Calibre Post Acute, LLC

Based on record review and interview, the facility failed to ensure nursing staff completed mandatory behavioral health training (a form of instruction that provides knowledge and skills to identify, understand, and respond to mental health and substance use challenges, including the promotion of well-being) for 1 (LPN #26) of 4 (LPN #17, LPN #18, LPN #25, and LPN #26) staff sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services. The findings are: A. Record review of staff training records revealed LPN #26 did not complete the mandatory behavioral health training. B. On 10/14/25 at 12:29 PM, during an interview, the Administrator stated the following: 1. He was unable to find LPN #26's behavioral health training. 2. If LPN #26 did not complete the behavioral health training, he would ensure she completed it that day. 3. All staff were required to complete behavioral health training.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure care plan revisions occurred for 3 (R #8, R #17, and R #25) of 3 (R #8, R #17, and R #25) residents when the staff failed to revise the care plan with the most current resident information. This deficient practice 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 #8 A. On 06/16/25 at 10:03 AM, during an observation of R #8's room the smell of urine became extremely strong. R #8 sat on his bed with nothing on only a brief. The brief appeared to be extremely soiled and was dark in color. The mattress did not have any sheets. B. On 06/17/25 at 8:50 AM, during an interview, the ADON said that R #8 will go days without letting anyone change his brief. The ADON said that R #8 will kick, throw…

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 medical records were complete and accurate for 3 (R #8, R #17, and R #25 ) of 3 (R #8, R #17, and R #25) residents reviewed for documentation accuracy when staff failed to do the following: 1. Document attempts to change R #8's brief. 2. Document attempts to shower/bathe R #8. 3. Document attempts to put sheets on R #8's mattress. 4. Document changing R #8's mattress. 5. Document R #17's fall on 04/05/25. 6. Document unavailable medication for R #25. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #8 A. On 06/16/25 at 10:00 AM, during a walk through of the facility, there was a strong smell of urine starting at room [ROOM NUMBER]. B. On 06/16/25 at 10:02 AM, during an interview, ADON #1 confirmed the smell of urine and indicated that it was coming from R #8's room. C. On 06/16/25 at 10:03 AM, during…

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 training (training that helps staff recognize and respond to various behavioral and mental health issues that residents may present with) for 3 (CNA #8, CNA #9 and ADON #1) of 3 (CNA #8, CNA #9 and ADON #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 the facility's assessment dated 2024-2025, revealed the facility has 20 residents with behavioral health needs and 30 residents with mental illness diagnoses. B. Record review of staff training records revealed the following: 1. CNA #8 did not complete training for behavioral health. 2. CNA #9 did not complete training for behavioral health. 3. ADON #1 did not complete training for behavioral health. C. On 06/18/25 at 11:46 AM, during an interview, Human Resources confirmed CNA #8, CNA #9, and ADON #1 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to notify the provider of missed medication doses for 1 (R #25) of 3 (R #18, R #25 and R #26) residents reviewed for medications not available when staff failed to: 1. Notify the provider of the missed dose of Amiodarone (medication used to treat affects the rhythm of your heartbeats. It is used to help keep the heart beating normally in people with life-threatening heart rhythm disorders of the ventricles) on 06/14/25 and 06/15/25. 2. Notify the provider of the missed dose of Levothyroxine (medication used to treat hypothyroidism underactive thyroid; a condition where the thyroid gland does not produce enough thyroid hormone) on 6/14/25 and 6/15/25. These deficient practices could likely result in residents not receiving the necessary care or worsening medical conditions due to lack of treatment. The findings are: A. Record review of R #25's face sheet, no date, revealed the following: 1. R #25 was admitted to the facility on [DATE]. 2. R #25 diagnoses…

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 interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #16) of 3 (R #16, R #17, and R #18) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #16's admission documents, no date, revealed R #16 was admitted to the facility on [DATE]. B. Record review of R #16's progress note, dated 05/07/25, revealed the following: 1. R #16 fell. 2. R #16 had a bruise noted to the side of her left eye. 3. R #16 had redness to her forehead, left shoulder, left hip, and both knees. C. Record review of R #16's quarterly MDS, dated [DATE], revealed staff documented the following: 1. R #16 had one fall with no injury. 2. R #16 had zero falls with injury (except major; skin tears, abrasions, lacerations, superficial bruises, hematomas and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #25) of 3 (R #18, R #25, and R #26) residents reviewed for neglect, when staff failed to administer R #25's heart rhythm and thyroid medication as ordered by the physician. This deficient practice could likely lead to the residents medical conditions worsening and having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered. The findings are: A. Record review of R #25's face sheet, no date, revealed the following: 1. R #25 was admitted to the facility on [DATE]. 2. R #25 diagnoses include the following: a. Gastrostomy status (is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage). b. Epilepsy, unspecified, intractable, with status epilepticus (a potentially life-threatening state in which a person experiences an abnormally…

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 for all 98 residents in the facility (residents were identified on the resident matrix provided by the DON on 02/13/25) who eat food prepared in the kitchen when staff failed to: 1. Keep the deep freezer and kitchen floors clean. 2. Keep the stoves and surrounding areas clean from oil. 3. Maintain the quality of the oil (fresh) in the deep fryer. 4. Perform hand hygiene prior to assisting R #24 with meal. These deficient practices could likely lead to foodborne illnesses. The findings are: A. On 02/14/25 at 11:16 AM, during an observation of the kitchen revealed the following: 1. The floors in the deep freezer and kitchen had food particles/paper, spilled liquid, and were sticky. 2. The oil in the deep fryer was dark and smokey and had food particles floating on top of the oil. 3. The floor under and the appliances next to the deep fryer were covered in oil. 4. Coffee spilled on the floor. 5. Jelly 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 record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #3) of 1 (R #3) resident reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #3's admission Record, no date, revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's baseline care plan dated 01/27/25 revealed the plan was created on 01/27/25 (not within 48 hours of admission). C. On 02/20/25 at 12:47 PM, during an interview with the MDS Nurse, he confirmed 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.

THIS IS A REPEAT DEFICIENCY FROM 11/06/24 Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for physician's orders, when staff did not administer R #3's blood pressure medication as ordered by the physician. 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 due to it not being administered. The findings are: A. Record review of R #3's Physician orders revealed the following: 1. Order date 01/24/25: carvedilol (medication used to treat high blood pressure) 25 mg, give via percutaneous endoscopic gastrostomy (PEG tube; to surgically insert a feeding tube into a patient's stomach bypassing the mouth and esophagus) one time a day for hypertension (high blood pressure) 2. Order date 01/24/25: hydralazine (medication used to treat high blood pressure) 50 mg, via PEG-Tube three times a day for hypertension. 3. Order date 01/24/25:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to receive medication needed for treatment of an illness for 1 (R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for quality of care. Failure to follow physician orders could likely lead to facility staff and physician being unaware of changes in resident's condition and could likely lead to worsening of resident's condition. The findings are: A. Record review of R #4's admission record (no date) revealed R #4 was admitted to the facility on [DATE]. B. Record review of R #4's change in condition evaluation dated 02/10/25 revealed R #4 presented with generalized weakness, altered mental status (change in awareness, movement and behaviors that stems from illnesses, disorders and injuries affecting your brain) and had an elevated temperature. She was tested for Covid-19 (coronavirus disease; acute disease in humans which is characterized mainly by fever and cough and can progress to severe symptoms and in some cases death, especially in older…

