PruittHealth-Durham

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident and staff interviews, the facility failed to maintain complete and accurate medical records for wound care (Resident #4, Resident #17, and Resident #76) for 3 of 6 residents reviewed for wound care. Findings Included: 1a. Review of the April 2026 Medication Administration Record (MAR) revealed treatment for the pressure ulcer to the left ischium was documented by Nurse #6 on 04/20/26, 04/21/26, 04/25/26, 04/26/26, and 04/27/26. Review of the May 2026 Medication Administration Record (MAR) revealed treatment for the Stage 4 pressure ulcer to the left buttock/ischium was documented by Nurse #6 on 05/26/26, 05/27/26, 05/28/26, and 05/29/26. Review of the June 2026 Medication Administration Record (MAR) revealed treatment for the Stage 4 pressure ulcer to the left buttock/ischium was documented by Nurse #6 on 06/01/26, 06/02/26, 06/03/26, 06/09/26, 06/10/26, and 06/11/26. The Wound Nurse documented the treatment on 06/04/26. On 06/09/2026 at 2:25 PM, an interview 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, Pharmacist, resident, responsible party (RP) and staff interviews, the facility failed to provide education regarding the benefits and potential side effects of the influenza immunization with documentation in the medical record and failed to offer the influenza immunization during the influenza season (October to March) for 6 of 7 residents reviewed for influenza immunization (Residents #38, #39, #56, #71, #77 and #121). The findings included: The facility's policy and procedure on influenza immunizations dated [DATE] was reviewed. The policy stated, in part, all patients who had no medical contraindications to the vaccine would be offered the influenza vaccine annually. The policy further indicated that the facility would provide pertinent information about the significant risks and benefits of the vaccine to patients and/or family members. Additionally, the policy read that current and newly admitted patients would be offered the influenza vaccine beginning on [DATE]st of each year, 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 record reviews, resident, responsible party (RP) and staff interviews, the facility failed to assess residents for the eligibility and ensure residents were offered the COVID-19 booster vaccination for 6 of 7 residents reviewed for COVID-19 booster immunizations (Residents #38, #39, #56, #71, #77 and #121). The findings included: The facility's policy and procedure on COVID-19 Vaccination, dated 5/3/24 was reviewed. The policy stated, in part, all partners, residents and patients who had no medical contraindications to the vaccine would be offered the updated COVID-19 vaccine per the Centers for Disease Control and Prevention (CDC) recommendations to encourage and promote the benefits associated with the vaccinations against COVID-19. The policy further indicated that the facility would provide pertinent information about the significant risks and benefits of the vaccine to partners, residents, patients and/or family members. A review of the CDC guidelines, dated 11/19/25, indicated that the CDC…

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 and staff interviews the facility failed to maintain a resident's dignity when staff spoke to a resident in an undignified manner. The resident stated she was upset by the way the staff member spoke to her when the staff told her not to hit her call bell (Resident #69). This deficient practice affected 1 of 5 residents reviewed for dignity and respect. The findings included:Resident #69 was admitted to the facility on [DATE] with hemiplegia (paralysis of one entire side of the body) and hemiparesis following CVA (cerebral vascular accident/stroke) affecting the left non-dominant side.A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was moderately cognitively impaired. She was assessed as needing substantial assistance with turning in bed and dependent.During an observation of Resident #69 on 6/11/26 at 2:58 PM it was noted her call bell was draped across the foot of the bed and lying on the floor. Resident #69 stated the staff put 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 observation, record review, resident, staff and Nurse Practitioner interviews, the facility failed to assess the ability of a resident to safely self-administer medications for 1 of 1 resident reviewed for self-administering medications (Resident #135).The findings included:Resident #135 was admitted to the facility on [DATE] with diagnoses of bipolar disorder and major depressive disorder, single episode, with psychotic features.Review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #135 was cognitively intact without behavioral concerns.A review of the active orders revealed an order dated 6/3/26 through 6/9/26 for Cipro 500 milligrams (mg); 1 tablet orally twice daily.A review of the nursing progress notes for Resident #135 revealed the following written by the Director of Nursing: 6/3/26 5:38 PM Resident is refusing to have her blood drawn for a CBC (complete blood count that measures the types and numbers of blood cells in your blood) with diff . She also has her own…

