Perry Creek Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and resident and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the COVID-19 vaccinations for 1 of 5 residents (Resident #67) reviewed for immunizations.The findings included:The facility policy for COVID-19 vaccination with the effective date 3/11/2024 read in part Vaccinations against COVID-19 will be offered to center patients as indicated. Contraindications for receiving the COVID-19 vaccination include severe allergic reaction to any component of the vaccine. COVID-19 vaccination tracking will be maintained by the Infection Preventionist or designee.Resident #67 was admitted to the facility on [DATE] with diagnoses that included arthritis and asthma. The annual MDS assessment dated [DATE] revealed Resident #67 was cognitively intact and was coded as not being up to date for the COVID-19 vaccination. Review of Resident #67's immunization record revealed no documentation that she had been offered, given, or refused the…

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

Based on observations, staff interviews, and record review, the facility failed to designate a full-time qualified director of food and nutrition services or Dietary Manager (DM). The findings included: Review of the complete staffing list of employees provided by the facility on 2/17/25 revealed that there was a designated Dietary Manager (DM) at the facility. During observations throughout the survey from 2/17/25 through 2/22/25, the facility DM was noted to be scheduled to work at the facility full-time and was observed as the staff member responsible for day-to-day operations in the kitchen. During an interview on 2/18/25 at 12:04 PM, the Regional Dietary Manager said he came to the facility several times a week to support and oversee the facility Dietary Manager. During an interview on 2/22/25 at 12:56 PM, the facility DM said he was in school to become a certified DM but was not certified yet, but the Regional DM was certified and managed the department while he was in school and would come several times a week. During an interview on 2/22/25 at 6:34 PM, the Administrator…

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 facility policy review, record review and staff interviews the facility failed to implement an antibiotic stewardship program to monitor antibiotic usage in the facility. This practice had the potential to affect 127 of 127 residents in the facility. The findings included: Review of the facility's policy titled, Antibiotic Stewardship Program, effective date 10/24/22 revealed the following: The Antibiotic Stewardship Program is designed to promote the appropriate use of antibiotics, monitoring, and management of clinical antimicrobial outcomes, reduce antibiotic resistance, to the extent possible. During an interview with the Director of Nursing (DON) #1 on 2/17/25 at 5:06 pm, she stated she was responsible for the Infection Prevention and Control program. The DON #1 further stated she had been in the DON position for 5 weeks and there was not an Antibiotic Stewardship Program, and she had not had the time to start one. When asked had the facility been monitoring and tracking infections within the facility, she replied no. She indicated she had just learned there was a…

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

Based on observations, interviews with Resident Council members and staff, and review of the Resident Council minutes, the facility failed to communicate the facility's efforts to address concerns voiced by the Resident Council members and to resolve repeat concerns in 3 of 3 months reviewed (November 2024, December 2024, and January 2025) and to maintain evidence that demonstrated the facility's response to grievances/recommendations made by the Resident Council from December 2023 through October of 2024. The findings included: On 2/18/25 at 8:49 AM, the Administrator revealed the facility had no record of Resident Council minutes from prior to November 2024. The Administrator indicated due to staff turnover they were unable to locate those minutes. Additionally, they had no documented evidence to demonstrate their responses and rationale for such responses for any grievances and recommendations made by the Resident Council prior to November 2024. Resident Council minutes dated 11/5/24 indicated residents voiced concerns call lights not being answered timely. The administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and resident and staff interviews, the facility failed to maintain shower floor tiles in good condition on 1 of 3 shower rooms (100-hallway shower room). Findings included: During a tour of the 100-hallway shower room on 2/16/25 at 3:48 PM, broken floor tiles were observed in the 1st and 2nd shower stalls on the left side of the shower room. Resident #70 was present. He reported he could bathe himself once he was assisted to the shower room. He stated he pulled himself up with the grab bar in the shower which placed him with his feet directly on the broken shower tiles. Resident #70 stated he had expressed concerns to staff with no results. He stated he could not remember the last time he reported it or to whom. An observation was made of the 100-hall shower room [ROOM NUMBER]/16/25 at 4:47 PM. In shower stall #1 there was 11 inches by 14 inches of broken tile below the temperature control and the handrail. In shower stall #2 there was 2 inches by 2 inches of broken tile at the center 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, observations, and staff, Pharmacist and Pharmacy Consultant interviews, the facility failed to protect the resident's right to be free from misappropriation of controlled medications. In [DATE], this affected six residents reviewed for misappropriation of property (Resident #232, Resident #109, Resident #87, Resident #81, Resident #16 and Resident #14) and on [DATE], Resident #14's discontinued controlled medications were removed from 300-hall medication cart and not returned to the pharmacy. The findings included: 1. a. Resident #232 was admitted to the facility on [DATE]. Physician orders dated [DATE] included Oxycodone HCL (an opioid) 5 milligrams(mg) every 4 hours as needed for pain. Pharmacy's control medication report recorded Resident #232 was dispensed two separate orders for 90 tablets of Oxycodone HCL 5mg tablet on [DATE]. The [DATE] Medication Administration Record indicated Resident #232's last dose of Oxycodone HCL 5mg was administered on [DATE] at 4:00 pm by Nurse #10.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Pre-admission Screening and Resident Review (PASARR) (Resident #17, Resident 67, and Resident #4), use of opioid pain medication (Resident #14), schizophrenia (Resident #41) and anticoagulants (Resident #10) for 6 of 54 residents whose MDS assessments were reviewed. Findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included depression and dementia. Resident #17's care plan included a focus for dementia and PASARR. Interventions included administering medications as ordered. Resident #17's medical record revealed a level II PASARR determination date of 8/17/23. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was not currently considered by the state level II PASARR process to have a serious mental illness. On 2/21/25 at 2:08 PM in an interview with MDS Coordinator #1, he stated the 7/6/24…

