Premier Living and Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #23 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, anxiety disorder, and recurrent moderate depressive disorder. The physician's orders revealed an order dated 4/30/25 for the psychotropic medication Depakote tablet delayed release 125 mg. Give 1 tablet by mouth two times a day for generalized anxiety. The quarterly Minimum Data Set (MDS) for Resident #23 dated 5/10/25 revealed he was severely cognitively impaired and received an antidepressant on a regular basis. A review of Resident #23's electronic medical record (EMR) indicated no documentation that the resident representative was informed in advance of the risks or benefits of initiating Depakote. The Medication Administration Record (MAR) from 4/30/25 through 6/25/25 indicated Resident #23 was administered Depakote as ordered. An interview with the Director of Nursing (DON) on 6/24/25 at 2:00 PM. Revealed the facility had not been obtaining consent for psychotropic medications. The DON stated she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, and Wound Care Physician interviews, the facility failed to notify the physician of pressure ulcers that were identified on admission and to notify the responsible party when a stage 2 pressure ulcer worsened to an unstageable pressure ulcer for 1 of 1 residents reviewed for pressure ulcers (Resident #64). Findings included: Resident #64 was admitted on [DATE]. A nursing admission progress note completed by Nurse #2 on 3/7/25 at 3:43 PM indicated the resident had Stage 2 pressure ulcers (partial thickness skin loss) to the bilateral buttocks. The admission progress note did not indicate that the physician was notified of the pressure ulcers. A review of the admission skin assessment dated [DATE] by Nurse #2 revealed that Resident #64 was noted with the following areas on the skin: - left buttock pressure ulcer 1 centimeter (cm) length with 2 cm width - right buttock pressure ulcer 2 cm length with 2 cm width The admission skin assessment did not indicate that the physician 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, and staff, Wound Care Physician, and Nurse Practitioner interviews, the facility failed to implement an effective discharge plan by failing to inform the responsible party of a pressure wound and provide wound care instructions before discharging a resident home for 1 of 1 residents reviewed for discharge (Resident #64). Findings: Resident #64 was admitted on [DATE] with diagnosis which included femur fracture (a fracture of the long thigh bone), multiple myeloma (a cancer of the white blood cells), Covid, pneumonia and encephalopathy. A nursing admission progress note completed by Nurse #2 on 3/7/25 at 3:43 PM indicated Resident #64 was admitted with Stage 2 pressure ulcers to bilateral buttock. A care plan dated 3/7/25 indicated Resident #64's family preferred short term placement with a goal for resident to return home after completion of rehabilitation. The care plan indicated that Resident #64 will require 24 hour care upon discharge. Interventions indicated that the Social Worker…

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 2. Resident #32 was admitted to the facility on [DATE]. Diagnoses included major joint replacement with right femur fracture. A progress note written on 04/11/25 by Nurse #10 revealed Resident #32 had a fall and an order was obtained to send Resident #32 to the emergency room for further evaluation. A nursing progress note written on 04/11/25 by Nurse #10 revealed Resident #32 was admitted to the hospital for right femur fracture. An admission summary note written by the Director of Nursing on 04/15/25 revealed that the resident arrived at the facility via Emergency Medical Services, had a right femur fracture and had an open reduction internal fixation (a type of surgical procedure used to repair a bone break or facture) done on 04/14/25. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #32 was moderately cognitively impaired and she had no impairments to her lower extremities. An interview with Resident #32 on 06/22/25 at 1:10 PM revealed she had a right femur fracture in April…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff, the Registered Dietitian, Nurse Practitioner, and Physician interviews the facility failed to provide an enteral tube feeding (nutrition provided directly into the digestive system through a tube inserted through the nose, stomach, or small intestine) according to the physician's order. This occurred for 1 of 2 residents reviewed for nutrition (Resident #48). Findings included. Resident #48 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident, dysphagia (difficulty swallowing), and gastrostomy tube placement (tube placed into a surgically created opening in the stomach). A care plan dated 9/19/24 revealed Resident #48 required tube feedings. Interventions included to maintain adequate nutrition and hydration status and provide the diet as ordered. A physician's order dated 1/6/25 for Resident #48 revealed enteral feeding in the evening for nutrition. Infuse the fortified nutritional supplement at 55 milliliters (ml) per hour…

