Lotus Village Center for Nursing and Rehabilitatio

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews with the resident, staff, Physician Assistant and Medical Director, the facility failed to provide pain management for a resident who reported acute, severe pain rated at a 8 out of 10 (0 meaning no pain and 10 meaning the worst pain experienced) during wound care treatment of a Stage 3 pressure ulcer. This deficient practice affected 1 of 3 residents reviewed for effective pain management (Resident #2).The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses including obstructive uropathy, cerebrovascular accident, diabetes mellitus, depression, moisture-associated skin damage (MASD) and other specified arthritis at multiple sites.A review of the admission Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed that Resident #2 was cognitively intact, did not display any behaviors, was able to make her needs known, received scheduled as needed (PRN) pain medication, had pain frequently and reported…

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 maintain a complete and accurate medical record by not documenting a resident's elopement from the facility and not documenting a nurse assessment to check for injuries upon the resident's return for 1 of 3 residents reviewed for complete and accurate medical records (Resident #58). Findings included:Resident #58 was admitted to the facility's locked memory care unit on 11/12/25.A statement written as part of the facility's investigation by the Activity Assistant and dated 01/08/26 revealed in part, at approximately 5:05 PM when leaving the facility, Resident #58 was observed walking down the road and had reached a point in the road between a food pantry and a thrift store. The Activity Assistant pulled her car over, asked Resident #58 what she was doing and Resident #58 asked the Activity Assistant for a ride. Resident #58 got into the car and was taken back to the facility. The Activity Assistant asked Resident #58 to go into the facility with her to figure things out, Resident #58 complied with the request and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to document that a Resident or Responsible Party (RP) were provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunization or if the Resident received the influenza and pneumococcal immunization or did not receive the vaccines due to a medical contradiction or refusal. In addition, there was no documentation that the Resident was offered the influenza and pneumococcal immunization. This occurred for 1 of 5 residents reviewed for immunizations (Resident #58).The findings included:A review of the facility's policy entitled Influenza Vaccination last revised 01/01/26 read in part that Influenza vaccinations will be routinely offered from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine. Following assessment for potential medical contraindications, influenza…

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 interviews, the facility failed to assess residents for eligibility and ensure residents were offered the COVID-19 vaccination for 3 of 5 residents reviewed for immunizations (Resident #2, Resident #6 and Resident #9).The findings included:A review of the facility's policy entitled COVID-19 Vaccination last revised 01/01/2026 read in part that COVID-19 vaccinations will be offered to resident as per Centers for Disease Prevention and Control (CDC) guidelines unless it is medically contraindicated, the individual has already been immunized or refuses to receive the vaccine. Following assessment for potential medical contraindications, COVID-19 vaccinations for residents may be administered in accordance with physician approved standing orders.a. Resident #2 was admitted to the facility on [DATE].Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 was cognitively intact and was coded Yes, for COVID-19 immunization being up to date.Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Physician Assistant (PA) interviews, the facility failed to transcribe on admission an order for surgical wound care and subsequently failed to provide care to the surgical wound as ordered by the physician for 1 of 3 residents reviewed for quality of care (Resident #1).The findings included:Review of Resident #1's hospital Discharge summary dated [DATE] revealed the following order: On the day of discharge (02/20/26) the physician opened up a small portion about 4 centimeters (cm) of the wound below the umbilicus that had some seropurulent drainage (a thin, watery, and cloudy wound exudate that appears yellowish or tan, often indicating an early or existing wound infection or inflammation) present. The discharge summary specified Resident #1 would need wet to dry dressing changes for that area of the wound with normal saline twice a day.Resident #1 was admitted to the facility on [DATE] following an exploratory laparotomy resulting in a colostomy (a surgical procedure that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and Physician Assistant interviews, the facility failed to maintain a complete and accurate medical record related to a resident's abdominal incision and colostomy for 1 of 3 residents reviewed for complete and accurate medical records (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] following an exploratory laparotomy resulting in a colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall, bringing a portion of the colon to the surface to divert stool into a replaceable pouch).Review of Resident #1's medical record from admission on [DATE] to discharge on [DATE] revealed there were no assessments of the Resident's abdominal incision or the new colostomy documented in the medical record.Resident #1 was discharged on 02/21/26.An interview was conducted with Nurse #1 via telephone on 03/18/26 at 3:55 PM who worked the day shift on 02/20/26 when Resident #1 was admitted to the facility. The Nurse explained that she…

