Windsor Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a consent was documented prior to administering the Influenza vaccination for 1 of 5 residents reviewed for vaccination status (Resident #80).Findings included:Resident #80 was admitted to the facility on [DATE].Review of Resident #80's Medication Administration Record for September 2025 revealed she received the Influenza vaccine on 9/22/25.Review of Resident #80's only immunization consent form in her medical record dated 11/20/25 revealed Resident #80 left the Influenza vaccination selection blank and did not sign consent for the Influenza vaccine. During an interview on 1/8/26 at 10:18 AM the Director of Nursing stated there was no consent on file for Resident #80 regarding the flu vaccination for 9/22/25. She further stated consents should always be acquired prior to administration of a vaccine and maintained in the resident's medical record.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and resident interviews, the facility failed to act in a dignified manner toward (Resident #1) and within hearing distance of (Resident #3) for 2 of 3 residents reviewed for dignity (Resident #1 and Resident #3). Findings included:Resident #1 was admitted on [DATE] and discharged on 9/25/2025.Documentation on an admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #1 as cognitively intact.Documentation in a behavior note dated 9/24/2025 at 3:29 PM written by the Administrator revealed, Resident [#1] requested to speak with Administrator concerning nursing care. [Resident #1] became very demanding requesting that the nurse who documented his refusal be brought in to see him. The issue had been addressed and taken care of two weeks ago. When suggesting that we move forward with today's plan of care [Resident #1] became belligerent, stating, you don't tell me to move forward. You can just kiss my [vulgar word]. [Resident #1] was then advised that his tone…

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 interviews, and a resident interview, the facility failed to protect a resident's right to be free from resident-to-resident physical abuse when Resident #3 struck Resident #4, resulting in a bruise to the right side of the face. This occurred for 1 of 3 residents reviewed for abuse (Resident #4). Findings included:Resident #3 was readmitted to the facility on [DATE].Documentation on an annual Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively intact.Resident #4 was admitted to the facility on [DATE].Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #4 had moderately impaired cognition.Documentation in a behavior note for Resident #3 dated 8/27/2025 at 2:45 PM written by the Assistant Director of Nursing (ADON) revealed the following information. The ADON heard yelling in the dining room area and went to the dining room. Resident #3 indicated to the ADON that Resident #4 needed help getting through the doorway in his…

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

Based on observation, record review and staff interview, the facility failed to: a.) follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a chronic wound when Nurse #1 and Nurse Aide (NA) #1 provided wound care without wearing gowns for 2 of 2 staff observed for infection control (Nurse #1 and NA #1) and b.) to implement their policy for EPB for the current 41 of 61 residents that required the precautions due to chronic wounds or indwelling medical devices. The findings included: The facility policy titled Isolation-Categories of Transmission Based Precautions dated October 2018 stated in part: 1. EBP requires the use of gown and gloves only for high contact resident care activities (unless otherwise indicated as part of Standard Precautions). a.) High contact resident care activities: in the resident room to include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter,…

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 designate a qualified Infection Preventionist who was certified in infection prevention and control, to be responsible for the facility's Infection Control and Prevention Program. This had the potential to affect 72 of 72 residents in the facility. The findings included: During an interview with the Assistant Director of Nursing (ADON) on 5/28/25 at 12:11 PM the ADON indicated she was also the facility's Infection Preventionist (IP) and stated she was responsible for oversight of infection control duties. The ADON further stated she had worked at the facility since late February 2025 and had completed 13 of the 20 modules needed to obtain IP certification through the Centers for Disease Control and Prevention (CDC) IP program. The ADON was not aware she had to have IP certification to hold the position of IP. In an interview with the Director of Nursing (DON) on 5/28/25 at 1:38 PM she stated she was aware the ADON did not yet have an IP certification and the ADON was working on it through the CDC IP program. The 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.