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, observation, and staff interviews, the facility failed to implement their policy for enhanced barrier precautions and hand hygiene during wound care for 1 of 3 residents (Resident #66) whose wound care was observed. The facility also failed to implement an infection surveillance plan for monitoring and tracking infections in the facility to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 70 of 70 residents in the facility. Findings included: 1. Review of the facility Enhanced Barrier Precautions policy documented enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact…

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 ensure all staff received training on dementia care, infection control policies and procedures and the elements of the Quality Assurance Performance Improvement (QAPI) program. This practice had the potential to affect all residents. Findings included: A review of the 2023 and 2024 annual education records from April 2023 to May 2024 provided by the facility revealed no documented evidence that dementia care, infection control training on policies and procedures and QAPI training were conducted for the staff. a. Medication Aide #5's personnel file was reviewed and revealed a date of hire of 11/8/2019. There was no documentation of dementia care, infection control and QAPI training in the personnel file. A phone interview was conducted on 7/1/2024 at 1:23 pm with Medication Aide #5. During the interview, Medication Aide #5 stated she was not able to recall having QAPI training since April 2023 and thought she had received some training on infection control and dementia care in the last year but was unable to recall…

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 submit a report of an allegation of neglect to Adult Protective Services (APS) and law enforcement within the required time frame for 4 of 4 residents (Resident #46, #51, #269 and #419) reviewed for neglect. The facility was officially notified of neglect on 06/13/24 at 2:15 PM when an immediate jeopardy template was issued. The facility did not notify APS or law enforcement within the required time frame following notification. Findings included: Review of the facility provided initial allegation report dated 06/14/24 regarding Residents #46, #51, #269, and #419 revealed no documentation of APS being notified and no record of law enforcement notification. During an annual recertification survey and complaint investigation, the facility was officially notified of neglect on 06/13/24 at 2:15 PM and an immediate jeopardy template was issued to the Administrator. The immediate jeopardy template was signed by the Administrator and the Administrator was verbally informed of the information regarding the situation…

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 the comprehensive Minimum Data Set (MDS) assessments within the required timeframe for 5 of 29 residents reviewed for MDS assessments (Resident #269, Resident #17, Resident #9, Resident #24 and Resident #16). Findings included: a. Resident #269 was admitted on [DATE]. Resident #269's admission Minimum Data Set (MDS) dated [DATE] was completed on 5/15/24. An interview was conducted with MDS Nurse #2 on 6/11/24 at 1:57 PM. MDS Nurse #2 stated she had been in training since she started in May taking online MDS courses to learn the requirements for the assessments. MDS Nurse #2 stated since she was still learning it was the Remote MDS Nurse that completed the assessments. MDS Nurse #2 stated she was told the MDS assessments were behind. An interview with the Administrator on 6/14/24 at 4:41 PM revealed there had been personnel changes in the role of MDS Nurse several times since she started in February. The Administrator stated she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete quarterly assessments within the required 14-day timeframe for 14 of 29 residents reviewed for quarterly MDS assessments. (Resident #20, Resident #36, Resident #51, Resident #22, Resident #38, Resident #61, Resident #63, Resident #5, Resident #21, Resident #47, Resident #7, Resident #14, Resident #26, and Resident #58). Findings included: a. Resident #20 was admitted on [DATE]. Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] was listed as in progress and was incomplete. b. Resident #36 was admitted to the facility on [DATE]. Resident #36's quarterly Minimum Data Set (MDS) assessment dated [DATE] was completed on 6/11/24. c. Resident #51 was admitted on [DATE]. Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] was completed on 6/4/24. d. Resident #22 was admitted on [DATE]. Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] was completed on 5/30/24. e. Resident #38 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 and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 3 of 26 residents reviewed (Resident #50, Resident #61, and Resident #8 ). Findings included: 1. Resident #50 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, and diabetic foot ulcer. Review of pharmacy consultant notes written on 01/22/24 and 02/15/24 revealed the resident had a diagnosis of diabetic foot infection and chronic inflammatory polyneuropathy. The Minimum Data Set (MDS) quarterly assessment dated [DATE] did not have Resident #50 coded as having a venous or arterial ulcer or as having a diabetic foot ulcer. Review of the care plan dated 03/08/24 revealed Resident #50 had a plan of care for diabetes mellitus with interventions to include inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness; and a plan of care for potential pressure area related to decreased mobility and peripheral vascular disease 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 3. Resident #52 was admitted to the facility on [DATE]. Diagnoses included, in part, dementia, seizures, syncope and chronic kidney disease. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #52 was severely cognitively impaired and required assistance with activities of daily living and was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #52's weight was recorded as 193 pounds and there were no nutritional approaches indicated. The care area assessment dated [DATE] indicated to initiate care plans in the following areas: activities of daily living, urinary incontinence, and nutritional status. Review of Resident #52's electronic medical record from admission on [DATE] through 06/19/24 revealed there were no care plans in place to address nutritional status, activities of daily living, or urinary incontinence. An interview was conducted on 06/14/24 at 4:00 PM with the Director of Nursing (DON). The DON stated she was not aware that care plans 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 record review, resident interviews, resident representative interviews, and staff interviews, the facility failed to ensure the resident and/or the responsible party was involved in the care planning process (Resident #61 and Resident #16), to revise a resident's care plan with new fall interventions (Resident #47), and to develop a care plan within 7 days after completion of the comprehensive assessment (Resident #319). This deficient practice affected 4 of 26 residents reviewed for care planning. Findings included: 1. a. Resident #61 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #61 was cognitively intact. There was no documentation of the facility having a care plan meeting with Resident #61 or Resident #61's Representative in Resident #61's medical record. On 6/10/2024 at 2:00pm in an interview with Resident #61, he stated since his admission to the facility he had not had a care plan meeting with the different disciplines…