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 wound care orders were obtained and implemented for 1 (R #3) of 1 (R #3) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). This deficient practice could likely result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of pressure ulcers. The findings are: A. Record review of R #3's admission Record (no date) revealed R #3 was admitted to the facility on [DATE]. B. Record review R #3's admit data collection (assessment completed by nursing staff upon admission) dated 01/24/25 revealed the following: 1. Stage II (shallow, open ulcer with a red-pink wound bed, without slough [non-viable tissue composed of dead cells accumulating on the wound surface. Can appear as a moist, yellow, tan, or white layer and is often fibrous or stringy in texture]) pressure injury to sacrum (area of spinal column just above…

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 nursing staff demonstrated competency in the skills and techniques necessary to safely change a suprapubic catheter (a thin flexible tube inserted directly into the bladder through a small incision in the lower abdomen, just above the pubic bone. It is used to drain urine from the bladder when a person is unable to urinate normally) for residents for 1 (ADON) of 1 (ADON) employees sampled for training and competency. This deficient practice could likely result in nurses working with residents without adequate knowledge and skills to do so; likely resulting in injury or inappropriate care being provided to the residents. The findings are: A. Record review of R #17's admission record, no date, revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17 had the following diagnoses: a. Acute Cystitis with Hematuria [a condition where someone experiences an inflammation of the bladder (acute cystitis) ac companied by blood in…

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 medical records were complete and accurate for 2 (R #17 and R #18) of 2 (R #17 and R #18) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #17 A. Record review of R #17's admission record, no date, revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17 had the following diagnoses: a. Acute Cystitis with Hematuria [a condition where someone experiences an inflammation of the bladder (acute cystitis) accompanied by blood in the urine (hematuria)]. b. Need for assistance with personal care. c. Obstructive and Reflux Uropathy (obstructive uropathy occurs when the urine can't drain normally, reflux occurs when urine flows backward into the upper urinary tract). B. Record review of R #17's progress note, dated 01/12/25, revealed 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 interview and record review, the facility failed to ensure the licensed nurses (RN's and LPN's) and CNA's are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 5 (CNA #8, CNA #9, LPN #8, LPN #9, and LPN #10) of 5 (CNA #8, CNA #9, LPN #8, LPN #9, and LPN #10) reviewed for competent nursing staff. This could affect all 94 residents in the facility (residents were identified by Resident Matrix provided by the DON on 10/28/24). This deficient practice could likely result in nurses and CNA's working with residents without adequate knowledge to do so; likely resulting in injury or inappropriate care being provided to the residents. The findings are: A. Record review of LPN #8's personnel files revealed the following: 1. LPN #8 was hired on 10/26/23. 2. Competency evaluation was not completed (the measurement of an individual's knowledge and skills as related to safe, competent performance) for LPN #8. B. Record review of LPN #9's personnel files revealed the following: 1. LPN #9 was hired on 08/10/23. 2. Competency evaluation 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 residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 2 (R #77 and R #94) of 2 (R #77 and R #94) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #77 A. On 10/28/24 at 3:28 PM, during an interview with R #77's family member (resident representative), she stated the following : 1. R #77 was transferred to the hospital three times since admission, one time was on 10/27/24. 2. She could not remember the dates of the other two hospital transfers. 3. Staff did not give R #77 or her representative a bed hold policy notification before R #77 was transferred to the hospital (all three times) or when R #77 returned to the facility. B. Record review of R #77's progress note, dated 09/23/24, revealed R #77…

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 ensure the Minimum Data Set Assessment (MDS, part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment) was accurate for 5 (R #33, R #36, R #48, R #84, and R #85) of 6 (R #5, R #33, R #36, R #48, R #84, and R #85) residents review for MDS assessment accuracy. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R #33 A. Record review of R #33's admission record, no date, revealed the following: 1. R #33 was admitted to the facility on [DATE]. 2. R #33 had the following diagnoses: a. Type 2 diabetes mellitus (a long-term condition in which the body is unable to make enough insulin to control blood sugar).…

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 2 (R #48 and R #77) of 6 (R #5, R #41, R #48, R #60, R #77 and R #81) 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: R #48 A. Record review of R #48's admission record, no date, revealed the following: 1. R #48 was admitted to the facility on [DATE]. 2. Diagnosis of hypertensive heart disease with heart failure (condition that occurs when chronic high blood pressure damages the heart and prevents the heart from pumping blood effectively to the rest of the body). B. Record review of R #48's physician's orders revealed: 1. Order dated 12/21/23; Furosemide (diuretic medication used to treat fluid retention and swelling) oral tablet, give 40 mg by mouth one time a day for congestive heart failure (CHF; chronic condition in which the heart does not pump blood as well as it…

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 care plans were reviewed and revised for 6 (R #26, R #28, R #46, R #59, R #64, and R #85) of 6 (R #26, R #28, R #46, R #59, R #64, and R #85) residents reviewed for care plans when they failed to: 1. Have an Interdisciplinary Team Meeting (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients) within seven days after the completion of the admission Minimum Data Set assessment (MDS, part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment) for R #85. 2. Revise the care plan with the most current resident information for R #26, R #28, R #46, R #59, and R #64. These deficient practices could likely result in the care plan…

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 services that meet professional standards of practice for 1 (R #81) of 5 (R #52, R #59, R #60, R #81 and R #251) residents reviewed for physician's orders when staff failed to: 1. Obtain a Dexcom (continuous glucose monitoring system that tracks glucose levels in the body, without requiring fingersticks [use of lancet to draw blood from the finger]) as ordered by the physician. 2. Ensure R #81 received weekly Trulicity (injectable medication used to treat diabetes by assisting the body to use the insulin it is already making) injections. These deficient practices could likely result in worsening of medical conditions. The findings are: A. On 10/29/24 at 09:27 AM, during an interview, R #81 stated she had not had her Dexcom to monitor her sugar levels in two months. She stated she now must get a fingerstick to check her glucose levels four times a day. B. Record review of R #81's physician's orders revealed the following: 1. Order dated 03/30/24; Trulicity Solution 3 mg/0.5 ml, inject 3 mg subcutaneously (under the…

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

Based on record review and interview, the facility failed to provide quality of care for 1 (R #36) of 1 (R #36) resident reviewed for diabetes (chronic condition that happens from persistently high blood sugar levels) when staff did not check blood glucose levels (the process of checking your blood sugar level to ensure they are within a healthy range) and administer diabetic medications. This deficient practice could likely result in R #36 having a higher risk of developing long-term health problems and a higher risk of diabetic ketoacidosis (DKA; a serious complication of diabetes that can be life-threatening. Occurs when blood sugar is very high, and ketones [acids your body makes when it's using fat instead of sugar for energy] build up in the body, causing symptoms of increased thirst, frequent urination, weakness and fatigue). The findings are: A. Record review of R #36's medical record dated 01/18/24, revealed R #36 was referred to hospice. B. Record review of R #36's medical record revealed the record did not contain any documentation R #6 was admitted to hospice. C. 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 Based on observation, record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #251) of 5 (R #52, R #59, R #60, R #81 and R #251) residents reviewed for medications when they failed to provide routine medication for a resident. This deficient practice could likely lead to unresolved or worsening of medical issues. The findings are: A. Record review of R #251's admission record (no date) revealed R #251 was admitted [DATE]. B. On 11/04/24 at 8:46 AM, during observation of medication pass by LPN #1, revealed the following: 1. LPN #1 stated he would not administer medications to R #251 because the medications were not available. 2. LPN #1 stated R #251's medications were on order from the pharmacy, since she was a new admission (admission within the last 30 days) she gets partial fills (less than 30-day supply) from the pharmacy. C. Record review of R #251's Physician's orders revealed the following: 1. Order…