Based on observation, record review, and staff interview, the facility failed to have an effective system in place to train nurses and nurse aides (NAs) and verify their competency with infection control policies for Enhanced Barrier Precautions (EBP). The Assistant Director of Nursing (ADON)/Infection Preventionist (IP) who was responsible for training staff on infection control practices and procedures was unaware that residents with chronic wounds and indwelling medical devices required EBP with high contact care. Nurse #1 and NA #1 failed to follow the infection control policy by providing wound care for a resident with chronic wounds without wearing gowns. The facility had 41 residents that required EBP due to chronic wounds or indwelling medical devices. This deficient practice was identified for 3 of 3 staff (ADON/IP, Nurse #1, and NA #1) reviewed for competency and had the potential to affect other facility residents. Findings included: This tag is cross-referenced to: F880: Based on observation, record review and staff interview, the facility failed to: a.) follow their…

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 maintain a resident's dignity when a resident wore a nightgown and no makeup to an outside appointment making the resident feel angry and unimportant for 1 of 1 resident (Resident # 4) reviewed for dignity and respect. Finding included: Resident #4 was admitted to the facility on [DATE]. The annual [NAME] Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact. An interview with the Transportation Driver at 2:37pm on 5/28/2025 revealed Resident #4 was unaware of her appointment on 5/27/25. He stated that he became aware of the appointment at 4:06am by text message from the Scheduler, after he learned about the appointment, he did call the facility and informed the nurse. Transport driver stated it was the nurse's job to provide verbally communicate appointments to residents. He was aware of Resident #4 was unhappy about wearing her night gown to her doctor's appointment and he tried to console Resident #4 by…

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 maintain evidence of grievance investigation and decisions for 3 of 3 residents reviewed for grievances (Resident #1, Resident #2 and Resident #3). Findings included: A review of the facility's grievance policy dated April 2017 stated in part: 4. The investigation and report would include: f.) employee account of the alleged incident and h.) recommendations for corrective action. a.) Resident # 1 was admitted to the facility on [DATE]. A review of the grievance filed by Resident #1 on 1/3/25 revealed she was concerned that third shift Nurse Aides (NA) did not come in and check on her or answer her call bell. Resident #1 was further concerned that she received dry and burnt food from the kitchen. The grievance was not completed, as there was no documentation regarding an investigation, outcome or recommendation for corrective action. b.) Resident #2 was admitted to the facility on [DATE]. A review of the grievance filed by Resident #2 on 12/19/24…

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 record review, and staff and Medical Director interviews, the facility failed to implement their policy for abuse, neglect, and misappropriation of property in the areas of reporting and investigating when Nurse #2 and Nurse #3 reported to the Unit Manager, Assistant Director of Nursing, and Director of Nursing allegations that Resident #1's liquid morphine appeared to be tampered with and Nurse #1 appeared impaired. These allegations were not reported to the State Agency, law enforcement, or Adult Protective Services (APS) and were not thoroughly investigated. This deficient practice affected 1 of 4 residents (Resident #1) reviewed for misappropriation of property and placed all facility residents who were ordered narcotic medication at risk of misappropriation of property. The findings included: Review of the facility policy Compliance with Reporting Allegations of Abuse, Neglect, Exploitation last reviewed on [DATE] revealed it was the policy to report all allegations including misappropriation 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.

