Hemingford Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to submit their investigation to the state agency for 1 (Resident 6) of 3 sampled residents within the required 5 working days for Resident 6. The facility reported a census of 33Record review of a facility-provided document titled Initial report revealed that Resident 6 was found to be wearing a brief that was overly wet and soiled at 6:00 AM on 1/2/26. The document further revealed that Nurse Aide-A (NA-A) from the shift prior was suspected of leaving the resident in the soiled brief for an extended period. The document revealed that this incident was reported to the state agency on 1/2/26.Record review of Resident 6's facesheet revealed they were admitted [DATE] and had diagnoses of cancer of the pancreas, rhabdomyolysis (a condition in which muscles break down rapidly and release harmful substances into the body), diabetes mellitus type 2 (a disorder where the body is unable to regulate blood sugar effectively), and a traumatic brain injury.Record…

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 interview, the facility failed to notify 1 (Resident 1) of 1 sampled resident and their representative in writing regarding the reason for their transfers to the hospital. The facility identified a census of 33.Findings Are: A record review of Resident 1's Progress Notes dated 1/2/2026 revealed the resident was transported to the emergency room at 3:11 PM and the facility confirmed at 5:14 PM the same day that the resident had been admitted to the hospital. A record review of a Bed Hold Agreement for Resident 1 confirmed the resident was placed on a bed hold on 1/2/26. A record review of Resident 1's Progress Note dated 1/19/2026 revealed the resident was sent to the emergency room at 7:10 PM. A record review of Resident 1's Progress Note dated 1/20/2026 confirmed the resident had been admitted to the hospital. A record review of a Bed Hold Agreement for Resident 1 confirmed the resident was placed on a bed hold on 1/19/2026. A record review of Resident 1's electronic medical records revealed no evidence of a written notice of the reason for transfer being…

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 Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to ensure the admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) was accurately coded in relation to the Level II Pre-admission Screening and Resident Review (PASRR, a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability) for 1 (Resident 20) of 1 sampled resident. The facility identified a census of 33.Findings Are: A record review of Resident 20's admission Record revealed the resident was admitted to the facility on [DATE]. A record review of Resident 20's Level II PASRR dated 10/28/25 revealed documentation under PASRR Determination:-Meets the federal definition of Serious Mental Illness? Yes.-Meets for Nursing…

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

Licensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident 11) of 12 sampled residents. The facility identified a census of 33.Findings Are: A record review of the facility policy Care Plans, Comprehensive Person-Centered with a revision date of March 2022 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A record review of Resident 11's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 9/29/2025 revealed in Section F, the following activities that were very important to the resident:-Being around animals, such as pets.-Keeping up with the news.-Going outside to get fresh air when the weather is good.-Participating in religious services or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide peri-cares as required to Resident 3 and failed to ensure Resident 21's lab work was obtained as ordered by the provider. The facility reported a census of 33. Findings are: A. Record review of Resident 3's face sheet revealed they were admitted to the facility on [DATE] with urinary tract infection, mood disorder, paralytic syndrome (loss of motor function, generalized muscle weakness, neurogenic bowel (an impaired ability to control bowel movements due to damage of the nervous system), and diabetes mellitus type 2 (a disorder where the body is unable to regulate blood sugar effectively). An interview with Resident 3 on 1/26/26 at 11:08 AM revealed the resident was upset about being left waiting for assistance to on prior occasions. Resident 3 revealed that on several prior occasions, they had been left to wait in their room for staff to help them with incontinence care. Resident 3 stated staff had answered their call light,…