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

Based on record review, and staff and Pharmacist #1 interviews, the facility failed to complete a return pharmacy form and return discontinued non-controlled medications and controlled medications for 11 of 11 residents whose controlled medications were observed located in the Director of Nursing office (Resident #70, Resident #113, Resident #96, Resident #400, Resident #71, Resident #85, Resident #14, Resident #401, Resident #402, Resident #124, Resident #95). Findings included: The facility's policy Disposal of Medications and Medications-Related Supplies: Returning Medications to Pharmacy with no reviewed or revised date stated with the exception of controlled substances, discontinued or unused medications were returned to the provider pharmacy for credit whenever possible. It also stated in part: for each medication returned, an entry was made on the medication return form and included the date, medication name and strength, quantity and prescription number. Medications to be returned to the pharmacy should be secured until the time of pick up. On 2/17/2025 at 7:17 am, 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, and staff , Pharmacist Consultant, and Physician interviews, the facility failed to administer antibiotic medications as ordered by the physician which resulted in a delay in starting antibiotic therapy for 2 of 4 residents reviewed for administration of significant medications (Resident #90 and Resident # 59). Findings included: 1. Resident # 90 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #90 was moderately cognitively impaired. The MDS was also coded Resident #90 as receiving antibiotics as a medication. Physician orders dated 2/4/2025 at 3:32 pm and written by the Wound Treatment Nurse included Clindamycin HCL (an antibiotic) 300 milligrams three times a day for 10 days for cellulitis. The February 2025 Medication Administration Record (MAR) for Resident #90 recorded Clindamycin HCL 300mg milligrams was not started at 9:00 pm on 2/4/2025 as scheduled.…

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 and Pharmacist interviews, the facility failed to maintain controlled medications on the medication carts that provided a separately locked and permanently affixed compartment for storage until the controlled medications were returned to the pharmacy for 1 of 1 filing cabinet observed storing control medications (Director of Nursing's filing cabinet). Findings included: On 2/18/2025 at 5:30 pm, the DON's office door was observed open while the DON was observed in Unit Manager #1's office for two minutes with Unit Manager #1's door closed. On 2/20/2025 at 4:30 pm an interview was conducted with the Director of Nursing (DON), who resigned on 2/19/2025. During the interview the DON informed the surveyor there were controlled medications in a filing cabinet behind the locked door of the DON's office. No further information was obtained in the interview. On 2/22/2025 at 4:10 pm in an interview with the interim Director of Nursing (DON), she stated the DON was responsible for sending back controlled medications to the pharmacy. She stated controlled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff, resident council, and resident interviews, and test tray, the facility failed to provide food that was palatable and served at an appetizing temperature for 10 of 13 residents (Residents #60, #85, #74, #70, #61, #5, #87, #62, #109, and #106) reviewed for food concerns. The findings included: a. The Resident Council minutes from December 2024 and January 2025 noted resident concerns with food palatability. In a Resident Council interview on 2/18/25 at 10:30 AM, 8 out of 11 participants (Residents #74, #70, #61, #5, #87, #62, #109, and #106) expressed the food served was not palatable, that the food would be served cold and the meat was tough. b. Resident #60's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and required supervision for eating. During an interview with Resident #60 on 2/17/25 at 9:23 AM, he reported the food did not taste good and that the meat that was served was dry. Resident #60 stated he ate his meals…

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

Based on record review and staff interviews, the facility failed to implement an effective training program to ensure staff received required training and to maintain documented evidence of trainings for 4 of 4 Nursing Assistants (NA #2, NA #8, NA #9, and NA #11). This practice had the potential to affect all residents. The findings included: A review of the 2024 annual education records provided by the facility revealed no documented evidence that communication, resident rights, compliance and ethics, behavioral health, infection control training on policies and procedures, and QAPI training were conducted for the staff. a. NA #9's personnel file revealed no documentation of communication, resident rights, compliance and ethics, behavioral health, infection control or QAPI training in 2024 through present. A phone interview was conducted on 2/21/25 at 3:46 pm with NA #9. She stated she had worked at the facility approximately 4 years. NA #9 stated she received dementia and abuse training on 9/24/24. She did not recall training related to communication, resident rights, compliance…

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 resident and staff interviews, the facility failed to: ensure an independent and unsupervised smoker was able to exit the smoking area to return inside the building without assistance when the designated smoking area was moved to a new location that had a concrete slope from the interior of the facility to the exterior area (Resident #37); and to place a resident's call light within reach to allow the resident to request staff assistance as needed (Resident #12) for 2 of 8 residents reviewed for accommodation of needs. Findings included: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses including stroke and absence of lower limb. Resident #37's care plan included a focus for assistance with activities of daily living dated 8/6/2024 that listed one person assist with transfers as an intervention. The care plan also included a focus for smoking dated 8/14/2024 and interventions included performing smoking assessments as needed. A physician progress note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, Physician interview, and record review, the facility failed to notify the Physician of Resident #25's complaints of pain after an unwitnessed fall for 1 of 4 residents (Resident #25) reviewed for notification of change. The findings included: Resident #25 was admitted to the facility on [DATE]. Review of Resident #25's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. A progress note dated 1/27/25 completed by Nurse #3 revealed Resident #25 was found on the floor lying on her back between her nightstand and her wheelchair and her left knee was bent. Resident #25 denied hitting her head but complained her left knee hurt pretty bad. The physician was notified. The physician ordered an x-ray of the left knee. Review of the neurological checklist dated 1/27/25 completed by Nurse #3 revealed the following: At 2:00 pm indicated Resident #25 had verbal expressions of pain and rated the pain as 6 (measured on a 0 to 10 scale with 0 being no pain…

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

Based on observation and staff interviews, the facility failed to protect a resident's health care information by leaving confidential medical information unattended, visible and accessible to others on the computer screen for 1 of 5 medication carts observed for privacy and confidentiality (100-hall medication cart). Findings included: During a continuous observation on 2/17/2025 at 5:58 am, Nurse #1 was observed walking away from the 100-hall medication cart located in the hallway with Resident # 43's medical information (name, date of birth , code status and list of six different medications) visible on the computer screen from the 100-hall medication cart positioned five feet from Resident #43's doorway. Nurse #1 was observed entering Resident # 43's room. At 6:00 am, as Nurse #1 returned to the 100-hall medication cart with the computer screen continuing to display Resident #43's medical information, Nurse aide #9 walked by the 100-hall medication cart. Nurse #1 was observed changing the computer screen to Resident #26's medical information (name, date of birth , code status…

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 provide a written notice of transfer and/or discharge to the resident and the resident representative for 1 of 1 resident reviewed for hospitalization (Resident #90). Findings included: Resident #90 was admitted to the facility on [DATE] with diagnoses included Alzheimer's disease. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #90 was moderately cognitively impaired. The discharge MDS assessment dated [DATE] indicated Resident #90 had an unplanned discharge to a hospital, and Resident #90's was anticipated to return to the facility. Nursing documentation on 2/9/2025 at 6:15 pm by Nurse #7 recorded Resident #90 was discharged from the facility to the hospital at the request of Resident #90's family member, and Resident #90's face sheet, medication list and medical orders for scope of treatment (MOST) form was given to the emergency medical services (EMS) personnel. There was no documentation that a written notice…

