Good Samaritan Society - Larimore

Based on observation, record review, and review of facility policy, the facility failed to provide appropriate respiratory care for 1 of 2 sampled residents (Resident #25) with orders for continuous oxygen. Failure to administer oxygen according to the physician's orders resulted in Resident #25 experiencing low oxygen saturation levels (level of oxygen circulating in the blood) and may compromise the resident's respiratory status. Findings include:Review of the facility policy titled Oxygen Administration, Safety, Mask Types occurred on 03/28/26. This policy, dated 07/30/25, stated, . Oxygen therapy is carried out only with a medical provider order. A licensed nurse or other employee trained . in the use of oxygen . will be . responsible for the proper administration of oxygen to the resident.Review of Resident #25's medical record occurred on all days of survey. A physician's order, dated 01/28/26, identified continuous oxygen via nasal cannula for oxygen saturation less than 88% (percent) for shortness of breath and low oxygen saturation levels. Observation on 03/15/26 at 2:04…

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 interview, the facility failed to post accurate and complete staffing information on 2 of 2 weekend days (March 14-15, 2026) reviewed. Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift. Findings include:Observation on 03/15/26 at 12:15 p.m. showed staff postings for Thursday 03/12/26 and Friday 03/13/26. The facility failed to update the number of licensed and unlicensed staff working on the days of Saturday 03/14/26 and Sunday 03/15/26.During an interview on 03/15/26 at 12:30 p.m., a charge nurse (#3) confirmed the facility failed to update the staffing information for Saturday and Sunday.

Based on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 5 residents (Resident #18 and #19) observed during medication administration. Two medication errors occurred during staff administration of 25 medications, resulting in an eight percent error rate. Failure to administer medications at the correct time may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health.Findings include:Prescribing information for levothyroxine (treats thyroid disorders), revised April 2019, found at https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/021116s017lbl.pdf, stated, . 2.1 General Administration Information Administer Levothyroxine Sodium Tablets as a single daily dose, on an empty stomach, one half to one hour before breakfast. Review of the facility policy titled Medication Administration Including Scheduling and Medication Aides occurred on 03/18/26. This policy, dated…

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

Based on observation, review of professional reference, and staff interview, the facility failed to ensure safe and secure storage of medications and/or private health information on 1 of 1 medication cart and failed to ensure medication labels matched provider's orders for 2 of 5 residents (Resident #18 and #19) observed during medication pass. Failure to secure medications and electronic health information may result in unauthorized access and failure to ensure medication labels matched the provider's orders placed residents at risk for medication errors.Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 838-840, stated, . Obtain the appropriate medication. Compare the label of the medication container or unit-dose package against the order on the MAR [medication administration record] or computer printout. Rationale: This is a safety check to ensure that the right medication is given. If these are not identical, recheck the prescriber's written order in the client's chart. If…

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, review of facility policy, and staff interview, the facility failed to monitor temperatures and follow safe storage practices for 1 of 3 freezer units. Failure to keep freezer temperatures at 0 degrees Fahrenheit or below and monitor freezer temperatures may increase the likelihood of food borne- illnesses.Findings include: Review of the facility policy titled Food-Supply Storage-Food and Nutrition Services occurred on 03/18/26. This policy, revised March 2026, stated, Procedure. 13. In the freezer, the temperature is 0 degrees Fahrenheit or lower. The freezer . 14. internal temperatures of all freezers in the food and nutrition department, dining room, and nourishment areas are recorded twice daily . Review of the untitled facility document provided by administrative staff member (#9) on 03/18/26 showed lack of documentation for monitoring freezer temperatures of the freezer located in the parlor area from 12/01/25 through 03/09/26. - Observation of the parlor area freezer unit on 03/17/26 at 11:15 a.m. showed the freezer temperature at 6 degrees Fahrenheit.…

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 review of the facility's Quality Assurance Performance Improvement (QAPI) meeting sign in sheets, and staff interview, the facility failed to ensure all required members attended meetings at least quarterly for 2 of 4 quarters (November 2025 and February 2026) reviewed. Failure to have the medical director participate in the facility's quality assurance activities may result in an ineffective QAPI program and deprives the committee of the physician's unique contributions for analysis of quality concerns and assisting with decision making based on identified concerns.Findings include:Review of the QAPI meeting sign-in sheets, from March 2025 to February 2026 showed the medical director failed to attend any meetings since August 2025.During an interview on 03/18/26 at 3:30 p.m., an administrative staff member (#8) confirmed that the medical director failed to attend the required quarterly QAPI committee meetings.