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 interview, the facility failed to implement interventions to prevent and alleviate the formation and worsening of pressure injuries for Resident 23. The facility identified a census of 33. A record review of Resident 23's face sheet revealed they were admitted to the facility on [DATE] with diagnoses of traumatic brain injury, dementia, chronic obstructive pulmonary disease, and congestive heart failure.A record review of Resident 23's nursing progress notes revealed the following:On 12/11/25, Resident 23 had a peeling skin/small open area to coccyx (tailbone). The area was cleaned and a nurse aide was educated to apply barrier cream with each brief change, and staff should attempt to reduce pressure to buttocks while in bed.On 12/15/25, the same area to Resident 23's coccyx split open and measured 3.2 x 0.5 centimeters (cm). Treatment and dressing were applied, and the resident's primary care provider was notified.On 12/20/25, the open area measured 2.4 by 0.2 cm.On 12/25/25, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(J)(iii)Based on observation, record review, and interview, the facility failed to ensure one (Resident 21) of one sampled resident received adequate fluid according to dietary recommendations based on resident weight and medication orders. The facility identified a census of 33. Findings are:Record review of Resident 21's clinical census sheet indicated the resident went to the hospital on 1/13/2026 and returned to the facility on 1/15/2026 with a diagnosis of Influenza A and hypoxia (low oxygen levels). A history of essential hypertension. Chronic kidney disease stage 3, unspecified urinary incontinence, and urinary tract infections.Record review of Resident 21's Minimum Data Set (MDS) (a federally mandatory assessment that identifies cares needed for the resident) dated 11/15/2025 revealed the following: Section C The Brief Interview for Mental Status (BIMS) (a brief screener that aids in detecting cognitive impairment) a score of 7, which indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure 1 (Resident 6) of 5 sampled residents was seen by a primary care physician as required by the federal regulation, which is every 120 days when alternating visits with a non-physician practitioner (NPP). The facility identified a census of 33. Record Review of Resident 6's admission record reveals that resident 6 was admitted [DATE] with diagnosis of unspecified injury of head, diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, obsessive-compulsive personality disorder, other dissociative and conversion disorders, dissociative identity disorder, anxiety disorder, and major depressive disorder. Record Review of Resident 6's Minimum Data Set (MDS) (a federally mandated assessment to help guide cares for a resident) dated 10/2/2025 revealed the following: Section C- Brief Interview for Mental Status (BIMS)(a brief screener that aids in detecting cognition impairment) a score of 7 indicating moderate cognitive…

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 Licensure Reference Number 175 NAC 12-006.08 Based on record review and interview, the facility failed to ensure the provider reviewed and documented what, if any, actions had taken place to address the pharmacist recommendations made during their monthly medication regimen review for 2 (Residents 6 and 13) of 5 sampled residents. The facility identified a census of 33.Findings Are: A record review of the facility policy Medication Utilization and Prescribing- Clinical Protocol with a revision date of July 2016 revealed in the Treatment/Management section that the physician and staff will adjust existing medications based on their efficacy and the continued presence of relevant conditions and risks. A record review of the facility policy Tapering Medications and Gradual Drug Dose Reduction with a revision date of July 2022 revealed that periodically the staff and practitioner will review the continued relevance of each resident's medications. A. A record review of Resident 13's January 2026 Medication…

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.

Licensure Reference Number 175 NAC 12-006.04(H)(i) Based on an interview and record reviews, the facility failed to employ a Registered Dietitian full-time or have a certified Food Service Director. This had the potential to affect 27 residents who ate from the kitchen. The facility census identified a census of 27. Findings are: Record review of a facility document titled, Hemingford Care Center Facility Assessment - 2024, section 3.2: Staffing Plan, revealed that the facility identified the need for one, Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services. An interview with the Kitchen Supervisor (KS) on 12/3/24 at 10:40 AM revealed KS had been the supervisor for several months but had not completed any special certifications and was not a certified FSD. An interview with the Administrator on 12/03/24 at 1:01 PM, revealed that the dietitian had resigned and no longer worked at the facility as of 11/29/24.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.11(E) Based on observations and interview, the facility failed to store, label, cover, and use or discard food and drink items in a manner that prevented the potential for foodborne illness. This had the potential to affect all 27 residents residing at the facility. Findings are: An observation on 12/2/24 at 8:49 AM during the initial kitchen tour revealed the following: Refrigerated items: -1 open half-full 32-ounce container, manufacturer-labeled garlic in water covered with foil and labeled AR 10/30, OPD 11/5. -1 unlabeled package of ground meat-like substance in tubular casing. -1 1-gallon ziplock bag of loose raw meat-like substance labeled 11/29, 12/3. -1 fiberglass tray with 3 1-gallon size ziplock bags of diced meat sitting in liquid on tray, labeled (a)8/23 [NAME], (b)diced chicken, arrive frozen 11/21 LO 11/28, and (c) diced turkey out 11/29. In the dry storage room, 1opened gallon-sized container [NAME] cooking wine, labeled with open date of 8/18 and Best-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.