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

Based on observations, record reviews and staff and Consultant Pharmacist interviews, the facility failed to remove loose and unsecure pills of various shapes, sizes and colors, failed to remove expired and unlabeled medications, failed to remove discharged residents' medications from a medication cart and failed to secure medications in locked medication carts. These failures occurred on 4 of 4 medication carts (100 Hall, 200 Hall, 300 Hall and 400 Hall medication carts) and 1 of 1 medication room (the main medication room) reviewed for medication storage. The findings included: 1a. An observation of the 100-hall medication cart was made on 05/21/25 at 3:30 PM accompanied by Nurse #3. The cart yielded 14 loose pills of various shapes, colors and sizes in the bottom of the drawers. An interview conducted with Nurse #3 on 05/21/25 at 3:30 PM. The Nurse explained that it was the responsibility of the nurse on the cart to keep the medication carts clean and orderly. b. An observation of the 300-hall medication cart was made on 05/21/25 at 2:04 PM accompanied by Nurse #1. The cart…

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 interviews, the facility failed to complete Care Area Assessments (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 1 of 2 residents reviewed for Activities of Daily Living and Indwelling Urinary Catheters (Resident #82). The findings included: Resident #82 was admitted to the facility on [DATE] with diagnoses that included spastic quadriplegic, cerebral palsy and neurogenic bladder. Review of Resident #82's 10/13/24 Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was moderately impaired and he required substantial to maximal assistance with his activities of daily living. The MDS also indicated Resident #82 had an indwelling urinary catheter. Review of Section V (CAA Summary) from the admission MDS dated [DATE] revealed the care area for activities of daily living for Resident #82. The MDS Coordinator who completed the assessment did not provide any information in the analysis of findings…

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 and record reviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment following hospice election for 1 of 1 resident reviewed for hospice (Resident #44). The findings included: Resident #44 was admitted to the facility on [DATE]. A medical record review revealed Resident #44 was admitted to hospice on 04/23/2025 with hospice admission diagnoses of dementia and failure to thrive. A review of Resident #44's MDS assessments revealed no significant change MDS assessment was completed after the resident was admitted to hospice services. A phone interview with the Remote MDS Nurse, who was responsible for the MDS assessments at the facility, at 9:17 AM on 05/22/2025 revealed if a resident went to hospice, then the resident should have a significant change MDS assessment completed. She further stated no significant change MDS assessment had been completed for Resident #44 and according to Resident Assessment Instrument (RAI) manual (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD, referring to the last day of the observation period) for 1 of 23 residents reviewed for Resident Assessment (Resident #38). The findings included: Resident #38 was admitted to the facility on [DATE]. Review of Resident #38's electronic medical record revealed the following: -A quarterly Minimum Data Set (MDS) assessment with an ARD of 04/12/25 that was marked as completed on 05/15/25. An interview was conducted on 05/21/25 at 8:39 AM with the former MDS Nurse who stated that she was aware that she got behind on completing the MDS assessments in the required timeframes and explained that she was given other duties that took her away from her MDS responsibility. The former MDS Nurse reported when she asked the previous Administrator for some support with the MDS process she was denied. During an interview with the Director of Nursing (DON)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and Nurse Practitioner (NP) interviews, the facility failed to change an indwelling urinary catheter as ordered for 1 of 1 resident reviewed for urinary catheters (Resident #82). The findings included: Resident #82 was admitted to the facility on [DATE] with diagnoses that included neurogenic bladder (a condition where bladder function is disrupted due to nerve damage or malfunction, leading to problems with bladder control and emptying). Resident #82 was discharged to home on [DATE]. Review of Resident #82's discharge summary from the hospital and physician orders dated 10/13/24 indicated to change the (indwelling urinary) catheter on 11/01/24. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #82's cognition was moderately impaired and had an indwelling urinary catheter. Review of Resident #82's admission orders transcribed into the resident's medical record by Nurse #1 included an order to change the indwelling urinary catheter on 11/01/24. The…