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 interviews with Resident and staff, the facility failed to honor residents' choices of getting out of bed for 2 of 11 residents reviewed for self determination (Residents #116 and #69). Findings included: 1. Resident #116 was admitted to the facility on [DATE] with diagnoses including incomplete quadriplegia (paralyzed from the neck down with minimal movement of his arms), traumatic brain injury, muscle weakness, spastic hemiplegia (involuntary jerking movements of his arms and legs). Review of the care plan for Resident #116 dated 4/13/26 for Activities of Daily Living (ADL) care due to impaired mobility included interventions to explain procedures prior to touching the resident, to report any rejection of care, and to encourage the resident to get out of bed as part of his long term participation in activities he enjoys. The annual Minimum Data Set, dated [DATE] indicated Resident #116 was cognitively intact and was dependent on staff for bed mobility and activities 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff and Health Care Power of Attorney interviews, the facility failed to distribute the funds within 30 days of discharge for 1 of 3 residents reviewed for refund of deposit (Resident #127).Findings included:Resident #127 was admitted to the facility on [DATE].A review of the discharge tracking Minimum Data Set (MDS) dated [DATE] revealed Resident #127 had a planned discharge to another facility on 03/07/26.On 06/09/26 at 1:30 PM a phone interview was conducted with Resident #127's Health Care Power of Attorney (HCPOA). The HCPOA explained Resident #127 was discharged to another skilled nursing facility on 03/07/26 and was owed a refund of approximately $1000. On 06/12/26 at 9:05 AM an interview with the Business Office Manager was conducted. She stated she received an email from the accepting facility in April 2026 indicating that they had not received Resident #127's funds. The Business Office Manager stated she initiated the the refund for Resident #127 on approximately 04/18/26 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 reviews, observations, and staff interviews, the facility failed to develop an individualized and comprehensive care plan for the potential for or history of behavioral symptoms as well as the use of psychotropic medications (Resident #35) and dental concerns (Resident #62). This deficient practice affected 2 of 10 residents reviewed for dementia and dental concerns. The findings included: 1. Resident #35 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, mood disorder, dementia with other behavioral disturbance, anxiety disorder and depression. A review of Resident #35's nursing progress notes from 3/26/26 to 4/2/26 revealed episodes of disrobing in the hallway and propelling self in wheelchair to other residents' rooms. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 had severe cognitive impairment and displayed wandering behavior one to three days during the seven-day look back period. He was coded for the use 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete a comprehensive care plan within 7 days of the admission Minimum Data Set assessment for 1 of 3 residents (Resident # 104) reviewed for smoking. The findings included:Resident #104 was admitted to the facility 4/6/26.A smoking assessment dated [DATE] assessed Resident #104 to be a safe smoker. The admission Minimum Data Set assessment dated [DATE] noted Resident #104 was cognitively intact and was coded for Current Tobacco Use.Review of Resident #104's medical record on 6/8/26 at 12:00 PM revealed no care plan that addressed smoking.An interview was conducted with the Director of Nursing (DON) on 6/11/26 at 1:30 PM. The DON reported she was not certain why Resident #104 did not have a care plan for smoking in place. The DON reported that the nurse completing the admission assessment should have initiated the smoking care plan. The DON reported she expected all smokers to have smoking addressed in a care plan on admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Medical Director, and staff interviews, the facility failed to administer insulin per the parameters in the physician order (Resident #62) for 1of 1 resident reviewed for well-being. The findings included: Resident #6 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus.Review of Resident #6's active physician orders showed the following: An order dated 10/13/25 for insulin lispro insulin pen, 100 units/milliliters (mL). Administer 10 units subcutaneously once daily with breakfast. Special instructions: hold if blood glucose is less than 90; give half dose (5 units) if blood glucose is less than 120; do not administer if the resident is not eating. An order dated 5/17/26 for insulin lispro insulin pen, 100 units/mL. Administer 8 units subcutaneously twice daily at 12:00PM and 5:00PM. Special instructions: hold if blood glucose is less than 90; give half dose (4 units) if blood glucose is less than 120; do not administer if the resident is not eating.Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, physician, and staff interviews, the facility failed to provide wound care for a non-pressure wound as order by the physician for 1 of 6 residents reviewed for wound care (Resident #76).The findings included:Resident #76 was readmitted to the facility 5/25/26 with diagnoses including hypertension, diabetes, and an unspecified open wound.Review of the physician orders revealed an order dated 5/25/26 for wound care to be completed to the wound on the lower right leg: cleanse with antiseptic wound cleanser, apply medi-honey (a topical antiseptic that provides moisture and protection to healing wounds) to the wound, apply a silicone bordered foam, change dressing every 3 days and as needed.A skin care assessment completed by Nurse #3 on 5/25/26 noted a skin tear to the right lower leg with an intact dressing and wound care ordered.The quarterly Minimum Data Set assessment dated [DATE] documented Resident #76 was cognitively intact and did not reject care. The assessment did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff, and Physician interviews, the facility failed to apply a right hand palmar guard orthosis (type of hand splint designed to protect the palm of the hand from injury caused by severe finger flexion contractures, also called palm protectors) as outlined in the care plan for 1 of 1 resident (Resident #8) reviewed for contractures and range of motion (ROM). Findings included:Record review showed that Resident #8 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side) following a cerebral infarction (stroke) affecting the right dominant side, a right wrist contracture, and a right hand contracture. Review of the Occupational Therapy (OT) Discharge summary dated [DATE] showed the resident received OT services from 4/14/26 through 4/30/26. At discharge, the resident had plateaued at the maximum producible end range Passive Range of Motion (PROM) and tolerated 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 and interviews with the Nurse Practitioner, resident, and staff, the facility failed to implement an active order to obtain a urinalysis with culture and sensitivity for a resident who exhibited symptoms of a urinary tract infection. This deficient practice resulted in missed diagnostic evaluation and affected 1 of 6 residents reviewed for urinary care management (Resident #135).The findings included:Resident #135 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit and prediabetes.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #135 was cognitively intact. A review of the Nurse Practitioner (NP) progress note dated 5/29/26 signed by NP #2 read Resident #135 was seen on 5/29/26 and endorsed feelings of dysuria (pain, burning, or discomfort with urinating) and would like a urinalysis (UA) with culture and sensitivity ordered. In the orders section of the progress note was an order for a UA with culture 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, Nurse Practitioner and staff interviews, the facility failed to transcribe blood glucose monitoring orders on admission to monitor the use of an oral diabetic medication for 1 of 10 residents whose medications were reviewed (Resident #130). The findings included: Resident #130 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. A review of Resident #130's hospital discharge medication list dated 9/25/25 included an order for blood glucose monitoring (accucheck) three times a day. The discharge summary indicated Resident #130 utilized Metformin (a hypoglycemic medication used to treat diabetes) 500 milligrams (mg) one tablet daily with breakfast to control the type 2 diabetes. The September 2025 physician orders did not include an order for blood glucose monitoring three times a day, however, it did include the order for Metformin 500 mg one tablet daily with breakfast. An interview occurred with Nurse #6 on 6/10/26 at 11:05 AM, who admitted Resident #130…

