Las Cruces Village Nursing & Rehabilitation LLC

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 #24) of 3 (R #24, R #26 and R #27) residents 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. On 09/15/25 at 9:04 AM, during an interview with R #24's family member, she stated R #24 did not have a plan of care in place. B. Record review of R #24's admission Record, no date revealed R #24 was admitted into the facility on [DATE]. C. Record review of R #24's physician orders dated 08/25/25, revealed wound care to the sacrum…

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 treatment and services specialized in managing and healing wounds that do not heal properly for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) for 1 (R #24) of 3 (R #8, R #24 and R #25) residents reviewed for pressure ulcers, when staff failed to: Obtain wound care orders for R #24's pressure ulcer until three days after admission, Perform wound care for one day of the six days R #24 was in the facility. These deficient practices 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. On 09/15/25 at 9:04 AM, during an interview with R #24's family member, she stated R #24 had a wound when he got to the facility and did not receive wound care on 08/21/25 (day of admission). R #24 received wound care on 08/25/25. B. Record review of R #24's face sheet no date, revealed…

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 the record review and interview, the facility failed to ensure RN coverage was provided for 8 consecutive hours a day and for 7 days a week. This failure could potentially affect all 79 residents who lived in the facility (residents were identified by the Resident Matrix provided by the Administrator on 06/23/25. This deficient practice is likely to result in residents not receiving the services they require. The findings are:A. Record review of the Payroll Base Journal (PBJ) Staffing Data Report (report from the data base of the federal agency overseeing certification for long term care facilities) dated Quarter #1 (October 1 through December 31) 2025 revealed no RN coverage for at least 8 consecutive hours on 10/19/24, 10/20/24, 10/26/24, and 10/27/24.B. On 06/27/25 at 3:40 PM during an interview, the corporate nurse stated they were unable to provide proof of RN coverage for 10/19/24, 10/20/24, 10/26/24, and 10/27/24.

Based on observation, interview, and record review, the facility failed to store and serve food under sanitary conditions by professional standards of food service safety, this could affect all 78 residents living in the facility (residents were identified by the Resident Matrix provided by the Administrator on 06/22/25). When they failed to ensure staff maintain refrigerator temperatures in the dietary west wing kitchen. This deficient practice could expose residents to foodborne illnesses, which includes failing to maintain safe food temperatures. This can lead to a range of health risks, such as foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), affecting residents and requiring immediate attention to ensure their safety.The findings are:A. On 06/23/25 at 7:15 AM, during an observation of the west wing kitchen the refrigerator temperature log temperatures were not documented for 06/21/25 and for 06/22/25.B. Record review of the refrigerator temperature log revealed the temperature log did not contain any records of temperatures…

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 maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections when they failed to have a water management program to minimize the risk of Legionella [a bacteria that can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains) and cause a serious type of pneumonia] and other opportunistic pathogens (bacteria that do not usually cause diseases in healthy people but may become extremely injurious to unhealthy individuals) in the building's water system. This failure could potentially affect all 79 residents who lived in the facility (residents were identified by the Resident Matrix provided by the Administrator on 06/23/25). If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are:A. Record review…

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

A. On 06/26/25 at 10:41 AM, during an interview, ADON #2 confirmed that she is the current IP and confirmed that she has started but has not completed the required IP training and does not have the training certificate yet.B. On 06/27/25 at 10:12 AM, during an interview, the Director of Clinical Services confirmed that ADON #2 had not completed the required IP training to receive her certification.

Based on interview, observation, and record review, the facility failed to provide a safe, comfortable, and homelike environment for 2 (R #47 and R #61) of 4 (R #27, R #30, R #47 and R #61) residents reviewed for missing property, when staff failed to ensure that that resident property was free from loss or theft. This deficient practice could likely cause residents to feel like they are not living in a safe, comfortable, and home-like environment and like they are not valued. The findings are:R #47 A. On 06/23/25 at 11:37 AM, during an interview, R #47 stated the following: 1. A couple of months ago (unsure of date), two of his hats went missing. 2. He notified a CNA or nurse (unsure of staff name). 3. He had not heard anything else about his missing hats. B. Record review of the facility's grievance log, dated 03/01/25 through 06/25/25, revealed there were no grievances regarding R #47's missing hats. C. Record review of R #47's entire medical record, no date, revealed staff did not document an inventory of R #47's belongings. D. On 06/25/25 at 11:22 AM, during an interview, LPN…

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

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 (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 3 (R #12, R #17, R #44,) of 6 (R #1, R #7, R #12, R #17, R #44, and R #75) residents reviewed for unnecessary medications, when staff failed to ensure: 1. Psychotropic medications for R #12 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. 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) was carried out for R #44. 3. Psychotropic medications ordered to be given as needed (PRN) for R #17 were not prescribed for longer than 14 days without documentation of the rationale to extend beyond 14 days in the resident's medical 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 record review and interview, the facility failed to provide the required discharge or transfer information to the resident and the resident's representative(s) in writing for 4 (R #12, R #47, R #78 and R #179) of 5 (R #12, R #47, R #75, R #78 and R #179) residents sampled for hospitalizations or discharge when staff failed to: 1. Notify the resident and the resident's representative of the plan to discharge the resident from the facility in writing and in a language and manner they understand for R #78. 2. Complete a discharge summary for R #78 that included the following: a. A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. A final summary of the resident's status including an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement accurate, person-centered comprehensive care plan for 4 (R #1, R #7, R #77, and R #179) of 4 (R #1, R #7, R #77, and R #179) residents reviewed for care plans when staff failed to:1. Include personal preferences for activities for R #1 and R #7.2. Include a care plan for R #77's primary diagnosis. 3. Include a care plan for R #179's diagnosis and level assistance needed for showering. These deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are:R #1 A. Record review of R #1's admission record, no date, revealed an admission date of 04/20/24 with the following diagnoses: 1. Unspecified dementia, unspecified severity, with other behavioral disturbances (is the loss of cognitive functioning, the ability to think, remember, or reason-to such an extent that it interferes with a person's daily life and activities). 2. Unspecified behavioral emotional disorders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure care plan revisions and care plan meeting requirements occurred for 8 (R #12, R #18, R #25, R #27, R #34, R #44, R #47, and R #61) of 8 (R #12, R #18, R #25, R #27, R #34, R #44, R #47, and R #61) residents reviewed for care plans, when the staff failed to: 1. Ensure the care plan meeting was held within 7 days from the completion of the MDS (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) assessment when creating or revising the care plan for R #44, R #47 and R #61. 2. Revise the care plan with the most current resident information for R #12, R #18, R #25, R #27, and R #34.These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare…