License Reference Number 175 NAC 12-006.18 Based on observations, interviews, and record reviews; the facility failed to handle contaminated linens for all residents who were residing within the facility in a way that prevented the potential for cross contamination; and the facility failed to complete hand hygiene between distributing laundry for Residents 11, 21, 130, and 131. The facility identified a census of 27. Findings are: A. An observation on 12/09/24 at 10:10 AM revealed Housekeeping/Laundry-G (HSKP-G) distributing personal laundry to residents on the 100 hall of the facility. HSKP-G exited Resident 21's room and returned a plastic bin to the linen cart. HSKP-G zipped the protective plastic covering closed on the cart, pushed the cart down the hall, then unzipped the plastic covering. HSKP-G removed hanging clothing from the cart, carried it into Resident 11's room, exited the room with empty hangers, retrieved a small plastic bin from the cart, returned to Resident 11's room, then exited the room again, recovered the cart, then moved down the hall. HSKP-G performed 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.

Licensure Reference 175 NAC 12-006.04(B)(i) Based on record review and interviews, the facility failed to ensure 1 (Nurse Aide (NA)-F) of 6 sampled employees had completed initial orientation with training on abuse. This had the potential to affect all 27 residing in the facility. Findings are: A record review of a facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revised date of April 2021 indicated the facility's process to prevent abuse, neglect, or exploitation included providing staff orientation that included topics such as abuse prevention, identification and reporting of abuse, stress management, and handing verbally or physical aggressive resident behavior. An interview on 12/10/2024 at 10:00 AM with NA-F revealed NA-F was unable to verbalize any types of abuse or when and whom to report to. NA-F revealed they had been employed with the facility since October 2024, but did not recall having had any initial orientation on abuse. An interview on 12/10/2024 at 11:40 AM with the Administrator revealed the Administrator had no evidence…

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.

Licensure Reference 175 NAC 12-006.09(F)(i) Based on record reviews and interviews, the facility failed to develop a baseline care plan within 48 hours of admission and provide a copy to the resident or resident's representative for 5 (Residents 13, 15, 16, 20, and 22) of 8 sampled residents. The facility identified a census of 27. A record review of a facility policy Care Plans - Baseline with last revised date of March 2022 revealed under the policy statement that a baseline care plan is developed for each resident within 48 hours of admission. The policy also revealed the facility would provide a copy of the summary to the resident and/or resident representative and be documented in the medical record. A. A record review of an admission Record indicated the facility admitted Resident 13 on 6/14/2024 with diagnoses of adult failure to thrive (decline in older adults that manifests as a downward spiral of health and ability,) seizures, atrial fibrillation (a common heart condition that causes an irregular and rapid beating of the heart,) Diabetes, depression, left femur (thigh…

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.

Licensure Reference 175 NAC 12- 006.09(I) Based on record reviews and interview, the facility failed to protect 4 (Residents 9, 16, 17, and 20) from Resident 15's adverse behaviors. The facility identified a census of 27. Findings are: A record review of a facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revised date of April 2021 indicated the facility would protect residents from abuse including from other residents. A record review of a facility policy, Abuse and Neglect - Clinical Protocol with a revise date of March 2018 indicated the physician and staff will address appropriately causes of problematic resident behavior where possible. A. A record review of an admission Record indicated the facility admitted Resident 15 on 2/21/2024 with diagnoses of Alzheimer's disease, agitation, mood disorder, wandering, and chronic pain. A record review of Resident 15's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents), revealed Resident 15 had a Brief Interview for Mental Status score 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.