Based on observation, review of facility policy, and staff interview, the facility failed to follow professional standards of infection control and prevention for 1 of 2 sampled residents (Resident #24) on enhanced barrier precautions (EBP) and 1 supplemental resident (Resident #22) during medication administration. Failure to practice infection control standards related to hand hygiene and glove and gown use has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 03/18/26. This policy, dated 11/13/25, stated, . HCW [healthcare worker] will use waterless alcohol-based sanitizer or soap and water to clean their hands: When entering the patient room. Before . administering medications. hand hygiene must be completed before donning gloves. After removing gloves . When exiting patient room. Review of the facility policy titled Standard, Enhanced Barrier, and Transmission-Based Precautions occurred on 03/18/26. This policy, dated July 2025, stated, . Enhanced barrier precautions expand the use of…

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

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#9) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 02/10/25 at 1:52 p.m., the dietary manager (#9) stated he is currently enrolled in a certified dietary manager course but has not completed it. The facility failed to ensure the dietary manager (#9) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

Based on review of the State Agency (SA) facility files, survey findings, and staff interview, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems and opportunities to improve services/outcomes, decrease or prevent likelihood of problems or occurrence of adverse events, and ensure compliance with federal requirements. Findings include: Review of the state agency files indicated the facility failed to maintain compliance at F657, F690, F725, F759, and F812 as indicated by deficiencies cited during the last standard survey on 02/01/24. Refer to F657, F690, F725, F759, and F812 for specific findings. During an interview on 02/13/25 at 12:01 p.m., an administrative staff member (#10) stated, We work as a team to develop the plan of correction and conduct audits following the federal survey. She stated the facility departments conducted various audits monthly, but was unaware if staff monitored the areas recited, other than care planning, Failure of the facility to effectively utilize QA resulted in continued…

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 review of employee files, review of facility policy, and staff interview, the facility failed to employ an individual who has completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control program. Failure to employ an Infection Control Preventionist (ICP) may affect all residents, staff, and visitors, placing them at risk for acquiring infectious diseases. Findings include: Review of the facility policy titled Infection Preventionist and Control Program occurred on 02/13/25. This policy, dated 12/02/24, stated, . The SNF [Skilled Nursing Facility] Infection Preventionist must . Have completed specialized training in infection prevention and control . During an interview on 02/10/25 at 4:14 p.m., an administrative nurse (#1) confirmed the facility failed to have a staff member with specialized training in infection prevention and control.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 4 of 12 sampled residents (Resident #3, #15, #24, and #183). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Comprehensive Care Plan And Care Conferences occurred on 02/13/25. This policy, dated 01/31/25, stated, . The care plan is driven by identified resident issues/conditions and their unique characteristics, strengths and needs. In addition to updates during a care plan review, care plans must be revised as the resident's needs/status changes. - Review of Resident #3's medical record occurred on all days of survey. A physician's order, dated 12/03/24, stated, FSBS (Finger Stick Blood Sugar) 2 times a day and PRN as needed . Oxygen . at night . The care plan stated, . The resident has altered respiratory r/t [related to] need for O2 [oxygen] at all times . The care plan failed to identify 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 review of resident council minutes, staffing record review, confidential resident and family interviews, and staff interview, the facility failed to provide sufficient nursing staff and related services to meet the residents' needs for 4 of 4 residents (Resident B, C, D, and E) who require staff assistance. Failure to provide sufficient nursing staff may result in residents experiencing unmet needs, poor hygiene, incontinence, and skin issues and may negatively affect the residents' physical, mental, and psychosocial well-being. Findings include: Review of the resident council meeting minutes, dated November 2024-February 2025, identified the following resident concerns: waiting too long to use the bathroom, no clean towels provided over the weekend, on-going problem with weekend trash removal from rooms, waiting too long for call lights to be answered, staff turn off the call light without asking what the resident needed and leave the room, often only one CNA on the floor, and not enough staff. Resident and family interviews identified the following: * 02/10/25 at 1:01…