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 the resident, Physician, and staff, the facility failed to secure prescribed medications stored at bedside for 2 of 6 residents reviewed for medication storage (Resident #84 and Resident #104). The findings included: 1. Resident #84 was admitted to the facility on [DATE] with a diagnosis of seborrheic dermatitis (a skin condition that causes redness, scaley patches, and rashes on areas of the body). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #84 had severe cognitive impairment. A review of the physician's orders revealed an order dated 6/4/26 for Triamcinolone Acetonide Cream 0.025% (cream used to relieve redness, itching, and dryness caused by skin conditions), with instructions to apply a small amount of the cream to the red area on the right side of his back and to the forearms daily for treatment of seborrheic dermatitis. A review of Resident #84's medical records revealed he had not been assessed for…

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, observation, resident and staff interviews, the facility failed to accommodate food preferences for 1 of 1 resident reviewed for food preferences (Resident #56).The finding Included:Resident #56 was admitted to the facility on [DATE].A review of Resident #56's records revealed a form titled Diet History/Food Preference List, completed by the Former Dietary Manager. The form indicated Resident #56 disliked foods such as bacon, beef liver, beef, veal, bologna, chicken liver, chicken, chili, enchiladas, fish, ham, lasagna, pork, sausage, shrimp, tuna, turkey, and other. The form was undated.The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #56 was cognitively intact and able to eat independently.A dining observation of Resident #56's lunch tray occurred on 06/09/2026 at 1:30 PM. The observation revealed brown, ground-up food on the resident's tray that had been pushed to the side. Resident #56's dietary meal ticket identified the meat as Mech Soft (mechanical soft diet,…