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 resident representative and staff interviews, the facility failed to provide incontinent care to a resident that was dependent on nursing staff assistance for activities of daily living (ADL) for 1 of 3 residents reviewed for ADL (Resident #33). Findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and aphasia (inability to speak). Resident #33's care plan dated 1/10/2025 indicated Resident #33 was incontinent of urine and stool. Interventions included one person assistance with toileting and providing toileting hygiene when changing adult briefs. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 was severely cognitively impaired, incontinent of urine and stool and was dependent on nursing staff to provide all activities of daily living. On 2/17/2025 at 10:47 am in a phone interview with Resident #33's Representative, she voiced a concern that Resident #33 was found soaked with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to equip 2 of 2 designated resident smoking areas with fire preventative equipment (Smoking Area #1 and Smoking Area #2) and to complete a quarterly smoking assessments for 1 of 1 resident reviewed for smoking (Resident #37). Findings included: 1. On 2/16/2025 at 12:35 pm, one resident was observed smoking in Smoking Area #1, the designated shelter covered smoking area outside the activities recreation room. Smoking Area #1 was observed with a fire extinguisher, two small 4 inch diameter ash trays and a small beige plastic trash can. There was no smoking aprons, fire blanket or self-closing metal containers to empty ashtrays observed in Smoking Area #1. On 2/16/2025 at 3:14 pm, a new non-sheltered designated smoking area, Smoking Area #2, was observed with three vinyl chairs, two plastic foot pedal trash cans, a fire extinguisher, three hanging fire aprons and one metal standing ash tray. There was no smoking blanket or metal…

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 and Physician interviews, the facility failed to ensure effective pain management for a resident with an unwitnessed documented fall on 1/27/25 and failed to provide pain management when assessed by the floor nurse during neurological assessments (an assessment done by the nurse to evaluate for potential brain injuries by checking mental status, level of consciousness, motor function, sensation, coordination, and reflexes) and used a numerical pain scale (a scale that uses numbers from 0 to 10 to measure pain with 0 meaning no pain and 10 meaning the worst pain) and having pain verbalized a 3 out of 10 for three (3) assessments and 6 out of 10 for four (4) assessments for 1 of 1 resident reviewed for pain management (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses which included transient ischemic attack (TIA), cerebral infarction without deficits, and type 2 diabetes mellitus. Resident #25's care plan dated…

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

Based on record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours for 3 of 92 days reviewed for staffing (12/30/24, 1/2/25 and 1/3/25). The findings included: Review of the facility's daily staff posting and staffing schedules from 11/1/24 through 1/31/25 revealed the following: a. On 12/30/24 the daily staff posting indicated a daily census of 113. Review of the staffing schedule revealed there was no RN working on any shift that day. b. On 1/2/25 the daily staff posting indicated a daily census of 118. Review of the staffing schedule revealed there was no RN working on any shift that day. c. On 1/3/25 the daily staff posting indicated a daily census of 119. Review of the staffing schedule revealed there was no RN working on any shift that day. In an interview with the Scheduler on 2/22/25 at 5:39 pm, she stated she worked on the schedule 2 weeks in advance verifying RN coverage. The Scheduler indicated she reported to the Administrator if there was no RN coverage. The Scheduler stated she did not have RN coverage 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 review, and staff and Consultant Pharmacist interviews the facility failed to act on recommendations made by the consultant pharmacist and maintain documentation of the physician's review and response to the pharmacist's findings for 3 of 5 residents reviewed for drug regimen review (Resident #17, Resident #67 and Resident #11). The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included depression and dementia. Resident #17's most recent Minimum Data Set (MDS) assessment dated [DATE], a quarterly revealed Resident #17 had severe cognitive impairment. Review of Resident #17's medication orders revealed she was taking Melatonin 3 milligrams at bedtime (ordered 12/3/24), Remeron 7.5 milligrams daily( ordered 1/3/25), Miralax 17 grams daily (ordered 5/30/24), Bisacodyl DR 5 milligrams twice daily every other day(ordered 12/3/24), and Senna S 8.6 milligrams/50 milligrams once daily (ordered 12/4/24). A medication regimen review completed by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 27 opportunities, resulting in a medication error rate of 7.41% for 2 of 6 residents (Residents #59 and #28) observed during the medication administration observation. The findings included: 1. Resident #59 was admitted to the facility on [DATE] with diagnoses including depression. Resident #59's physician's orders dated 1/31/2025 included Olanzapine 5 milligrams at bedtime for mood stabilizer. An observation on 2/18/25 at 8:47 am revealed due to technical difficulties, electronic medication administration records (MAR) were not available and the facility had printed Medication Aide #4 paper copies of Resident #59's MAR. Before starting medication preparation, Medication Aide #4 was observed asking Resident #59 about her calcium tablet which Resident #59 refused. Medication Aide #4 was observed returning to the medication cart and preparing four…