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 2. Resident #419 was admitted to the facility most recently on 08/07/23. Diagnoses included, in part, a sacral stage 4 pressure ulcer, and hemiplegia and hemiparesis following a stroke (cerebral infarction) affecting his dominant right side. Review of a quarterly Minimum Data Set (MDS) assessment date 02/09/24 revealed Resident #419 had severely impaired cognition. Both upper and lower extremities on one side were impaired. He had one stage 4 pressure ulcer and one deep tissue injury that were not present on admission. He had received pressure ulcer care. The care plan for Resident #419 revised on 03/05/24 documented a focus area of antibiotic therapy. The goal was for the resident to be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions included administering antibiotic medication as ordered by the physician and to monitor and document any side effects, the effectiveness, and any signs of secondary infection related to the antibiotic therapy. 2a. 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, staff, Registered Dietitian and Facility Physician interviews, the facility failed to obtain physician ordered weekly weights for 4 of 6 residents reviewed for nutrition and wound care evaluation (Resident #36, Resident #38, Resident #219, Resident #52) and failed to address a Registered Dietitian recommendation for a medication to stimulate appetite for 2 of 6 residents reviewed for nutrition (Resident #36, Resident #38). Findings included: 1. Resident # 36 was admitted on [DATE] with diagnoses which included dysphagia (difficulty swallowing), chronic obstructive pulmonary disease and diabetes. Resident # 36's electronic health record included a 2/8/24 physician order for weight on admission then weekly for 3 weeks (4 weights total); then monthly or as specified by the physician. Resident # 36's weight record contained the following: 2/9/2024 10:13 AM 118.7 pounds (lbs.) 2/16/2024 No weight recorded. 2/23/2024 No weight recorded. 3/3/2024 7:06 PM 121.0 lbs. A 3/12/24 Registered Dietitian…