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, physician, Physician Assistant, and staff interviews, the facility failed to implement their infection control policy regarding hand hygiene when a staff member failed to perform hand hygiene while performing wound care (Resident #17). This deficient practice occurred for 1 of 28 staff observed for infection control (Wound care nurse).The findings included:Review of the facility policy Infection Prevention and Control with a revised date of 3/11/21 revealed the following: The Infection Prevention and Control Program will incorporate risk assessments, surveillance activities, evidence-based prevention practices, education, and communication to mitigate risks and decrease adverse outcomes related to Infection Prevention and Control.The responsibilities of the Infection Preventionist include directing all infection control activities and assessing, developing, implementing, monitoring, evaluating, and managing the Infection Control Program.Objectives include surveillance activities to identify infections and causative factors and identify…

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, observations and staff interviews, the facility failed to provide a working privacy curtain that allowed for full visual privacy to protect a resident from view of others during activities of daily living care while bathing. This deficient practice affected 1 of 3 residents reviewed for privacy curtains (Resident #57).The findings included:On 6/11/26 at 10:33 AM an observation was conducted for activities of daily living (ADL) care for Resident #57. Resident #57's bed was closest to the door of the room. NA #2 was providing Resident #57 a bed bath with the door closed and privacy curtain pulled between Resident #57 and her roommate who was resting in bed. This surveyor was standing at the foot of Resident #57's bed during the observation when Nurse #1 simultaneously knocked on and opened the door to the resident's room. Resident #57's bare bottom was exposed to the hallway while being washed. No other staff or visitors were observed in the hallway. Nurse #1informed NA #2 that the hospice NA needed to visit Resident #57's roommate then told hospice NA #1 she…

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

Based on record review and staff interviews, the facility failed to effectively document in the electronic medical record for conveyance of medical information for two (Resident #1 and Resident #5) of three residents reviewed for accidental falls. Resident #1 lacked initial documentation of a fall by Nurse #4, initial physical assessments by Nurse #4, and administration of pain medication by Nurse #2 and Nurse #3. Resident #1 had incorrect documentation of the administration of pain medication by Nurse #5. Resident #5 lacked documentation of a nursing physical assessment after a fall. Findings included: 1. a. Documentation on a timesheet for Nurse Aide (NA #1) revealed she worked at the facility from 7:18 AM to 10:53 PM on 5/17/2025. Documentation on the corresponding nursing schedule revealed NA #1 was assigned to care for Resident #1 during that time period. NA #1 was interviewed on 6/10/2025 at 11:54 AM. NA #1 revealed the following information. Resident #1 had a fall on 5/17/2025. NA #1 heard Resident #1 fall, and she told Nurse #4. Nurse #4 was interviewed on 6/10/2025 at 6:41…

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 and a resident interview, the facility failed to immediately notify the Administrator of an abuse allegation made by a resident for one (Resident #2) of three residents reviewed for abuse investigations. Findings included: Documentation on the facility procedures for Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property dated as last reviewed on 11/15/2024 revealed the following statement. Any allegations, suspicion, or identified occurrence identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. Resident #2 was admitted to the facility on [DATE] with diagnoses of schizophrenia, depression, dementia, and bipolar disorder. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 was cognitively intact, always incontinent of bowel 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 reviews and interviews with staff, resident, and the Pharmacist, the facility failed to administer medications as ordered for 1 of 6 residents (Resident #64). Staff did not remove medication from the refrigerator believing the medication had not been received by the pharmacy, resulting in 11 missed doses of eyedrops for glaucoma. Findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses including glaucoma. A physician's order dated 1/04/2025 noted Resident #64 was to receive timolol maleate 0.5 % eyedrops twice a day for glaucoma. Resident #64's February 2025 Medication Administration Record (MAR) noted she did not receive her timolol maleate eyedrops on 2/01/2025 at 9:00 AM, 2/01/2025 at 5:00 PM, 2/11/2025 at 5:00 PM, 2/12/2025 at 5:00 PM, 2/13/2025 9:00 AM, and on 2/14/2025 at 9:00 AM. The reasons noted by nursing staff were that the medication was unavailable, and they were awaiting delivery from the pharmacy. Resident #64's March 2025 MAR noted she did not receive…