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 did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was medically necessary for 3 (R #5, R #26 and R #48) of 5 (R #5, R #26, R #31, R #33 and R #48) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason or when no longer necessary, placing these residents at a higher risk of adverse side effects (unwanted, harmful, or abnormal result) when the facility failed to: 1. 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 #5 and R #48. 2. Ensure that antipsychotic for R # 26 was prescribed to treat a specific…

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 interview and record review the facility failed to ensure residents obtained dental services for 4 (R #41, R #50, R #81, and R #84) of 4 (R #41, R #50, R #81, and R #84) residents sampled for dental services, when: 1. Receive 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 R #41 and R #50. 2. Schedule required dental follow-up for R #50 and R # 81. 3. Emergency dental services for R#84. These deficient practices are likely to cause the resident unnecessary pain, embarrassment over the condition and/or appearance of teeth, and potential dental or oral complications. The findings are: R #41 A. On 10/29/24 at 11:01 AM, during an interview with R #41's power of attorney, she stated R #41 had been at the facility for over one year and she would like R #41 to go to the dentist for her regular appointments and to have her teeth cleaned. B. Record review of R #41's admission record revealed R #41…

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 by professional standards of food service safety. This failure could potentially affect all 40 residents on the north unit (residents were identified by the Resident Matrix provided by the Administrator on 10/28/24). When they failed to ensure staff maintain refrigerator temperatures in the nutrition refrigerators. If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 11/04/24 at 11:31 AM, during an observation of the nourishment room refrigerator by nurses station on the north unit, the following was revealed: 1. The refrigerator thermometer read 48 degrees Fahrenheit. 2. There was condensation on the back wall inside the refrigerator. B. Record review of the refrigerator temperature log for the nourishment room by the nurses station on the north unit revealed the following: 1. The log stated refrigerator…

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 and interview, the facility failed to ensure call lights worked at all times as intended for Rooms 133 to 152 on the South Unit reviewed for call system functioning. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance. The findings are: A. On 10/29/24 at 12:46 PM, during an interview, a resident stated sometimes her call light does not work. The resident said it happens often and she had told staff, but it still happens. B. On 10/29/24 at 2:21 PM, during an interview, a resident stated her call light does not work half the time. The resident said that she had told staff. C. On 10/28/24 at 1:28 PM, during an interview, a resident stated her call light does not work sometimes. She said that if a resident's call light gets unplugged, then none of the call lights on the unit will work. She said that it seems to happen mostly at night. The resident stated she is unable to call for help because she can not really yell. She said…

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 nursing staff have completed the mandatory Effective Communication training for 5 (LPN #8, LPN #9, LPN #10, LPN #11, and CNA #8) of 5 (LPN #8, LPN #9, LPN #10, LPN #11, and CNA #8) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services. The findings are: A. Record review of LPN #8's Online Training Transcript revealed the Effective Communication training was not completed. B. Record review of LPN #9's Online Training Transcript revealed revealed the Effective Communication training was not completed. C. Record review of LPN #10's Online Training Transcript revealed the Effective Communication training was not completed. D. Record review of LPN #11's Online Training Transcript revealed the Effective Communication training was not completed. E. Record review of CNA #8's Online Training Transcript revealed the Effective Communication training was not completed. F. On 11/06/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident and the resident's representative of a transfer in writing for 1 (R #77) of 2 (R #77 and R #94) residents sampled for hospitalizations when they failed to: 1. Notify the resident or the resident's representative of the transfers to the hospital in writing and in a language and manner they understand. 2. Contents of the notice include the following: -The name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman on the transfer notification form. -Statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 3. Send a written copy of the Transfer Notices to the Ombudsman. These deficient practices could likely result in the resident and/or their representative 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.

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 that reflects a resident's functional capabilities) was completed for 2 (R #82 and R #88) of 3 (R #5, R #82, and R #88) residents reviewed for resident assessments. This deficient practice could likely result in in the facility receiving monies they are not entitled to and possible delays in transitions to a new setting. The findings are: R #82 A. Record review of R #82's medical record revealed a discharge date of 07/02/24. B. Record review of R #82's medical record revealed staff did not complete a Discharge MDS assessment until 11/01/24. C. On 011/06/24 at 4:10 PM, during interview, MDS Coordinator #1 confirmed R #82's Discharge MDS assessment was not completed upon discharge. R #88 D. Record review of R #88's medical record revealed a discharge date of 06/06/24. E. Record review of R #88's medical record revealed staff did not complete a Discharge MDS assessment until 11/01/24. F. On 011/06/24 at 4:10…

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 interview, and record review, the facility failed to keep residents free from accidents for 2 (R #46 and R #64) of 2 (R #46 and R#64) residents reviewed for smoking, when staff failed to complete smoking evaluations to determine resident safety while smoking. This deficient practice could likely result in residents being at risk of serious harm or injury. The findings are: R #46 A. Record review of R #46's admission documents, no date, revealed R #46 was admitted to the facility on [DATE]. B. Record review of the facility's list of residents that smoke, no date, revealed R #46 was a smoker. C. On 10/29/24 at 1:00 PM, during an interview with R #46, he revealed the following: 1. He goes outside to smoke twice a day. 2. He smokes without supervision. D. Record review of R #46's smoking evaluation, dated 10/07/24, revealed the following: 1. R #46 may not smoke independently pending review by the interdisciplinary team. 2. R #46 stated he will not be smoking during stay. E. On 11/04/24 at 8:51 AM, during 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observation, and record review, the facility failed to ensure a resident who entered the facility with an indwelling Foley catheter [a tube inserted through the urethra (the tube through which urine leaves the body) and into the bladder to drain urine] received appropriate treatment for 2 (R #77 and R #85) of 2 (R #77 and R #85) residents reviewed for urinary catheter care, when they failed to: 1. Assess R #77 for urinary retention (a condition that occurs when a person is unable to empty their bladder, either partially or completely) after the removal of her foley catheter. 2. Remove R #85's Foley catheter after the completion of bladder training (a behavioral technique that can help people regain bladder control.) These deficient practices could likely result in residents being susceptible (likely to be influenced) to infection due to the use of a Foley catheter or urinary retention after the removal of a Foley catheter. The findings are: R #77 A. On 10/28/24 at 3:17 PM, during 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.

Based on interview and record review, the facility failed include performance reviews as part of their 12 hours of annual training for 1 (CNA #9) of 2 (CNA #8 and CNA #9) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care. The findings are: A. Record review of CNA #9's personnel records revealed CNA # 9 date of hire was 01/16/18. B. Record review of CNA #9's training records revealed the record did not any contain performance evaluations. C. On 11/06/24 at 11:24 pm, the DON confirmed CNA #9 had been working at the facility for more than a year. The DON confirmed that the performance evaluation for CNA #9 was not completed and the 12 hours of annual training was not done based on the performance evaluation.