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 staff, Pharmacist, Corporate Nurse Consultant, and Physician interviews, the facility failed to maintain complete and accurate medical records for medication administration (Resident #50) and for documentation of nursing assessments and accurate physician notification time (Resident #34) for 2 of 46 residents whose medical records were reviewed. Findings included: 1. Resident #50 was admitted to the facility on [DATE] with diagnoses including depression. Physician orders included Zoloft (brand name for Sertraline, an antidepressant medication) 50 milligrams (mg) one tablet a day for depression written on 1/30/2025 to start on 1/31/2025 at 9:00am and Sertraline (generic name for Zoloft) HCl 50 mg one time a day for depression written on 1/31/2025 to start on 2/1/2025 at 9:00am. The order for Zoloft was discontinued on 2/5/20205. The February 2025 Medication Administration Record (MAR) for Resident #50 recorded Sertraline 50mg was scheduled for 9:00 am and administered on 2/1/2025 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident and staff interviews, the facility failed to explain the arbitration agreement to the resident prior to having them sign the agreement and to ensure they explicitly informed the resident that signing the agreement was not required as a condition of admission. This occurred for 2 of 3 residents (Resident#72, and Resident #109) reviewed for arbitration. Findings included: Review of the facility's Arbitration Agreement, which was not dated, revealed documentation by signing the Arbitration Agreement the resident and/or the resident's representative acknowledged they had read and understood the agreement and that the agreement had been adequately explained to them in plain language. a. Resident #72 was admitted to the facility on [DATE]. Review of Resident #72's arbitration agreement revealed the resident had signed the agreement on 6/5/24. Resident #72's most recent Minimum Data Set (MDS) assessment dated [DATE], a quarterly assessment revealed she was cognitively intact. 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 and interviews with the facility Administrator, the facility failed to include the selection of a venue that was convenient to both parties in the Arbitration Agreement. This was for 1 of 3 (Resident #70) residents who were reviewed for entering into an Arbitration Agreement with the facility. The findings included: Resident #70 was admitted to the facility on [DATE]. A review of the Arbitration Agreement signed by Resident #70 on 9/12/24 revealed there was no information to address the selection of a venue convenient to both parties. Resident #70's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. The Administrator was interviewed on 2/22/23 at 6:26 PM. The Administrator stated she expected the arbitration agreement to contain all the required components. She reported the facility changed ownership in June 2024 and the required components were on the arbitration agreement currently in use. The Administrator stated she was not employed 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 observations, record review, and interviews with resident and staff, the facility failed to ensure full visual privacy was available for 1 of 5 rooms (room [ROOM NUMBER]) reviewed for the privacy curtain. The findings were: An observation on 2/16/25 at 10:54 AM of room [ROOM NUMBER] revealed that the privacy curtain would not close to provide full visual privacy to the resident. There was approximately 24 inches of the head of the bed and the resident visible from the door. An observation on 2/22/25 at 1:12 PM revealed the privacy curtain did not close fully around the bed. Upon closer inspection it was noted the curtain connectors got stuck where the two tracks were joined since the curtain connectors did not line up with the second track. There was approximately 24 inches of the head of the bed and the resident visible from the door. In an interview on 2/22/25 at 1:13 PM, the resident who resided room [ROOM NUMBER] said the privacy curtain had not been able to be completely pulled closed for a long…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interview the facility failed to create a person-centered baseline care plan and provide a summary to the residents and/or responsible party within 48 hours of admission for 3 (Resident #6, Resident #7, Resident #10) of 5 residents reviewed for new admission procedures. Findings included: 1. Resident #7 was admitted to the facility on [DATE] with multiple diagnoses some of which included Type 2 Diabetes, protein calorie malnutrition, gastrostomy status, and chronic kidney disease stage 3. Documentation in the care plan written by the Minimum Data Set (MDS) /Care plan coordinator initiated on 8/20/2024 for Resident #7 did not address discharge planning. Documentation on an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Resident #7 was coded as previously, prior to current illness, as being independent with self-care, mobility, stairs, and functional cognition. Resident #7 was coded as requiring substantial…

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 resident, staff, family interview the facility failed to develop and implement a comprehensive care plan to address individual needs related to a resident refusing care secondary to mental illness (Resident # 1), a resident's need for specialized skin care secondary to a genetic disorder (Resident # 2), care for an indwelling catheter (Resident # 16), and discharge planning (Residents # 6). This was for four (Residents # 1, #2, #6, #16) residents of eleven residents whose care plans were reviewed to determine if they addressed individual needs. The findings included: 1. Resident # 1 was admitted to the facility on [DATE] and had diagnoses in part which included a degenerative neuromuscular disease and bipolar disorder with psychotic features. Resident # 1's quarterly Minimum Data Set assessment, dated 6/19/24, coded Resident # 1 as cognitively intact and as being totally dependent on staff for bathing, dressing, hygiene, and bed mobility. The resident was not coded as…

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 interview, staff and pharmacist interview the facility failed to 1) ensure an accurate accounting system for controlled substances for three (Residents # 26, #27, and #28) of three sampled residents whose controlled substance records were reviewed and during a time in which the facility was accountable for overseeing a nurse working under a restricted nursing license related to narcotic handling and 2) ensure medications were available and administered for one (Resident # 10) of seven sampled residents reviewed for pharmacy services. The findings included: 1a. Resident # 27 was admitted to the facility on [DATE]. One of the resident's diagnoses included osteomyelitis. Review of orders revealed an order dated [DATE] for Oxycodone 5 mg (milligrams) every six hours as needed (PRN) for pain. Resident # 27's controlled drug receipt record was reviewed on [DATE] for the dates of [DATE] through [DATE]. (The controlled drug receipt record is a form which details how many…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, pharmacist interview, and physician interview the facility failed to ensure Protimes/ International normalized ratios (INRs) were completed per orders for a resident receiving Coumadin. This was for one (Resident # 2) of one sampled resident receiving Coumadin. The findings included: Resident # 2 was admitted to the facility on [DATE]. One of the resident's diagnoses included atrial fibrillation. (Atrial fibrillation is a heart arrhythmia and can lead to ineffective blood pumping by the heart which then can subsequently lead to blood pooling in the heart chambers and thereby forming clots.) Review of July 2024 physician orders revealed an order transcribed onto the MAR (medication administration record), dated 7/1/24, for Coumadin 2.5 milligrams one time daily on Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday for the diagnosis of Atrial Fibrillation. According to the order the resident was not to receive the Coumadin on Mondays. (Coumadin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review the facility failed to accurately and consistently document vital signs, blood glucose readings, and medication administration for two (Resident #22 and Residnet #13) of three residents reviewed for accuracy of medical record documentation. Findings included: Documentation in a physician order dated 6/22/2024 revealed Resident #22 was ordered to receive Novolog insulin solution to be injected subcutaneously (under the skin) three times day at 8:00 AM, 12:00 PM, and 4:00 PM per the following sliding scale: If the blood glucose level was 201 milligrams per deciliter (mg/dL) to 250 mg/dL administer 4 units; 251 mg/dL to 300 mg/dL administer 6 units; 301 mg/dL to 350 mg/dL administer 8 units; 351 mg/dL to 400 mg/dL administer 10 units; greater than 400 mg/dL call the physician. Novolog is a fast-acting insulin used to treat high blood glucose for people with diabetes. Documentation on the July Medication Administration Record (MAR) for Resident #22 revealed on 7/9/2024 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 residents and staff the facility failed to ensure a resident was allowed the opportunity to see the room and meet the roommate prior to being moved to a new room within the facility. This was for one (Resident # 19) of one resident reviewed for room change notification. The findings included: Resident # 19 was admitted to the facility on [DATE]. Review of Resident # 19's quarterly Minimum Data Set assessment, dated 8/2/24, revealed the resident was assessed to be cognitively intact. A nursing noted on 8/26/24 noted that Resident # 19 was notified of a room change for medical management reasons. The resident's record indicated the room change occurred on 8/27/24. The record also indicated the resident's responsible party was given written notification of the room change prior to the room change. Resident # 19 was interviewed on 8/29/24 at 9:15 AM and reported the following information. She had been told on 8/26/24 (Monday) that she had to move because of insurance…