License Reference Number 175 NAC 12-006.02(H) Based on interviews and record review, the facility failed to report alleged misappropriation of resident property to a state agency within 24 hours and submit an investigation within 5 working days of the incident as required for 1(Resident 12) of 1 sampled resident. The facility identified a census of 27. Findings are: Record review of a facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last revised September 2022, revealed if misappropriation of resident property is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy also indicated that immediately was defined as within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Record review of an undated facility document titled, Investigation report, Misappropriation, revealed the following: -On 8/7/24 at 10:30AM, the dialysis center called the facility to report that (Resident 12) had alleged that someone stole 4 million…

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.

Licensure Reference 175 NAC 12-006.09(D) Based on record reviews and an interview, the facility failed to accurately code active diagnoses, medication use, and Gradual Dose Reduction (GDR) information on the Minimum Data Sets (MDS, a standardized assessment tool that measures health status in nursing home residents) for 2 (Resident 9 and 17) of 3 sampled residents. The facility identified a census of 27. Findings are: A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual with a date of October 2023 revealed the following: -Code medications for anticoagulants if a resident is taking warfarin, heparin, or low-molecular weight heparin. -Code medications for antiplatelet use if a resident is taking clopidogrel or dipyridamole. -If a GDR has been determined clinically contraindicated, enter the date. -Code active diagnoses if that disease has a direct relationship to resident's current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death. A. A record review of Resident 9's annual MDS with a 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.

Licensure Reference 175 NAC 12- 006.09(G)(i) Based on record reviews and interview, the facility failed to develop and provide a discharge summary that included a recapitulation (a brief review or summary) of stay for 1 (Resident 79) of 1 sampled resident. The facility identified a census of 27. Findings are: A record review of a facility policy, Discharge Summary and Plan with a revision date of October 2022 revealed the following: - 1. The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge. - 12. A copy of the following is provided to the resident and will be filed in the resident's medical record: an evaluation of the resident's discharge needs, the post discharge plan, and the discharge summary. A record review of an admission Record revealed Resident 79 was discharged from the facility on 10/7/2024. A record review of a Discharger Planning Review v1.1 with a date of 10/7/2024 revealed section Recap of the resident's stay was left blank. An interview on 12/4/2024 at 12:00 PM…

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.

Licensure Reference 175 NAC 12-006.09(H) Based on record reviews and interview, the facility failed to ensure two prophylactic antibiotics had stop dates and had indications for use for 1 (Resident 2) of 1 sampled resident. The facility identified a census of 27. Findings are: A record review of an undated policy Antibiotic Stewardship - Order for Antibiotics indicated if an antibiotic is indicated, prescribers will provide complete antibiotic orders including the drug name, dose, frequency, duration of treatment (start and stop date or number of days of therapy), route and indication. A record review of Resident 2's Order Summary with an active order date of 12/5/2024 revealed orders for Macrobid (an antibiotic), with directions to give one capsule by mouth in the morning for prophylactic with a start date of 11/14/2024 and did not have a stop date or duration. It also revealed an order for bacitracin-polymyxin ophthalmic ointment, an antibiotic for the eye, with directions to instill one ribbon in the right eye at bedtime for supplement with a start date of 4/13/2024 and did not…

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.