Based on record review and interview the facility failed to report injuries of unknown source within two hours to the State Agency (SA) for 3 (R #8, R #9, and R #11) of 3 (R #8, R #9, and R #11) residents sampled for abuse and neglect. If the facility fails to report allegations of injuries of unknown source to the SA within two hours, then residents could likely continue to be abused or suffer serious bodily injury. The findings are: R #8 A. On 08/22/24 at 10:03 AM, during an interview, R #8 said that on 06/07/24, she was being transferred from her bed to the shower chair. R #8 said that the Hoyer lift (designed to lift and transfer patients from one place to another e.g., from bed to bath, chair to stretcher) tipped over and it hit her in the head. B. Record review of R #8's progress note dated 06/07/24 revealed R #8 was being transferred with a lift to a shower chair when it tipped over and hit the resident on the head. The progress note revealed that the resident reported pain to her head and three small open wounds were noted to R #8's forehead and top of head. R # 8's provider…

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 complete a thorough investigation regarding allegations of abuse for 1 (R #9) of 3 (R #8, R #9, and R #10) residents reviewed for abuse and neglect. This failure could likely lead to residents' claims of abuse, neglect, or exploitation not being thoroughly investigated and determining the cause. The findings are: A. Record review of the Incident Report dated 06/08/24, revealed an allegation of abuse of R #9 was reported to the facility on [DATE] by R #9's daughter and son-in-law. B. Record review of the Facility 5 day Follow Up Report dated 06/12/24, sent to the state agency revealed CNA #11 was sent home pending investigation for the allegations of abuse for R #9. CNA #11 had provided care for R #9 at the time of the incident. Interviews with CNA #11 were not documented. The follow up report did not contain any documentation that R #9's family or other CNA's involved in the incident were interviewed. The Follow Up Report did not contain any…

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 ensure resident was assessed for risk of entrapment (state of being stuck or caught on bed rail) from bed rails for 1 (R #25) of 1 (R #25) 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 #25 A. Record review of R #25's admission record revealed R #25 was admitted to the facility on [DATE]. B. Record review of R #25's physician orders dated 07/30/24, revealed an ordered per physical therapist (PT) recommendations for a half bed rail for the left side. C. Record review of R #25's care plan revealed R #25 had bed rails for mobility, positioning and safety. D. Record review of R #25 MDS assessment dated [DATE] under section P0100, revealed the resident does not have bed rail use. E. On 08/23/24 at 11:38 AM, during an observation of R #25's bed, the bed had two bilateral half side rails instead of one. F. On 08/23/24 at…

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 safe, orderly discharge occurred for 1 (R #22) of 1 (R #22) residents reviewed for discharge. This deficient practice could likely cause the resident not to have their needs met outside of the facility, and the resident could decline and be re-hospitalized . The findings are: A. Record review of the face sheet for R #22 indicated an admission date of 12/07/23. B. On 01/02/24 at 3:27 PM during an interview with the Administrator, he revealed the following: 1. R #22 smoked what the facility believed was fentanyl in the bathroom of his room on 12/30/23. 2. The Social Services Director (SSD) handled the incident. 2. The staff called the Police to the facility on [DATE], but the Police did not find anything illegal. 3. R #22 discharged from the facility against medical advice (AMA; a term used in health care institutions when a patient leaves a medical institution against the advice of their doctor) on 12/30/23. C. Record review of R #22's 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.

Based on observation, interview, and record review, the facility failed to properly store medications, when they failed to: 1) Secure medications in a insulin cart on South Unit, 2) Dispose of a loose tablet stored in the medication cart on North Unit, and 3) Keep temperature logs for a medication refrigerator. This could affect all 95 residents in the facility (Residents were identified by the resident matrix provided by the Administrator on 07/27/23). This deficient practice could result in residents obtaining medications that have no longer effective or that are not prescribed to them resulting in adverse side effects. The findings are: Insulin Cart A. On 07/27/23 at 8:30 AM, during an observation of the south unit, the insulin cart was found to be unlocked. B. On 07/27/23 at 8:32 AM, during interview, Med Tech #11 confirmed that the insulin cart was not locked. Loose Tablet C. On 07/28/23 at 2:28 PM, during an in observation of North Unit Medication Cart revealed 1 tablet loose in the medication cart. D. On 07/28/23 at 2:29 PM, during an interview Med Tech #4 confirmed the loose…

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 for all 95 residents in the facility (residents were identified on the resident matrix provided by the Administrator on 07/27/23) who eat food prepared in the kitchen when they failed to: 1. Keep the deep freezer and kitchen floors clean, 2. Wear hairnets in the kitchen 3. Failed to keep the stoves and surrounding areas clean from grease, 4. Maintain the quality of the oil (fresh) in the deep fryer, and 5. Ensure that spices in the kitchen are labeled and dated. These deficient practices could likely lead to foodborne illnesses. The findings are: A. On 07/31/23 at 8:31 AM, during an observation of the kitchen the following was observed: 1. The floors in the deep freezer and kitchen had food particles/paper and were sticky, and 2. The Dietary Assistant #1 did not have a hair net on in the kitchen. B. On 07/31/23 at 8:36 AM, during an interview with the Dietician Manager, he confirmed that the floors were dirty. 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, record review, and interview, the facility failed to have reasonable accommodations for 1 (R #72) of 2 (R #8 and R #72) residents sampled for environment, when they failed to provide R #72 with a mattress to fit her bed. This deficient practice could likely result in the resident being at risk for accidents. The findings are: A. Record review of R #72's Face sheet no date revealed an admission date of 03/07/23. B. On 07/28/23 at 8:41 AM, during an interview with R #72 and observation of R #72's room, it was observed that R #72's mattress was too short and did not fit the bed. R #72 stated that the mattress had been like that since she was admitted . C. On 08/02/23 at 3:57 PM, during an interview with Maintenance Director, he confirmed that the mattress was too short and did not fit the bed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that resident's New Mexico Medical Orders For Scope of Treatment (MOST Advance Directives) were completed accurately for 2 (R #3 and R #53) of 5 (R #3, R #8, R #28, R #53 and R #69) reviewed for Advance Directives. When they failed to: 1) Ensure that the resident's wishes were accurately reflected 2) Ensure that the MOST form was signed by the resident or their designated healthcare decision maker. These deficient practices could likely result in the residents' end-of-life choices not being known. The findings are R #3 A. Record review of R #3's Electronic Medical Record (EMR) revealed a readmission date of [DATE]. B. Record review of R #3'S MOST form dated [DATE] revealed: Section -EMERGENCY RESPONSE SECTION (when a person has no pulse or is not breathing) Do Not Attempt Resuscitation/DNR was marked. C. Record review of R #3'S Physician's Orders revealed: Order date [DATE] CPR/Full code (Cardiopulmonary resuscitation and all other life saving…

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 provide a comfortable and homelike environment for 1 (R #8) of 2 (R #8 and R #72) residents sampled for environment, when they failed to match the existing paint from previous repairs. This deficient practice could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued. The findings are: A. On 07/27/28 at 9:44 AM, during an observation of R #8's room, the wall had scuff marks at knee height and about a foot wide below the window and the corner of the room from the roof to halfway down the wall was painted a different color then the rest of the room. B. On 08/02/23 at 2:39 PM, during an interview with the Maintenance Director, he confirmed that there were previous repairs made in R #8's room and the wall was not painted the same as the rest of the room. He also confirmed that there were scuff marks on the wall.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to report to the State Survey Agency timely for 4 (R #28, R #43, R #53, and R #74) of 5 (R #3, R #28, R #43, R #53, and R #74) residents sampled for abuse and accidents when they failed to report allegations of abuse or serious bodily injury within two hours to the State Agency. If the facility fails to report allegations of abuse or serious bodily injury to the State Agency within two (2) hours, then residents could likely continue to be abused or suffer serious bodily injury. The findings are: R #28 A. Record review of the Health Facility Incident Report dated 06/19/23, revealed an allegation of abuse of R #28 was reported to the facility on [DATE] by R #28's daughter. The facility reported the allegation to the State Agency on 06/19/23. B. On 08/01/23 at 1:42 PM, during an interview with the DON, she confirmed the incident of abuse was not reported to the State Agency within two hours of the facility being aware of the allegation of abuse…

