Luna Wellness Rehabilitation, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were assessed for risk of entrapment (state of being stuck or caught on bed rail) from bed rails for 2 (R #16, and R #24) of 3 (R #16, R #17, and R #24) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail. The findings are: R #16 A. Record review of R #16's admission documents, no date, revealed R #16 was admitted to the facility on [DATE]. B. On 08/27/25 at 1:38 PM, during an observation of R #16 in her bed, revealed the following: 1. A fall mat was on the floor next to R #16's bed. 2. Bed rails were in place at the top of both sides of R #16's bed. C. On 08/27/25 at 1:44 PM, during an interview with LPN #17, she stated the following: 1. About three (3) weeks before LPN #17's interview with the surveyor (she did not know specific dates), R #16 had several falls. 2. Prior to her falls, she used to use a walker but now…

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 interview, the facility failed to store food under sanitary conditions for all 33 residents (residents were identified by the resident census provided by the Administrator on 03/31/25) when staff failed to: 1. Label and date all items in the kitchen refrigerator. 2. Cover food in the refrigerator. Failure to store food under safe and sanitary conditions could likely to lead to foodborne illnesses in residents. The findings are: A. On 03/31/25 at 1:10 PM, during an observation of the kitchen, revealed the following: 1. The walk-in refrigerator had four trays with 12 bowls of strawberry desserts on each tray. 2. The desserts did not have a cover over them. 3. The desserts did not have a date to indicate when they were prepared. B. On 03/31/25 at 1:20 PM, during an interview the Director of Dietary confirmed that the desserts should be covered with clear plastic wrap and each tray should be labeled with the date the desserts were prepared.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was medically necessary for 3 (R #8, R #23, and R #24) of 5 (R #8, R #13, R #23, R #24, and R #25) residents reviewed for unnecessary medications, when staff failed to: 1. Ensure that antidepressant medication for R #8 was prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. Carry out a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) and failed to document clinical rationale to continue psychotropic medications for R #23 and R #24. These deficient practices could likely result in residents receiving medications without a medical reason and 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 Based on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 2 (R #8 and R #13) of 2 (R #8 and R #12) residents reviewed for hospitalization. This deficient practice could likely result in the residents and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #8 A. On 04/01/25 at 10:55 AM, during an interview with R #8's family member, he stated the following: 1. R #8 was transferred to the hospital on [DATE], due to having high blood pressure. 2. The facility contacted him by phone (R #8's family member was not specific on when) to notify him that R #8 was being transferred to the hospital. 3. He was notified verbally that R #8 was being transferred to the hospital and that the facility would hold R #8's bed for her. 4. He did not receive a written notification of the bed hold policy and was not aware of how…

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 the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was accurate for 1 (R #24) of 4 (R #11, R #15, R #24 and R #25) residents reviewed for accurate MDS assessments. If staff do not document accurately on the MDS assessment then the facility may not be aware of the residents needs. The findings are: A. Record review of R 24's admission record, no date, revealed the following: 1. R #24 was admitted to the facility on [DATE]. 2. Diagnosis of anxiety disorder (mental health conditions that cause excessive fear and worry in response to situations). B. Record review of R #24's physician's orders dated 08/17/24, revealed the following, hydroxyzine (antihistamine medication used for short-term treatment of nervousness and tension which may occur with certain mood disorders such as anxiety) 25 mg give 1 tablet by mouth at bedtime for anxiety (feeling of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #35) of 3 (R #8, R #13, and R #35) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #35's admission record revealed R #35 was admitted to the facility on [DATE]. B. Record review of R #35's physician order, dated 03/07/25, revealed an order for a diabetic, consistent carbohydrate diet (a diet that aims to maintain stable blood sugar levels by consuming a similar amount of carbohydrates at each meal and snack to help prevent blood sugar spikes and crashes) with ground texture (foods that are soft, moist, and easily chewed, with solid pieces no larger than ¼ inch, often recommended for individuals with difficulty swallowing or chewing) and thin consistency (liquids that flow like water) for fluids. B. Record review of R #35's admission Minimum…