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 activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 1 (R #55) of 3 (R #55, R #61, and R #179) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:A. Record review of R #55's admission record, no date, revealed the following: 1. R #55 was admitted to the facility on [DATE]. 2. R #55 had the following diagnoses: a. Dementia b. Repeated falls c. Muscle weakness d. Difficulty in walkingB. On 06/23/25 at 9:55 AM during an interview with R #55's family member, she stated the following: 1. Staff were supposed to give R #55 showers on Tuesday or Wednesday and Saturday every week. 2. R #55 had missed several showers (dates unknown).C. Record review of the unit shower schedule, no date, revealed R #55 was supposed to receive showers on Wednesday 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 provide an ongoing program of activities designed to meet the interests for 3 (R #1, R #7, and R #75) of 5 (R #1, R #7, R #18, R #27 and R #75) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meets their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are:R #1 A. Record review of R #1's admission record, no date, revealed an admission date of 04/20/24 with the following diagnoses: 1. Unspecified dementia, unspecified severity, with other behavioral disturbance (is the loss of cognitive functioning, the ability to think, remember, or reason-to such an extent that it interferes with a person's daily life and activities). 2. Unspecified behavioral emotional disorders with onset usually occurring in childhood and adolescence (mental heath…

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 interviews the facility failed to have a qualified activities professional to direct an ongoing program of activities designed to meet the interests for resident, for all 13 residents residing in the secure unit of the facility (resident were identified by the Resident Matrix provided by the Administrator on 06/22/25) sampled for activities when staff failed to do the following: 1. Have the Activities Director (AD) licensed or registered as a Activities Director. 2. Have 2 years experience in a social or recreational program within the last 5 years.If the facility is not providing an ongoing activity program this can lead to a less engaging and beneficial program for residents and can negatively impact residents' well-being and quality of life.The findings are:A. On 06/27/25 at 12:57 PM during an interview, the AD stated she was certified as a CNA, and van driver, and had no other training for activities. AD stated she has not taken the [Name of the State] Activities Director training course because she hurt her foot. B. On 07/02/25 at 10:52 AM during an interview with 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 nursing staff were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 3 (RN #16, LPN #16, and CNA #16) of 3 (RN #16, LPN #16, and CNA #16) staff reviewed for competent nursing staff, when they failed to have a competency evaluation (the facility's way to measure an individual's knowledge and skills as related to safe, competent performance through demonstration of those skills) for RN #16, LPN #16, CNA #16, and CNA #17at the time of hire before they start to work with residents. These deficient practices could likely result in nursing staff 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 RN #16's personnel file revealed the following: 1. RN #16 was hired on 04/11/25. 2. RN #16 did not have any competency evaluations demonstrating their knowledge, ability, and skills to care for residents. B. Record review of LPN #16's personnel files…

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 obtained dental services for 4 (R #25, R #34, R #44, and R #61) of 7 (R #7, R #25, R #34, R #44, R #58, R #61, and R #75) residents sampled for dental services, when staff failed to ensure residents received 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. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are:R #25 A. Record review of R #25's admission record (no date) revealed he was admitted to the facility on [DATE]. B. Record review of R #25's medical record revealed no dental visits from June 2024 to June 2025. C. Record review of dental house call note, dated 05/29/24, revealed dental staff documented PT (patient) doesn't want to be seen today as per staff. PT is feeling lethargic and is…

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 medical records were complete and accurate for 2 (R #27 and R #34) of 4 (R #27, R #30, R #34, and R #78) residents reviewed for documentation accuracy when they failed to do the following: 1. Document R #27's fall. 2. Document applying R #34's elbow splint and palm guard. 3. Document R #34's refusal to wear elbow splint and palm guard.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 #27A. Record review of an incident report dated 06/04/25, revealed R #27 was found sitting on the floor next to his bed. R #27 had fallen while he was transferring from his walker to his bed.B. Record review of R #27's medical record, no date, revealed the fall was not documented.C. On 06/26/25 at 3:34 PM, during an interview, the Director of Clinical Services (DCS) confirmed that R #27's fall on 06/04/25 was 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 nursing staff completed the mandatory training for Effective Communication for 6 (RN #16, LPN #16, CNA #16, Nursing Assistant (NA) #16, Dietary Aide (DA) #16, and Activity Aide (AA) #16) of 6 (RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16) staff sampled for training completion. 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, no date, revealed RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16 did not complete the mandatory training Effective Communication. B. On 06/27/25 at 1:43 PM, during an interview, the administrator confirmed RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16 did not complete the mandatory training for effective communication.

Based on record review and interview, the facility failed to ensure nursing staff completed the mandatory Quality Assurance and Performance Improvement (QAPI, a systematic approach used in healthcare, particularly in nursing homes and other long-term care facilities, to enhance the quality of care and resident experience) training for 6 (RN #16, LPN #16, CNA #16, Nursing Assistance (NA) #17, Dietary Aide (DA) #16, and Activity Aide (AA) #16) of 6 (RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16) staff sampled for staffing. This deficient practice could likely result in staff being unable to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor the effectiveness of interventions. The findings are:A. Record review of staff training records, no date, revealed RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16 did not complete the mandatory training for QAPI B. On 06/27/25 at 1:43 PM, during an interview, the administrator confirmed RN #16, LPN #16, CNA #16, NA #16, DA #16,…

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 nursing staff completed the mandatory behavioral health training for 6 (RN #16, LPN #16, CNA #16, Nursing Assistant (NA) #16, Dietary Aide (DA) #16, and Activity Aide (AA) #16) of 6 (RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16) staff sampled for staffing. 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 staff training records, no date, revealed RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16 did not complete the mandatory behavioral health training. B. On 06/27/25 at 1:43 PM, during an interview, the administrator confirmed RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16 did not complete the mandatory behavioral health training.