Based on record review and staff interviews, the facility failed to provide a Registered Nurse (RN) for 8 consecutive hours per day, 7 days per week for 9 of 163 days reviewed. Findings included: Review of the PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 3, 2024 (April 1-June 30, 2024) revealed the facility had no Registered Nurse (RN) coverage on 5/15/24, 5/25/24, 5/26/24, 6/1/24, 6/2/24, 6/8/24, 6/9/24, 6/22/24, and 6/23/24. There were no daily assignment schedules or daily nursing positing available for review for the period that included May 2024 and June 2024. Review of payroll punches revealed no RN's worked any shift on 5/15/24, 5/25/24, 5/26/24, 6/1/24, 6/2/24, 6/8/24, 6/9/24, 6/22/24, and 6/23/24. a. The time sheets for 5/14/24 were reviewed and no RN had worked any shift on 5/14/24. b. The time sheets for 5/25/24 were reviewed and no RN had worked any shift on 5/25/24. c. The time sheets for 5/26/24 were reviewed and no RN had worked any shift on 5/26/24. d. The time sheets for 6/1/24 were reviewed and no RN had worked any shift on 6/1/24. e. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff and resident interviews, the facility failed to treat a resident in a dignified manner when staff referred to a resident who needed assistance with eating as a feeder for 1 of 3 residents reviewed for dignity (Resident #64). This caused Resident #64 to feel like an animal. Findings included: Resident #64 was admitted to the facility on [DATE]. Resident #64's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. She required set up assistance with meals. Resident #64's care plan dated 10/6/24 revealed she was care planned to require assistance to total care with activities of daily living. The interventions included staff to provide assistance with meals. During a dining observation on 10/7/24 at 12:35 PM Nurse Aide #5 was observed to enter Resident #64's room and stated Resident #64 was a feeder within hearing range of Resident #64 as she provided the lunch tray to the resident. During an interview on 10/7/24 at 12:36 PM Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and resident and staff interviews the facility failed to ensure a sufficient number of clean mechanical lift pads were available to allow a resident to get out of bed in accordance with his preference (Resident #65) and failed to allow a resident who was assessed as a safe independent smoker to smoke in accordance with her preference (Resident #41). This was for 2 of 3 residents reviewed for self-determination. Findings included: 1. Resident #65 was admitted to the facility on [DATE] with a diagnosis of generalized muscle weakness. A review of Resident #65's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He was dependent for transfers. A review of Resident #65's care plan dated last revised 9/16/24 revealed a problem area of activities of daily living self-performance deficit. The goal was for Resident #65 to maintain his current level of function through the next review. An intervention was to praise all efforts at self-care. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide a complete CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) by omitting the estimated cost for 1 of 3 residents reviewed for beneficiary notices (Resident #49). Findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy and dementia. Medicare part A services began the day of admission. Review of Resident # 49's record indicated the SNF ABN dated 6/22/24 had no estimated cost documented on the form. The last covered date was 6/26/24 and Resident #49 remained in the facility. The admission Minimum Data Set assessment (MDS) dated [DATE] revealed Resident # 49 was assessed as severely cognitively impaired. During an interview on 10/8/24 at 11:33 AM Social Worker #1 stated the estimated cost on the SNF ABN should be completed to ensure the residents or family have the cost provided to them to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews the facility failed to submit a 5-day investigation report (Resident #172) and an initial 24 hour and 5-day investigation report to the State Agency and report to Adult Protective Services (APS) and local law enforcement after allegations of misappropriation of property (Resident #3). This was for 2 of 6 residents reviewed for misappropriation. Findings included: 1. Resident #172 was re-admitted to the facility on [DATE] A review of an initial 24 hour report dated as submitted to the State Agency on 12/1/23 at 3:51 PM written by the facility's previous Director of Nursing (DON) #2 indicated the facility became aware on 12/1/23 at 1:15 PM that Resident #172 reported a missing bank card and $10.00. Resident #172 had immediately called his bank to have his card cancelled, and the card had not been used. A search for the missing items was conducted, and the items had not been found. A review of the facility's investigation folder of the 12/1/23 allegation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to code cognition, mood, and behavior for 1 of 24 residents reviewed for MDS accuracy (Resident #66). The findings included: Resident #66 was admitted to the facility on [DATE] with diagnoses that included dementia. Resident #66's most recent Minimum Data Set (MDS) assessment dated [DATE], a quarterly assessment revealed he was not assessed for cognition, mood and behaviors. An interview was conducted with the facility Social Worker on 10/9/24 at 10:26 AM who stated she was responsible for conducting the cognition, mood, and behavior section of the assessment. She reported that she could not recall the reason she did not assess Resident #66 for cognition, mood and behavior. The Social Worker stated it may have been an oversight. An interview was conducted with the Administrator on 10/11/24 at 10:10 AM who stated Resident #24's assessment should have been completed accurately.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident and staff interviews the facility failed to develop a comprehensive care plan that included the use of a mechanical lift device for transfers for 1 of 24 residents (Resident #65) whose comprehensive care plans were reviewed. Findings included: Resident #65 was admitted to the facility on [DATE] with a diagnosis of generalized muscle weakness. A review of Resident #65's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He was dependent for transfers. A review of Resident #65's comprehensive care plan dated last revised on 9/16/24 did not reveal any information regarding his use of a mechanical lift device for 2 person dependent transfers or any other transfer status. On 10/7/24 at 2:36 PM an interview with Resident #65 indicated he used a mechanical lift with 2 person assistance for his transfers. A review of Resident #65's [NAME] (an informational sheet) dated 10/8/24 did not reveal any information regarding his use of a mechanical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Physician, staff and resident interviews, the facility failed to update care plan interventions (Resident # 2) and invite residents to care plan meetings (Resident # 43 and Resident #11) for 3 of 5 residents reviewed for care planning. Findings included: a. Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia and schizophrenia. The quarterly Minimum Data Set, dated [DATE] revealed Resident #2 was severely cognitively impaired and other behavioral symptoms not directed at others. Review of the Care Plan for Resident #2 initiated on 4/7/23, identified problems of: Behaviors including swinging at staff, yelling, history of throwing himself on the floor for attention, kicking and hitting at staff, wandering in and out of other resident's rooms, resident to resident altercation and pushing equipment forcefully. The goal was that the resident would have no negative outcomes related to behaviors through the next review. Current interventions included one on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility failed to prevent a cognitively impaired resident from exiting the facility without staff knowledge for 1 of 8 residents reviewed for accidents (Resident #2). Resident #2 exited the building through a back door and was found by a staff member sitting outside in his wheelchair facing the door. Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia. The quarterly Minimum Data Set, dated [DATE] revealed Resident #2 was severely cognitively impaired and required supervision or touching assistance with wheelchair mobility. Resident #2 was not coded with wandering behaviors. The care plan for Resident #2, initiated on 4/7/23 and updated on 9/29/23, identified a problem of exit seeking and wandering. The goal was the resident would have no negative outcomes related to exit seeking or wandering through the next review. On 9/29/23 an intervention was added for a Wanderguard alarm system (a sensor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, the facility failed to ensure a Resident #322 was driven to her physician's office in time to attend an 11:00 AM medical appointment. Resident #322 arrived one- and one-half hours late and the physician was unable to see her. The appointment had to be rescheduled for the following week. This deficient practice affected 1 of 1 sampled resident reviewed for medically related social services (Resident # 322). The findings included: Resident #322 was admitted on [DATE] with diagnoses that included an acquired absence of her right leg. Resident #322's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact with no moods or behaviors. An interview was conducted with Resident #322 on 10/9/24 at 9:45 AM who stated she had an appointment on 4/16/24 at 11:00 AM to have the staples removed from her right leg. She stated she arrived at her appointment two hours late and the doctor could not see her. Her appointment was rescheduled…