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 ensure a room was cleaned prior to moving a resident into the room. This was for one (Resident # 19) of four residents reviewed for a homelike and clean environment. The findings included: Resident # 19 was admitted to the facility on [DATE]. Review of Resident # 19's quarterly Minimum Data Set assessment, dated 8/2/24, revealed the resident was assessed to be cognitively intact. A nursing noted on 8/26/24 noted that Resident # 19 was notified of a room change that would occur. The resident's record indicated the room change occurred on 8/27/24. Resident # 19 was interviewed on 8/29/24 at 9:15 AM and reported the following information. She had been told on 8/26/24 (Monday) that she had to move to a new room for insurance reasons. When they moved her on 8/27/24 she had to wait in the hall for 20 minutes because the new room was not cleaned. When they did move her completely in the room, she found the entire room had…

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 the facility failed to report an allegation of neglect of services to law enforcement and adult protective services for one (Resident #22) of three residents reviewed for abuse. Findings included: Documentation in the facility abuse/neglect/misappropriation/crime policies and procedures dated as effective 2/5/2023 revealed under procedure, there was the requirement of reporting to the state agency, adult protective services, and local law enforcement authorities for alleged violations of neglect. Documentation on an initial allegation report faxed to the state on 7/16/2024 at 12:14 AM revealed the facility was made aware of an allegation of neglect on 7/15/2024 at 9:05 PM for an incident that occurred on 7/11/2024. The documentation revealed a family member of Resident #22 alleged resident's catheter wasn't reinserted, blood sugar was high, and resident [did] not receive Eliquis. Eliquis was [discontinued on] 6/1/24. It was alleged the [Certified Nursing Assistant] improperly placed briefs on the resident. Resident was sent to [Emergency Room]. The initial…

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 family, staff, and physicians the facility failed to ensure a thorough investgation was conducted when they received an allegation of neglect for one (Resident # 22) of one sampled resident whose family lodged a complaint of neglect. Resident # 22's family member filed an allegation of neglect after receiving an anonymous phone call that Resident # 22 needed to be sent to the hospital. Interviews revealed the anonymous phone call was made by a medication aide when she feared the resident was about to die and was not receiving medical care while under the care of Nurse # 4. Interview with the medication aide revealed she had previously reported concerns regarding Nurse # 4 not responding to an emergeny situation and former administration did not investigate. The findings included: Review of the facility's policy entitled Abuse/Neglect, Missappropriation/ Crime Reporting Requirements/ Investigations revealed nursing will immediately initiate a thorough internal…

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 family interviews the facility failed to refer a resident for home health services and order necessary equipment for 1 of 1 resident reviewed for discharge (Resident #6). The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease. Resident #6's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She had no mood symptoms or behaviors. She was coded as planning to discharge to the community. Review of the Discharge summary dated [DATE] indicated that Resident #133 was discharged from the facility on 8/26/24. The discharge summary was signed by Social Worker #2. The discharge summary indicated a rollator walker had been recommended. Home Health assistance with activities of daily living and home health physical therapy had been recommended by the physical therapist. An interview was conducted with Resident #6's family member on 8/28/24 at 2:47 PM who stated Resident…

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

Based on family interview, record review, staff interviews, and emergency medical services (EMS) report the facility failed to obtain physician orders for one (Resident #4) of five residents reviewed for admission procedures. Findings included: There was no documentation in the electronic medical record of Resident #4 other than the hospital Discharge summary dated as uploaded by the facility on 7/10/2024. The hospital discharge summary, for the 7/3/2024 to 7/10/2024 hospital stay, revealed Resident #4 had the discharge diagnoses of generalized muscle weakness, chronic lymphocytic leukemia, age related physical debility, primary hypertension, Stage 3 chronic kidney disease, Type 2 diabetes mellitus, and a history of transient ischemic attack (stroke). The hospital discharge summary listed an expected medication list at discharge but did not include any orders for oxygen. There was no documentation of any orders or any admission documentation in the electronic medical record to indicate initial orders were obtained for Resident #4 from a facility physician. An interview was conducted…

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 6 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease. She was discharged to the community on 8/26/24. Resident #6's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She was coded as planning to discharge to the community. Review of the resident's care plan, dated 8/1/24, revealed no mention of discharge planning. There was no documentation Resident #6, or the Responsible Party (RP) had been invited and involved in a care plan meeting. An interview with Resident # 6's RP on 8/28/24 at 2:47 PM revealed she had never been involved in any type of care plan for the resident. She stated she was initially told Resident #6 was going to be discharged on 8/17/24 and that did not happen. The RP stated she was contacted on 8/23/24 and was told the resident was going to be discharged on 8/24/24. The RP felt that the communication was very poor at the facility about what needed to be done for the resident. She further stated better…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and resident interview the facility failed to implement an effective discharge planning process for one (Resident #7) of one resident who wished to discharge from the facility. The findings included: Resident #7 was admitted to the facility on [DATE] with multiple diagnoses some of which included Type 2 Diabetes, protein calorie malnutrition, gastrostomy status, and chronic kidney disease stage 3. Documentation in the base line care plan written by the Minimum Data Set (MDS) /Care plan coordinator initiated on 8/20/2024 revealed there was no documentation for Resident #7's discharge plan to return to the community. Documentation on an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Resident #7 was coded as previously, prior to current illness, as being independent with self-care, mobility, stairs, and functional cognition. Resident #7 was coded as requiring substantial or maximal assistance for all activities of daily…

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 resident, family, and staff the facility failed to ensure a resident received assistance with incontinent care. This was for one (Resident # 2) of four residents reviewed for activity of living needs being met. The findings included: Record review revealed Resident # 2 was admitted to the facility on [DATE]. The resident's diagnoses included in part a history of congestive heart failure, a history of spinal stenosis and stroke. Resident # 2's significant change [NAME] Data Set assessment, dated 8/22/24, coded the resident as moderately cognitively impaired. The resident was also assessed to be totally dependent on staff for bed mobility, hygiene needs, toileting needs, and bathing needs. He was assessed to be frequently incontinent of bowel and bladder. Review of Resident # 2's care plan revealed it had been updated on 7/18/24 to include that the resident required assistance with his activities of daily living due to congestive heart failure and chronic medical…