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #75) of 6 (R #1, R #7, R #12, R #17, R #44, and R #75) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are:A. Record review of R #75's physician's orders revealed the following: 1. An order dated 06/10/25 for seroquel (used to treat various mental health conditions) oral tablet 50 mg, give by mouth two times a day for depression. 2. An order dated 06/10/25 for buspirone (primarily used to treat anxiety disorders) oral tablet 10 mg, give by mouth three times a day for anxiety. B. Record review of R #75's medical record revealed staff did not document consent for seroquel and buspirone. C. On 06/27/25 at 10:12 AM, during an interview,…

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

Based on record review and interview, the facility failed to report an allegation of abuse to the State Survey Agency within two (2) hours of the allegation for 1 (R #12) of 2 (R #12 and R #179) residents reviewed for abuse. If the facility fails to report incidents of possible abuse to the State Agency, then the State Agency is unable to ensure residents have a safe environment. The findings are:A. On 06/23/25 at 12:24 PM, during an interview, R #12 stated the following: 1. On 06/22/25, CNA #16 and CNA #16 were rough with her when they changed her. 2. She told LPN #16 but she wasn't sure what was done. B. Record review of R #12's progress note dated 06/21/25 at 6:45 AM, revealed the following: 1. R #12 was assisted out of bed for her shower in the morning and was crying and stated that the CNAs were being rough with her. 2. LPN #16 stood in the shower room to assist and monitor R #12's care. 3. R #12 continued to cry and state the CNAs were hurting her, while the CNAs weren't near R #12. C. Record review of R #12's progress note dated 06/22/25, revealed the following: 1. R #12 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 interview and record review, the facility failed to meet regulatory requirements for discharge for 1 (R #78) of 1 (R #78) resident when staff failed to:1. Conduct discharge planning.2. Ensure proper notification was given to the resident.3. Confirm resident receipt of the discharge notice.4. Notify Ombudsman of R #78's discharge. These failures have the potential for an incomplete, unsafe discharge and increase risk of resident harm. The findings are:A. Record review of the facility's Transfer and Discharge policy, dated 10/24/22, revealed the facility must ensure documentation is/ complete, involve the physician in the decision, notify the residents and/or their representative, issue a written notice, and assist with safe and appropriate discharge planning. The policy also stated residents must be informed of their right to appeal, and staff must notify the Ombudsman.B. Record review of R #78's face sheet revealed he was admitted to the facility on [DATE]. R #78 was discharged on 04/28/25. 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 interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was accurate for 1 (R #61) of 6 (R #10, R #17, R #25, R #61, R #77 and R #179) 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. On 06/23/25 at 10:11 AM, during an interview, R #61's sister stated she thinks R #61 has had three urinary tract infections (UTI; infection in any part of the urinary system) since R #61 was admitted to the facility. B. Record review of R #61's admission record revealed R #61 was admitted to the facility on [DATE].C. Record review of R #61's physician's orders revealed an order dated 03/23/25 for amoxicillin-pot clavulanate (combination prescription antibiotic used to treat various bacterial infections including urinary tract…

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 #75) of 3 (R #18, R #27 and R #75) residents 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 #75's admission Record, no date, revealed R #75 was admitted into the facility on [DATE]. B. On 06/23/25 at 11:21 AM during an interview, R #75's daughter said she was told by the activity staff that R #75 did not participate in activities. R #75's daughter said R #75 was not interested in the activities that 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 interview and record review, the facility failed to ensure a resident received restorative rehabilitation (focuses on maximizing an optimal level of functioning, enabling clients to regain/retain their independence following the debilitating effects of illness or injury) services as recommended by physical therapy and occupational therapy for 1 (R #34) of 1 (R #34) residents reviewed for rehabilitation services. This deficient practice is likely to result in a decrease in residents functional mobility. The findings are:A. Record review of R #34's admission documents, no date, revealed the following: 1. R #34 was admitted to the facility on [DATE]. 2. R #34 had the following diagnoses: a. Hemiplegia (a condition characterized by paralysis or severe weakness on one side of the body, often resulting from brain damage or spinal cord injury) and hemiparesis (a condition characterized by weakness on one side of the body) following cerebral infarction (also known as an ischemic stroke, is a condition where…

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 implemented, wound care was completed, and staff documented that the wound care was performed for 1 (R #58) of 1 (R #58) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time).These deficient 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 #58's face sheet no date, revealed R #58 was admitted to the facility on [DATE], with the diagnosis of pressure ulcer of the sacral region, stage 3 (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis). B. Record review of R #58s MDS dated [DATE], revealed the following: 1. R #58 has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. 2. R #58 has one stage 1 pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #44) of 2 (R #27 and R #44) resident reviewed for accidents, when staff failed to ensure that ordered fall mats were in place when R #44 was in bed. This deficient practice could likely result in residents getting injured if they fall from their bed. The findings are:A. Record review of R #34's admission documents, no date, revealed the following:1. R #34 was admitted to the facility on [DATE].2. R #34 had the following diagnoses: a. Hemiplegia (a condition characterized by paralysis or severe weakness on one side of the body, often resulting from brain damage or spinal cord injury) and hemiparesis (a condition characterized by weakness on one side of the body) following cerebral infarction (also known as an ischemic stroke, is a condition where blood flow to part of the brain is blocked, causing brain tissue to die due to lack of oxygen and nutrients) affecting left non-dominant side. b.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #44) of 2 (R #27 and R #44) resident reviewed for accidents, when staff failed to ensure that ordered fall mats were in place when R #44 was in bed. This deficient practice could likely result in residents getting injured if they fall from their bed. The findings are:A. Record review of R #44's admission documents, no date, revealed the following: 1. R #44 was admitted to the facility on [DATE]. 2. R #44 had the following diagnoses: a. Repeated falls. b. Unsteadiness on feet. c. Need for assistance with personal care. d. Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities).B. On 06/23/25 at 10:14 AM, during an interview with R #44, the following was revealed: 1. She had several falls. 2. She had fallen from the bed. 3. She wasn't sure what was being done to prevent her from falling again. 4. She needed assistance to get in and out of bed.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 record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation for 1 (R #44) of 5 (R #1, R #7, R #12, R #44, and R #75) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are:A. Record review of R #44's admission record, no date, revealed the following: 1. R #44 was admitted to the facility on [DATE]. 2. R #44 had the following diagnoses: a. Dementia with other behavioral disturbance (refers to the non-cognitive…