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 label and date an opened vial of influenza vaccine stored in the medication room refrigerator for 1 of 1 medication storage rooms reviewed. Finding included: An observation of the medication storage room was made on 10/9/24 at 8:40 am in the presence of the Assistant Director of Nursing (ADON). An opened 5 milliliter multidose vial of Flucelvax 2024-2025 influenza vaccine was in the refrigerator. The protective plastic cap/tab had been removed and the rubber stopper was noted to have needle entry marks. There was no open date or discard date marked on the vaccine vial. During an interview with the ADON on 10/09/24 at 8:50 am she stated the opened influenza vial should have been labeled with the nurse's initial, date opened, and a discard date that should have been 28 days after it was opened. She stated she did not know when the vial was opened but thought it was 2 weeks ago. The ADON discarded the opened, unlabeled vial. In an interview with the Administrator on 10/11/24 at 11:44 am she stated she expected all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and physician interviews the facility failed to provide a pneumococcal vaccine to a resident with a signed consent form to receive the vaccine. This was for 1 of 5 residents reviewed for immunizations (Resident #61). Findings included: Resident #61 was admitted to the facility on [DATE]. A review of Resident #61's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Her pneumococcal vaccine was not up to date because it had not been offered. A review Resident #61's Pneumococcal Immunization Consent Form dated 9/10/24 revealed in part the date of Resident #61's last pneumococcal vaccination was unknown. It further revealed Resident #61's Responsible Party (RP) accepted pneumococcal vaccine immunization for Resident #61. A review of Resident #61's medical record did not reveal any evidence a pneumococcal vaccine had been administered to her since her admission to the facility. On 10/11/24 at 10:12 AM an interview with the Assistant…