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 maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #35) of 3 (R #24, R #25, and R #35) residents sampled for nutrition, when staff failed to follow protocols for identifying weight loss when R #35 had weight loss. This deficient practice could likely result in residents losing weight without the facility being aware of causing physical and mental health issues. The findings are: A. Record review of R #35's admission record revealed R #35 was admitted to the facility on [DATE]. B. Record review of R #35's hospital records, dated 03/01/25, revealed the following: 1. On 02/25/25 R #35 weighed 132.4 pounds. 2. On 03/02/25 R #35 weighed 145.11 pounds (12.71 pound weight gain). C. Record review of R #35's weights in the medical record revealed the following: 1. On 03/07/25, R #35 weighed 149 pounds. 2. On 03/10/25, R #35 weighed 142.6 pounds. 3. On 03/17/25, R #35 weighed 143 pounds. 4. On 03/31/25, R #35 weighed 126.2…

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 the consultant pharmacist's recommendations were reviewed and implemented by the physician and the physician provided a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation for 2 (R #23 and R #24) of 5 (R #8, R #13, R #23, R #24, and R #25) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #23 A. Record review of R #23's face sheet revealed R #23 was admitted to the facility on [DATE], with the diagnosis of Major Depressive Disorder (mental health condition that causes a persistently low or depressed mood and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident medical records contained documentation that residents received, or staff offered the pneumococcal (a bacteria that caused pneumonia infection of the respiratory tract) vaccination for 1 (R #35) of 5 (R #9, R #15, R #23, R #25, and R #35) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are: A. Record review of R #35's admission record, revealed R #35 was admitted on [DATE]. B. Record review of R #35's pneumococcal vaccination consent, no date, revealed R #35 consented to the pneumococcal vaccination. C. Record review of R #35 medical record, revealed the record did not contain documentation that staff administered the pneumococcal vaccination. D. On 04/07/25 at 3:45 PM, during an interview, the Infection Preventionist (IP) confirmed the facility did not administer the pneumococcal…

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 report allegations of abuse or neglect within two hours to the State Agency (SA) for 6 (R #21, R #22, R #23, R #25, R #26, and R #27) of 6 (R #21, R #22, R #23, R #25, R #26, and R #27) residents sampled for abuse. If the facility fails to report allegations of abuse or neglect to the SA within two hours, then residents could likely continue to be abused, suffer serious bodily injury, and/or experience in psychosocial distress (unpleasant emotions associated with a highly stressful situation) or worsening of current mental health conditions. The findings are: R #21 A. Record review of CNA #22's witness statement, dated 05/05/24, revealed CNA #22 witnessed R #24 rubbing R #21's thigh and was trying to take her to his room. B. Record review of the Health Facility Incident Report, dated 05/06/24, revealed the following: 1. The facility identified the type of alleged incident as abuse. 2. R #24 was the consumer identified in the allegation. 3. R #24 was touching a female resident's thigh. 4. The facility did not report the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have evidence that a thorough investigation of an allegation of abuse was conducted and preventive measures to keep residents safe were implemented for 6 (R #21, R #22, R #23, R #25, R #26, and R #27) of 6 (R #21, R #22, R #23, R #25, R #26, and R #27) residents sampled for abuse. These deficient practices could likely result in residents being at risk of continued abuse if allegations are not thoroughly investigated and preventative measures are not implemented. The findings are: R #21 A. Record review of R #21's medical record revealed R #21 was admitted on [DATE]. B. On 07/18/24 at 2:01 PM, during an interview with R #21's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters), the following was revealed: 1. The ADON notified her that R #21 was trying to leave, and another resident tried to move her from going by the door. 2. That the other resident touched R #21's thigh. 3. The facility…