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, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 3 (R #3, R #55, and R #89) of 3 (R #3, R #55, and R # 89) residents reviewed for hospitalization. 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: R #3 A. Record review of R #3's Progress Notes revealed the following: R #3 was transferred to the hospital on [DATE] due to low blood sugar. B. Record review of R #3's medical record revealed no written Transfer Notice. R #55 C. Record review of R #55's Progress Notes revealed the following: R #55 was transferred to the hospital on [DATE] due to PEG tube (feeding tube that allows you to receive nutrition directly through your stomach) being dislodged. D. Record review of R #55's medical record revealed no written Transfer Notice. R #89 E. Record review of R…

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 provide written information to the resident or resident representative that specifies the bed hold policy at the time of the transfer for 3 (R #3, R #55, and R #89) of 3 (R #3, R #55, and R #89) residents sampled for hospitalizations. This deficient practice could likely result in the resident and/or their representative being unaware of the resident ability to return to their previous room or the next available room upon return from the hospital. The findings are: R #3 A. Record review of R #3's Progress Notes revealed the following: R #3 was transferred to the hospital on [DATE] due to low blood sugar. B. Record review of R #3's medical record revealed no written Bed Hold Policy Notice. R #55 C. Record review of R #55's Progress Notes revealed the following: R #55 was transferred to the hospital on [DATE] due to PEG tube (feeding tube that allows you to receive nutrition directly through your stomach) being dislodged. D. Record review of R #55's…

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

Based on record review and interview the facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurate for 1 (R #55) of 2 (R #55 and R #74) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need. The findings are: A. Record review of R #55's physician's orders revealed: Order Date 05/07/23 Cephalexin (antibiotic medication used to treat a wide variety of bacterial infections) Give 10 ml (milliliters) every 6 hours for UTI (Urinary Tract Infection) for 7 Days. B. Record review of R #55's Quarterly MDS completed 05/22/23 revealed: Section I Active Diagnosis question I2300 Urinary Tract Infection (UTI) (LAST 30 DAYS) was not marked to indicate that R #55 was treated for UTI on 05/07/23 through 05/14/23. C. On 08/02/23 at 3:13 PM, during an interview, the DON confirmed that R #55 was treated for a UTI on 05/07/23 and the MDS was not accurately completed to include this information.

Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan for 3 (R #34, R #53, and R #74) of 7 (R #8, R #28, R #29, R #34, R #53, R #55, and R #74) 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: R #34 A. Record review of R #34's Face sheet revealed an admission date of 07/03/23. B. On 07/28/23 at 11:22 AM, during an interview, R #34 stated that she was changed from short term skilled care to long term care and she didn't know what or when the plan was for her to go home. C. Record review of R #34's Care Plan dated 07/12/23 revealed no care plan for R #34's transition from short term care to long term care and no discharge plan. D. On 08/01/23 at 4:07 PM, during an interview with the DON she confirmed that the Care Plan was not developed to include R #34's transition from short term care to long term care and…

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

Based on record review and interview, the facility failed to revise the Care Plan for 2 (R #55) of 3 (R #3, R #55 and R #74) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of changes in care being provided and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. Record review of R #55's Physician's orders revealed: 1. Order date 05/25/23 NPO diet (nothing by mouth) .for Strict Aspiration precautions (practices that help prevent foods or fluids getting into the airway that can lead to trouble breathing or infections such as pneumonia). 2. Order date 06/08/23 cleanse site (wound) with normal saline, pat dry, apply 50/50 (half and half mixture of creams) zinc (topical treatment that may help wounds heal more quickly and prevent infection) and antifungal (topical treatment to treat fungal infections) cream. Apply twice a day and as needed with each incontinence episode; stage 2 pressure ulceration injury (open, shallow, crater-like wound) of sacrum (area at…

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 care plan hospice/facility care responsibilities for 1 (R #29) of 1 (R #29) residents sampled for hospice. This deficient practice could likely result in residents not receiving the care they need from hospice. The findings are: A. Record review of R #29's Physicians Orders revealed an order for Hospice dated 06/08/23. B. Record review of R #29's Care Plan dated 04/12/23 revealed no hospice/facility care responsibilities (The division of care responsibilities (i.e. providing personal care, activities, medication administration .) that the hospice staff and the facility staff will be responsible for providing to R #29). C. On 08/02/23 at 10:24 AM, during an interview the DON confirmed that the facility had not care planed the hospice/facility care responsibilities R #29.

Based on interview, observation, and record review, the facility failed to ensure that a resident who enters the facility without an indwelling foley catheter (tube that is inserted through the urethra and into the bladder to drain urine) is not catheterized (procedure that involves placing a foley catheter) unless clinical condition demonstrates that catheterization was necessary and was treated appropriately for Urinary Tract Infection (UTI) for 1 (R #55) of 2 (R #55 and R #241) residents reviewed for Urinary Tract Infections and Foley Catheters when they: 1) Failed to document the need for foley catheter insertion. 2) Failed to ensure an appropriate diagnosis for long term use of a foley catheter. 3) Failed to ensure that a resident received all doses of antibiotic to treat UTI These deficient practices could result in residents being susceptible to infection due to insertion of foley catheter, worsening of infection or becoming septic (potentially life-threatening when the body responds to infection by damaging it's own tissues) The findings are: A. On 07/28/23 at 3:53 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.

Based on record review, and interview the facility failed to provide trauma informed care (care to help prevent furtherance of trauma and promote safety and well-being) to 1 (R #72) of 1 (R #72) resident diagnosed with a trauma incident. Failing to provide care and seek out knowledge of triggers is likely to cause the resident to become secluded (withdrawn), exhibit behaviors, or cause self harm. The findings are: A. Record review of R #72's Face sheet revealed and admission date of 03/07/23 and admitting diagnosis of Post-Traumatic Stress Disorder (psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event), unspecified. B. On 07/28/23 at 8:49 am, during an interview R #72 said the facility was not addressing her PTSD and that counseling would be beneficial. C. Record review of R #72's care plan dated 03/21/23 revealed no care plan related to R #72's PTSD diagnosis. D. On 07/31/23 at 4:07 PM, during an Interview with DON, she stated that R #72 did not have a current care plan to address PTSD diagnosis. The DON further stated R #72 has not been…

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 to have competent staff when the failed to have competencies for 4 (CNA #23, CNA #24, CNA #25, and LPN #5) of 4 (CNA #23, CNA #24, CNA #25, and LPN #5) nursing staff sampled for competency. This deficient practice could likely result in staff working who are not competent to give care to residents. The findings are: A. Record review of CNA #23's personnel records revealed 1) No CNA competency evaluation completed. B. Record review of CNA #24's personnel file revealed 1) No CNA competency evaluation completed. C. Record review of CNA #25's personnel records revealed 1) No CNA competency evaluation completed. D. Record review of LPN #5's personnel records revealed 1) No Nursing competency evaluation completed. E. On 08/02/23 at 9:22 AM, during an interview the ADON confirmed that the facility did not have competencies for CNA #23, CNA #24, CNA #25, and LPN #5.