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 allow residents who were assessed to be safe smokers the ability to smoke independently per their individual preference for 2 of 8 residents (Resident # 38, and #41) reviewed for preferences. The findings included: 1. Resident #38 was admitted to the facility on [DATE]. A review of Resident #38's Smoking Agreement dated 2/24/2023 revealed he could smoke independently. A review of Resident #38's Annual Care Plan dated 3/30/2023 revealed Resident #38 could smoke unsupervised. A review of the smoking assessments for Resident #38 dated 10/7/2022, 1/22/2023, and 6/8/2023 revealed he was a safe smoker and did not require supervision. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 to be cognitively intact. An interview with Resident #38 on 8/7/2023 at 10:39 a.m. revealed he was required to be supervised at smoke times since June 2023. Resident #38 revealed he had been assessed multiple times by the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff and physician interviews, the facility failed to obtain post dialysis vital signs as ordered by the physician for 1 of 1 resident reviewed for dialysis (Resident #33). Findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease. Review of Resident #33's Physician's orders revealed an order dated 3/28/23 for vital signs post dialysis in the afternoon every Monday, Wednesday, and Friday. The quarterly Minimum Data Set, dated [DATE] revealed that Resident #33 had severe cognitive impairment. He was also coded for dialysis. Review of Resident #33's care plan last revised on 5/05/23 included a focus for renal insufficiency with an intervention to monitor for signs and symptoms of hypovolemia or hypervolemia (fluid imbalances) which included increased pulse, increased respirations, and increased blood pressure. Review of Resident #33's July 2023 Medication Administration Record (MAR) revealed that he was…

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

Based on observation and staff interviews the facility failed to date opened insulin for 2 of 3 (Hall 200 and Hall 300) medication carts reviewed for medication storage. Findings included: 1a. Hall 200 medication cart was observed on 8-9-23 at 8:10am with Certified Medication Aide (CMA) #1, who was working on the 200 Hall medication cart. The observation revealed the following insulins were open with no date. Aspart 10 cubic centimeter (CC) multi vial insulin bottle. Novolog Flex pen Lantus Flex Pen Glargine Flex Pen CMA #1 was interviewed on 8-9-23 at 8:13am. The CMA explained she had never looked at the insulin because she was not allowed to provide insulin to the residents. She further explained it was the responsibility of the nurse to provide the insulin. The CMA said she did not know who was responsible for checking the medication cart to ensure insulin was dated. 1b. Hall 300 medication cart was observed on 8-9-23 at 8:20am with Nurse #3 who was working on the 300 Hall medication cart. The observation revealed the following insulin had been opened but not dated. Glargine 5cc…