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

Based on record review and interview, the facility failed to ensure care plan revision occurred for 2 (R #24 and R #31) of 3 (R #24, R #31, and R #32) residents when the staff failed to: 1. Revise R #24's care plan to include behavior of touching other residents without consent. 2. Revise R #24's care plan to include behavior of entering other residents rooms without consent. 3. Revise the care plan with the most current resident information for R #31. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #24 A. Record review of R #23's nursing progress note, dated 04/27/24, revealed the following: 1. R #23 reported that a male resident (R #24) touched her leg and made her feel unsafe. 2. R #23 sat in her wheelchair having a conversation in front of male resident's (R #24) doorway. 3. R #23 was unable to propel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to keep resident free from sexual abuse for 1 (R #1) of 2 (R #1 and R #2) residents sampled for abuse. This deficiency caused R #1 to have severe psycho-social distress having to deal with sexual abuse and past trauma brought on by the sexual abuse without mental health service. The findings are: A. Record review of R #1's medical record revealed R #1 was admitted on [DATE]. B. Record review of R #1's nursing progress notes revealed the following: 1. 02/01/24 R #1 was addmitted for therapy due to a right hip fracture with repair due to a fall. R #1 is alert and oriented, and able to make her needs known. 2. 02/01/24 R #1 is alert and oriented to herself. R #1 is able to express her needs. R #1 does require staff assistance for her ADLs. R #1 is nonweight bearing to the right lower extremity. R #1 is incontinent on both bowel and bladder. D. Record review of the facility complaint investigation file, no date, revealed the following: 1. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have evidence that a thorough investigation of an allegation of abuse was conducted and preventive measures to keep residents safe were implemented for 1 (R #1) of 2 (R #1, and R #2) residents sampled for abuse. This deficient practice could likely result in residents being at risk of continued abuse if allegations are not thoroughly investigated and preventative measures are not implement. The findings are: A. Record review of R #1's medical record revealed R #1 was admitted on [DATE]. B. Record review of R #1's nursing progress notes revealed the following: 1. 02/01/24 R #1 was addmitted for therapy due to a right hip fracture with repair due to a fall. R #1 is alert and oriented, and able to make her needs known. 2. 02/01/24 R #1 is alert and oriented to herself. R #1 is able to express her needs. R #1 does require staff assistance for her ADLs. R #1 is nonweight bearing to the right lower extremity. R #1 is incontinent on both bowel and bladder. C.…

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 develop a comprehensive care plan for (R #1) of 2 (R #1 and R #2) residents sampled for abuse. This deficient practice could likely result in staff being unaware of the needs of residents. The findings are: A. Record review of R #1's medical record revealed R #1 was admitted on [DATE]. B. Record review of R #1's admission MDS revealed it was completed on 02/05/24. C. Record review of R #1's care plan, dated 02/01/24, revealed the following: 1. R #1's wished to return home. 2. Preferences for activities. 3. Advanced directives for emergencies. 4. The record did not include any other care plan documentation to include diagnosis, treatment/medications, assistance needed and provided by the facility, etc. D. On 03/07/24 at 12:49 pm, during an interview the DON confirmed R #1's Care Plan was not complete. The DON stated the facility should have completed R #1's care plan to include resident specific needs of care.

Based on interview and observation, the facility failed to post the results of the most recent state survey and make them accessible to residents and the public. This failure could affect all 39 residents in the facility (residents were identified by the Resident Matrix provided by the DON on 01/08/23). If residents are unable to review the latest survey conducted by State Surveyors, then residents, representatives, and visitors are likely unable to know how the facility is doing and make decisions accordingly. The findings are: A. On 01/10/24 at 2:00 PM, an observation of the survey binder revealed that the results of the most recent survey conducted on 08/08/23 were not available in the survey binder. B. On 01/10/24 at 2:32 PM, during an interview with the DON, she confirmed the survey binder did not have the survey results for the most recent survey conducted on 08/08/23. She also confirmed that the expectation is for the results from surveys to be in the survey binder.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, the facility failed to designate a qualified, trained, or certified Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP.) This failure affected all 39 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 01/08/24). This deficient practice could likely result in residents being at greater risk of infectious disease. The findings are: A. On 01/16/24 at 3:27 PM, during an interview with the DON, she said the IP was the ADON, but the ADON left the faciity on [DATE]. The DON said she was now responsible for the IP duties. The DON said she did not have specialized training in infection prevention and control.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to inform residents when changes in coverage were made to items and services covered by Medicare and/or by Medicaid for 2 (R #13 and 98) of 3 (R #13, R #38, and R #98) residents reviewed for beneficiary notices when they failed to provide R #13 and R #98 with Form CMS-10055- Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage [form used to inform the beneficiary (resident) about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services.] This deficient practice can likely result in confusion for the resident or their representative as to what services they receive or do not have financial coverage for under Medicare and/or Medicaid. The findings are: R #13 A. Record review of R #13's Electronic Medical Record revealed: 1. R #13 was admitted to the facility on [DATE] for skilled services (Physical/Occupational Therapy) due to a leg fracture. 2. R #13 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 a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff, which included the traditional care of the resident, the prevention and early detection of disease, and rehabilitation) was completed and accurate for 5 (R #16, R #17, R #27, R #38, and R #197) of 6 (R #15, R #16, R #17, R #27, R #38, and R #197) residents reviewed for completion of a comprehensive MDS assessment. When they failed to: 1. Complete an Annual MDS assessment for R #17 no less than once every 12 months. 2. Complete a Discharge MDS assessment for R #16, R #27, and R #38 within 14 days after discharge. 3. Complete an admission MDS assessment for R #197 within 14 calendar days after admission. These deficient practices could likely result in residents' preferences and needs not being met. The findings are: A. On 01/16/24 at 10:47 AM, during an interview, the DON confirmed the following: 1. A comprehensive MDS assessment should…