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

Based on record review and interview, the facility failed to ensure there was a coordinated plan of care for 1 (R #17) of 1 (R #17) resident reviewed for hospice services. This deficient practice is likely to result in residents not receiving necessary services. The findings are: A. Record review of R #17's physician's orders revealed an order dated 05/15/25 under the care of [name of hospice company].B. On 06/27/25 at 2:15 PM during an interview LPN #1 confirmed R #17 was receiving hospice services. C. Record review of R #17's hospice binder revealed no hospice care plan was in place. D. Record review of R #17's medical record revealed that the hospice care plan was not in the medical record. E. On 06/27/25 at 2:19 PM during an interview, the medical records staff confirmed R #17's hospice care plan was not in the medical record or the hospice binder. F. On 06/27/25 at 2:15 PM during an interview, the corporate nurse confirmed the following: 1.The facility should have a copy hospice care plan delineating (describe with accuracy and in detail) which services hospice will provide. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure that staff were properly trained for feeding 1 (R #53) of 1 (R #53) residents reviewed for dining. This deficient practice could likely result in the increased risk of choking and aspiration pneumonia, brain damage (brain damage refers to the destruction or deterioration of brain cells, which can result from various conditions such as trauma, stroke, or infections), or even death from improper feeding techniques.The findings are: A. Record review of R #53's face sheet revealed that she was admitted to the facility on [DATE] with the following diagnoses: 1. Unspecified dementia, unspecified severity, with other behavioral disturbance. 2. Dysphagia, unspecified B. Record review of R #53's MDS dated [DATE] revealed: 1.R #53's diet is a mechanically altered diet (require changes in texture of food or liquids (e.g., pureed food, thickened liquids)). 2. R #53 requires partial/moderate assistance (Helper does less than half the effort. Helper lifts,…

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 abnormal vital signs (blood pressure and heart rate outside of set parameters) for 1 (R #2) of 3 (R #1, R #2, and R #3) residents reviewed for provider notification, when staff failed to notify the provider that R #2's blood pressure (bp) was high and R #2's pulse was low. This deficient practice could likely result in residents not receiving necessary care or worsening medical conditions due to lack of or changes in treatment. The findings are: A. Record review of R #2's admission record (no date) revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2 had a diagnosis of essential (primary) hypertension (common form of high blood pressure that does not have a known secondary cause and is influenced by various lifestyle and genetic factors). B. Record review of R #2's physician orders revealed the following: 1. Order dated 10/04/23 for, isosorbide (medication primarily used to chest pain by dilating blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 1 (R #1) of 3 (R #1, R #2 and R #3) residents reviewed for medication regimen when staff failed to: 1. Contact the physician/provider when medication is held. 2. Contact the physician/provider to notify them of medication refusals. If the facility is not providing care per physician's orders, notifying the provider of changes and providing care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 diagnoses include the following: a. Cerebrovascular disease (conditions that affect blood flow to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #16) of 1 (R #16) resident when staff failed to adequately assess the cause and adequately treat R #16's prolonged diarrhea. Failure to adequately assess the cause of diarrhea and provide appropriate treatment could likely lead to worsening of resident's condition. The findings are: A. Record review of R #16's admission record, no date, revealed R #16 was admitted to the facility on [DATE] with the following diagnoses: a. Metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance). b. Type 2 Diabetes Mellitus (a chronic condition that affects how the body uses sugar (glucose) for energy). c. Unspecified Dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and decision-making, severe enough to interfere with daily life…

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 reviews and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of 4 (R #1, R #3, R #4, and R #5) of 5 (R #1, R #2, R #3, R #4, and R #5) residents reviewed for staffing when staff failed to: 1. Assist R #1 to the toilet as ordered by the physician. 2. Assist R #3 and R #5 with transfers in and out of bed when requested. 3. Get R #4 up and ready to eat meals in the dining room. These deficient practices are likely to cause residents psychological distress, make them feel as if they are not valued, and negatively impact resident comfort. The findings are: R #1 A. Record review of R #1's physician's orders revealed the following: 1. Order start date 11/25/24, order discontinue date 01/28/25: Resident to be toileted (assisted to the restroom to urinate and/or defecate) three times a day once in AM at the start of the shift. Once after dinner at the end of the shift and once in the evening PM shift. 2. Order start date 01/29/25: Resident to be toileted three times a day, once in AM at the start of the shift. Once after dinner 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 medical records were complete and accurate for 2 (R #16 and R #19) of 4 (R #16, R #17, R #18, and R #19) 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 #16 A. Record review of R #16's admission record, no date, revealed R #16 was admitted to the facility on [DATE] with the following diagnoses: a. Metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance). b. Type 2 Diabetes Mellitus (a chronic condition that affects how the body uses sugar (glucose) for energy). c. Unspecified Dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and decision-making, severe enough to interfere with daily life and activities). d. Delirium (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 observation and interview, the facility failed to maintain proper infection prevention measures when they failed to ensure facility staff follow transmission-based precautions (actions to prevent the spread of infectious agents from individuals who are suspected to be infected, such as gloves, facemasks, and gowns) for residents diagnosed with COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions). Failure to adhere to an infection control program could likely cause the spread of infections and illness to all 67 residents in the facility (residents were identified by the resident matrix provided by the administrator on 12/11/24). The findings are: A. On 12/11/24 at 9:33 AM, during an interview, the front desk staff stated the following: 1. The facility currently has residents diagnosed with COVID-19. 2. All staff and visitors must wear N95 masks (a respiratory protective device designed to achieve a…

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

Based on interview and record review, the facility failed to keep residents free from involuntary seclusion (separation of a resident from other residents, from her/his room or confinement to her/his room [with or without roommates] against the resident's will, or the will of the resident representative) for 1 (R #1) of 3 (R #1, R #2, and R #5) residents sampled for involuntary seclusion when the staff failed to allow a resident to move freely throughout the unit. This deficient practice is likely to result in residents experiencing anxiety and/or depression related to being isolated from staff and other residents. The findings are: A. Record review of R #1's face sheet revealed the following: 1. Original admission date of 09/25/23. 2. Diagnoses; Alzheimer's disease (brain condition that causes a decline in memory, thinking, learning and organizing skills over time), insomnia (sleep disorder that can make it hard to fall asleep or stay asleep) and hypertension (high blood pressure). B. Record review of the facility's incident report for R #1, dated 09/03/24 revealed on 09/02/24, 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.