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

Based on observations, staff interviews, and record reviews, the facility failed to follow their Hand Hygiene and Enhanced Barrier Precautions policies when Nurse #2 did not perform hand hygiene prior to donning second pair of gloves and when she did not perform hand hygiene and don new gloves prior to reinserting a new disposable trach cannula. This deficient practice occurred for 1 of 2 staff members observed for infection control practices (Nurse #2). The findings included: The Enhanced Barrier Precautions (EBP) policy implemented on 07/2023 and reviewed/revised in 07/2024 revealed the following: an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, Peripherally inserted central lines, midline catheters) even if the resident is not known to be infected or colonized with a Multi-Drug Resistant Organism. A review of the hand hygiene policy implemented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set assessment in the area of dental for 1 of 3 residents reviewed for accuracy of assessment (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. A review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's dental status was coded as unable to examine. During a phone interview on 4/9/25 at 4:59 PM the Administrator revealed the current MDS Coordinator was not employed when the significant change MDS was completed for Resident #1. The Administrator revealed the MDS Coordinator who completed and signed Resident #1's significant change MDS dated [DATE] worked remotely and no longer employed at that company and she was unable to provide their contact information. A joint phone interview was conducted on 4/10/25 at 10:26 AM with the Administrator and Director of Nursing (DON). The Administrator revealed it was the responsibility of the remote…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Nurse Practitioner, Director of Dental Clinical Operations and staff, the facility failed to withhold antiplatelet medication per physician's order prior to a scheduled dental visit for tooth extractions which delayed the tooth extractions for 1 of 1 resident reviewed for providing care according to professional standards (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including heart failure, hypertension, and chronic pain. A review of Resident #1's current physician orders included aspirin 81 milligrams (mg) give one time a day prophylactic started on 5/3/24 with no end date. (Aspirin is the most commonly used oral antiplatelet drug.) The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1's cognition was intact and the current medications he was taking included an antiplatelet (helps prevent blood clots). A review of the Nurse Practitioner (NP) note dated 8/26/24 revealed Resident #1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff, Nurse Practitioner (NP), Medical Director (MD) and Poison Control interviews, the facility failed to provide an environment free from a potential hazard when Sodium Polyacrylate (a super-absorbent powder used to absorb large volumes of liquids) and a glass of solidified fruit punch was left at the bedside within a resident's reach for 1 of 3 residents (Resident #1) reviewed for accidents. The findings included: Review of a bottle labeled Liqui-Loc, generically known as Sodium Polyacrylate, revealed it solidified (made solid) 1500 milliliters of blood and body fluids and contained 1.8 ounces. Resident #1 was admitted to the facility on [DATE] with diagnoses which included mild intellectual disability. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired and exhibited no behaviors during the assessment period. Resident #1 required extensive assistance with bed mobility, was dependent for transfers, 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, staff, and Nurse Practitioner interviews the facility failed to notify the medical provider of an allegation of alleged sexual abuse involving Resident #2. This affected 1 of 4 residents reviewed for abuse. The findings included: Resident #2 was admitted to the facility on [DATE]. Review of an initial allegation dated 07/25/24 at 9:16 PM read in part; staff alleged that Resident #1 stated he was sexually inappropriate with Resident #2. Resident #1 was placed on one-on-one supervision and investigation has been initiated. The report was electronically signed by the Administrator. Review of the daily schedule for 07/25/24 revealed that Nurse #4 and Nurse #5 were working the night shift. Nurse #4 was interviewed via phone on 07/31/24 at 5:53 PM who explained that she was not the nurse for Resident #1 or Resident #2 that night (07/25/24) but shortly after shift change Nurse Aide (NA) #3 and NA #4 came and stated that they needed to talk in private. The two NAs reported to Nurse #4 that while…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident, and staff interviews the facility failed to protect a resident's right to be free from resident-to-resident abuse when Resident #7 hit Resident #4 with a closed fist in the left eye after Resident #7 believed that Resident #4 was looking at inappropriate pictures on the shared facility computer located in the communal activity room. Resident #4 had a red area under his left eye and since the incident avoided Resident #7 and the use of the shared facility computer for approximately a week and a half which Resident #4 spent a lot of time on a daily basis. This affected 1 of 4 residents reviewed for abuse (Resident #4). The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses that included aphasia (inability to communicate verbally). Review of a care plan updated on 01/13/24 read, it is important to engage in daily routines that are meaningful. The goal read; Resident #4 will have opportunities to make decisions/choices related to/for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff, Resident, family member and Police Detective interviews the facility failed to have systems in place to prevent illegal substances from entering the facility. This affected 2 of 3 residents (Resident #1 and Resident #3) reviewed for supervision to prevent accidents. The finding included: 1. Resident #3 was readmitted to the facility on [DATE] with diagnoses that included end stage renal disease requiring hemodialysis, diabetes mellitus, diabetic retinopathy and blindness. A review of Resident #3's care plan revised 01/19/23 revealed a vision impairment related to diagnosis of diabetic retinopathy and blindness with the goal to remain free from falls, injury and decreased socialization. The interventions utilized included giving verbal instructions and explanation, providing a clutter free environment and do not rearrange items in her room. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact with highly…