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 ensure a Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was completed every three months for 14 (R #2, R #7, R #9, R #10, R #12, R #19, R #22, R #26, R #31, R #34, R #35, R #36, R #38, and R #42) of 12 (R #2, R #7, R #9, R #10, R #12, R #19, R #22, R #26, R #31, R #34, R #35, R #36, R #38, and R #42) residents reviewed for quarterly MDS assessments. This failed practice is likely to result in resident assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: A. Record review of R #2's Electronic Medical Record (EMR) revealed R #2's quarterly MDS assessment was due on 12/23/23 and was in progress. B. Record review of R #7's EMR revealed R #7's quarterly MDS assessment was due on 11/16/23, but staff completed it on 01/12/24. C. Record review of R #9's EMR revealed R #9's quarterly MDS assessment was due on 12/21/23 and was in progress. D. Record review of R #10's EMR revealed R #10's quarterly MDS assessment was…

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

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R #32) of 5 (R #2, R #15, R #26, R #31, and R #32) residents reviewed for comprehensive care plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are: A. Record review of R #32's Electronic Medical Record (EMR) revealed diagnosis of Post-Traumatic Stress Disorder (PTSD; mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations.) B. Record review of R #32's care plan initiated 10/12/22, revealed the record did not contain a care plan for the diagnosis of PTSD. C. On 01/16/24 at 4:29 PM, during an interview with the DON, she confirmed R #32's diagnosis of PTSD was not included in the resident's care plan, but it should be included.

Based on record review and interview, the facility failed to revise the care plan for 1 (R #29) of 3 (R #26, R #29 and R #31) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. On 01/09/24 at 10:55 AM, during an interview, R #29 said he no longer received restorative care. R #29 said the program closed. B. Record review of R #29's care plan, dated 10/24/22, revealed R #29 was on a restorative nursing program (RNP; helps residents practice activities of daily living to improve, or at least maintain, overall functioning). C. On 01/12/24 at 11:43, during an interview with the DON, she confirmed R #29's care plan documented R #29 was in a RNP. The DON said the RNP ended in September 2023, and they did not do RNP anymore. The DON confirmed staff did not update R #29's care plan.

Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 (R #31) of 3 (R #15, R #26, and R #31) residents reviewed for professional standards of care, when staff did not follow physician's orders. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication. The findings are: A. Record review of R #31's Physician's orders revealed an order dated 11/22/22, for metoprolol succinate (blood pressure medication that may cause a low heart rate) tablet, 100 mg. Give one tablet by mouth in the morning for hypertension (HTN; high blood pressure.) Hold if heart rate is below 60. B. Record review of R #31's medication administration record, dated November 2023, revealed staff administered the metoprolol outside of the parameters as follows: 1. On 11/06/23 at 8:00 AM, the resident's heart rate was 59, and staff administered the medication. 2. On 11/16/23 at 8:00 AM, the resident's heart rate was 58, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide activities of daily living (ADL) assistance for 1 (R #25) of 2 (R #11 and R #25) residents reviewed for ADL care when they failed to assist R #25 with brushing her teeth and eating. This deficient practice is likely to affect the dignity and health of the residents. The findings are: Assistance with Oral Care A. On 01/08/24 at 3:16 PM, during an interview with R #25's daughter, she said the staff did not help R #25 brush her teeth. B. Record review of R #25's Quarterly Minimum Data Set (MDS) dated [DATE] (most recent) revealed R #25 required limited assistance from one staff for personal hygiene C. Record review of R #25's ADL sheet, dated December 2023, 6:00 AM to 6:00 PM revealed the following: 1. 12/01/23, R#25 did not receive oral care. 2. 12/05/23, R #25 did not receive oral care. 3. 12/11/23, R #25 did not receive oral care. 4. 12/13/23, R #25 did not receive oral care. 5. 12/16/23, R #25 did not receive oral care. 6.…