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 staff and physicians the facility failed to obtain orders for the care of a resident's indwelling urinary catheter. This was for one (Resident # 16) of three sampled residents with indwelling urinary catheters. The findings included: Resident # 16 was admitted to the facility on [DATE]. One of the resident's diagnoses included urinary retention. The discharge summary also noted the resident had an indwelling urinary catheter and discharge orders included the instructions that the catheter should be changed monthly. There was a notation in the discharge summary that the next due date for catheter change was on 7/3/24. Review of Resident # 16's admission Minimum Data Set assessment, dated 6/20/24, revealed the resident had an indwelling urinary catheter. Review of the resident's care plan, dated 8/9/24, revealed no mention of the urinary catheter. A review of physician orders for Resident # 16 revealed no orders for the care of the urinary catheter or when…

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, Emergency Medical Services (EMS) record, staff and family interviews the facility failed to provide respiratory care services for one (Resident #4) of three residents reviewed for respiratory care. Findings included: There was no documentation in the electronic medical record of Resident #4 other than the hospital Discharge summary dated as uploaded by the facility on 7/10/2024. The hospital discharge summary, for the 7/3/2024 to 7/10/2024 hospital stay, revealed Resident #4 had the discharge diagnoses of generalized muscle weakness, chronic lymphocytic leukemia, age related physical debility, primary hypertension, Stage 3 chronic kidney disease, Type 2 diabetes mellitus, and a history of transient ischemic attack (stroke). The hospital discharge summary listed an expected medication list at discharge but did not include any orders for oxygen. There was no documentation of any orders or any admission documentation in the electronic medical record to indicate initial orders were obtained for Resident #4 from a facility physician. An interview was conducted…

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 resident, staff, and family the facility failed to ensure a system was in place to manage call outs in nursing so incontinent care and showers could be provided. This was for one of four residents reviewed for sufficient staff to meet residents' individual needs (Resident #2). The findings included: Record review revealed Resident # 2 was admitted to the facility on [DATE]. The resident's diagnoses included in part a history of congestive heart failure, a history of spinal stenosis and stroke. The resident also had a diagnosis of peripheral neurofibromatosis (a genetic condition that causes skin tumors). Resident # 2's significant change [NAME] Data Set assessment, dated 8/22/24, coded the resident as moderately cognitively impaired. The resident was also assessed to be totally dependent on staff for bed mobility, hygiene needs, toileting needs, and bathing needs. He was assessed to be frequently incontinent of bowel and bladder. Review of Resident # 2's care plan…

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 residents and staff the facility failed to ensure a system where residents who preferred and requested larger portions received the portions per their preference without having to go to the dietary department and ask for more food. This was for two (Residents # 9 and # 11) of six sampled residents reviewed for dietary services to meet their preferences and needs. The findings included: 1. Resident # 9 was admitted to the facility on [DATE] with multiple diagnoses which in part included congestive heart failure and diabetes. Review of Resident # 9's admission Minimum Data Set assessment, dated 8/21/24, revealed the resident had moderate cognitive impairment. A review of Resident # 9's diet orders revealed an order, dated 8/15/24, for a diabetic regular diet. The order did not note any preferences for larger portions. A review of Resident # 9's care plan, dated 8/16/24, revealed the resident's dietary preferences were to be reviewed as needed for 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, family interview, and staff interview the facility failed to provide rehabilitation services per the resident's plan of care. This was for one (Resident # 16) of three sampled residents reviewed for therapy services. The findings included: Resident # 16 was admitted to the facility on [DATE] following a fourteen day hospitalization. According to a hospital Discharge summary dated [DATE] the resident was found to be treated for acute ulcerative esophagitis, upper gastrointestinal bleeding, and a urinary tract infection while hospitalized . Additionally, the resident had diagnoses in part which included a hiatal hernia, urinary retention, congestive heart failure, chronic obstructive pulmonary disease, seizure disorder, and hypertension. According to the 6/17/24 discharge summary Resident # 16 was to have physical therapy upon discharge. Resident # 16's Minimum Data Set assessment, completed on 6/20/24, coded the resident as moderately cognitively impaired. The resident was assessed to need…

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 residents, staff, pharmacists, and physician the facility failed to ensure 1) controlled drug receipt disposition records coincided with the order and administration of a resident's morphine which indicated the resident had not received the morphine as prescribed (Resident # 3) and 2) ensure non controlled medications were obtained from the pharmacy and administered per orders (Residents # 8 and # 13). This was for three of five sampled residents reviewed for medications. The findings included: 1. Resident # 3 was readmitted to the facility on [DATE]. The resident had a diagnosis of chronic pain. Per the resident's 7/3/24 hospital discharge summary, the resident and her guardian had chosen comfort care, and the facility was to follow up with a hospice referral once she was admitted to the facility. Discharge instructions on the 7/3/24 summary also included the resident should receive morphine sulfate 100mg/5 ml (20 mg/ml) concentrated solution. Give .25 ml…

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 interview, staff interview, and physician interview the facility failed to ensure residents received antibiotics or insulin correctly. This was for one (Resident # 1) of six sampled residents whose medications were reviewed and for one (Resident # 14) out of four residents observed during a medication pass observation. The findings included: 1. Record review revealed Resident # 1 was admitted to the facility on [DATE]. Resident # 1's hospital Discharge summary, dated [DATE], included the following information. The resident had wounds. One of Resident # 1's wounds was located on the right ankle and a MRI had shown right lateral ankle with underlying osteomyelitis of the distal fibula. (Osteomyelitis is a bone infection and the fibula is the leg bone which extends into the ankle joint). Resident # 1's discharge summary indicated going to SNF (skilled nursing facility) for extended antibiotics, wound care, and rehab. The discharge summary did not note which antibiotic…

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 resident interviews, record reviews, staff interviews, pharmacist interviews, and physician interviews administration failed to ensure adequate training and systems were in place as the facility changed over from one medical record system to another during a week when the facility had 14 hospital admissions which required orders to be initiated for care, medications, and treatments. This was for four (Residents #1, Resident # 2, Resident # 3, and Resident # 13) sampled residents of the 13 residents who were admitted during the week of the facility's change over to their new medical record system. (One of the thirteen residents was admitted twice during the first week of transition). The findings included: 1a. Resident # 1 was admitted on [DATE]. Resident # 1's hospital Discharge summary, dated [DATE], included the information that Resident # 1 had wounds and osteomyelitis (a bone infection). According to the discharge summary the resident was to be transferred to a skilled nursing facility for extended…