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

Based on observations, record reviews and staff, family member, Nurse Practitioner, Urology Surgeon, Wound Physician, and Medical Doctor interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the Complaint Survey on 07/12/23 and Recertification and Complaint Survey of 09/14/22. This failure was for 3 deficiencies that were originally cited in the areas of (F580) Notification of Change, (F600) Neglect and (F684) Quality of Care that were subsequently recited on the current Complaint Survey on 04/08/24. The repeat deficiencies during the three surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. The finding included: This tag is cross referenced to: F-580: Based on record reviews, and staff, Nurse Practitioner, and Medical Doctor interviews the facility failed to notify the Nurse Practitioner or the Medical Doctor when a Urology Consult was not able to be scheduled per the Nurse Practitioner's order after a CT…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and review of the facility's Advance Directive policy the facility failed to provide written advance directive information and/or opportunity to formulate an advance directive and also failed to ensure a residents code status election was evident and accurately documented in the medical record for 10 of 10 (Resident #7, #12, #25, #27, #50, #63, #67, #71, #73, and #84) residents reviewed for advance directive. Findings included: a. Resident #50 was admitted to the facility on [DATE]. Review of a physician order dated [DATE] read, Advanced care planning-goals of care refer to state form. The order did not explain where the form was kept. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #50 was severely cognitively impaired for daily decision making and had long/short term memory problems. A review of the facilities advanced directives book that was kept at the nursing station revealed a Medical Order for Scope of Treatment (MOST)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint surveys conducted on [DATE] and [DATE]. This failure was for 8 deficiencies that were originally cited in the areas of (F561) Self Determination, (F578) Request/Refuse/Discontinue Treatment/Formulate Advanced Directive, (F641) Accuracy of Assessments, (F656) Develop, Implement Comprehensive Care Plan, (F688) Increase/Prevent Decrease in ROM/Mobility, (F690) Bowel/Bladder Incontinence, Catheter, UTI, (F695) Respiratory/Tracheostomy Care and Suctioning, and (F761) Label/Store Drugs and Biologicals that were subsequently recited on the current recertification and complaint survey on [DATE]. The repeat deficiencies during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. The findings include:…

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, interviews with residents and staff, the facility failed to honor residents' choice to eat their meals in the main dining room (Residents #2, #21, #22, #23, #51, and #53) for 6 of 6 sampled residents. The findings included: During a Resident Council group interview conducted on 02/21/24 at 9:52 AM, Resident #2, Resident #21, Resident #22, Resident #23, Resident #51, and Resident #53 all stated since the new corporation took over last year, they were not given the option to eat supper in the dining room during the week or lunch and supper on the weekends and they had brought up their concern during previous Resident Council meetings, most recently last month. The residents did state that on occasion, depending on who was the manager-on-call, they were able to eat lunch in the dining room on the weekends but not supper. The residents stated they were told a staff member had to be present in the dining room during the meal and there wasn't enough staff available which was why they had to eat in their rooms. Resident #2 and Resident #22 added 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to secure a free standing oxygen cylinder in a resident room (Resident #27), failed to ensure an oxygen filter was free from dust and debris (Resident #63), failed to ensure oxygen was delivered at the prescribed rate (Resident #25 and Resident #73), and failed to ensure oxygen in use signage was noted in the residents' environment (Resident #8, Resident #10, Resident #25, Resident #63, and Resident #73). These practices occurred for 6 of 6 residents reviewed for respiratory care and services. Findings included: 1. Resident #27 was admitted to the facility on [DATE] with a diagnosis of asthma. The annual MDS dated [DATE] revealed Resident #27 was moderately cognitively impaired and required the use of oxygen. Resident #27's care plan dated 2/20/2024 revealed goals and interventions for use of oxygen. A record review revealed Resident #27 had an active order for oxygen to be administered at a rate of 2 liters per minute via nasal…