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 residents received treatment and care in accordance with professional standards of practice for 3 (R #4, R #9, and R #20) of 3 (R #4, R #9, and R #20) residents when they failed to: 1. Answer call lights in a timely manner for R #4 and R #9. 2. Complete skin assessments as ordered for R #20. This deficient practice could likely lead to residents needs not being met and/or a worsening of their condition. Call Lights R#4 A. On 01/10/24 at 2:13 PM, during an interview with resident council members, R #4 said sometimes it took around 30 minutes for staff to answer the call lights. B. Record review of R #4's Call Light History Log, dated 12/01/23 to 01/16/24, revealed the following: 1. On 12/05/23 at 6:30 AM, wait time of 31 minutes. 2. On 12/05/23 at 8:39 AM, wait time of 21 minutes. 3. On 12/05/23 at 10:46 PM, wait time of 15 minutes. 4. On 12/13/23 at 1:49 PM, wait time of 25 minutes. 5. On 01/13/24 at 5:23 AM, wait time of 24 minutes. R #9 C. 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.

Based on observation, record review, and interview, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease in range of motion for 2 (R #26 and R #29) of 3 (R #26, R #29 and R #41) residents reviewed for restorative therapy, when they failed to initiate a restorative nursing program (RNP; nursing service that often follows skilled rehabilitation services provided by physical or occupational therapists with the goal to maximize function and prevent functional decline in residents dependent on staff for certain actions). This deficient practice could likely result in decreased mobility or a decrease in residents' abilities to participate or perform their own activities of daily living (ADLs). The finding are: R#26 A. On 01/08/24 at 2:35 PM, during an interview with R #26, he stated he participated in therapy. R #26 continued to state a CNA worked with him on some exercise. R #26 stated that exercises had stopped several months ago but did help. B. Record review of R #26's Occupational Therapy Discharge Summary, dates of service…

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 ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician or to ensure the physician provided rationale for not following the recommendation for 2 (R #8 and R #25) of 5 (R #2, R #8, R #9, R #25, and R #32) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions or adverse side effects. The findings are: R #8 A. Record review of the pharmacy consultation report for R #8, dated 12/01/23, revealed: 1. R #8 received fluoxetine (an antidepressant medication), 10 mg, for depression since 12/17/22. 2. The pharmacist recommended an assessment of medication therapy, showing the benefit to risk for continuing therapy, and a periodic dose reduction trial when medications may no longer be necessary. 3. The recommendation form was not signed by the provider. B. Record review of R # 8's physician's orders revealed she had an active order (date 03/17/23)…

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 provide a drug regimen that was free from unnecessary medication by giving medication as ordered for 1 (R #29) of 1 (R #29) residents reviewed for unnecessary medication. This deficient practice could likely lead to R #29 receiving medication he doesn't need. The findings are: A. Record review R #29's physician order, dated 06/17/22, revealed an order for tramadol tablet (opioid medicine used for the short-term relief of moderate to severe pain), 50 mg. Give one tablet by mouth every six hours for pain level 5-10. B. Record review of R #29's medication administration record (MAR), dated December 2023, revealed staff administered R #29 tramadol every 6 hours regardless of pain being below the level of 5-10 a total of 95 times between 12/01/23 through 12/31/23. C. Record review of R #29's MAR, dated January 2024, revealed staff administered R #29 tramadol every 6 hours regardless of pain being below the level of 5-10 a total 20 times between 01/01/24 through 01/09/23. D. On 01/09/24 at 1:43 PM, during an interview with LPN…