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 interviews, the facility failed to cover facial hair during food service for 1 of 2 dietary staff (Cook #1) observed and clean the convection oven and the deep fryer. These practices had the potential to affect food served to residents. The findings included: 1. During a follow-up tour of the kitchen, an observation and interview with [NAME] #1 were conducted on 4/2/25 at 11:30 AM. [NAME] #1 had facial hair and was without facial hair covering while taking temperatures of the lunch meal items located in the steam table. [NAME] #1 stated he did not cover his facial hair because he was about to go on break. He stated he should have always covered his beard and mustache while in the kitchen. During a follow-up interview with the DM on 4/2/25 at 11:40 AM, she revealed that the dietary staff were trained most recently on facial hair coverings last Friday (3/28/25). All dietary staff should know how to always cover facial hair while in the kitchen and [NAME] #1 should have taken the food temperatures prior to going on break. The Administrator was interviewed…

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, records review, and resident and staff interviews, the facility failed to apply a left-hand splint for 1 of 3 residents (Resident #31) reviewed for contractures. Findings included: Resident #31 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contractures of muscle (multiple site), altered mental status, diabetes mellitus type2, and congestive heart failure. Review of the physician orders dated 10/17/24 indicated Occupational Therapy (OT) to be provided 5 times per week for 8 weeks and treat diagnoses of left hemiplegia, contractures, reduced mobility, impaired coordination, and general weakness. This order was discontinued on 12/5/24. Review of the OT Discharge summary dated [DATE] indicated Resident #31 received OT services from 10/17/24 to 12/5/24. The resident at discharge was able to tolerate left upper extremity wrist/hand orthosis (external devices to correct alignment or…

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 staff interviews, the facility failed to label and shake a new tube feeding formula bottle before hanging for 1 of 3 residents (Resident #307). The findings included: Review of the facility's Enteral Feeding: Using a Pump instructions for nurses dated 2022 read in part: Shake the container of formula to ensure that it is mixed well .Label the bag or container with the type of formula, strength, amount, and rate of administration as well as the date, time, and your initials. Resident #307 was admitted to the facility on [DATE] with diagnoses which included stroke, dysphagia, and gastrostomy status (surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage). Review of Resident #307's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and required substantial/maximal assistance with most activities of daily living (ADL). Resident #307 received all…

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, observations and staff interviews, the facility failed to date opened multi-dose pen injectors of insulin medication in 2 of 5 medication administration carts (100 hall and 200 hall), failed to remove expired multi-dose pen injectors of insulin from the medication cart drawer for 1 of 5 medication administration carts (200 hall). Findings included: 1.a. On 3/31/25 at 9:55 AM, an observation of the medication administration 100 hall cart with Nurse #1 revealed one opened and undated multi-dose vial of Lantus insulin pen fill. A review of the manufacturer's literature indicated to discard Lantus insulin multi-dose vial 28 days after opening. On 3/31/25 at 10:00 AM, during an interview, Nurse #1 indicated that the nurses who worked on the medication carts, were responsible for discarding opened and undated multi-dose vials. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medications. The nurse stated that she had not checked the date of opening on insulin vials in her medication administration cart at 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, and staff interviews, the facility failed to prevent a significant medication when a nurse administered 40 mg of liquid morphine when the physician order was for 5mg to 1 of 3 sampled residents (Resident #1) reviewed for medication administration. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia, Dysphagia, Depression, chronic pain, muscle spasm, and gastrostomy status (medication/nutrition through a feeding tube). The quarterly Minimum Data Set, dated [DATE] indicated Resident #1 had short/long term memory problems, gastrostomy status and received medication/nutrition through a feeding tube. Review of the medical record documented Resident #1's was discharged from Hospice services on 6/19/24 and code status as DNR (do not resuscitate). The physicians order dated 10/27/23 revealed an order for morphine concentrate - Schedule II solution; 100 mg/5 mL (milligram/milliliter) (20 mg/mL); Amount to Administer: 0.25 mL (5MG);…