Based on record review and interview, the facility failed to prevent misappropriation (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) of residents medication for 3 (R #8, R #9, and R #10) of 3 (R #8, R #9, and R #10) residents when they failed to ensure that as needed (PRN) controlled narcotics (drug or chemical that is regulated by the government) prescribed to residents were given when it was documented as given. This deficient practice could likely result in residents not having medication available when they need them. The findings are: A. Record review of the facility's Narrative Investigation Report (a five day report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations), dated 07/13/24, revealed CMA #8 texted CMA #9 to ask if he could find one of the resident's hydrocodone (a medication used to treat moderate to severe pain and cough) or Percocet (oxycodone with acetaminophen) for her. CMA #9 did not reply, he…

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 57 residents in the facility who eat food prepared in the kitchen (residents were identified by the Resident Matrix provided by the Administrator on 03/04/24). When they failed to: 1. Keep the kitchen floors clean. 2. Keep the stoves and surrounding areas clean from grease. 3. Ensure food in the dry pantry and freezer was labeled and dated. 4. Ensure staff maintain refrigerator temperatures. 5. Have staff perform hand hygiene when assisting residents in the dining room. If the facility fails to adhere to safe food handling practices, hygiene practices, and 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: Kitchen A. On 03/04/24 at 10:38 AM, an observation of the main kitchen revealed the following: 1. Dried seeds on the tile floor and in between the tile on the…

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

Based on observation and interview the facility failed to provide a homelike environment for all 35 residents on the 300 and 400 units (residents were identified by the resident matrix provided by the Administrator on 03/04/24), when they failed to repair: 1) Damaged/broken ceiling tiles in the hallways of the 300 and 400 units. 2) A hole in R #31's bathroom wall caused by maintenance staff removing a hand rail. If residents do not have a homelike environment, they may become depressed and anxious that things are in disrepair. The findings are: A. On 03/04/24 at 2:44 PM, during an interview R #31 stated that there was hole in the bathroom wall where maintenance removed a handrail. R #31 could not recall when maintenance removed the handrail. B. On 03/04/24 at 2:44 PM, an observation of R #31 bathroom revealed a hole in the wall where the handrails were removed. C. On 03/04/24 at 2:55 PM, during observation of the 300 and 400 units hallways revealed several ceiling tiles broken/damaged. D. On 03/04/24 at 3:35 PM, during an interview RN #15 confirmed in the 300 and 400 Units hallways…

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: 1) Notify the resident and resident's representatives of a transfer in writing, and 2) Have all the required information on the written notice of transfer for 4 (R #8, R #33, R #37, and R #51) of 4 (R #8, R #33, R #37, and R #51) resident sampled for hospitalizations. These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer, their rights to advocate and make informed decision regarding their healthcare. The findings are: R #8 A. On 03/04/24 at 3:12 PM, during an interview with R #8, she revealed the following: 1. She was transferred to hospital about two and a half weeks before this interview. R #8 was not able to recall the specific date. 2. She did not receive any paperwork regarding her transfer to the hospital. B. Record review of R #8's medical record revealed R #8 was transferred to the hospital on [DATE]. C. Record review of R #8's Notification of Transfer or Discharge,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to: 1) Ensure residents or their representatives received a written notice of the bed hold policy within 24 hours of a transfer, and 2) Indicated the duration the bed would be held on the notice for 4 (R #8, R #33, R #37, and R #51) of 4 (R #8, R #33, R #37, and R #51) residents reviewed for hospitalization. These deficient practices 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 #8 A. On 03/04/24 at 3:12 PM, during an interview with R #8, she revealed the following: 1. She was transferred to hospital about two and a half weeks before this interview. R #8 did not remember the date of the transfer. 2. She did not receive any paperwork regarding her transfer to the hospital. B. Record review of R #8's medical record revealed R #8 was transferred to the hospital on [DATE]. C. Record review of R #8's Notice of Bed Hold Policy, dated 02/18/24, revealed: 1.…

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, observation, and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status at the time of the assessment for 2 (R #15 and R #43) of 4 (R #8, R #15, R #33, and R #43) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need. The findings are: R #15 A. On 03/05/24 at 8:35 AM, during an interview with R #15, she revealed that she had wounds on her right leg. R #15 was not specific about what type of wound she had. B. On 03/05/24 at 8:35 AM, during an observation of R #15's right leg, she had two bandages on her right leg. C. Record review of R #15's care plan, dated 11/02/23, revealed R #15 has venous/stasis ulcers (leg wounds caused by problems with blood flow (circulation) in your leg veins) related to congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should) and Diabetes Mellitus Type 2 (DMII, a long-term…

