the state regulatory agency for an allegation of resident- to- resident abuse for 1 of 4 residents reviewed for abuse (Resident #8). The findings included: Review if the Initial Allegation Facility Report (FRI) revealed the Administrator became aware resident - to - resident abuse on 7/17/24 at 6:10 PM. The initial FRI report indicated that Resident #7 became upset when Resident #8 entered his room, and a verbal argument transpired. Resident #7 removed a small black pipe from the arm of a wheelchair and struck Resident #8 on the back of his left hand and wrist 3 times causing redness, swelling and a skin tear. Resident #8 had a negative x ray for injury. The initial report was faxed to the state regulatory agency on 7/22/24 at 11:36 AM. The initial report allegation was related to resident abuse. An interview conducted with the Administrator on 8/29/24 at 5:30 PM revealed he was made aware of the allegation of abuse on 7/17/24 at 7:15 PM and as he was out of town for 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 record review, observations, and Pharmacist, Nurse Practitioner, and staff interviews, the facility failed to provide routine medications ordered by the physician for 1 of 3 residents reviewed for medication pharmaceutical services (Resident #3). The findings included: Resident #3 was admitted to the facility 7/9/24 with diagnoses including major depression with psychotic symptoms. Orders for Resident #3 were reviewed, and an order dated 7/9/24 ordered quetiapine fumarate (an antipsychotic medication) 50 milligrams (mg) to be administered in the morning for bipolar disorder, and quetiapine fumarate 200 mg to be administered at bedtime. The admission Minimum Data Set assessment dated [DATE] documented Resident #3 was severely cognitively impaired with verbal and physical behaviors for 1-3 days with rejection of care and wandering noted. Review of the medication administration record revealed the morning doses of quetiapine fumarate were not administered on 8/12/24 and 8/13/24 by Nurse #1, and the bedtime…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and Nurse Pracitioner and staff interviews, the facility failed to administer 3 of 4 doses over 2 days of quetiapine fumarate (an antipsychotic medication) as ordered by the physician for 1 of 3 residents reviewed for pharmaceutical services (Resident #3). The findings included: According to manufacturer's instructions: Do not stop taking quetiapine fumarate suddenly, your condition may get worse, or you could have symptoms such as trouble sleeping, nausea, and vomiting. Ask your doctor before stopping the medication. Resident #3 was admitted to the facility 7/9/24 with diagnoses including major depression with psychotic symptoms. Orders for Resident #3 were reviewed, and an order dated 7/9/24 ordered quetiapine fumarate 50 milligrams (mg) to be administered in the morning for bipolar disorder, and quetiapine fumarate 200 mg to be administered at bedtime. The admission Minimum Data Set assessment dated [DATE] documented Resident #3 was severely cognitively impaired 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews with staff and resident the facility failed to provide a fork during a lunch meal for 4 of 6 residents (Resident #3, Resident #9, Resident #10, and Resident #11) who ate independently. Resident #3, Resident #9, Resident #10, and Resident #11 were given a spoon on their lunch meal tray and indicated they would prefer a fork to eat their meal of breaded chicken covered with barbeque sauce, cabbage, dressing, and a piece of cake. Findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses of dysphagia. An annual Minimum Data Set assessment dated [DATE] indicated Resident #3 was cognitively intact and was able to feed himself with set up assistance with his meals. A Physician's order dated 7/1/2024 stated resident #3 required a regular texture diet with thin liquids. During an observation of Resident #3 on 7/16/2024 at 12:48 pm he was sitting up in his electric wheelchair and Nurse Aide #1 brought his lunch meal tray to him. Resident #3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interviews the facility failed to ensure milk and thickened juice for the lunch meal observation was within safe temperature range of 41 degrees Fahrenheit (F) or below and failed to maintain the wash temperature of the high temperature dishwasher according to manufacturer's recommendations for sanitation of dishware. The facility also failed to ensure soiled cups did not come in contact with the clean ice scoop used to refill residents' water cups. The practices had the potential to affect food served to residents. The findings included: 1. On 4/16/24 at 11:32 AM the temperature check for the lunch meal was observed. After all hot food was checked, dietary staff was requested to check cold beverages. Dietary Staff #1 used a digital thermometer to check the following cold beverages: milk 49 degrees F, thickened orange juice 57 degrees F, and honey tea 60 degrees F. The Senior Culinary Manager threw out all milks and indicated fresh cold beverages would be given out. An 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.