License Reference Number 175 NAC 12-006.11(D) Based on observations, record review, and interviews, the facility failed to maintain the nutritive value of pureed food. This had the potential to affect 2 residents (Residents 5 and 15). The facility identified a census of 27. Findings are: An observation of meal service on 12/3/24 at 11:46 AM revealed the following: -Cook-A measured three foods into three separate blender containers: (a) chicken and dumplings, (b) boiled seasoned peas, and (c) cornbread. -The foods were blended by Cook-A with an electric blender attachment. -Cook-A added unmeasured hot water from a coffee carafe to each container, then re-blended to achieve a pureed consistency for the chicken and the peas, and a slurry for the cornbread. -The three blended foods were each distributed to two separate plates, and a serving of cooked canned sweet potatoes was also put on each plate. A record review of the undated facility recipe, Chicken and Dumplings, revealed no guidance for mechanical soft or pureed diet modifications. No recipe was available for the peas or…

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 Licensure Reference Number 175 NAC 12-006.11(A)(iv) Based on observation, interview, and record review, the facility failed to serve food in the texture ordered by the medical provider for two affected residents (Residents 5 and 15). The facility identified a census of 27. Findings are: A record review of active physician's orders for Resident 5 revealed an order for, regular diet, mechanical soft texture, thin consistency liquids, ordered on 7/30/2024. A record review of active physician's orders for Resident 15 revealed an order for, liberalized diet, mechanical soft texture, regular consistency liquids, ordered on 9/23/2024. An observation of meal service on 12/3/24 at 11:46 AM revealed the following: -Cook-A measured three foods into three separate blender containers: (a) chicken and dumplings, (b) boiled seasoned peas, and (c) cornbread. -The foods were blended by Cook-A with an electric blender attachment. -Cook-A added unmeasured hot water from a coffee carafe to each blender container to achieve a pureed…

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.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to submit an accurate investigation report to the state agency following an elopement for 1 (Resident 1) of 2 sampled residents. The facility census was 25. The Findings Are: A record review of a facility provided document titled New Investigation Report revealed that the Director of Nursing (DON) submitted an investigation report to the State Agency on 7/11/24 regarding the elopement of Resident 1. The report stated that the facility called the incident in to Adult Protective Services (APS) on 7/6/24 at 9:32 PM, and that the facility administrator was notified of Resident 1's elopement on 7/6/24 at 6:57 PM. In the section labeled Describe the incident, the document stated that Resident 1's elopement occurred on 7/6/24 at 6:57 PM and that the NHA (Nursing Home Administrator) was notified of the incident on 7/5/24 around 5:12 PM. In the Outcome of the Facility Investigation section, the document stated that Resident 1 had been outside the facility from approximately 5:37 PM or…

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 Licensure Reference Number 175 NAC 12-006.09(I)(i)(3) Based on record review and interview, the facility failed to implement interventions to prevent elopements for 1 (Resident 1) of 2 sampled residents. The facility census was 25. The Findings Are: A record review of facility policy Wandering and Elopements with revision date of March 2019, revealed that if a resident was identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. The policy did not contain information regarding implementing new interventions after an elopement occurred and did not contain examples of interventions that could be put into place if a resident was at risk for wandering or elopements. A record review of Resident 1's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 3/12/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3/15, which…

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 Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interviews, the facility failed to notify the resident's representative of a resident's change in condition for 1 (Resident 1) of 4 sampled residents. The facility census was 27. The Findings Are: A record review of facility policy Change in a Resident's Condition or Status with a last revised date of February 2021, revealed in #2 A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions., in #4 Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status., and in #8 The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A record 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.

Licensure Reference Number 175 NAC 12-006.09D1c Based on record review, observations, and interviews, the facility failed to assist a dependent resident with toileting. This affected Resident 2. The facility identified a census of 27. The findings are: A record review of Resident 2's admission Record indicated the facility admitted Resident 2 on 5/4/2023 with diagnoses of: left side hemiplegia, paraplegia, epilepsy, Spina Bifida, and muscle weakness. A record review of Resident 2's Minimum Data Set (MDS a standardized assessment tool that measures health status in nursing home residents), dated 2/22/2024 revealed Resident 2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS also revealed the resident had impairment of upper and lower extremities and required total assistance for all Activities of Daily Living (ADLs.) A record review of Resident 2's undated Care Plan revealed Resident 2 required two-person total assistance for toileting. An observation on 3/26/2024 at 11:57 AM revealed Resident 2 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D8b Based on record reviews and interviews, the facility failed to identify a significant weight loss for 1 (Resident 1) of 4 sampled residents. The facility census was 27. The findings are: A record review of facility policy Weight Assessment and Intervention with last revised date of September 2008, revealed in the Weight Assessment section, #3 Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. and #6 The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months-7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months- 10% weight loss is significant; greater than 10% is severe. A record review of facility policy Change in a…