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 12 (R #8, R #12, R #15, R #19, R #33, R #37, R #40, R #41, R #43, R #44, R #50, and R #51) of 12 (R #8, R #12, R #15, R #19, R #33, R #37, R # 40, R #41, R #43, R #44, R #50, and R #51) residents reviewed for care plans when they failed to: 1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participate in the care plan meeting for R #8, R #15, R #33, R #44, and R #51. 2. Have the care plan meeting within seven days after the completion of the quarterly assessment for R #8, R #15, R #33, R #44, and R #51. 3. Revise the care plan with the most current resident information for R #8, R #12, R #15, R #19, R #33, R #37, R #40, R #41, R #43, R #44, R #50, and R #51. These deficient practices could likely result in the care plan not being updated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to have a discharge summary that includes a compilation of the resident's stay at the facility for 1 (R #57) of 1 (R #57) residents reviewed for discharge. If residents do not have a discharge summary that includes a compilation of the resident's stay at the facility, then the receiving facility or home health will not have the information to provide care. The findings are: A. Record review of the progress notes revealed that R #57 discharged on 12/22/23. B. Record review of the Discharge summary dated [DATE] revealed staff did not document a recapitulation of R #57's stay. C. On 03/12/24 at 10:57 AM, during an interview the DON confirmed that R #57's discharge summary did not include a recapitulation of her stay at the facility. The DON confirmed that staff should fully document the recapitulation on the discharge summary.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide an ongoing activity program to support residents in their choice of activities designed to support their physical, mental, and psychosocial well-being for 2 (R #33 and R #51) of 2 (R #33 and R #51) residents reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression and could likely experience a decline in independence. The findings are: R #33 A. On 03/04/24 at 3:25 PM, during an observation of R #33's room the following was revealed: 1. R #33 laid in bed with his eyes open. 2. The room was dark. 3. The TV was off. B. On 03/05/24 at 9:51 AM, during an interview with R #33's mother, she stated the following: 1. R #33 does not attend activities, that he just goes to the dining room to eat and returns to his room. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 3 (R #8, R #15, and R #51) of 4 (R #8, R #15, R #17 and R #51) residents when they failed to: 1. Monitor R #8 after an episode of altered mental status (a change in mental function) on 02/18/24. 2. Obtain information from wound care appointments (outside of the facility) for R #15 and R #51. 3. Obtain wound care information from contracted wound care staff caring for R #15 and R #51 in the facility. These deficient practices could likely lead to residents needs not being met and/or a worsening of their condition. The findings are: R #8 A. On 03/04/24 at 3:12 PM, during an interview R #8 stated that she was transferred to the hospital about two and a half weeks before this interview. R #8 was unsure of specific date. B. Record review of R #8's Notification of Transfer or Discharge form, dated 02/18/24, revealed that R #8 was transferred…

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 that a resident who enters the facility without an indwelling Foley catheter (tube that is inserted through the urethra (The tube through which urine leaves the body) 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 for 1 (R #15) of 1 (R #15) residents reviewed for Foley Catheters when they failed to ensure an appropriate diagnosis for long term use of a Foley catheter. This deficient practice could likely result in residents being susceptible (likely or liable to be influenced) 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 03/05/24 at 8:29 AM, during an observation of R #15, she laid in bed, and Foley catheter tubing and bag were hung…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure: 1) Residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was necessary to treat a specific psychiatric diagnosis and was documented in the medical record, and 2) Have the consent of resident/representative for psychotropic medications for 5 (R #33, R # 40, R #48, R #50 and R #51) of 5 (R #33, R #40, R #48, R #50 and R #51) residents reviewed for unnecessary psychotropic medications. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #33 A. Record review of R #33's Physician orders revealed the following: 1. Fluoxetine 40 mg once a day for Major Depressive Disorder (MDD, A mental health disorder characterized by persistently depressed mood or loss of interest 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.

Based on observation and interview, the facility failed to store medications properly and medication carts were locked for all 25 residents in the 200 and 400 Units (residents were identified by the resident matrix provided by the Administrator on 03/04/24) . Randomly sampled residents when they failed to dispose of one loose tablet in the medication cart on the 400 unit. This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: A. On 03/06/24 at 7:37 AM, during an observation of the 200-unit hallway revealed the medication cart was unlocked, staff was not present. B. On 03/06/24 at 7:39 AM, during an interview CMA #5 confirmed that the medication cart was unlocked on 200 unit. C. On 03/12/24, at 11:07 AM, during an observation, the medication cart on 400 unit revealed one loose tablet in the medication cart. D. On 03/12/24, at 11:08 AM, during an interview, CMA #11 confirmed one loose tablet in the medication cart. E. On 03/12/24, at 1:32 PM, during an interview, the DON confirmed that…

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 physical therapy (therapy that is used to preserve, enhance, or restore movement and physical function) screening for 1 (R #19) of 1 (R #19) resident reviewed for activities of daily living (ADL's; daily self-care activities such as eating, dressing and using the toilet). This deficient practice could likely result in residents not receiving services as needed or ordered to improve or maintain their physical functional ability. The findings are: A. Record review of R #19's Quarterly MDS, dated [DATE], Section GG: Functional Abilities and Goals revealed: 1. Question GG0130.C - Toileting hygiene; The resident required substantial/maximum assistance. One staff helps and provides more than half the effort (decline from 10/17/23). 2. Question GG0130.F - Upper body dressing; The resident required substantial/maximum assistance. One staff helps and provides more than half the effort (decline from 10/17/23). 3. Question GG0130.G - Lower body…

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 abuse, neglect, and exploitation (ANE) training to 2 staff (CNA #1 and RN #1) of 6 (CNA #1, CNA #2, CNA #3, LPN #1, RN #1, and RN #2) staff sampled for training. This deficient practice could likely result in staff not knowing who, what, and when to report abuse, neglect, and exploitation. The findings are: A. Record review of CNA #1's training transcript for date range 03/01/23 through 03/11/2024 revealed that abuse, neglect, and exploitation training was not completed. B. Record review of RN #1's training transcript for date range 03/01/23 through 03/11/2024 revealed that abuse, neglect, and exploitation training was not completed. C. On 03/12/24 at 5:20 PM, during an interview, the Administrator confirmed that CNA #1 and RN #1 did not complete the required ANE training.