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, review of resident council minutes, and resident and staff interviews, the facility failed to provide snacks to residents within the facility. Failure to provide snacks may result in hunger, weight loss, and hypoglycemia (low blood sugar) for diabetic residents. Findings include: Upon request on the afternoon of 02/11/25, the facility failed to provide a policy on snacks. Review of the resident council meeting minutes, dated November 2024-February 2025, identified the following resident concerns: *11/27/24, Evening snack pass is happening more often but still not consistently. *12/18/24, Evening snack pass is inconsistent; residents still need to ask for evening snack. *01/14/25, The snack cart remains problematic. One resident often wanders and touches the food on the cart. [Resident #15] reported inconsistency in passing snacks to residents in their rooms. During an interview on 02/10/25 at 2:44 p.m., Resident #15 stated the snacks are delivered to the nurse's station and that's where they stay, they are not delivered to residents in their rooms. Resident #15…

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, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure food is stored in accordance with professional standards for food service sanitation in 1 of 1 kitchen. Failure to ensure food is stored, prepared, and served in a sanitary environment may result in contamination for residents, visitors, and staff. Findings include: Review of the facility policy titled Food-Supply Storage -Food and Nutrition Services occurred on 02/12/25. This policy, revised on 05/07/24, stated, . Storeroom layout: 1. All food/supply items are stored six inches off the floor. 20. Employee . food/fluids are not stored in the preparation kitchen cooler/freezer or dry storage. Review of the facility policy titled Employee Hygiene and Dress Code occurred on 02/12/25. This policy, revised 06/12/24, stated, . Hairnets or hair restraints . are used: a. When cooking, preparing, assembling food or ingredients. This includes dish rooms and storage areas. Hair is to be covered completely . The 2022 Food and Drug Administration (FDA) Food Code,…

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 review of the facility reported incident and investigation documents, record review, policy review, and staff interview, the facility failed to protect the resident's right to be free from abuse from 1 of 1 sampled resident (Resident #10) who displayed sexual behaviors towards other residents. Failure to protect residents from sexual abuse may result in fear, anxiety, mental anguish, and physical injury. Findings include: Review of the facility policy titled Abuse and Neglect - Rehab/Skilled occurred on 02/12/25. This policy, revised 07/22/24, stated, . Purpose . To ensure that residents are not subjected to abuse by anyone, including, but not limited to . other residents . To ensure that all identified incidents of alleged or suspected abuse/neglect . are promptly reported and investigated. Review of Resident #10's medical record occurred on all days of survey. A Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment. The care plan, dated 10/05/24, stated, The resident has…

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, review of facility policy, and staff interview, the facility failed to report incidents of resident-to-resident abuse to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #10) who exhibited sexual behaviors. Failure to report incidents of sexual abuse may result in unwanted physical and/or sexual contact and may cause all residents to experience fear, anxiety, and psychosocial harm. Findings include: Review of the facility policy titled Abuse and Neglect - Rehab/Skilled occurred on 02/12/25. This policy, revised 07/22/24, stated, . Purpose . To ensure that residents are not subjected to abuse by anyone, including, but not limited to . other residents . To ensure that all identified incidents of alleged or suspected abuse/neglect . are promptly reported and investigated. Designated agencies will be notified . including the State Survey and Certification Agency. Review of Resident #10's medical record occurred on all days of survey. A Minimum Data Set (MDS), dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 12 sampled residents (#14, #15, and #183). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised October 2024, pages I-5 and I-8, stated, . Active Diagnoses in the Last 7 Days - Check all that apply . Coding Instructions: Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status . during the 7-day look-back period . - Review of Resident #14's medical record occurred on all days of survey. The care plan stated, The resident has…

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, review of facility policy, and staff interview, the facility failed to implement a baseline care plan to fully reflect the resident's needs for 1 of 2 sampled residents (Resident #179) newly admitted to the facility. Failure to develop and implement a complete baseline care plan may result in care that is inconsistent with residents' needs. Findings include: Review of the facility policy titled Comprehensive Care Plan And Care Conferences occurred on 02/13/25. This policy, dated 01/31/25, stated, . Baseline Care Plan. If utilized, review the Pre-admission Data Collection and other admission information . to develop an initial care plan that includes specific interventions including but not limited to: Initial goals . physician orders . and resident-specific care. Review of Resident #179's medical record occurred on all days of survey and identified an admission date of 02/03/25. Diagnoses included diabetes and hydrocephalus (accumulation of fluid in the brain). Physician's orders included, Lantus Solo Star (Insulin) . Inject 40 unit . one time a day for blood…