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 interview, the facility failed to ensure staff were trained and competent in the process to obtain medications from the pharmacy for 10 of 10 staff (Nurse #8, Nurse #9, Nurse #3, Nurse #6, Nurse #17, Nurse #16, Nurse #7, Unit Manager #1, Unit Manager #2, and the Director of Nursing) reviewed for pharmacy procedures for obtaining medications. Findings included: 1a. Resident #51 was admitted on [DATE]. Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain. The May 2024 MAR indicated Resident #51's gabapentin was not administered as ordered from 5/8/24 through 5/13/24 due to the medication not being obtained from the pharmacy. An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was assigned to Resident #51 on 5/8/24 and 5/9/24. Nurse #8 indicated she did not know the process for obtaining medications from the pharmacy and had been informed by other 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 record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours per day seven days a week for 17 of 130 days reviewed for sufficient staffing ( 2/18/2024, 3/10/2024, 3/12/2024, 3/16/2024, 3/17/2024, 3/23/2024, 3/24/2024, 3/30/2024, 3/31/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 5/4/2024, 5/5/2024, 6/8/2024 and 6/9/2024). Finding included: The Payroll Based Journal (PBJ) report for the first quarter of 2024 (January, February, March) reported the facility without RN coverage for eight consecutive hours per day. A review of the daily census posting sheets for the months of February 2024 to June 9, 2024, reported a constant census greater than 60 residents in the facility and no RN coverage for eight consecutive hours for the following dates: 2/18/2024, 3/10/2024, 3/12/2024, 3/16/2024, 3/17/2024, 3/23/2024, 3/24/2024, 3/30/2024, 3/31/2024, 4/13/2024, 4/14/2024, 4/20/2024, 4/21/2024, 5/4/2024, 5/5/2024, 6/8/2024 and 6/9/2024. A review of the daily nursing staffing sheets for the months of February 2024 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #50 was admitted to the facility on [DATE]. Diagnoses included, in part, coronary artery disease, high blood pressure, chronic kidney disease, and congestive heart failure. A review of a physician's order written on 10/06/23 revealed give one tablet of Carvedilol (a medication to treat coronary artery disease) 12.5 milligrams twice daily and to hold medication for a heart rate less than 60 beats per minute (bpm) or systolic blood pressure (SBP) less than 110 milligrams per mercury (mg/Hg) and administer with meals. A review of Resident #50's medication administration record (MAR) for May 2024 to administer the Carvedilol 12.5 milligrams revealed the following: 05/11/24 the blood pressure recording was 100/59 mm/Hg and the heart rate recording was 59 bpm at 9:00 AM and was signed off by Unit Manager #1 05/15/24 the blood pressure recording was 106/68 mm/Hg at 9:00 AM and was signed off by Nurse #9 05/26/24 the blood pressure recording was 109/63 mm/Hg at 5:30 PM and was signed off by Unit Manager #1…

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 Consultant Pharmacist, staff and Physician interviews the facility failed to limit an as needed (PRN) psychotropic medication to 14 days (Resident #18 and Resident #22), provide an appropriate diagnosis for an antipsychotic medication (Resident #269), and monitor for abnormal involuntary movements on a resident receiving an antipsychotic medication (Resident #47) for 4 of 5 residents reviewed for unnecessary medications. Findings included: 1. Resident #18 was admitted to the facility most recently on 06/23/23. Diagnoses included, in part, generalized anxiety disorder. Review of the physician orders for Resident #18 revealed the following order that started on 11/08/23: Ativan 0.5 mg (Milligram)-give one tablet by mouth every 6 hours as needed for anxiety or agitation. Review of the January 2024 MAR (Medication Administration Record) for Resident #18 revealed on 01/27/24 she had been administered PRN Ativan 0.5 mg that had a start date of 11/08/23. Review of the April 2024 MAR 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.

Based on observation and staff interviews, the facility failed to: discard 10 doses of COVID-19 vaccine and a bottle of senna syrup (a liquid laxative medication) that were expired in the South station medication room for 1 of 2 medication rooms reviewed. The facility failed to store an unopened bottle of eye drops in the refrigerator per manufacturer's instructions on the 400-hall medication cart. The facility failed to dispose of 4 bottles of expired eye drops and had an in use inhaler with no resident name, opened date or expiration date on the 200 Hall medication cart. The facility failed to label a tube of eye ointment with an opened and expiration date and failed to discard an expired bottle of atropine solution on the 300 Hall medication cart. This was for 3 of 3 medication carts observed for medication storage. Findings included: 1a. Observation of the South station medication room was conducted on 6/11/24 at 2:30 PM with Unit Manager #1 in attendance. The following expired medications were observed: 14 doses of COVID-19 vaccine were observed with a printed expiration date…