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

Licensure Reference Number 175 NAC 12-006.10D Based on observations, interviews, and record review, the facility failed to prepare and administer the correct dosage for 2 (Resident 8 and Resident 12) of 11 sampled residents. The medication error rate was 7.69%. The facility identified a census of 27. The findings are: An observation on 3/26/2024 at 12:18 PM revealed Licensed Practical Nurse (LPN) - A prepare an unmeasured amount of Resident 8's Dicolfenac Gel 1%. An interview on 3/26/2024 at 12:20 PM with LPN-A revealed [gender] was not knowledgeable of how to measure Diclofenac Gel 1%. A record review of Resident 8's order revealed Diclofenac Gel 1% with a direction to apply 2 grams to both knees. A continuous observation on 3/26/2024 at 12:23 PM revealed LPN-A had administered 17 grams or a converted measurement of 1.1497 tablespoons of Miralax to Resident 12. An interview on 3/27/2024 at 10:43 AM with LPN-A revealed [gender] follows the orders to know the correct amount to administer and had acknowledged the dosage varies for each resident. A record review of Resident 12'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, interviews, and record reviews, the facility failed to provide supervision to prevent the potential for elopement to 2 (Residents 2 & 4) of 5 sampled residents. This had the potential to affect 5 of 5 residents who resided in the facility's Memory Care Unit. The facility census was 25. The Findings Are: A record review of the facility policy Emergency Procedure-Missing Person, with a last revised date of August 2018, Policy Interpretation and Implementation #1 revealed Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety. A record review of the facility's resident roster on 1/30/24 revealed there were 5 residents residing in the Memory Support Unit (MCU). A. A record review of Resident 4's admission record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of Schizoaffective disorder, Bipolar type. A record review of Resident 4'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.

Licensure Reference Number 175 NAC 12-006.04D2 Based on record review and interview, the facility failed to have a Qualified Dietary Manager. This had the potential to affect all residents who ate food served by the kitchen. The facility census was 22. A record review of the facility's dietary department staff list revealed no evidence of a Certified Dietary Manager being employed by the facility. A interview on 12/12/2023 at 10:15 AM was conducted with Registered Dietician (RD) M. During the interview RD M reported being new to the facility with plans of being at the facility monthly. RD M reported the facility did not have a Certified Dietary Manager (CDM) and was in the process of hiring one, likely from in house. RD M reported the internal candidate did not a CDM currently.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11E Based on observation and record review; the facility kitchen staff failed to store food, failed to complete hand hygiene during food preparation and failed to ensure kitchen equipment was maintained in a clean manor to prevent the potential for food borne illness. This had the potential to effect all residents who ate food from the kitchen. The facility staff identified a census of 22. Based on observation, interview, and record review the facility failed to ensure equipment in the kitchen was fu. This had the potential to affect all residents who received meals from the kitchen. The facility census was 22. The findings are: A. An initial observation of the kitchen tour on 12/06/2023 from 8:50 AM to 9:25 PM revealed the following: -A one gallon container of vegetable oil opened and undated. -A container of Raisin Bran cereal with a preparation dated of 9/20 and did not identify a use by date or expiration date. -A container of [NAME] Krispie's with a preparation…