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, review of facility policy, and staff interview, the facility failed to provide adequate supervision for 1 of 1 sampled residents (Resident #16) who smoked. Failure to ensure the resident smoked outside in the designated area and to keep cigarettes and lighters locked in a cabinet placed all residents at risk for injury. Findings include: Review of the facility policy titled Smoking and Tobacco Use occurred on 02/12/25. The policy, dated 11/27/24, stated, . Smoking and tobacco use inside Society-owned buildings is not permitted . Smoking and tobacco use is permitted only in acceptable outdoor, location-designated areas. Review of the facility policy titled Smokers Policy occurred on 02/12/25. The policy, dated 12/24/24, stated, . Smoking is permitted in the smokers shed located on the North end of the building. It is not permitted to smoke anywhere else on this campus. Smoking is not permitted anywhere inside this building . Review of Resident #16's medical record occurred on all days of survey. The care plan stated, The resident uses tobacco…

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, review of a professional reference, and staff interview, the facility failed to provide appropriate toileting for 2 of 9 sampled residents (Resident #4 and #8) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed the residents at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and fall and/or injuries. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 892, stated, Fecal and Urinary Incontinence: Moisture from incontinence promotes skin maceration [tissue softened by prolonged exposure to being wet or soaked] and makes the epidermis [skin] more easily eroded and susceptible to injury. Digestive enzymes in feces, urea in urine . also contribute to skin excoriation [area of loss of the superficial layers of the skin] . Any accumulation of secretions . is irritating…

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, policy review, and staff interviews, the facility failed to provide the care and services consistent with professional standards of practice for 1 of 1 sampled resident (#183) currently receiving dialysis. Failure to receive dialysis treatment communication may result in an unidentified change in the resident's condition. Findings include: Review of the facility policy titled Dialysis Services occurred on 02/13/25. This policy, dated 09/25/24, stated, . Care plan dialysis care specific to the resident: for example, unique nutritional needs or fluid restriction, avoid B/P [blood pressure] in arm with fistula, any other restrictions per provider. Provide education specific to the resident and their support system. Review of Resident #183's medical record occurred on all days of survey. A nursing order, dated 02/07/25, stated, Complete UDA [user defined assessment]: Clinical Monitoring - Dialysis: prior to departure of dialysis and after returning from dialysis two times a day every Mon, Wed, Fri [Monday, Wednesday, Friday] for dialysis monitoring. The current…

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, review of facility policy, review of professional reference, and staff interview the facility failed to ensure a medication error rate of less than five percent for 3 of 5 residents (Resident #2, #4, and #5) observed during medication administration. Four medication errors occurred during staff administration of 26 medications, resulting in a fifteen percent error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions. Findings include: Review of the facility policy titled Medication: Insulin Administration, Insulin Pens, Insulin Pumps occurred on 02/13/25. This policy, dated 09/05/24, stated, . Insulin Pen . Turn the dosage knob to '2' units to prime the pen. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. Review of the facility policy titled Medications: Crushing occurred on 02/13/25. This policy, dated 01/31/24, stated, . Some medications, such as sustained release medications among others,…

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, review of facility policy, review of resident council meeting minutes, and resident, staff and family interviews, the facility failed to ensure sufficient nursing staff and related services available at all times to meet the residents' needs for 5 of 16 sampled residents (Residents #9, #11, #12, #24, and #25) who required assistance. Failure to provide sufficient staffing may result in residents experiencing falls, poor hygiene, incontinence, and skin issues and may negatively affect the residents physical, mental, and psychosocial well-being Findings include: Review of the facility policy titled Nursing Services Staff occurred on 01/31/24. This policy, revised October 2023, stated, . The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the resident council meeting minutes, dated October 2023-January 2024, identified…

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, review of facility policy, review of professional reference, review of product information, and staff interview, the facility failed to store, prepare, and serve food in a sanitary manner for 1 of 1 kitchen. Failure to label, date and discard food, monitor and record sanitizing levels of the dishwashing machine, and ensure the appropriate concentration levels of sanitizer solution has the potential to affect food quality and may result in the spread of foodborne illness to residents, staff, and visitors. Findings include: FOOD STORAGE Review of the facility's policy titled Food Storage occurred on 01/31/24. This policy, revised November 2010, stated, . foods opened will be placed in an enclosed container, dated and labeled . the date/time the original container is opened . expiration dates will be checked on a regular basis and foods/fluids which have expired will be discarded . A tour of the kitchen occurred on 01/29/24 at 1:30 p.m. with a dietary manager (#7). Observation in the walk-in freezer showed the following opened and undated food items: * One box 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, review of the Centers for Medicare and Medicaid Services (CMS) internet Quality Improvement Evaluation System (iQIES), and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), the facility failed to electronically transmit completed Minimum Data Sets (MDSs) to iQIES for 1 of 17 sampled residents (Resident #230) and 2 supplemental residents (Resident #82 and #181). The facility also failed to transmit entry tracking within 14 days of admission for 3 of 17 sampled residents (Resident #81, #230, and #231) and 2 supplemental residents (Resident #82 and #181). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.18.11), page 5-1, stated, Transmitting MDS Data. All Medicare and/or Medicaid-certified nursing homes . must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). Required MDS records are those assessments and…