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, Pharmacy Technician, and Consultant Pharmacist interviews the facility failed to accurately document on the Medication Administration Record (MAR) the administration of medications for 2 of 10 residents (Resident #10 and Resident #8) reviewed for medications. Findings included. 1. A physician's order dated 03/06/24 for Resident #10 revealed Tetrabenazine 25 milligrams (mg) oral tablets. Give 2 tablets by mouth in the morning for Tardive Dyskinesia. Review of the Medication Administration Record (MAR) dated May 2024 for Resident #10 revealed Tetrabenazine 25 mg oral tablets. Give 2 tablets by mouth daily at 9:00 AM was signed off as administered on the following dates and time. 05/14/24 at 9:00 AM 05/16/24 at 9:00 AM 05/19/24 at 9:00 AM 05/21/24 at 9:00 AM 05/22/24 at 9:00 AM 05/23/24 at 9:00 AM 05/29/24 at 9:00 AM Review of the Medication Administration Record (MAR) dated June 2024 for Resident #10 revealed Tetrabenazine 25 mg oral tablets. Give 2 tablets by mouth daily at 9:00…

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, and resident interviews, the facility failed to treat a resident (Resident #50) with dignity and respect when a nurse refused to leave the resident's room upon request and when the resident was not assisted out of the shower when requested. The resident expressed feelings of anger and frustration. This was for 1 of 1 resident reviewed for dignity. Findings included: Resident #50 was admitted to the facility on [DATE]. Diagnoses included, in part, right below the knee amputation with prothesis. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed resident was cognitively intact and demonstrated no behaviors. 1a. Review of an investigation report submitted to the Department of Health and Human Services (DHHS) on 02/21/24 for an abuse allegation on 02/15/24 indicated Resident #50 reported that the nurse on night shift (Nurse #12) hit his leg three times and was verbally aggressive towards him while attempting to give him his medication. No physical or mental injury…

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 transmit the quarterly Minimum Data Set within the required time frame for 1 of 26 resident assessments reviewed (Resident #5). Findings included: Resident #5 was admitted into the facility on [DATE]. Resident #5's medical record revealed his quarterly Minimum Data Set, dated [DATE] was signed as completed on 04/15/24 with a transmission date of 06/11/24. An interview was conducted on 06/17/24 at 1:37 PM with the Minimum Data Set Coordinator. She stated she was aware that the quarterly Minimum Data Set for Resident #5 had not been transmitted within the designated time frame. She stated she knew Resident #5's MDS was transmitted late. An interview was conducted on 06/14/24 at 11:15 AM with the Administrator. She indicated that all Minimum Data Sets should be transmitted in a timely manner as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop an individualized person-centered baseline care plan within forty-eight hours of admission for 2 of 26 residents reviewed for care planning (Resident #16 and Resident #319). Findings included: 1. a. Resident #16 was admitted to the facility on [DATE] with diagnoses including stroke. The physician's orders dated 4/26/2024 included an order for rivaroxaban (an anticoagulant medication that prevents or break down blood clots) 20 milligrams(mg) via gastrostomy tube (G-Tube) in the evening for anticoagulation. Resident #16's April 2024 Medication Administration Record (MAR) recorded rivaroxaban 20 milligrams (mg) was administered 4/27/2024, 4/28/2024 and 4/29/2024. There was no individualized person-centered baseline care plan located in Resident #16's medical record for the 4/26/2024 admission. Nursing documentation dated 4/29/2024 at 8:25 p.m. reported Resident #16 was coughing up blood and bleeding profusely from the nose. Emergency…