Based on observation, record review and interview, the facility failed to ensure that 1 (R #55) of 6 (R #53, R #55, R #69, R #72, R #73, and R #74) residents reviewed for behavioral-emotional health were receiving necessary behavioral health care to meet their needs. This deficient practice could likely result in residents having a decline in their physical, mental, and psychosocial well-being. The findings are: A. On 07/28/23 at 3:53 PM, during an observation, R #55 was lying in bed was very quiet and had a flat affect (reduced expression and displays of emotion) on her face. Resident was unable to answer questions. B. On 08/02/23 at 11:36 AM, during an observation of medication administration. R #55 again had a flat affect on her face. RN #1 stated that R #55 has been sad and her daughter doesn't live here. C. On 08/02/23 at 1:54 PM, during an interview, the Wound Care nurse stated R #55 has declined, she is sad, and her daughter lives out of town. D. Record review or R #55's Physician's Orders revealed: order date 06/27/23 Referral to Psychiatrist (medical practitioner…

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 pharmaceutical services (the direct, responsible provision of medication-related care) were met for 2 (R #55 and R #241) of 3 (R #55, R #74, and R #241) residents reviewed for pharmacy services when they failed to provide routine and emergency medications to residents. These deficient practices could likely lead to unresolved infections, worsening of infection or uncontrolled pain. The findings are: R #55 A. Record review of R #55's Physician's orders revealed: Order date 05/07/23 Cephalexin (antibiotic medication used to treat a wide variety of bacterial infections) Give 10 ml (milliliter) every 6 hours for UTI (Urinary Tract Infection) for 7 days. B. Record review of R #55's Electronic Medical Record (EMR) revealed missed doses for Cephalexin antibiotic as follows: 1) 05/07/23 at 5:04 PM med on order 2) 05/08/23 at 11:31 PM med not in yet 3) 05/08/23 at 5:06 PM med not here 4) 05/13/23 at 4:47 AM no documentation 5) 05/13/23 at 5:07 PM pending delivery 6) 05/14/23 at 11:14 AM pending pharmacy delivery R#241 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.

Based on record review and interview, the facility failed to ensure that each resident received or was offered Pneumococcal (a bacteria that causes pneumonia infection of the respiratory tract) immunization for 1 (R #28) of 5 (R #8, R #16, R #28, R #69 and R #72) 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 #28's Face sheet revealed an admission date of 03/20/23. B. Record review of R #28's Medical Record revealed no documentation of the pneumococcal vaccine was given or offered. C. On 08/03/23 at 9:12 AM, during an interview, the Infection Preventionist confirmed that R #28 had not received or was offered the pneumococcal vaccine.

Based on interview and record review the facility failed complete 12 hours of annual training that included the performance reviews and the facility assessment for 3 (CNA #26, CNA #27, and CNA #28) of 3 (CNA #26, CNA #27, and CNA #28) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care. The findings are: A. Record review of CNA #26's personnel records revealed 1) No information from the performance evaluation or facility assessment were included in the trainings. B. Record review of CNA #27's personnel records revealed 1) No information from the performance evaluation or facility assessment were included in the trainings. C. Record review of CNA #28's personnel records revealed 1) No information from the performance evaluation or facility assessment were included in the trainings. D. On 08/02/23 at 9:22 AM, during an interview the ADON confirmed that the facility did not use the performance reviews or the facility assessment for CNA #26's, CNA #27's, and CNA #28's annual trainings.

Based on interview and record review, the facility failed to obtain laboratory testing for 1 (R #72) of 1 (R #72) residents reviewed for laboratory services. If the facility fails to obtain labs that have been ordered, this could likely cause a delay in chemotherapy (the treatment of disease by the use of chemical substances, especially the treatment of cancer), causing unnecessary harm to the resident. The findings are: A. On 07/28/23 at 8:50 AM, during an interview with R #72, she stated that she misses appointments because her labs aren't getting done on the days they are supposed to be done. B. Record review of R #72's Face sheet revealed and admission date of 03/07/23. It also revealed a diagnosis of Malignant Neoplasm of Esophagus (a disease in which malignant cancer cells form in the tissues of the esophagus). C. Record review of R #72's Physician's orders revealed order date 06/26/23 CBC (complete blood count) with Differential, CMP (Comprehensive Metabolic Panel) one time a day every 14 day(s) for standing order for chemotherapy. D. Record review of R #72's Lab Results…

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 complete a thorough investigation regarding allegations of abuse for 7 residents that CNA #11 worked with (Residents were identified by the interview with the DON on 08/08/23 at 2:26 PM). This failure could likely lead to residents' claims of abuse, neglect, or exploitation not being thoroughly investigated and determining the cause. The findings are: A. Record review of the Health Facility Incident Report dated 06/19/23, revealed an allegation of abuse of R #28 was reported to the facility on [DATE] by R #28's daughter. B. Record review of the Facility 5 day Follow Up report sent to the state agency revealed CNA #11 was terminated for the allegations of abuse for R #28. No other residents were included in the report. C. On 08/01/23 at 1:42 PM, during an interview with the DON she confirmed that allegation of abuse for R #28 was confirmed. The DON stated that through her investigation of the incident with R #28, 6 other residents were found to have…

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 observation, the facility failed to ensure residents knew where the most recent survey was located and accessible to all residents. This could affect all 57 residents in the facility (residents were identified by the facility census provided by the Administrator on 08/31/22). If residents are unable to locate the latest survey conducted by State Surveyors, then residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly. The findings are: A. On 09/01/22 at 1:35 PM, during the resident council interview, R #3, R #4, R #13, R #19, R #28, and R #43, revealed: 1. Residents were not aware that they have access to the most recent Survey 2. The residents did not know where the latest survey was located. B. On 09/01/22 at 3:19 PM, during an interview with Activity Director revealed confirmed that the survey binders were in a location that the residents may not know or reach. C. On 09/08/22 at 3:59 PM, during an interview, the Administrator confirmed that all residents should have access and knowledge as to the…

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

Recite from 06/24/2021 Based on record review, and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, seven days a week. This could affect all 57 residents in the facility (residents were identified by census list provided by the Administrator on 08/31/22). This deficient practice could likely result in resident's not receiving the services that they require to provide the optimal quality of care. The findings are: A. Record review of the facility schedule for August 2022 revealed no full time RN coverage. B. On 09/08/22 at 3:59 PM, during an interview, the Administrator confirmed the facility only has 2 RNs, the DON on the weekdays and the MDS on the weekends and they are not assigned to work the floor.

Based on record review, and interview, the facility failed to follow pharmacy recommendations for all 58 residents in the facility (residents were identified by the Resident matrix provided by the Administrator on 08/31/22), when they failed to: 1) Receive the pharmacy recommendation for June 2022 for all 58 residents, 2) Follow the pharmacy recommendation to provide rationale (reason why) for R #25's PRN (as needed) Lorazepam (antianxiety) longer than 14 days. 3) Follow Pharmacy recommendation for R #21, to update the directions on the MAR (Medication administration Record) to monitor and report any signs and symptoms of bleeding. 4) Follow Pharmacy recommendation for R #40, to add a standing order for PRN (as needed) Naloxone (generic name for Narcan a medication used for the emergency treatment of known or suspected opioid overdose) to the MAR. These deficient practices could likely result in resident taking medication longer than needed if pharmacy recommendations are not addressed. The finding are: June Monthly Review A. On 09/06/22 at 10:46 AM during an interview, the DON…

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

Recite from 06/24/2021 Based on observation, and interview, the facility failed to ensure that food items in the kitchen were labeled and dated. These deficient practices could likely lead to foodborne illnesses that could affect all 57 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 08/31/22). The findings are: A. On 08/31/22 at 10:43 AM, an observation of the Kitchen revealed the following items with no name, or expiration/use-by date: 1. an open bag of thickener not labeled or dated 2. An open bag of dry red crushed pepper, not labeled 3. large container of flour with no label or date 4. large Container of rice with no label or date Refrigerator 5. 3 sandwiches, no label or date 6. 1 container of apple sauce, no date 7. 1 package of cheese, no date or label 8. 1 container of Tuna with no date or label 9. diced onion in a bag, not labeled or dated B. On 09/07/22 at 03:57 PM, during an interview, the Dietary Manager confirmed that the items out of their original container and open food items should be labeled and dated.