Based on observations, record review, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor the interventions that the committee put into place in following the recertification survey of recertification surveys of 7/15/2021 and 12/8/2022, and complaint investigation survey of 10/17/2023. This was for 2 deficiencies in the areas of F584 Safe/Clean/Comfortable/Homelike Environment and F812 Food Procurement, Store/Prepare/Serve Sanitary. These deficiencies were recited on the current recertification and complaint investigation survey of 4/18/2024. The continued failure of the facility during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This tag is cross referred to: F584: Based on record review, observations, and staff interviews the facility failed to ensure the wall and window valance in a resident's rooms were clean for 1 of 3 residents (Resident # 84) observed for environmental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and staff and responsible party interviews the facility failed to ensure a resident's hair was not greasy for 1 of 4 residents (Resident #44) who were dependent on staff for personal hygiene. Findings included: Resident #44 was admitted to the facility on [DATE]. His cumulative diagnoses included stroke, hemiplegia, and aphasia. An annual Minimum Data Set assessment dated [DATE] indicated Resident #44 was moderately cognitively impaired and he sometimes understood and responded adequately to simple, direct communication only. The annual Minimum Data Set assessment further indicated Resident #44 had no behaviors, dependent for toileting and was always incontinent of bowel and bladder. Resident #44's Care Plan dated 2/22/2024 stated all care needs would be met by staff due to decreased mobility related to a stroke. The Care Plan also stated Resident #44 had disruptive behaviors. Resident #44's Care Plan had interventions of redirecting during behaviors, do not argue 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 reviews and staff interviews, the facility failed to complete a performance review every 12 months for 4 of 5 nursing assistants (NAs) reviewed to ensure in-service education was designed to address the outcome of the performance reviews (NA #4, NA #5, NA #6, and NA #7). The findings included: a. NA #4 date of hire was 2/12/2001. A review of her employment record revealed no performance evaluation had been completed in the past 12 months. NA #4 was interviewed on 4/18/2024 at 11:28 AM and she reported she did not recall the last time she had a performance evaluation completed. b. NA #5's date of hire was 8/12/2014. A review of the employment record revealed no performance evaluation had been completed for the past 12 months. NA #5 was not available for interview. c. NA #6's date of hire was 8/21/2014. A review of the employment record revealed no performance evaluation had been completed for the past 12 months. NA #6 was not available for interview. d. NA #7's date of hire was 4/18/1995. A review of the employment record revealed no performance evaluation had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, Pharmacist and Medical Director interviews, the facility failed to act upon a pharmacy recommendation by failing to change the dose of atorvastatin (medication to decrease unhealthy fat in the body) from 40 milligram (mg) to 20 mg as ordered by the physician for 1 of 1 resident reviewed for drug regimen (Resident #88). The findings included: Resident #88 was admitted to the facility on [DATE] with a diagnosis of hyperlipidemia. Review of physician orders on 11/1/23 revealed an entry for atorvastatin 40 mg for hyperlipidemia one tablet daily at bedtime. Review of the Pharmacist's monthly medication review on 3/19/24 revealed a recommendation to decrease atorvastatin to 20 mg at bedtime if appropriate. The physician response section revealed the Medical Director checked the box indicating he agreed with the recommendation, and signed and dated the form on 4/1/24. The resident's medication administration record (MAR) revealed the nurses continued to offer atorvastatin 40 mg daily at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, Pharmacist and Medical Director interviews, the facility failed to change the dose of atorvastatin (medication to decrease unhealthy fat in the body) from 40 milligram (mg) to 20 mg as ordered by the physician for 1 of 6 residents reviewed for unnecessary medications (Resident #88). The findings included: Resident #88 was admitted to the facility on [DATE] with a diagnosis of hyperlipidemia. Review of physician orders on 11/1/23 revealed an entry for atorvastatin 40 mg for hyperlipidemia one tablet daily at bedtime. Review of the Pharmacist's monthly medication review on 3/19/24 indicated a recommendation to decrease atorvastatin to 20 mg at bedtime if appropriate. The Pharmacist revealed Resident #88's cholesterol was 89, triglyceride 26, high density lipoprotein 42 and low-density lipoprotein was 39 on 3/7/24. The physician response section revealed the Medical Director checked the box indicating he agreed with the recommendation, and signed and dated the form on 4/1/24. The…