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 family interviews the facility failed to notify the responsible party of a transport to the hospital for one (Resident #2) of three residents reviewed for notification of a change in condition. Findings included: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses some of which were dementia, benign prostatic hyperplasia, chronic kidney disease, and atrial fibrillation. Documentation under the profile tab in the electronic medical record of Resident #2 revealed a family member was listed as the responsible party. Documentation on a SNF/NF to Hospital Transfer form dated 7/11/2024 at 2:00 PM revealed Nurse #3 sent Resident #2 to the emergency room for bleeding from the urethra. Nurse #3 documented on the transfer form; the facility name was the resident representative who was notified of the transfer of Resident #2. An interview was conducted on 7/31/2024 at 1:20 PM with the family member who was listed as the responsible party for Resident #2. 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 resident, staff, and physician the facility failed to ensure clarification was obtained when a resident arrived for facility admission without orders for a medication the hospital discharge summary indicated he needed to treat a bone infection. This was for one (Resident # 1) of three residents reviewed for provision of medical care per professional standards of practice. The findings included: Record review revealed Resident # 1 was admitted to the facility on [DATE]. Resident # 1's hospital Discharge summary, dated [DATE], included the following information. The resident had a history of stroke, paraplegia, prostate cancer, lumbar stenosis, chronic pain and lymphedema, and wounds. Vascular surgery was consulted during the hospitalization, and the vascular physician did not think the resident had peripheral vascular disease. One of Resident # 1's wounds was located on the right ankle and a MRI had shown right lateral ankle with underlying osteomyelitis of the distal…

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 a resident, family, staff, and physician the facility failed to ensure orders were obtained and carried out for flushes for a peripheral inserted central catheter. (A peripheral inserted central catheter is a type of intravenous access, which requires flushes with an ordered solution to maintain the patency in order that the line not clot off). This was for one (Resident # 1) of one sampled resident with an intravenous access site. The findings included: Record review revealed Resident # 1 was admitted to the facility on [DATE]. Resident # 1's hospital Discharge summary, dated [DATE], included the following information. Resident # 1's discharge summary indicated going to SNF (skilled nursing facility) for extended antibiotics, wound care, and rehab. On 7/3/24 the resident was transferred to the facility for care. On the resident's admission nursing assessment, it was noted the resident had a PICC (peripheral inserted central catheter). From the dates of 7/3/24 through…

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 resident, family, and staff the facility failed to ensure appropriate transportation was arranged in order that a resident attend a scheduled appointment with a specialist physician. This was for one (Resident # 1) of two residents reviewed for missed appointments. The findings included: Record review revealed Resident # 1 was admitted to the facility on [DATE]. The resident's diagnoses in part included prostate cancer and chronic progressive lower extremity weakness with paraplegia. Resident # 1's admission Minimum Data Set) assessment, dated 7/8/24, coded the resident as cognitively intact. He was also assessed to be 79 inches tall (6 feet and 7 inches tall.) Interview with Resident # 1 on 7/31/24 at 2:40 PM revealed he had missed a urology appointment since his admission date to the facility on 7/3/24. He further reported the following information about the missed appointment. He was a very tall man and they had placed him in a wheelchair to be transported in a van…

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, record review and staff interview the facility failed to ensure their medication rate was below five percent. Two nurses and two Medication Aides were observed to administer medications. Three errors were detected out of 26 opportunities for error resulting in a 11.53 % medication error rate. One error was an omission, one error was because of the wrong medication administered, and one error was the wrong administration time for sliding scale insulin. The findings included: 1a. On 8/1/24 at 8:05 AM Medication Aide #1 (MA # 1) was observed as she administered medications to Resident # 14. MA # 1 viewed the electronic medication administration record and reported Resident # 14 was due to receive Ferrous Gluconate. MA # 1 looked through the cart and could not find any. She then went to look in a different area of the facility and returned to say that there was none. She was not observed to give any Ferrous Gluconate to Resident # 14. Following the medication pass observation, a review of orders revealed Resident # 14's orders included he receive Ferrous Gluconate…

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 a resident's guardian, staff, hospice provider, and physician the facility failed to initiate a hospice referral when the resident was readmitted with clear instructions that her wishes were for comfort measures which included comfort foods and no tube feedings. After the hospice referral was made, Resident # 3's wishes were still not made known by the hospice provider and facility staff to the physician so that tube feedings could be stopped and comfort foods initiated until the guardian questioned the plan of care. This was for one (Resident # 3) of one sampled resident reviewed for hospice services provided at the facility. The findings included: Record review revealed Resident # 3 was readmitted to the facility on [DATE] after being hospitalized from [DATE] to 7/3/24. Resident # 3's hospital Discharge summary, dated [DATE], included the following information. The resident had a history of multiple strokes, history of tracheostomy with decannulation,…

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, record review, and staff interview the facility failed to 1) perform hand hygiene while performing dressing changes and prior to obtaining supplies from the facility's treatment cart and 2) keep scissors in a clean field before using them to cut dressing items used directly in a resident's wound bed and 3) ensure caring of different wounds was a separate task with different gloves and hand hygiene to avoid potential cross contamination between wound beds. This was for one (Resident # 1) of one sampled resident who was observed during wound care. The findings included: Review of the facility's infection prevention control policy, dated 2/6/20, revealed staff were to perform hand hygiene when removing gloves and gloves were to be removed when moving from a contaminated body site to a clean body site. On 8/1/24 at 6:15 PM Nurse # 11 prepared to care for Resident # 1's wounds. At the time, the resident reported his left foot had already been dressed for the day. Unit Manager # 1 also joined Nurse # 11 while she was in the room and also helped with the direct care…

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 staff, family, Nurse Practitioners, and physicians, for a resident with multiple wounds caused by shearing and pressure, the facility failed to have a system in place to accurately evaluate the extent nutrition was contributing to the development and non-healing of the wounds and develop a plan to address any nutritional deficit. This was for one (Resident # 4) out of three sampled residents with pressure sores. The findings included: Resident # 4 was initially admitted to the facility on [DATE] with a most recent readmission date on [DATE] following hospitalization. The resident had diagnoses which included chronic encephalopathy, hypertension, history of remote infarcts to the basal ganglia and thalami, gastrostomy placement, and history of ileus. Review of Resident # 4's quarterly Minimum Data Set assessment, dated [DATE], revealed the resident was severely cognitively impaired. Additionally, the resident was assessed to be totally dependent on staff for her bathing,…