Based on record review and staff interview, the facility failed to ensure the facility assessment was accurate and current. This could affect all 57 residents in the facility (residents were identified by census list provided by the Administrator on 08/31/22). This deficient practice could lead to the residents not receiving the care they need to reach their highest well-being. The finding are: A. Record review of the Facility Assessment revealed: The document is titled Facility Assessment Worksheet was dated 07/29/21. B. On 09/08/22 at 3:59 PM, during an interview, the Administrator stated that he did not have a revised Facility Assessment.

Based on record review and interview, the facility failed to ensure that all staff were tested two times a week for Covid-19 (virus that causes a variety of respiratory, gastrointestinal, and neurological diseases] which is characterized mainly by fever and cough). At the time of the recertification survey the facility should have been testing staff twice weekly due to facility having a Covid-19 outbreak (when 1 covid-19 positive staff or resident is identified) . This deficient practice could affect all 57 residents in the facility (residents were identified by census list provided by the Administrator on 08/31/22) and could likely lead to lack of identifying Covid-19 positive staff or residents and continue the spread of the infection within the facility. The findings are: A. Record review of staff Covid-19 test results dated 08/19/22 revealed that Staff #1 tested positive for Covid-19. Review of the test results revealed that staff and residents have only been tested on ce weekly. B. On 09/08/22 at 9:25 AM, during an interview, the IP (Infection Preventionist; the nurse…

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

Based on observation, interview, and record review, the facility failed to ensure that residents were treated with respect and dignity for 2 (R #29 and R #41) of 2 (R #29 and R #41) residents randomly sampled, when the facility failed to provide a dignity cover for their Foley catheter bag (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected in a collecting bag). This deficient practice could likely result in residents becoming depressed, anxious, and lacking self-worth. The findings are: A. On 08/31/22 at 1:51 PM during an observation of R #41's room revealed catheter bag did not have a dignity cover on catheter bag visible from the entrance of the room. B. 08/31/22 at 2:15 PM, during an observation of R #29's room revealed catheter bag did not have a dignity cover on his catheter bag which was visible upon entering. C. On 08/31/22 at 2:25 PM during an interview, LPN #11 confirmed that the catheter bags should have covers. D. Record review of [name of facility] Resident Right's policy, no date revealed, The facility will treat you with…

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 to provide written notice for room/roommate change for 2 (R #33, and R #45) of 2 (R #33, and R #45) resident sampled for notification of change. This deficient practice could likely cause residents to become anxious and depressed if they are not given written room/roommate change notices. The finding are: R #33 A. On 09/07/22 at 2:19 PM, during an interview the SW stated that R #33 moved rooms on 07/20/22. B. Record review of R #33 medical record revealed no documentation of a written notice of room change. R #45 C. Record review of R #45 medical record revealed no documentation of a written notice of room change. D. On 09/07/22 at 9:56 AM, during an interview the Social Worker (SW) stated that R #33 and R #45 had become roommates after R #33 had issues with her roommate. The SW also confirmed that no written notification of room/roommate changes occurred for R #33 or R #45. The SW stated he had been only working as the SW for 2 months.

Based on interview and record review, the facility staff did not demonstrate their response and rationale to grievances/concerns for 6 (R #3, R #4, R #13, R #19, R #28, and R #43) out of 6 (R #3, R #4, R #13, R #19, R #28, and R #43) residents in Resident Council. This deficient practice could result in the issues continuing and resident's rights not being honored. The findings are: A. On 09/01/22 at 3:00 PM, during an interview with Resident Council members R #3, R #4, R #13, R #19, R #28, and R #43 revealed they did not know how to file a grievance and did not recall the process being reviewed with them upon admission or in any of the resident council meetings. B. Record review of Resident Council minutes dated, June 2022, July 2022, August 2022 revealed: 1. that the grievance process was not reviewed with the resident's, 2. during the August 2022 meeting the resident's reported: transportation to and from appointments has been an issue and a grievance was filed by staff on behalf of the residents. 3. Old Business refers to concerns from the previous month and does not have 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 ensure residents, or their representatives received a written notice of transfer as soon as practicable for 3 (R #22, R #25, and R #34) of 3 (R #22, R #25 and R #34) residents reviewed for hospitalizations. This deficient practice could likely result in the resident and/or their representative not knowing the reason that the resident was sent to the hospital. The findings are: R #22 A. Record review of R #22's Progress Notes revealed: 1. R #22 was transferred to the hospital on [DATE]. B. Record review of R #22's Medical Record revealed no documentation of a written notice of transfer was found to be provided to the resident or the resident's guardian/family. R #25 C. Record review of R #25's Progress Notes revealed the following: 1. R #25 was transferred to the hospital on [DATE]. D. Record review of R #25's medical record revealed no documentation of a transfer notice. R #34 E. Record review of R #34's Progress Notes revealed: 1. R #34 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 residents, or their representatives received a written notice of their bed hold policy indicating the duration that the bed would be held for 3 (R #22, R #25, and R #34) of 3 (R #22, R #25, and R #34) residents reviewed for transfers to hospital. This deficient practice could likely result in the resident and/or their representative being unaware of the resident being able to return to their previous room upon return from the hospital. The findings are: R #22 A. Record review of R #22's Progress Notes revealed: 1. R #22 was transferred to the hospital on [DATE]. B. Record review of R #22's Medical Record revealed no written notice of the facilities bed hold policy was found to be provided to the resident or the resident's guardian/family. R #25 C. Record review of R #25's Progress Notes revealed the following: 1. R #25 was transferred to the hospital on [DATE]. D. Record review of R #25's medical record revealed no documentation of a bed hold…

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 an accurate, comprehensive person-centered care plan for 4 (R #21, R #23, R #33, and R #42) of 4 (R #21, R #23, R #33, and R #42) residents reviewed for care plans, when they failed to: 1) Develop a Care Plan for R #21's Enoxaparin Sodium Solution (medication that helps prevent the formation of blood clots given by subcutaneous injection [injection given under the skin] following surgery] and Eliquis (oral [taken by mouth] medication that helps prevent the formation of blood clots after surgery) 2) Develop a Care Plan for R #23's Primary diagnosis of Hepatic Failure (condition in which the liver is unable to perform its normal functions and is unable to rid the body of toxic substances such as ammonia [waste product made by the body during the digestion of protein], the build-up of ammonia can lead to nausea, vomiting, mental disorientation [altered mental state with loss of sense of time, identity, direction and place], confusion [change in mental status in which a person is not able to think with…

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 to provide quality of care for 1 (R #33) of 1 (R #33) residents review for food, when the facility changed R #33's dietary order from mechanical soft diet chopped constancy (chopped up foods) to regular consistency (regular whole foods) on 07/26/22 without the Medical Providers approval. This deficient practice could likely result in the resident having the wrong consistency diet and not being able to consume her food. The finding are: R #33 A. Record review of R #33's Physician's Orders revealed the following: 1. 04/18/22 CCD diet (diabetic diet), Mechanical Soft texture, Thin Liquids consistency liberalized. B. On 09/07/22 at 2:32 PM, during an interview the Dietary Manager (DM) stated that R #33 is on a diabetic diet regular constancy. The DM stated that R #33 was on a mechanical soft diet but had been upgraded. The DM explained that she had received a note from R #33's dentist saying that R #33 could do a regular diet. The DM stated that she talked to the nurse on duty who was the Infection Preventionist (IP). The DM…