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

Based on observations and staff interviews the facility failed to date five medications that had been opened and stored in 2 of 2 medication carts (2-hall cart and 3-hall cart) observed for medication storage. Findings included: 1a. During an observation of the 2-hall medication cart on 4/17/2024 at 2:09 pm the following medications were found opened and were not dated: -Chlorhexidine gluconate oral rinse 0.12 % (an antiseptic mouthwash) was found opened and undated. -Dextromethorphan/Guaifenesin (an over-the-counter cough suppressant medication) 20 milligrams/200 milligrams in 20 milliliters liquid was found opened and undated. -Lactulose solution 10grams in 15 milliliters (a laxative) was found opened and undated. An interview was conducted with Nurse #1 on 4/18/2024 at 8:25 am and she stated there were several nurses that work on the 2-hall medication cart, and someone must have opened the bottles and forgot to put the date on the bottle. She stated she thought it was just human error because the nurses and medication aides all know they should date the bottles when they 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 staff interviews and record reviews the facility failed to maintain accurate advance directive information (code status) throughout both the electronic medical record and paper medical record for 1 of 6 residents reviewed for advance directives (Resident #37). The findings included: Resident #37 was admitted to the facility on [DATE]. Resident #37's electronic medical record (EMR) revealed a physician's order dated [DATE] that read code status Do Not Resuscitate (DNR). Resident #37's Care Plan dated [DATE] revealed Resident #37 elected to be a DNR. Review of Resident #37's paper medical record located at the nurse's station revealed Resident #37 had a Medical Orders for Scope of Treatment (MOST) form that indicated to attempt Cardiopulmonary Resuscitation (CPR) with limited additional interventions dated [DATE]. Resident #37's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #37 was moderately cognitively impaired. Resident #37's EMR showed a communication banner on the top of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident, and staff interviews the facility failed to resolve a grievance for 1 of 1 resident reviewed for grievances (Resident #63). Findings included: Resident #63 was admitted to the facility on [DATE] with cumulative diagnoses of renal failure which required dialysis treatments and diabetes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #63 was cognitively intact. The facility's Grievance/Concern Forms were reviewed, and a Grievance/Concern Form dated 2/13/2024 indicated Resident #63 had a concern regarding his snack/meal for dialysis not being sent when he was transported to his dialysis treatments. The concern form further documented when he returned to the facility after dialysis the kitchen would be closed, and he had discussed the issue with the Dietary Manager, and nothing had changed. The Grievance/Concern Form was signed by the Dietary Manager as the individual that followed up and resolved Resident #63's grievance. The…