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 ensure residents did not receive antipsychotic medications unless the medication was necessary to treat a specific psychiatric condition or diagnosis and was documented in the medical record for 2 (R #25 and R #32) of 3 (R #8, R #25 and R #32) residents reviewed for unnecessary psychotropic medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #25 A. Record review of R #25's Physician's orders, dated 12/27/22, revealed an order for seroquel (an antipsychotic medication used to treat schizophrenia and bipolar disorder) tablet, 25 mg. Give one tablet by mouth at bedtime for dementia. B. Record review of R #25's medical record revealed the record did not contain a psychiatric diagnosis to indicate the need for an antipsychotic. C. On 01/12/24 at 11:29 AM, during an interview, the DON confirmed R #25 did not have a psychiatric diagnosis on file for the…

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

Based on observation and interview, the facility failed to properly store medications in the medication carts for all 39 residents (residents were identified by the resident matrix provided by the Administrator on 01/08/24) randomly sampled, when they failed to secure the medication carts on the East unit. This deficient practice could likely result in residents obtaining medication not prescribed to them and residents having adverse side effects. The findings are: A. On 01/08/24 at 10:04 AM, during observation of the East Unit, the medication cart was unlocked, and staff was not around. B. On 01/08/24 at 10:06 AM, during an interview with LPN #11, he confirmed the medication cart was not locked, and the cart was supposed to be locked. C. On 01/08/24 at 10:29 AM, during an interview with the DON, she confirmed staff should not leave medication carts unlocked when they are not in site of the cart.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure residents obtained routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments for 8 (R #2, R #11, R #15, R #25, R #26, R #29, R #31, and R #41) of 8 (R #2, R #11, R #15, R #25, R #26, R #29, R #31, and R #41) residents reviewed for dental services. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: A. Record review of the facility's Dental Services Policy, not dated, revealed the following: 1. Routine and 24-hour emergency dental services are provided to residents. 2. A contract agreement with a licensed dentist that comes to the facility monthly. 2. Social Services representatives will assist residents with appointments and transportation arrangements. 3. All dental services are recorded in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to maintain proper infection prevention measures when the did not ensure a waste receptacle for doffed (removed) personal protection equipment (PPE; clothing, gloves, face shields, goggles, facemasks, gowns and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) was available inside the room of residents on transmission-based precautions (TBP; residents who are known or suspected to be infected or colonized with infectious agents). Failure to adhere to an infection control program is likely to cause the spread of infections and illness to all 39 residents (residents were identified by the resident matrix provided by the DON on 01/08/24). The findings are: A. Record review of the facility's Personal Protective Equipment Policy- Using Gowns (no date), instructed staff to remove the gloves and gown inside the room and to discard them in a waste receptacle inside the room. B. 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.

Based on record review and interview, the facility failed to ensure each resident received or staff offered them the Influenza (the flu; an infection of the nose, throat, and lungs) immunization for 2 (R #11 and R # 41) of 6 (R #9, R #11, R #25, R #31, R# 36 and R #41) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are: R #11 A. Record review of R #11's face sheet revealed an admission date of 04/12/22. B. Record review of R #11's medical record revealed the record did not contain documentation staff offered or administered the Influenza vaccine to the resident. C. On 01/16/23 at 3:13 PM, during an interview with the DON, she confirmed R #11 did not receive the Influenza vaccine. R #41 D. Record review of R #41's face sheet revealed an admission date of 03/27/23. E. Record review of R #41's medical record revealed the record did not contain documentation staff offered or administered the Influenza vaccine to the resident. F. 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.

Based on interview and record review, the facility failed ensure CNAs completed 12 hours of annual training that included dementia management training for 3 (CNA #1, CNA #2 and CNA #3) of 3 (CNA #1, CNA #2 and CNA #3) CNAs sampled for required annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care. The findings are: A. Record review of CNA #1's training records revealed: 1) CNA #1 completed 8 hours and 47 minutes of annual training from January 2023 through December 2023, but the trainings did not include dementia training. B. Record review of CNA #2's training records revealed: 1) CNA #2 completed 11 hours and 27 minutes of annual training from January 2023 through December 2023, but the trainings did not include dementia training. C. Record review of CNA #3's training records revealed: 1) CNA #3 completed more than 12 hours of annual training from January 2023 through December 2023, but the trainings did not include dementia training. D. On 01/16/24 at 4:22 PM, during an interview, the DON confirmed CNA #1 and CNA #2…