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 ongoing communication and collaboration with the dialysis (clinical purification of blood as a substitute for the normal function of the kidney) facility regarding dialysis care and services for 1 (R #42) of 1 (R #42) residents sampled for dialysis. This deficient practice could likely result in residents not receiving the care and monitoring they need after dialysis treatment. The findings are: A. Record review of R #42's admission record revealed an admission date of 06/30/22 with diagnosis of Dependence on Renal (medical term for kidney) dialysis. B. Record Review or R #42's Physician's orders revealed: 07/05/22: Dialysis tues (Tuesday), thurs (Thursday), Sat (Saturday) C. Record review of R #42's progress notes revealed: 1. 07/02/22 Medication Administration Note- away at dialysis 2. 07/07/22 Medication Administration Note-pt (abbreviation for patient) at dialysis 3. 07/09/22 Medication Administration Note-Resident at dialysis 4. 07/14/22 Medication Administration Note-Resident at dialysis 5. 07/16/22 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.

Based on record review, and interview, the facility failed to provide 12 hours of annual training that included the staff performance review and the facility assessment for 3 (CNA #12, CNA #13, and CNA #14) of 3 (CNA #12, CNA #13, and CNA #14) CNAs reviewed for 12 hours of annual training. This deficient practice could likely result in staff not receiving the proper training's for areas needing improvement or for special needs populations they care for. The finding are: A. Record review of the employee records revealed the following: 1) CNA #12 had not completed training that included the staff performance review or the facility assessment. 2) CNA #13 had not completed training that included the staff performance review or the facility assessment. 3) CNA #14 had not completed training that included the staff performance review or the facility assessment. B. On 09/08/22 at 4:04 PM, during an interview the ADON confirmed that the facility was not using the performance evaluations or the facility assessment for the 12 hours of annual training's.

Based on record review, and interview, the facility failed keep residents free from unnecessary Psychotropic medications for 1 (R #25) of 5 (R #9, R #21, R #22, R #25, R #34) sampled for unnecessary medications, when they failed to: 1) Provide rationale (reason for) for R #25's PRN (as needed) Lorazepam (antianxiety) longer than 14 days, and 2) Provide a correct diagnosis for R #25's antipsychotic (used to treat psychotic symptoms such as hallucinations, and delusions) medication QUEtiapine Fumarate ordered to treat dementia. This deficient practice could likely result in residents receiving psychotropic medications longer than needed. The findings are: A. Record review of R #25's Physicians Orders revealed the following: 1. 7/21/2022 LORazepam Tablet 1 MG. Give 1 tablet by mouth every 8 hours as needed for anxiety. 2. 7/20/2022 QUEtiapine Fumarate Tablet 25 MG. Give 25 mg by mouth two times a day for Dementia. B. Record review of R #25's Care Plan revealed the following: Resident on psychotropic medication r/t (related to) antianxiety mood disorder and depression. Potential to…

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

Based on observation, and interview, the facility failed to properly label medication for all 5 residents on North unit (residents were identified by the resident matrix provided by the Administrator on 08/31/22), when they failed to label 9 open over-the-counter medications with an open date in the medication cart. This deficient practice could likely result in resident receiving expired medications. The finding are: A. On 09/08/22 at 9:20 AM, during an observation of the medication cart on north hallway revealed the following over the counter medications open and not dated: 1. Acidophilus (probiotic) 2. Vitamin D3 25 mg 3. Aspirin 81 mg 4. Ferrous Sulfate 325 mg (iron supplement) 5. Loratadine 10 mg (antihistamine) 6. Sodium Chloride tablets (salt) 1 gm 7. Vitamin B-12 500mg 8. Melatonin (sleep aide) 5 mg 9. Vitamin D3 125 MCG B. On 09/08/22 at 9:22 AM, during an interview the ADON confirmed that the 9 medications were open and not dated. C. On 09/08/22 at 12:29 PM during an interview the DON confirmed that the 9 open medications should have an open date on them.

Based on record review, and interview, the facility failed to ensure there was relevant communication in the resident's record indicating the delivery of hospice services (services provided for a person experiencing an advanced, life-limiting illness) for 1 (R #2) of 1 (R #2) residents reviewed for Hospice Services. This deficient practice could likely lead to the resident not receiving the services needed due to lack of collaboration and communication between the facility and hospice provider. The findings are: A. Record review of R #2's Physicians Orders revealed the following: 02/09/22 Admit to (name of hospice provider) B. Record Review of R #2's medical record miscellaneous tab revealed no hospice notes for dates of service after 07/26/22. C. On 09/08/22 at 5:50 PM, during an interview, the DON confirmed that all hospice visit notes should be scanned into the miscellaneous tab of the residents medical record but their medical records staff is behind on scanning.

Based on record review, and interview, the facility failed to provide abuse, neglect, and exploitation training to 3 (LPN #7, LPN #8, and LPN #9) of 3 (LPN #7, LPN #8, and LPN #9) staff members sampled for abuse, neglect, and exploitation training. This deficient practice could likely result in staff not knowing who, what, and when to report things like abuse, neglect and exploitation. The findings are: A. Record review of the employee records revealed the following: 1) LPN #7 no completed training for abuse, neglect, and exploitation. 2) LPN #8 no completed training for abuse, neglect, and exploitation. 3) LPN #9 no completed training for abuse, neglect, and exploitation. B. On 09/08/22 at 4:04 PM, during an interview, the ADON confirmed that LPN's have not completed the abuse, neglect, and exploitation training.

Based on record review, and interview, the facility failed to develop and implement an accurate, effective, person-centered baseline care plan within 48 hours of admission to include Physician's Orders for 1 (R #159) of 1 (R #159) resident reviewed for baseline care plans. This deficient practice could likely lead to residents not receiving the appropriate care, services, and monitoring needed upon admission to the facility. The findings are: A. Record review of R #159's admission Record revealed an admission date of 08/09/22 with diagnosis of Osteomyelitis (infection in the bone) of right foot and ankle and Type 2 Diabetes Mellitus (condition that results from insufficient production of insulin [hormone produced in the pancreas which regulates the amount of glucose in the blood] causing high blood sugar). B. Record review of R #159's Physician's Orders revealed 1. Vancomycin HCl Solution (antibiotic medication used to treat many infections commonly used intravenously [medication given through a vein] as a treatment for complicated bone infections) 1250 mg (unit of measurement for…

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

Based on observation, and interview, the facility failed to maintain repairs on the facility's van that is used to transport residents to and from appointments. This deficient practice could likely affect all 57 residents (resident were identified on the census provided by the Administrator on 08/31/22.) This could lead to resident's being in danger of harm or death if the Facility Van is not operating in a safe manner during a transport. The findings are: A. On 09/01/22 at 1:35 PM, during an interview, R #4 revealed that the facility van was having issues with the air conditioner in the back. R #4 reported having to use alternative transportation (through insurance provider) that has not been reliable and very inconvenient. B. On 09/01/22 at 3:00 PM, during an interview, R #3 revealed that the van only has 1 seatbelt in the back and only 1 resident can be transported at a time. C. On 09/06/22 at 9:18 AM, during an interview, the Transporter confirmed that the van only has one seatbelt in the back and the air conditioner in the back does not work. The Transporter reported scheduling…

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.