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 Licensure Reference Number 175 NAC 12-006.18A Based on observation and interview; the facility staff failed ensure ventilation system vents were maintained in a clean functional condition for 6 rooms (rooms 103, 201, 207, 211, 305, and 307) affecting Residents 5, 6, 8, 10, 13, 14, 15, and 20 and 2) and failed to ensure bathroom vents were in working order in 2 rooms (307 and 311) affecting Residents 13 and 125. The facility staff identified a census of 22 residents at the time of the survey. Findings are: An observation in room [ROOM NUMBER] on 12/6/2023 at 8:30 AM revealed the bathroom vent was not in working order. An observation in room [ROOM NUMBER] on 12/7/2023 at 8:49 AM revealed the bathroom vent had thick chunks of a grey-color build-up of what appeared to be dust and debris. Some of the build-up was protruding from the vent. An observation in room [ROOM NUMBER] on 12/7/2023 at 9:00 AM revealed the bathroom vent had a grey-in-color build-up that appeared to be dust that was covering the vent. An…

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

Licensure Reference Number 175 NAC 12-006.05 (8) Based on record review, observations, and interviews; the facility failed to identify a positioning wedge as a restraint for 1 (Resident 3) of 1 sampled resident. The facility identified a census of 22 residents at the time of the survey. Findings are: A record review of Resident 3's admission Record with a printed date of 12/7/2023 revealed the resident had diagnoses of unspecified intracranial injury without loss of consciousness and aphasia. A record review of Resident 3's Minimum Data Set (MDS- a comprehensive assessment tool used to develop a resident's Care Plan) with a date of 8/1/2023 revealed Section C-Cognitive Patterns, the resident had a Brief Interview for Mental Status (BIMS-a test to evaluate how well an individual is cognitively functioning) did not have a score, but under C100. Cognitive Skills for Daily Decision Making, Made decisions regarding tasks of daily life: Resident 3 had a score of 3 Severely impaired-never/rarely made decisions. A record review of Resident 3's MDS with a date of 10/24/2023 revealed Section…

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 Licensure Reference number 175 NAC 12-006.05 (5) Based on interview and record reviews, the facility failed to provide notice to the state ombudsman of resident transfer or discharge. This failure affected 1 of 1 sampled resident (Resident 17). The facility identified a census of 22 residents at the time of the survey. A record review of Resident 17's face sheet revealed they were admitted on [DATE] with an admitting diagnosis of end stage renal disease (ESRD). Further review of Resident 17's face sheet revealed Resident 17 had a power of attorney (POA). Record review of Resident 17's Progress Note (PN) dated 7/17/2023 at 2:59 PM revealed Resident 17 was taken to the Emergency Department (ER). A record review of Resident 17's PN dated 8/4/2023 revealed Resident 17 was sent to the ER. A record review of Resident 17's PN dated 8/23/202 revealed Resident 17 was sent to the hospital. A record review of Resident 17's PN dated and 9/27/2023 revealed Resident 17 was sent to the ER. A record review of Resident 17's PN…

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.

Licensure Reference Number 175 NAC 12-006.09B1 (2) Based on record review, the facility failed to complete a significant change assessment within 14 days of determining the status change was significant for 1 (Residents 21) of 2 sampled residents. The facility census was 22. Findings are: A record review of Resident 21's admission Record with a printed date of 12/13/2023 revealed the resident had diagnoses of Malignant neoplasm of the brain, unspecified with an onset of 9/11/2023 and Hemiplegia, unspecified affecting the right dominant side. Record review of Resident 21's Hospice admission Orders revealed the Resident was admitted to Hospice on 11/7/2023 with an admitting diagnosis of malignant neoplasm of the brain. A record review of Resident 21's a list of Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) revealed there had not been a significant change MDS completed. An interview with the MDS Coordinator on 12/11/2023 at 3:35 PM. During the interview the MDS Coordinator had confirmed Resident 21 had been placed on Hospice 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 Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility staff failed to identify mental illness diagnoses on a Level 1 Preadmission Screening and Resident Review (PASARR- an evaluation used to identify the presence of mental illness, intellectual disability, or related condition) for 1 resident (Resident 6) of 1 sampled resident. The facility staff identified a census of 22 residents at the time of the survey. Findings are: A record review of Resident 6's PASARR level 1 with a date of 5/5/2023 revealed Section III: PASARR Conditions Number 1. MI (mental illness) or suspected MI: No mental health diagnosis is known or suspected. Under Section V: PASARR Screen Completion A PASARR Level II Evaluation and Determination is not required at this time. It was marked, No diagnosis or suspicion of serious Mental Illness (SMI) or intellectual disability or related condition (ID (intellectual disability/RC (related condition) were indicated. A record review of Resident 6's admission Record…