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 Nurse Practitioner (NP) interviews, the facility failed to assess, obtain physician orders for treatment, and communicate about the new pressure ulcer so assessments and treatments could be provided for 1 of 5 residents reviewed for pressure ulcers (Resident #119). Findings included: Resident #119's Hospital admission note dated 03/02/24 revealed resident with pressure ulcer of coccygeal region that was present on admission. Resident #119 was admitted from the hospital to the facility on [DATE]. The diagnoses included diabetes, congestive heart disease, end stage renal disease, atrial fibrillation, and hypertension. Review of the head-to-toe skin assessment for Resident #119 dated 04/04/24 done by Nurse #2, identified and documented a Sacrum - small, reddened area to bony prominence, pressure absorbent bandage in place. A nursing note dated 04/05/24 at 2:37 AM by Nurse #10 revealed Resident #119 admitted to facility via stretcher from hospital during day shift. Resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, the facility failed to supervise a dependent resident (Resident #50) when he was left alone in the shower room on the shower chair and waited for staff to answer the call light and provide assistance for 1 of 7 residents reviewed for accidents. Findings included: Resident #50 was admitted to the facility on [DATE]. Diagnoses included right below the knee amputation with prothesis, coronary artery disease, high blood pressure, chronic kidney disease, and congestive heart failure. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed resident was cognitively intact and demonstrated no behaviors. He required supervision with one person physical assistance with transfers, had impairment one side to lower extremity, used a wheelchair and had limb prosthesis. Resident #50 required partial to moderate assistance with showering and bathing, lower body dressing below the waist, getting in and out of shower, and transferring from chair to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a physician visit occurred for a resident within 30 days from admission for 1 of 8 sampled residents reviewed for physician visits (Residents #48). Findings included: Resident #48 was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, dementia, depression, anxiety, pain, seizures, hallucinations, and edema. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #48 had moderate cognitive impairment. Review of Resident #48's Electronic Medical Record (EMR) revealed she was not seen by the attending physician. Review of Resident #48's EMR revealed she was seen by Nurse Practitioner (NP) on 05/14/24. An interview was conducted on 06/14/24 at 11:15 AM with the Administrator. She stated their past Medical Director (MD) was not personally visiting their facility as often as he should have. The Administrator the stated reason for switching MD companies, was for that reason, MD was not visiting on…

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

Based on record review and staff interviews, the facility failed to complete a performance review every 12 months for 1 of 5 nursing assistants (NAs) reviewed to ensure in-service education was designed to address the outcome of the performance reviews (Medication Aide #5). Findings included: Medication Aide #5's personnel file was reviewed and revealed a date of hire of 11/8/2019. The personnel file for Medication Aide #5 did not include evidence a performance review had been completed since the Medication Aide #5's date of hire. A phone interview was conducted on 7/1/2024 at 1:23 pm with Medication Aide #5. During the interview, Medication Aide #5 stated her annual performance evaluation was due in November 2023 and had not received a performance evaluation in the last year. A phone interview was conducted on 6/19/24 at 10:22 am with the Director of Nursing (DON). During the interview, the DON stated since starting at the facility in March 2024, she had not conducted a performance review for Medication Aide #5. The DON did not provide a reason as to why she had not conducted an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and hospice staff interviews the facility failed to maintain communication and coordination of services provided by hospice in the medical record complete with hospice admission documentation, hospice plan of care, and hospice visit notes in the facility's electronic medical record and failed to obtain physician orders for hospice services for 1 of 1 resident reviewed for hospice (Resident #48). Findings included: Resident #48 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, dementia, seizures, and edema. Review of Resident #48's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment. Resident #48 was coded as receiving Hospice services while a resident. A review of Resident #48's medical record revealed no evidence of the following: physician order for hospice services, hospice plan of care, facility hospice care plan, hospice certification statement, hospice nursing…

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

Based on record review and staff interviews the facility failed to have a Registered Nurse (RN) scheduled for 8 consecutive hours a day for 3 of 92 days (08/07/22, 09/03/22, and 09/04/22) reviewed for staffing. This failure had the potential to affect all residents in the facility. Findings included. Review of the facility's Payroll Based Journal (PBJ) staffing data report for Quarter 4 of 2022 (July 1 - September 30, 2022) revealed 7 infraction dates of 07/09/22, 07/10/22, 08/07/22, 08/28/22, 09/03/22, 09/04/22, and 09/25/22 when there was no RN coverage in the facility. During an interview on 04/05/23 at 09:00 AM the Administrator stated of the 7 infraction dates listed on the PBJ report she could verify through timecard reports that there was an RN on duty for 8 consecutive hours on 07/09/22, 07/10/22, 08/28/22, and 09/25/22 but stated she could not confirm RN coverage for 8 hours on the infraction dates of 08/07/22, 09/03/22, and 09/04/22. A review of the facility Timecard Report revealed on 07/09/22, 07/10/22, 08/28/22, and 09/25/22 there was RN coverage in the facility for 8…