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 staff and the Nurse Practitioner the facility failed to ensure the medical record was complete and accurate regarding administration of treatments, administration of medications, administration of enteral feedings, and weights. This was for one (Resident # 4 of one sampled resident reviewed for accuracy of medical records. The findings included: Resident # 4 was initially admitted to the facility on [DATE] with a most recent readmission date on 8/29/23 following hospitalization. The resident resided at the facility until 5/16/24. 1 a. Review of Wound Physician notes from December 2023 through the resident's discharge revealed she was to receive wound care for multiple pressure sores. Review of Resident # 4's TARs (Treatment Administration Records) for the month of January 2024 revealed multiple Ns beside treatments where the nurses were to document a check mark to signify the treatment was done. The facility's Nurse Consultant was interviewed on 5/31/24 at 2:52 PM and…

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

Based on observations, record review, resident, staff, nurse practitioners, and physician interview the facility Quality Assessment Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the complaint survey completed 6/6/2024. This was for three repeat deficiencies in the areas of pressure sore care, nutritional status, and resident record documentation that were originally cited on 6/6/2024. The continued failure of the facility showed a pattern of the facility's inability to sustain an effective QAPI committee. The findings included: This citation is cross referred to: F686: During the complaint survey of 8/6/2024 the facility failed to 1) ensure orders were entered into the electronic medical record upon admission and after treatment order changes were made by a weekly visiting Wound Physician in order that nurses would know and provide the correct treatment on correct days 2) clarify which Wound Physician was to be overseeing the care of a resident's pressure sores when 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 staff and physicians, for a resident whose weights showed a trending decline, the facility failed to ensure a system was in place for the registered dietician to become aware of accurate weights and develop a plan of care to address weight loss. This was for one (Resident # 4) of two sampled residents reviewed for nutritional status interventions. The findings included: Resident # 4 was initially admitted to the facility on [DATE] with a most recent readmission date on [DATE] following hospitalization. The resident had diagnoses which included chronic encephalopathy (a change in brain function), hypertension, history of remote infarcts to the basal ganglia and thalami (brain damage in specific areas of the brain) , gastrostomy placement, and history of ileus. Review of Resident # 4's quarterly Minimum Data Set assessment, dated [DATE], revealed the resident was severely cognitively impaired. Additionally, the resident was assessed to be totally dependent on staff 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 record review, resident, and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint surveys of 4/1/21, 8/11/22 and 11/30/23 and the complaint survey of 1/18/23. This was for a deficiency in the area of Residents Rights/Exercise of Rights (F550). The continued failure during five federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings: This tag is cross-referenced to: F550: Based on record review, staff, and resident interviews, the facility failed to treat a resident with dignity and respect when Nursing Assistant (NA) #3 refused to assist Resident #2 with eating her meal at lunch time and then yelled at Resident #2 when her lunch tray fell on the floor. Nurse #2 observed the resident shaking and crying after the incident with NA #3. This occurred for 1 of 2 residents reviewed for dignity and respect. During recertification…

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 Nurse Practitioner interview, the facility failed to follow a physician order for laboratory services for 1 of 1 resident reviewed for providing care according to professional standards (Resident #1). Findings: Resident #1 was admitted to the facility on [DATE] with the following diagnose cerebral infarction due to embolism and osteomyelitis. The 11/27/23 Annual Minimum Data Set (MDS) revealed Resident #1 was moderately cognitively impaired. There were no other MDS completed. A review of the Nurse Practitioner's progress note dated 12/10/23 for 12/8/23 visit revealed documentation of her assessment of Resident #1. The progress notes documented Resident #1 stating he did not feel well and was nauseated. The Practitioner documented that she would obtain lab work due to Resident #1's weakness, complaints of not feeling well and nausea. Review of the paper physician's orders dated 12/8/23 revealed Resident #1 was to have a complete blood count (CBC) and a comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, interview with the Pharmacy Consultant, interview with the Physician (MD), the facility failed to assess for tardive dyskinesia (involuntary movements and a side effect of long-term treatment with antipsychotic medications) for a resident prescribed an antipsychotic medication (Resident #81). Additionally, the facility failed to ensure a physician's order for as needed (PRN) psychotropic medication for a resident (Resident #56) was time limited in duration. This affected 2 of 5 residents reviewed for unnecessary medications. Findings included: 1. Resident #81 was admitted to the facility on [DATE] with diagnoses including a schizophrenia disorder. An Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] indicated Resident #81 was not experiencing abnormal involuntary movements, a side effect when taking antipsychotic medications. There were no other AIMS assessments documented in Resident #81's electronic medical record. A review of the Pharmacy…

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 Dietician, and physician interviews, the facility failed to follow a physician order for obtaining a resident's weight twice per week for 1 of 5 residents (Resident #32) reviewed for nutrition. Findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses that included dementia and hypertension. A review of the active November physician's orders indicated a physician order dated 8/19/21 that revealed, obtain weight twice weekly. If weight changes 2-3 pounds overnight or 5 pounds in 1 week notify doctor. The quarterly Minimum Data Set, dated [DATE] revealed Resident #32 had moderate cognitive impairment with no rejection of care or significant weight loss coding. Review of Resident #32's weights from 10/1/23 through 11/29/23 revealed two weights obtained and recorded. The weight for 10/13/23 was 118.4 pounds and the weight for 11/11/23 was 119.8 pounds. Review of Resident #32's Medication Administration Records (MAR) for October and November 2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review the facility failed to rinse soap from a resident's skin per manufacturer's directions during a bath for 1 of 4 resident reviewed for activities of daily living care (Resident #26). Findings included: Review of the directions printed on the bottle of body wash and shampoo combination soap (which was used for the bath on 11/28/23 at 11:34 AM) read in part, DIRECTIONS: Shampoo - Apply a small amount to wet hair or scalp and work into a lather. Massage scalp and hair. Rinse well. Shower or tub bath - Apply product to wet washcloth or directly to wet skin to create light lather. Gently cleanse skin. Rinse well. Resident #26 was admitted to the facility on [DATE]. Her active diagnoses included progressive neurological conditions, dementia, and anemia. Resident #26's Minimum Data Set assessment dated [DATE] revealed she was assessed as severely cognitively impaired. She had no behavior noted. She was dependent on staff for eating, oral hygiene, toileting…

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.