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 Licensure Reference Number 175 NAC 12-006.04C3a (5) Based on observation, record review, and interviews the facility failed to ensure 1 (Resident 14) of 2 sampled resident who received dialysis services had care plan interventions for dialysis monitoring. The facility census was 22. The Findings Are: A record review of Resident 14's admission record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of End Stage Renal Disease (ESRD). A record review of Resident 14's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning), dated 11/13/23 revealed the facility staff assessed Resident 14 with a Brief Interview of Mental Status (BIMS) of a 10. According to the MDS [NAME] a score of 8 to 12 indicates a person has moderately impaired cognition. An observation on 12/06/23 at 10:30 AM of Resident 14 revealed the resident had a white dressing with a clear covering to on right upper chest. Resident 14 stated this was their dialysis catheter site. Record review…

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 LICENSURE REFERENCE NUMBER:175 NAC 12-006.09D2b Based observations, record reviews and interview; the facility staff failed to identify, obtain treatment and monitor the development of a pressure ulcer for 1 (Resident 20) of 1 sampled resident. The facility staff identified a census of 22. Findings are: A record review of Resident 20's admission Record indicated the facility admitted Resident 20 on 7/17/2023 with diagnoses of paraplegia, muscle weakness, hypothyroidism, history of traumatic brain injury, and a pressure ulcer. Record review of Resident 20's Minimum Data Set (MDS) dated [DATE] revealed the facility staff assessed the following about the resident: -Required total assistance with transfers and bathing. -Required extensive assistance with bed mobility, dressing, and toilet use. -Required supervision with personal hygiene and locomotion. -Brief Interview of Mental Status BIMS) was a 15. According to the MDS [NAME], a score of 13 to 15 indicates a person is cognitively intact. Record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 175 NAC 12-006.09D7 Based on observations, interviews, and record review, the facility failed to utilize bath chair seatbelts during the use of the whirlpool bathing system according to the operational procedures manual for 1 (Resident 20) of 1 sampled resident. The facility census was 22. The findings are: A record review of the undated Operational Procedures Manual for Century Whirlpool Bathing System, under Section II Transfer In, read B. Transfer the patient into the Saf-[NAME] seat using the proper nursing transfer techniques. Secure the seatbelt around the patient's lap. The operations manual also read under Section II Transfer In, Warning: Failure to secure the patient properly with the seatbelt could result in injury to the operator or patient. A record review of the Bath, Shower/Tub policy, last revised in February of 2018, revealed the facility policy did not include information regarding the required safety feature of a bath chair seatbelt during whirlpool use. The policy did not follow the operation…

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 LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on interview and record review, the facility staff failed to provide assessment and monitoring for 2 ( Resident 14 and 17) of 2 residents who was receiving Hemodialysis (A method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood). The facility staff identified a census of 22. The Findings Are: A. Record review of Resident 14's admission record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of End Stage Renal Disease (ESRD). A record review of Resident 14's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 11/13/23 revealed the facility assessed Resident 14 with a Brief Interview of Mental Status (BIMS) of a 10. According to the MDS [NAME] a score of 8 to 12 indicates a person has moderately impaired cognition. Further review of Resident 14's MDS dated [DATE] revealed Resident 14 received dialysis services. An observation 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.