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

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans for 5 of 17 sampled residents (Resident #9, #15, #80, #81, and #231). Failure to update care plans with residents' current care needs may negatively impact the care provided to residents. Findings include: Review of the facility policy titled Care Plan occurred on 02/01/24. This policy, dated 11/01/23, stated, . This plan of care will be modified to reflect the care currently required/provided for the resident. The interdisciplinary team will review care plans at least quarterly. Care plans also will be reviewed, evaluated and updated when there is a significant change in the resident's condition. - Review of Resident #9's medical record occurred on all days of survey. The care plan identified, . TRANSFER: Total assist of 2 with total lift [full body mechanical lift] . Revision on: 01/15/2024 . Observations during the survey showed staff transferred Resident #9 with a sit to stand mechanical lift and not the total lift. - Review of Resident #15's…

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 review of facility policy, the facility failed to provide care in a manner that maintained or enhanced resident dignity for 2 of 17 sampled residents (Resident #9 and #11). Failure to provide privacy during toileting does not enhance the residents' quality of life. Findings include: Review of the facility policy titled Resident Dignity occurred on 02/01/24. This policy, dated 11/16/23, stated, . The location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect . Ideas for maintaining a resident's dignity may include, but not be limited to: . Respecting resident's private space and property. Treating residents with respect . - Observation on 01/29/24 at 1:38 p.m. showed an unidentified certified nurse aide (CNA) exited Resident #9's room, leaving the door open. Observation showed the bathroom door also open, and Resident #9 seated on the toilet. - Observation on 01/29/24 at 4:27 p.m. showed Resident #11's room and bathroom doors open, and Resident #11 seated on the toilet. 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 record review, review of facility policy, and resident interview, the facility failed to ensure residents received the necessary service to maintain personal hygiene for 1 of 16 sampled residents (Resident #12) who required staff assistance for bathing. Failure to provide assistance to residents who cannot perform the bathing task independently may result in poor hygiene, skin issues and decreased self-esteem. Findings include: Review of the facility policy titled Bathing occurred on 01/31/24. This policy, revised 08/29/23, stated . To promote cleanliness and general hygiene . to stimulate circulation of the skin. Review of Resident #12's medical record occurred on all days of survey. Diagnoses included Psoriasis (condition of the skin). The care plan stated, . Resident requires extensive assist of 1 for bathing . Psoriasis needs: monitor skin rashes for infection . notify nurse immediately of any new areas of skin breakdown noted during bath. Resident #12's bathing record identified baths scheduled twice per week on Mondays and Thursdays. Review of the December 1-31, 2023…

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

Based on observation, record review, review of facility policy, and staff and resident interview, the facility failed to provide care and services to promote the healing or prevent the development of pressure ulcers for 3 of 17 sampled residents (Resident #15, #80, and #81). Failure to provide pressure relief interventions may result in the deterioration of existing pressure ulcers and/or the development of new pressure ulcers. Findings include: Review of the facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation occurred on 02/01/24. This policy, dated 04/26/23, stated, . Developing an individualized repositioning schedule is required for those residents unable to position themselves . The bruise/contusion/skin tear/abrasion should be monitored weekly and any changes and/or progress toward healing should be documented on the Skin Observation UDA [user defined assessment] . - Review of Resident #15's medical record occurred on all days of survey. Diagnoses included diabetes mellitus type II. The care plan stated, . The resident has potential for pressure…

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, review of facility policy, and staff and resident interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 2 of 15 sampled residents (Resident #11 and #25) observed during transfers. Failure to provide appropriate assistance and assistive devices during transfers placed the residents at risk for accidents, falls, and/or injuries. Findings include: Review of the policy/procedure titled Safe Resident Handling Program Resource Packet occurred on 01/30/24. This policy, revised 08/01/23, stated, .The Care Plan is part of the communication process to the caregiver. Interventions must include. the type and size of the sling, the size of the harness, and the number of employees required for safety . - Review of Resident #11's medical record occurred on all days of survey. The current care plan stated, . TRANSFER: Resident requires limited assist of 1 [staff member] pivot transfer . The resident is at risk for falls R/T [related to] balance problems and left sided weakness from cva [cerebrovascular…