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 reviews and interviews the facility failed to maintain the ice scoop holder clean, failed to have deep fryer cleaned and free of food crumbs, failed to maintain the walk-in freezer clean, failed to discard expired food from reach-in refrigerator, failed to label, and date food placed in 2 of 2 nourishment refrigerator. Failed to ensure dietary staff covered their facial hair. These practices had the potential to affect food served to residents. Findings included: 1. On 1/8/24 at 6:10 AM, observation of the ice scoop holder placed beside the ice machine in the kitchen revealed black colored stains on the base of the scoop holder. During an interview on 1/8/24 at 6:10 AM, the dietary manager stated the scoop holder should be washed daily. Review of the Cleaning Schedule form- Daily for 1/6/24 and 1/7/24 revealed the ice scoops were cleaned and sanitized. There was no mention of the ice scoop holder. 2. On 1/8/24 at 6:15 AM, during an observation of the deep fryer equipment. The fryer had dried food crumbs on the top panel of the equipment. The floor below…

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 ensure advanced directive information was accurate throughout resident's electronic and paper medical records for 1 of 1 resident (Resident #97) reviewed for advanced directives. Findings included: Resident #97 was admitted to the facility on [DATE]. Resident #97's electronic medical record (EMR) revealed a physician's order dated 8/14/23 that read full code. This order was still active on 1/10/24. Resident #97's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 was moderately cognitively impaired. Review of a physician progress note dated 1/3/24 read in part spoke with (Guardian), agrees with DNR status. Resident #97's EMR showed a communication banner on the top of Resident #97's opened EMR and her code status read DNR (Do Not Resuscitate). Resident #97's EMR showed no copy of a signed DNR form scanned into the medical record. Review of the code status binder located at the nurse's station showed Resident #97 had 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 staff interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to reflect a resident's admission to Hospice for 1 of 2 residents (Resident #13) reviewed who had received Hospice services. The findings included: Resident #13 was admitted to the facility on [DATE]. A review of the resident's electronic medical record (EMR) revealed Resident #13 was admitted to Hospice on 10/12/23. Further review of Resident #13's EMR revealed a significant change Minimum Data Set (MDS) assessment dated [DATE] was completed. The MDS section on Health Conditions indicated Resident #13 had a life expectancy of less than 6 months. However, the MDS section on Special Treatments, Procedures, and Programs did not report the resident received Hospice services while she was a resident. An interview was conducted on 1/11/24 at 2:25 PM with the facility's MDS nurses. When asked what prompted the significant change MDS to be completed for Resident #13 on 10/18/23, the nurses…

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 with staff, and record reviews, the facility failed to: 1) Label a medication stored on 1 of 2 medication (med) carts (300 Long Hall Med Cart) with the minimum information required, including the resident's name; 2) Store medications in accordance with the manufacturer's storage instructions on 1 of 2 med carts (300 Long Hall Med Cart); and 3) Maintain clean and sanitary conditions for the storage of medications on 1 of 2 medication carts observed (200 Short Hall Med Cart). The findings included: 1. An observation was conducted on 1/10/24 at 2:40 PM of the 300 Long Hall Medication (Med) Cart in the presence of Nurse #4. The observation revealed the following medications were stored on the med cart: a. An opened vial of Novolog insulin was stored on the med cart. Neither the insulin vial itself nor the medication vial it was stored in was labeled with the minimum information required, including the name of the resident the insulin had been dispensed for. b. An unopened bottle of 1% prednisolone acetate ophthalmic suspension (a steroid eye drop…

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's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification surveys dated 10/27/22 in order to achieve and sustain compliance. These were for recited deficiencies cited during a recertification survey on 1/12/24. The deficiencies were in the following areas: comprehensive assessment, quarterly assessment, and encoding. The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: This tag is cross-referenced to: 1. F636- Based on staff interviews and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (the last day of the assessment period) for 1 of 32 residents (Residents #51) whose MDS assessments were reviewed. During a previous recertification and complaint investigation on 10/27/22, the facility failed to complete admission Minimum Data Set…

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.