Based on record review and interview, the facility failed to notify the physician or resident representative of a change in medical status for 1 (R #8) of 1 (R #8) residents reviewed for hospitalization, when they failed to immediately notify R #8's representative and the physician of R #8's low oxygen saturation (amount of oxygen in the blood) and altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain). This deficient practice could likely result in the resident's representative and the physician being unaware of resident's current condition resulting in delay in treatment. The findings are: A. On 03/04/24 at 3:12 PM, during an interview with R #8, she revealed that she was transferred to hospital for pneumonia about two and a half weeks before this interview. R #8 was unsure of the exact date. B. Record review of the Notification of Transfer or Discharge form, dated 02/18/24, revealed that resident was transferred to the hospital for Altered Mental Status. C. Record review of R #8's nursing progress note, dated…

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

Based on 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 deficient practice is likely to affect all 55 residents (residents were identified by the Census List provided by facility administrator on 01/19/23). This deficient practice could likely result in resident's not receiving the services required for care. The findings are: A. Record review of facility schedules for 01/01/23 through 01/31/23 revealed that the facility failed to have an RN on duty for at least 8 consecutive hours a day, seven days a week on the following days: 1) 01/01/23 2) 01/07/23 3) 01/08/23 B. On 01/31/22 at 4:47 pm, during an interview, the Infection Preventionist stated that she assists with scheduling and confirmed that the facility did not have an RN seven days a week. She stated We have a nurse every day of the week every other weekend when [name of RN #1] works her weekend.

Based on record review and interview, the facility failed to ensure that residents representatives or medical provider (physician or nurse practitioner) were notified following a change in condition or treatment for 3 (R #8, R #53, and R #107) of 3 (R #8, R #53, and R #107) residents reviewed for notification of change. If the facility does not notify resident's representatives or medical provider of the change in treatments or condition, then they will not have an opportunity to make decisions and/or advocate for treatment or care on behalf of the resident. The findings are: R #8 A. Record review of R #8's Medical Administrative Review (MAR) revealed the following: 1.Ertapenem, (a carbapenem antibiotic, are a class of very effective antibiotic agents most commonly used for the treatment of severe bacterial infections. This class of antibiotics is usually reserved for known or suspected multidrug-resistant bacterial infections), 1 GM (gram), . for Urinary Tract Infection (UTI) Start Date 11/22/22 . Medication was documented as given as ordered. B. On 02/02/23 at 4:17 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 observation and interview the facility failed to provide a comfortable and homelike environment for 3 (R #19, R #21, and R #43) of 3 (R #19, R #21, and R #43) residents sampled for environment, when they failed to maintain a temperature range of 71° to 81°F when the heating system went out in the 300 unit in January 2023. This deficient practice could likely result in residents being cold and uncomfortable due to loss of body heat. The findings are: A. On 01/19/23 at 12:30 AM, during an interview R #43 stated that she was cold in her room. R #43 stated the heater had been broken. B. On 01/26/23 at 9:03 AM, during an interview the Maintenance Director (MD) stated the heater unit on the 300 unit does not work. The MD also stated that it has been broken for 3 weeks (roughly since the beginning on January, 2023). C. On 01/26/23 at 9:05 AM, during an observation of a phone call to the Air Conditioning company from the MD revealed the AC company were not expected to out to fix the heater for an estimated week or so from 01/26/23. D. On 01/26/23 at 9:07 AM, during an observation…

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 6 (R #6, R #8, R #11, R #36, R #42, and R #50 ) of 6 (R #6, R #8, R #11, R #36, R#42, and R #50) residents reviewed for discharge. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location that the resident was discharged . The findings are: R #6 A. Record review of R#6's Notification of Transfer or Discharge record revealed the following: 1. R #6 was transferred to the hospital on [DATE] for an unwitnessed fall. R #8 B. Record review of R #8's Notification of Transfer or Discharge record revealed the following: 1. R#8 was admitted on [DATE]. 2. R#8 was transferred to the hospital on [DATE] for a fall. R #11 C. Record review of R #11's Medical Record revealed: 1. R #11 was sent to the hospital after a fall on 10/04/22, R #36 D. Record review of R #36's Notification of Transfer or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 6 (R #6, R #8, R #11, R #36 R #42, R #50 ) of 6 (R #6, R #8, R #11, R #36, R #42, ,and , R #50 ) residents reviewed for transfers to hospital. 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 #6 A. Record review of R #6's medical record revealed the following: 1. R #6 was transferred to the hospital on [DATE] for an unwitnessed fall. R#8 B. Record Review of R #8's Medical Record revealed: 1. R #8 was sent to the hospital on [DATE] after a fall. R #11 C. Record Review of R #11's Medical Record revealed: 1. R #11 was sent to the hospital after a fall on 10/04/22 R#36 D. Record Review of R #36's Medical Record revealed: 1. R #36 was sent to the hospital on R#36 was transferred to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement an accurate, effective, person-centered Baseline Care Plan within 48 hours of admission for 2 (R #50 and R #52) of 3 (R #50, R #52 and R #105) residents sampled for baseline care plans. If resident's Baseline Care Plans are not accurate, then residents are not likely to get the care and services needed. The findings are: R #50 A. Record review of R #50's admission Record (face sheet) document dated 01/06/23 revealed: 1. admission date 01/06/23 2. admission diagnosis of Unspecified Dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). B. Record review of R #50's Care Plan dated 01/06/23 revealed 1. The resident is resistive to care R/T (related to) anxiety, dementia E/B (Evidence By) aggression towards staff, refusing medications, refusing assistance with ADL's (Activities of daily living; fundamental skills required to independently care for oneself, such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to develop and/or implement a comprehensive person-centered care plan for 4 (R #6, R #36, R #43, and R #107) of 10 (R #5, R #6, R #15, R #16, R #25, R #28, R #36, R #43, R #44, and R #107) residents reviewed for Comprehensive Care Plans by: 1. Not developing a care plan for psychotropic medications for R #6, 2. Not implementing washing of feet daily for R #36, 3. Not developing a care plan for Irritability and anger diagnosis for R #43, and 4. Not implementing Occupational and Physical therapy for R #107. Failure to develop a resident centered care plan is likely to result in staff's failure to understand and implement the needs and treatments for residents to achieve their highest level of well-being. The findings are: R #6 A. Record review of R #6's Medical Record revealed diagnosis: 1.Unspecified dementia (general term that describes the deterioration of memory, language, and other thinking abilities enough to interfere with daily life),…

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 revise the Care Plan for 3 (R #8, R #27, and R #154) of 3 (R #8, R #27, and R #154) residents sampled for Care Plan documentation. 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. The findings are: R #8 A. Record review of R #8's Care Plan dated 11/28/22 revealed: 1. [Resident admitted [DATE]]Focus The resident has bowel incontinence .The resident will be continent during daytime through the review date . Observe pattern of incontinence, and initiate tolieting. Check resident every two hours and assist with toileting . B. On 01/25/23 at 2:12 PM, during an interview with CNA #11 confirmed that R #8 does try to go to the bathroom on her own but is not being toileted. CNA #11 stated that they try to change R #8 after every meal. C. On 01/26/23 at 3:44 PM, during an interview the ADON confirmed R #8 will not regain continence…