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 resident, staff and physician interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 9/2/20 focused infection control and complaint investigation survey, the 5/19/22 recertification and complaint investigation survey, the 10/19/22 complaint investigation survey, and the 3/8/23 complaint investigation survey. This was for one deficiency in the area of F880 Infection Prevention and Control that was cited on the 9/2/20 focused infection control and complaint investigation survey, 2 deficiencies in the areas of F550 Resident Rights and F677 Activities of Daily Living (ADL) Care that were cited on the 5/19/22 recertification and complaint investigation survey, 1 deficiency in the area of F745 Medically Related Social Services that was cited on the 10/19/22 complaint investigation survey and 1 deficiency in the area of F550 Resident Rights that was cited on the 3/8/23 complaint investigation survey. These…

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 interviews the facility failed to have a staff member stay out of work following testing positive for COVID-19 per the facility's return to work criteria, and the facility failed to don personal protective equipment (PPE) for 2 of 3 residents reviewed for isolation precautions (Resident #31 and Resident #48). Findings included: 1. Review of the facility's return to work criteria for COVID-19 positive staff, last revised 5/16/23, revealed a staff member could return to work after at least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. Review of a COVID-19 test for the Transport Driver revealed he tested positive 7/24/23. He had no further COVID-19 tests…

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 interviews the facility failed to avoid the use of the term 'feeder' to refer to a resident who needed assistance with meals for 1 of 1 dining observation (Resident #22). The reasonable person concept was applied as individuals have the expectation of being treated with dignity and would not want to be labeled 'feeders'. Findings included: Resident #22 was admitted to the facility on [DATE]. Review of Resident #22's minimum data set assessment dated [DATE] revealed he was assessed as severely cognitively impaired and required extensive assistance with eating. Review of Resident #22's care plan dated 6/19/23 revealed he was care planned for and activities of daily living self-care performance and mobility deficit related to dementia with behaviors. The interventions included for staff to provide assistance with meals. During observation on 8/7/23 at 12:32 PM Nurse Aide #4 saw Nurse Aide #2 enter Resident #22's room with his lunch tray. Nurse Aide #4 went to 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, resident and staff interviews, the facility failed to provide showers, bed baths, or nail care for 2 of 5 dependent residents reviewed for activities of daily living (Resident #33 & Resident #16). Findings included: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia. The quarterly Minimum Data Set, dated [DATE] revealed that Resident #33 had severe cognitive impairment. He was also coded as total dependence for bathing. He was coded for no rejection of care. Resident #33's care plan last revised on 6/14/23 revealed interventions which included to anticipate and meet needs, use a soft toothbrush, use electric razor, and ensure the resident has an unobstructed path to the bathroom. Review of the facility shower book revealed Resident #33 was scheduled for showers on Tuesday and Friday on the 7:00 AM - 3:00 PM shift. An interview on 8/08/23 at 1:25 PM with NA #2 revealed she provided Resident #33's ADL care often as she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, staff, and Physician interviews, the facility failed to provide a resident (Resident #58) medications after returning from the hospital. This occurred for 1 of 1 resident reviewed. Findings included: Resident #58 was admitted to the facility on [DATE] with multiple diagnosis that included diabetes. The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was cognitively intact. Resident #58's July 2023 Medication Administration Record (MAR) was reviewed. The following medications that were to be given between 8:00pm and 9:00pm on 7-26-23 were documented as not provided due to Resident #58 being hospitalized . Crestor (cholesterol medication) 20 (milligrams) mg at bedtime. Gabapentin (pain medication) 100mg 2 capsules at bedtime. Mirapex (treats muscle spasms) 0.25mg 2 tablets at bedtime. Vitamin E 400 units at bedtime. Review of the emergency room documentation for Resident #58 revealed the resident arrived in the emergency room at 2:07pm and was discharged at 5:57pm.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident, staff, and Physician interviews, the facility failed to follow a physician order for a pressure ulcer dressing change for 1 of 2 residents reviewed for pressure ulcers (Resident #39). Findings included: Resident #39 was admitted to the facility on [DATE] with multiple diagnoses that included stage 4 pressure ulcer to the sacrum, hemiplegia, and diabetes. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was moderately cognitively impaired and was documented as having one stage 4 pressure ulcer. Resident #39's care plan dated 6-23-23 revealed Resident #39 had a potential and actual pressure ulcer related to hemiplegia and diabetes. The goal for Resident #39 was that her pressure ulcer will show signs of healing and remain free from infection. The interventions associated with the goal were administer treatments as ordered, assist with reposition and/or turn frequently, and observe skin integrity. A Physician order dated 6-28-23 revealed to cleanse…