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 the annual Minimum Data Set (MDS) assessments within the required timeframe for 5 of 5 residents reviewed for annual MDS assessments (Resident #39, Resident #4, Resident #19, Resident #34 and Resident #7) Findings included: a. Resident #39 was admitted to the facility on [DATE]. Resident #39's 2/28/23 annual Minimum Data Set (MDS) assessment was listed as in process. Assessment was not completed. b. Resident #4 was admitted to the facility on [DATE]. Resident #4's 3/6/23 annual MDS assessment was listed as in process. Assessment was not completed. c. Resident #19 was admitted to the facility on [DATE]. Resident #19's 2/1/23 annual MDS had a completion date of 3/10/23. d. Resident #34 was admitted to the facility on [DATE]. Resident #34's 2/11/23 annual MDS was completed on 3/23/23. e. Resident #7 was admitted to the facility on [DATE]. Resident #7's 1/21/23 annual MDS was completed on 3/7/23. Interview with the Administrator on 4/04/23…

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 quarterly assessments within the required 14-day timeframe for 6 of 6 residents reviewed for MDS assessments. (Resident #15, Resident #21, Resident #10, Resident #40, Resident #35, and Resident #17). Findings included: a. Resident #15 was admitted to the facility on [DATE]. Resident #15's 2/13/23 quarterly MDS assessment was completed on 3/9/23. b. Resident #21 was admitted to the facility on [DATE]. Resident #21's 2/22/23 quarterly MDS was completed on 3/16/23. c. Resident #10 was admitted to the facility on [DATE]. Resident #10's 2/18/23 quarterly MDS was completed on 3/9/23. d. Resident #40 was admitted to the facility on [DATE]. Resident #40's 2/24/23 quarterly MDS was completed on 3/27/23. e. Resident #35 was admitted to the facility on [DATE]. Resident #35's 2/12/23 quarterly MDS was completed on 3/9/23. f. Resident #17 was admitted to the facility on [DATE]. Resident #17's 1/31/23 quarterly MDS was completed on 2/22/23. 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 record review and staff interview the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of Level II Preadmission Screening and Resident Review (PASARR) for 3 of 3 residents (Resident #15, Resident #7, and Resident #3) reviewed for PASARR. Findings included: 1. Resident #15 was admitted to the facility 9/29/17 with diagnoses which included major depressive disorder and anxiety. Record review indicated Resident #15 had a level II Preadmission Screening and Resident Review (PASARR), indicating serious mental illness evaluation on 8/16/18. Resident #15's 11/13/22 annual Minimum Data Set (MDS) indicated a No response to the question which asked if Resident #15 had been evaluated by a Level II PASARR and determined to have serious mental illness and/or intellectual disability or a related condition. Interview with the Director of Nursing (DON) on 4/05/23 at 2:57 PM revealed she was responsible for completing the MDS assessments for all residents since the MDS Nurse left several months ago. The DON stated some of the questions in the MDS are…

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 Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitoring interventions the committee put into place following a COVID-19 Focused Infection Control survey and complaint investigation survey on 01/06/2021. The failure was for one deficiency that was cited for Resident Assessment (F641) and was subsequently recited on the current recertification and complaint investigation survey of 04/06/2023. The repeat deficiency during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referenced to F 641: Based on record review and staff interview the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of Level II Preadmission Screening and Resident Review (PASARR) for 3 of 3 residents (Resident #15, Resident #7, and Resident #3) reviewed for PASARR. During the COVID-19 Focused Infection Control Survey and Complaint investigation on 01/06/2021 the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to administer the influenza vaccine during the 2022-2023 season after informed consent was obtained for 2 of 5 residents reviewed for influenza vaccinations (Resident #248 and Resident #44) and failed to administer the pneumococcal vaccination after obtaining informed consent for 1 of 5 residents reviewed for pneumococcal vaccinations (Resident #248). Findings included: 1.Resident #248 was admitted on to the facility on 3/13/23. A review of Resident #248's medical record revealed the 2022-2023 Influenza Consent Form indicated consent to receiving the influenza immunization for the annual season of October 1, 2022-March 31,2023 was signed by the resident's responsible party on 3/10/23. A review of Resident #248's medical record revealed the facility Pneumococcal Consent Form indicated consent given to receive the pneumococcal vaccination was signed by the resident's responsible party on 3/10/23. A review of Resident #248's physician orders revealed…

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