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

Based on record review and interview, the facility failed to ensure residents receiving dialysis (process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally) receive services consistent with professional standards of practice and the comprehensive person-centered care plan facility regarding dialysis care and services for 1 (R #16) of 1 (R #16) 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 #16's Medical Record revealed an admission date of 06/30/22 with diagnosis of End stage renal disease (kidney reaches advanced state of loss of function and requires dialysis). B. Record Review of R #16's Physician's Orders revealed: Order date 09/02/21: Dialysis on M, W, F (Monday, Wednesday, Friday) at 11:30 am. C. Record review of R #16's Care Plan revealed: 1. Focus: Alteration in Renal (kidney) Function: Renal End Stage Renal Disease with Hemodialysis (dialysis) 2.…

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

Based on observation, record review, and interview the facility failed to maintain appropriate staffing levels to meet the needs of the residents. This failure has the potential to affect all 14 residents in the secure unit (residents were identified by the resident census list provided by the Administrator on 01/12/23). This deficient practice could likely result in residents not receiving the care and service needed while in the facility. The findings are: A. On 01/23/23 at 12:09 PM, during an observation of the Secured Unit revealed CNA #12 was assisting R #30 and all other residents were unattended. During an interview with CNA #12 at that time, she was asked if she was the only CNA on the secure unit and she stated that she was. CNA #12 continued to state that she is usually the only one scheduled in the secure unit. B. On 01/23/23 at 12:10 PM during an observation of the Secure Unit revealed eight residents in the common area eating lunch. CNA #12 was assisting a resident in their room. No other staff were observed present. R #38, who is in a wheelchair, tried to seat himself…

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 that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 3 (CNA #4, CNA #5, and CNA #6) of 3 (CNA #4, CNA #5, and CNA #6) CNAs randomly 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 #4's personnel records revealed 1) No CNA competency evaluation completed. B. Record review of CNA #5's personnel file revealed 1) No CNA competency evaluation completed. C. Record review of CNA #6's personnel records revealed 1) No CNA competency evaluation completed. D. On 01/26/23 at 11:01 AM, during an interview the Executive Director confirmed that the facility did not have CNA competencies for CNA #4, CNA #5, and CNA #6.

Based on interview and record review, the facility failed to complete performance reviews at least every 12 months for 3 (CNA #4, CNA #5, and CNA #6) of 3 (CNA #4, CNA #5, and CNA #6) 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 #4's personnel records revealed that the CNA had worked for the facility longer than 12 months and there were no performance evaluation completed. B. Record review of CNA #5's personnel records revealed that the CNA had worked for the facility longer than 12 months and there were no performance evaluation completed. C. Record review of CNA #6's personnel records revealed that the CNA had worked for the facility longer than 12 months and there were no performance evaluation completed. D. On 01/26/23 at 11:01 AM, during an interview the Executive Director confirmed that the facility did not have performance reviews for CNA #4, CNA #5, and CNA #6.

Based on interview and record review, the facility failed to ensure that 1 (CNA #5 ) of 3 (CNA #4, CNA #5, and CNA #6) CNA's reviewed for behavioral health training had the appropriate training to provide care for residents with behavioral health issues/needs. This deficient practice could likely result in residents not receiving the appropriate care to meet their needs. The findings are: A. Record review of the training transcripts provided for CNA #5 revealed no trainings pertaining to Behavioral Health issues. B. On 01/31/22 at 4:47 pm, during an interview, the Infection Preventionist confirmed that CNA #5 worked in the special care unit (Dementia unit) and did not have her training for Behavioral Health completed at this time.

Based on record review and interview, the facility failed to ensure documents in resident records were complete and accurate for 9 (R #9, R #11, R #12, R #24, R #42, R #43, R #43, R #45 and R #105) of 9 (R #9, R #11, R #12, R #24, R #39, R #42, R #43, R #45 and R #105) residents reviewed for advanced directives (MOST form- Medical Orders for Scope of Treatment legal document also known as a living will which specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity). This deficient practice could likely result in staff not knowing the medical intervention wishes of residents during an emergency. The findings are: R #9 A. Record review of R #9's Medical Record revealed: An admission date of 10/24/22. B. Record review of R #9's MOST form dated 10/25/22 revealed, 1. No printed name of patient or healthcare decision maker. 3. R #9's resident/resident's representative signature is not dated. 4. R #9's resident/resident's representative relationship to the patient is not indicated. R #11 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 record review and interview, the facility failed to ensure the MDS ((Minimum Data Set) accurately reflected all the falls for 1 (R #8) of 1 (R #8) resident randomly sampled when they failed to document R #8's falls on the MDS. If the resident's MDS is not accurate it is likely that residents will not get the care and assistance needed. The findings are: A. Record review of R #8's Care Plan revealed R #8 had fallen on 06/26/22 and 07/11/22. B. Record review of R #8's Quarterly MDS dated [DATE] revealed no documentation of the falls on 06/26/22 or 07/11/22. C. On 01/26/23 at 3:39 PM during an interview with MDS Coordinator (MDSC), it was confirmed that R #8 had fallen on 06/26/22 and 07/11/22. The MDSC also confirmed that the facility had not documented the falls on R #8's Quarterly MDS dated [DATE] and they should have.

Based on observation, and interview, the facility failed to keep residents free from accidents for all 15 residents on the 400 hallway (Residents were identified by the resident matrix provided by the Administrator on 01/26/23) when they failed to secure a treatment cart. This deficient practice could result in residents obtaining medical equipment that could be harmful to them resulting in injury. The findings are: A. On 01/20/23 at 3:05 PM, during an observation of the 400 Unit revealed the treatment cart was left unsecured with no staff were present. B. On 01/20/23 at 3:08 PM, during an interview the Executive Director confirmed that the treatment cart was unsecured with no staff present and should have been.