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 include documentation in the medical record of education regarding the benefits and potential side effects of the COVID-19 immunization for 3 of 5 (Resident #63, Resident #75, and Resident #84) residents reviewed for infection control. The findings included: a. Resident #63 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #63 was moderately cognitively impaired. Review of Resident #63's medical record revealed no information that the Resident or legal representative was provided information about the benefits and potential side effects of the COVID-19 immunization. b. Resident #75 was admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE] revealed that Resident #75 was cognitively intact. Review of Resident #75's medical record revealed no information that the Resident or legal representative was provided information about the benefits and potential…

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, Guardian and staff interviews, the facility failed to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 of 1 sampled resident (Resident #139). The findings included: Resident #139 was admitted to the facility on [DATE] with multiple diagnoses that included dementia unspecified severity without behavioral disturbance, bipolar disorder, persistent mood disorder, anxiety disorder, and paranoid schizophrenia. A care plan initiated on 09/01/23 indicated Resident #139 exhibits or has the potential to demonstrate verbal behaviors related to poor impulse control and at times, told untrue stories about his care, about staff members and had paranoid thoughts. Interventions included to monitor medical conditions that may contribute to verbal behaviors, evaluate the nature and circumstances of the verbal behavior, and gently remove the resident from the environment while speaking in a calm, reassuring voice. The quarterly Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code an attempted gradual dose reduction of an antipsychotic medication and failed to code a level 2 PASARR (preadmission screening and resident review) for 1 of 5 residents reviewed for unnecessary medications (Resident #2) and 1 of 2 residents reviewed for PASARR (Resident #61). The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar disorder, and major depressive disorder. Review of Resident #2's physician orders revealed the following physician orders: Aripiprazole 2 milligram tablet - give one half tablet by mouth one time a day for schizophrenia, with a start date of 06/07/23 and a discontinue date of 12/22/23. Review of Resident #2's pharmacy recommendations revealed a recommendation dated 12/18/23 that indicated Resident #2 was due for a gradual dose reduction for Aripiprazole 1 milligram started on 06/07/23. Per the recommendation, 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 reviews and interviews, the facility failed to develop a care plan in the area of Level II Preadmission Screening and Resident Review (PASRR) (Resident #61) and failed to implement the care plan in the area of range of motion (Resident #50) for 2 of 31 residents reviewed for care planning. The findings included: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses that included schizophrenia and post traumatic stress disorder. A review of Resident #61's medical record revealed a Level II PASRR Determination Notification letter dated 04/11/22 which indicated that Resident #61 had a Level II PASRR number ending in a B which was indicative of a PASRR Level II determination with no limitation on the timeframe. The results of the determination of a Level II PASRR were used for formulating a determination of need, an appropriate care setting and a set of recommendations for services to help develop Resident #61's care plan. A review of Resident #61's care plan last…

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 provide a shower, shave, clean, and trim a dependent resident's fingernails for 1 of 7 residents reviewed for activities of daily living (ADL) (Resident #63). Findings included: Resident #63 was admitted to the facility on [DATE] with diagnoses which included muscle weakness and unsteadiness on feet. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 was moderately cognitively impaired and was totally dependent for toileting, showering, bathing, and personal hygiene. Resident #63's care plan dated 2/6/2024 revealed goals and interventions for ADL care which included substantial assistance for grooming and personal hygiene. A record review for Resident #63 revealed he was scheduled for showers two times per week on Monday and Wednesday nights. The last documented shower was on 1/22/2024. A review of Resident #63's shower sheet dated 2/19/2024 indicated that Resident #63 had received a shower, shave, and nail…