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

Based on record review and staff interviews, the facility failed to implement their abuse policy in the area of reporting for an allegation of misappropriation of property for 2 of 7 residents reviewed for misappropriation of resident property (Resident #4 and Resident #86). Findings included: A review of the facility policy titled: Abuse Prevention, Intervention, Reporting, and Investigation dated February 2021 Revision read as follows: Reporting/Response It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interviews, the facility failed to refer a resident with a new mental health diagnosis for a Level II Preadmission Screening and Resident Review (PASRR) for 1 of 3 residents reviewed for PASRR (Resident #52). The findings include: Review of Resident #52's medical record revealed documentation of a Level I PASRR determination dated 4/20/23 prior to his admission on [DATE]. His admission diagnoses included end stage renal disease and stroke. A diagnosis of major depressive disorder was added on 10/31/23. Further record review did not indicate a referral for a Level II PASRR review had been made. During an interview on 4/17/24 at 10:12 am, the Social Services Director (SSD) revealed she was not trained with PASRR and was still learning the process. She stated she checked PASRR levels during the resident admission process and made referrals for residents without PASRR determinations. She stated she was not aware of Resident #52's mental health diagnosis being added on 10/31/24. 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, observation, and staff interviews the facility failed to provide 1 of 1 resident (Resident #63) a meal for a resident who had dialysis. Resident #63 traveled to a dialysis center three days a week, leaving before breakfast was served and returning to the facility after breakfast was served. Findings included: Resident #63 was admitted to the facility on [DATE] and his cumulative diagnoses included renal failure which required dialysis treatments and diabetes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #63 was cognitively intact and required set up assistance with his meals. Resident #63's Care Plan dated 8/23/2023 was reviewed and stated he was at risk of nutritional decline related to his dialysis treatment. The facility's interventions included providing snacks and therapeutic diet as ordered. Resident #63's Care Plan stated his intake varied food but there was not a care plan for refusing meals. Physician's Orders for Resident #63 dated 8/24/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident, and staff interviews, the facility failed to honor a resident's preference for meals when they served him a double portion of peas when he had requested not to be served peas (Resident #69). This was for 1 of 2 residents reviewed for choices. The findings included: Resident #69 was admitted to the facility on [DATE] . The most recent quarterly Minimum Data Set assessment dated [DATE] noted Resident #69 had adequate vision and hearing, was able to understand and was understood by others, was cognitively intact, and without behaviors. A review of Resident #69's updated meal preferences and diet order dated 11/4/2023 revealed he was ordered a regular textured diet with thin liquids, controlled carbohydrates, and double portions of protein. The dietary choices included that Resident #69 disliked peas. Resident #69 was interviewed on 4/15/2024 at 12:09 PM and he reported there were instances where his dietary choices were not honored and provided a picture on his phone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of resident property. This deficient practice was for 6 of 7 residents reviewed for misappropriation of resident property (Resident #3, Resident #63, Resident #86, Resident #89, Resident #4 and Resident #41). Findings included: A review of the initial facility report dated 2/8/24 at 10:30 AM documented that a resident (Resident #89) complained of giving money to a staff member to purchase items, no items were purchased, and no money was returned. A facility investigation report revealed that after investigation it was discovered that this was not an isolated event as there were three more residents (Resident #63, Resident #41 and Resident #3) with the same circumstance. The employee (Activities Assistant #1) who was accused by Resident #89, Resident #63, Resident #41 and Resident #3 was brought in the office and was questioned about the allegations against her and was…

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

Based on observations and staff interviews the facility failed to remove expired food from 1 of 1 dry storage room and failed to date and label opened food in 1 of 1 walk in cooler. The findings included: a. On 10/3/2023 at 9:42 a.m. observations were made of the facility's dry storage area with Dietary Staff #1. Contents stored in the dry storage area were noted to have 14 containers of ready care thickened orange juice with an expiration date of 8/11/2023 and 2 with an expiration date of 7/27/2023. A box of opened coconut flakes was dated as opened on 10/5/2022. 7 bags of jet puffed marshmallows were on a shelf with an expiration date of 3/3/2023. During the observation of the dry storage on 10/3/2023 at 9:42 a.m. an interview was conducted with Dietary Staff #1, and she revealed all expired food was to be discarded and not stored in the kitchen area. She added all opened food, in the dry storage area, should be discarded and thrown away within a few months, but she was unsure of the exact date it should be thrown out. b. On 10/3/2023 at 9:58 a.m. observations were made of the…