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 schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 2 days of 19 days (6-11-23 and 7-8-23) reviewed for staffing. Findings included: Review of the facility's daily posting from 5-4-23 through 7-30-23 revealed there was no RN coverage for 6-11-23 and 7-8-23. During an interview with the facility's scheduler on 8-8-23 at 1:03pm, the scheduler stated if there was not a RN scheduled, she would reach out to in-house staff first and then contact the agency to try and find coverage. She said she was aware there was supposed to be a RN in the facility at least eight hours a day. The scheduler explained somedays there just isn't any RNs to cover. The scheduler confirmed through timesheets 6-11-23 and 7-8-23 did not have RN coverage. The Director of Nursing (DON) was interviewed on 8-8-23 at 2:13pm. The DON discussed meeting with the scheduler two to three times a week to review the schedule. She stated she was aware there needed to be a RN in the facility at least eight hours a day and said the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and physician interviews, the facility failed to schedule an appointment for a mammogram as ordered by the physician for 1 of 1 resident (Resident #19) reviewed for medically related social services. Findings included: Resident #19 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated [DATE] revealed Resident #19 was a [AGE] year old female who had severe cognitive impairment. Review of Resident #19's physician's orders revealed an order dated 5/09/23 which read to obtain a mammogram to bilateral breasts. Review of the physician's progress note dated 5/09/23 revealed the mammogram was ordered at the resident's request. Review of Resident #19's electronic medical record revealed no evidence of a mammogram appointment. An interview on 8/08/23 at 3:02 PM with the Social Worker (SW) revealed she was responsible for scheduling appointments in May 2023. She stated she sent the request to the hospital to get an appointment scheduled in the radiology department 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 record review, resident, staff, and Physician interview the facility failed to prevent a significant medication error by failing to administer a prescribed antibiotic for 2 of 2 residents (Resident #39 and Resident #58) reviewed for medication errors. Findings included: 1. Resident #39 was admitted to the facility on [DATE] with multiple diagnoses that included diabetes, stage 4 sacral pressure ulcer, and hemiplegia and hemiparesis. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was moderately cognitively impaired. A wound care note dated 8-2-23 by the wound care Physician revealed documentation that Resident #39's sacral wound had deteriorated and the Physician suspected a wound infection. Documentation also revealed the Physician wanted a wound culture to be completed and Bactrim DS (antibiotic) twice a day for 14 days started while the results of the culture were pending. Review of Resident #39's Physician orders from 8-2-23 through 8-6-23 revealed no order for Bactrim DS.…

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 offer the Pneumococcal 15-valent Conjugate Vaccine (PCV 15) or Pneumococcal 20-valent Conjugate Vaccine (PCV 20) in accordance with nationally recognized standards for 1 of 5 residents reviewed for immunizations (Resident #31). Findings included: Resident #31 was admitted to the facility on [DATE] and was over [AGE] years of age. Review of Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccination last reviewed 4/27/23 read in part that if an individual 65 years or older, [p]reviously received only PPSV23: 1 dose PCV15 OR 1 dose PCV20 at least 1 year after the PPSV23 dose. If PCV15 is used, it need not be followed by another dose of PPSV23. Review of Resident #31's immunization records revealed he received the pneumococcal polysaccharide vaccine (PPSV23) on 3/19/18 outside of the facility by his primary care provider. There was no documentation that Resident #31 had been offered the PCV 20. Review of Resident…

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