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 provide behavioral health (the emotions and behaviors that affect your overall well-being) training for 6 staff (CNA #1, CNA #2, CNA #3, LPN #1, LPN #11 and RN #1) of 6 (CNA #1, CNA #2, CNA #3, LPN #1, LPN #11 and RN #1) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are: A. Record review of R #32's admission record (no date), revealed the following diagnoses 1. Bipolar disorder (serious mental illness characterized by extreme mood swings, that can include extreme excitement episodes or extreme depressive feelings 2. Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) 3. Post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback,…

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 create a baseline care plan within 48 hours, that accurately reflected the resident's current condition for 1 (R #197) of 3 (R #9, R #8, and R #197) residents sampled for behavioral health services. This deficient practice could likely result in residents not receiving the appropriate care and services and may place residents at risk of an adverse event (an event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #197's face sheet revealed she was admitted to the facility on [DATE]. B. Record review of R #197's medical record revealed the baseline care plan was not initiated until 12/10/23. C. Record review of R #197's medical record revealed R #197 had a diagnosis of anxiety and post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks,…

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 staff completed a discharge summary to include a recapitulation (a concise summary describing the resident's course of treatment while residing in the facility) and a medication reconciliation for 1 (R #16) of 1 (R #16) residents sampled for discharge from the facility. This deficient practice could likely lead to the resident, caregivers, and/or receiving home health agency not knowing what the current care needs and significant medical history are for the resident. The findings are: A. Record review of R #16's medical record revealed she was admitted to the facility on [DATE] and discharged from the facility on 09/04/23. B. Record review of R #16's Recapitulation of Stay form revealed, the form did not include information regarding the course of R #16's care and treatment while at the facility, to include course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. C. Record review of R #16's discharge…

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, interview, and record review, the facility failed to ensure appropriate treatment and services for the treatment of a urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder and urethra) for 1 (R #198) of 2 (R #31 and R #198) residents sampled for urinary tract infections, when they failed to administer antibiotics (medication used to treat bacterial infections) according to the physician orders. This deficient practice could likely result in prolonged symptoms and worsening of the Urinary Tract Infection. The findings are: A. Record review of R #198's face sheet revealed she was admitted to the facility on [DATE]. B. Record review of the nursing hand-off communication (up-to-date information regarding patient care, treatment and service, condition, and any recent or anticipated changes, between individuals who give and receive patient information) for R #198 from the hospital on [DATE] revealed the receiving nurse signed…

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, interview, the facility failed to ensure residents were not restricted from having visitors. This deficient practice could affect all 48 residents (identified on the census list provided on 08/04/23). If the facility is restricting residents to have visitors, the residents could likely have a decline in psychosocial health and not have additional advocacy for resident health and safety needs. The findings are: A. On 08/04/23 at 9:36 AM during an observation revealed a sign posted on the front door of the facility stated, NURSING HOME VISITING HOURS 6 AM-8 PM DOORS WILL LOCK AT 8 PM. B. On 08/04/23 at 9:48 AM during an interview, the administrator revealed that he was not aware of the sign posted on the front door of the Nursing home and he did not know who placed it there. The Administrator was asked for the visitation policy and this Surveyor was provided the policy for the Hospital (connected to the Nursing home) and reported that he did not have a policy for this facility.

Based on record review and interview the facility failed to report to the State Survey Agency timely for 1(R #21) of 1(R #21) residents sampled for abuse and accidents when they failed to report allegations of abuse within two hours to the State Agency. If the facility fails to report allegations of abuse to the State Agency within two hours, then residents could likely continue to be abused. The findings are: A. Record review of the Health Facility Incident Report dated 07/07/23, revealed an allegation of abuse of R #21 was reported to the facility in April 2023 by CNA #23 (to the previous Administrator). B. On 08/04/23 at 10:00 AM during an interview with CNA #24 revealed being approached by CNA #21 and CNA #22 who were laughing and trying to show her a picture on CNA's #21's phone. CNA #23 identified (R #21) in the picture standing at the foot of the bed with her breast exposed. C. On 08/04/23 at 10:23 AM during an interview CNA #23 revealed that on 03/05/23, CNA #21 showed a picture from her cell phone of R #21 holding on to the foot board and had her shirt pulled up exposing…