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 record review, the facility failed to provide appropriate incontinence care for 1 of 15 sampled residents (Resident #15) who required staff assistance with toileting. Failure to provide incontinence care may result in a loss of dignity and placed residents at risk for skin breakdown and urinary tract infections (UTIs). Findings include: Review of Resident #15's medical record occurred on all days of survey. Diagnoses included dementia and a hospitalization in November 2023 for a UTI. The care plan identified, . check and change q [every] 2-3 hours during the day and q 4 [hours] at night . TOILET USE: Resident is not toileted . A skin assessment, dated 01/18/24, stated, . Coccyx . slight redness/intact scab remained to coccyx area and Mepilex applied for protection. Observations on 01/30/24 from 8:10 a.m. until approximately 11:45 a.m. showed Resident #15 seated in her wheelchair in the living room area. At 11:45 a.m., staff took the resident to the dining for lunch, and at approximately 12:35 p.m., brought the resident to her room to lie down. Staff failed…

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, review of facility policy, and staff interview, the facility failed to identify a history of trauma, and/or trauma triggers for 1 of 2 sampled residents (Resident #3) reviewed for Post-Traumatic Stress Disorder (PTSD) and/or Trauma. Failure to identify a resident's history of trauma and/or trauma triggers may cause re-traumatization. Findings include: Review of the facility policy and procedure titled Trauma Informed Care occurred on 01/31/24. This policy/procedure dated 11/16/23, stated, . Staff will ensure that residents who experience trauma receive culturally competent, trauma-informed care . accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization . Review of Resident #3's medical record occurred on all days of survey. The record showed a diagnosis of PTSD. A psychiatry provider note, dated 09/25/23, stated, . patient endorses history meeting DSM [Diagnostic and Statistical Manual of Mental Disorders] criteria for PTSD. Symptoms include nightmares, flashbacks, startle response, and…

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

Based on review of facility policy, review of the facility's nursing staff schedules, and staff interview, the facility failed to provide the services of a registered nurse (RN) for eight consecutive hours a day, seven days a week, for 2 of 92 days reviewed (10/7/23 and 10/28/23). Failure to ensure sufficient, qualified nursing staff are available eight consecutive hours a day has the potential to affect the health and safety of all residents residing in the facility. Findings Include: Review of the facility policy titled Nursing Services Staff occurred on 01/31/24. This policy, revised October 2023, stated, . The location will use the services of a registered nurse for at least eight consecutive hours a day, seven days a week . Review of the nursing schedule for the time period of 10/01/23 to 12/31/23 showed showed the facility lacked the required RN coverage on 10/07/23 and 10/28/23. During an interview on 01/31/24 at 10:38 a.m., an administrative nurse (#1) confirmed the facility lacked eight consecutive hours of RN coverage on 10/07/23 and 10/28/23.

Based on record review, facility policy review, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 supplemental resident (Resident #17) reviewed who experienced a medication error. Failure to practice professional standards of medication administration resulted in Resident #17 receiving a double dose of Methadone (a narcotic analgesic), a missed dose of Lorazepam (an antianxiety medication), and an as needed (PRN) dose of Morphine Sulfate (narcotic analgesic) too early which have resulted in negative health outcomes. Findings include: Review of the facility policy titled Medication: Administration Including Scheduling and Medication Aides. This policy, revised 03/29/23, stated . Follow the 'Six Rights': Right medication, right dose, right resident, right route, right time, and right documentation. Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before…

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, review of facility policy, and staff interview the facility failed to ensure safe and secure storage of controlled medications for 1 of 1 medication cart. Failure to store medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Medication Storage occurred on 01/31/24. This policy, dated August 2021, stated, . 1. General guidelines: a. All drugs and biologicals will be stored in locked compartments. during medication pass, medications must be. locked in the medication storage area/cart. Review of the facility policy titled Medication Administration occurred on 01/31/24. This policy, dated March 2023, stated, . controlled drugs . and other drugs subject to possible abuse will be stored in separate, locked, permanently fixed compartments . Review of the facility policy titled Medications: Controlled occurred on 1/31/24. This policy, dated June 2023, stated . Controlled Medications: . schedules II-V, have a potential for abuse . Observations during medication pass 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.