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

Based on record review and staff interviews and observations, the facility's Quality Assurance and Performance committee (QAPI) failed to maintain implemented procedures and monitor the interventions the committee put into place for 1 re-cited deficiency F812. F812 was originally cited during the recertification and complaint investigation survey dated 07/15/21, F812 was re-cited during a revisit and complaint investigation dated 09/20/21, F812 was re-cited during a recertification and complaint investigation dated 12/08/22, and F812 was re-cited during a complaint investigation dated 10/17/23. The continued failure of the facility during four federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program. The findings included: This tag is cross-referenced to: 1.F812: Based on observations and staff interviews the facility failed to remove expired food from 1 of 1 dry storage room and failed to date and label opened food in 1 of 1 walk in cooler. During the recertification and complaint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews and review of records, the facility failed to 1) wash dishes in the dish machine in water that reached at least 155 degrees Fahrenheit (F), per manufacturer recommendations, 2) store frozen foods at least 0 degrees F, and 3) store canned goods and snacks off the floor. This failure had the potential to effect 87 of 88 residents. The findings included: 1. A continuous observation of the dish machine (DM) in use occurred on 12/07/22 at 9:50 AM until and 10:30 AM. The Assistant Dietary Manager (ADM) was observed washing meal trays, small bowls, and insulated dome lids. Each item was stored ready for use. The wash cycle temperature gauge consistently remained at 128 degrees F. The ADM stated when she observed the wash cycle temperature gauge earlier that morning (12/7/22), the wash cycle reading was 158 degrees F. The ADM stated she would notify her supervisor. Manufacturer instructions for the wash cycle recorded on the DM were, Wash Cycle 155 - 165 degrees Fahrenheit. An interview with the Certified Dietary Manager (CDM) on 12/07/22 at 10:00 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interviews, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor these interventions the committee put into place in May 2019. This was for 2 re-cited deficiencies which were originally cited on 5/23/2019 (F656 and F812), and 7/15/2021 (F812) during the recertification/complaint survey, and on the current recertification/complaint survey on 12/8/2022 (F656 and F812). The continued failure of the facility during the two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program. The findings included: This tag is cross referred to: 1. F656 During the recertification survey of 5/23/2019, the facility failed to develop a comprehensive person-centered plan to address discharge plans for 1 of 1 residents reviewed (Resident # 146). The Administrator was interviewed on 12/8/2022 at 2:03 PM. The Administrator reported the facility had weekly QAPI meetings that included all department managers,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident interview and staff interviews, the facility failed to accurately include information on the Minimum Data Set (MDS) assessment in the area of dialysis and antipsychotic medication review for 2 of 19 residents reviewed (Resident #32 and Resident #20). Findings included: 1. Resident #32 had been admitted on [DATE] and readmitted on [DATE]. Her diagnoses included end stage renal disease and diabetes. a. A hospital Discharge summary dated [DATE] noted Resident #32 had diagnoses including End-Stage Renal Disease requiring hemodialysis which she received every Monday, Wednesday, and Friday. Nursing documentation dated 9/23/22 at 6:23 PM noted Resident #32 had received dialysis this day. Resident #32's admission MDS assessment dated [DATE] included a diagnosis of End-Stage Renal Disease. The assessment did not indicate she received dialysis. b. Nursing documentation dated 11/16/22 at 10:49 AM noted Resident #32 was out of the facility to dialysis this day. A Nurse Practitioner note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, resident and staff interviews, the facility failed to develop and implement a care plan that addressed discharge plans for 1 of 1 resident reviewed for discharge (Resident #3). Findings included: Resident #3 was admitted to the facility 8/12/2021 with diagnoses to include lung disease, diabetes, and hypertension. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 to be cognitively intact. The MDS documented that Resident #3 did not have an active plan in place to return to the community. A review of the care plans last reviewed 11/1/2022 revealed there were no care plans in place that addressed long-term care. No care plan was in place that addressed a discharge plan for Resident #3. A social work note dated 10/25/2022 documented that Resident #3 wanted to go to Assisted Living Facility (ALF). The note documented that the Social Worker (SW) was going to start working on a discharge and determine an appropriate level of care for Resident #3. 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 record reviews, observations, resident and staff interviews, the facility failed to apply compression hose prescribed to control lower leg swelling to 1 of 1 resident reviewed for quality of care (Resident #12). Findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses to include fluid overload, cellulitis (skin infection) of lower leg, and hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #12 to be cognitively intact without behaviors or refusal of care. The MDS documented Resident #12 required extensive assistance of one person to dress. A physician order dated 10/18/2022 ordered for compression hose to be applied to Resident #12's lower legs every morning at 8:00 AM. The order further specified for the compression hose to be removed at 8:00 PM. A care plan initiated 10/18/2022 addressed edema (swelling) of the lower legs and directed compression hose to be applied to lower legs on in the morning and off in the evening. A nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and staff interviews, the facility failed to accurately document the application of the compression hose on the medication administration record (MAR) for 1 of 19 residents reviewed for record accuracy (Resident #12.) Findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses to include fluid overload, cellulitis (skin infection) of lower leg, and hypertension. A physician order dated 10/18/2022 ordered for compression hose to be applied to Resident #12's lower legs every morning at 8:00 AM. The order further specified for the compression hose to be removed at 8:00 PM. The medication administration record (MAR) for December 2022 was reviewed. The order for compression hose to be applied on 12/5/2022 and 12/6/2022 was marked as completed by evidence of the nurse initials and a check mark. Resident #12 was observed on 12/5/2022 at 11:42 AM. Resident #12's lower legs were swollen, and she did not have compression hose on her lower legs. Resident #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.