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 interview and record review facility failed to keep residents free from abuse for 1 (R #21) of 3 (R #21, R #22 and R #23) residents reviewed for abuse when the facility failed to protect a resident. This deficient practice could likely result in residents feeling anger, shame, anxiety, embarrassment or fear. The findings are: A. Record review of R #21's medical records revealed: 1. admission date 04/15/2022, 2. Severely impaired cognitive function related to Alzheimer's Dementia (A progressive disease that destroys memory and other important mental functions.) B. On 08/04/23 at 10:00 AM during an interview with CNA #24 revealed being approached by CNA #21 and CNA #22 who were laughing and trying to show her a picture on CNA's #21's phone. CNA #23 identified (R #21) in the picture standing at the foot of the bed with her breast exposed. C. On 08/04/23 at 10:23 AM during an interview CNA #23 revealed that on 03/05/23, CNA #21 showed a picture from her cell phone of R #21 holding on to the foot board and had her shirt pulled up exposing her breast and pants pulled down, CNA…

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 interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety by not: 1. Ensuring food items in the dry pantry are labeled and dated, 2. Ensuring Food/food products are discarded by their expiration dates, 3. Ensure Dry Pantry's floor and shelves are clean and grime free, This deficient practice is likely to affect all 46 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 11/29/22), who eat food prepared in the kitchen. If the facility fails to adhere to safe food handling practices residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 11/30/22 at 10:18 AM during an observation of the kitchen's Dry pantry revealed: 1. The floor in the pantry was visibly dirty and sticky, 2. Expired food not discarded: a) 1 bag of rice expired 07/30/22 b) 2 bags of dried pinto beans expired 08/27/22 c) 1 bag of granola expired…

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 implement the comprehensive person-centered care plan developed for 1 (R #39) of 1 (R #39) residents reviewed for nutrition, when they failed to follow a Care Plan for weekly weights for R #39. This deficient practice could likely lead to residents going without the appropriate monitoring and not receiving the appropriate care and services to help maintain the highest practicable well-being. The findings are: A. Record review of R #39's admission Record (no date) revealed an admission date of 10/28/22. B. Record review of R #39's Diagnosis list (no date) revealed the following diagnoses: CACHEXIA (loss of more than 5 percent of your body weight over 12 months or less, when not trying to lose weight), ADULT FAILURE TO THRIVE (loss of appetite, eating and drinking less than usual, weight loss, and being less active than normal) and ABNORMAL WEIGHT LOSS (significant/ongoing weight loss when not trying to lose weight). C. Record review of R #39's Care Plan initiated 11/02/22, revealed: FOCUS: Nutritional Status Improvement.…

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 ensure residents, or their representatives received a written notice of transfer as soon as practicable for 1 (R #41) of 2 (R #41, and R #45) residents reviewed for discharge. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location that the resident was discharged . The findings are: A. Record review of R #41's Electronic Medical Record (EMR) revealed: 1) R #41 was sent to the hospital after an unwitnessed fall on 10/26/22 2) No written notice for hospital transfers was found. B. Record review of R #41's Progress Notes revealed that she returned from the hospital on the same day she went out. C. Record review of R #41's Care Plan revised date 11/30/22 revealed: 1. I, [name of resident] have had an actual fall with minor Injury with Poor Balance and poor decision making, overestimates abilities, 2. Transferred to ED (Emergency Department), Safety reminders intact. D. On 12/06/22 at 2:20 PM, during an interview with the Administrator, she confirmed that a…

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

Based on record review, and interview, the facility failed to act upon the pharmacy recommendations for 1 (R #23) of 5 (R #6, R #23, R #35, R #41, and R #43) residents reviewed for unnecessary medications, when they failed to clarify R #23's order for Digoxin (is used to treat heart failure) indicating to hold the medication if the pulse is below 60. This deficient practice could likely result in residents receiving medications that may cause unnecessary drug interactions or adverse side effects. The findings are: A. Record review of Pharmacy Recommendation for R #23 dated 10/12/22 revealed: 1. an order for Digoxin 125 mcg (Microgram) on Electronic Medication Administration Record (eMAR). The directions indicate to hold the medication if the pulse is below 60. The pharmacist also stated, There were few times the medication was administered even though the pulse was below 60. B. Record review of Pharmacy Recommendation for R #23 dated 11/05/22 revealed: 1. There is an order for Digoxin 125 mcg on EMAR. The eMAR indicate to hold the medication if the pulse is below 60. The pharmacist…

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.