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 apply a resting hand splint as directed by the functional maintenance program for 1 of 2 residents reviewed for range of motion (Resident #50). The findings included: Resident #50 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis that included hemiplegia. Review of an active care plan revised on 11/17/22 read, Resident #50 requires assistance with activity of daily living care related to vascular dementia. The interventions listed included right resting hand splint may wear up to 8 hours per day. Review of the quarterly Minimum Data Set, dated [DATE] revealed that Resident #50 was severely cognitively impaired for daily decision making and had no behaviors or rejection of care. Resident #50 required limited to extensive assistance with activities of daily living and received no restorative splinting assistance. Review of a functional maintenance program dated 01/22/24 through 02/19/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to keep an indwelling catheter bag off the floor to decrease the risk of infection and secured the tubing to prevent irritation for 1 of 1 resident reviewed with a catheter (Resident #84). The findings included: Resident #84 was admitted to the facility on [DATE] with diagnosis that included neuromuscular dysfunction of the bladder. A physician order dated 12/21/23 read, perform catheter care everyday shift and night shift and as needed, change indwelling catheter when leaking or occluded. The comprehensive admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #84 was severely cognitively impaired, had no behaviors or rejection of care and required an indwelling catheter. A care plan initiated on 01/02/24 read, Resident #84 required a catheter due to neurogenic bladder. The interventions included: monitor for skin irritation and report as indicated and keep catheter bag off the floor. An observation of Resident #84 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to complete a bed rail assessment to determine the need for bed rail use for 1 of 1 sampled resident (Resident #41). Findings Included: Resident #41 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and insomnia. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #41 with severe cognitive impairment. Resident #41 was dependent on staff assistance for bed mobility with rolling left and right and bed rails were not used as a restraint. An observation on 02/19/24 at 10:41 AM revealed Resident #41 lying in bed with bilateral quarter bed rails in the up position. Review of Resident #41's electronic medical record on 02/20/24 revealed the last completed bed rail assessment was dated 02/17/22. There were no further bed rail assessments completed for the use of the bilateral quarter bed rails. Additional observations conducted on 02/20/24 at 2:41 PM and 02/21/24 at 3:20 PM revealed 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 observations, record review and interviews with residents and staff, the facility failed to provide sufficient nursing staff to ensure residents choices were honored for eating meals in the main dining room, bathing and personal hygiene was provided as needed and resting hand splints were applied as directed for 8 of 15 sampled residents (Residents #2, #21, #22, #23, #50, #51, #53, and #63) reviewed for choices and activities of daily living. This tag is cross-referenced to: F561: Based on observations, record review, interviews with residents and staff, the facility failed to honor residents' choice to eat their meals in the main dining room (Residents #2, #21, #22, #23, #51 and #53) for 6 of 6 sampled residents. F 677: Based on observations, record review, and staff interviews the facility failed to provide a shower, shave, clean, and trim a dependent resident's fingernails for 1 of 7 residents reviewed for activities of daily living (ADL) (Resident #63). F 688: Based on observations, record review, and staff interviews the facility failed to apply a resting hand splint…

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

Based on observations, record reviews and staff interviews the facility failed to store schedule III and IV controlled medications in a locked compartment in the refrigerator in 1 of 1 medication room reviewed for medication storage. The finding included: On 02/21/24 at 3:10 PM an observation was made of the Main Medication room along with Nurse #4. The Nurse opened the refrigerator door to find a clear affixed box that contained 22 tablets of Marinol (a scheduled III controlled substance which means it has a low to moderate abuse potential) and 2 vials of Ativan (a scheduled IV controlled substance which means it carries a risk for abuse, addiction and dependence) stored in the clear box. The box was able to be opened without using a key to unlock the lock on the box. An interview was conducted with Nurse #4 on 02/21/24 at 3:10 PM who explained that both the combination lock on the outside of the refrigerator and the clear box inside the refrigerator that stored the Marinol and Ativan should have been locked. She continued to explain that the clear box inside the refrigerator was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident and staff interviews the facility failed to included documentation in the medical record of education regarding the benefits and potential side effects of the Influenza immunization for 2 of 5 (Resident #63, Resident #84) residents reviewed and failed to include documentation in the medical record of education regarding the benefits and potential side effects of the Pneumococcal immunization for 2 of 5 residents reviewed (Resident #63 and Resident #75). The findings included: 1. Resident #63 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #63 was moderately cognitively impaired for daily decision making. The MDS also indicated that Resident #63 had not received the influenza vaccine in the facility for this flu season and the reason indicated that it was not offered, and he was up to date with his Pneumococcal vaccine. A review of Resident #63's medical record revealed that there was no information in 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.